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The hypoth- esis arose early that purchase 250mg chloroquine fast delivery treatment quad tendonitis, following the physiological restoration of the patient chloroquine 250mg otc medications used for anxiety, a patient who otherwise may have received a stoma could avoid this order chloroquine 250mg without prescription chapter 9 medications that affect coagulation, as a primary anastomo- sis might now be safely performed in this new physiological milieu discount 250mg chloroquine with visa treatment 4 burns. A retrospective, nonrandomized series, and a more recent prospective series, lend support that this approach may indeed be warranted [25, 26]. Examples include vascular pathologies such as ruptured aneurysms, ulcer disease, and spontaneous hemorrhage of hepatic tumors or a rupture of a pathological spleen. Similar with other situations, the open abdo- men may facilitate a temporizing treatment strategy, or a multistage intervention, where repeated access to the peritoneal cavity is required. The situation with a ruptured aortic abdominal aneurysm is notable given histori- cal changes. However, the physiological manifestation with increased compartment pressures and even- tual tissue and organ compromise is the common outcome. The severe associated morbidity and mortality needs to be avoided by early recognition and institution of appropriate management strategies. The steps have been well described in the published guidelines from the World Society of the Abdominal Compartment Syndrome . The laparotomy offers defnitive surgical treatment of the syndrome, particularly where nonoperative measures have failed or have been insuffcient. However, as evident from the discussions above, both in the trauma setting and in the situation of severe sepsis, the surgeon may elect to leave the abdomen open prophylactically and potentially prevent the syndrome occurring in the frst place. The appropriateness of the risks of an open abdomen compared with the potential benefts needs to be judged in the individual case. For example, in the management of severe acute pancreatitis, the occasional need for an open abdomen is accepted and widely reported [3, 29, 30]. The precise indications and triggers prompting an operative decompression and open abdomen are generally less well documented, as is the infuence of patient and environmental factors in this deci- sion. In particular, issues with fuid and protein loss, issues with the loss of the abdominal domain and often associated failure of primary abdomi- nal closure, and issues with fstula formation complicate the management of these patients. These complications impart signifcant morbidity and mortality to these patients and must be offset by the previously discussed benefts from the laparotomy. These insensible losses are potentiated by the pathological processes and need to be considered in the overall fuid balance of the patient. As an exudate, the protein losses also must be accounted for; around 2 gm will be lost with every liter of fuid . After around 1 week, the magnitude of this retraction begins to preclude primary abdominal closure and is associated with a rapidly increasing rate of complications during the patient’s recovery [1–4]. In a series of laparotomies for traumatic indications, patients closed within 8 days expe- rienced a 12% complication rate, compared with a rate of 52% after 8 days . A recent meta-analysis highlights the worsened mortality, complication rates, and length of hospital stay, among patients that underwent procedures associated with delayed fascial closure; a relative risk of 0. The coordination and planning of the surgical efforts to facilitate this closure need to begin at the time of the index operation where the abdomen is frst left open. The type of temporary closure, the nature of the ongoing resuscitation, and the timing of subsequent sur- geries are all defning factors. A coordinated strategy should be established by the treating team, optimizing these factors. A large variety of temporary abdominal closure prostheses/dressings have been described, with many variations developed locally by individual institutions. Apart from the superior wound management and nursing ease, these systems appear to minimize fascial retraction, yielding improved primary fascial closure rates. Further research is required, but it is hypothesized that this alteration in the infammatory milieu may assist the improved outcomes observed in these patients. In recent trials, this combina- tion has been reported to have a primary closure rate around 90% [36, 37]. A further study suggested a higher than expected incisional hernia rate (26%), though this issue requires further clarifcation in studies targeted to address this outcome measure . In patients where a primary closure of the open abdomen is achieved, around 10% may expect an incisional hernia at 21 months , appearing similar to other laparotomy hernia rates. This situation will need to be dealt with on its own merits; an optimal treatment strategy will depend on the underlying reasons: infection, fas- cial necrosis, loss of domain, etc. The