13.04.

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SurgicalApproachtoPeritonitisandAbdominalSepsis:Background,PreoperativePreparation,ConsiderationsforSurgicalManagement

SurgicalApproachtoPeritonitisandAbdominal
Sepsis
Author:RubenPeralta,MD,FACSChiefEditor:JohnGeibel,MD,DSc,MSc,MAmore...
Updated:Jul15,2015

Background
Surgeryremainsacornerstoneofperitonitistreatment.Anyoperationshould
addressthefirsttwoprinciplesofthetreatmentofintraperitonealinfections:
Earlyanddefinitivesourcecontrol
Eliminationofbacteriaandtoxinsfromtheabdominalcavity
Thetimingandadequacyofsurgicalsourcecontrolareparamountconcerns,inthat
animproper,untimely,orincorrectoperationmayhaveanoverwhelminglynegative
effectonoutcome,comparedwithmedicaltherapy.
Theoperativeapproachisdirectedbytheunderlyingdiseaseprocessandthetype
andseverityoftheintraabdominalinfection. [1]Inmanycases,theindicationfor
operativeinterventionwillbeclear,asincasesofperitonitiscausedbyischemic
colitis,arupturedappendix,orcolonicdiverticula.Thesurgeonshouldalwaysstrive
toarriveataspecificdiagnosisanddelineatetheintraabdominalanatomyas
accuratelyaspossiblebeforetheoperation.
Insevereabdominalsepsis,however,delaysinoperativemanagementmayleadto
asignificantlyhigherneedforreoperationandtoworseoutcomesoverallearly
exploration(ie,beforecompletionofdiagnosticstudies)maybeindicated.Surgical
interventionmayincluderesectionofaperforatedviscuswithreanastomosisorthe
creationofafistula.Toreducethebacterialload,lavageoftheabdominalcavityis
performed,withparticularattentiontoareaspronetoabscessformation(eg,
paracolicguttersandthesubphrenicarea). [2]
Laparoscopyisgainingwideracceptanceinthediagnosisandtreatmentof
abdominalinfections.Aswithallindicationsforlaparoscopicsurgery,outcomes
vary,dependingontheskillandexperienceofthelaparoscopicsurgeon.
Initiallaparoscopicexaminationoftheabdomencanassistindeterminationofthe
etiologyofperitonitis(eg,rightlowerquadrantpathologyinfemalepatients).
GotoPeritonitisandAbdominalSepsisforcompleteinformationonthistopic.

PreoperativePreparation
Volumeresuscitationandthepreventionofsecondaryorgansystemdysfunctionare
oftheutmostimportanceinthetreatmentofpatientswithintraabdominal
infections.Dependingontheseverityofthedisease,placementofFoleycatheters
maybeindicatedtomonitorurineoutput.Invasivehemodynamicmonitoringis
warrantedinseverelyillpatientstoguidevolumeresuscitationandinotropic
support.Anyexistingserumelectrolytedisturbancesandcoagulationabnormalities
shouldbecorrectedtotheextentpossiblebeforeanyintervention.
Empiric,broadspectrum,systemicantibiotictherapyshouldbeinitiatedassoonas
thediagnosisofintraabdominalinfectionissuspected,andtherapyshould
subsequentlybetailoredaccordingtotheunderlyingdiseaseprocessandthe
cultureresults.
Becausepatientswithperitonitisoftenhavesevereabdominalpain,adequate
analgesiawithparenteralnarcoticagentsshouldbeprovidedassoonaspossible.
Inthesettingofsignificantnausea,vomiting,orabdominaldistentioncausedby
obstructionorileus,nasogastricdecompressionshouldbeinstitutedassoonas
possible.
Inpatientswithevidenceofsepticshockoralteredmentalstatus,intubationand
ventilatorsupportshouldbeconsideredatanearlystagetopreventfurther
decompensation.
Evenifpatientsdonotappearcriticallyillinitially,arrangingforpostoperative
intensivecaresupportbeforesurgeryisoftenwise,particularlyinpatientsof
advancedageandthosewithsignificantcomorbidities.
Inpatientswithsevereinfectionsandcertaindiseaseprocesses(eg,necrotizing
pancreatitis,bowelischemia),informedconsentshouldincludethepotentialneed
forseveralreoperationsandentericdiversion.Theinvolvedphysiciansandsurgeon
shouldnotdownplaythesignificantmorbiditiesassociatedwithabdominalsepsis
whendiscussingtheseissueswiththepatientorthefamily.

