Skip to main content
SpringerLink
Log in

Clinical Predictors of Ongoing Infection in Secondary Peritonitis: Systematic Review

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1.
Figure 2.

Similar content being viewed by others

References

  1. Lamme B, Boermeester MA, Reitsma JB, et al. Meta-analysis of relaparotomy for secondary peritonitis. Br J Surg 2002;89:1516–1524

    Article  PubMed  CAS  Google Scholar 

  2. Hinsdale JG, Jaffe BM. Re-operation for intra-abdominal sepsis: indications, results in modern critical care setting. Ann Surg 1984; 199:31–36

    Article  PubMed  CAS  Google Scholar 

  3. Machiedo GW, Tikellis J, Suval W, et al. Reoperation for sepsis. Am Surg 1985;51:149–154

    PubMed  CAS  Google Scholar 

  4. Beal AL, Cerra FB. Multiple organ failure syndrome in the 1990s: systemic inflammatory response and organ dysfunction. JAMA 1994;271:226–233

    Article  PubMed  CAS  Google Scholar 

  5. Ferraris VA. Exploratory laparotomy for potential abdominal sepsis in patients with multiple-organ failure. Arch Surg 1983;118:1130–1133

    PubMed  CAS  Google Scholar 

  6. Fry DE, Garrison RN, Heitsch RC, et al. Determinants of death in patients with intraabdominal abscess. Surgery 1980;88:517–523

    PubMed  CAS  Google Scholar 

  7. Koperna T, Schulz F. Relaparotomy in peritonitis: prognosis and treatment of patients with persisting intraabdominal infection. World J Surg 2000;24:32–37

    Article  PubMed  CAS  Google Scholar 

  8. Pacelli F, Doglietto GB, Alfierri S, et al. Prognosis in intra-abdominal infections: multivariate analysis on 604 patients. Arch Surg 1996;131:641–645

    PubMed  CAS  Google Scholar 

  9. Wickel DJ, Cheadle WG, Mercer-Jones MA, et al. Poor outcome from peritonitis is caused by disease acuity and organ failure, not recurrent peritoneal infection. Ann Surg 1997;225:744–753

    Article  PubMed  CAS  Google Scholar 

  10. Altman DG. Systematic reviews of evaluations of prognostic variables. BMJ 2001;323:224–228

    Article  PubMed  CAS  Google Scholar 

  11. Chalmers TC, Smith H, Blackburn B, et al. A method for assessing the quality of a randomized control trial. Control Clin Trials 1981;2:31–49

    Article  PubMed  CAS  Google Scholar 

  12. Evans M, Pollock AV. A score system for evaluating random control clinical trials of prophylaxis of abdominal surgical wound infection. Br J Surg 1985;72:256–260

    PubMed  CAS  Google Scholar 

  13. Fletcher B, Sackett DL. Canadian Task Force on the periodic health examination: the periodic health examination. CMAJ 1979;121:1193–1254

    Google Scholar 

  14. Lamme B, Boermeester MA, Belt EJ, et al. Mortality and morbidity of planned relaparotomy versus relaparotomy on demand for secondary peritonitis. Br J Surg 2004;91:1046–1054

    Article  PubMed  CAS  Google Scholar 

  15. Teichmann W, Wittmann DH, Andreone PA. Scheduled reoperations (etappenlavage) for diffuse peritonitis. Arch Surg 1986;121:147–152

    PubMed  CAS  Google Scholar 

  16. Penninckx FM, Kerremans RP, Filez L. Planned relaparotomies for advanced, established peritonitis from colonic origin. Acta Chir Belg 1990;90:269–274

    PubMed  CAS  Google Scholar 

  17. Ohmann C. Prognostic scores and design of clinical studies. Infection 1998;26:342–344

    PubMed  CAS  Google Scholar 

  18. Jiffry BA, Sebastian MW, Amin T, et al. Multiple laparotomies for severe intra-abdominal infection. Aust N Z J Surg 1998;68:139–142

    PubMed  CAS  Google Scholar 

  19. Billing A, Frohlich D, Schildberg FW. Prediction of outcome using the Mannheim peritonitis index in 2003 patients: Peritonitis Study Group. Br J Surg 1994;81:209–213

    PubMed  CAS  Google Scholar 

  20. Oberholzer A, Keel M, Zellweger R, et al. Incidence of septic complications and multiple organ failure in severely injured patients is sex specific. J Trauma 2000;48:932–937

    PubMed  CAS  Google Scholar 

  21. Spence PA, Mathews RE, Khanna R, et al. indications for operation when peritonitis occurs in patients on chronic ambulatory peritoneal dialysis. Surg Gynecol Obstet 1985;161:450–452

    PubMed  Google Scholar 

  22. Bohnen JM, Schouten BD. Predicting the need for reoperation for abdominal infection. New Horiz 1998;6:S89–S96

    PubMed  CAS  Google Scholar 

  23. Velmahos GC, Degiannis E, Souter I. Relaparotomies for abdominal sepsis—why, when, how? A collective review. S Afr J Surg 1998;36:52–56