quality of the resuscitation, both during the initial hospitalization and ongo- ing during these patients’ intensive care treatment, continues to improve [1–4]. Goal-directed therapies, more restrictive fuid prescription algorithms particularly with minimization of crystalloid use, early hemostatic transfusion practices, etc. Furthermore, more careful attention to nutrition also appears to be providing results: enteral nutrition appears safe in patients with open abdomens and has been associated with decreased infective complications as well as improved fascial closure rates [1, 31]. Despite best efforts, primary fascial closure will fail to be achieved in some patients. In these cases, the visceral contents will require protection by alternative means: native tissue faps and grafts, synthetic meshes, and biosynthetic constructs all offer options. Typically, the viscera form an infammatory cocoon from adhe- sions, and the laparotomy is dressed and nursed until a temporary mesh closure can be achieved. As mentioned, these situations are clinically challenging, presenting the treat- ing team with frequent complications to overcome, including fstula formation. A committed multidisciplinary clinical team is required to deal with the complex needs demanded by these patients’ pathology. It may affect up to one-ffth of patients with an open abdomen, though the risk will vary greatly between patients depending on individual circumstance and the pathology involved [1, 32, 40]. The degree of sepsis, the number of re-explorations and manipulation of tissues, the quality of the resuscitation, and the use of polypropyl- ene mesh in direct contact with the bowel are also linked [1, 32, 40]. The management of this complication is complex, involving nutritional support, meticulous wound management, and challenging reconstructive and restorative sur- geries, and is beyond the scope of this chapter [1, 32, 40]. Nasim should be undertaken to avoid such fstulae in the frst place; the majority of this will surround optimal patient selection, prosthesis/wound management, and early clo- sure of the open abdomen wherever possible. For the optimal management of the open abdomen, ideal patient selection is frst and fore- most infuenced by the patient’s physiology [1–6]. However, the subtleties of the pathology and overall treatment strategy, as well as more general patient factors (comorbidities, patient habitus, psychological well-being, etc. In the absence of robust, randomized controlled data, this remains a situation for clinical gestalt. The clinical challenge for the surgeon considering the use of an open abdomen remains the ability to balance this complex, multifactorial equation—an art of weighing the benefts against the potential harm. In an analogous problem to poten- tial overuse of the open abdomen, several authors have recently discussed issues relating to the overuse of the damage control surgical strategy [20, 41]. Simply put, compared with primary defnitive operations, damage control laparotomies are associated with increased mortality and morbidity (anastomotic leak, ileus, abdomi- nal wall dehiscence and skin infection, etc. Therefore, a clinically riskier situation is required to offset these increased costs. This only occurs in select cases that are not amendable or ideally suitable to the primary defnitive surgical strategies. The quest to understand infammation remains ongoing; an improved pathophysiological understanding of the infammatory processes in the shocked patient is urgently needed. An improved understanding of how the different clinical types of shock manifest and alter the patient’s normal processes is critical.
Concerning when there is a contraindication for cardiac trans- implantability discount chloroquine online medications zithromax, one can distinguish between plantation chloroquine 250mg for sale symptoms 1 week after conception, such as irreversible pulmonary implantable devices buy 250 mg chloroquine with visa medications for factor 8, where the pump housing hypertension generic chloroquine 250 mg medicine 8 capital rocka, active systemic infection, active and cannulas are placed into the body with power malignancy or history of malignancy with pro- supply and driving unit being still extracorporeal, bability of recurrence, or inability to comply with and external devices, where the only implantable 14 complex medical regimen. In a few cases, these components are the pump infow and outfow devices can be used as bridges to recovery, such as cannulas. Te duration of use constitutes another in case of acute cardiac failure following cardiac factor to distinguish devices: one can have short- surgery or acute myocarditis infections. As a result of cannulation to the lef atrium is sometimes also the impeller action, the blood leaves the impeller used. Te outlet cannula is commonly sutured to at a higher pressure and velocity than at its the ascending aorta, but the descending aorta or entrance. Te infow is 5 Guarantee continuous operation without cannulated to the lef ventricle and outfow to the maintenance for years (5–10 years). Rotary blood pumps are small in size, which 