ConsiderationsforSurgicalManagement
Generalprinciplesofoperativeintervention
Adiscussionofthespecificdetailsoftheoperativetreatmentofallthepotential
etiologiesofintraperitonealinfectionsisbeyondthescopeofthisarticle.Certain
principlesalwaysapplytotheperformanceofceliotomiesinpatientswithperitonitis.
Operativetreatmentofperitonitishasthreemaingoals:

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Toeliminatethesourceofcontamination
Toreducethebacterialinoculum
Topreventrecurrentorpersistentsepsis
Averticalmidlineincisionistheincisionofchoiceinmostpatientswithgeneralized
peritonitisbecauseitallowsaccesstotheentireperitonealcavity.Inpatientswith
localizedperitonitis(eg,acuteappendicitis,cholecystitis),anincisiondirectlyover
thesiteofthepathologiccondition(eg,arightlowerquadrantorrightsubcostal
incision)isusuallyadequate.Incaseswheretheetiologyoftheperitonitisis
unclear,initialdiagnosticlaparoscopymaybeuseful.
Theintraabdominalanatomymaybesignificantlydistortedbytherepsenceof
inflammatorymassesandadhesions.Normaltissueplanesandboundariesmaybe
obliterated.Theinflamedorgansareoftenveryfriable,andthesurgeonmust
exercisegreatcautionwhenexploringthepatientwithperitonealinfection.
Hemodynamicinstabilitymayoccuratanytimeduringtreatmentasaconsequence
ofbacteremiaandcytokinerelease.Patientsoftendemonstratesignificantfluid
shiftswiththirdspacing.Swellingofthebowel,retroperitoneum,andabdominal
wallmayprecludesafeabdominalclosureafterprolongedcasesinpatientswhoare
severelyill.
Inflammationcausesregionalhyperemia,andsepsismaycausecoagulationdeficits
andplateletdysfunction,leadingtoincreasedbleeding.Carefuldissectionand
meticuloushemostasisareoftheutmostimportance.
Whenfacedwithextensiveabdominalinflammatorydiseaseandsepticshock,the
surgeonmaybebetteradvisedtodraintheinfectiontemporarily,controlthevisceral
leakquickly(eg,withoversewingorentericdiversion),anddeferanydefinitiverepair
untilafterthepatienthasrecoveredfromtheinitialinsult(ie,adamagecontrol
operation).

Openabdomenvsclosedabdomen
Oneofthecriticaldecisionsinthesurgicaltreatmentofpatientswithsevere
peritonitisconcernswhethertouseanopenabdomenoraclosedabdomen
technique.
Thegoaloftheopenabdomentechniqueistoprovideeasy,directaccesstothe
affectedarea.Sourcecontrolisachievedthroughrepeatedreoperationsorthrough
openpackingoftheabdomen.Thistechniquemaybewellsuitedforinitialdamage
controlinextensiveperitonitis.
Theopenabdomentechniqueshouldalsobeconsideredinpatientswhoareathigh
riskforthedevelopmentofabdominalcompartmentsyndrome(eg,patientswith
intestinaldistention,extensiveabdominalwallandintraabdominalorganedema),
becauseattemptstoperformprimaryfascialclosureundersignificanttensionin
thesecircumstancesareassociatedwithanincreasedincidenceofmultipleorgan
(eg,renalandrespiratory)failure,necrotizingabdominalwallinfections,and
mortality.
Thegoaloftheclosedabdomentechniqueistoprovidedefinitivesurgicaltreatment
attheinitialoperation.Primaryfascialclosureisemployed,andrepeatlaparotomy
isperformedonlywhenclinicallyindicated.

Pancreatitisassociatedperitonitis
Amongthecausesofperitonitis,pancreatitisisuniqueinseveralways.Patients
maypresentwithsignificantabdominalsymptomsandasevere,systemic
inflammatoryresponse,yettheymayhavenoclearorganspecificindicationsfor
emergencyexploration.Notallcasesofsevere(ie,necrotizing)pancreatitisand
peripancreaticfluidcollectionareassociatedwithasuperinfection.
Patientswithpancreatitisassociatedperitonitismaybebestservedbyaperiodof
1224hoursofobservationandintensivemedicalsupport.Deteriorationofthe
patient'sclinicalstatusorthedevelopmentoforganspecificindications(eg,intra
abdominalbleedingorgasforminginfectionofthepancreas)shouldleadtoprompt
operation.
Percutaneoustreatmentisreservedforthemanagementofdefinedperipancreatic
fluidcollectionsinstablepatients.
Pancreaticabscessorinfectedpancreaticnecrosisgenerallyshouldbetreatedwith
surgicaldebridementandrepeatedexploration.

