Open abdominal management for perforative peritonitis with septic shock: a retrospective analysis on usefulness of a standardized treatment protocol

Abstract

Background

Damage control surgery (DCS) with open abdominal management (OAM) has been increasingly expanded to include critically ill non-trauma patients. However, there is limited data regarding the usefulness of this protocol for the treatment of severe perforative peritonitis (PP), especially with septic shock (SS). Here, we retrospectively evaluated the usefulness of our OAM protocol for PP with SS.

Methods

We retrospectively reviewed patients with from June 2015 to September 2018. The proposed protocol was composed of the following steps: (1) rapid control of contamination; (2) temporary abdominal closure; (3) repeated washout of the abdominal cavity; and (4) delayed definitive surgery. For temporary abdominal closure, a negative pressure wound therapy device was used. The end points were the morbidity and 30-day mortality rates. Logistic backward regression was performed to identify factors associated with complications.

Results

The mortality rate was 4% (1/25) and the overall morbidity rate of surviving patients was 58.3% (14/24). The mean duration of the first DCS was 67.36 ± 22.83 min. The median durations of ventilation and intensive care unit stay were 5 and 7 days, respectively. Although not significant, morbidity might be associated with age, diabetes mellitus, initial operative time, and OAM duration.

Conclusions

A standardized protocol for OAM may improve the outcomes of patients with SS due to PP. This damage control approach can be applied for the treatment of severe abdominal sepsis.

Background

Damage control surgery (DCS) with open abdominal management (OAM) is a well-established technique for the treatment of severe trauma patients that has been increasingly adapted and expanded to include the management of critically ill patients with intra-abdominal septic and vascular catastrophes [1, 2]. In many studies, the indications for OAM among non-trauma patients vary, as the preoperative indications include peritonitis, mesenteric ischemia, gastrointestinal hemorrhage, and pancreatitis [3, 4]. Meanwhile, intraoperative indications include damage control, the facilitation of an early second look, excessive contamination, and decompression, among others. Nonetheless, it is difficult to estimate the usefulness of OAM simply based on the wide application of the procedure. Despite the relatively wide adoption of this technique among non-trauma patients, existing data are limited, leading many to call for further investigations into the usefulness of OAM for non-trauma patients [5, 6].

Perforative peritonitis (PP) is the main indication of OAM, especially when combined with septic shock (SS), which continues to have a relatively high mortality rate. However, there are limited data regarding the usefulness of OAM and DCS for SS with acute diffuse peritonitis, such as PP. Based on the encouraging results reported in the literature and our own experience, we developed and adopted, from June 2013, a treatment protocol for patients with SS due to PP, in order to standardize OAM. Therefore, the aim of the present study was to evaluate the usefulness of a standardized OAM protocol for PP with SS and to identify factors associated with medical complications.

Methods

After being granted institutional review board approval, patients who received OAM for SS due to PP from June 2015 to September 2018 at Sakai City Medical Center were enrolled in this retrospective study. The acute care surgery (ACS) team managed all patients.

Patients with SS were clinically identified by a vasopressor requirement to maintain a mean arterial pressure of ≥ 65 mmHg and serum lactate level of > 2 mmol/L ( > 18 mg/dL) in the absence of hypovolemia [7].

In our protocol, every patient with the diagnosis of SS due to PP received OAM that was adapted for damage control, which included: (1) rapid control of contamination without anastomosis; (2) temporary abdominal closure; (3) ICU care, with correction of organ failure, and washout of the abdominal cavity every 24 h; and if necessary (4) delayed definitive surgery [8].

A negative pressure wound therapy (NPWT) device (RENASYS® system; (Smith & Nephew Medical, Ltd., London, England) or a vacuum-assisted closure system (Acelity L.P. Inc., San Antonio, TX, USA) was used for the temporary abdominal closure. Silicon-faced wound dressing mesh (SI-Mesh®; ALCARE Co., Ltd., Tokyo, Japan) was spread out between the bowel and peritoneum as a wound contact layer (Fig. 1a). A foam dressing that was cut in accordance with the shape of the wound was applied upon the mesh. NPWT at − 80 to 100 mmHg was performed (Fig. 1b).

