Performing a repeat surgery for patients with peritonitis (severe intra-abdominal inflammation or infection) only when clinical improvement is lacking may have some advantages compared with having the repeat procedure routinely scheduled after the operation, according to a study in the August 22/29 issue of JAMA.
Secondary peritonitis (inflammation involving the tissue that lines the abdominal wall and covers the intra-abdominal organs) has a high rate of death (20 percent-60 percent), long hospital stays, and high rate of illness due to the development of sepsis with multiple organ failure. Approximately 12 percent-16 percent of patients undergoing elective abdominal surgery develop postoperative peritonitis. "Health care utilization due to secondary peritonitis is extensive, with operations to eliminate the source of infection (laparotomy [surgery involving the intra-abdominal contents]) and multidisciplinary care in the intensive care unit setting," the authors write.
The researchers add that after the initial (emergency) laparotomy, relaparotomy may be necessary to eliminate persistent peritonitis or new infections. "There are 2 widely used relaparotomy strategies: relaparotomy when the patient's condition demands it ('on-demand') and planned relaparotomy. ... In the planned strategy, a relaparotomy is performed every 36 to 48 hours for inspection, drainage, and peritoneal lavage [flushing out] of the abdominal cavity until findings are negative for ongoing peritonitis."
Oddeke van Ruler, M.D., of the Academic Medical Center, Amsterdam, and colleagues conducted a randomized trial comparing the on-demand strategy with the planned relaparotomy strategy following initial emergency surgery for patients with severe secondary peritonitis. The clinical trial was conducted at two academic and five regional teaching hospitals in the Netherlands from November 2001 through February 2005. A total of 232 patients (116 on-demand and 116 planned) were included.
The researchers found that there was no significant difference in primary end point (death and/or peritonitis-related illness within a 12-month follow-up period; 57 percent on-demand vs. 65 percent planned) or in death alone (29 percent on-demand vs. 36 percent planned) or illness alone (40 percent on-demand vs. 44 percent planned). A total of 42 percent of the on-demand patients had a relaparotomy vs. 94 percent of the planned relaparotomy group. A total of 31 percent of first relaparotomies were negative in the on-demand group vs. 66 percent were negative in the planned group.
Patients in the on-demand group had shorter median (midpoint) intensive care unit stays (7 vs. 11 days) and shorter median hospital stays (27 vs. 35 days). Direct medical costs per patient were reduced by 23 percent using the on-demand strategy.
"This randomized trial found that compared with planned relaparotomy, the on-demand strategy did not result in statistically significant reductions in the primary outcomes of death or major peritonitis-related morbidity but did result in significant reductions in the secondary outcomes of health care utilization, including the number of relaparotomies, the use of percutaneous drainage, and hospital and ICU stay," the authors write. "Despite a lack of statistically significant improvement in primary clinical outcome, these substantial reductions in health care utilization and costs with the on-demand strategy suggest that it may be the preferred strategy."
Reference: JAMA. 2007;298(8):865-873.
Editorial: Timing of Reoperation for Patients With Severe Peritonitis
In an accompanying editorial, E. Patchen Dellinger, M.D., of the University of Washington School of Medicine, Seattle, writes that this study helps in the decision-making process regarding relaparotomy.
"The trial by van Ruler et al is the best evidence yet that mandatory or scheduled relaparotomy for peritonitis is not helpful except in the obvious settings of patients whose first procedure has resulted in retained surgical packing or because the pathology could not be dealt with completely at the first operation. What surgeons should focus on now is the search for more accurate and sensitive methods to recognize in as timely a manner as possible when a patient will need another intervention. This may include improved understanding of clinical patterns, novel imaging techniques, and possibly new biomarkers. Ultimately, though, the diligent attention of the surgical team to the clinical progress of the patient after laparotomy for peritonitis is currently the most effective management technique."
Reference for first editorial: JAMA. 2007;298(8):923-924.
Editorial: When Not Being Superior May Not Be Good Enough
Farhood Farjah, M.D., M.P.H., and David R. Flum, M.D., M.P.H., of the University of Washington, Seattle, and Contributing Editor, JAMA (Dr. Flum), comment on this trial, which examined superiority.
"Data from the well-designed and conducted superiority trial of van Ruler and colleagues will inform the design of future studies aiming to establish the superiority, inferiority, or noninferiority of on-demand compared with planned relaparotomy. While the negative results of this superiority trial may not be enough to rule out alternative interpretations, the results are consistent with the notion that an on-demand relaparotomy approach may improve outcomes and save health care resources."
Reference for second editorial: JAMA. 2007;298(8):924-925.
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