Dehiscence
Ifananastomoticdehiscenceissuspected,percutaneousdrainageisoflimited
value,andthepatientshouldbetreatedsurgically.Theimagebelowdemonstrates
theresultsofanastomoticdehiscencefollowingcoloncancersurgery.

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A48yearoldmanunderwentsuprapubiclaparotomy,righthemicolectomy,andgastroduodenal
resectionforrightcoloncancerinvadingthefirstportionoftheduodenum.Hedeveloped
abdominalpainanddistension.Computedtomography(CT)scanningwasusedtoconfirman
anastomoticdehiscence.FigureAshowsacontrastenhancedscanoftheabdomenandpelvis
thatrevealsmultiplefluidcollections,perihepaticascites,andmildperiportaledema.A
collectionoffluidcontaininganairfluidlevelisvisibleanteriortotheleftlobeoftheliver.A
secondcollectionisanteriortothesplenicflexureofthecolon.InfigureB,athirdfluidcollection
ispresentintheinferioraspectofthelesserspaceandinthetransversemesocolon.FigureC
showsthepelviswithacollectionoffreefluidintherectovesicalpouch.

OpenAbdomenApproach
Secondlooksurgery
Incertainsituations,stagingtheoperativeapproachtointraperitonealinfectionsis
appropriate.Stagingmaybeperformedasascheduledsecondlookoperationor
throughopenmanagement,withorwithouttemporaryclosure(eg,withmeshor
vacuumassistedclosure[VAC]). [3]
Secondlookoperationsmaybeemployedinadamagecontrolfashion.Inthese
cases,thepatientatinitialoperationisseverelyillandunstablefromsepticshock
orcoagulopathy(eg,mediatorliberationordisseminatedintravascularcoagulation).
Thegoaloftheinitialoperationistoprovidepreliminarydrainageandtoremove
obviouslynecrotictissue.Thepatientisthenresuscitatedandstabilizedinan
intensivecareunit(ICU)settingfor2436hoursandreturnedtotheoperatingroom
formoredefinitivedrainageandsourcecontrol.
Inconditionsrelatedtobowelischemia,theinitialoperationaimstoremoveall
franklydevitalizedbowel.Thesecondlookoperationservestoreevaluateforfurther
demarcationanddecisionmakingregardingreanastomosisordiversion.

Closureofabdomen
Temporaryclosureoftheabdomentopreventherniationoftheabdominal
contentsandcontaminationoftheabdominalcavityfromtheoutsidecanbe
achievedbyusinggauzeandlarge,impermeable,selfadhesivemembrane
dressingsmesh(eg,Vicryl,Dexon)nonabsorbablemesh(eg,GORETEX,
polypropylene),withorwithoutzipperorVelcrolikeclosuredevicesandVAC
devices(seeTable1below). [4]Theadvantagesofthismanagementstrategy
includeavoidanceofabdominalcompartmentsyndrome(ACS)andprovisionof
easyaccessforreexploration.Thedisadvantagesincludesignificantdisruptionof
respiratorymechanicsandpotentialcontaminationoftheabdomenwithnosocomial
pathogens.
Table1.OptionsforTemporaryandPermanentClosureAfterCeliotomy(Open
Tableinanewwindow)
Closure
Technique

Description

Advantages

Disadvantages
Difficultto
maintainseal

Inexpensive
Abdominaldressingwithgauze
Selfadhesive andcoverageoftheentirewound
impermeable withimpermeablemembranewith Easy
membranes andwithoutplacementofdrains application
betweenthelayers

Potentiallylarge
volumelosses

Fistula
formation

Rapidlossof
tensilestrength
(inthesettingof
infection)

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Canbe
applied
directlyover
bowel
Vicrylor
Dexonmesh

Suturingofthemeshtothe
fascialedgesdifferentoptionsfor
Allowsfor
dressing
drainageof
peritoneal
fluid

Potentiallylarge
volumelosses

Higher
incidenceof
laterventral
hernia
development

Noreopenand
closeoption

Fistula
formation

Riskof
intestinal
erosionwhen
applieddirectly
overbowel
Goodtensile
strength
Potentiallylarge
volumelosses
Suturingofthemeshtothe
Polypropylene
Allowsfor
fascialedgesdifferentoptionsfor
mesh
drainageof
dressing
peritoneal
fluid

