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Planned reoperations and open management in critical intra-abdominal infections: Prospective experience in 52 cases

Abstract

Open management and “planned relaparotomies” in the treatment of critical abdominal infections have recently generated interest and hope. Most studies which examine the value of these therapeutic modalities are retrospective and include poorly stratified groups of patients. Since 1985, we have consistently applied these aggressive methods of treatment in all patients presenting with ultra-abdominal infections belonging to the following groups: I) diffuse postoperative peritonitis (29 cases); II) diffuse fecal peritonitis (14 cases); and III) infected pancreatic necrosis (9 cases). The overall mortality rate was 44%; it was 55%, 14% and 56%, respectively, in the 3 groups. The abdomen was closed between reoperations in 21 patients who required an average of 1.7 relaparotomies; the mortality in this group was 24%. Thirty-one patients, who required an average of 3.8 relaparotomies, were managed with the open method resulting in a mortality of 58%. Multiple organ failure was the cause of death in 87% of the patients. We conclude that “planned relaparotomies” may have been beneficial in group II. The value of open management in patients belonging to groups I and III remains unproven. The mechanical-surgical answers to severe forms of peritonitis may have reached their limit.

Résumé

La technique de ventre ouvert avec des laparotomies répétées dans le traitement des infections abdominales graves est une méthode thérapeutique d'intérêt et d'espoir récent. La plupart des études concernant cette modalité thérapeutique souffrent d'être rétrospectives et d'être inhomogènes quant aux type de patients inclus. Depuis 1985, l'auteur a appliqué cette technique chez tous les patients ayant une infection abdominale qui se répartissaient dans les groupes suivants: I — péritonite diffuse postopératoire (29 cas), II — péritonite diffuse fécale (14 cas), III — nécrose pancréatite infectée (9 cas). La mortalité globale a été de 44%; elle a été de 55%, 14% et 56%, respectivement, dans les groupes I, II et III. Chez 21 patients qui ont nécessaité une moyenne de 1.7 relaparotomies, l'abdomen était fermé entre les réopérations (“réouverture planifiée”). La mortalité dans ce groupe a été de 24%. Chez les 31 patients qui ont nécessité une moyenne de 3.8 relaparotomies, l'abdomen a été laissé ouvert entre les explorations successives avec une mortalité de 58%. La défaillance polyviscérale était la cause de mortalité dans 87% des cas. La “réouverture planifiée” a pu être bénéfique dans le groupe II, mais sa valeur reste à démontrer dans les groupes I et III. Les moyens mécaniques ont peut-être atteint leur apogée dans le traitement des péritonites sévères.

Resumen

El manejo de abdomen abierto (laparostomía) con “relaparotomías planeadas” en el tratamiento de infecciones abdominales críticas ha generado reciente interés y esperanza. La mayoía de los estudios destinados a valorar estas modalidades terapéuticas han sido de carácter retrospectivo y basados en grupos de pacientes pobremente estratificados. A partir de 1985 el autor ha aplicado en forma consistente estos agresivos métodos de terapia en la totalidad de los pacientes con infecciones intraabdominales, clasificados en los siguientes grupos: I — Peritonitis postoperatoria difusa (29 casos); II — Peritonitis fecal difusa (14 casos); y III — necrosis pancréatica infectada (9 casos). La tasa global de mortalidad fue 44%; correspondió a 55%, 14% y 56%, respectivamente, en los 3 grupos. El abdomen fue cerrado entre reoperaciones en 21 pacientes que requirieron un promedio de 1.7 relaparotomías; la mortalidad en este grupo fue de 24%. Treinta y un pacientes que requirieron un promedio de 3.8 relapatomías fueron manejados mediante el método abierto, con una mortalidad de 58%. La falla orgánica múltiple fue la causa de muerte en 87% de las muertes. Nuestra conclusión es que las “relaparotomías planeadas” pueden ser beneficiosas en el grupo II; su valor no queda demostrado en pacientes de los grupos I y III. Las soluciones de tipo quirúrgico mecánico pueden haber llegado a su límite de beneficio en las formas severas de peritonitis.

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Schein, M. Planned reoperations and open management in critical intra-abdominal infections: Prospective experience in 52 cases. World J. Surg. 15, 537–545 (1991). https://doi.org/10.1007/BF01675658

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Keywords

  • Peritonitis
  • Organ Failure
  • Multiple Organ
  • Open Management
  • Therapeutic Modality