An elderly man underwent an elective open left hemicolectomy for a splenic flexure tumour. On day 4 he was admitted to the intensive care due to fevers, fast AF and hypotension. He developed respiratory failure and required intubation. CT abdomen revealed free fluid in the abdomen, and emergency laparotomy found anastomotic breakdown and faecal peritonitis. He was washed out, and had further bowel resection and his abdomen was closed. He developed anuria requiring renal replacement therapy and continued to have persistently raised inflammatory markers. On day 9 he had a further deterioration and repeat CT revealed several large collections. He underwent relook laparotomy and washout, but continued to deteriorate and died 48 hours later.

Do patients with severe secondary peritonitis benefit from on-demand relaparotomy or planned relaparotomy?

David Garry

Abdominal sepsis (secondary peritonitis) is associated with a high mortality rate (20-60%, mean 30%), long hospital stays and high morbidity from sepsis and organ failures. Additionally there is often a resulting considerable long-term morbidity. After the initial laparotomy is performed for treatment and source control further surgery is often needed to treat either persistent peritonitis or a new focus of infection. There are two surgical treatment strategies, planned relaparotomy or relaparotomy when the patients’ clinical condition demands it (on-demand). The planned strategy involves relaparatomy every 36 to 48 hours for inspection, drainage and lavage of the abdominal cavity until the there is no further ongoing peritonitis. This strategy risks unnecessary surgery in critically ill patients. The on-demand strategy restricts relaparotomy to those patients who deteriorate clinically or fail to improve. The risk of a potentially harmful delay in detection of treatable intra-abdominal infectious sources should be avoided by combining clinical criteria, laboratory and radiological results. Additionally, the on-demand strategy allows for consideration of less invasive treatments such as CT guided drainage of abscesses. Both strategies were recently found to be widely used in clinical practice (1,2). A retrospective study of 278 consecutive patients (3) who underwent emergency laparotomy for secondary peritonitis found that the in-hospital and long-term survival rates were higher in patients with secondary peritonitis treated by an on-demand strategy than in patients with disease of comparable severity treated with a planned strategy (in-hospital mortality rate of 21.8 versus 36 per cent, p = 0.016).

The first prospective data was published in 2007 (Comparison of On-Demand vs Planned Relaparotomy Strategy in Patients With Severe Peritonitis (4)). Two hundred and thirty two patients from 7 hospitals with secondary peritonitis and an APACHE score >10 were randomised to one of the two treatment arms. Patients in the planned relaparotomy group had interventions every 36-48 hours after the index laparotomy to inspect, drain and lavage, this sequence was terminated when a macroscopically clean abdomen was found at the discretion of the operating surgeon. The on-demand group had inventions in the presence of clinical deterioration or lack of clinical improvement with a likely intra-abdominal cause. The primary end-point was death, and/or peritonitis-related morbidity within a 12-month follow-up period, secondary end points included health care utilization and costs. One hundred and sixteen patients were randomised to each arm. There was no significant difference in primary end point (57% on-demand vs 65% planned; p = 0.25) or in mortality alone (29% on-demand vs 36% planned, p = 0.22) or morbidity alone (40% on-demand vs 44% planned; p = 0.58). A total of 42% of the on-demand patients had a relaparotomy vs 94% of the planned relaparotomy group. A total of 31% of first relaparotomies were negative in the on-demand group vs 66% in the planned group (p <0.001). Patients in the on-demand group had shorter median intensive care unit stays (7 vs 11 days; p = 0.001) and shorter median hospital stays (27 vs 35 days; p = 0.008). Direct medical costs per patient were reduced by 23% using the on-demand strategy. This cost saving is in keeping with a 2012 economic evaluation of the two strategies4 that found a mean cost of 65,738 euros per patient in the on-demand group vs 83450 euros per patient in the planned group. A Cochrane review (5) titled “Planned relaparotomy versus relaparotomy on demand for treatment of secondary peritonitis” is planned (currently at the protocol stage) which may offer further guidance on how to best treat this group of patients.

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Lessons learnt
An on-demand strategy for the surgical management of patients with secondary peritonitis after their index emergency laparotomy does not seem to be associated with morbidity or mortality. It is associated with a substantial reduction in relaparotomy rate and medical costs. A Cochrane review is currently being drafted which should offer additional guidance.

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References

1 Mulier S, Penninckx F, Verwaest C, et al. Factors affecting mortality in generalized postoperative peritonitis: multivariate analysis in 96 patients. World J Surg. 2003; 27(4): 379-384.

2 Rakic M, Popovic D, Rakic M, et al. Comparison of on-demand vs planned relaparotomy for treatment of severe intra-abdominal infections. Croat Med J. 2005; 46(6): 957-963.

3 Lamme B, Boermeester M, Belt E, Van Till J, Gouma D, Obertop H. Mortality and morbidity of planned relaparotomy versus relaparotomy on demand for secondary peritonitis. Br J Surg. 2004 Aug; 91(8): 1046-54

4 Opmeer BC, Boer KR, van Ruler O et al. Costs of relaparotomy on-demand versus planned relaparotomy in patients with severe peritonitis: an economic evaluation within a randomized controlled trial. Crit Care. 2010; 14(3): R97

5 Trastulli S, Cirocchi R, Boselli C, Noya G, Guarino S. Planned relaparotomy versus relaparotomy on demand for treatment of secondary peritonitis. http://summaries.cochrane.org/CD010396/planned-relaparotomy-versus-relaparotomy-on-demand-for-treatment-of-secondary-peritonitis. Accessed 29/05/13

6 Schein M. Surgical management of intra- abdominal infection: is there any evidence? Langen- becks. Arch Surg. 2002; 387(1): 1-7