Value of "Second-look laparotomy" in peritoneal sepsis

Abstract

Background: Evaluation of the post-laparotomy patient, particularly if still on a ventilator, is difficult and assessment of resolution of sepsis controversial.
Methods: A retrospective study of all cases of severe peritonitis seen over a 14-year period in Bulawayo on one surgical firm from 1989 to 2003 was carried out. Patients studied included cases of sepsis de novo and septic complications of semi-elective or emergency abdominal surgery.
Results: Out of a total of 691 cases of generalized septic peritonitis seen between 1989 and 2003, 170 patients met the criteria and formed the basis of this study. Their ages ranged from 3 days to 90 years. Cases of severe generalized septic peritonitis in which the Acute Physiology and Chronic Health Evaluation (APACHE) II score was over 16 were analyzed. Fifty-four patients died within 48 hours of surgery. Thirty-nine patients survived after a second laparotomy; three of these had two re-laparotomies. There were 24 patients who underwent a second laparotomy, but succumbed nonetheless. Benefits of single or multiple laparotomies for intra-abdominal sepsis were computed where the predicted mortality was 20-30% (APACHE II 12-16) the actual mortality was reduced to zero; where the predicted mortality was 30-45% (APACHE II 16-20) the actual mortality came down to <10%; where the predicted mortality was 45-60% (APACHE II 20-25) the actual mortality dropped to <30% .