5 Be small to reduce surgical trauma and allows minimally invasive implantation. Schima operation, which is important for patient quality depends on the interaction between the residual of life. Tey sufer however from a lack of ventricular function, the overall hemodynamics adaptation to changing hemodynamics, which and the pump speed setting. Generally one leads, for example, to pump fow rate decrease in distinguishes between partial support and full response to an increasing arterial pressure or to support. Trombus formation, strokes and toward the aorta, and the aortic valve stays bleeding still remain an issue with these devices, permanently closed (see. In both support types, the fow rate still challenging for coagulation and hemostasis generated by the rotary pump is related to the [3, 4]. Further complications include infections of ventricular and aortic pressures as well as to the the percutaneous driveline. In case of 167 14 Engineering and Clinical Considerations in Rotary Blood Pumps Q, and it is measured in liters per minute (l/min). In this paragraph, a simplifed and which the impeller rotates is referred to as pump graphical analysis of the infuence of these factors speed. It is symbolized by the letter N, and it is on the pump fow rate will be presented. Considering the diferent head will lead, via the pump characteristic for a speeds, one speaks of the pressure-fow-speed given rotational speed, to a pulsatile pattern of the characteristics. For a more unloading of the ventricle since blood is technical description of hydraulic characteristics continuously pumped through the heart cycle and design concepts of centrifugal- and axial-fow (the fow rate is >0). In the rightmost panel (c), the time course diference during systole (Hs) and diastole (Hd) is shown. It is preload and aferload is therefore strictly valid in therefore incorrect to name rotary blood pumps the short time afer the speed change; the later as “nonpulsatile” assist devices. Only in the rare changes can be investigated in a similar manner, case of ventricular fbrillation (no residual however, as it is presented next. Instead Doppler ultrasound can diastolic one, leading to a reduction of the Hs and be used to detect fow in the radial artery when an almost constant Hd (. Also this assumption is strictly valid in three abovementioned variables is considered the short time afer the preload change, and a here; when a decrease occurs, the opposite further analysis can be performed considering changes will take place. Te increase of AoP leads to an increase of and diastolic pressure head are constant too. Te analysis is however similar and Thrombogenicity with just one relevant diference. In this case, the trauma and triggering platelet activation and systolic pump fow rate will have a rather constant coagulation of thrombi. Te In the early developments, spinning disks systolic fow rate will be indeed the intercept of were preferably used to avoid high shear stress the pump characteristic with the x-axis (e. Monitoring using an implantable pump fow Terefore, an ultrashort exposure to high shear rate sensor has been reported in patients . Patient be destroyed per passage) is difcult to measure, monitoring that relies only on available pump and short exposure times at well-defned shear data seems very promising, particularly because would require new test setups, which are not additional sensors are ofen afected by drifs and available yet. Several hemodynamic decades of research, numerical models of blood indices and methods were developed based on trauma are limited in reliability and accuracy available pump signals: a ventricular contractility . A method to evaluate heart rate roughness, and long residence times in stagnation and arrhythmic events (e. To provide thrombogenicity tests for tachycardia or atrial fbrillation) as well as heart pumps and specifc blood pathways, several rate variability  and methods to detect in vitro setups have been developed [13, 14]. All these most critical parts in design, due to their shear methods and indices use either pump fow rate gradient, the generated friction heat, and critical waveform, which can be either measured or location in the center of the rotor in usually low- estimated from pump motor current and speed fow areas. As a potential solution to this issue, , or directly the motor current/speed pumps with either actively controlled magnetic waveforms. Tese and successfully implemented in commercially methods take advantage of the pulsatility in the available devices. In this setting, the pump can be understood as a “turbo A detailed knowledge of the hemodynamic discharger” of the ventricle, which – simply interaction of the pump and the cardiovascular speaking – facilitates ventricular output by system allows one to predict hemodynamic providing pressure work. If the ventricle has some behavior depending on the pump fow rate remaining contractile force or recovers afer waveform and therefore perform patient implant, it can overtake some physiological monitoring using pump data. Tis is especially adaptation by the Starling mechanism still important in rotary blood pumps