Surgical Options for Severe Peritonitis

Performing a repeat surgery (relaparotomy) for patients with peritonitis only when clinical improvement is lacking may have some advantages compared with having the repeat procedure routinely scheduled after the operation, according to a new study.

Researchers from the Academic Medical Center (Amsterdam, The Netherlands) conducted a randomized trial comparing the on-demand strategy with the planned relaparotomy strategy following initial emergency surgery for patients with severe secondary peritonitis. The clinical trial was conducted at two academic and five regional teaching hospitals in the Netherlands from November 2001 through February 2005. A total of 232 patients (116 on-demand and 116 planned) were included.

The researchers found that there was no significant difference in death and/or peritonitis-related illness within a 12-month follow-up period. A total of 4% of the on-demand patients had relaparotomy vs. 94% of the planned relaparotomy group. Patients in the on-demand group had shorter median (midpoint) intensive care unit (ICU) stays (7 vs. 11 days) and shorter median hospital stays (27 vs. 35 days). The study was published study in the August 22, 2007 issue of the Journal of the American Medical Association (JAMA).

"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 healthcare utilization, including the number of relaparotomies, the use of percutaneous drainage, and hospital and ICU stay,” concluded lead author Oddeke van Ruler, M.D., and colleagues. "Despite a lack of statistically significant improvement in primary clinical outcome, these substantial reductions in healthcare utilization and costs with the on-demand strategy suggest that it may be the preferred strategy.”

Secondary peritonitis has a high rate of death (20-60%), long hospital stays, and a high rate of illness due to the development of sepsis with multiple organ failure. Approximately 12-16% of patients undergoing elective abdominal surgery develop postoperative peritonitis.


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