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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Saline versus Metronidazole Peritoneal Lavage in Operated Cases of Peritonitis- A Longitudinal Study
Correspondence Address :
Dr. Nikhil Mahajan,
32, Green Avenue, Opposite Rose Garden, Near Mittal Mall, Bathinda, Punjab, India.
E-mail: nikhilmahajan85@yahoo.co.in
Introduction: Perforation peritonitis is a fairly common surgical problem. Despite recent advances in surgical practice, postoperative minor and major complications are common in patients of peritonitis. Intraoperative peritoneal lavage is an important operative management and the choice of fluid can affect the outcome.
Aim: To compare the outcomes of peritoneal lavage using normal saline versus metronidazole in cases of perforation peritonitis in patients undergoing laparotomy, with respect to surgical site infections, sepsis, wound dehiscence, hospital stay.
Materials and Methods: The present study was a longitudinal study done on 80 patients, divided in two groups with 40 cases in each group. In one group, peritoneal cavity was lavaged with 2 L of normal saline and closed after putting drains. In the other group, peritoneal cavity was lavaged with 2 L normal saline mixed with 100 mL (500 mg) of metronidazole and abdomen was closed in layers after placing two drains, kept closed for one hour after abdominal closure. Chi-square test was used, and p<0.05 was considered as level of significance.
Results: The mean age of patients in metronidazole group was 47.72±15.64 years, and was comparable to mean age 45.92±15.26 years in saline group, difference was not significant (p=0.6039). Male/female in Metronidazole and Saline groups were 31/9 and 30/10, respectively. It was observed that the patients in metronidazole group had less surgical site infections (22.5%) compared to saline group 42.5% (p=0.056), less sepsis (20% vs 62.5%) (p<0.001), less wound dehiscence (5% vs 15%) (p=0.136), and shorter hospital stay with a mean±SD of 9.975±2.25 and 11.82±2.85 days (p=0.0019).
Conclusion: The metronidazole lavage is better than saline lavage. However, larger multicentric randomised controlled trials need to be done.
Hospital stay, Laparotomy, Perforation peritonitis, Postoperative complications, Sepsis
The peritoneum is the most extensive serosal membrane of the body composed of two main segments. One covering the internal surface of the wall of the abdomen, including the diaphragm and pelvis, called the parietal peritoneum, and other covering the surface of intra-abdominal organs, called the visceral peritoneum. The surface area of the peritoneum is nearly 2 m2, which is approximately equal to the area of the skin. The peritoneal cavity normally contains only about 75 mL of fluid to serve as lubrication between abdominal viscera and wall (1).
Peritonitis is an inflammatory response which occurs as a result of infectious, ischaemic and perforating injuries of Gastro-Intestinal Tract (GIT) and genitourinary system. Peritonitis can be: (a) primary peritonitis, when source of peritoneal infection is from outside the peritoneal cavity and the infection is often monomicrobial; (b) secondary peritonitis, when source of infection is intra-abdominal usually a perforated hollow viscous organ; or (c) tertiary peritonitis that develops following treatment of secondary peritonitis (2). The prognosis and outcome of peritonitis depend upon the interaction of many factors including patient-related factors, disease specific factors and diagnostic and therapeutic interventions (3).
After initial resuscitation, the main treatment is explorative laparotomy and correction of underlying cause along with intraperitoneal lavage and drainage (4),(5),(6). Various fluids have been used for lavage. One of them is metronidazole which is an antibiotic and antiprotozoal drug. It inhibits nucleic acid synthesis by disrupting the Deoxyribonucleic Acid (DNA) of microbial cells. There are published studies comparing efficacy of saline, metronidazole, chloramphenicol, cephalosporin and imipenem lavage (7),(8),(9),(10),(11),(12),(13). Bhushan C et al., found significant reduction in sepsis and mortality after antibiotic lavage (9). Other studies found reduction in respect of surgical site infection, sepsis, postoperative abscess formation in antibiotic lavage group compared to saline group, but those differences were not statistically significant (8),(10),(11),(13). Imipenem lavage was found to have statistically significant reduction in wound infection, intra-abdominal abscess, and sepsis compared to saline lavage (12). In view of inconclusive results in the literature, this study was done as an attempt to find if metronidazole lavage offers a significant advantage vs saline lavage in patients of perforation peritonitis undergoing laparotomy in tertiary care hospital.