because of their working against a lower output pressure. Only in patients with completely divided in those which make use of external dysfunctional ventricle such adaptation is sensors and those that rely on assist device motor difcult, with circadian hemodynamic changes parameters to estimate hemodynamic variables that may lead to suction during night and 171 14 Engineering and Clinical Considerations in Rotary Blood Pumps Q Heart rhythm Aortic valve Contractility Pump ﬂow-rate estimated from Relaxation motor current and speed Time Suction. A target desired fow depending on heart rate is possible fow is automatically achieved. This is achieved by automatically a minimal acceptable level, set by the physician, a fail-safe adjusting pump speed. In case of reduced venous return mode is activated to avoid further decrease insufcient supply during the day even at rest intermittent opening of the aortic valve, support . Especially for such weak patients, for early pulsatility of aortic pressure, and provide postoperative recovery, and particularly for myocardial protection or even myocardial activity and exercise, a physiologically adaptive training for recovery, is currently under debate. Te To fulfl these requirements, many algorithms key problem for such algorithms however still is have been described and tested in silico and the lack of reliable, drif-free, durable, and in vitro, but only very few made it into in vivo or biocompatible pressure transducers, which even clinical tests. A physiological control including targets: it should maintain atrial pressure within suction detection and speed based on remaining a physiological range, but at the same time pulsatility and heart rate has been successfully avoid excessive ventricular unloading or suction clinically tested. For details about the controller design a physiological control should allow also and the clinical study, please refer to [34, 35]. J Biomech Eng 137(9): 094501 (10 Pages) pump control activity (“how to prove the innocence 12. Artif Organs patient needs for better life quality related to full 17(7):605–608 participation in life, physical activity, and improved 14. Dimasi A, Rasponi M, Sherif J, Chiu W-C, Bluestein D, usability of ventricular assist systems. Biomed report: risk factor analysis from more than 6,000 Microdevices 14(1):235–245 mechanical circulatory support patients. J Heart Lung monitoring for ambulatory left ventricular assist Transplant Of Publ Int Soc Heart Transplant 33(6):555– device patients. Moscato F, Granegger M, Naiyanetr P, Wieselthaler G, (1970) An efcient, compact blood pump for assisted Schima H (2012) Evaluation of left ventricular circulation.
Regional anesthesia can block part generic 250mg chloroquine fast delivery treatment syphilis, but not all cheap chloroquine 250 mg treatment authorization request, of the metabolic stress response during surgery order chloroquine 250mg on-line medications epilepsy, probably by blockade of the neural communication from the surgical area buy chloroquine 250 mg with visa medicine hunter. Endorphins are a group of endogenous peptides with opioid activity that have been isolated from the central nervous system. Large increases in the central nervous system and plasma concentrations of endorphins in response to emotional or surgical stimuli suggest that these substances play a role in the body’s response to stress. These substances modulate painful stimuli by binding to opiate receptors located throughout the brain and spinal cord. Numerous experiments have focused on the stress response and its relation to the depth of anesthesia. Regional anesthesia and general anesthesia appear to blunt the release of various stress hormones during the period of surgical stimulation in a dose-dependent fashion. Historically, anesthesiologists have relied on the indirect measurement of hemodynamic variables such as blood pressure and heart rate to evaluate the level of autonomic activity in response to anesthesia and surgery. It is assumed that the physiologic manifestations of stress are potentially harmful, especially in patients with limited functional reserve. As such, anesthetic techniques and pain management strategies are designed to limit this neurohormonal response in the hope of providing the patient with some benefit. Further investigations are needed to assess the impact of these efforts on perioperative morbidity and mortality. A Prospective Randomized Controlled Trial of the Laryngeal Mask Airway Versus the Endotracheal Intubation in the Thyroid Surgery: Evaluation of Postoperative Voice, and Laryngopharyngeal Symptom. Anesthetic implications for robot-assisted transaxillary thyroid and parathyroid surgery: a report of twenty cases. Anesthetic considerations and perioperative management of patients with hypothyroidism. The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism. Minimally invasive parathyroidectomy using local anesthesia with intravenous sedation and targeted approaches. Effects of propofol on intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism undergoing parathyroidectomy: a randomized control trial. Glucocorticoid replacement in pituitary