Peritonitis Priorities

Paul Finan

Department of Colorectal SurgeryLeeds General Infirmary

PeritonitisClassification

• Primary - often spontaneous and single organism

• Secondary - multiple organisms, perforations, leaks, ischaemia etc

• Tertiary - no organisms, disturbance in host immune response

Priorities in PeritonitisEarly Recognition

• Often classical clinical picture but….

• Beware of immuno-suppressed patients

• Elderly patients

• Post-operative patients with cardiac problems

• Unexplained failure to progress clinically

Peritonitis PrioritiesRadiological Support

• Plain films e.g. free gas or unexplained ileus

• Abdominal ultrasound – simple collections

• CT scanning – of particular value in the post-operative patient

• Labelled white cell scans

• MR imaging – no experience

Peritonitis on CT Scanning

Peritonitis Priorities

Radiologist

Microbiologist

Anaesthetist

Nursing Staff Surgical Staff

Wound Care Specialists

Nutritional Team

Scoring Systems

Scoring Systems

An effort to quantify case mix and so estimate outcome

• APACHE – initially 34 variables

• APACHE II – reduced to 12 variables

• Sepsis Score (SS)

• Sepsis Severity Score (SSS)

Relationship Between APACHE-IIand Mortality

Prognostic Scoring Systems in Peritonitis

Comparison of APACHE II, APS, SSS, MOF and MPI, in 50 patients with peritonitis

• All scoring systems predicted outcome in univariate analysis

• APACHE II and MPI contributed independently in a multivariate analysis

• All patients with an APACHE II of >20 or MPI >27 died in hospital

Bosscha et al 1997

Peritonitis Priorities

Source ControlSource Control Damage Limitation

Source Control

• Drainage of abscesses

• Debridement of devitalised tissue

• Diversion, repair or excision of focus of infection from a hollow viscus

Source ControlDrainage of abscesses

Surgical or non-surgical drainage governed by..

• Clinical state of patient

• Site of collection

• Extent of collection

• Underlying aetiology

Diverticular Abscess

Drainage of Diverticular Abscess

Drainage of Diverticular Abscess

Non-surgical Drainage of Intra-abdominal Abscesses

A study of PCD in 96 patients with 137 abscesses accumulated over a 3-year period

• Successful resolution in 70% after a single procedure and 82% with a second drainage

• More often successful in post-operative abscesses.

• Poorer results with pancreatic abscesses and those containing yeasts

Cinat et al 2002

Non-surgical drainage of Intra-abdominal Abscesses

A study of 75 patients undergoing PCD of intra-abdominal abscess

• Successful treatment in 62/75 patients (83%)• Success associated with unilocular collections,

<200 mls., APACHE score <30 and accessible regions

Betsch et al 2002

Pancreatic Collection

Pancreatic Drainage

Source ControlDebridement of Devascularised Tissue

• Most commonly encountered in necrotic pancreatitis

• Removal of dead bowel

• Debridement of other necrotic intra-abdominal tissue

Source ControlManagement of the Source of Contamination

• Excision – appendicitis, cholecystitis

• Repair – perforated ulcer, early iatrogenic injury

• Diversion +/- excision – leaking anastamosis

NB These are the decisions that require experience

Damage Limitation

• Procedures at the time of surgery

• Decisions in the post-operative period

Peritoneal Lavage

Damage LimitationDecisions at the time of Surgery

• Management of the infective source

• Peritoneal toilet and removal of particulate matter

• Peritoneal lavage

• Drains

• Wound closure

VAC Dressing

Damage LimitationPost-operative Decisions

• Re-laparotomy

• Laparostomy

• Interval imaging

• Duration of antibiotic therapy

Re-laparotomy in Peritonitis

• Failure to progress clinically

• Prompted by radiological imaging

• Where viability is in doubt

• Failure to control source of infection

Relaparotomy for Secondary Peritonitis

Meta-analysis comparing planned relaparotomy and laparotomy on demand

• No randomised studies

• Non-significant reduction in mortality with the latter approach

• Evidence based on eight heterogeneous studies

Lamme et al 2002

Laparostomy

Abdominal wall cannot or should not be closed

• Major loss of the abdominal wall• Visceral or retroperitoneal oedema• If decision has already been taken to

perform a re-laparotomy• Likelihood of creating abdominal

compartment syndrome

Peritonitis Priorities

Radiologist

Microbiologist

Anaesthetist

Nursing Staff Surgical Staff

Wound Care Specialists

Nutritional Team

Antibiotics in Peritonitis

• Consideration to source of infection and likely bacteria

• Fewer drugs for shorter periods of time

• A policy of reculture and change if necessary

• No clear benefit of a particular regimen in the Cochrane review (Wong et al 2005)

Peritonitis PrioritiesConclusions

• Multi-disciplinary approach

• Increasing role of the radiologist

• Emphasis on source control

• Need for correct decision at time of laparotomy

• Lack of trial evidence