World J. Surg. 14, 210-217, 1990
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World Journal of Surgery 9 1990 by the Soci~t6 lnternationale de Chirurgie
Principles and Limitations of Operative Management of Intraabdominal Infections E d u a r d H. F a r t h m a n n , M . D . , and Ulrich Sch6ffel, M . D . Department of Surgery, University of Freiburg, Freiburg, Federal Republic of Germany Operative management of intraabdominal infections still rests on the principles of elimination of focus, reduction of contamination of the peritoneal cavity, and treatment of residual infection. To control the source of contamination from a perforated viscus primary closure, exclusion or resection may be considered with respect to the severity of peritonitis and to the underlying disease. The principle of "peritoneal toilet" with complementary use of systemic and/or local antibiotics is generally accepted even if the value of aggressive debridement is still debated controversely. For the treatment of residual and the prevention of recurrent infection, closed and open lavage techniques, the left-open abdomen, and planned relaparotomy represent the major approaches in severe generalized peritonitis when the infectious focus might not be securely controlled. The values and disadvantages of different regimens are discussed , additional measures are briefly described, and an outlook on areas of further research is given.
Standards or principles of surgical management can be best defined in a historical perspective. At the meeting of the German Surgical Society in 1926, Kirschner [1] presented a paper which stands out as a hallmark in the treatment of peritonitis. In the following article, this work is taken as a backdrop to point out what has been achieved since then and what still remains to be done. Every inflammatory response within the peritoneal cavity may lead from local peritonitis to generalized peritonitis or to abscess formation. For the purpose of clarity, these entities should be differentiated, although this may be difficult due to constant overlap. According to historical terminology, surgical management deals with "secondary peritonitis." Primary or spontaneous peritonitis, which is induced by hematogenous bacterial invasion of the peritoneal cavity, does not play a major role in the context of surgical therapy because nonoperative therapy is the treatment of choice. Secondary peritonitis can be subgrouped according to etiology with a certain impact on prognosis (Table 1). Independent of their intraabdominal anatomic origin, however, acute intraabdominal infections or perforations of a viscus will invariably lead to local or generalized peritonitis as does the Reprint requests: Eduard H. Farthmann, M.D., Department of Surgery, Universit/itsklinik Freiburg, Hugstetter Str. 55, 7800 Freiburg, Federal Republic of Germany.
so-called chemical peritonitis which is followed by bacterial invasion. Postoperative peritonitis is often regarded as a separate entity, partly because of its poor prognosis. When Kirschner [1] reviewed 1,626 cases treated in Krnigsberg from 1895 to 1925, he found the vast majority to be due to appendicitis. The situation has changed considerably since then (Table 2). Perforation of the appendix has dropped to fourth place with those of the stomach, duodenum, small intestine, and large bowel making up two-thirds of all cases. The mortality of intraabdominal infections in different time periods can be compared for different anatomic areas of origin (Table 3) [2, 3]. Obviously, the mortality has declined in all categories. This reduction is most pronounced for stomach and duodenum, for infections arising from the biliary tract, and for postoperative peritonitis, which was invariably fatal at the beginning of the century. The overall mortality, however, has not markedly improved since the days of Kirschner [1], who reported a mortality of 30% for the years 1920-1924 in contrast to 87.5% for the period 1895-1905. One should remember that, until that time, peritonitis was not generally regarded as a surgical disease. "The opinion seems to be gaining ground that in evacuating the pus in peritonitis the advantages outweigh the disadvantages," Kirschner [1] stated cautiously. The general acceptance of this principle in the 1920's led to a considerable reduction of mortality which then remained stable for about 40 years. Since then, another reduction has occurred with the development of intensive care medicine [4].
Therapeutic Principles
Surgical management can be conveniently subdivided into 3 principles which, at the same time, represent the usual sequence of maneuvers: 1. Elimination of the focus, to seal the leak and control the source of contamination. 2. Reduction of contamination, also known as "peritoneal toilet," to reduce or eliminate the bacterial inoculum. 3. Treatment of residual and prevention of recurrent infection.
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Table 1. Etiology of secondary peritonitis.
Table 4. Elimination of infectious focus.
Acute intraabdominal infection Perforation of viscus Translocation of bacteria from the gut Chemical peritonitis with bacterial invasion Postoperative peritonitis
Resection With primary anastomosis Strangulated hernia Mesenteric infarction Small bowel perforation (inflammatory disease, ischemic injury, malignoma, unknown cause) Large bowel perforation (unaltered bowel wall, irrigated bowel) Perforated sigmoid diverticulitis (low risk) Without anastomosis Large bowel perforation (unprepared bowel, irrigation not possible, gross peritonitis) Perforated sigmoid diverticulitis (high risk) Perforated malignancy of the colon (generalized peritonitis) Ulcerative colitis Complicated small bowel perforation Suture and Plication Without enterostomy Duodenal ulcer perforation Iatrogenic perforation (small bowel) Single small foreign body perforation (within 24 hr) Small traumatic perforation of the small bowel (within 24 hr) With proximal diverting ("protective") enterostomy Iatrogenic perforation of the large bowel (irrigated bowel)
Table 2. Etiology of intraoperative findings. Anatomic origin
1926
1986
Stomach and duodenum Small intestine Large bowel Appendix Pancreas and biliary tract Other
11%
20% 20% 25% 15% 10% 10%
12% 58% 2% 17%
Table 3. Mortality of intraabdominal infections. Mortality (%) Anatomic area Stomach and duodenum Small intestine Large bowel Biliary tract Pancreas Appendicitis Postoperative
1896--1925 [1] 58.3 82.8 72.7 85.7 35.2 100.0
1970-1985 [2, 3] (range) 2.%13 20.0-25 20.0-50 0--6 22.0-57 0-8 30.0-60
Elimination of Focus This can be done basically by closing, excluding, or resecting the primary source and by evacuating contaminated fluid (Table 4).
Table 5. Generalized peritonitis secondary to diverticular disease: Treatment modalities and mortality.
No. Died Mortality (%) Drainage with/without suture Colostomy with/without suture Colostomy with/without drainage Exteriorization Resection without anastomosis Resection with anastomosis Resection with anastomosis and colostomy
156
34
21.8
657 189 84 11 262 32 100 9 33 2
28.7 13.1 12.2 9.0 6.1
Modified from [9]. Review of 58 reports: 1957-1984.