Highriskof
meshinfection

Fistula
formation

Potentialfluid
accumulation
underneaththe
mesh

Goodtensile
strength
GORETEX
mesh

Suturingofthemeshtothe
fascialedgesdifferentoptionsfor
Reopenand
dressing
closeoption

Limitedtissue
integrationand
granulation
tissueformation
overthemesh

Riskofmesh
infection

Fistula
formation

Expensive

Human
acellular
dermis

Suturingofthemeshtothe
fascialedges

Goodtensile
strength

Needs10
minutesof
rehydration

Controlled
drainageof
secretions
Cost
Accelerated
granulation
tissue
formation

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Riskof
intestinal
erosionwhen

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Vacuum
Spongesappliedovermeshand
assisted
attachedtocontrolled,lowlevel
closuredevice suction

applieddirectly
overbowel
Wound
debridement
Fistula
formation
Canremainin
placefor
longerthan
48hours

Goodtensile
strength

Wittmann
patch

Suturingofartificialburr(ie,
Velcro)tofascia,staged
abdominalclosurebyapplication
ofcontrolledtension

Allowsfor
easy
Fistula
reexploration formation
andeventual
primary
fascialclosure

Fordelayedprimaryclosure(permanent),ourexperiencewiththeuseofhuman
acellulardermis(commerciallyknownasAlloDerm)hasbeensatisfactory,though
thisoptionhasthedisadvantageofbeingmoreexpensivethanothers.
AstudybyMutafchiyskietalincluded108patientswithdiffuseperitonitisandopen
abdomenwhoweretreatedeitherwithmeshfoillaparostomywithoutnegative
pressureorwithVAC. [5]TheinvestigatorsfoundVACtobeassociatedwithhigher
overallandlateprimaryfascialclosurerates,alowerincidenceofnecrotising
fasciitis,fewerintraabdominalabscessesandenteroatmosphericfistulas,reduced
overallmortality,andshorterICUandhospitalstays.
Inastudythatinvolved53patientswithperitonitiswhounderwentopenabdomen
management,Willmsetalfoundthatregardlessoftheprocessunderlyingthe
peritonitis,theuseofacombinationofVACandmeshmediatedfascialtraction
wasabletoachievehighratesoffascialclosure. [6]

LaparoscopicApproach
Laparoscopicsurgeryiscommonlyusedinthetreatmentofuncomplicated
appendicitis,thoughinpreliminarystudies,ithasgenerallyyieldedpositive
outcomesforcomplicatedappendicitisaswell. [7]
Forbothcomplicatedanduncomplicatedappendicitis,thelaparoscopicapproachis
associatedwithashorterlengthofhospitalstayandfewerwoundinfectionsthanis
theopenapproach.However,laparoscopicsurgerymaybeassociatedwithahigher
rateofintraabdominalabscess.
Laparoscopicdiagnosisandperitoneallavageinpatientswithperitonitissecondary
todiverticulitishasbeenshowntobesafeandhashelpedtoavoidtheneedfor
colostomyinmanypatientsinsmallclinicaltrials. [8]
Inaprospectivestudycomparinglaparoscopicperitoneallavagetoanopen
Hartmannprocedureforperforateddiverticulitiswithgeneralizedperitonitis,
peritoneallavagewithoutoperativeinterventionwasfoundtobefeasible,witha
comparablemortalityandalowriskofshorttermrecurrence.Successful
laparoscopicrepairofperforatedgastricandduodenalulcershasalsobeen
reported.
Nodefinitiveguidelineshavebeenestablishedregardingtheoptimalselectionof
patientsforsuccessfullaparoscopicrepair.Studieshavebeeninvestigatingscoring
systems(eg,APACHEII,Boeyscore)forpatientriskstratification,inordertoallow
betterselectionofpatientsforlaparoscopicrepair.
Thetreatmentofperihepaticinfectionsviathelaparoscopicapproachhasbeenwell
establishedinacutecholecystitis,wherelaparoscopiccholecystectomyhasbecome
themainstayoftherapy.Primarytreatmentofsubphrenicabscessesand
laparoscopicultrasonographicallyassisteddrainageofpyogenicliverabscesses
havealsobeenperformedsuccessfully.
Individualreportsalsodescribesuccessfuldrainageofperipancreaticfluid
collectionsandcomplicatedintraabdominalabscessesthatarenotamenableto
percutaneousdrainageguidedbyeithercomputedtomography(CT)or
ultrasonography.
Asminimallyinvasiveprocedurescontinuetoadvancetechnologically,useofthese
approachesislikelytoincrease,reducingtheneedfortheopensurgicalapproach
forperitonealabscessdrainage.

