Turkish Journal of Trauma & Emergency Surgery Ulus Travma Acil Cerrahi Derg 2009;15(1):52-57 Original Article Klinik Çal›flma Laparostomy in patients with severe secondary peritonitis A¤›r sekonder peritonitli hastalarda laparostomi Do¤an GÖNÜLLÜ,1 Ferda Nihat KÖKSOY,1 Okan DEM‹RAY,1 Sibel Gürdal ÖZKAN,2 Tayfun YÜCEL,3 Osman YÜCEL1 BACKGROUND AMAÇ The aim of this study was to evaluate the effectiveness of laparostomy with the Bogota bag for the management of patients with severe secondary peritonitis and the risk factors for survival. Bu çal›flmada, sekonder peritonitli hastalar›n tedavisinde, Bogota bag ile geçici kar›n kapatman›n etkinli¤i ve sa¤ kal›mdaki risk faktörleri de¤erlendirildi. METHODS GEREÇ VE YÖNTEM Thirty-seven patients (22 males, 15 females; mean age 63.5; range 44 to 83 years) with secondary peritonitis were treated by laparostomy and temporary closure with Bogota bag. APACHE II scores and Mannheim Peritonitis Index (MPI) were used to calculate the disease severity. The outcomes and effectiveness of APACHE II and MPI values were analyzed retrospectively. Sekonder peritonit nedeniyle Bogota bag kullan›larak geçici olarak kar›n kapat›lmas› uygulanan 37 hasta (22 erkek, 15 kad›n; ort. yafl 63,5; da¤›l›m 44-83) ele al›nd›. Hastal›¤›n fliddetinin belirlenmesinde Acute Physiology and Chronic Health Evaluation II (APACHE II) ve Mannheim Peritonit ‹ndeksi (MPI) skorlar› kullan›ld›. APACHE II’nin sonuçlar› ve etkilili¤i ve MPI de¤erleri, geriye dönük olarak de¤erlendirildi. RESULTS BULGULAR The mortality rate was 43.2%. Significant differences were noted between survivors and non-survivors according to initial APACHE II and MPI scores and the number of operations. The non-survivors had higher APACHE II (r=0.81, p=0.001) and MPI (r=0.39, p=0.02) scores. The patients who survived were re-operated 1.6 times and those who died were re-operated 4.7 times. In five patients, laparostomy was closed primarily, while in the others, the wound was left open to heal secondarily. Mortalite oran› %43,2 olarak belirlendi. Yaflayan ve hayat›n› kaybeden hastalar›n, baflvuru APACHE II (r=0,81, p=0,001) ve MPI (r=0,39, p=0,02) skorlar› ve ameliyat say›lar› (1,6’ya karfl›n 4,7 ameliyat) aras›nda yaflayanlar›n lehine anlaml› fark saptand›. Befl hastada laparostomi primer olarak kapat›l›r ken, yaflayan di¤er hastalar sekonder iyileflmeye b›rak›ld›. CONCLUSION SONUÇ Patients with higher APACHE II and MPI scores and number of operations had higher rates of mortality due to their major risk factors. Temporary abdominal closure using the Bogota bag in patients with secondary peritonitis is an inexpensivesimple method, permitting evaluation of underlying viscera and recognition of infection. Sekonder peritonitli hastalarda Bogota bag ile geçici kar›n kapat›lmas›, ucuz ve basit bir yöntem olup, fleffafl›¤›yla alt›ndaki organlar›n ve enfeksiyonun gözlenmesine olanak sa¤lar. Yüksek APACHE II ve MPI skorlar› ve fazla say›da relaparotomi uygulanmas›, daha yüksek mortalite oran› ile sonuçlanmaktad›r. Key Words: APACHE II; Bogota bag; intraabdominal morbidity; Mannheim Peritonitis Index; mortality; secondary peritonitis; temporary abdominal closure. Anahtar Sözcükler: APACHE II; Bogota bag; kar›n içi morbidite; Mannheim Peritonit ‹ndeksi; mortalite; sekonder peritonit; geçici abdominal kapatma. 1 Department of General Surgery, Taksim Training and Research Hospital, Istanbul; 2Department of General Surgery, Nam›k Kemal University 3 Faculty of Medicine, Tekirda¤; Department of General Surgery, Sakarya University Faculty of Medicine, Sakarya, Turkey. 1 Taksim E¤itim ve Araflt›rma Hastanesi, Genel Cerrahi Klini¤i, ‹stanbul; 2 Nam›k Kemal Üniversitesi T›p Fakültesi, 3 Genel Cerrahi Anabilim Dal›, Tekirda¤; Sakarya Üniversitesi T›p Fakültesi, Genel Cerrahi Anabilim Dal›, Sakarya. Correspondence (‹letiflim): Do¤an Gönüllü, M.D. Taksim E¤itim ve Araflt›rma Hastanesi, 1 . Cerrahi Klini¤i, Beyo¤lu 80060 ‹stanbul, Turkey. Tel: +090 - 212 - 252 43 00 Fax (Faks): +090 - 212 - 252 63 00 e-mail (e-posta): dogangonullu@yahoo.com 52 Laparostomy in patients with severe secondary peritonitis Severe secondary peritonitis is a life-threatening condition; the patient’s survival mainly depends on supportive care, rational and intense antibiotherapy and effective operative procedures to control the source of infection. Operative management consists of effective debridement, source control, and laparostomy following planned or on-demand relaparotomies.[1 , 2] Benefits of laparostomy include facility of re-exploration, watching the abdominal contents, reduction of the risk of intra-abdominal hypertension, and fascial preservation for further closure of the abdominal wall.[3] Several techniques have been published, but no clear consensus on the best technique or device exists.