Which Surgical Strategy in Sepsis from Retro Peritoneal Colic Perforation

Materials and Methods: The study was carried out on 12 patients from January 01.01.2015 to December 31.12.2018 consulting in retrospect the Database and medical records of ‘AOU Policlino University of Catania. Department of Medical Surgical Specialties II. In the selection of patients undergoing surgery for retro peritoneal intestinal perforation n 10 cases affected the colorectal, n 2 ileum cases, Patients n 8 were male, and the remaining 4 cases were female with an average age of 62 years [7-61].


Introduction
In the last decade, attention has been paid to severe abdominal infections which, due to their severity and difficulty in treatment, cause death in 30-60% of cases [1][2][3][4][5][6]. Despite the improvement of diagnostic techniques, selective antimicrobials, and an effective system for monitoring critical parameters, diffuse peritonitis remains a real challenge, due to the complexity and multifactorial nature of the functional deficits that characterize its decoration, both for the different answer that the single organism succeeds in giving to the treatment, the latter peculiarity that determines a difficult one. Framework of safe driving parameters, in the timing and monitoring of the therapeutic treatment as well as of the organism's response to it. the knowledge of the anatomy of the retroperitoneal space constitutes an essential support for the correct diagnostic and therapeutic approach to the infections that develop in it [2][3][4][62][63][64][65]. The pelvic retroperitoneal area is therefore divided into 4 spaces : prevesical (between pubis and bladder), retescerical (between bladder and rectum), presacral (between rectum and sacrum), bilateral perirectal From the etiological point of view, we can distinguish between primitive and secondary forms.
In secondary retroperitoneal infections are due to direct contamination by contiguous structures, mainly due to gastrointestinal diseases (Crohn's disease, diverticulitis, pancreatitis, colon cancer) or renal disease. from post-traumatic pathologies, post-operative infections, iatrogenic maneuvers (eg duodenal perforation during CPRE), coagulopathy or anticoagulant therapy, osteomyelitis. The most commonly isolated germs are Gram negative and anaerobic of gastrointestinal origin, such as E. Coli and Bacteroides Fragilis (1). a bacterial peritonitis,] is evaluated with a currently most used system which is the APACHE II (Acute Physiologic and Chronic Health Score) of Knaus [76][77][78][79] which has a great predictive value. In 1997 Ohmann [1] and Peritonitis Study Group proposed a new prognostic model (Prognostic Peritonitis Model, PPM), in the end identifying patients with an unfavorable outcome and a high risk of infectious complications.
the classification system of the severe forms involves the evaluation of the anatomic-physiological parameters, the extension of the process, the nature of the contamination, highlighting the differences in the charge and in the bacterial contaminant stipe, the presence of associated tissue necrosis, as well as the persistence of a continuous source of contamination. Finally, these data are associated with the evaluation of the nutritional status, the immune status and the time between the pathogenic insult and the therapy.
This complex data acquisition provides the surgeon with the elements to select patients who require more aggressive treatment.
In this article, surgical strategies in abdominal infections due to colonic perforation with sepsis are discussed.   Figure 2) and computed tomography, as well as having a specificity of 77%, a sensitivity of 100% and a diagnostic accuracy around 88% [74], are particularly suitable for the study of retrofascial musculature and the renal compartment (Figures 1 & 2).

Materials and Methods
The information on the morphology and on the relationships with the adjacent structures were fundamental for the planning of the surgical strategy to adopt; of utmost importance was the taking of samples for culture tests, with the consequent administration of targeted antibiotic therapy. magnetic resonance, particularly suitable for studying the bone compartment of the retroperitoneum, was also able to make a differential diagnosis with hematomas ( Figure 3). The objectives of the treatment were:

1)
The cases in which the diagnosis was not possible with less invasive methods or remain doubtful.

2)
The need to obtain a rapid diagnosis (always when this is not possible with non-invasive diagnostic procedures).

3)
When a diagnosis is made there is the possibility of a laparoscopic treatment.

Result
Alongside the known advantages of the minimally invasive approach (20% of cases treated) such as less postoperative pain, shorter hospital stays, less morbidity, in cases of acute abdomen the possibility of avoiding in the first instance the laparotomy, weighed down by of a morbidity that varies from 5 to 22% and the possibility, in the case of conversion, of performing a laparotomy "calibrated" to the clinical picture, in the presence of perforations for more than 24 hours, with a diameter> 1 cm, in addition to a poor performance status and / or hemodynamic instability., were the factors that indicated for an "open" approach (9 cases equal to 80%), "free"

Discussion
The literature data agree in affirming the central role of surgery in the treatment of patients with abdominal sepsis [80][81][82][83][84][85][86], but despite the progress of recent years mortality of these patients it remains unacceptably high (30-60%) and more often than not more surgical interventions aimed at eradicating sepsis are required. The objectives of the surgical treatment are:

a)
The timely diagnosis of sepsis.
b) The identification and elimination of all the collections.

c)
The repair or removal from the peritoneal cavity of the source of contamination.

d)
Closure of the abdominal wall without high tension.

e)
Careful monitoring of any septic persistence or recurrence [87][88][89][7][8][9] The control of the peri-tonal source of contamination is was obtained by the resection of colonic perforation of the interested segment and the creation of an upstream enterostomy (Hartmann's intervention which represents the most rational choice since a primary anastomosis packaged in a septic medium has a high probability of dehiscence [10][11][12][13][14].

Conclusion
In cases of retroperitoneal sepsis, as well as in the adequate