MultipleReexplorations
Insevereperitonitis,particularlywhenitincludesextensiveretroperitoneal
involvement(eg,necrotizingpancreatitis),opentreatmentwithrepeatreexploration,
debridement,andintraperitoneallavagehasbeenshowntobeeffective.
Thedecisiontoperformaseriesofreexplorationsmaybemadeduringtheinitial

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surgeryifadditionaldebridementandlavageisneededbeyondthatwhichcanbe
achievedinthefirstprocedure.Indicationsforplannedrepeatlaparotomymay
includefailuretoachieveadequatesourcecontrol,diffusefecalperitonitis,
hemodynamicinstability,andintraabdominalhypertension.
Multiplereoperationsmaybeassociatedwithsignificantrisks,includingthosefrom
asubstantialinflammatoryresponse,fluidandelectrolyteshifts,andhypotension
however,thesemustbebalancedagainsttherisksofpersistentnecroticor
infectiousabdominalfoci.
Theopenabdomentechniqueallowsthoroughdrainageoftheintraabdominal
infection,butthespecificindicationsarenotclearlydefined.Manytrialslackcontrol
groupsorusehistoricalcontrolsoutcomevariables(eg,mortality)areoftennot
specificenough,anddataonresourceusearelimited.
Todate,noconclusivedatasuggestaclearadvantagefortheopenapproach
overtheclosedapproachinthetreatmentofsevereabdominalsepsishowever,in
theauthor'sexperience,boweledemaandsubsequentinflammatorychangeslimit
theuseoftheclosedabdomentechnique.SecondaryACSmayensueifabdominal
closureisperformedbeforetheinflammatoryprocesshasresolved.
Insomecases,stagedoperativeinterventionswillbeplanned.Inothercases,
patientsmaypresentwithcontinuedperitonitisorabscessformationrequiring"on
demand"relaparotomy.
A2004studysuggestedthatthemortalityofondemandlaparotomyishigherfor
thosepatientsreceivinginterventionmorethan48hoursaftertheirindexoperation.

PostoperativeCare
Postoperatively,allpatientsshouldbecloselymonitoredintheappropriateclinical
settingforadequacyofvolumeresuscitation,resolutionorpersistenceofsepsis,
andthedevelopmentoforgansystemfailure.Appropriatesystemicbroadspectrum
antibioticcoveragemustbecontinuedwithoutinterruption,fortheappropriate
amountoftime.
Thepatient'soverallconditionshouldimprovesignificantlyandprogressivelywithin
2472hoursoftheinitialtreatment(asevidencedbyresolutionofthesignsand
symptomsofinfectionandmobilizationofinterstitialfluid).However,thistime
coursemaybeprolongedinpatientswhoarecriticallyillwithsignificantmultiple
organsystemdysfunction.
Alackofimprovementshouldpromptanaggressivesearchforapersistentor
recurrentintraperitonealornewextraperitonealinfectiousfocus.
Allpatientswhoarecriticallyillandpatientswhoarereceivingprolongedantibiotic
therapyareatincreasedriskforthedevelopmentofsecondary,opportunistic
infections(eg,Clostridiumdifficilecolitis,fungalinfections,centralvenouscatheter
infections,andventilatorassociatedpneumonia).Acordingly,theyshouldbeclosely
monitoredforsignsandsymptomsofthesecomplications.
Patientswithsevereabdominalinfectionsdemonstratehigherincidencesoffascial
dehiscenceandincisionalherniadevelopmentnecessitatinglaterreoperation.

SurgicalSiteInfectionandDelayedHealing
Patientsrequiringsurgicalinterventionforperitonitisdemonstrateasignificantly
increasedriskforsurgicalsiteinfection(SSI)andfailedwoundhealingtheyshould
thereforebecloselymonitoredforthesepotentialcomplications.
TheincidenceofSSIincreaseswiththedegreeofcontaminationtherefore,SSI
occursatmuchhigherratesafteroperationsforperitonitisandperitonealabscess
(ie,515%,comparedwith<5%forelectiveabdominaloperationsfornoninfectious
etiologies).
SSImaybeexpectedifthewoundisclosedinthesettingofgrossabdominal
contamination(seeTable2below).Theemploymentofperioperative,systemic
antibioticswoundprotectordevicesandlavageofthewoundattheendoftherapy
donotreliablypreventthiscomplication.Thesewoundsshouldbeleftopenand
shouldbetreatedwithwettodrydressingchangesseveraltimesaday,orVAC
dressingshouldbeapplied.
Table2.WoundClassificationandRiskofSurgicalSiteInfection(OpenTableina
newwindow)
Incidenceof
SurgicalSite
Infection
Classification Examples
(%)

