Background: The preferred surgical treatment strategy of secondary peritonitis is still an unresolved issue. In similar clinical situations, some surgeons perform a planned relaparotomy after 1 or 2 days, while others only perform a relaparotomy when the patient deteriorates or shows lack of improvement (i.e., on demand). Opponents of planned relaparotomy argue that multiple laparotomies for peritoneal lavage do not change the course of disease and may even be harmful. Opponents of relaparotomy on demand argue that this strategy introduces a delay harbouring the risk that the patient has reached a 'point of no return'. There are insufficient data to indicate which policy indeed contributes to recovery and survival. We addressed this dilemma in our own series.
Methods: The clinical data of 278 consecutive patients who received an emergency laparotomy for secondary peritonitis between 1994 and 1999 in our hospital were examined retrospectively. Based upon the decision made during the first (index)laparotomy whether or not to perform a relaparotomy ('wait and see' or 'planned'), patients' outcome was analyzed. In addition, all patients receiving at least one relaparotomy for peritonitis (n=170) were analyzed by comparison of planned relaparotomy (PR, n=81) and relaparotomy on demand (OD, n=89).
Results: Overall, mortality increased with an increasing number of relaparotomies (p<0.01). When all 278 patients were considered, the mortality rate of the 'wait and see' group (n=197) was 21.8% compared to 35.8% in the planned relaparotomy group (p=0.01, logrank). Admission APACHE II scores of these groups were 10.7 (0-30) and 11.7 (2-28), respectively (p=n.s.). For the 170 patients who received at least 1 relaparotomy, the mortality rates were 30.3% in the OD group and 35.8% in the PR group (p=n.s.). APACHE II scores on admission were comparable between the OD and PR groups. Mechanical ventilation and ICU-stay were slightly longer in the OD group (17.9 and 21.4 days, resp.) compared to the PR group (13.8 and 17.8 days, resp.; p=n.s.). A significantly longer hospital stay was found for the OD group (60.4 vs 45.9 days, p=0.04).
Conclusions: Our data indicated that in patients with secondary peritonitis, mortality increased with the number of relaparotomies. In 278 patients, a higher mortality was found when a planned relaparotomy strategy was applied, even though APACHE II scores were comparable. However, when comparing 170 patients with at least 1 relaparotomy, an on demand strategy resulted in a longer ICU- and hospital stay.