    PubMed  CAS  Google Scholar 

  24. Krause R. Reintervention in abdominal surgery. World J Surg 1987;11:226–232

    Article  PubMed  CAS  Google Scholar 

  25. Dellinger EP. Use of scoring systems to assess patients with surgical sepsis. Surg Clin North Am 1988;68:123–145

    PubMed  CAS  Google Scholar 

  26. van Goor H. Interventional management of abdominal sepsis: when and how. Langenbecks Arch Surg 2002;387:191–200

    Article  PubMed  Google Scholar 

  27. Holzheimer R, Dralle H. Paradigm change in 30 years peritonitis treatment: a review on source control. Eur J Med Res 2001;6:161–168

    PubMed  CAS  Google Scholar 

  28. Bohnen JM, Mustard RA. A critical look at scheduled relaparotomy for secondary bacterial peritonitis. Surg Gynecol Obstet 1991;172(Suppl):25–29

    Google Scholar 

  29. Pusajo JF, Bumaschny E, Doglio GR, et al. Postoperative intra-abdominal sepsis requiring reoperation: value of a predictive index. Arch Surg 1993;128:218–222

    PubMed  CAS  Google Scholar 

  30. Sinanan M, Maier RV, Carrico CJ. Laparotomy for intra-abdominal sepsis in patients in an intensive care unit. Arch Surg 1984;119:652–658

    PubMed  CAS  Google Scholar 

  31. Mustard RA, Bohnen JM, Rosati C, et al. Pneumonia complicating abdominal sepsis: an independent risk factor for mortality. Arch Surg 1991;126:170–175

    PubMed  CAS  Google Scholar 

  32. Ohmann C, Hau T. Prognostic indices in peritonitis. Hepatogastroenterology 1997;44:937–946

    PubMed  CAS  Google Scholar 

  33. Ohmann C, Wittmann DH, Wacha H. Prospective evaluation of prognostic scoring systems in peritonitis: Peritonitis Study Group. Eur J Surg 1993;159:267–274

    PubMed  CAS  Google Scholar 

  34. Dellinger EP, Wertz MJ, Meakins JL, et al. Surgical infection stratification system for intra-abdominal infection: multicenter trial. Arch Surg 1985;120:212–219

    Google Scholar 

  35. Pine RW, Wertz MJ, Lennard ES, et al. Determinants of organ malfunction or death in patients with intra-abdominal sepsis: a discriminant analysis. Arch Surg 1983;118:242–249

    PubMed  CAS  Google Scholar 

  36. Zer M, Dux S, Dintsman M. The timing of relaparotomy and its influence on prognosis: a 10 year survey. Am J Surg 1980;139:338–343

    Article  PubMed  CAS  Google Scholar 

  37. Wacha H, Hau T, Dittmer R, et al. Risk factors associated with intraabdominal infections: a prospective multicenter study; Peritonitis Study Group. Langenbecks Arch Surg 1999;384:24–32

    Article  PubMed  CAS  Google Scholar 

  38. Koperna T, Schulz F. Prognosis and treatment of peritonitis: do we need new scoring systems? Arch Surg 1996;131:180–186

    PubMed  Google Scholar 

  39. Makela J, Kairaluoma MI. Relaparotomy for postoperative intra-abdominal sepsis in jaundiced patients. Br J Surg 1988;75:1157–1159

    PubMed  CAS  Google Scholar 

  40. Meisner M, Tschaikowsky K, Palmaers T, et al. Comparison of procalcitonin (PCT) and C-reactive protein (CRP) plasma concentrations at different SOFA scores during the course of sepsis and MODS. Crit Care (Lond) 1999;3:45–50

    Article  Google Scholar 

  41. Gotzinger P, Gebhard B, Wamser P, et al. [Revision of diffuse peritonitis: planned versus on demand.] Langenbecks Arch Chir 1996;381:343–347

    Article  PubMed  CAS  Google Scholar 

  42. Grunau G, Heemken R, Hau T. Predictors of outcome in patients with postoperative intra-abdominal infection. Eur J Surg 1996;162:619–625

    PubMed  CAS  Google Scholar 

  43. Hau T, Ohmann C, Wolmershauser A, et al. Planned relaparotomy vs relaparotomy on demand in the treatment of intra-abdominal infections: The Peritonitis Study Group of the Surgical Infection Society–Europe. Arch Surg 1995;130:1193–1196

    PubMed  Google Scholar 

  44. Bunt TJ. Urgent relaparotomy: the high-risk, no-choice operation. Surgery 1985;98:555–560

    PubMed  CAS  Google Scholar 

  45. Bunt TJ. Non-directed relaparotomy for intra-abdominal sepsis: a futile procedure. Am Surg 1986;52:294–298

    PubMed  CAS  Google Scholar 

  46. Butler JA, Huang J, Wilson SE. Repeated laparotomy for postoperative intra-abdominal sepsis: an analysis of outcome predictors. Arch Surg 1987;122:702–706

    PubMed  CAS  Google Scholar 

  47. Bohnen JM, Mustard RA, Oxholm SE, et al. APACHE II score and abdominal sepsis: a prospective study. Arch Surg 1988;123:225–229

