peritonitis priorities paul finan department of colorectal surgery leeds general infirmary
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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