Rather than carrying out repeat surgery for patients with severe intra-abdominal inflammation or infection (peritonitis) routinely, it might be better to just have the repeat surgery when clinical improvement is lacking, according to an article published in the
Secondary peritonitis has a death rate of between 20%-60%, patients stay in hospital for a long time and also are much more likely to experience illness due to the development of sepsis with multiple organ failure. About 12%-16% of patients who choose to undergo abdominal surgery develop post-operative peritonitis. The authors wrote “Health care utilization due to secondary peritonitis is extensive, with operations to eliminate the source of infection (laparotomy [surgery involving the intra-abdominal contents]) and multidisciplinary care in the intensive care unit setting.”
The writers also point out that after the initial laparotomy, relaparotomy may be needed to eliminate persistent peritonitis or new infections. “There are 2 widely used relaparotomy strategies: relaparotomy when the patient’s condition demands it (‘on-demand’) and planned relaparotomy. In the planned strategy, a relaparotomy is performed every 36 to 48 hours for inspection, drainage, and peritoneal lavage [flushing out] of the abdominal cavity until findings are negative for ongoing peritonitis.”
Oddeke van Ruler, M.D., the Academic Medical Center, Amsterdam, The Netherlands, and team carried out a randomized trial. On-demand strategy was compared with the planned relaparotomy strategy after initial emergency surgery for patients with severe secondary peritonitis. They carried out the trial at five regional teaching hospitals and two academic hospitals from November 2001 to February 2005. This included 116 on-demand and 116 planned patients – a total of 232.
There was no significant difference in primary end point (death and/or peritonitis-related illness within a 12-month follow-up period; 57 percent on-demand vs. 65 percent planned) or in death alone (29 percent on-demand vs. 36 percent planned) or illness alone (40 percent on-demand vs. 44 percent planned).
42% of the on-demand patients had a relaparotomy, compared to 84% of the planned relaparotomy patients. 31% of first relaparotomies were negative among the on-demand patients, compared to 66% among the planned ones.
The on-demand patients were in intensive care for a shorter time and had 23% lower costs.
The authors wrote “This randomized trial found that compared with planned relaparotomy, the on-demand strategy did not result in statistically significant reductions in the primary outcomes of death or major peritonitis-related morbidity but did result in significant reductions in the secondary outcomes of health care utilization, including the number of relaparotomies, the use of percutaneous drainage, and hospital and ICU stay. Despite a lack of statistically significant improvement in primary clinical outcome, these substantial reductions in health care utilization and costs with the on-demand strategy suggest that it may be the preferred strategy.”
Written by: Christian Nordqvist