Management of Secondary Peritonitis

Abstract

ObjectiveThe authors review current definition, classification, scoring, microbiology, inflammatory response, and goals of management of secondary peritonitis. Summary Background DataDespite improved diagnostic modalities, potent antibiotics, modern intensive care, and aggressive surgical treatment, up to one third of patients still die of severe secondary peritonitis. Against the background of current understanding of the local and systemic inflammatory response associated with peritonitis, there is growing controversy concerning the optimal antibiotic and operative therapy, intensified by lack of properly conducted randomized studies. In this overview the authors attempt to outline controversies, suggest a practical clinical approach, and highlight issues necessitating further research. MethodThe authors review the literature and report their experience. ResultsThe emerging concepts concerning antibiotic treatment suggest that less-in terms of the number of drugs and the duration of treatment-is better. The classical single operation for peritonitis, which obliterates the source of infection and purges the peritoneal cavity, may be inadequate for severe forms of peritonitis; for the latter, more aggressive surgical techniques are necessary to decompress increased intra-abdominal pressure and prevent or treat persistent and recurrent infection. The widespread acceptance of the more aggressive and demanding surgical methods has been hampered by the lack of randomized trials and reportedly high associated morbidity rates. ConclusionsSepsis represents the host's systemic inflammatory response to bacterial peritonitis. To improve results, both the initiator and the biologic consequences of the peritoneal infective-inflammatory process should be addressed. The initiator may be better controlled in severe forms of peritonitis by aggressive surgical methods, whereas the search for methods to abort its systemic consequences is continuing.Intra-abdominal infections after spontaneous gastro-overview is to present the "state of the art" in the manintestinal perforation and those resulting from injuries agement of secondary peritonitis, to emphasize persistor complicating abdominal operations, still represent the ing controversies, and to identify the gaps in our knowl-"bread and butter" for surgeons. The purpose of this edge that require further study.

Management of Peritonitis in the Critically Ill Patient

“…Almost 80% of cases result from necrosis of the digestive conduit [1][2][3][4]. The perforation of the small intestine caused by the inflammation and necrosis of the intestine, such as in typhoid fever and mesenteric ischemia secondary to the intestinal obstruction, occurs initially as a paralytic ileus, with subsequent progression to necrosis and perforation.…”

“…In some instances of postoperative peritonitis, the anastomosis may be intact; however, the patient may remain sick because of residual peritonitis from diverse causes. Among them is the inadequate drainage of the initial septic focus, in which the surgeon failed to drain completely, or more commonly, the peritoneum does not have the sufficient defense capacity to control the problem [1,2,25].…”

“…Special attention should be given to areas where abscess may form such as the pelvis, the gutters, and the subphrenic spaces. These areas should be carefully exposed and debrided, avoiding bleeding by excessive peeling of the fibrin [1][2][3][4]. Warm saline solution is used until a clear return is obtained.…”

“…Alternatively, a more localized phenomenon in peritonitis is the formation of abscesses, a condition characterized by the isolation and walling off of the infectious process from the rest of abdominal cavity [1][2][3].…”

Tumor Necrosis Factor-Dependent Adhesions as a Major Protective Mechanism Early in Septic Peritonitis in Mice

“…There are controversial opinions as to whether abscesses are favorable or detrimental in bacterial peritonitis (14). At least initially, localization and containment of the bacterial insult within the peritoneal cavity, even with abscess formation as its consequence, might be beneficial to the host (16,29). Besides TNF, interleukin-12 (IL-12) seems to be another cytokine important for formation of protective abscesses, because increased lethality of CLP after IL-12 neutralization was correlated with irregular organization of cecal abscesses (24).…”