STAGED ABDOMINAL REPAIR COMPARES FAVORABLY WITH CONVENTIONAL OPERATIVE THERAPY FOR INTRAABDOMINAL INFECTIONS WHEN ADJUSTING FOR PROGNOSTIC FACTORS WITH A LOGISTIC MODEL

Staged abdominal repair (STAR) is a newly developed operative approach for the treatment of diffuse peritonitis. It demands a commitment at the first laparotomy for multiple relaparotomies scheduled at 24-h int ervals. STAR reverses the pathophysiological impact of increased intra -abdominal pressure on pulmonary, renal, cardiovascular, and liver fun ction and peritoneal blood flow. If required, prosthetic devices may b e used to bridge any fascial gap and to accommodate the edematous peri toneum and distended bowels. This minimizes fistula formation and dete rs abdominal fascial retraction, while permitting definitive abdominal fascial closure without evisceration and hernia formation. Since pros pective controlled studies are difficult to perform and are therefore not available, we provide another model to test improvement in outcome following STAR. We stratified 95 patients treated by STAR according t o the APACHE-II score and compared this series with 260 patients with intra-abdominal infections treated by conventional operative managemen t (NON-STAR) and entered into a prospective multicenter observation st udy. Pearson chi-square analysis revealed no significant difference (P = 0.624) between mortality of STAR (24.2%) and NON-STAR (21.8%). The Mann-Whitney U-Test, however, showed a significant difference (P < 0.0 01) between the APACHE-II scores of STAR and NON-STAR, indicating that there might be a difference in mortality when comparing patients at e qual mortality risk. To adjust for the significant differences in prog nostic factors, we used a logistic model with APACHE-II scores as depe ndent variables and introduced a therapeutic categorical variable pair (STAR and NON-STAR) to examine the difference of their respective con tribution to the event rate. A significant difference in the mortality was confirmed in favor of STAR (P = 0.0179), and the logistic equatio n is given by [Log p/1-p -4.14 + (0.193() APACHE-II) + (0.4121(*) OPE RATION)], where OPERATION is +1 for NON-STAR patients and -1 for STAR patients. We conclude that STAR is superior to conventional operative therapy for advanced suppurative peritonitis.