surgery: guidelines for perioperative assessment and management. The blocking effect of epidural analgesia on the adrenocortical and hyperglycemic responses to surgery. Perioperative glucocorticoid coverage: a reassessment 41 years after emergence of a problem. Physiological cortisol substitution of long-term steroid-treated patients undergoing major surgery. A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency. Perianesthetic risks and outcomes of pheochromocytoma and paraganglioma resection. The North American Neuroendocrine Tumor Society consensus guideline for the diagnosis and management of neuroendocrine tumors. Sensitivity of diagnostic and localization tests for pheochromocytoma in clinical practice. Pheochromocytoma and paraganglioma: an Endocrine Society clinical practice guideline. Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma. Perioperative management of pheochromocytoma: Focus on magnesium, clevidipine, and vasopressin. The role of hyperglycemia in acute illness: supporting evidence and its limitations. New-onset treatment-dependent diabetes mellitus and hyperlipidemia associated with atypical antipsychotic use in older adults without schizophrenia or bipolar disorder. Reciprocal relationships between insulin resistance and endothelial dysfunction: molecular and pathophysiological mechanisms. Scientific principles and clinical implications of perioperative glucose regulation and control. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Bariatric surgery improves the metabolic profile of morbidly obese patients with type 1 diabetes. Microalbuminuria: marker of vascular dysfunction, risk factor for cardiovascular disease. Not all neuropathy in diabetes is of diabetic etiology: differential diagnosis of diabetic neuropathy. Preoperative autonomic function abnormalities in patients with diabetes mellitus and patients with hypertension. Autonomic reflex dysfunction in patients presenting for elective surgery is associated with hypotension after anesthesia induction. Effect of diabetes mellitus on the cardiovascular responses to induction of anaesthesia and tracheal intubation. Patients with diabetic neuropathy are at risk of a greater intraoperative reduction in core temperature. Recent metformin ingestion does not increase in- hospital morbidity or mortality after cardiac surgery. Guidelines for application of continuous subcutaneous insulin infusion (infusion pump) therapy in the perioperative period. Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society clinical practice guideline. Early post-operative glucose levels are an independent risk factor for infection after peripheral vascular surgery: a retrospective study. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. Peri-operative glucose control and development of surgical wound infections in patients undergoing coronary artery bypass graft. Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery. Reduction of surgical mortality and morbidity in diabetic patients undergoing cardiac surgery with a combined intravenous and subcutaneous insulin glucose management strategy. Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients.
A sterile polyethylene plastic sheet is fenestrated to allow egress of ascites fuid and then spread over the bowel and extending under the abdominal wall laterally to the paracolic gutters cheap chloroquine online visa medicine abuse. A towel is placed over the top of the sheet cheap 250 mg chloroquine fast delivery treatment 3 phases malnourished children, flling the wound and as an additional barrier to bowel protrusion discount chloroquine uk medicine 2. However order chloroquine 250 mg with mastercard treatment coordinator, in the scenario of high risk for ongoing bleeding, the towel is omitted to facilitate direct observation of the peritoneal cavity. Two silastic drains are placed along the wound edges to evacuate the ascites fuid from the wound. These may be tunneled through the skin or laid on top of the skin and brought out at the cephalad aspect of the wound. Finally, the entire wound and a generous margin of skin are covered with an incise drape. We favor an iodophor-impregnated drape that is adhesive and contains some antibacterial properties. The silastic drains are con- nected to bulbs, and the bulbs are connected to continuous wall suction, as ascites is produced at a high level during resuscitation. Iodophor-impregnated incise fascia, exiting toward the drape extends over entire patient’s head opening; Drains placed to wall suction Fig. Ongoing bleeding can be occult, particularly if blood is contained deep within the abdomen and not reaching the drains. Correction of coagulopathy is essential to limit hemorrhage and to restore physio- logic normality prior to returning for defnitive surgery. In other cases, such as when a major liver injury is packed, it may be best to wait longer so that the packs may be removed with less chance of rebleeding. Resuscitation should be targeted at correcting coagulopathy as well as reversing metabolic acidosis. Continued bleeding or failure to correct acidosis may be indi- cators of uncontrolled surgical bleeding or ischemic