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Laparostomy versus laparotomy in severe abdominal infection: microbiological assessment

Introduction

Mortality of severe abdominal infection, due to peritonitis after anastomotic dehiscence, visceral organ necrosis or necrotic pancreatitis, remains high. The efficacy of laparostomy in damage control surgery and uncontrolled intra-abdominal infection is controversial [1].

Methods

We retrospectively reviewed the records of all patients with severe abdominal infection secondary to peritonitis admitted to the ICU of a university teaching hospital from 1998 to 2000. The following information was collected: age, simplified acute physiology score (SAPS II) and sepsis-related organ failure assessment (SOFA) on admission, length of stay (LOS), ICU and hospital outcome, type of bacteria, number of isolations and haematogenous dissemination.

Results

Thirty-nine critically ill patients were studied. The mean age was 66.1 ± 16.9; the overall SAPS II at admission was 41.7 ± 14.6; the SOFA was 10.9 ± 4.3. A total of 13 laparostomy were performed (group I). Twenty-six patients were undergoing a laparotomy (group II). No differences regarding age (group I vs group II 61.1 +± 12.7 vs 68.5 ± 18.1, P = 0.08), SAPS II (41.8 ± 20.6 vs 41.5 ± 10.6, P = 0.65) and SOFA (11.8 ± 5.5 vs 10.4 ± 3.5, P = 0.49) were found. The duration of ICU stay was longer in group I than in group II (44.4 ± 52.2 vs 19.8 ± 17.3, P = 0.04). ICU mortality was equal between two groups (30.7%). Hospital mortality was not statistically different between two groups (38.4% vs 42.3%, P = 0.77). The number of positive cultural specimens was 19 in both groups. Isolated microorganisms were: Gram-positive cocci (21% vs 26.3%), Pseudomonas aeruginosa (26.4% vs 31.6%), other non-fermenting Gram-negative bacilli (21% vs 10.5%), Enterobacteriaceae (16% vs 10.5%), fungi (15.8% vs 15.8%). Two of five P. aeruginosa isolations in Group I were multiresistant to available antibiotics and sensible only to combinations. Four out of 13 patients in group I presented candidemia compared with two of 26 patients in group II. Haematogenous dissemination was greater in group I (85.7% vs 50%).

Conclusions

The laparostomy technique used in the management of severe intra-abdominal sepsis appears to correlate with significant ICU stay and costs. Prolonged antibiotic therapy and frequent intra-abdominal procedures determine higher incidence of infections caused by Gram-negative, enterobacteriaceae and multiresistant pseudomonaceae. The incidence of fungal infection is not influenced by surgical approach, but the 'open abdomen' strategy seems to facilitate dissemination.

References

  1. 1.

    Wittmann DH, Schein M, et al.: Management of secondary peritonitis. Ann Surg 1996, 224: 10-18. 10.1097/00000658-199607000-00003

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Pavoni, V., Gianesello, L., Paparella, L. et al. Laparostomy versus laparotomy in severe abdominal infection: microbiological assessment. Crit Care 9, P40 (2005). https://doi.org/10.1186/cc3103

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Keywords

  • Pancreatitis
  • Necrotic Pancreatitis
  • Acute Physiology Score
  • Open Abdomen
  • Anastomotic Dehiscence