This was a longitudinal study done on 80 patients (40 in each group)of perforation peritonitis. The study was done at Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India, from November 2018 to December 2019.The ethical approval was obtained from the Institutional Ethical Committee (IEC) vide letter number AU/EC/FM/142/2018.
Eighty patients of perforation peritonitis were divided in two equal groups. One group received metronidazole 100 mL plus 2 L normal saline lavages and the second group received 2 L normal saline lavage. In both groups, drains were kept closed for one hour postoperatively. Results were compared with respect to surgical site infection, intra-abdominal abscess, sepsis, wound dehiscence and hospital stay.
Inclusion criteria: All patients with perforation peritonitis diagnosed and confirmed based on Ultrasound/ Contrast Enhanced Computed Tomography (USG/CECT) abdomen to have pneumoperitoneum and free fluid who underwent laparotomy. All patients who gave written informed consent for enrollment in the study.
Exclusion criteria: Patients who had co-morbid conditions like diabetes, cirrhosis, chronic kidney failure and steroid use.
Patients who visited the study institute with clinical features of peritonitis (such as pain abdomen, distension, vomiting) were clinically examined, and diagnosis was confirmed using erect radiograph of the abdomen with the evidence of the gas under diaphragm in most of the cases. The USG abdomen was done in some cases and in some cases CT of abdomen was done. Routine blood investigations were done as well. Patients were managed with intravenous fluids and antibiotics and optimised for surgery. The condition of the patient and prognosis were explained to the patient and patient relatives in their own language.
Study Procedure
Cases were divided in two groups (alternate patient in the next group)- plain saline lavage group and metronidazole lavage group. Plain saline lavage group received intra-peritoneal lavage with 2 L of normal saline. Metronidazole lavage group received intra-peritoneal lavage using 2 L of normal saline mixed with 100 mL (500 mg) of metronidazole. The lavage was done for 20 minutes and after closure of perforation. Different operators were involved in different cases. Cases were followed-up till the discharge or death of the patient. Postoperative complications were noted. Postoperative hospital stay was noted.
Postoperative course: All patients were given institutional care in the postoperative period. Regular monitoring of vitals and input output was done. Necessary investigations were done and follow-up was done and pain management was also done as well. Patient was encouraged active and passive limb movement and ambulation. Physiotherapy was done for chest and limbs thrice a day. All patients performed monitored incentive spirometry, thrice a day, till their hospital stay in the postoperative period. The antibiotics given postoperatively were the same in all patients (piperacillin/tazobactam 4.5 gm i.v. 8 hrly, amikacin 500 mg i.v. 12 hourly, and metronidazole 500 mg i.v. 8 hourly for seven days).
The wound was primarily dressed with sterile surgical gauze and covered with occlusive adherent bandage. The primary dressing was removed after 48 hours, and daily dressing done with povidone-iodine solution. The wound was inspected and expressed for signs of infection (sinus formation, seroma formation and pus formation any discharge or bleed). Sutures were cut in case of any collection or frank discharge, secondary suturing was done later after the control of infection. Swab cultures were taken in case of any purulent discharge. Drain output was monitored daily 24 hourly for amount and character of the content (serous, purulent, blood). Drain was removed when output was less than 50 mL and serous in nature. Auscultation of abdomen was done for presence of bowel sounds. Auscultation was done over right para-umbilcal region and hearing of bowel sounds for one minute. Stitches were removed on postoperative day 12.
Statistical Analysis
Statistical Analysis was done using Statistical Package for the Social Sciences (SPSS) 24.0. Descriptive and inferential statistics were performed using Chi-square test, and p<0.05 was considered as significant.
Maximum number of cases in both the groups were in the age group <40 years. Mean age in both the groups was comparable (Table/Fig 1).
The most common cause of perforation was ileal perforation (32.6%), followed by gastric perforation (21.3%) and duodenal perforation (12.5%). The cases with rectal perforation were less (1.3%) (Table/Fig 2).