Resection. Resection of the primary source seems to be the safest way and is possible if the causative organ can be removed as in appendicitis or in peritonitis due to a perforated gallbladder. Resection of a perforated or necrotic bowel segment obviously eliminates the focus, too, but entails the problem of restoring the continuity of the gut without undue danger of subsequent anastomotic leakage. In general, there seems to be a tendency to perform more and more anastomoses in the presence of frank peritonitis [5-8]. The principle of primary anastomosis seems to be fairly standardized for mesenteric ischemia and strangulated bowel, but is still widely debated in diverticular perforation of the colon, reflecting changing attitudes. Hartmann's procedure has been regarded as a gold standard in this situation and generally seems to be the safest way to deal with it. It should be performed in all but definitely favorable circumstances where a primary anastomosis can be performed after on-table irrigation [91. The listing in Table 5 represents the development of methods and the improvement of their results. The breakthrough came with the principle of eliminating the septic focus from the abdomen. Since then, only marginal improvements have been achieved. The favorable results reported for resection followed by anastomosis are probably due to a selection effect. Hart-
mann's procedure is generally preferred for the unprepared colon, if on-table irrigation is not possible, and if the underlying disease might affect the resection margins. Perforation of colon tumors, peritonitis in perforated ulcerative colitis, and larger traumatic perforations are best treated without restoration of continuity. Drainage and enterostomy as a time-honored procedure is mostly regarded as obsolete today. The same applies to the principle of exteriorization, which is rarely applied and may be technically cumbersome. If possible at all, a resection can usually be performed as well. The use of a proximal diverting colostomy to protect a colonic anastomosis has come into doubt since the occurrence of an anastomotic leakage is not affected [7] and a transverse colostomy will have little effect on pressures in the sigmoid colon [10]. In rare cases, subcutaneous positioning of high-risk anastomoses might be considered [11]. Resection followed by primary anastomosis is the treatment of choice for perforations of the small bowel [8]. The main indications are inflammatory lesions, ischemic injury, malignant disease, and perforations of unknown etiology. In high-risk patients with frank peritonitis or Crohn's disease, discontinuity
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procedures or a temporary proximal loop ileostomy may be of value [7, 12]. Suture and Plication. Suture and plication of a perforation is mainly performed today for perforated peptic ulcer. Additionally, it may be considered for single, small, foreign body or traumatic perforations of the small bowel diagnosed early [7, 8] or in cases of iatrogenic lesions during colonoscopy in a clean colon. In lesions of the pancreatic and biliary system, simple drainage following resection of infected necrosis or evacuation of contaminated fluid still has a place in the initial treatment of this type of peritonitis. Peritoneal Toilet
The principle of reduction of peritoneal contamination has received much attention since the beginnings of surgical treatment of peritonitis. Three different approaches have been suggested: mechanical cleansing, intraoperative lavage, and aggressive debridement. When Kirschner [1] compared the effect of intraoperative lavage and mechanical cleansing, he did not find any difference in mortality rates. Mechanical cleansing by the use of swabs has long been recommended for the treatment of a localized process (e.g., perforated appendicitis), but it is now widely accepted that bacterial contamination is rapidly disseminated throughout the peritoneal cavity by the so-called intraperitoneal circulation [13]. Intraoperative irrigation is considered, today, to be safe and helpful if contamination of the abdominal cavity has occurred. Objections to that procedure were the spread of localized bacterial infection, dilution of opsonins, and suspension of bacteria in a fluid medium where they are less amenable to phagocytosis. Despite recent statements to the contrary [14], it has become generally accepted that peritoneal lavage reduces the number of bacteria within the peritoneal cavity, thus giving the peritoneal defense mechanisms a greater chance. The question whether the irrigation fluid should contain antibiotic or antiseptic preparations is still widely discussed. A considerable amount of conflicting data has been accumulated in recent years dealing with the effects of a great variety of antibiotics under experimental and clinical conditions. Concerning local antibiotic treatment, none of the generally used substances showed an obviously superior effect [15], while in the range of antiseptic solutions, some beneficial effects of Taurolidine (in contrast to povidone-iodine solutions, which have been shown to be toxic [16]) might be supposed [17]. There are, however, only a few randomized controlled studies [18-23]. Their value is limited by the fact that most authors used systemic antibiotics as well. Small patient numbers [20, 21], unusual concentrations of antiseptic solutions [22], and minor forms of peritonitis [19] gave rise to additional objections. Noon [ 18] randomized 404 patients and showed that irrigation with Kanamycin and Bacitracin had no effect on mortality but decreased the wound infection rate from 24% to 11%. Stewart and Mattheson [19], using systemic antibiotic therapy as well, reported no fatal cases in their series of 185 patients with appendicular peritonitis. They found a reduction in wound infection rates by local tetracycline treatment in contrast to a
World J. Surg. Vol. 14, No. 2, Mar./Apr. 1990
Table 6. Radical peritoneal debridement (RPD) versus standard treatment (STD). RPD STD No. of patients 22 24 Perforated peptic ulcer 9 11 Perforated appendicitis 4 5 Bowel perforation 8 7 Other 1 1 Died 7 7 Reoperation for intraperitoneal infection 5 4 Modified from [31].
Noxythiolin-treated group, which did not differ from the controls. Recently, a study on the effects of antibiotics on bacterial growth kinetics in generalized peritonitis, beside supporting the use of systemic antibiotics, provided bacteriological evidence for the value of intraoperative lavage with tetracycline [24]. In animal studies, it has been demonstrated that a continuous peritoneal lavage was only helpful in the treatment of peritonitis if the lavage solution contained antibiotics, and was harmful if it did not [25]. It might be assumed that the concentration in the peritoneal exudate of antibiotics given systemically parallels the concentration in the serum while local application results in an unequal distribution within the peritoneal cavity [26]. On the other hand, local therapy may be advantageous because penetration to the infected spaces during systemic therapy is markedly reduced [13]. Generally, it can be stated that peritoneal lavage reduced the rates of wound infection, abscess formation, and mortality. A further reduction in wound infection may be achieved if the lavage fluid contains antibiotics [18, 19, 23, 27]. Other authors have definitely abandoned local antibiotic treatment [28]. Aggressive Debridement. Aggressive debridement has received much attention recently, but it should be remembered that it was an area of controversy in the past as well. Kirschner [1] seemed not to be really convinced of that procedure when he said, "The early cleansing fanaticism to eliminate fibrin deposits by the barbaric procedure of wiping and ripping is to be condemned." The controversy was reopened again by Hudspeth [5]. He felt that the main benefit attained from lavage was its debridement effect. In his study, he reported on the results of a procedure where all spaces within the peritoneal cavity were opened and cleaned. The series consisted of 92 patients with generalized peritonitis where he almost always found an abscess in the pouch of Douglas, and 22 subdiaphragmatic abscesses. All patients in whom the source of contamination could be eliminated survived with only 1 late complication cured conservatively. There are, however, several objections to this method, the most serious being that Needing from damaged surfaces results in hemoglobin and fibrin deposition, both known to be potent adjuvants to infection [29, 30]. In a prospective randomized trial, Polk and Fry [31] found no differences in terms of hospital mortality or the frequency of reoperation for abscesses (Table 6). It seems, therefore, that a general recommendation of
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Table 7. Mortality rates in comparative studies evaluating closed postoperative peritoneal lavage.
Treatment group Source Prospective, randomized studies Del Carmen Nieto and Nava, 1975 Olesen et al., i980 Shwani et al., 1980 Hunt, 1982 Beger, 1983 Nonrandomized, comparative studies McKenna et al., 1970 Kiene, 1974 Giessing and Tomlin, 1974 Bhushan et al., 1975 Hunt et al., 1975 Stephen and Loewenthal, 1978 Esser and Rappen, 1980 Uden et al., 1983 Washington et al., 1983
n
Died
Controls Mortality (%)
n
Died
Mortality (%)
40 20 20 15 14
4 0 4 5 3
10.0 0 20.0 33.3 21.4
20 10 19 29 16
8 0 2 8 7
40.0 0 10.5 27.6 43.8
25 97 72 30 38 27 41 181 50
5 42 11 6 9 6 17 1 7
20.0 43.0 15.3 20.0 23.7 22.2 41.5 0.6 14.0
25 100 106 30 38 68 71 188 44
15 71 6 18 18 33 30 1 4
60.0 71.0 5.7 60.0 47.4 48.5 42.3 0.5 9.1
Modified from [16, 32].
aggressive debridement in all cases of peritonitis cannot be given. At the termination of the intraabdominal procedure, the question remains whether a drain or several drains should be left behind. Removal of contaminated fluid and of necrotic material through intraperitoneally-placed drains is still a matter of controversy. N o b o d y would object to the statement that it is better to allow dead and live bacteria to be drained out continuously instead of being absorbed. It is still questionable, however, whether and how this can be achieved. Kirschner [1] compared the effect of closure of the abdomen with or without drainage on mortality, abscess formation, and wound infection. He did not find any difference and stated briefly, "The free peritoneal cavity cannot be drained." Basically, there are still several objections to drainage of the peritoneal cavity [29]: 1. Fibrous tracts will develop within a short period which do not communicate with the abdominal cavity as such. 2. Contamination from the outside might occur which, however, will not be of major concern in this situation. 3. Visceral erosion with fistulization and bleeding has been reported. 4. Drains may interfere with proper sealing of anastomoses. On the whole, the main objection against leaving drains behind is not their negative effect, but rather that they simply do not work. While these statements refer to drainage of the peritoneal cavity as such, drains will, of course, be effective in evacuating abscesses, establishing a controlled fistula, or offering a preferential pathway for the escape of visceral secretions after extensive damage to the pancreas or the biliary tract.
Treatment of Residual and Prevention of Recurrent Infection In the attempt to continue peritoneal toilet postoperatively, 3 major approaches have emerged: (a) continuous postoperative peritoneal lavage, (b) planned relaparotomy, (c) laparostomy (the left-open abdomen). Closed postoperative lavage may be
Table 8. Etappenlavage in generalized peritonitis.