Fig. 1
figure1

Temporary closure method. a Silicon-faced wound dressing mesh was spread out between the bowel and peritoneum. b A foam dressing that was cut in accordance with the shape of the wound was applied upon the mesh and then vacuumed

In the proposed OAM protocol, the patient was extubated after fascial closure because the abdominal cavity was repeatedly washed out under deep sedation to prevent re-intubation during abdominal closure. The ACS team used the World Journal of Emergency Surgery guidelines to decide the timing to close the fascia safely without contamination of the abdominal cavity and to prevent edema of the bowel and retroperitoneum [9].

Patient demographics and clinical variables were retrospectively collected to evaluate the usefulness of a standardized OAM protocol for PP with SS. Demographic data, the Mannheim peritonitis index (MPI), and the Acute Physiology and Chronic Health Evaluation (APACHE II) score were retrieved from medical records [10, 11]. The MPI is a scoring system of risk factors (i.e., age, sex, organ failure, malignancy, origin of sepsis, preoperative duration, extension of peritonitis, and character of exudates) to predict death among patients with peritonitis.

Operative data included the duration of the first surgery, the number of abdominal washouts before fascial closure, and length of ICU stay. Outcome data included the incidences of surgical site infection (SSI) and mortality. Mortality was defined as death within 30 days postoperative or before hospital discharge.

All statistical analyses were performed using IBM SPSS Statistics for Windows, version 24.0. (IBM Corporation, Armonk, NY, USA). The Mann–Whitney U test was used to compare continuous data between the two groups, whereas categorical data were analyzed using the chi-square or Fisher’s exact test, as appropriate. Logistic backward regression was performed to independently identify factors associated with complications. A probability (p) value of < 0.05 was considered statistically significant.

Results

Over the 3-year study period, 46 non-trauma patients received OAM, which included 25 with SS due to PP. DCS and OAM were performed for all cases with SS. All 25 patients underwent primary fascial closure. The median patient age was 72.6 years of age and 40% of patients were male. Perforations were located in the stomach in two patients, duodenum in 3, small intestine in1, right-side colon in 4, left-side colon in 14, and the appendix in one. Of the surgical interventions performed, 20 (80%) were bowel resections.

The mean MPI and APACHE II scores were 26.28 ± 5.17 and 18.84 ± 4.69, respectively. The mean duration of the first damage control operation was 67.36 ± 22.83 min (Table 1). The median durations of ventilation and ICU stay were 7 (range 5.75–10) days and 5 (range 4–7) days, respectively. Abdominal washouts before fascial closure were performed a mean of 3 (range 2–4) times, which was equal to the number of days of OAM (Table 2).

Table 1 Characteristics and perioperative risk factor of OAM patients
Table 2 Patient outcomes after OAM

Only one person died during hospitalization, thus the 30-day mortality rate was 4%. The overall complication rate among the surviving patients was 58.3% (14/25). The main complication was SSI. Of the six patients with a grade II SSI, two had dehiscence of the fascia and three had developed an intra-abdominal abscess. However, there was no incidence of enteric fistula formation among the patients who received OAM. Failed extubation requiring tracheotomy occurred in five patients. For one patient, primary closure was not possible, so a planned ventral hernia was performed.

The results of multivariate analysis with logistic regression were showed in Table 3. Although not significant, patients with a low MPI score (OR 0.479; 95% CI 0.044–5.17) tended to incur fewer complications. In contrast, patients with a relatively OAM duration > 3 days (OR 2.85; 95% CI 0.367–22.2), diabetes mellitus (DM) (OR 2.05; 95% CI 0.133–31.6), initial operative time more than 60 min (OR 1.86; 95% CI 0.288–12.1), or age over 70 years old (OR 1.68; 95% CI 0.193–14.7) tended to have more complications.

