Survey among Surgeons on Surgical Treatment Strategies for Secondary Peritonitis

Abstract

Background: There is controversy about performing either a planned relaparotomy (PR) or relaparotomy on demand (ROD) in patients with secondary peritonitis. Subjective factors influencing surgeons in decision making for either surgical treatment strategy have never been studied. Methods: All 858 surgeons of the Association of Surgeons of The Netherlands were sent a survey with 16 case vignettes simulating peritonitis patients and evaluating the preference for PR or ROD. Results: Sixty-two percent of surgeons responded to the survey. Of the returned surveys, 407 were eligible for evaluation. The responding surgeons had a slight overall preference for the ROD strategy, as shown by the mean overall preference score of 5.2 (range 3.54–6.52, with a maximal score of 7). Gastrointestinal surgeons and surgeons working in regional and smaller hospitals were significantly more in favour of a ROD strategy than their counterparts. Factors significantly influencing the preference towards PR were ischaemia as aetiology and performing a primary anastomosis; as for ROD, it was small bowel as focus, local extent of contamination and the question whether abdominal closure was possible. However, there was a considerable variability in treatment decisions by surgeons. Conclusion: The majority of responding surgeons would make a choice for a particular treatment strategy based on peritonitis and surgical treatment characteristics. There was a slight overall preference towards the ROD strategy despite the considerable variability per case vignette.

Decision Making for Relaparotomy in Secondary Peritonitis

“…More than half of the surgeons performed at least 25% GI operations yearly; although 90% indicated that they performed other operations as well. Surgeon characteristics have previously been described in detail [19]. …”

“…Accurate and timely selection of patients for relaparotomy is a prerequisite for improvement of the treatment of secondary peritonitis, especially regarding the growing popularity of the on-demand relaparotomy strategy compared to other relaparotomy strategies [3, 4, 19,27,28,29,30]. Particularly the on-demand strategy encompasses extensive monitoring and multidisciplinary care with frequent radiological imaging and adjustments of treatment policy at every stage of the acute disease, as this strategy harbors the risk of a potentially harmful delay.…”

“…The following characteristics of surgeons were recorded: age, years since registration as a surgeon, surgical subspecialty, number of subspecialties, number of operations performed annually, and percentage of gastrointestinal (GI) operations. Hospital characteristics included type of hospital (academic, nonacademic teaching, regional), number of hospital beds and the experience of the individual surgeon with planned relaparotomy, relaparotomy on demand and primary open abdomen technique [19]. Also, choice of treatment strategy (planned or on-demand relaparotomy) was assessed for 16 different case vignettes, of which the results were published previously [19].…”

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

“…The median age was 69 years (IQR, 58-75 years), 48% were men, and the median APACHE-II score was 15 (IQR, [13][14][15][16][17][18]. The most common cause for peritonitis was gastrointestinal perforation (58%).…”

“…There is consensus that the preferred strategy for mild peritonitis (APACHE-II [Acute Physiology and Chronic Health Evaluation] score of Յ10) is on-demand relaparotomy. 4,[12][13][14] Despite lacking evidence from randomized trials, overall support for the on-demand strategy even among patients with severe peritonitis is growing, 4,12,13,15,16 but both strategies are still used side-by-side in clinical practice. 17,18 The debate on which strategy is preferred dates back as far as the call for a randomized trial comparing both strategies by the Joint Working Party of the North American and European Surgical Infection Society in 1990.…”