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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Laparotomy for abdominal sepsis in the critically ill

and .

University of Edinburgh, Department of Clinical and Surgical Sciences, Royal Infirmary, Edinburgh, U.K.

Introduction

Intra-abdominal sepsis is the most frequent reason for admission of a surgical patient to the intensive care unit (ICU). The decision to operate or re-operate on such a patient can be one of the most difficult faced by surgeons. In the absence of clear clinical guidelines, this decision is based upon individual surgeon's experience and on the influence of intensive care colleagues. European and North American experience of intra-abdominal sepsis is similar, with reported mortality rates for this condition ranging between 30% and 60%. Irrespective of the surgical strategies employed, laparotomy in the critically ill is associated with significant morbidity and mortality, the incidence of which increases with each re-laparotomy. Therefore the decision to intervene surgically for intra-abdominal sepsis in the critically ill requires the determination of specific treatment goals in patients in whom the benefits of these goals outweighs the risks.

Demographics of intra-abdominal sepsis

A prospective evaluation of the management of intra-abdominal sepsis (1) in critically ill patients with an acute physiology and chronic health evaluation (APACHE) II score of greater than 10, reported the overall mortality to be 32%. In patients in whom a single surgical intervention was performed the mortality rate was 27%, compared with 42% for subjects undergoing multiple laparotomies (table I). These data are comparable with the European experience (2). The increased mortality associated with re-laparotomy is most probably a function of the patient's severity of illness and the presence of persistent intra-abdominal infection. The impact of repeated surgical trauma has yet to be defined. Whilst historically the literature has focussed on the influence of differing surgical pratices on outcome from intra-abdominal sepsis, it is now apparent that the main determinants of mortality are the level of host response and physiological reserve of patients, such that high APACHE II scores, low serum albumin, poor cardiac status and high organ failure scores independently predict poor survival (1, 3) .

Table I. The relationship between the number of re-operations and mortality in intra-abdominal sepsis (from Christou et al. 1993).

Table I

The relationship between the number of re-operations and mortality in intra-abdominal sepsis (from Christou et al. 1993).

Patient populations are older and comorbid disease more prevalent and complex. As a consequence, the mortality from intra-abdominal sepsis has not significantly altered, despite more aggressive resuscitation, surgery and intensive care. Patients may survive longer, but only to develop progressive multiple organ dysfunction syndrome (MODS) as the most frequent mode of death. Early descriptions of multisystem organ failure identified intra-abdominal sepsis as the most common underlying cause, therefore it was regarded as justifiable to intervene surgically on the grounds of MODS alone, so that potential intra-abdominal infective foci may be cleared. Hinsdale's study of indications for re-operation in intra-abdominal sepsis (4) identified 11 of 77 patients whose indication for surgical exploration was solely MODS. Six patients had identifiable foci of infection, which were drained with two patients surviving. The remaining 5 patients had negative laparotomies, and all died. Although the numbers in this series were small, the authors concluded that re-laparotomy for multiple organ failure was defensible, even though the benefits to a small number of patients was marginal. With the advent of easily available ultrasound, spiral CT, MRI and the development of interventional radiology for diagnosis and therapeutic drainage of collections, more recent data suggests that a blanket surgical approach is less likely to be beneficial in current critical care settings (5). In 105 consecutive patients with peritonitis, the mortality was 36% (38 patients), all but one died as a consequence of organ failure and 73% of patients had one or more failing organ systems. Based on operative, clinical, radiological and autopsy findings, only one patient with organ failure had unresolved intraperitoneal infection. This would indicate that in the presence of normal imaging results, the role for re-laparotomy for MODS is diminishing, since the probability of identifying and clearing an intra-peritoneal cause for organ failure will be small.

