Bas Lamme

Variables associated with positive findings at relaparotomy in patients with secondary peritonitis.

Objective:The decision whether and when to perform a relaparotomy in secondary peritonitis is largely subjective and based on professional experience. No existing scoring system aids in this decisional process. Our aim was to search for variables that could predict positive findings at relaparotomy. Design:Retrospective, clinical study. Setting:Tertiary university hospital. Patients:Two hundred and nineteen patients of a consecutive series who underwent an emergency laparotomy for secondary peritonitis. Interventions:None. Sequential prediction models were constructed by accumulation of clinical information in chronological order using logistic regression to determine the strength of association between predictive variables and positive findings at relaparotomy outcome. Positive findings were defined as persistent peritonitis or a new infectious focus at relaparotomy. Measurements and Main Results:Relaparotomy (planned or on demand) for secondary peritonitis was performed in 117 of 219 patients (53%), yielding either positive (n = 62) or negative (n = 55) findings. Discriminatory power for positive findings at relaparotomy improved in the successive (multivariate) models: general patient characteristics (area under the curve, 0.60; 95% confidence interval, 0.52–0.68), adding peritonitis-related variables (area under the curve, 0.73; 95% confidence interval, 0.66–0.80), adding operation-related variables (area under the curve, 0.74; 95% confidence interval, 0.67–0.81), and adding postoperative variables (area under the curve, 0.87; 95% confidence interval, 0.82–0.92). Bootstrap resampling reduced the areas under the curve of the subsequent models only slightly. Sensitivity and specificity of the final model were 82% and 76%, respectively, at a total error rate of 16%. One preoperative predictor and five postoperative predictors significantly increased the need for relaparotomy: younger age, decreased hemoglobin levels, temperature >39°C, lower Pao2/Fio2 ratio, increased heart rate, and increased sodium levels. Conclusions:These data suggest that the causes of secondary peritonitis and findings at emergency laparotomy for peritonitis are poor indicators for whether patients will need a relaparotomy. Factors indicative of progressive or persistent organ failure during early postoperative follow-up are the best indicators for ongoing infection and associated positive findings at relaparotomy.

Clinical Predictors of Ongoing Infection in Secondary Peritonitis: Systematic Review

IntroductionThe decision to perform a relaparotomy in patients with secondary peritonitis is based on “clinical judgment” with inherent variability among surgeons. Our objective was to review the literature on prognostic variables for ongoing abdominal infection. Predictive variables for positive findings at relaparotomy can generate more objective criteria to support the decision whether to perform a relaparotomy in patients with secondary peritonitis.MethodsMultiple databases were searched for studies assessing the prognostic value of clinical variables predicting outcome of relaparotomy or general outcome in patients with secondary peritonitis. Data on the methodologic quality of the study as well as statistical strength of predictors and validity of individual variables were extracted and scored. A cumulative score was calculated from these three scores, and the variables were ranked.ResultsA total of 37 of 197 retrieved articles were included for final assessment. The median score for methodologic quality of individual articles was 36 (range 19–54). After calculation of the combined scores, 76 individual variables (patient, peritonitis, surgery, clinical, and laboratory variables) were identified from which the top 10 were eventually selected. These variables were age, concomitant disease, upper gastrointestinal source of peritonitis, generalized peritonitis, elimination of the focus, bilirubin, creatinine, lactate, PaO2/FiO2 ratio, and albumin. This set of variables proved to be moderately predictive for positive findings during relaparotomy in a retrospective cohort of 219 patients operated on for secondary peritonitis (receiver operator curve 0.75, with 95% confidence interval 0.68–0.82).ConclusionsThis review generated a hierarchy (weighted ranking) of published variables that could play a role in the decision to perform a relaparotomy in patients with secondary peritonitis. The top sixtile of ranked variables (10 variables) showed promising results in the discrimination between patients having a positive and negative relaparotomy when tested on a peritonitis patient database. This ranking of variables provides evidence for potential inclusion of variables in future predictive scores, although improvement in overall predictive strength of a set of variables in such a score is needed.