    PubMed  CAS  Google Scholar 

  48. Bosscha K, Reijnders K, Hulstaert PF, et al. Prognostic scoring systems to predict outcome in peritonitis and intra-abdominal sepsis. Br J Surg 1997;84:1532–1534

    Article  PubMed  CAS  Google Scholar 

  49. Christou NV, Barie PS, Dellinger EP, et al. Surgical Infection Society intra-abdominal infection study: prospective evaluation of management techniques and outcome. Arch Surg 1993;128:193–198

    PubMed  CAS  Google Scholar 

  50. Makela J, Kiviniemi H, Laitinen S. Prevalence of perforated sigmoid diverticulitis is increasing. Dis Colon Rectum 2002;45:955–961

    Article  PubMed  Google Scholar 

  51. Mulier S, Penninckx F, Verwaest C, et al. Factors affecting mortality in generalized postoperative peritonitis: multivariate analysis in 96 patients. World J Surg 2003;27:379–384

    Article  PubMed  Google Scholar 

  52. Ozguc H, Yilmazlar T, Gurluler E, et al. Staged abdominal repair in the treatment of intra-abdominal infection: analysis of 102 patients. J Gastrointest Surg 2003;7:646–651

    Article  PubMed  Google Scholar 

  53. Holzheimer RG, Gathof B. Re-operation for complicated secondary peritonitis: how to identify patients at risk for persistent sepsis. Eur J Med Res 2003;8:125–134

    PubMed  CAS  Google Scholar 

  54. Cerra FB, Negro F, Abrams J. APACHE II score does not predict multiple organ failure or mortality in postoperative surgical patients. Arch Surg 1990;125:519–522

    PubMed  CAS  Google Scholar 

  55. Bohnen JM, Christou NV, Maclean LD, et al. Predicting postoperative complications. Br J Surg 1983;70:128

    PubMed  CAS  Google Scholar 

  56. McCrory C, Crowley K. Is repeat laparotomy of value in patients with suspected intra-abdominal sepsis in the intensive care unit? Ir J Med Sci 1997;166:88–91

    Article  PubMed  CAS  Google Scholar 

  57. Marshall JC, Maier RV, Jimenez M, et al. Source control in the management of severe sepsis and septic shock: an evidence-based review. Crit Care Med 2004;32:S513–S526

    Article  PubMed  Google Scholar 

  58. Dupont H, Paugam-Burtz C, Muller-Serieys C, et al. Predictive factors of mortality due to polymicrobial peritonitis with Candida isolation in peritoneal fluid in critically ill patients. Arch Surg 2002;137:1341–1346

    Article  PubMed  Google Scholar 

  59. Berard A, Andreu N, Tetrault J, et al. Reliability of Chalmers’ scale to assess quality in meta-analyses on pharmacological treatments for osteoporosis. Ann Epidemiol 2000;10:498–503

    Article  PubMed  CAS  Google Scholar 

  60. Linder MM, Wacha H, Feldmann U, et al. [The Mannheim peritonitis index: an instrument for the intraoperative prognosis of peritonitis.] Chirurg 1987;58:84–92

    PubMed  CAS  Google Scholar 

  61. Marshall JC, Cook DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med 1995;23:1638–1652

    Article  PubMed  CAS  Google Scholar 

  62. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure: on behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996;22:707–710

    PubMed  CAS  Google Scholar 

  63. Ohmann C, Yang Q, Hau T, et al. Prognostic modelling in peritonitis: Peritonitis Study Group of the Surgical Infection Society Europe. Eur J Surg 1997;163:53–60

    PubMed  CAS  Google Scholar 

  64. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818–829

    Article  PubMed  CAS  Google Scholar 

  65. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg 1991;78:355–360

    PubMed  CAS  Google Scholar 

  66. Moreno R, Vincent JL, Matos R, et al. The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care: results of a prospective, multicentre study; Working Group on Sepsis Related Problems of the ESICM. Intensive Care Med 1999;25:686–696

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgment

The present study was supported by a grant from The Center for Clinical Guidelines of the Academic Medical Center, Amsterdam.

Author information

Authors and Affiliations

  1. Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105, AZ, The Netherlands

    Bas Lamme MD, PhD, Cecilia W. Mahler MD, Oddeke van Ruler MD, Dirk J. Gouma MD, PhD & Marja A. Boermeester MD, PhD

  2. Department of Clinical Epidemiology and Biostatistics, Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105, AZ, The Netherlands

    Johannes B. Reitsma MD, PhD

Authors
  1. Bas Lamme MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Cecilia W. Mahler MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Oddeke van Ruler MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dirk J. Gouma MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Johannes B. Reitsma MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Marja A. Boermeester MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marja A. Boermeester MD, PhD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lamme, B., Mahler, C.W., van Ruler, O. et al. Clinical Predictors of Ongoing Infection in Secondary Peritonitis: Systematic Review. World J. Surg. 30, 2170–2181 (2006). https://doi.org/10.1007/s00268-005-0333-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-005-0333-1

Keywords

Search

Navigation