Surgical approaches and treatment goals

In the critical care setting, prior to any surgical intervention, general supportive measures should have already be instituted. Namely, the correction of circulating volumes and the treatment of shock to allow adequate tissue perfusion and oxygenation. Failing organ systems should be identified and supported and nutritional deficiencies addressed. Recent meta-analyses would indicate that in high risk surgical patients on intensive care have reduced mortality when selective decontamination of the digestive tract is employed (6). It is also of interest that the opposite approach using recontamination of the digestive tract with probiotic flora such as lactobacillus has been advocated (7). Appropriate systemic antibiotic cover should be in place, with agents effective against E. coli and B. fragilis. The bacteriology results of specimens obtained at previous surgery and aspirations should be reviewed with particular attention to antibiotic sensitivities. The principles of surgical treatment for intra-abdominal sepsis have already been described (chapter XV. 8), the basis of which is source control, to eradicate the feeding lesion; peritoneal toilet, to evacuate bacterial inocula and pus; and operative interventions to treat persistent or recurrent infections. As mentioned previously, much of recent surgical theory in the treatment of intra-abdominal sepsis in ICU is based on the findings from early studies of outcome from this condition. Dellinger reported on 187 patients treated for intra-abdominal sepsis (8), 48% of cases were “cleared” of intra-abdominal infection by a single operation and appropriate antibiotic therapy. In the 44 patients whom died, 80% died with persistent intra-abdominal infection. It is not possible to ascertain the cause of death from this study and whether or not the presence of intra-abdominal infection was contributory. More current data indicates that the presence of persistent or recurrent peritoneal infection in patients treated for secondary peritonitis is now considerably lower, being in the region of 14% in some reports. Furthermore it would seem that the patients experiencing recurrent intra-abdominal infection now die infrequently or develop organ failure (5). Nevertheless, there are clear concerns that the presence of persistent intra-abdominal infection is related to the mortality of this condition and that the presence of infection may be regarded as a treatment failure.

Such treatment failures have been the subject of controversy with regard to differing surgical strategies to manage the situation. The policy of laparotomy on demand, whereby further surgery is undertaken only when clearly indicated, has been criticized as ineffective, being “too little and too late”, prompting the formulation of alternative strategies. Critics of the on demand policy have proposed a strategy of planned second look laparotomies and advanced open operative procedures (e.g.: STAR, see chapter XV. 8). Early studies of scheduled re-laparotomy (Ettapenlavage) (9) adopted a technique of repeated laparotomies until the time when peritoneal exudates became clear and anastomotic healing was apparent. Patients originally selected for this type of surgical care had diffuse peritonitis and in whom it was felt that a single operative procedure would be inadequate at clearing intra-abdominal infection. These studies produced impressive survival statistics in the region of 80% (impressive in that the mean age of patients was 63 years and 92% of patients had two or more organ systems failing). Retrospective comparisons of laparotomy on demand and planned re-laparotomy have yielded consistent improvements in mortality with scheduled re-laparotomy (10), yet prospective studies, albeit non-randomized, have failed to demonstrate any survival benefit with scheduled re-laparotomies (11). The most recent comparison of planned versus on demand re-laparotomy in the literature (12) advocates an approach of scheduled re-laparotomy, on the grounds that it reduces the mortality of patients (as predicted by APACHE II score) from 55.6% to an actual mortality of 36.3%. Despite these encouraging results, patients undergoing a single laparotomy in the same study, had an actual mortality rate of 23%, whereas the predicted mortality was 42.4%, therefore this study does not further the case for planned re-laparotomy. The nearest body of evidence to a prospective randomized trial addressing this issue is the case control study of Hau et al. (13). In this study there was no difference in mortality in patients treated by laparotomy on demand and those undergoing scheduled procedures. Moreover, the rate of unplanned re-laparotomies was similar in both groups and the incidence of post-operative complications greater in patients treated by planned re-laparotomies. Therefore based on current evidence, there would appear to be little role for scheduled re-laparotomies in the treatment of intra-abdominal sepsis in the ICU. Instead, stringent attempts should be made to clear intra-abdominal infection at the first operative procedure. Thereafter careful clinical observation and radiological evaluation should allow the majority of patients to be managed without planned re-laparotomy.

Expectations of re-laparotomy

It is apparent that laparotomy performed for progressive MODS in patients with previous abdominal sepsis frequently yields no identifiable intra-abdominal infective focus and in these circumstances factors such as organ failure amplification or gut barrier failure may be key elements contributing to the patients deterioration. Patients selected for a course of repeated laparotomies are clearly thought to be at high risk of recurrent intra-abdominal infection, yet despite this, the negative laparotomy rates for such patients is significant. Schein (14) performed 43 second look laparotomies of which 8 (19%) were negative and in Penninckx's study the negative second look laparotomy rate was 29% (10). Thus the predictive indices/criteria used to initiate a course of planned re-laparotomy cannot be regarded as failsafe indeed it would be surprising if they were-!