Table 3 Multivariate analysis with logistic regression

Discussion

SS, by definition, is associated with organ dysfunction or tissue hypoperfusion [12]. Although treatment options have improved for the management of the underlying infection and support of failing organs, the mortality rates associated with SS remain high [13]. In fact, the 2014 Complicated Intra-abdominal Infections Worldwide Observational study [14] reported a mortality rate of 36.5% in patients with SS due to intra-abdominal infections.

The OAM technique, when used appropriately, may be useful for the management of surgical patients with severe abdominal sepsis [15]. However, at present, there is no established protocol of OAM for these patients. In the proposed method, every patient with SS due to PP received OAM with adaptation for damage control. Because it is considered the concept of DCS, OAM was applied to the treatment protocol of all patients with intra-abdominal SS.

The principles and sequence of damage control include an abbreviated laparotomy for control of massive bleeding and fecal spillage, secondary correction of abnormal physiological parameters in an ICU setting, followed by a planned definitive re-exploration for the correction of anatomical derangements [16, 17]. In a 1-year prospective observational study conducted by Bruns et al. [18], OAM was applied to 96 non-trauma patients, which included 35 (37%) and 10 (10%) indicated for damage control and excessive contamination, respectively. A total of 29 OAM patients (30%) died during hospitalization. In addition, Kritayakirana et al. [19] reported that the open abdomen technique for DCS was associated with a significantly high mortality rate of 31% among patients requiring emergency surgery.

The MPI is a good predictor of mortality due to PP [20,21,22,23,24,25]. Recent studies have reported mortality rates of 50–67.4% among patients with an MPI score of > 29 and 29.4–40.7% among those with an MPI score of > 25 [26,27,28]. In comparison, the overall 30-day mortality rate in the present study was only 4% and 16.7% (1/6) among patients with an MPI score of > 29 and 6.25% among those with an MPI score of > 25 (1/16). These data show that the proposed OAM protocol is an effective treatment option for PP with SS.

There are two main benefits of OAM for PP: (1) overcoming the impossibility to completely control contamination in a single operation and (2) reducing the risk of development of abdominal compartment syndrome due to extensive visceral edema and a further decrease in abdominal wall compliance. In the proposed protocol, the dressing is regularly changed and the abdominal cavity is washed out every 24 h until fascial closure. We speculate that repeated washout of the abdominal cavity and the alleviation of high abdominal pressure can help prevent bacterial infection of the bloodstream.

In the present study, no case required blood purification therapy. Additionally, recent studies have highlighted the benefit of drainage of inflammatory ascites with NPWT, which has a profound positive effect on the inflammatory response [29, 30]. So, this mechanism may be beneficial for SS.

The most common complications after OAM are enterocutaneous or enteroatmospheric fistulae formation and SSI. There was no incidence of enteric fistula formation following OAM in this study. However, of the 26 surviving patients, 6 (23.1%) developed an SSI. It should be noted that in five patients, extubation failed and required tracheotomy. As the cause of failed extubation, upper airway narrowing was noted in two patients and difficulty with sputum expectoration in one. The other two patients required a tracheotomy because of a prolonged intubation duration. Notably, prolonged OAM was associated with an increased risk of failed extubation, which was primarily due to the prolonged intubation period in the proposed protocol. Even though the overall risk of morbidity remained relatively high, the application of this technique was beneficial for reducing the mortality rate and improving survival.

According to the results of multivariate analysis, age, DM, initial operative time, and OAM duration might also be predictors of morbidity.

As a limitation, this was a retrospective single-center study with a small number of cases. Notably, such a protocol should be performed only under specific conditions and may not apply to all centers. Additionally, the timing of abdominal fascial closure may be partially dependent on the subjective judgment of the ACS team as there are no definite standards. Despite these limitations, OAM was found to be beneficial for abdominal sepsis. To the best of our knowledge, this is the first study to report the usefulness of OAM for SS.

Conclusions

Our findings suggest that DCS with OAM is a viable option for the treatment of PP with SS and might be associated with low mortality. However, other improvements should be explored to further reduce morbidity. Moreover, future studies are needed to compare the benefits of DCS with OAM versus conserve treatment.