The patients of metronidazole group had a shorter hospital stay as compared to normal saline group, and the difference was significant (Table/Fig 3).
There was a 20% reduction in incidence of surgical site infection in metronidazole group as compared with normal saline group; 5% reduction was seen in incidence of intra-abdominal abscess in metronidazole group as compared with normal saline group.Incidence of sepsis was higher in normal saline lavage group. Incidence of mortality and wound dehiscence was also higher in normal saline lavage group (Table/Fig 4).
Perforation peritonitis is a common surgical emergency. Despite all advances in surgical field these patients still have a significant post operative complication rate contributing to morbidity and mortality.Peritoneal lavage is essential step in surgery for perforation peritonitis. Choice of fluid used for lavage can have an effect on postoperative complications. In this study, mean age of patients were 46.82±15 years. Majority of the patients were male. Ileal perforation was the leading cause of peritonitis followed by gastic perforation and dudonal perforation. All patients had perforation peritonitis and received either saline or saline +metroindazole lavage. Metroindazole lavage proved better in all aspects however difference was found to be statistically significant in sepsis and shorter hospital stay.
Bhushan C et al., also found significant reduction in mortality in antibiotic lavage group (9). Sulli D and Rao MS reported a decreased incidence of infection sepsis hospital stay and mortality in metronidazole group, but the difference was not statistically significant for any parameter (10). Choudhary V and Dhankar AA found reduction in wound infection, sepsis, abscess formation and mortality in metronidazole group vs saline group but the difference was not statistically significant (11). Santosh CS et al., compared imipenem with saline lavage and found statistically significant reduction in wound infection intra-abdominal abscess, sepsis and mortality in imipenem group (12).
Surgical site infection: In this study, there was 20% reduction in incidence of wound infection in metroindazole group, however the difference was not statistically significant (p=0.056). On reviewing the published studies, superoxidised solution lavage did not offer any advantage over normal saline lavage. While metronidazole lavage has been found to reduce wound infection more than povidine-iodine and normal saline lavage. Best results have been obtained with imipenem lavage (33% reduction in wound infection and difference statistically significant) (12).
Intra-abdominal abscess: There was 5% reduction in incidence of postoperative intra-abdominal abscess in metronidazole group, however, it was not statistically significant (p=0.456). In previous studies also, no significant difference were found with superoxidised solution lavage, metronidazole lavage, povidine-iodine lavage. The only drug which showed significant reduction in intraperitoneal abscess formation was imipenem lavage (12).
Sepsis: There was 42.5% reduction in sepsis in metronidazole group which was statistically significant (p<0.001). In other studies when metronidazole lavage was compared with normal saline lavage, there was reduction in sepsis, but when metronidazole lavage was compared with povidine-iodine lavage, no significant reduction in sepsis was found (14),(15),(16). Imipenem lavage was the best, with 23.3% reduction in sepsis and difference was statistically significant (12). Table/Fig-5 (10),(11),(12), (14),(15),(16),(17), shows the comparison of different parameters in present study with other studies (10),(11),(12),(14),(15),(16),(17).
Hospital stay: In this study, there was shorter hospital stay in metronidazole group, and the difference was statistically significant (p=0.0019). Similarly, Schein M et al., also reported a lesser hospital stay (10 days) in chloramphenicol lavage group than in saline group (13 days) (8).
Limitation(s)
The surgeries were not performed by a single surgeon hence operator bias was a limitation of the study.
As per this study, peritonitis was most common in middle age group (31-40 years). The majority of the patients were male. Ileal perforation and duodenal perforation were the leading causes. Primary closure of perforation with peritoneal is main treatment. Metronidazole based lavage is definitely better than saline lavage and the difference is statistically significant in respect of sepsis and hospital stay. However, larger multicentric randomised controlled trials should be done to further establish this.
DOI: 10.7860/JCDR/2022/53422.16058
Date of Submission: Nov 25, 2021
Date of Peer Review: Jan 11, 2022
Date of Acceptance: Feb 12, 2022
Date of Publishing: Mar 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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