Failure of available scoring systems to predict ongoing infection in patients with abdominal sepsis after their initial emergency laparotomy

BackgroundTo examine commonly used scoring systems, designed to predict overall outcome in critically ill patients, for their ability to select patients with an abdominal sepsis that have ongoing infection needing relaparotomy.MethodsData from a RCT comparing two surgical strategies was used. The study population consisted of 221 patients at risk for ongoing abdominal infection. The following scoring systems were evaluated with logistic regression analysis for their ability to select patients requiring a relaparotomy: APACHE-II score, SAPS-II, Mannheim Peritonitis Index (MPI), MODS, SOFA score, and the acute part of the APACHE-II score (APS).ResultsThe proportion of patients requiring a relaparotomy was 32% (71/221). Only 2 scores had a discriminatory ability in identifying patients with ongoing infection needing relaparotomy above chance: the APS on day 1 (AUC 0.61; 95%CI 0.52-0.69) and the SOFA score on day 2 (AUC 0.60; 95%CI 0.52-0.69). However, to correctly identify 90% of all patients needing a relaparotomy would require such a low cut-off value that around 80% of all patients identified by these scoring systems would have negative findings at relaparotomy.ConclusionsNone of the widely-used scoring systems to predict overall outcome in critically ill patients are of clinical value for the identification of patients with ongoing infection needing relaparotomy. There is a need to develop more specific tools to assist physicians in their daily monitoring and selection of these patients after the initial emergency laparotomy.Trial registration numberISRCTN: ISRCTN 51729393

Long-term prevalence of post-traumatic stress disorder symptoms in patients after secondary peritonitis

IntroductionThe aim of this study was to determine the long-term prevalence of post-traumatic stress disorder (PTSD) symptomology in patients following secondary peritonitis and to determine whether the prevalence of PTSD-related symptoms differed between patients admitted to the intensive care unit (ICU) and patients admitted only to the surgical ward.MethodA retrospective cohort of consecutive patients treated for secondary peritonitis was sent a postal survey containing a self-report questionnaire, namely the Post-traumatic Stress Syndrome 10-question inventory (PTSS-10). From a database of 278 patients undergoing surgery for secondary peritonitis between 1994 and 2000, 131 patients were long-term survivors (follow-up period at least four years) and were eligible for inclusion in our study, conducted at a tertiary referral hospital in Amsterdam, The Netherlands.ResultsThe response rate was 86%, yielding a cohort of 100 patients; 61% of these patients had been admitted to the ICU. PTSD-related symptoms were found in 24% (95% confidence interval 17% to 33%) of patients when a PTSS-10 score of 35 was chosen as the cutoff, whereas the prevalence of PTSD symptomology when borderline patients scoring 27 points or more were included was 38% (95% confidence interval 29% to 48%). In a multivariate analyses controlling for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of relaparotomies and length of hospital stay, the likelihood of ICU-admitted patients having PTSD symptomology was 4.3 times higher (95% confidence interval 1.11 to 16.5) than patients not admitted to the ICU, using a PTSS-10 score cutoff of 35 or greater. Older patients and males were less likely to report PTSD symptoms.ConclusionNearly a quarter of patients receiving surgical treatment for secondary peritonitis developed PTSD symptoms. Patients admitted to the ICU were at significantly greater risk for having PTSD symptoms after adjusting for baseline differences, in particular age.

The innate immune response to secondary peritonitis.

