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Re-operation for complicated secondary peritonitis - how to identify patients at risk for persistent sepsis
1Department of Surgery, University Halle-Wittenberg, Germany. Gresser.holzheimer@t-online.de
Introduction:
There is an ongoing dispute on the benefit of planned relaparotomy for patients with diffuse peritonitis.
Setting:
Surgery Department, university hospital.
Patients:
145 patients with diffuse peritonitis treated with planned relaparotomy were analysed for APACHE II, MOF- and MODS-score (Goris and Marshall), complications, outcome and clinical/laboratory factors indicating intra-abdominal compartment syndrome (positive endexpiratory pressure (PEEP), central venous pressure (CVP), creatinine, blood urea nitrogen (BUN)) after termination of planned relaparotomy. Statistical analysis of data (mean and standard deviation) was performed using Mann-Whitney, chi-square, ANOVA and multiple regression analysis.
Results:
The overall mortality was 29.7% and APACHE II score on admission 16.7 +/- 8.3. In 107 patients (mortality 17.8%) closure of the abdomen was achieved at termination of planned relaparotomy, 20 patients (mortality 30%) were treated with mesh closure and in 18 patients (mortality 100%) closure of the abdomen was not feasible. After closure of the abdomen 39 patients showed signs of persistent sepsis. Patients who were explored had a mortality of 37.5% and without re-exploration a mortality of 67%. BUN, PEEP and CVP were significantly different in survivors and non-survivors. Independent predictors of outcome were closure of the abdomen, complications, APACHE II and MOF scores.
Conclusion:
Patients with planned relaparotomy for diffuse peritonitis are not a uniform group and differ in mortality depending on source control and closure of the abdomen. Patients with persistent sepsis after termination of planned relaparotomy may be recognized by clinical and laboratory parameters and benefit from a timely reexploration. The decision when to close the abdomen may not only be based on intraperitoneal findings but also on the existence and level of organ failure.
Insights
Planned relaparotomy for diffuse peritonitis offers varying outcomes. Abdomen closure and sepsis management are critical for survival, with early re-exploration benefiting some patients.
Area of Science:
- Surgical critical care
- Abdominal surgery
- Peritonitis management
Background:
- Diffuse peritonitis presents challenges in surgical management.
- The efficacy of planned relaparotomy remains debated.
- Identifying prognostic factors is crucial for patient outcomes.
Purpose of the Study:
- To analyze outcomes of planned relaparotomy in diffuse peritonitis.
- To identify factors influencing mortality and morbidity.
- To explore predictors of intra-abdominal compartment syndrome.
Main Methods:
- Retrospective analysis of 145 patients with diffuse peritonitis undergoing planned relaparotomy.
- Assessment of APACHE II, MOF, and MODS scores.
- Evaluation of clinical and laboratory parameters (PEEP, CVP, BUN, creatinine) and their correlation with outcomes.
Main Results:
- Overall mortality was 29.7%.
- Abdomen closure feasibility significantly impacted survival (17.8% mortality with closure vs. 100% with no feasible closure).
- Persistent sepsis occurred in 39 patients; BUN, PEEP, and CVP differed between survivors and non-survivors.
Conclusions:
- Patient outcomes in planned relaparotomy for diffuse peritonitis are heterogeneous.
- Source control and abdominal closure are key determinants of survival.
- Timely re-exploration guided by clinical and laboratory parameters may improve outcomes in persistent sepsis.