Clean

Electivesurgerywithoutviolationofthegutor
infectedspaces

<2

Clean
contaminated

Electivebowelsurgery(preparedbowel,
mechanicalandantibiotic)

515

Contaminated

Emergencybowelsurgery(unpreparedbowel,
minorspillage),drainageofinfectedspaces

1530

Dirty

Grosslycontaminatedtraumaticwounds,
significantintestinalspillage,grosslyinfectedand
devitalizedtissue(necrotizinginfection)

>30

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Thesamefactorsthatimpairtheclearanceoftheabdominalinfectioncontributeto
increasedproblemsrelatedtowoundhealing(eg,malnutrition,severesepsis,
multipleorgansystemdysfunctions,advancedage,immunosuppression)andshould
beaddressedaggressively.

ContributorInformationandDisclosures
Author
RubenPeralta,MD,FACSProfessorofSurgery,AnesthesiaandEmergencyMedicine,SeniorMedicalAdvisor,
BoardofDirectors,ProgramChiefofTrauma,EmergencyandCriticalCare,ConsultingStaff,ProfessorJuan
BoschTraumaHospital,DominicanRepublic
RubenPeralta,MD,FACSisamemberofthefollowingmedicalsocieties:AmericanAssociationofBlood
Banks,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AssociationforAcademicSurgery,
MassachusettsMedicalSociety,SocietyofCriticalCareMedicine,SocietyofLaparoendoscopicSurgeons,
EasternAssociationfortheSurgeryofTrauma,AmericanCollegeofHealthcareExecutives
Disclosure:Nothingtodisclose.
Coauthor(s)
LenaMNapolitano,MD,FACS,FCCPFCCM,ProfessorofSurgery,UniversityofMichiganSchoolof
MedicineChief,SurgicalCriticalCare,ProgramDirector,SurgicalCriticalCareFellowship,AssociateChair,
DepartmentofSurgery,UniversityofMichiganHealthSystem
LenaMNapolitano,MD,FACS,FCCPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanSocietyforParenteralandEnteralNutrition,CaliforniaProfessionalSocietyontheAbuseofChildren,
EasternAssociationfortheSurgeryofTrauma,AssociationofWomenSurgeons,AmericanAssociationforthe
SurgeryofTrauma,AmericanCollegeofChestPhysicians,AmericanCollegeofCriticalCareMedicine,
AmericanCollegeofPhysicians,AmericanCollegeofSurgeons,AmericanMedicalAssociation,Associationfor
AcademicSurgery,AssociationofVASurgeons,PhiBetaKappa,ShockSociety,SocietyofCriticalCare
Medicine,SocietyofUniversitySurgeons
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
DavidLMorris,MD,PhD,FRACSProfessor,DepartmentofSurgery,StGeorgeHospital,UniversityofNew
SouthWales,Australia
DavidLMorris,MD,PhD,FRACSisamemberofthefollowingmedicalsocieties:BritishSocietyof
Gastroenterology
Disclosure:ReceivednonefromRFAMedicalfordirectorReceivednonefromMRCBiotecfordirector.
ChiefEditor
JohnGeibel,MD,DSc,MSc,MAViceChairandProfessor,DepartmentofSurgery,SectionofGastrointestinal
Medicine,andDepartmentofCellularandMolecularPhysiology,YaleUniversitySchoolofMedicineDirector,
SurgicalResearch,DepartmentofSurgery,YaleNewHavenHospitalAmericanGastroenterologicalAssociation
Fellow
JohnGeibel,MD,DSc,MSc,MAisamemberofthefollowingmedicalsocieties:AmericanGastroenterological
Association,AmericanPhysiologicalSociety,AmericanSocietyofNephrology,AssociationforAcademic
Surgery,InternationalSocietyofNephrology,NewYorkAcademyofSciences,SocietyforSurgeryofthe
AlimentaryTract
Disclosure:ReceivedroyaltyfromAMGENforconsultingReceivedownershipinterestfromArdelyxfor
consulting.
Acknowledgements
TheauthorsandeditorsofMedscapeReferencegratefullyacknowledgethecontributionsofpreviousauthors
ThomasGenuit,MD,MBAandSarahCLangenfeld,MD,tothedevelopmentandwritingofthesourcearticle.

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