Combined forecasting system for peritonitis severity assessment is created. The system includes clinical, laboratory data, assessment of systemic inflammatory response (SIRS) and severity of organ failure (qSOFA). The authors focused on easily identifiable parameters which are available in virtually any surgical hospital. Threshold value (lethal outcome probability over 50%) is 8 scores in this system. Sensitivity, specificity and accuracy were 93.3, 99.7 and 98.9%, respectively according to ROC-curve that exceeds those parameters of MPI and APACHE II.
Despite improvements in the methods of diagnostics, surgical interventions and intensive care, the problem of treating patients with diffuse peritonitis remains relevant. Diffuse peritonitis is a major contributor to mortality in all urgent care settings and the second leading cause of sepsis in critically ill patients. At the same time, even in developed countries, the number of patients with peritonitis does not tend to decrease, and mortality rates remain high, reaching 90-93% with the development of abdominal sepsis and toxic shock syndrome. One of the ways to reduce mortality in peritonitis is the use of objective systems for prognosis of the peritonitis outcome, allowing to compare the results of patient treatment and to choose the optimal treatment tactics for each particular patient. The objective — To develop a new system for predicting the outcome of secondary peritonitis (survival or death) focused on the criteria of abdominal sepsis and multiple organ dysfunction syndrome (associated or not associated with peritonitis), and to analyze its accuracy versus the most common comparable systems. Material and Methods — Our study was based on analyzing the treatment outcomes in 352 patients with secondary diffuse peritonitis. On admission, sepsis was diagnosed in 15 (4.3%), and toxic shock in 4 (1.1%) patients. The main causes of death were purulent intoxication and/or sepsis (51 cases or 87.9%), cancer intoxication (4 cases or 6.9%), and acute cardiac failure (3 cases or 5.2%). We analyzed the effectiveness of several systems of predicting the peritonitis outcomes: the Mannheim’s Peritoneal Index (MPI), World Society for Emergency Surgery Sepsis Severity Score (WSES SSS), Acute Physiology and Chronic Health Evaluation II (APACHE II) system, general Sequential Organ Failure Assessment Score (gSOFA), as well as the Peritonitis Prognosis System (PPS) developed by the authors. The probability of the effect of 40 clinical and laboratory parameters on the outcome of patients with secondary peritonitis was analyzed via using parametric and nonparametric methods of statistical analysis (Fisher’s test, Mann-Whitney U test, Chi-squared test with Yates’s continuity correction). The criteria were selected that had a predictive power for the lethal outcome (p <0.05), and they were included in the PPS system. To compare the predictive value of the PPS, ROC analysis was conducted with construction of receiver operating characteristic curves for each analyzed system of predicting the peritonitis outcome. The STATISTICA 8 software was used for performing the statistical analysis. Results — The following criteria were of greatest importance in predicting the lethal outcome: a patient’s age, a presence of a malignant neoplasm, a nature of the exudate, the development of sepsis (toxic shock), as well as multiple organ dysfunction not associated with the developed peritonitis. PPS exhibited the greatest accuracy in terms of predicting mortality in patients with secondary diffuse peritonitis (AUC=0.942) versus minimal in APACHE II (AUC=0.840). Conclusion — APACHE II, MPI, WSES SSS and PPS can be considered reliable in terms of mortality prognosis in peritonitis patients. PPS has the greatest accuracy of predicting the mortality in patients with secondary diffuse peritonitis (94%).