[3] Despite the above, the mortality rate is 59%,[4] and morbidity associated with severe complications (abscess, fistulas, bleeding, wound infection, dehiscence, ventral hernias)[5,6] is followed by re-operations and months of convalescence. Temporary closure of the abdominal wall with Bogota bag (BB) in these patients is a simple and inexpensive method, and this transparent bag permits evaluation of the intraabdominal space.[7] Our aim was to present our experiences in temporary closure technique with BB in severe secondary peritonitis and to discuss our results in light of the recent literature. In addition, the differences between survivor and non-survivor cases are discussed. MATERIALS AND METHODS Thirty-seven serious secondary peritonitis patients who underwent temporary closure with BB between 2000 and 2006 were included in this retrospective study. Acute abdomen was the initial diagnosis in all of the operated patients; preoperative computed tomography and conventional radiographs were performed as needed. In the resuscitative phase, we followed the surviving sepsis guidelines in order to deliver standard therapy to every patient, which included intravenous fluid hydration with isotonic crystalloid solutions, oxygen support, broad spectrum antibiotherapy and warming of the patients. After a duodenal feeding tube placement, nutrition was initiated progressively within 12-36 hours of surgery; when it was not possible, the patients were submitted to total parenteral nutrition. The indications for surgery are listed in Table 1. Cilt - Vol. 15 Say› - No. 1 We used the temporary closure methods in patients with generalized peritonitis in whom it was difficult to control the infection and/or in cases with increased intra-abdominal pressure.[8] The decision criterias to perform a laparostomy in patients with generalized peritonitis and without the intra-abdominal hypertension is not well-defined.[9] The relaparotomy decision was based on patients’ clinical findings and observations through BB by the same surgical team: presence of a gastrointestinal leakage and increase in intra-abdominal pressure and APACHE II/Mannheim Peritonitis Index (MPI) scores during the intensive therapy in the intensive care unit (ICU) (relaparotomy ondemand). Use of the BB technique for abdominal closure has been reported primarily in the management of trauma;[10,11] we used a bag of intravenous fluids or 3L urologic irrigation fluid, spreading over the intestinal loops and sutured to the skin part of the wound edge. At a later stage, if the intraabdominal sepsis was resolved, the abdominal wall was reconstructed. Age, sex, preoperative APACHE II and MPI scores, number of operations, duration in ICU, intraabdominal complications, mortality rate, morbidity, and modality of abdominal closure were evaluated in all patients. The results of survivors and non-survivors according to several parameters were compared by using Student’s t, Pearson correlation, and MannWhitney U tests. Probability values less than 0.05 were considered statistically significant. RESULTS Thirty-seven patients were included in this research (22 M, 59.4%; 15 F, 40.5%). Average age Table 1. Indications in initial operations Etiology Patients (n) (%) Perforated malignant colorectal disease 14 (37.8) Infected pancreatic necrosis 10 (27.0) Multiple small bowel perforations 4 (10.8) Gangrenous small bowel 4 (10.8) Peptic ulcer perforation 2 (5.4) Anastomotic leakage from urologic ileal conduit 2 (5.4) Perforated splenic abscess 1 (2.7) Total 37 (100) 53 Ulus Travma Acil Cerrahi Derg was 63.5 (44-83) years. Postoperatively, all the patients were admitted to the surgical ICU (18 patients) (48.6%) or the general ICU (19 patients) (51.4%) for close follow up and monitoring. Mechanical ventilatory support was necessary in 19 patients (51.4%) in the ICU. The overall mortality rate was 43.2% (16/37). intestinal obstruction (secondary to operation of peptic ulcer perforation). In 5 patients (23.8%), laparotomies were closed in one stage. The diagnosis was perforated malignant colorectal disease in 2 cases (APACHE II scores: 18 and 21; MPI scores: 21 and 22, respectively), peptic ulcer perforation in 2 cases (APACHE II scores: 15 and 19; MPI scores: 16 and 17, respectively) and perforated splenic abscess in 1 case (APACHE II score: 17; MPI score: 18). Multi-organ failure was the cause of death in 2 patients with perforated malignant colorectal disease and in 2 patients with multiple small bowel perforations. A pulmonary embolus occurred in 1 patient with perforated malignant colorectal disease and it progressed to death. In the other 32 cases, relaparotomies were needed. In relaparotomy cases, laparotomy intervals varied between 12-96 hours according to operative and