viscera. Nutritional support should be provided early, and the enteral route is preferred to enhance pro- tein availability. Data from a multicenter prospective cohort study indicate that immediate enteral nutrition after damage control is safe, with no adverse effect on abdominal closure rate . In addition, the investigators found a reduction in pneumonia associated with immediate enteral nutrition, consistent with previous work in injured patients. In order to avoid later complications such as enteroatmospheric fstula, the bowel should be cov- ered by 8 days. Our proposed technique has proven to have a very high fascial clo- sure rate . At the frst reoperation, after defnitive repairs are made, the fascia and skin are closed as long as there is no tension or signifcant increase in abdominal pressure. If complete closure cannot be attained, then negative pressure wound ther- apy is applied with white sponges on the bowel and fascial sutures providing traction (Fig. Plastic adhesive dressing is through the fascia, placed over the white sponge to prevent fascial retraction and adjacent skin. Large black sponges are placed by cutting along the wound edges, on top of the white sponges leaving only that adherent to the skin and plastic-protected skin e 6. Black sponges are affixed with an occlusive dressing and standard suction tubing is placed. Skin is closed over approximated fascia White sponge covers viscera b Skin is closed over approximated fascia Fig. The group from Vanderbilt  found that 25% of patients had wound complica- tions, and only 65% had primary fascial closure. Packing and planned reexploration for hepatic and retroperitoneal hemorrhage: critical refnements of a useful technique. Damage control: an approach for improved survival in exsanguinat- ing penetrating abdominal injury. Avoidance of abdominal compartment syndrome in damage-control laparotomy after trauma. Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients. Effect of immediate enteral feeding on trauma patients with an open abdomen: protection from nosocomial infections. One hundred percent fascial approximation can be achieved in the postinjury open abdomen with a sequential closure protocol. Sartelli (*) Department of Surgery, Macerata Hospital, Macerata, Italy e-mail: massimosartelli@gmail. Pathogenic microbial agents trigger cascades of events in sepsis by stimulating the host’s immune system. Current treatment of severe sepsis involves prompt source control, early appro- priate antimicrobial therapy, and adequate resuscitation. Source control encompasses all measures undertaken to eliminate the source of infection, reduce the bacterial inoculum, and correct or control anatomic derange- ments to restore normal physiologic function. Its timing and adequacy are the most important issues in the management of intra-abdominal infections, because inade- quate and late operation may have a negative effect on the outcome [3, 4]. In certain circumstances, infection not completely controlled may trigger an excessive immune response, and sepsis may progressively evolve. Such patients may beneft from immediate and aggressive surgical treatment with subsequent relaparotomy strategies, to curb the spread of organ dysfunctions caused by ongoing sepsis. In these patients, an early relaparotomy with surgical lavage of the peritoneal cavity and evacuation of toxic content and infammatory cytokines may be crucial for stopping the septic cascade. This allows better control of the local infammatory response and improved outcomes. The abbreviated laparotomy for trauma patients was defned as the initial control of surgical bleeding by simple operative lifesaving techniques. Once the patient had regained their physiologic reserve, defnitive re- exploration and reconstructive surgery was performed with or without fnal abdominal closure. Patients progressing from sepsis to septic shock can present with hypotension and myocardial depression associated with coagulopathy. These patients are 7 Open Abdomen in Patients with Abdominal Sepsis 97 hemodynamically unstable and not optimal candidates for complex operative interventions. Over the following 24–48 h, when abnormal physiology is corrected, the patient can be safely taken back to the operating room for reoperation. Animal models have shown that peritonitis is associated with a signifcant and prolonged peritoneal infammatory response. The levels of selected peritoneal cytokines have been reported to be signifcantly different between animals that sur- vived as compared to those who died following a septic challenge. The reduction of the local infammatory response can be best achieved with mechanical surgical control by reducing the load of cytokines and other infammatory substances and by preventing their production, thus removing the source itself. The fnal decision to perform a reoperation on a patient is based on the patient generalized septic response and on the lack of clinical improvement during early postoperative period [10, 11]. However, these conditions are not well defned  and often relaparotomy may be performed too late.
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