Резюме Хирургическое лечение-метод выбора у детей с кортикальными дисплазиями (КД) и фармакорезистентной симптоматической эпилепсией, однако его результативность и доля благоприятных исходов с полным прекращением приступов и стойкой ремиссией широко варьируют. Цель исследования-выявить критерии, которые влияют на исход лечения и ассоциированы с прекращением приступов. Материал и методы. Оперировано 169 детей. Все дети обследованы с помощью видеоэлектроэнцефалографии (ЭЭГ) и магнитно-резонансной томографии (МРТ), 14-с помощью инвазивной ЭЭГ. Произведено 196 операций, включая 27 повторных вмешательств: 116 кортэктомий, 46 лобэктомий и 34 различных дисконнекции. Рутинно (134 случая) использовали интраоперационную электрокортикографию (ЭКОГ), сочетая ее в 47 случаях с картированием сенсомоторных зон коры, а в части случаев-и кортикоспинального тракта. Новый непредвиденный и стойкий неврологический дефицит отмечен у 5 (2,5%) больных. Катамнез длительностью более 2 лет с повторными видео-ЭЭГ и МРТ известен у 56 больных (медиана-3 года). Благоприятный результат с полным прекращением всех приступов и стойкой ремиссией (исход IA Engel) достигнут у 32 (57,2%) пациентов. Анализировали связь между различными данными, которые характеризовали пациента (возраст дебюта и длительность эпилепсии, возраст на момент операции, ведущий тип приступов и их электро-клиническая картина, локализация и морфологический тип КД), и тем, как и насколько радикально удалось иссечь (или изолировать) эпилептический фокус. Результаты. Вероятность благоприятного исхода наиболее высока у больных со II типом фокальной КД (ФКД), которые лучше распознаются и на МРТ, и визуально во время операции, и потому иссе каются радикальнее. Зона инициации приступов при этих мальформациях соответствует и тождественна анатомическим границам ФКД и поэтому разрушается вместе с ней. Остаточная эпилептическая активность на ЭКОГ на результатах не сказывается. Заключение. Пациенты со II, особенно с IIb-типом фокальной кортикальной дисплазии-наилучшие кандидаты для операции с перспективой на полное прекращение приступов при минимальной морбидности, к тому же если фокальная кортикальная дисплазия расположена вблизи от функционально критических зон коры. У детей с I типом кортикальной дисплазии шансы на прекращение приступов путем кортэктомии невелики. В части подобных случаев, особенно у детей с катастрофическим течением заболевания, несмотря на вынужденный новый неврологический дефицит, возможны расширенные резекции (лобэктомии) или дисконнекции. Ключевые слова: фокальная кортикальная дисплазия, прогностические факторы, отдаленные результаты, критически важные зоны коры, электрокортикография, инвазивная электроэнцефалография.
Objectives. To develop a new system for predicting the outcome of secondary peritonitis and analyze its accuracy in comparison with the most common analogous systems. Methods. The study is based on the analysis of treatment results in patients (n=352) with secondary peritonitis. At admission sepsis was diagnosed in 15 (4.3%) patients, septic shock - in 4 (1.1%) persons. There were the following main causes of death in the mortality structure: purulent intoxication and/or sepsis - 51 cases (87.9%), cancer intoxication - 4 (6.9%) cases, acute cardiovascular failure - 3 cases (5.2%). The efficacy of the Mantheim Peritoneal Index (MPI), WSES prognostic score, APACHE-II scale, gSOFA score and Peritonitis Prediction System (PPS) developed by the authors were analyzed. The likelihood of the effect of 85 clinical and laboratory parameters on the outcome of patients with secondary peritonitis using nonparametric methods of statistical research (Fisher’s test, Mann-Whitney test, Chi-square with Yates correction) have been analyzed. Criteria predictively associated with lethal outcome (p <0.05) were selected, they were included in the PPS scale. To compare the predictive value of peritonitis prediction systems, ROC analysis was used with the construction of ROC curves for each of the systems. Results. The most important criteria in predicting fatal outcome are the patient’s age, the presence of malignant tumor, the exudate nature, sepsis (septic shock), and also polyorganic insufficiency which is not associated with developed peritonitis. To assess the prognostic value of peritonitis prediction systems, ROC curve analysis was used. The greatest accuracy in terms of predicting mortality in patients with generalized secondary peritonitis is possessed by PPS (AUC 0.942), minimal - APACHEII (AUC 0.840). Conclusion. APACHEII, MPI, WSESSSS and PPS systems can be considered as reliable in predicting mortality in patients with peritonitis. The greatest accuracy in predicting fatal outcome in patients with generalized secondary peritonitis had PPS (94%). What this paper adds An original system for predicting the outcome of peritonitis (PPS) has been developed. It was found that the criteria of the patient’s age, the presence of a malignant neoplasm, the nature of the exudate, sepsis (septic shock), as well as polyorganic insufficiency not associated with the developed peritonitis are of the greatest importance in predicting the death outcome. When conducting a comparative assessment with the most common similar systems (MPI, WSES SSS, APACHE-II), it was found that the most accurate in terms of predicting mortality in a patient with generalized secondary peritonitis is the PPS (AUC 0.942), the minimum - APACHEII (AUC 0.840).
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