laparostomy observation findings, and the mean number of re-operations was 2.9±1.8. The patients who survived were re-operated 1.6 times and those who died were re-operated 4.7 times. There was a statistically significant difference between survivors and non-survivors, with the survivors undergoing fewer operations (Table 2). Twelve (32.4%) of the relaparotomy cases had major complications. Four patients had (10.8%) intra-abdominal abscesses (abscesses were drained), 4 patients (10.8%) had intra-abdominal abscess and fistula (abscesses were drained; 2 intestinal fistulas were exteriorized, 2 pancreatic fistulas were drained), 2 patients had bleeding (5.4%, packed), and 2 patients (5.4%) had intestinal obstructions (1 detorsion, 1 adhesiolysis were performed). It is important to mention that all patients with intraabdominal complications died, except one who had Among the 5 patients who died without major intra-abdominal complications, 4 died due to multiorgan failure (MOF) affecting at least five systems and 1 due to pulmonary embolus. The etiologies in 16 patients who died were: 6 perforated colorectal cancer, 5 pancreatic necrosis, 3 multiple intestinal perforation (2 non-specific vasculitis, 1 typhoid lesion) and 2 intestinal necrosis (Table 3). When comparing survivors and non-survivors, there was no significant difference between sex and ages of the patients (Table 2). The APACHE II scores calculated at admission and MPI scores based on operative findings between survivors and non-survivors were significantly different (Table 2 and Fig. 1). Patients with higher APACHE II and MPI scores demonstrated significantly higher mortality rate (p=0.001 and p=0.02, respectively). The APACHE II scores ≥ 30 were correlated with very high mortality rates (r=0.95, p=0.001). Duration of ICU or surgical ICU hospitalization was 8.2 days for patients who survived and 22.4 days for non-survivors. There was a significant difference in ICU/surgical ICU hospitalization times between survivors and non-survivors (Table 2). Table 2. Statistical analysis of sex, age, APACHE II and MPI scores, number of operations, and ICU hospitalization duration between survivors and non-survivors Mean (± SD) Sex (male/female) Age APACHE II MPI Number of operations ICU Survivors Non-survivors p 95% Confidence Interval 13 / 8 63.3±9.8 22.4±4.3 29.4±7.1 1.6±0.8 8.2±2.1 9/7 67.9±7.6 34.9±5.0 35.4±7.7 4.7±1.1 22.4±9.1 0.77 0.13 0.001 0.02 0.001 0.001 NS NS (-9.3)–(-15.6) (-1.0)–(-11.1) (-2.5)–(-3.7) (-10.1)–(-18.4) MPI: Mannheim Peritonitis Index; ICU: ICU hospitalization duration. 54 Ocak - January 2009 Laparostomy in patients with severe secondary peritonitis Table 3. The survival and intra-abdominal complications according to the sources of infection Etiology n Mortality (n) Causes of mortality (n) Intra-abdominal complications (n) Perforated malignant colorectal disease 14 6 Abscess: 3 5 Intra-abdominal complications: 3 MOF: 2 PE: 1 Intra-abdominal complications: 5 Infected pancreatic necrosis 10 4 3 Intra-abdominal complications: 3 4 2 2 2 0 0 MOF: 2 0 0 Bleeding: 2 Fistula and abscess: 2 Abscess (recurrence): 1 Fistula and abscess: 2 MIO: 1 0 MIO: 1 0 Multiple small bowel perforations Gangrenous small bowel Peptic ulcer perforation Anastomotic leakage from urologic ileal conduit Perforated splenic abscess Total 1 37 0 16 0 16 0 12 MOF: Multiple organ failure; PE: Pulmonary embolism; MIO: Mechanic intestinal obstruction. In the 16 surviving patients, the wound was left open to heal secondarily. Ten (47.6%) of them were unable to be followed and did not inform us regarding incisional hernia. In 1 (4.8%) of the remaining 6 patients (28.6%), skin grafting was used for abdominal wall closure. Skin graft was preferred because we were not able to dissect through the abdominal planes. In 2 patients (9.6%), incisional hernias were repaired with on-lay polypropylene mesh and in 3 patients (14.3%) with intraperitoneal polyglactin 910-polypropylene dual mesh. In these cases, a polypropylene mesh was placed into the preperitoneal space. These operations were done within the first year of the incisional hernia development. DISCUSSION The key steps in the management of severe secondary peritonitis are early detection and care of these patients with adequate antimicrobials and removal or drainage of all septic sources. Postoperative ICU support and balanced volume should be applied with careful monitoring of intraabdominal pressure, especially in patients where ventilation support is needed.[5] Elimination of the septic focus and contents is mandatory for successful treatment. If it is not achieved in one stage, planned re-laparotomy, planned re-laparotomy via laparostomy (STAR procedure), relaparotomy on-demand, and open treatCilt - Vol. 15 Say› - No. 1 ment with laparostomy are accepted as the surgical treatment alternatives.