Relaparotomy in peritonitis: Prognosis and treatment of patients with persisting intraabdominal infection

Some patients are prone to persisting intraabdominal infection regardless o f initial eradication of the source of infection. Our aim was to characteri ze patients who had to undergo relaparotomy for persisting abdominal sepsis using simple clinical parameters and to define those patients who are susc eptible to benefit of aggressive surgical treatment by early and repeated r eoperations to control multiple organ dysfunction syndrome (MODS) caused by ongoing intraabdominal infection. Persisting abdominal sepsis was the caus e of death in all of our patients who had to undergo relaparotomy. Controll ing persisting abdominal sepsis should achieve a reduction in the tremendou sly high mortality rate, Performing a case-control study, we retrospectivel y reviewed 523 consecutive patients with secondary peritonitis treated from 1986 to 1996 and focused our attention on 105 patients, in whom standard s urgical treatment of secondary peritonitis failed and who had to undergo re laparotomy for persisting abdominal sepsis (study group). Overall, there wa s no significant difference in the postoperative mortality rate between "pl anned relaparotomy" and "relaparotomy on demand" (54.5% versus 50.6%). Equa lly clear risk estimations were given preoperatively by both the Acute Phys iology and Chronic Health Evaluation (APACHE) II and the Goris scores. Ther e was a significant difference between patients of the control group and pa tients of the study group with regard to preoperative APACHE II score, Gori s score, age >70 years, albumin <30 gn, extent of peritonitis, and outcome (p = 0.0001), Reexploration performed more than 48 hr after the initial ope ration resulted in a significantly higher mortality rate (76.5% versus 28%; p = 0.0001), However, the time of reoperation had no significant impact on survival in patients with an APACHE II score of greater than or equal to 2 6, because physiologic derangement is such that only a few patients could b enefit from reoperation. The lowest mortality rate (9%) was achieved in pat ients who underwent reoperation on demand within 48 hr. We conclude that pa tients >70 years of age with secondary peritonitis extending over the entir e abdomen and a greater degree of physiologic compromise (serum albumin lev els <30 g/L, preoperative APACHE II scores >20, and existing organ failure measured by the Goris score) are at high risk for developing persistent int raabdominal infection. Our data show that timely relaparotomy provides the only surgical option that significantly improves outcome. However, aggressi ve surgical treatment has reached its limit in patients whose source of inf ection could not be controlled at the initial operation. To improve overall survival the decision to perform a relaparotomy on demand after an initial ly successful eradication of the source of infection must be made within 48 hr, at least before MODS emerges.