In patients with secondary peritonitis who undergo initial emergent laparotomy, does planned relaparotomy reduce morbidity, mortality, and costs over on-demand relaparotomy?

Mortality rates did not differ between the 2 approaches, but on-demand laparotomy resulted in reduced intensive care unit (ICU) length of stay, reduced overall hospital length of stay, and decreased costs. (LOE = 1b)

van Ruler O, Mahler CW, Boer KR, et al, for the Dutch Peritonitis Study Group. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis. JAMA 2007;298:865-873.  [PMID:17712070]

Randomized controlled trial (nonblinded)

Government

Concealed

Inpatient (any location)

Patients with severe secondary peritonitis who require emergency laparotomy often undergo scheduled relaparotomy to inspect, drain, and lavage the abdominal cavity, with the aim of early identification of persistent or new infection. This multicenter study compared this planned laparotomy approach to on-demand relaparotomy, wherein repeat surgery was only performed if there was clinical deterioration or lack of improvement with a likely intra-abdominal cause. In the planned relaparotomy group, procedures were performed every 36 hours to 48 hours until a macroscopically clean abdomen was found. Eligible patients had peritonitis due to perforation, infection, or ischemia/necrosis that was verified during surgery and APACHE-II scores greater than 10. Patients with peritonitis due to pancreatitis, peritoneal dialysis, and bowel perforation after endoscopy were excluded. The primary end point was a combination of all-cause mortality and major disease-related morbidity at the 12-month follow-up after index laparotomy. Results were analyzed by intention to treat and outcome assessors were masked. Of the 510 patients registered for the study, 229 were enrolled. Most patients were excluded because their APACHE-II scores were too low or because they were not in the specified age range (18 years to 80 years). Enrolled patients were matched for baseline characteristics. A total of 233 relaparotomies were done in the planned relaparotomy group compared with 113 in the on-demand group (P < .001). Relaparotomy results were negative for persistent peritonitis or infection in 31% of the on-demand and 66% of the planned groups; positive findings were found in approximately 30% of both groups on re-exploration. There was no difference in morbidity or mortality at 2 months or 12 months (at 12 months, the planned vs on-demand mortality was 29% vs. 36%, respectively). ICU length of stay was shorter in the on-demand group (median = 7 days vs 11 days; P = .001), as was duration of mechanical ventilation (5 days vs 8 days; P = .007) and overall hospital length of stay (median = 27 days vs 35 days; P = .008).