The purpose of this review was to identify the relationship between the gut microbiome and the development of postoperative complications like anastomotic leakage or a wound infection. Recent reviews focusing on underlying molecular biology suggested that postoperative complications might be influenced by the patients’ gut flora. Therefore, a review focusing on the available clinical data is needed. In January 2017 a systematic search was carried out in Medline and WebOfScience to identify all clinical studies, which investigated postoperative complications after gastrointestinal surgery in relation to the microbiome of the gut. Of 337 results 10 studies were included into this analysis after checking for eligibility. In total, the studies comprised 677 patients. All studies reported a postoperative change of the gut flora. In five studies the amount of bacteria decreased to different degrees after surgery, but only one study found a significant reduction. Surgical procedures tended to result in an increase of potentially pathogenic bacteria and a decrease of Lactobacilli and Bifidobacteria. The rate of infectious complications was lower in patients treated with probiotics/symbiotics compared to control groups without a clear relation to the systemic inflammatory response. The treatment with synbiotics/probiotics in addition resulted in faster recovery of bowel movement and a lower rate of postoperative diarrhea and abdominal cramping. There might be a relationship between the gut flora and the development of postoperative complications. Due to methodological shortcomings of the included studies and uncontrolled bias/confounding factors there remains a high level of uncertainty.

Background: Acute mesenteric ischemia (AMI) is an uncommon, but life-threatening clinical entity due to late diagnosis resulting in irreversible ischemic bowel necrosis. The most common causes of AMI are the embolic occlusion and the acute thrombosis of the mesenteric circulation. Typical treatment is composed of an early revascularization of the mesenteric circulation followed by abdominal surgery for resection of nonviable intestine and restoration of the intestinal continuity, but the mortality rates remain high. Methods: A retrospective cohort analysis was conducted, aiming to evaluate clinical characteristics, performed surgical procedures and outcomes of patients with acute mesenteric ischemia who underwent emergency abdominal surgery at a high volume surgical center in Germany. Results: Overall, 53 patients were identified with the intraoperatively proven diagnosis of AMI. Overall hospital mortality was with 62% comparable to the literature. Nineteen patients presented with an intraoperatively verified complete and non-reversible intestinal infarction without any angiographic or surgical option for a revascularization of the mesenteric circulation or an option for intestinal resection. From the rest of the patients, 14 underwent intestinal resection of the ischemic area without restoration of intestinal continuity; the other 20 underwent resection with a primary anastomosis to restore intestinal continuity. The mortality rate of these patients with curative-intended surgery remained high (41% of patients died). Pre- and postoperative hyperlactatemia were associated with lower survival of these patients. Conclusion: AMI remains a life-threatening abdominal emergency. Therapeutic approaches are highly depended on acting surgeon’s decision, being affected by subjectively rated bowel viability and physical condition of the affected patient. Only selected patients with good bowel viability appear to be suitable for receiving primary anastomosis. The results clearly indicate the need for further research to develop therapeutic approaches for a better management of AMI and to improve outcome of affected patients.

Background: Etiology of hyperlactatemia in ICU patients is heterogeneous—septic, cardiogenic or hemorrhagic shock seem to be predominant reasons. Multiple studies show hyperlactatemia as an independent predictor for ICU mortality. Only limited data exists about the etiology of hyperlactatemia and lactate clearance and their influence on mortality. The goal of this single-center retrospective study, was to evaluate the effect of severe hyperlactatemia and reduced lactate clearance rate on the outcome of unselected ICU surgical patients. Methods: Overall, 239 surgical patients with severe hyperlactatemia (> 10 mmol/L) who were treated in the surgical ICU at the University Medical Center Freiburg between June 2011 and August 2017, were included in this study. The cause of the hyperlactatemia as well as the postoperative course and the patient morbidity and mortality were retrospectively analyzed. Lactate clearance was calculated by comparing lactate level 12 h after first measurement of > 10 mmol/L. Results: The overall mortality rate in our cohort was 82.4%. Severe hyperlactatemia was associated with death in the ICU (p < 0.001). The main etiologic factor was sepsis (51.9%), followed by mesenteric ischemia (15.1%), hemorrhagic shock (13.8%) and liver failure (9.6%). Higher lactate levels at ICU admission were associated with increased mortality (p < 0.001). Lactate clearance after 12 h was found to predict ICU mortality (ANOVA p < 0.001) with an overall clearance of under 50% within 12 h. The median percentage of clearance was 60.3% within 12 h for the survivor and 29.1% for the non-survivor group (p < 0.001). Conclusion: Lactate levels appropriately reflect disease severity and are associated with short-term mortality in critically ill patients. The main etiologic factor for surgical patients is sepsis. When elevated lactate levels persist more than 12 h, survival chances are low and the benefit of continued maximum therapy should be evaluated.