ABSTRACT Secondary peritonitis continues to cause high morbidity and mortality despite improvements in medical and surgical therapy. This review combines data from published literature, focusing on molecular patterns of inflammation in pathophysiology and prognosis during peritonitis. Orchestration of the innate immune response is essential. To clear the microbial infection, activation and attraction of leukocytes are essential and beneficial, just like the expression of inflammatory cytokines. Exaggeration of these inflammatory systems leads to tissue damage and organ failure. Nonsurvivors have increased proinflammation, complement activation, coagulation, and chemotaxis. In these patients, anti-inflammatory systems are decreased in blood and lungs, whereas the abdominal compartment shows decreased neutrophil activation and decreased or stationary chemokine and cytokine levels. A later down-regulation of proinflammatory mediators with concomitant overexpression of anti-inflammatory mediators leads to immunoparalysis and failure to clear residual bacterial load, resulting in the occurrence of superimposed infections. Thus, in patients with adverse outcome, the inflammatory reaction is no longer contained within the abdomen, and the inflammatory response has shifted to other compartments. For the understanding of the host response to secondary peritonitis, it is essential to realize that the defense systems presumably are expressed differently and, in part, autonomously in different compartments.

Costs of relaparotomy on-demand versus planned relaparotomy in patients with severe peritonitis: an economic evaluation within a randomized controlled trial

IntroductionResults of the first randomized trial comparing on-demand versus planned-relaparotomy strategy in patients with severe peritonitis (RELAP trial) indicated no clear differences in primary outcomes. We now report the full economic evaluation for this trial, including detailed methods, nonmedical costs, further differentiated cost calculations, and robustness of different assumptions in sensitivity analyses.MethodsAn economic evaluation was conducted from a societal perspective alongside a randomized controlled trial in 229 patients with severe secondary peritonitis and an acute physiology and chronic health evaluation (APACHE)-II score ≥11 from two academic and five regional teaching hospitals in the Netherlands. After the index laparotomy, patients were randomly allocated to an on-demand or a planned-relaparotomy strategy. Primary resource-utilization data were used to estimate mean total costs per patient during the index admission and after discharge until 1 year after the index operation. Overall differences in costs between the on-demand relaparotomy strategy and the planned strategy, as well as relative differences across several clinical subgroups, were evaluated.ResultsCosts were substantially lower in the on-demand group (mean, €65,768 versus €83,450 per patient in the planned group; mean absolute difference, €17,682; 95% CI, €5,062 to €29,004). Relative differences in mean total costs per patient (approximately 21%) were robust to various alternative assumptions. Planned relaparotomy consistently generated more costs across the whole range of different courses of disease (quick recovery and few resources used on one end of the spectrum; slow recovery and many resources used on the other end). This difference in costs between the two surgical strategies also did not vary significantly across several clinical subgroups.ConclusionsThe reduction in societal costs renders the on-demand strategy a more-efficient relaparotomy strategy in patients with severe peritonitis. These differences were found across the full range of healthcare resources as well as across patients with different courses of disease.Trial RegistrationISRCTN51729393

Single-drug therapy or selective decontamination of the digestive tract as antifungal prophylaxis in critically ill patients: a systematic review

IntroductionThe objective of this study was to determine and compare the effectiveness of different prophylactic antifungal therapies in critically ill patients on the incidence of yeast colonisation, infection, candidemia, and hospital mortality.MethodsA systematic review was conducted of prospective trials including adult non-neutropenic patients, comparing single-drug antifungal prophylaxis (SAP) or selective decontamination of the digestive tract (SDD) with controls and with each other.ResultsThirty-three studies were included (11 SAP and 22 SDD; 5,529 patients). Compared with control groups, both SAP and SDD reduced the incidence of yeast colonisation (SAP: odds ratio [OR] 0.38, 95% confidence interval [CI] 0.20 to 0.70; SDD: OR 0.12, 95% CI 0.05 to 0.29) and infection (SAP: OR 0.54, 95% CI 0.39 to 0.75; SDD: OR 0.29, 95% CI 0.18 to 0.45). Treatment effects were significantly larger in SDD trials than in SAP trials. The incidence of candidemia was reduced by SAP (OR 0.32, 95% CI 0.12 to 0.82) but not by SDD (OR 0.59, 95% CI 0.25 to 1.40). In-hospital mortality was reduced predominantly by SDD (OR 0.73, 95% CI 0.59 to 0.93, numbers needed to treat 15; SAP: OR 0.80, 95% CI 0.64 to 1.00). Effectiveness of prophylaxis reduced with an increased proportion of included surgical patients.ConclusionAntifungal prophylaxis (SAP or SDD) is effective in reducing yeast colonisation and infections across a range of critically ill patients. Indirect comparisons suggest that SDD is more effective in reducing yeast-related outcomes, except for candidemia.