Performing a negative laparotomy in a critically ill individual is an undesirable situation and one ideally avoided. Such an attitude, however, is not an excuse for poor clinical evaluation, neglected investigation or untimely action. Our experience of laparotomy in the critically ill is based on a series of 125 patients treated in the intensive care unit for intra-abdominal sepsis (2). Sixty (48%) required further surgery, in only 7 cases was this as a scheduled re-intervention. However, in 23 patients the decision was made to undertake a further laparotomy as a consequence of deteriorating clinical condition and in a further 30 patients, surgery was initiated by the identification of a specific lesion suitable for operative intevention (e.g. Collection on US or CT). A total of 95 laparotomies were performed in the 60 patients, 85% of laparotomies resulted in the drainage of pus or the debridement of necrotic material and could therefore be regarded as indicated and appropriate. A total of 41 laparotomies (43%) were associated with an improvement in clinical status within 48 hours of the procedure. Twentysix patients benefited clinically after a single operative intervention, 21 of these (81%) survived. Of the 34 patients who did not improve within 48 hours the mortality rate was 88%.

Thirty seven patients (62%) from our series had an infective focus cleared from the abdomen. Of these, 23 patients (62%) survived. No patient survived to leave hospital without undergoing surgical clearance of residual sepsis. Sepsis was more likely to be cleared at the first re-operative intervention (43%), whereas the second procedure only resulted in a 25% sepsis clearance rate, and the third and subsequent procedures cleared sepsis in only 7% of cases (fig. 1). Irrespective of whether the operative intervention was performed as a planned procedure, on account of clinical deterioration, or performed to treat an identified lesion, the clearance rates for sepsis were no different. However, procedures directed by a specific indication (such as an intra-abdominal abscess) yielded significantly better rates of clinical improvement (table II). Such data emphasises the importance of the use of diagnostic techniques, particularly spiral CT scanning, MRI and ultrasound to allow the surgeon to perform more focused re-laparotomies, thereby increasing the likelihood of therapeutic procedures which will result in a clinical improvement.

Figure 1. The clinical effectiveness of Laparotomy and Re-Laparotomy in Intra-Abdominal Sepsis.

Figure 1

The clinical effectiveness of Laparotomy and Re-Laparotomy in Intra-Abdominal Sepsis.

Table II. Value and outcome of first operative procedure following admission to ICU by operation type (from Anderson et al. 1996).

Table II

Value and outcome of first operative procedure following admission to ICU by operation type (from Anderson et al. 1996).

There has been some work on the use of predictive indices in aiding the decision process to reoperate (15) (table III). The utilization of these indices, such that patients with a score of less than 10 were kept under observation, patients scoring between 11 and 15 were subject to specialist studies and the decision to re-operate based on these findings, score of greater than 20 prompted immediate re-operation, and scores between 16 and 20 invariably resulted in re-operation irrespective of the results of special investigations. This approach lowered the mortality rate of patients reoperated on, compared with controls. In addition the time elapsed to reoperation and the total length of stay in ICU was reduced. Clearly these indices would be more useful if they were more extensively evaluated prospectively.

Table III. Weighted indices used to derive the abdominal reoperation predictive index of Pusajo et al. (from Pusajo et al. 1993).

Table III

Weighted indices used to derive the abdominal reoperation predictive index of Pusajo et al. (from Pusajo et al. 1993).

Conclusion

Surgery is no panacea for the critically ill with intra-abdominal sepsis. The emerging hypothesis is that it is that the physiological derangement and not the severity of the initial peritoneal infection that is the main determinant of outcome and therefore questions the role of undirected re-laparotomies. Surgery in a patient with an enhanced inflammatory response may further compromise their physiological state. Experience indicates that multiple operations in the ICU are associated with diminishing returns and poor outcome. The most important prognostic factor is secure elimination of intra-abdominal infection at the initial operation. The greatest benefits of surgery come from procedures which are performed in response to a definite treatable abnormality, irrespective of whether organ failure is present or not. Surgeons and intensivists should strive, by non-invasive or minimally invasive means, to identify infective foci so that they can be dealt with early at the stage of the systemic inflammatory response, prior to the development of organ dysfunction. The question of which surgical strategy is suitable for the management of high risk patients with intra-abdominal infection, can only be answered by further prospective randomized trials.

References

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Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6925
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