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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
  • 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 priorities1
Peritonitis Priorities

Wound Care Specialists



Nutritional Team

Nursing Staff


Surgical Staff

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)
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
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

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
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
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


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



Nutritional Team

Nursing Staff


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