Source
n
Died
Teichmann et al. [36], 1980 Arbogast [37], 1983 Teichmann et al. [34], 1986 Andrus et al. [38], 1986 (no planned reoperation Schein et al. [39], 1988
27 29 61 34 43 22
5 13 14 21 25) 7
performed by different means. Two inflow catheters in the subphrenic spaces and 2 outflow catheters in the pelvis are the most prevalent arrangement. The time period of either intermittent or continuous lavage usually ranges from 1 to 5 days. Most authors add antibiotics to the lavage fluid [32]. In a special form of dorsoventral lavage, the left-open abdomen is covered by a palisade of drains to allow removal of the fluid [33]. The basic question in all lavage procedures is whether it is possible to irrigate the abdomen properly or whether drainage tracts develop so that only the drains communicate and are irrigated continuously ("the irrigated a b d o m e n " versus "the irrigated drain" controversy). Recently, Leiboff [32] reviewed 39 reports on the results of closed postoperative peritoneal lavage published between 1963 and 1986. Despite conclusions, mostly in favor of postoperative lavage in those reports, Leiboff felt that the therapeutic value remains to be determined. The reason was that only one-half of the 12 comparative studies reported beneficial effects on postoperative mortality and that in the 4 prospective randomized studies, major limitations were small sample sizes and an unproven comparability between treatment groups (Table 7). The principle of planned relaparotomy or " e t a p p e n l a v a g e " has been suggested for patients with diffuse peritonitis being at high risk of developing multiple organ failure. Routine exploration is performed on a daily basis until evidence of improvement or healing is present [34]. Thus, at least the last intervention might be judged as unnecessary. Histologic observations showed that the inflammatory response declined at day 3 in most cases [35]. By using this method, promising results have
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Table 9. Treatment of residual and prevention of recurrent infection. Principle
Advantages
Objections
Continuous postoperative peritoneal l a v a g e
Continuous washout of infectious material Possibility of local antibiotic treatment No anesthesia required
Planned relaparotomy (scheduled reintervention)
Prompt recognition of complications No psychologic problem in reintervention No drainage Spontaneous drainage Relief of intraabdominal pressure Simplified reintervention
Inducement of bacterial fluid suspension Complications of drains Risk of fluid overload Development of adhesion-lined drainage tracts preventing adequate lavage Prolonged intubation Repeated damage to the abdominal wall Rebleeding (risk of additional damage) Retraction of the abdominal wall Succulence of the intestine Fistula formation Prolonged morbidity (major reintervention necessary)
Laparostomy (the left-open abdomen)
been reported (Table 8) [36-39]. As in all developing fields, however, there is conflicting evidence: Andrus [38] compared planned reoperation with the policy of observation following the primary operation and reoperation when indicated by signs of continuing infection. With respect to the acute physiology score (APS), both groups were comparable and no difference in mortality was found. An objection to this study is that it was not truly randomized and that the frequency of reoperations in the control group was fairly high with a mean of 1.8 --- 0.7, representing a high incidence of salvage operations. So, truly, there are, as yet, no standards in this field. The same applies for the method of closure of the abdomen when the policy of repeated laparotomies is applied. Sutures, meshes, zippers, and other techniques have been used for temporary closure. Leaving the cutis untouched, some of these procedures seem to combine the advantages of the scheduled lavage and of the left-open abdomen as well as their disadvantages (Table 9). The advocates of an absorbable mesh claim that it reduces intraabdominal pressure, prevents evisceration, and allows for effective drainage of the abdominal cavity [40]; however, the development of diffuse, patchy necrosis of the bowel wall resulting in fistula formation has been described [41]. The zipper offers the advantage of an easy access route and prevents damage to the abdominal wall during relaparotomy [34]. On the other hand, spontaneous drainage is prevented and a major reintervention inevitably becomes necessary. Recently, some favorable results have been reported in the treatment of intraabdominal necrotic foci with the use of a modified zipper technique [42]. Laparostomy or the left-open abdomen has been employed widely in France. It certainly relieves intraabdominal pressure which, at times, is crucial for impaired ventilation and intraabdominal circulation. It allows spontaneous drainage and simplifies reinterventions. The major objections are nursing problems, succulence of the intestine, fistula formation, and problems with the later closure of a retracted abdominal wall [43]. Much remains to be done in this field in order to develop standards of management that can be generally accepted. At the moment, in severe cases, we would favor a variable policy adapted to the biphasic course of peritonitis including intraoperative irrigation, short-term continuous lavage, followed by planned relaparotomy guided and indicated by adequate moni-
Table 10. Intraabdominal abscesses [44]. Intraperitoneal 36% Retroperitoneal 38% Visceral 26% Source Appendicitis Biliary tract Diverticulitis Pancreatic
Mortality (%) 2 4 21 44
toring of the illness and local conditions in the abdominal cavity. Additional Measures Decompression of the gut has long been recognized as a necessary measure when prolonged postoperative paralysis indicates poor prognosis. Treatment modalities covered a wide range from laxatives, sympathetic blockade, enterostomies, and even multiple percutaneous bowel punctures. Today, in the treatment of generalized peritonitis, decompression of the bowel is generally recommended and performed either by nasogastric tubes, long intestinal tubes, or an enterostomy. The long intestinal tube has the additional advantage of splinting the gut, and its preoperative placement has been suggested for immediate decompression, postoperative drainage, and nonobstructive adhesive bowel plication. These tubes may be placed either nasally or via a proximal jejunostomy. Their liberal use is generally recommended and can be regarded as a standard procedure. Treatment of Localized Abscesses About two-thirds of intraabdominal abscesses occur at the site of a localized inflammatory process with a slowly developing viscus perforation. In one-third, free peritonitis leads to abscess formation during the resolution phase when infected fluid becomes loculated within an anatomic recess [13]. Studying 540 abscesses in 501 patients, Altemeier [44] found a striking difference in mortality in relation to the underlying disease with appendicular abscesses having the best prognosis and pancreatic abscesses the worst prognosis (Table 10). The primary importance of surgical drainage with comple-
E.H. Farthmann and U. Sch/~ffel: Operative Management
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Table 11. Percutaneous (PD) versus surgical (SD) drainage of intraabdominal abscesses. No. of patients/
Source Johnson et al., 1981 Aeder et al., 1983 Haslaz and van Sonnenberg, 1983 Brolin et al., 1984 Glass and Cohn, 1984 Olak et al. [47], 1986 Deveney et al. [48], 1988 Treutner et al. [49], 1989
PD SD PD SD PD SD PD SD PD SD PD SD PD SD PD SD
No. of abscesses
Success of drainage (%)
Duration of drainage (days)
Complications (%)
Mortality (%)
27/27 43/43 10/13 31/32 11/15 19/29 24/24 24/24 15/15 44/44 27/27 27/27 29/29 37/37 27/30 38/43
89.0 79.0 69.0 91.7 87.5 47.0 88.0 70.3 85.2 72.0 78.0 93.3 95.3
17 29 11.7 21.2 30.8 15.9 36 33 7.4 6.8
4.0 16.0 31.0 47.0 27.3 18.1 8.3 20.8 6.0 27.0 40.7 29.6 3.3 0
1i.0 26.0 23.0 3%0 9.1 10.3 0 12.5 11.0 7.4 21.0 22.0 3.7 2.6
Modified from [47].
mentary use of defunctioning procedures has been standardized for a long time [10, 44]. Emphasizing the importance of a safe access route, the principle of extraserous drainage has been proposed for single well-loculated and precisely-localized abscesses adjacent to the abdominal wall. On the other hand, transperitoneal drainage and thorough exploration has been suggested if multiple intraabdominal abscesses must be assumed. With regard to an incidence of multiple abscesses of 12--45%, it has been concluded that all patients should be explored via the transperitoneal approach [45]. General objections to routine transperitoneal exploration are higher mortality rates and a fairly high rate of recurrent abscesses [29]. Abscess walls often tend to collapse when evacuated by closed drainage. This allows contaminated material in the depth to become walled off, thus setting the stage for recurrence. Packing of the abscess cavity prevents this collapse until the wall is stabilized by granulation tissue [46]. The technique of open drainage or marsupialization combined with temporary packing for a couple of days is used mostly in the treatment of pancreatic abscesses, but may sometimes be indicated in the subphrenic and subhepatic spaces or the pelvis. Open packing is regarded as being relatively safe when abscesses are present or likely to form, or when the control of bleeding might be an additional problem. With the improvement of imaging procedures in recent years, the principle of percutaneous puncture has received increasing attention. Until now, there have only been retrospective studies on the outcome ofpercutaneous versus surgical drainage (Table 11) [47--491. In the case-controlled study by Olak and associates [47], they could not prove the Superiority of the percutaneous drainage which was claimed earlier. Thus, for individual localized intraabdominal abscess, the question remains whether it should be approached surgically by open evacuation and drainage or whether percutaneous aspiration and drainage might suffice. Percutaneous drainage will certainly not be curative in every instance where it may be technically possible. Surgical and percutaneous procedures are probably complementary rather
than alternative, each with its own indications. At present, percutaneous drainage is considered as the initial mode of therapy or as a temporary procedure if laparotomy is not indicated per se.
