Peritonitis priorities
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Peritonitis Priorities. Paul Finan Department of Colorectal Surgery Leeds General Infirmary. Peritonitis Classification. Primary - often spontaneous and single organism Secondary - multiple organisms, perforations, leaks, ischaemia etc

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Peritonitis priorities

Peritonitis Priorities

Paul Finan

Department of Colorectal Surgery

Leeds General Infirmary


Peritonitis classification

PeritonitisClassification

  • Primary - often spontaneous and single organism

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

  • Tertiary - no organisms, disturbance in host immune response


Priorities in peritonitis early recognition

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 priorities radiological support

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 on CT Scanning


Peritonitis priorities1

Peritonitis Priorities

Wound Care Specialists

Radiologist

Anaesthetist

Nutritional Team

Nursing Staff

Microbiologist

Surgical Staff


Scoring systems

Scoring Systems


Scoring systems1

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 ii and mortality

Relationship Between APACHE-IIand Mortality


Prognostic scoring systems in peritonitis

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 priorities2

Peritonitis Priorities

Source Control

Source Control

Damage Limitation


Source control

Source Control

  • Drainage of abscesses

  • Debridement of devitalised tissue

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


Source control drainage of abscesses

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

Diverticular Abscess


Drainage of diverticular abscess

Drainage of Diverticular Abscess


Drainage of diverticular abscess1

Drainage of Diverticular Abscess


Non surgical drainage of intra abdominal abscesses

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 abscesses1

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 Collection


Pancreatic drainage

Pancreatic Drainage


Source control debridement of devascularised tissue

Source ControlDebridement of Devascularised Tissue

  • Most commonly encountered in necrotic pancreatitis

  • Removal of dead bowel

  • Debridement of other necrotic intra-abdominal tissue


Source control management of the source of contamination

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

Damage Limitation

  • Procedures at the time of surgery

  • Decisions in the post-operative period


Peritoneal lavage

Peritoneal Lavage


Damage limitation decisions at the time of surgery

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

VAC Dressing


Damage limitation post operative decisions

Damage LimitationPost-operative Decisions

  • Re-laparotomy

  • Laparostomy

  • Interval imaging

  • Duration of antibiotic therapy


Re laparotomy in peritonitis

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

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

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 abdominalcompartment syndrome


Peritonitis priorities3

Peritonitis Priorities

Wound Care Specialists

Radiologist

Anaesthetist

Nutritional Team

Nursing Staff

Microbiologist

Surgical Staff


Antibiotics in peritonitis

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 priorities conclusions

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


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