Cecilia W. Mahler

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.

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.

Health related quality of life six months following surgical treatment for secondary peritonitis – using the EQ-5D questionnaire

BackgroundTo compare health related quality of life (HR-QoL) in patients surgically treated for secondary peritonitis to that of a healthy population. And to prospectively identify factors associated with poorer (lower) HR-QoL.DesignA prospective cohort of secondary peritonitis patients was mailed the EQ-5D and EQ-VAS 6-months following initial laparotomy.SettingMulticenter study in two academic and seven regional teaching hospitals.Patients130 of the 155 eligible patients (84%) responded to the HR-QoL questionnaires.ResultsHR-QoL was significantly worse on all dimensions in peritonitis patients than in a healthy reference population. Peritonitis characteristics at initial presentation were not associated with HR-QoL at six months. A more complicated course of the disease leading to longer hospitalization times and patients with an enterostomy had a negative impact on the mobility (p = 0.02), self-care (p < 0.001) and daily activities: (p = 0.01). In a multivariate analysis for the EQ-VAS every doubling of hospital stay decreases the EQ-VAS by 3.8 points (p = 0.015). Morbidity during the six-month follow-up was not found to be predictive for the EQ-5D or EQ-VAS.ConclusionSix months following initial surgery, patients with secondary peritonitis report more problems in HR-QoL than a healthy reference population. Unfavorable disease characteristics at initial presentation were not predictive for poorer HR-QoL, but a more complicated course of the disease was most predictive of HR-QoL at 6 months.

Relaparotomie bei sekundärer Peritonitis

ZusammenfassungDie sekundäre Peritonitis ist trotz Verbesserungen in antibiotischer Therapie, Intensivmanagement und chirurgischen Verfahren mit einer erheblichen Morbidität und einer anhaltend hohen Mortalität verbunden. Die bezüglich der chirurgischen Vorgehensweise bei sekundärer Peritonitis verfügbare Literatur wurde aus Pub-Med (1966 bis Januar 2005) sowie aus einigen ausgewählten Referenzen der erfassten Literatur recherchiert. Definitionen, Pathophysiologie, die Klassifikation der sekundären Peritonitis und die wissenschaftlichen Grundprinzipien für das chirurgische Vorgehen bei sekundärer Peritonitis werden diskutiert. Ebenso werden historische Entwicklungen sowie die wissenschaftliche Grundlage heute gültiger Relaparotomiestrategien bei sekundärer Peritonitis evaluiert: die programmierte Relaparotomie und die Relaparotomie „on demand“. Es werden Kriterien für die Relaparotomie nach der initialen Laparotomie und mögliche zukünftige Forschungsfelder hinsichtlich der Reduktion sowohl der Morbidität als auch der Mortalität diskutiert. Die Behandlung von Patienten mit sekundärer Peritonitis entwickelt sich von einer chirurgischen Disziplin zu einer multidisziplinären Aufgabe, welche sowohl Chirurgen, Intensivmediziner als auch Radiologen und Mikrobiologen gleichermaßen einbezieht. Die Forschung muss auf neue Bereiche ausgeweitet werden, um Morbidität und Mortalität weiter senken zu können.AbstractSecondary peritonitis is associated with serious morbidity and a persistent high mortality in recent decades, this despite improvement in antibiotic, intensive care and surgical treatment. The available literature regarding the surgical treatment of secondary peritonitis was searched through Pubmed (1966- January 2005) as well as a hand search of references of retrieved articles. Definitions, pathophysiology and classification of secondary peritonitis are discussed, as well as the scientific rationale for the surgical treatment in secondary peritonitis. The historical development and the scientific foundation of present-day relaparotomy strategies in secondary peritonitis are evaluated, with an emphasis on two frequently applied surgical treatment strategies: planned relaparotomy and relaparotomy on demand. Criteria for relaparotomy after the initial laparotomy and potential areas for further research to reduce both morbidity and mortality are discussed. Furthermore, the care of patients with secondary peritonitis is evolving from a surgical entity to a more multidisciplinary challenge uniting surgeons, intensivists, radiologists and microbiologists. Research needs to be expanded into novel fields to further decrease morbidity and mortality.

Relaparotomie bei sekundärer Peritonitis@@@Relaparotomy in secondary peritonitis: Programmierte Relaparotomie oder Relaparotomie „on demand“?@@@Planned relaparotomy or relaparotomy on demand?

ZusammenfassungDie sekundäre Peritonitis ist trotz Verbesserungen in antibiotischer Therapie, Intensivmanagement und chirurgischen Verfahren mit einer erheblichen Morbidität und einer anhaltend hohen Mortalität verbunden. Die bezüglich der chirurgischen Vorgehensweise bei sekundärer Peritonitis verfügbare Literatur wurde aus Pub-Med (1966 bis Januar 2005) sowie aus einigen ausgewählten Referenzen der erfassten Literatur recherchiert. Definitionen, Pathophysiologie, die Klassifikation der sekundären Peritonitis und die wissenschaftlichen Grundprinzipien für das chirurgische Vorgehen bei sekundärer Peritonitis werden diskutiert. Ebenso werden historische Entwicklungen sowie die wissenschaftliche Grundlage heute gültiger Relaparotomiestrategien bei sekundärer Peritonitis evaluiert: die programmierte Relaparotomie und die Relaparotomie „on demand“. Es werden Kriterien für die Relaparotomie nach der initialen Laparotomie und mögliche zukünftige Forschungsfelder hinsichtlich der Reduktion sowohl der Morbidität als auch der Mortalität diskutiert. Die Behandlung von Patienten mit sekundärer Peritonitis entwickelt sich von einer chirurgischen Disziplin zu einer multidisziplinären Aufgabe, welche sowohl Chirurgen, Intensivmediziner als auch Radiologen und Mikrobiologen gleichermaßen einbezieht. Die Forschung muss auf neue Bereiche ausgeweitet werden, um Morbidität und Mortalität weiter senken zu können.AbstractSecondary peritonitis is associated with serious morbidity and a persistent high mortality in recent decades, this despite improvement in antibiotic, intensive care and surgical treatment. The available literature regarding the surgical treatment of secondary peritonitis was searched through Pubmed (1966- January 2005) as well as a hand search of references of retrieved articles. Definitions, pathophysiology and classification of secondary peritonitis are discussed, as well as the scientific rationale for the surgical treatment in secondary peritonitis. The historical development and the scientific foundation of present-day relaparotomy strategies in secondary peritonitis are evaluated, with an emphasis on two frequently applied surgical treatment strategies: planned relaparotomy and relaparotomy on demand. Criteria for relaparotomy after the initial laparotomy and potential areas for further research to reduce both morbidity and mortality are discussed. Furthermore, the care of patients with secondary peritonitis is evolving from a surgical entity to a more multidisciplinary challenge uniting surgeons, intensivists, radiologists and microbiologists. Research needs to be expanded into novel fields to further decrease morbidity and mortality.