Survey among Surgeons on Surgical Treatment Strategies for Secondary Peritonitis

Background: There is controversy about performing either a planned relaparotomy (PR) or relaparotomy on demand (ROD) in patients with secondary peritonitis. Subjective factors influencing surgeons in decision making for either surgical treatment strategy have never been studied. Methods: All 858 surgeons of the Association of Surgeons of The Netherlands were sent a survey with 16 case vignettes simulating peritonitis patients and evaluating the preference for PR or ROD. Results: Sixty-two percent of surgeons responded to the survey. Of the returned surveys, 407 were eligible for evaluation. The responding surgeons had a slight overall preference for the ROD strategy, as shown by the mean overall preference score of 5.2 (range 3.54–6.52, with a maximal score of 7). Gastrointestinal surgeons and surgeons working in regional and smaller hospitals were significantly more in favour of a ROD strategy than their counterparts. Factors significantly influencing the preference towards PR were ischaemia as aetiology and performing a primary anastomosis; as for ROD, it was small bowel as focus, local extent of contamination and the question whether abdominal closure was possible. However, there was a considerable variability in treatment decisions by surgeons. Conclusion: The majority of responding surgeons would make a choice for a particular treatment strategy based on peritonitis and surgical treatment characteristics. There was a slight overall preference towards the ROD strategy despite the considerable variability per case vignette.

Decision Making for Relaparotomy in Secondary Peritonitis

Background/Aims: To provide a qualitative ranking of clinical variables by surgeons that influence their decision for reoperation and to evaluate whether these variables are related to positive findings at relaparotomy. Methods: Importance in decision making for relaparotomy was evaluated for 21 factors using a 10-point visual analogue scale (VAS). Variables with median VAS scores >5.0 were labeled ‘important’. Predictive value for positive findings was evaluated by multivariate analysis. Results: The response rate was 64%. For each variable, a wide range of VAS scores was given. Of variables labeled ‘important’, a diffuse extent of abdominal contamination (odds ratio, OR 1.9; 95% CI 0.99–3.8; p = 0.052), localization of the infectious focus (upper gastrointestinal tract including small bowel: OR 2.6, 95% CI 0.98–7.0, p = 0.055; colon: OR 2.4, 95% CI 0.93–6.0, p = 0.071), and both low (<3 × 109/l: OR 4.6, 95% CI 1.3–17, p = 0.021) and high (>20 × 109/l: OR 2.2, 95% CI 1.0–4.9, p = 0.042) leukocyte counts independently predicted positive relaparotomy. As a set, these variables had only moderate predictive accuracy (c-statistic 0.69). Conclusions: There was no consensus among surgeons which variables were important in decision making for relaparotomy. Only three out of ten variables labeled as ‘important’ were indeed independently predictive, but even as a set had only moderate predictive accuracy.

Clinical studies on intra-abdominal hypertension and abdominal compartment syndrome.

A elevation in intra-abdominal pressure (IAP) may result in intra-abdominal hypertension (IAH) or even abdominal compartment syndrome and occurs in a wide variety of critically ill patients. Although recent international consensus definitions and recommendations have helped to define, characterize, and raise awareness of abdominal compartment syndrome, multiple aspects of the diagnosis and treatment remain a subject of discussion. The association between IAP and organ function was described as early as 1876 when the German Wendt reported the association between a high IAP and oliguria. Thereafter, several reports on the effect of increased IAP on different organ systems were made. It was only until 1984 that Kron et al. measured the IAP as a criterion for abdominal decompression. This group was also the first to use the term abdominal compartment syndrome (ACS). Thereafter, the number of publications related to IAH, IAP, and ACS seem to have increased exponentially. This study aimed to analyze the increasing number of publications on the ACS in number, origin, and type of the study and to categorize and discuss the topics and findings of the main clinical studies.