Outlook: Areas of Interest Turning from standards to the future, some areas of interest will be indicated that come to mind if one reviews the treatment of intraabdominal infections. I. What is really needed is the implementation of scoring systems. It has become evident that future studies should not be performed without a thorough classification of patient groups. This applies to the severity of illness at the beginning as well as during the further course. 2. The definition of early indicators of sepsis is needed to define indications for relaparotomy. To wait for organ failure usually means to wait too long for reintervention. Means of defining the indications for relaparotomy according to the state of the peritoneal cavity at operation are needed as well. 3. Whether to perform an anastomosis in the presence of diffuse peritonitis is still controversial. At present, anastomosis of an unaltered bowel wall may be recommended with the exception of lesions located in the sigmoid colon or upper rectum and of leakage of the colonic anastomosis. The principles of monitoring the postoperative course and of early relaparotomy must, however, be kept in mind. 4. Whether lymphaticostomy, which was mentioned by Kirschner in 1926 [1], can lead to further improvements must be kept in doubt despite the fact that some experimental results have shown the transport of living bacteria and endotoxins via lymphatic channels into the systemic circulation [50]. An improved survival rate after lymphaticostomy, however, has not been shown until present. At the moment, this method does not seem ready for clinical employment. Coming back to the question of standard treatment, Kirschner's [1] sentence in closing the discussion of his paper may
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still be valid, "Where different opinions prevail, neither our theoretical knowledge nor the reports on animal studies nor statistical analyses permit definite decisions." And he went on, on a rather optimist note, that research into the remaining controversies will discover the grain from which the fruit of knowledge will grow. R6sum~
Le traitement chirurgical des infections intra-abdominales repose sur l'61imination des foyers septiques, la r6duction de la contamination de la cavit6 p6riton6ale et le traitement de l'infection r6sidueUe. Pour contr61er la source de contamination qu'est la fermeture primitive de la perforation d'un organe creux, on peut pratique r une r6section ou une d6rivation selon la srvrrit6 de la prritonite ou le terrain. Le principe de la "toilette prritoneale" avec utilisation complrmentaire d'antibiotiques par voie locale ou systrmique est admis mais sa valeur est fort contestre. Quant au traitement des infections rrsidueiles et h la prrvention des rrcidives, on peut utiliser les techniques d'irrigation ouverte ou fermre, le ventre ouvert et le second look, techniques majeures dans l'approche de la prritonite grnrralisre srvrre lorsqu'on ne peut contrrler le foyer infectieux avec srcuritr. La valeur et les inconvrnients des diffrrentes techniques sont discutres. On drcrit 6galement les mrthodes adjuvantes et les domaines de la recherche future. Resumen
El manejo operatorio de las infecciones intraabdominales todavfa se fundamenta en los principios de eliminar el foco, reducir la contaminaci6n de la cavida peritoneal, y tratar la infecci6n residual. Para controlar la fuente de contaminaci6n a partir del cierre primario de una viscera perforada se puede considerar la exclusi6n o la resecci6n, segtin la gravedad de la peritonitis y de la enfermedad de base. El principio de la "toilet peritoneal" con el empleo complementario de antibi6ticos sist6micos y/o locales es generalmente aceptado, aunque la utilidad del desbridamiento agresivo es todavia motivo de controversia. En cuanto al tratamiento de la infecci6n residual y la prevenci6n de la infecci6n recurrente, [as trcnicas de lavado abierto y cerrado, el abdomen abierto (laparostomiaL y la relaparotom/a programada representan los principales aproches en casos de peritonitis generalizada severa en que el foco infeccioso no puede set controlado con entera seguridad. Se discuten las ventajas y desventajas de los diferentes reg/menes. se describen brevemente las medidas terapruticas adicionales, y se presenta una visi6n prospectiva sobre las areas de investigaci6n futura. References
1. Kirschner. M.: Die Behandlung der akuten eitrigen freien BauchfellentzOndung. Arch. Klin. Chir. 142:253. 1926 2. Meakins. J.L., Solomkin. J.S.. Allo. M.D.. Dellinger, P., Howard. R.J.. Simmons, R.L.: A proposed classification of intra-abdominal infections. Arch. Surg. 119:1372. 1984 3. Dellinger, E.P., Wertz. M.J.. Meakins. J.L.. Solomkin. J.S., Allo. M.D.. Howard. R.J.. Simmons. R.L.: Surgical infection stratification system for intra-abdominal infection. Arch. Surg. 120:20. 1985 4. Wittmann. D.H.. Teichmann. W.. Frommelt. L.: Die Bedeutung
World J. Surg. Vol. 14, No. 2, Mar./Apr. 1990
der Infektionserreger for die Therapie der eitrigen Peritonitis. Chirurg 56:363, 1985 5. Hudspeth, A.S.: Radical surgical debridement in the treatment of advanced generalized bacterial peritonitis. Arch. Surg. 110:1233, 1975 6. Bohnen, J., Boulanger, M., Meakins, J.L., McLean, P.H.: Prognosis in generalized peritonitis. Arch. Surg. 118:285, 1983 7. Hohenberger, W., Mewes, R., Kfckerling, F., Gall, F.P.: Perforationen an D~inn-und Dickdarm. Chirurg 58:561, 1987 8. Chaikof, E.L.: Nontraumatic perforation of the small bowel. Am. J. Surg. 153:355, 1987 9. Krukowski, Z.H., Matheson, N.A.: Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: A review. Br. J. Surg. 71:921, 1984 10. Eng, K., Ransom J.H.C., Localio, S.A.: Resection of the perforated segment. Am. J. Surg. 133:67, 1977 11. Blanco-Benavides, R.: Subcutaneous positioning of high-risk colonic anastomoses and colonic lesions (letter). Arch. Surg. 121:974, 1986 12. Fatzer, H., Wyss, C.: lleumperforation als Erstmanifestation eines M. Crohn w/ihrend der Schwangerschaft. Chirurg 57:646, 1986 13. Ahrenholz, D.H., Simmons, R.L.: Peritonitis and other intraabdominal infections. In Surgical Infectious Disease, R.L. Simmons, R.J. Howard, editors, New York, Appleton Century-Crofts, 1982, pp. 795-843 14. Maingot, R.: Acute peritonitis. In Abdominal Operations, vol. 2, sixth edition, R. Maingot, editor, New York, Appleton CenturyCrofts, 1974, p. 1416 15. Linder, M.M., Wacha, H.: Lokale Antibiotika oder Antiseptika bei der Behandlung der diffusen eitrigen Peritonitis. In Peritonitis, H. Wacha, editor, Berlin, Springer-Verlag, 1987, pp. 30-35 16. Oguz, M., Bektemir, M., Dfilger, M., Yalin, R.: Treatment of experimental peritonitis with intraperitoneal povidone-iodine-solution. Can. J. Surg. 31:169, 1988 17. GOrtz, G., Hfiring, R.: Die intraoperative antiseptiscbe Lokaltherapie der Peritonitis--Experimentelleund klinische Erfahrungen. In Peritonitis, H. Wacha, editor, Berlin, Springer-Verlag, 1987, pp. 10-29 18. Noon, G.P., Beall, Jr., A.C., Jordan, Jr., G.L., Riggs, S., De Bakey, M.E.: Clinical evaluation of peritoneal irrigation with antibiotic solution. Surgery 62:73, 1967 19. Stewart, D.J., Matheson, N.A.: Peritoneal lavage in appendicular peritonitis. Br. J. Surg. 65:54, 1978 20. Weissenhofer, W., Meissner, K., Metka, K.: Peritonealspiilung mit Betaisodona-Lrsung. Medizin 4, 19:1895, 1976 21. Browne, M.K., McKenzie, M., Doyle, P.J.: A controlled trial of Taurolin in established bacterial peritonitis. Surg. Gynecol. Obstet. 146:721, 1978 22. Linder, M.M., Ott, W., Wesch, G., Wicki, O., Marti, M.C., Moser, G.: Die Behandlung der eitrigen Bauchfellentz/indung. Untersuchungen des Krankengutes und Erfahrungen mit dem neuen Chemotherapeutikum und AntiendotoxinTaurolin. Langenbecks Arch. Chir. 353:241, 1981 23. Nomikos, I.N., Katsonyanni, K., Papaioannon, A.N.: Washing with or without chloramphenicol in the treatment of peritonitis: A prospective clinical trial. Surgery 99:20, 1986 24. Krukowski, Z.H., AI-Sayer, H,M., Reid, T.M.S., Matheson, N.A.: Effect of topical and systemic antibiotics on bacterial growth kinesis in generalized peritonitis in man. Br. J. Surg. 74:303, 1987 25. Dobrin, P.B., O'Keefe, P., Tataronicz, W., Stachowski, M., Freeark, R.J.: The value of continuous 72-hour peritoneal lavage for peritonitis. Am. J. Surg. 157:368, 1989 26. Wittmann, D.H,, Schassan, H.-H.: Penetration of eight/3-1actam antibiotics into peritoneal fluid. Arch. Surg. 118:205, 1983 27. Saha, S.K.: Peritoneal lavage with metronidazole. Surg. Gynecol. Obstet. 160:355, 1985 28. Wacha, H., lnterwies, E.: Prognose der diffusen Peritonitis vor und nach Einfiihrung der Antibiotika--Eine Literaturstudie. In Peritonitis, H. Wacha, editor, Berlin, Springer-Verlag, 1987, pp. 36-72 29. Hau, T., Ahrenholz, D.H., Simmons, R.L.: Secondary bacterial peritonitis: The biologic basis of treatment. Curr. Probl. Surg. 16:1, 1979 30. Rotstein, O.D., Pruett, T.L., Simmons, R.L.: Fibrin in peritonitis.
