Management of postoperative peritonitis after anterior resection - Experience from a referral intensive care unit

Anastomotic leakage is the main cause of death after anterior resection. if it causes a single abscess, it may be successfully cured by percutaneous d rainage, but in case of extensive peritoneal infection (multiple abscesses and generalized peritonitis), it is associated with a 40 to 60 percent mort ality. This study aimed at evaluating aggressive, one-stage surgical manage ment in such cases, METHODS: All patients referred to our surgical intensiv e care unit during the past ten years with generalized, multilocular, intra -abdominal sepsis after anterior resection were reviewed. There were 32 pat ients, with a mean age of 65 years, among which 15 (47 percent) were referr ed from other institutions. The mean Acute Physiology and Chronic Health Ev aluation II score on admission was 18. All patients underwent a laparotomy with complete peritoneal exploration, intraoperative lavage, fecal diversio n, capillary drainage of the pelvis excluding the rectal stump or the leaki ng anastomosis from the peritoneal cavity, and primary closure of the abdom en. A Hartmann's operation was done in 22 cases, and conservation of the an astomosis with proximal colostomy was done in 10 cases. The choice was base d on the size of the leak, the viability of the colon, and the site of the anastomosis. RESULTS: Four patients died (12 percent), and five patients (1 6 percent) had recurrent sepsis. When the anastomosis had been conserved, r estoration of continuity was achieved in all cases. After Hartmann's operat ion 8 patients of 19 survivors kept a permanent stoma; 7 had undergone a lo w anterior resection. CONCLUSIONS: Extensive intra-abdominal infection afte r anterior resection may be efficiently controlled by a surgical approach c ombining peritoneal debridement, fecal diversion, and capillarity drain-age of the pelvis. Intestinal continuity may be restored after diversion stoma or Hartmann's procedure after high anterior resection. This is not the cas e after a Hartmann's operation after a low colorectal anastomosis, and this procedure should be avoided whenever possible.