Abbreviations

DCS:

Damage control surgery

NPWT:

Negative pressure wound therapy

OAM:

Open abdominal management

PP:

Perforative peritonitis

SS:

Septic shock

WBC:

White blood cell

BMI:

Body mass index

COPD:

Chronic obstructive pulmonary disease

ICU:

Intensive care unit

References

  1. 1.

    Patel NY, Cogbill TH, Kallies KJ, Mathiason MA. Temporary abdominal closure: long-term outcomes. J Trauma. 2011;70:769–74.

    Article  PubMed  Google Scholar 

  2. 2.

    Diaz JJ Jr, Cullinane DC, Dutton WD, Jerome R, Bagdonas R, Bilaniuk JW, et al. The management of the open abdomen in trauma and emergency general surgery: part 1-damage control. J Trauma. 2010;68:1425–38.

    Article  PubMed  Google Scholar 

  3. 3.

    Aprahamian C, Wittman DH, Bergstein JM, Quebbeman EJ. Temporary abdominal closure (TAC) for planned relaparotomy (Etappenlavage) in trauma. J Trauma. 1990;30:719–23.

    Article  CAS  PubMed  Google Scholar 

  4. 4.

    van Ruler O, Mahler CW, Boer KR, Reuland EA, Gooszen HG, Opmeer BC, et al. Comparison of on-demand vs. planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA. 2007;298:865–72.

    Article  PubMed  Google Scholar 

  5. 5.

    Morris JA Jr, Fildes J, May AK, Diaz J, Britt LD, Meredith JW. A research agenda for emergency general surgery: clinical trials. J Trauma Acute Care Surg. 2013;74:329–33.

    Article  PubMed  Google Scholar 

  6. 6.

    Leppäniemi A, Kimball EJ, De Laet I, Malbrain ML, Balogh ZJ, De Waele JJ. Management of abdominal sepsis—a paradigm shift? Anaesthesiol Intensive Ther. 2015;47:400–8.

    Article  PubMed  Google Scholar 

  7. 7.

    Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315:801–10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Lee JC, Peitzman AB. Damage-control laparotomy. Curr Opin Crit Care. 2006;12:346–50.

    Article  PubMed  Google Scholar 

  9. 9.

    Coccolini F, Roberts D, Ansaloni L, Ivatury R, Gamberini E, Kluger Y, et al. The open abdomen in trauma and non-trauma patients: WSES guidelines. World J Emerg Surg. 2018;13:7.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Wacha H. Mannheim peritonitis index-prediction of risk of death from peritonitis: construction of a statistical and validation of an empirically based index. Theor Surg. 1987;1:169–77.

    Google Scholar 

  11. 11.

    Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–29.

    Article  CAS  PubMed  Google Scholar 

  12. 12.

    Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008;36:296–327.

    Article  PubMed  Google Scholar 

  13. 13.

    Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med. 2013;369:840–51.

    Article  CAS  PubMed  Google Scholar 

  14. 14.

    Sartelli M, Catena F, Ansaloni L, Coccolini F, Corbella D, Moore EE, et al. Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW study. World J Emerg Surg. 2014;9:37.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Ivatury RR. Update on open abdomen management: achievements and challenges. World J Surg. 2009;33:1150–3.

    Article  PubMed  Google Scholar 

  16. 16.

    Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin N Am. 1997;77:761–77.

    Article  CAS  PubMed  Google Scholar 

  17. 17.

    Burch JM, Denton JR, Noble RD. Physiologic rationale for abbreviated laparotomy. Surg Clin N Am. 1997;77:779–82.

    Article  CAS  PubMed  Google Scholar 

  18. 18.

    Bruns BR, Ahmad SA, OʼMeara L, Tesoriero R, Lauerman M, Klyushnenkova E, et al. Nontrauma open abdomens: A prospective observational study. J Trauma Acute Care Surg. 2016;80(4):631–6.

    Article  PubMed  Google Scholar 

  19. 19.

