Circulating Mediators and Organ Function in Patients Undergoing Planned Relaparotomy vs Conventional Surgical Therapy in Severe Secondary Peritonitis

Abstract

Hypothesis: Planned relaparotomy (PRL) has been suggested to have detrimental effects on the systemic activation of inflammation mediators, thereby enhancing organ dysfunctions as assessed by clinical scores in secondary peritonitis.Design: Prospective, nonrandomized control trial.Setting: Intensive care units of an urban and a university teaching hospital.Patients: Twenty-nine patients with secondary peritonitis.Interventions: Of the 29 patients with comparable initial peritonitis conditions, 11 underwent PRL and 18 obtained primary abdominal closure. Blood samples were obtained preoperatively and at 2, 6, 8, 12, 18, 24, 30, 36, 42, and 48 hours after the primary operation, then every 12th hour until day 5 and once daily until day 8. Main Outcome Measures: Quantification of circulating inflammation parameters (coagulation, acute-phase proteins, cytokine system, cell adhesion, opsonization) in correlation with Acute Physiology and Chronic Health Evaluation II, multiple organ failure, and Sepsis-Related Organ Failure Assessment scores.Results: Preoperatively, the patient groups did not differ in mean age, cause of peritonitis, or clinical scores. On average, 5.1 (SEM, ± 0.7; range, 3-11) lavage treatments were performed in the PRL group, with 90% of the procedures executed during the first 6 days. The PRL treatment resulted in a significantly higher need of blood components and an increased inflammation mediator response, especially concerning coagulation factors, proinflammatory cytokines, adhesion molecules, and opsonic parameters. During PRL, clinical score systems showed higher values and a delayed decline compared with primary abdominal closure treatment. Incidence of multiorgan failure, mortality, and the mean intensive care unit hospitalization period were clearly more pronounced in the PRL group. Conclusion:In our pilot study, additional lavage treatment of secondary peritonitis resulted in an enhancement of systemic inflammatory mediator response (in particular interleukin 8), which may contribute to a further impairment of organ function.

Lavage Enhances the Production of Proinflammatory Mediators by Peritoneal Mesothelial Cells in an Experimental Model

“…19 This proinflammatory cytokine response is linked to the upregulation of coagulation factors, adhesion molecules, and opsonic components. 20 These findings are consistent with reports from animal studies. Mice who survived an episode of peritonitis had significantly decreased levels of TNF␣ and IL-6 in blood as well as in the peritoneal cavity, 21 and TNF-deficient mice exhibit significantly improved morbidity and mortality from "multiple organ dysfunction syndrome" induced by the administration of zymosan.…”

Comparison of On-Demand vs Planned Relaparotomy Strategy in Patients With Severe Peritonitis

“…25,26 We also observed that patients treated with the planned strategy had longer ICU stays and had a longer overall hospital stay. The duration of mechanical ventilation was significantly longer for the planned treatment patients.…”

Evaluation of Procalcitonin for Predicting Septic Multiorgan Failure and Overall Prognosis in Secondary Peritonitis

“…[2][3][4] However, repeated or even unnecessary surgical procedures are an additional risk factor for the patient and may further enhance morbidity. [5][6][7] Facing this clinical dilemma, there is major interest in the search for an optimum diagnostic tool for an early, noninvasive, and reliable diagnosis of abdominal infections and sepsis. 8 Clinical scoring systems allow satisfactory prediction of overall prognosis [9][10][11][12][13][14] and are an established means of interinstitutional comparison of patient groups for study purposes.…”