E.H. Farthmann and U. Sch6ffeh Operative Management
31. 32.
33.
34. 35. 36.
37.
38. 39.
V. Fibrin inhibits phagocytic killing of E. coli by human polymorphonuclear leukocytes. Ann. Surg. 203:413, 1986 Polk, H.C., Fry, D.E.: Radical peritoneal debridement for established peritonitis. Ann. Surg. 192:350, 1980 Leiboff, A.R., Soroff, H.S.: The treatment of generalized peritonitis by closed postoperative peritoneal lavage. A critical review of the literature. Arch. Surg. 122:1005, 1987 Lehr, L., Pichlmayr, R., Pahlow, J., Guthy, E.: Postoperativkontinuierliche offene dorsoventrale Bauchsptilung bei schweren Formen der Peritonitis--Technik und Taktik. In Die chirurgische Behandlung der Peritonitis, E. Kern, editor, Berlin, SpringerVerlag, 1983, pp. 67-81 Teichmann, W., Wittmann, D.M., Andreone, P.A.: Scheduled reoperations (etappenlavage) for diffuse peritonitis. Arch. Surg. 121:147, 1986 Kujath, P., Arbogast, R., Kern, E., D~.mmrich, J.: Histologische Untersuchungen w~ihrend des Verlaufs der programmierten Peritoneal-Lavage. Chirurg 56:170, 1985 Teichmann, W., Eggert, A., Herden, N., Kirschner, H., Welter, J.: Erfahrungen mit der Etappenlavage seit 1980. In Die chirurgische Behandlung der Peritonitis, E. Kern, editor, Berlin, SpringerVerlag, 1983, pp. 62-66 Arbogast, R.: Erfahrungen der W0rzburger Klinik mit der programmierten Lavage bei Peritonitis. In Die chirurgische Bebandlung der Peritonitis, E. Kern, editor, Berlin, Springer-Verlag, 1983, pp. 91-101 Andrus, C., Doering, M., Herrmann, V.M., Kaminski, D.: Planned reoperation for generalized intraabdominal infection. Am. J. Surg. 152:682, 1986 Schein, M., Saadia, R., Freinkel, Z., Decker, G.A.G.: Aggressive
217
40.
41. 42.
43. 44. 45. 46. 47. 48. 49.
50.
treatment of severe peritonitis: A prospective study. Br. J. Surg. 75:173, 1988 Gross, E., Erhard, J., Eigler, F.W.: Kunststoffnetze als Hilfsmittel zum Bauchdeckenverschlufi bei postoperativer Peritonitis, postoperativer Bauchdeckendehiszenz und zur Rekonstruktion der Bauchwand. Zentralbl. Chirurgie 109:1238, 1984 Krause, R.: Reintervention in abdominal surgery. World J. Surg. 11:226, 1987 Garcia-Sabrido, J.L., Tallado, J.M., Christou, N.V., Polo, J.R., Valdecantos, E.: Treatment of severe intra-abdominal sepsis and/or necrotic foci by an "open-abdomen" approach. Arch. Surg. 123: 152, 1988 Hoffmann, R., Kessler, W., Angwerd, R.: Das "'offengelassene Abdomen." Helv. Chir. Acta 52:137, 1985 Altemeier, W.A., Culbertson, W.R., Fullen, W.D., Shook, C.D.: Intraabdominal abscesses. Am. J. Surg. 125:70, 1973 Haslaz, N.A.: Subphrenic abscess: Myths and facts. J. Am. Med. Assoc. 214:724, 1970 Bradley, S.J., Jurkovich, G.J., Pearlman, N.W., Stiegmann, G.V.: Controlled open drainage of severe intra-abdominal sepsis. Arch. Surg. 120:629, 1985 Olak, J., Christou, N.V., Stein, L.A., Casola, G., Meakins, J.L.: Operative vs percutaneous drainage of intra-abdominal abscesses. Arch. Surg. 121:141, 1986 Deveney, C.W., Lurie, K., Deveney, K.E.: Improved treatment of intraabdominal abscess. Arch. Surg. 123:1126, 1988 Treutner, K.H., Truong, S., Klose, K., Schubert, T., Schumpelick, V., G~inther, R.W.: Intra-abdominal abscesses--percutaneous catheter drainage versus operative treatment. Kiln. Wochenschr. 67:486, 1989 Olofson, P., Nylander, G., Olsson, P.: Endotoxin: Routes of transport in experimental peritonitis. Am. J. Surg. 151:443, 1986
0
World Journal of Surgery 9 1990 by the Soci~t6 lnternationale de Chirurgie
Principles and Limitations of Operative Management of Intraabdominal Infections E d u a r d H. F a r t h m a n n , M . D . , and Ulrich Sch6ffel, M . D . Department of Surgery, University of Freiburg, Freiburg, Federal Republic of Germany Operative management of intraabdominal infections still rests on the principles of elimination of focus, reduction of contamination of the peritoneal cavity, and treatment of residual infection. To control the source of contamination from a perforated viscus primary closure, exclusion or resection may be considered with respect to the severity of peritonitis and to the underlying disease. The principle of "peritoneal toilet" with complementary use of systemic and/or local antibiotics is generally accepted even if the value of aggressive debridement is still debated controversely. For the treatment of residual and the prevention of recurrent infection, closed and open lavage techniques, the left-open abdomen, and planned relaparotomy represent the major approaches in severe generalized peritonitis when the infectious focus might not be securely controlled. The values and disadvantages of different regimens are discussed , additional measures are briefly described, and an outlook on areas of further research is given.
Standards or principles of surgical management can be best defined in a historical perspective. At the meeting of the German Surgical Society in 1926, Kirschner [1] presented a paper which stands out as a hallmark in the treatment of peritonitis. In the following article, this work is taken as a backdrop to point out what has been achieved since then and what still remains to be done. Every inflammatory response within the peritoneal cavity may lead from local peritonitis to generalized peritonitis or to abscess formation. For the purpose of clarity, these entities should be differentiated, although this may be difficult due to constant overlap. According to historical terminology, surgical management deals with "secondary peritonitis." Primary or spontaneous peritonitis, which is induced by hematogenous bacterial invasion of the peritoneal cavity, does not play a major role in the context of surgical therapy because nonoperative therapy is the treatment of choice. Secondary peritonitis can be subgrouped according to etiology with a certain impact on prognosis (Table 1). Independent of their intraabdominal anatomic origin, however, acute intraabdominal infections or perforations of a viscus will invariably lead to local or generalized peritonitis as does the Reprint requests: Eduard H. Farthmann, M.D., Department of Surgery, Universit/itsklinik Freiburg, Hugstetter Str. 55, 7800 Freiburg, Federal Republic of Germany.
so-called chemical peritonitis which is followed by bacterial invasion. Postoperative peritonitis is often regarded as a separate entity, partly because of its poor prognosis. When Kirschner [1] reviewed 1,626 cases treated in Krnigsberg from 1895 to 1925, he found the vast majority to be due to appendicitis. The situation has changed considerably since then (Table 2). Perforation of the appendix has dropped to fourth place with those of the stomach, duodenum, small intestine, and large bowel making up two-thirds of all cases. The mortality of intraabdominal infections in different time periods can be compared for different anatomic areas of origin (Table 3) [2, 3]. Obviously, the mortality has declined in all categories. This reduction is most pronounced for stomach and duodenum, for infections arising from the biliary tract, and for postoperative peritonitis, which was invariably fatal at the beginning of the century. The overall mortality, however, has not markedly improved since the days of Kirschner [1], who reported a mortality of 30% for the years 1920-1924 in contrast to 87.5% for the period 1895-1905. One should remember that, until that time, peritonitis was not generally regarded as a surgical disease. "The opinion seems to be gaining ground that in evacuating the pus in peritonitis the advantages outweigh the disadvantages," Kirschner [1] stated cautiously. The general acceptance of this principle in the 1920's led to a considerable reduction of mortality which then remained stable for about 40 years. Since then, another reduction has occurred with the development of intensive care medicine [4].
