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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 priorities1
Peritonitis Priorities

Wound Care Specialists

Radiologist

Anaesthetist

Nutritional Team

Nursing Staff

Microbiologist

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


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