Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial.

CONTEXT: In patients with severe secondary peritonitis, there are 2 surgical treatment strategies following an initial emergency laparotomy: planned relaparotomy and relaparotomy only when the patient's condition demands it ("on-demand"). The on-demand strategy may reduce mortality, morbidity, health care utilization, and costs. However, randomized trials have not been performed. OBJECTIVE: To compare patient outcome, health care utilization, and costs of on-demand and planned relaparotomy. DESIGN, SETTING, AND PATIENTS: Randomized, nonblinded clinical trial at 2 academic and 5 regional teaching hospitals in the Netherlands from November 2001 through February 2005. Patients had severe secondary peritonitis and an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 11 or greater. INTERVENTION: Random allocation to on-demand or planned relaparotomy strategy. MAIN OUTCOME MEASURES: The primary end point was death and/or peritonitis-related morbidity within a 12-month follow-up period. Secondary end points included health care utilization and costs. RESULTS: A total of 232 patients (116 on-demand and 116 planned) were randomized. One patient in the on-demand group was excluded due to an operative diagnosis of pancreatitis and 3 in each group withdrew or were lost to follow-up. There was no significant difference in primary end point (57% on-demand [n = 64] vs 65% planned [n = 73]; P = .25) or in mortality alone (29% on-demand [n = 32] vs 36% planned [n = 41]; P = .22) or morbidity alone (40% on-demand [n = 32] vs 44% planned [n = 32]; P = .58). A total of 42% of the on-demand patients had a relaparotomy vs 94% of the planned relaparotomy group. A total of 31% of first relaparotomies were negative in the on-demand group vs 66% in the planned group (P <.001). Patients in the on-demand group had shorter median intensive care unit stays (7 vs 11 days; P = .001) and shorter median hospital stays (27 vs 35 days; P = .008). Direct medical costs per patient were reduced by 23% using the on-demand strategy. CONCLUSION: Patients in the on-demand relaparotomy group did not have a significantly lower rate of death or major peritonitis-related morbidity compared with the planned relaparotomy group but did have a substantial reduction in relaparotomies, health care utilization, and medical costs. TRIAL REGISTRATION: http://isrctn.org Identifier: ISRCTN51729393.

Health related quality of life six months following surgical treatment for secondary peritonitis--using the EQ-5D questionnaire.

BACKGROUND: To compare health related quality of life (HR-QoL) in patients surgically treated for secondary peritonitis to that of a healthy population. And to prospectively identify factors associated with poorer (lower) HR-QoL. DESIGN: A prospective cohort of secondary peritonitis patients was mailed the EQ-5D and EQ-VAS 6-months following initial laparotomy. SETTING: Multicenter study in two academic and seven regional teaching hospitals. PATIENTS: 130 of the 155 eligible patients (84%) responded to the HR-QoL questionnaires. RESULTS: HR-QoL was significantly worse on all dimensions in peritonitis patients than in a healthy reference population. Peritonitis characteristics at initial presentation were not associated with HR-QoL at six months. A more complicated course of the disease leading to longer hospitalization times and patients with an enterostomy had a negative impact on the mobility (p = 0.02), self-care (p < 0.001) and daily activities: (p = 0.01). In a multivariate analysis for the EQ-VAS every doubling of hospital stay decreases the EQ-VAS by 3.8 points (p = 0.015). Morbidity during the six-month follow-up was not found to be predictive for the EQ-5D or EQ-VAS. CONCLUSION: Six months following initial surgery, patients with secondary peritonitis report more problems in HR-QoL than a healthy reference population. Unfavorable disease characteristics at initial presentation were not predictive for poorer HR-QoL, but a more complicated course of the disease was most predictive of HR-QoL at 6 months.

Long-term prevalence of post-traumatic stress disorder symptoms in patients after secondary peritonitis.

INTRODUCTION: The aim of this study was to determine the long-term prevalence of post-traumatic stress disorder (PTSD) symptomology in patients following secondary peritonitis and to determine whether the prevalence of PTSD-related symptoms differed between patients admitted to the intensive care unit (ICU) and patients admitted only to the surgical ward. METHOD: A retrospective cohort of consecutive patients treated for secondary peritonitis was sent a postal survey containing a self-report questionnaire, namely the Post-traumatic Stress Syndrome 10-question inventory (PTSS-10). From a database of 278 patients undergoing surgery for secondary peritonitis between 1994 and 2000, 131 patients were long-term survivors (follow-up period at least four years) and were eligible for inclusion in our study, conducted at a tertiary referral hospital in Amsterdam, The Netherlands. RESULTS: The response rate was 86%, yielding a cohort of 100 patients; 61% of these patients had been admitted to the ICU. PTSD-related symptoms were found in 24% (95% confidence interval 17% to 33%) of patients when a PTSS-10 score of 35 was chosen as the cutoff, whereas the prevalence of PTSD symptomology when borderline patients scoring 27 points or more were included was 38% (95% confidence interval 29% to 48%). In a multivariate analyses controlling for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, number of relaparotomies and length of hospital stay, the likelihood of ICU-admitted patients having PTSD symptomology was 4.3 times higher (95% confidence interval 1.11 to 16.5) than patients not admitted to the ICU, using a PTSS-10 score cutoff of 35 or greater. Older patients and males were less likely to report PTSD symptoms. CONCLUSION: Nearly a quarter of patients receiving surgical treatment for secondary peritonitis developed PTSD symptoms. Patients admitted to the ICU were at significantly greater risk for having PTSD symptoms after adjusting for baseline differences, in particular age.

Clinical predictors of ongoing infection in secondary peritonitis: systematic review.

INTRODUCTION: The decision to perform a relaparotomy in patients with secondary peritonitis is based on "clinical judgment" with inherent variability among surgeons. Our objective was to review the literature on prognostic variables for ongoing abdominal infection. Predictive variables for positive findings at relaparotomy can generate more objective criteria to support the decision whether to perform a relaparotomy in patients with secondary peritonitis. METHODS: Multiple databases were searched for studies assessing the prognostic value of clinical variables predicting outcome of relaparotomy or general outcome in patients with secondary peritonitis. Data on the methodologic quality of the study as well as statistical strength of predictors and validity of individual variables were extracted and scored. A cumulative score was calculated from these three scores, and the variables were ranked. RESULTS: A total of 37 of 197 retrieved articles were included for final assessment. The median score for methodologic quality of individual articles was 36 (range 19-54). After calculation of the combined scores, 76 individual variables (patient, peritonitis, surgery, clinical, and laboratory variables) were identified from which the top 10 were eventually selected. These variables were age, concomitant disease, upper gastrointestinal source of peritonitis, generalized peritonitis, elimination of the focus, bilirubin, creatinine, lactate, PaO2/FiO2 ratio, and albumin. This set of variables proved to be moderately predictive for positive findings during relaparotomy in a retrospective cohort of 219 patients operated on for secondary peritonitis (receiver operator curve 0.75, with 95% confidence interval 0.68-0.82). CONCLUSIONS: This review generated a hierarchy (weighted ranking) of published variables that could play a role in the decision to perform a relaparotomy in patients with secondary peritonitis. The top sixtile of ranked variables (10 variables) showed promising results in the discrimination between patients having a positive and negative relaparotomy when tested on a peritonitis patient database. This ranking of variables provides evidence for potential inclusion of variables in future predictive scores, although improvement in overall predictive strength of a set of variables in such a score is needed.