Therapeutic Principles
Surgical management can be conveniently subdivided into 3 principles which, at the same time, represent the usual sequence of maneuvers: 1. Elimination of the focus, to seal the leak and control the source of contamination. 2. Reduction of contamination, also known as "peritoneal toilet," to reduce or eliminate the bacterial inoculum. 3. Treatment of residual and prevention of recurrent infection.
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Table 1. Etiology of secondary peritonitis.
Table 4. Elimination of infectious focus.
Acute intraabdominal infection Perforation of viscus Translocation of bacteria from the gut Chemical peritonitis with bacterial invasion Postoperative peritonitis
Resection With primary anastomosis Strangulated hernia Mesenteric infarction Small bowel perforation (inflammatory disease, ischemic injury, malignoma, unknown cause) Large bowel perforation (unaltered bowel wall, irrigated bowel) Perforated sigmoid diverticulitis (low risk) Without anastomosis Large bowel perforation (unprepared bowel, irrigation not possible, gross peritonitis) Perforated sigmoid diverticulitis (high risk) Perforated malignancy of the colon (generalized peritonitis) Ulcerative colitis Complicated small bowel perforation Suture and Plication Without enterostomy Duodenal ulcer perforation Iatrogenic perforation (small bowel) Single small foreign body perforation (within 24 hr) Small traumatic perforation of the small bowel (within 24 hr) With proximal diverting ("protective") enterostomy Iatrogenic perforation of the large bowel (irrigated bowel)
Table 2. Etiology of intraoperative findings. Anatomic origin
1926
1986
Stomach and duodenum Small intestine Large bowel Appendix Pancreas and biliary tract Other
11%
20% 20% 25% 15% 10% 10%
12% 58% 2% 17%
Table 3. Mortality of intraabdominal infections. Mortality (%) Anatomic area Stomach and duodenum Small intestine Large bowel Biliary tract Pancreas Appendicitis Postoperative
1896--1925 [1] 58.3 82.8 72.7 85.7 35.2 100.0
1970-1985 [2, 3] (range) 2.%13 20.0-25 20.0-50 0--6 22.0-57 0-8 30.0-60
Elimination of Focus This can be done basically by closing, excluding, or resecting the primary source and by evacuating contaminated fluid (Table 4).
Table 5. Generalized peritonitis secondary to diverticular disease: Treatment modalities and mortality.
No. Died Mortality (%) Drainage with/without suture Colostomy with/without suture Colostomy with/without drainage Exteriorization Resection without anastomosis Resection with anastomosis Resection with anastomosis and colostomy
156
34
21.8
657 189 84 11 262 32 100 9 33 2
28.7 13.1 12.2 9.0 6.1
Modified from [9]. Review of 58 reports: 1957-1984.
Resection. Resection of the primary source seems to be the safest way and is possible if the causative organ can be removed as in appendicitis or in peritonitis due to a perforated gallbladder. Resection of a perforated or necrotic bowel segment obviously eliminates the focus, too, but entails the problem of restoring the continuity of the gut without undue danger of subsequent anastomotic leakage. In general, there seems to be a tendency to perform more and more anastomoses in the presence of frank peritonitis [5-8]. The principle of primary anastomosis seems to be fairly standardized for mesenteric ischemia and strangulated bowel, but is still widely debated in diverticular perforation of the colon, reflecting changing attitudes. Hartmann's procedure has been regarded as a gold standard in this situation and generally seems to be the safest way to deal with it. It should be performed in all but definitely favorable circumstances where a primary anastomosis can be performed after on-table irrigation [91. The listing in Table 5 represents the development of methods and the improvement of their results. The breakthrough came with the principle of eliminating the septic focus from the abdomen. Since then, only marginal improvements have been achieved. The favorable results reported for resection followed by anastomosis are probably due to a selection effect. Hart-
mann's procedure is generally preferred for the unprepared colon, if on-table irrigation is not possible, and if the underlying disease might affect the resection margins. Perforation of colon tumors, peritonitis in perforated ulcerative colitis, and larger traumatic perforations are best treated without restoration of continuity. Drainage and enterostomy as a time-honored procedure is mostly regarded as obsolete today. The same applies to the principle of exteriorization, which is rarely applied and may be technically cumbersome. If possible at all, a resection can usually be performed as well. The use of a proximal diverting colostomy to protect a colonic anastomosis has come into doubt since the occurrence of an anastomotic leakage is not affected [7] and a transverse colostomy will have little effect on pressures in the sigmoid colon [10]. In rare cases, subcutaneous positioning of high-risk anastomoses might be considered [11]. Resection followed by primary anastomosis is the treatment of choice for perforations of the small bowel [8]. The main indications are inflammatory lesions, ischemic injury, malignant disease, and perforations of unknown etiology. In high-risk patients with frank peritonitis or Crohn's disease, discontinuity
212
procedures or a temporary proximal loop ileostomy may be of value [7, 12]. Suture and Plication. Suture and plication of a perforation is mainly performed today for perforated peptic ulcer. Additionally, it may be considered for single, small, foreign body or traumatic perforations of the small bowel diagnosed early [7, 8] or in cases of iatrogenic lesions during colonoscopy in a clean colon. In lesions of the pancreatic and biliary system, simple drainage following resection of infected necrosis or evacuation of contaminated fluid still has a place in the initial treatment of this type of peritonitis. Peritoneal Toilet
The principle of reduction of peritoneal contamination has received much attention since the beginnings of surgical treatment of peritonitis. Three different approaches have been suggested: mechanical cleansing, intraoperative lavage, and aggressive debridement. When Kirschner [1] compared the effect of intraoperative lavage and mechanical cleansing, he did not find any difference in mortality rates. Mechanical cleansing by the use of swabs has long been recommended for the treatment of a localized process (e.g., perforated appendicitis), but it is now widely accepted that bacterial contamination is rapidly disseminated throughout the peritoneal cavity by the so-called intraperitoneal circulation [13]. Intraoperative irrigation is considered, today, to be safe and helpful if contamination of the abdominal cavity has occurred. Objections to that procedure were the spread of localized bacterial infection, dilution of opsonins, and suspension of bacteria in a fluid medium where they are less amenable to phagocytosis. Despite recent statements to the contrary [14], it has become generally accepted that peritoneal lavage reduces the number of bacteria within the peritoneal cavity, thus giving the peritoneal defense mechanisms a greater chance. The question whether the irrigation fluid should contain antibiotic or antiseptic preparations is still widely discussed. A considerable amount of conflicting data has been accumulated in recent years dealing with the effects of a great variety of antibiotics under experimental and clinical conditions. Concerning local antibiotic treatment, none of the generally used substances showed an obviously superior effect [15], while in the range of antiseptic solutions, some beneficial effects of Taurolidine (in contrast to povidone-iodine solutions, which have been shown to be toxic [16]) might be supposed [17]. There are, however, only a few randomized controlled studies [18-23]. Their value is limited by the fact that most authors used systemic antibiotics as well. Small patient numbers [20, 21], unusual concentrations of antiseptic solutions [22], and minor forms of peritonitis [19] gave rise to additional objections. Noon [ 18] randomized 404 patients and showed that irrigation with Kanamycin and Bacitracin had no effect on mortality but decreased the wound infection rate from 24% to 11%. Stewart and Mattheson [19], using systemic antibiotic therapy as well, reported no fatal cases in their series of 185 patients with appendicular peritonitis. They found a reduction in wound infection rates by local tetracycline treatment in contrast to a
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Table 6. Radical peritoneal debridement (RPD) versus standard treatment (STD). RPD STD No. of patients 22 24 Perforated peptic ulcer 9 11 Perforated appendicitis 4 5 Bowel perforation 8 7 Other 1 1 Died 7 7 Reoperation for intraperitoneal infection 5 4 Modified from [31].
