Relaparotomy in Peritonitis: Prognosis and Treatment of Patients with Persisting Intraabdominal Infection

Abstract

Some patients are prone to persisting intraabdominal infection regardless of initial eradication of the source of infection. Our aim was to characterize patients who had to undergo relaparotomy for persisting abdominal sepsis using simple clinical parameters and to define those patients who are susceptible to benefit of aggressive surgical treatment by early and repeated reoperations to control multiple organ dysfunction syndrome (MODS) caused by ongoing intraabdominal infection. Persisting abdominal sepsis was the cause of death in all of our patients who had to undergo relaparotomy. Controlling persisting abdominal sepsis should achieve a reduction in the tremendously high mortality rate. Performing a case-control study, we retrospectively reviewed 523 consecutive patients with secondary peritonitis treated from 1986 to 1996 and focused our attention on 105 patients, in whom standard surgical treatment of secondary peritonitis failed and who had to undergo relaparotomy for persisting abdominal sepsis (study group). Overall, there was no significant difference in the postoperative mortality rate between "planned relaparotomy" and "relaparotomy on demand" (54.5% versus 50. 6%). Equally clear risk estimations were given preoperatively by both the Acute Physiology and Chronic Health Evaluation (APACHE) II and the Goris scores. There was a significant difference between patients of the control group and patients of the study group with regard to preoperative APACHE II score, Goris score, age >70 years, albumin <30 g/L, extent of peritonitis, and outcome (p = 0.0001). Reexploration performed more than 48 hr after the initial operation resulted in a significantly higher mortality rate (76.5% versus 28%; p = 0.0001). However, the time of reoperation had no significant impact on survival in patients with an APACHE II score of > or = 26, because physiologic derangement is such that only a few patients could benefit from reoperation. The lowest mortality rate (9%) was achieved in patients who underwent reoperation on demand within 48 hr. We conclude that patients >70 years of age with secondary peritonitis extending over the entire abdomen and a greater degree of physiologic compromise (serum albumin levels <30 g/L, preoperative APACHE II scores >20, and existing organ failure measured by the Goris score) are at high risk for developing persistent intraabdominal infection. Our data show that timely relaparotomy provides the only surgical option that significantly improves outcome. However, aggressive surgical treatment has reached its limit in patients whose source of infection could not be controlled at the initial operation. To improve overall survival the decision to perform a relaparotomy on demand after an initially successful eradication of the source of infection must be made within 48 hr, at least before MODS emerges.

A comparative study between Mannheim peritonitis index and APACHE II in predicting the outcome in patients of peritonitis due to hollow viscous perforation

“…13,14 In actual MPI score predicts higher mortality rate (26%) in both survivors as well as in non survivors as compared to APACHE II score (15% A prediction accuracy of 84-90% has been reported for APACHE in the previous studies. [15][16][17] Dino et al in their study had reported sensitivity, specificity, positive predictive value and negative predictive value of APACHE as 82.5%, 54.7%, 82.8%, 66% respectively. In present study APACHE II is more specific than MPI in prediction of mortality.…”

Prediction for a planned relaparotomy in secondary peritonitis

“…Some studies comparing the two strategies in patients with secondary peritonitis revealed a significant advantage for patients treated by the on demand strategy as measured by mortality and complication rate [2,5,21,23]. Exceptions include patients with intestinal ischemia, advanced tertiary peritonitis, infected ascites, or those who need to have a reestablishment of intestinal continuity at a second operation [8].…”

Management of Peritonitis in the Critically Ill Patient

“…The surgeon should make the diagnosis within the first 48 hours after any of these nonspecific findings occur and avoid waiting until the fifth or seventh postoperative day, even though some authors suggest that anastomotic failure or leaks may take that long to manifest themselves. Koperna and Schulz [86] showed that patients reoperated after 48 hours had mortality significantly higher than those operated earlier (76.5% versus 28%; P = .001); however, the timing of the relaparotomy did not have any repercussion on survival in those patients who had an acute physiology and chronic health (APACHE) II score greater than 26. This finding suggested that under these circumstances of severely impaired physiology the early operation had little effect.…”