[2,4,10] Although there are some disadvantages such as evisceration, fistulization and development of difficult incisional hernias, the laparostomy technique has been generally accepted for the management of severe intra-abdominal infections; the laparostomy could be covered with BB simply and cheaply.[7 , 1 0] In a few studies, some authors have found planned re-laparotomy to be more advantageous than relaparotomy on-demand,[12] while others found the opposite.[13,14] However, the majority of studies, including one meta-analysis,[15] state that there is no significant difference between these two methods.[16-18] Our patients were managed with temporary laparostomy with BB and relaparotomy on-demand after observing the patient’s condition and abdomi50 40 30 20 APACHE II 10 n= MPI 21 21 Survivor 16 16 Non-survivor Survival Fig. 1. APACHE II and MPI scores for survivors and non-survivors. 55 Ulus Travma Acil Cerrahi Derg nal contents through the bag. Among the few heterogeneous and mostly retrospective studies, the lowest mortality rate was reported as 23%[19] for severe intra-abdominal infection patients. Our mortality rate of 43% for these patients might be considered as acceptable when compared with mortality rates as high as 59% reported in the literature.[4] Clinical follow-up of the patients in the ICU according to specific parameters has been used frequently. APACHE II and MPI scores were used in our cases; these parameters were also used as predictors for higher mortality. Their use was significantly effective in our study: patients with higher APACHE II and MPI scores demonstrated higher rates of mortality (r=0.81 and r=0.39, respectively), and the differences were statistically significant. Furthermore, the r=0.95 value found for APACHE II scores ≥30 was notable. The mean number of re-operations was 2.9±1.8 in our series, but this rate was higher in non-survivors than in survivors. Our results are similar to those of Kirshtein.[7] Higher APACHE and MPI scores during the management period could be accepted as poor prognostic predictors. In addition, patients requiring more re-operations and with a longer ICU period could present a poor outcome. The high rate of intra-abdominal complications (32.4%) in our cases was in correlation with the available literature; furthermore, the results were better than in some studies.[6] The literature reported high incidences of intraabdominal complications, e.g. 24% (5) for abscess, 2-25% (5,6) for fistulas, and 24% (6) for bleeding. Towel clip closure, BB, polyglycolic acid mesh, polyglactin 910 mesh, zipper and vacuum-assisted closure (VAC) systems are available options in the temporary abdominal closure procedures.[5] BB was used in our cases. It was an inexpensive material, and it usually permitted us to observe severe intraabdominal infections, leakages and soft tissue necrosis through it.[7] For repairing the full-thickness abdominal wall soft-tissue defect developing after the BB procedures, there are several alternative techniques and materials, such as polypropylene, polytetrafluorethylene (PTFE) graft, composite materials, plastic surgery techniques, biologic materials, and primary fascial closure.[2,7,19,20] 56 Primary closure was the preferred form of definitive closure, but its use quite various in the literature, between 8-10% (8,16) and 70%.[1] Only 5/21 (23.8%) patients in our study underwent primary fascial closure; the others required delayed closure. As shown in our study, in accordance with the literature, the limited number of re-operations could increase the chance of primary closure;[19,21] all five cases with primary closure were re-operated only once. As mentioned in Bailey’s study as well,[22] 16 (76.4%) of our cases had secondary healing and needed delayed closure. The period before delayed closure was four weeks in different studies;[4] however, for most of the cases this period could be longer.[7] In our study, 6 patients with ventral hernia (28.6%) underwent hernia repair within 3-12 month periods (1 patient with skin graft; the other 5 patients with mesh repair). Mesh repair was performed easily in the late period. In conclusion, in the initial period of severe intraabdominal sepsis, the laparostomy procedure with temporary closure using BB could be sufficient and permits observation of abdominal content and further on-demand explorations. These patients can be followed with MPI and APACHE II scores in the ICU. Limited number of re-operations, decreased APACHE II and MPI scores and shorter periods in the ICU unit were associated with decreased mortality rates and intra-abdominal complications in our series. REFERENCES 1. 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