Noxythiolin-treated group, which did not differ from the controls. Recently, a study on the effects of antibiotics on bacterial growth kinetics in generalized peritonitis, beside supporting the use of systemic antibiotics, provided bacteriological evidence for the value of intraoperative lavage with tetracycline [24]. In animal studies, it has been demonstrated that a continuous peritoneal lavage was only helpful in the treatment of peritonitis if the lavage solution contained antibiotics, and was harmful if it did not [25]. It might be assumed that the concentration in the peritoneal exudate of antibiotics given systemically parallels the concentration in the serum while local application results in an unequal distribution within the peritoneal cavity [26]. On the other hand, local therapy may be advantageous because penetration to the infected spaces during systemic therapy is markedly reduced [13]. Generally, it can be stated that peritoneal lavage reduced the rates of wound infection, abscess formation, and mortality. A further reduction in wound infection may be achieved if the lavage fluid contains antibiotics [18, 19, 23, 27]. Other authors have definitely abandoned local antibiotic treatment [28]. Aggressive Debridement. Aggressive debridement has received much attention recently, but it should be remembered that it was an area of controversy in the past as well. Kirschner [1] seemed not to be really convinced of that procedure when he said, "The early cleansing fanaticism to eliminate fibrin deposits by the barbaric procedure of wiping and ripping is to be condemned." The controversy was reopened again by Hudspeth [5]. He felt that the main benefit attained from lavage was its debridement effect. In his study, he reported on the results of a procedure where all spaces within the peritoneal cavity were opened and cleaned. The series consisted of 92 patients with generalized peritonitis where he almost always found an abscess in the pouch of Douglas, and 22 subdiaphragmatic abscesses. All patients in whom the source of contamination could be eliminated survived with only 1 late complication cured conservatively. There are, however, several objections to this method, the most serious being that Needing from damaged surfaces results in hemoglobin and fibrin deposition, both known to be potent adjuvants to infection [29, 30]. In a prospective randomized trial, Polk and Fry [31] found no differences in terms of hospital mortality or the frequency of reoperation for abscesses (Table 6). It seems, therefore, that a general recommendation of
E.H. Farthmann and U. Sch6ffel: Operative Management
213
Table 7. Mortality rates in comparative studies evaluating closed postoperative peritoneal lavage.
Treatment group Source Prospective, randomized studies Del Carmen Nieto and Nava, 1975 Olesen et al., i980 Shwani et al., 1980 Hunt, 1982 Beger, 1983 Nonrandomized, comparative studies McKenna et al., 1970 Kiene, 1974 Giessing and Tomlin, 1974 Bhushan et al., 1975 Hunt et al., 1975 Stephen and Loewenthal, 1978 Esser and Rappen, 1980 Uden et al., 1983 Washington et al., 1983
n
Died
Controls Mortality (%)
n
Died
Mortality (%)
40 20 20 15 14
4 0 4 5 3
10.0 0 20.0 33.3 21.4
20 10 19 29 16
8 0 2 8 7
40.0 0 10.5 27.6 43.8
25 97 72 30 38 27 41 181 50
5 42 11 6 9 6 17 1 7
20.0 43.0 15.3 20.0 23.7 22.2 41.5 0.6 14.0
25 100 106 30 38 68 71 188 44
15 71 6 18 18 33 30 1 4
60.0 71.0 5.7 60.0 47.4 48.5 42.3 0.5 9.1
Modified from [16, 32].
aggressive debridement in all cases of peritonitis cannot be given. At the termination of the intraabdominal procedure, the question remains whether a drain or several drains should be left behind. Removal of contaminated fluid and of necrotic material through intraperitoneally-placed drains is still a matter of controversy. N o b o d y would object to the statement that it is better to allow dead and live bacteria to be drained out continuously instead of being absorbed. It is still questionable, however, whether and how this can be achieved. Kirschner [1] compared the effect of closure of the abdomen with or without drainage on mortality, abscess formation, and wound infection. He did not find any difference and stated briefly, "The free peritoneal cavity cannot be drained." Basically, there are still several objections to drainage of the peritoneal cavity [29]: 1. Fibrous tracts will develop within a short period which do not communicate with the abdominal cavity as such. 2. Contamination from the outside might occur which, however, will not be of major concern in this situation. 3. Visceral erosion with fistulization and bleeding has been reported. 4. Drains may interfere with proper sealing of anastomoses. On the whole, the main objection against leaving drains behind is not their negative effect, but rather that they simply do not work. While these statements refer to drainage of the peritoneal cavity as such, drains will, of course, be effective in evacuating abscesses, establishing a controlled fistula, or offering a preferential pathway for the escape of visceral secretions after extensive damage to the pancreas or the biliary tract.
Treatment of Residual and Prevention of Recurrent Infection In the attempt to continue peritoneal toilet postoperatively, 3 major approaches have emerged: (a) continuous postoperative peritoneal lavage, (b) planned relaparotomy, (c) laparostomy (the left-open abdomen). Closed postoperative lavage may be
Table 8. Etappenlavage in generalized peritonitis.
Source
n
Died
Teichmann et al. [36], 1980 Arbogast [37], 1983 Teichmann et al. [34], 1986 Andrus et al. [38], 1986 (no planned reoperation Schein et al. [39], 1988
27 29 61 34 43 22
5 13 14 21 25) 7
performed by different means. Two inflow catheters in the subphrenic spaces and 2 outflow catheters in the pelvis are the most prevalent arrangement. The time period of either intermittent or continuous lavage usually ranges from 1 to 5 days. Most authors add antibiotics to the lavage fluid [32]. In a special form of dorsoventral lavage, the left-open abdomen is covered by a palisade of drains to allow removal of the fluid [33]. The basic question in all lavage procedures is whether it is possible to irrigate the abdomen properly or whether drainage tracts develop so that only the drains communicate and are irrigated continuously ("the irrigated a b d o m e n " versus "the irrigated drain" controversy). Recently, Leiboff [32] reviewed 39 reports on the results of closed postoperative peritoneal lavage published between 1963 and 1986. Despite conclusions, mostly in favor of postoperative lavage in those reports, Leiboff felt that the therapeutic value remains to be determined. The reason was that only one-half of the 12 comparative studies reported beneficial effects on postoperative mortality and that in the 4 prospective randomized studies, major limitations were small sample sizes and an unproven comparability between treatment groups (Table 7). The principle of planned relaparotomy or " e t a p p e n l a v a g e " has been suggested for patients with diffuse peritonitis being at high risk of developing multiple organ failure. Routine exploration is performed on a daily basis until evidence of improvement or healing is present [34]. Thus, at least the last intervention might be judged as unnecessary. Histologic observations showed that the inflammatory response declined at day 3 in most cases [35]. By using this method, promising results have
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Table 9. Treatment of residual and prevention of recurrent infection. Principle
Advantages
Objections
Continuous postoperative peritoneal l a v a g e
Continuous washout of infectious material Possibility of local antibiotic treatment No anesthesia required
Planned relaparotomy (scheduled reintervention)
Prompt recognition of complications No psychologic problem in reintervention No drainage Spontaneous drainage Relief of intraabdominal pressure Simplified reintervention
Inducement of bacterial fluid suspension Complications of drains Risk of fluid overload Development of adhesion-lined drainage tracts preventing adequate lavage Prolonged intubation Repeated damage to the abdominal wall Rebleeding (risk of additional damage) Retraction of the abdominal wall Succulence of the intestine Fistula formation Prolonged morbidity (major reintervention necessary)
Laparostomy (the left-open abdomen)
been reported (Table 8) [36-39]. As in all developing fields, however, there is conflicting evidence: Andrus [38] compared planned reoperation with the policy of observation following the primary operation and reoperation when indicated by signs of continuing infection. With respect to the acute physiology score (APS), both groups were comparable and no difference in mortality was found. An objection to this study is that it was not truly randomized and that the frequency of reoperations in the control group was fairly high with a mean of 1.8 --- 0.7, representing a high incidence of salvage operations. So, truly, there are, as yet, no standards in this field. The same applies for the method of closure of the abdomen when the policy of repeated laparotomies is applied. Sutures, meshes, zippers, and other techniques have been used for temporary closure. Leaving the cutis untouched, some of these procedures seem to combine the advantages of the scheduled lavage and of the left-open abdomen as well as their disadvantages (Table 9). The advocates of an absorbable mesh claim that it reduces intraabdominal pressure, prevents evisceration, and allows for effective drainage of the abdominal cavity [40]; however, the development of diffuse, patchy necrosis of the bowel wall resulting in fistula formation has been described [41]. The zipper offers the advantage of an easy access route and prevents damage to the abdominal wall during relaparotomy [34]. On the other hand, spontaneous drainage is prevented and a major reintervention inevitably becomes necessary. Recently, some favorable results have been reported in the treatment of intraabdominal necrotic foci with the use of a modified zipper technique [42]. Laparostomy or the left-open abdomen has been employed widely in France. It certainly relieves intraabdominal pressure which, at times, is crucial for impaired ventilation and intraabdominal circulation. It allows spontaneous drainage and simplifies reinterventions. The major objections are nursing problems, succulence of the intestine, fistula formation, and problems with the later closure of a retracted abdominal wall [43]. Much remains to be done in this field in order to develop standards of management that can be generally accepted. At the moment, in severe cases, we would favor a variable policy adapted to the biphasic course of peritonitis including intraoperative irrigation, short-term continuous lavage, followed by planned relaparotomy guided and indicated by adequate moni-
