Infections in Surgery by Unknown

Author:Unknown
Language: eng
Format: epub
ISBN: 9783030621162
Publisher: Springer International Publishing

13.5.2 Post Emergency Surgery Treatment

For abdominal sepsis that progresses or fails to improve after emergency laparotomy, there is a need for relaparotomy, based on the “on-demand” relaparotomy strategy. Aggressive surgical approached such as radical peritoneal debridement and open abdomen treatment are associated with higher morbidity and mortality and should be abandoned [73–75]. Planned relaparotomy, where laparotomy is performed every 2 to 3 days until no intraperitoneal infection is observed, has lost popularity during the last decade. One RCT has compared planned relaparotomy with on-demand relaparotomy in patients with severe abdominal sepsis, and shows no significant difference in mortality and morbidity. However, using an on-demand strategy, a clear decrease in the number of laparotomies is seen as two-thirds of patients recovered without relaparotomy in the on-demand group, as well as shorter ICU stay and lower health care costs [76]. A strategy still popular is damage control surgery, adopted from trauma care where staged laparotomies with open abdomen are performed with the goal of treating immediate life-threatening causes, and delay of reconstructive surgery [77]. However, there is a lack of convincing evidence that damage control surgery is beneficial in non-trauma setting such as secondary peritonitis, and is therefore not preferable over on-demand treatment [8, 77]. On-demand treatment is a safe strategy and surgeons should strive for primary closure of the abdomen whenever possible. Primary open abdomen increases mortality [78]. When primary closure is not possible due to edema, the use of a temporary abdominal closure technique is recommended. A recent meta-analysis indicates that continuous mesh-mediated fascial traction with negative pressure therapy has the best results in terms of delayed closures and fistula rates [79]. Some fear abdominal compartment syndrome with progressive closure strategies, however with adequate ICU support and fluid management this is infrequently seen.

The decision to perform a relaparotomy remains difficult, since traditional scoring systems are inadequate for the prediction of ongoing peritonitis [80]. A recently developed and validated decision tool for ongoing abdominal sepsis may advise the surgeon on when to perform CT imaging in a patient who deteriorates or fails to progress [81, 82]. Furthermore, care should be provided by a multidisciplinary team with 24/7 decision making. Critically ill patients are admitted to an ICU facility with adequate set-up for complex patients (high-level ICU).

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