    Kritayakirana K, Maggio P, Brundage S, Purtill MA, Staudenmayer K, Spain DA. Outcomes and complications of open abdomen technique for managing non-trauma patients. J Emerg Trauma Shock. 2010;3:118–22.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Wacha H, Linder MM, Feldman U, Wesch G, Gundlach E, Steifensand RA. Mannheim peritonitis index—prediction of risk of death from peritonitis: construction of a statistical and validation of an empirically based index. Theor Surg. 1987;1:169–77.

    Google Scholar 

  21. 21.

    Billing A, Frohlich D. Prediction of outcome using the Mannheim peritonitis index in 2003 patients. Br J Surg. 1994;81:209–13.

    Article  CAS  PubMed  Google Scholar 

  22. 22.

    Demmel N, Maag K, Osterholzer G. The value of clinical parameters for determining the prognosis of peritonitis-validation of the Mannheim Peritonitis Index. Langenbecks Arch Chir. 1994;379:152–8.

    Article  CAS  PubMed  Google Scholar 

  23. 23.

    Fugger R, Rogy M, Herbst F, Schemper M, Schulz F. Validation study of the Mannheim peritonitis index. Chirurg. 1988;59:598–601.

    CAS  PubMed  Google Scholar 

  24. 24.

    Chaudhari ND, Nakum A, Mahida H. Mannheim’s peritonitis index validation study in the Indian set-up. Int J Sci Res. 2012;7:43–8.

    Google Scholar 

  25. 25.

    Notash AY, Salimi J, Rahimian H, Fesharaki MS, Abbasi A. Evaluation of Mannheim peritonitis index and multiple organ failure score in patients with peritonitis. Indian J Gastroenterol. 2005;24:197.

    PubMed  Google Scholar 

  26. 26.

    Baothman AB, Md F, Reddy NV. Study of mannheims peritonitis index in patients with peritonitis. Int Surg J. 2016;3(2):746–50.

    Article  Google Scholar 

  27. 27.

    Budzyński P, Dworak J, Natkaniec M, Pędziwiatr M, Major P, Migaczewski M, et al. The usefulness of the Mannheim Peritonitis Index score in assessing the condition of patients treated for peritonitis. Pol Przegl Chir. 2015;87:301–6.

    Article  Google Scholar 

  28. 28.

    Sharma R, Ranjan V, Jain S, Joshi T, Tyagi A, Chaphekar R. A prospective study evaluating utility of Mannheim peritonitis index in predicting prognosis of perforation peritonitis. J Nat Sc Biol Med. 2015;6:S49.

    CAS  Google Scholar 

  29. 29.

    Kubiak BD, Albert SP, Gatto LA, Snyder KP, Maier KG, Vieau CJ, et al. Peritoneal negative pressure therapy prevents multiple organ injury in a chronic porcine sepsis and ischemia/reperfusion model. Shock. 2010;34:525–34.

    Article  CAS  PubMed  Google Scholar 

  30. 30.

    Emr B, Sadowsky D, Azhar N, Gatto LA, An G, Nieman GF, et al. Removal of inflammatory ascites is associated with dynamic modification of local and systemic inflammation along with prevention of acute lung injury: in vivo and in silico studies. Shock. 2014;41(4):317–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Funding

Not applicable.

Author information

Affiliations

Authors

Contributions

KI drafted the manuscript. AU, MY, KA, NM, YT, and YN critically revised the article for important intellectual content. JY is the Department Chairperson and supervised the writing of the manuscript. All of the authors approved the final version of the manuscript.

Corresponding author

Correspondence to Koichi Inukai.

Ethics declarations

Conflict of interest

The authors have no competing interests to declare.

Ethics approval and consent to participate

Ethical approval was obtained from Institutional Review Board of Sakai City Medical Hospital. Consent to participate was not applicable owing to the retrospective nature of the study.

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Inukai, K., Usui, A., Yamada, M. et al. Open abdominal management for perforative peritonitis with septic shock: a retrospective analysis on usefulness of a standardized treatment protocol. Eur J Trauma Emerg Surg (2019). https://doi.org/10.1007/s00068-019-01132-2

Download citation

Keywords

  • Damage control surgery
  • Open abdominal management
  • Perforative peritonitis
  • Secondary peritonitis
  • Septic shock