Table 10. Intraabdominal abscesses [44]. Intraperitoneal 36% Retroperitoneal 38% Visceral 26% Source Appendicitis Biliary tract Diverticulitis Pancreatic
Mortality (%) 2 4 21 44
toring of the illness and local conditions in the abdominal cavity. Additional Measures Decompression of the gut has long been recognized as a necessary measure when prolonged postoperative paralysis indicates poor prognosis. Treatment modalities covered a wide range from laxatives, sympathetic blockade, enterostomies, and even multiple percutaneous bowel punctures. Today, in the treatment of generalized peritonitis, decompression of the bowel is generally recommended and performed either by nasogastric tubes, long intestinal tubes, or an enterostomy. The long intestinal tube has the additional advantage of splinting the gut, and its preoperative placement has been suggested for immediate decompression, postoperative drainage, and nonobstructive adhesive bowel plication. These tubes may be placed either nasally or via a proximal jejunostomy. Their liberal use is generally recommended and can be regarded as a standard procedure. Treatment of Localized Abscesses About two-thirds of intraabdominal abscesses occur at the site of a localized inflammatory process with a slowly developing viscus perforation. In one-third, free peritonitis leads to abscess formation during the resolution phase when infected fluid becomes loculated within an anatomic recess [13]. Studying 540 abscesses in 501 patients, Altemeier [44] found a striking difference in mortality in relation to the underlying disease with appendicular abscesses having the best prognosis and pancreatic abscesses the worst prognosis (Table 10). The primary importance of surgical drainage with comple-
E.H. Farthmann and U. Sch/~ffel: Operative Management
2i5
Table 11. Percutaneous (PD) versus surgical (SD) drainage of intraabdominal abscesses. No. of patients/
Source Johnson et al., 1981 Aeder et al., 1983 Haslaz and van Sonnenberg, 1983 Brolin et al., 1984 Glass and Cohn, 1984 Olak et al. [47], 1986 Deveney et al. [48], 1988 Treutner et al. [49], 1989
PD SD PD SD PD SD PD SD PD SD PD SD PD SD PD SD
No. of abscesses
Success of drainage (%)
Duration of drainage (days)
Complications (%)
Mortality (%)
27/27 43/43 10/13 31/32 11/15 19/29 24/24 24/24 15/15 44/44 27/27 27/27 29/29 37/37 27/30 38/43
89.0 79.0 69.0 91.7 87.5 47.0 88.0 70.3 85.2 72.0 78.0 93.3 95.3
17 29 11.7 21.2 30.8 15.9 36 33 7.4 6.8
4.0 16.0 31.0 47.0 27.3 18.1 8.3 20.8 6.0 27.0 40.7 29.6 3.3 0
1i.0 26.0 23.0 3%0 9.1 10.3 0 12.5 11.0 7.4 21.0 22.0 3.7 2.6
Modified from [47].
mentary use of defunctioning procedures has been standardized for a long time [10, 44]. Emphasizing the importance of a safe access route, the principle of extraserous drainage has been proposed for single well-loculated and precisely-localized abscesses adjacent to the abdominal wall. On the other hand, transperitoneal drainage and thorough exploration has been suggested if multiple intraabdominal abscesses must be assumed. With regard to an incidence of multiple abscesses of 12--45%, it has been concluded that all patients should be explored via the transperitoneal approach [45]. General objections to routine transperitoneal exploration are higher mortality rates and a fairly high rate of recurrent abscesses [29]. Abscess walls often tend to collapse when evacuated by closed drainage. This allows contaminated material in the depth to become walled off, thus setting the stage for recurrence. Packing of the abscess cavity prevents this collapse until the wall is stabilized by granulation tissue [46]. The technique of open drainage or marsupialization combined with temporary packing for a couple of days is used mostly in the treatment of pancreatic abscesses, but may sometimes be indicated in the subphrenic and subhepatic spaces or the pelvis. Open packing is regarded as being relatively safe when abscesses are present or likely to form, or when the control of bleeding might be an additional problem. With the improvement of imaging procedures in recent years, the principle of percutaneous puncture has received increasing attention. Until now, there have only been retrospective studies on the outcome ofpercutaneous versus surgical drainage (Table 11) [47--491. In the case-controlled study by Olak and associates [47], they could not prove the Superiority of the percutaneous drainage which was claimed earlier. Thus, for individual localized intraabdominal abscess, the question remains whether it should be approached surgically by open evacuation and drainage or whether percutaneous aspiration and drainage might suffice. Percutaneous drainage will certainly not be curative in every instance where it may be technically possible. Surgical and percutaneous procedures are probably complementary rather
than alternative, each with its own indications. At present, percutaneous drainage is considered as the initial mode of therapy or as a temporary procedure if laparotomy is not indicated per se.
Outlook: Areas of Interest Turning from standards to the future, some areas of interest will be indicated that come to mind if one reviews the treatment of intraabdominal infections. I. What is really needed is the implementation of scoring systems. It has become evident that future studies should not be performed without a thorough classification of patient groups. This applies to the severity of illness at the beginning as well as during the further course. 2. The definition of early indicators of sepsis is needed to define indications for relaparotomy. To wait for organ failure usually means to wait too long for reintervention. Means of defining the indications for relaparotomy according to the state of the peritoneal cavity at operation are needed as well. 3. Whether to perform an anastomosis in the presence of diffuse peritonitis is still controversial. At present, anastomosis of an unaltered bowel wall may be recommended with the exception of lesions located in the sigmoid colon or upper rectum and of leakage of the colonic anastomosis. The principles of monitoring the postoperative course and of early relaparotomy must, however, be kept in mind. 4. Whether lymphaticostomy, which was mentioned by Kirschner in 1926 [1], can lead to further improvements must be kept in doubt despite the fact that some experimental results have shown the transport of living bacteria and endotoxins via lymphatic channels into the systemic circulation [50]. An improved survival rate after lymphaticostomy, however, has not been shown until present. At the moment, this method does not seem ready for clinical employment. Coming back to the question of standard treatment, Kirschner's [1] sentence in closing the discussion of his paper may
216
still be valid, "Where different opinions prevail, neither our theoretical knowledge nor the reports on animal studies nor statistical analyses permit definite decisions." And he went on, on a rather optimist note, that research into the remaining controversies will discover the grain from which the fruit of knowledge will grow. R6sum~
Le traitement chirurgical des infections intra-abdominales repose sur l'61imination des foyers septiques, la r6duction de la contamination de la cavit6 p6riton6ale et le traitement de l'infection r6sidueUe. Pour contr61er la source de contamination qu'est la fermeture primitive de la perforation d'un organe creux, on peut pratique r une r6section ou une d6rivation selon la srvrrit6 de la prritonite ou le terrain. Le principe de la "toilette prritoneale" avec utilisation complrmentaire d'antibiotiques par voie locale ou systrmique est admis mais sa valeur est fort contestre. Quant au traitement des infections rrsidueiles et h la prrvention des rrcidives, on peut utiliser les techniques d'irrigation ouverte ou fermre, le ventre ouvert et le second look, techniques majeures dans l'approche de la prritonite grnrralisre srvrre lorsqu'on ne peut contrrler le foyer infectieux avec srcuritr. La valeur et les inconvrnients des diffrrentes techniques sont discutres. On drcrit 6galement les mrthodes adjuvantes et les domaines de la recherche future. Resumen
El manejo operatorio de las infecciones intraabdominales todavfa se fundamenta en los principios de eliminar el foco, reducir la contaminaci6n de la cavida peritoneal, y tratar la infecci6n residual. Para controlar la fuente de contaminaci6n a partir del cierre primario de una viscera perforada se puede considerar la exclusi6n o la resecci6n, segtin la gravedad de la peritonitis y de la enfermedad de base. El principio de la "toilet peritoneal" con el empleo complementario de antibi6ticos sist6micos y/o locales es generalmente aceptado, aunque la utilidad del desbridamiento agresivo es todavia motivo de controversia. En cuanto al tratamiento de la infecci6n residual y la prevenci6n de la infecci6n recurrente, [as trcnicas de lavado abierto y cerrado, el abdomen abierto (laparostomiaL y la relaparotom/a programada representan los principales aproches en casos de peritonitis generalizada severa en que el foco infeccioso no puede set controlado con entera seguridad. Se discuten las ventajas y desventajas de los diferentes reg/menes. se describen brevemente las medidas terapruticas adicionales, y se presenta una visi6n prospectiva sobre las areas de investigaci6n futura. References
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