Background. The aim of this study was to evaluate the influence of prolonged length of stay in an intensive care unit (ICU) on the mortality and morbidity of surgical patients.Methods. We performed a monocentric and retrospective observational study in the surgical critical care unit of the department of surgery at the Medical Center of the University of Freiburg, Germany. Clinical data was collected from patients assigned to the ICU with a length of stay (LOS) of 90 days and greater.Results. From the total of the 19 patients with ICU LOS over 90 days, ten patients died in the ICU whereas nine patients were discharged to the normal ward. The ICU mortality rate was 52%. The overall survival one year after ICU discharge was 32%. Regarding factors affecting mortality of the patients, significantly higher mortality was associated with age of the patients at the time point of the ICU admission and with postoperative need of renal replacement therapy.Conclusions. We found a high but in our opinion acceptable mortality rate in surgical patients with ICU LOS of 90 days and greater. We identified age and the need of renal replacement therapy as risk factors for mortality.

Purpose: Although Ogilvie’s syndrome was first described about 70 years ago, its etiology and pathogenesis are still not fully understood. But more importantly, it is also not clear when to approach which therapeutic strategy. Methods: Patients who were diagnosed with Ogilvie’s syndrome at our institution in a 17-year time period (2002–2019) were included and retrospectively evaluated regarding different therapeutical strategies: conservative, endoscopic, or surgical. Results: The study included 71 patients with 21 patients undergoing conservative therapy, 25 patients undergoing endoscopic therapy, and 25 patients undergoing surgery. However, 38% of patients (n = 8) who were primarily addressed for conservative management failed and had to undergo endoscopy or even surgery. Similarly, 8 patients (32%) with primarily endoscopic treatment had to proceed for surgery. In logistic regression analysis, only a colon diameter ≥ 11 cm (p = 0.01) could predict a lack of therapeutic success by endoscopic treatment. Ninety-day mortality and overall survival were comparable between the groups. Conclusion: As conservative and endoscopic management fail in about one-third of patients, a cutoff diameter ≥ 11 cm may be an adequate parameter to evaluate surgical therapy.

Background. Nontraumatic renal rupture due to pyelonephritis with obstructive uropathy is an uncommon but life-threatening situation. Case Presentation. A 25-year-old female presented to the emergency department with acute worsening of abdominal pain that began four weeks earlier. She was found to have peritonitis, leukocytosis, severe lactic acidosis, and a pronounced anemia and imaging was consistent with nontraumatic renal rupture with retroperitoneal abscess, perforation of the colon, and severe necrotizing fasciitis of the right lower limb. She underwent a right nephrectomy, a right hemicolectomy, surgical debridement of the retroperitoneum, and an upper thigh amputation. Due to severe septic shock and rhabdomyolysis with acute renal failure we performed a combined treatment of hemoadsorption using a Cytosorb hemoadsorber and continuous venovenous hemodialysis (CVVHD). Subsequently the patient recovered and was discharged home with no signs of infections and with normal renal function. Conclusion. We present a case of pyelonephritis with nontraumatic renal rupture leading to necrotizing fasciitis with osteomyelitis of the lower limb. The early treatment of the patient with a Cytosorb hemoadsorber led to a rapid hemodynamic and metabolic stabilization and preservation of the renal function, suggesting that hemoadsorption might be a rescue therapy in patients with severe septic shock and traumatic rhabdomyolysis.