‘Laparostomy’: a technique management of intractable abdominal sepsis

Br. J. Surg. 1986, Vol. 73, April. 253-259 for the intra-

M . M. Mughal, J. Bancewict and M. H . Irving

Department of Surgery, Hope Hospital (University of Manchester School of Medicine), Eccles Old Road, Salford M6 8HD, UK Correspondence to: Professor M. Irving

Following laparotomy for severe intra-abdominal sepsis, the abdominal cavity was left open to heal by granulation in 18 patients. I n 14 patients, operation was required because of recurrent gastrointestinal perforation or anastomotic dehiscence. In three, the indication for this procedure was recurrent pancreatic abscess. Of the 17, 13 had previously undergone multiple operations which had failed to control sepsis. Laparostomy was performed as a primary procedure in only one case, a patient with fulminating pancreatitis requiring pancreatic necrosectomy. All patients received parenteral nutrition. The overall mortality was 28 per cent. However, there was only one death among the last 9 patients treated compared with 4 in the preuious 9. The median sepsis score in the first 9 (19, range 1&26) was not significantly different (P > 0.05) from that in the subsequent 9 patients (1 7, range 8-21). Three of the four who had initially presented with severe acute pancreatitis died. N o patient eviscerated and only 9 (50 per cent) required mechanical ventilation for a median duration of 5 days. The median time for wound healing was 10 weeks and 6patients have subsequently undergone definitive surgery with satisfactory results. Laparostomy is a valuable technique in the management of severe, intractable intra-abdominal sepsis. Keywords: Laparostomy, peritonitis, gastrointestinal fistulae, pancreatic abscess

Despite steady improvements in anaesthesia, and the development of increasingly powerful antibiotics over the past 30 years, the mortality of intra-abdominal sepsis remains forbiddingly high. U p to 20 per cent of patients presenting with suppurative peritonitis’, and over 50 per cent of those with postoperative intra-abdominal sepsis’ or pancreatic abscess3, die despite intensive treatment including surgery. Although age, pre-existing medical conditions, delay in presentation and inadequate treatment are undoubtedly contributory factors, this mortality is largely due to failure to eradicate sepsis at the initial operation or to the recurrence of sepsis with its sequelae of multi- organ failure.

Methods of dealing with severe intra-abdominal sepsis include the use of multiple sump drains, peritoneal lavage (both during4, and after5v6 operation) and the technique of radical peritoneal debridement7**. Unfortunately these techniques, though useful in controlling initial sepsis, have not been shown to prevent its recurrence.

If recurrence is anticipated after adequate drainage of intra- abdominal sepsis and the correction of its cause, the situation can be managed in two ways: laparotomy may be repeated at set intervals until the abdominal cavity is clean’, or the abdominal cavity can be left open. Although both methods have been shown to improve mortality, the latter would appear to have certain advantages: better drainage of pus, possible inhibition of anaerobic organisms and less ‘stenting’ of the diaphragm.

Although the open treatment of intra-abdominal sepsis, ‘laparostomy’, has been used with some success by European surgeons”-”, the few publications on the subject in the English literature’ report variable results. Because of our special interest in intestinal failure and gastrointestinal fistulae, we have been afforded a unique opportunity to use the technique of ‘laparostomy’ in difficult cases. This report is a review of our experience.

Materials and methods Eleven women and seven men aged 30 to 78 years (median 48 years) have undergone laparostomy during the past 4 years. All except two were referred from other hospitals, often after multiple operations for intra- abdominal sepsis. The initial operation had been performed as an emergency in seven patients. Laparostomy was performed as a primary procedure in only one case, a patient with fulminating pancreatitis who required pancreatic necrosectomy. In the remaining cases the indication was intractable sepsis which was related to gastrointestinal fistulae in 14 patients (82 per cent). Sepsis was graded according to the scoring system of Elebute and Stonerz3. The median’score for the 18 patients was 17 with a range of 8-26. The primary pathology and other details of individual cases are summarized in Table I , the cases being listed in the order in which they were treated on our unit.

All patients were managed on a 4-bedded, purpose-built unit specializing in the treatment of difficult gastrointestinal problems requiring total parenteral nutritionz4. After correction of any fluid and electrolyte deficits, patients were assessed with regard to the necessity and timing of surgery. Diagnostic studies to determine the site of intra- abdominal collections were performed where necessary in those well enough to tolerate them. In such cases, ultrasound scanning and computerized tomography were helpful in planning managment (Figure I ) . The structure of sinuses or fistulae was explored by the injection of radio-opaque contrast media. This was helpful in identifying abscess cavities and demonstrating any communications with the viscera. Patients who were shocked as a result of septicaemia or bleeding (due to stress ulceration or reactionary haemorrhage into abscess cavities) underwent operation as matter of urgency. Parenteral nutrition was commenced within 48 h of admission.

Procedure The choice of incision was usually based on clinical impression aided by the results of diagnostic tests. As a general rule, the upper abdominal transverse or ‘rooftop’ incision was employed for draining upper abdominal collections and was particularly useful in pancreatic abscesses. As the resultant cavity was packed and not sutured,

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~ 7 - 1 3 2 3 / 8 6 / 0 4 0 2 5 3 - 0 7 $ 3 . ~ 8 1986 Butterworth & Co (Publishers) Ltd 253

'Laparostomy': M. M. Mughal et al.

Table 1 Details of patients undergoing laparostomy

Case

1

2

3

4

5

6

7

8

9

10

1 1

12

13

14

Primary Sex Age disease

M

M

M

F

M

F

M

F

F

F

M

M

M

F

56 Gallstones

48 Crohn's fistula

31 Pancreatic pseudocyst

61 Perforated duodenal ulcer

54 Pancreatic pseudocyst

78 Bleeding duodenal ulcer

33 Barrett's ulcer

47 Crohn's, vesico- colic fistula

45 Crohn's, Previous Rx for carcinoma cervix

64 Perforated sigmoid carcinoma

48 Severe pancre- atitis

48 Chronic pancre- atitis

43 Blunt abdominal trauma

40 Perforated duodenal ulcer

Indication for Previous surgery laparostomy

Laparostomy Sepsis incision Ventilation Reconstructive scorez3 and procedure (days) Outcome surgery

0 Cholecystectomy Fistula + ECBD sepsis + + 24 drainage of re-bleeds subphrenic abscess

0 Bowel resection Fistula + and ileostomy sepsis

0 Cystogastrostomy Fistula+ + 10 laparotomy for sepsis+ sepsis and gastric +bleed fistula

0 Oversew of Fistula + perforation sepsis + 8 intubation of perforation and gastrostomy

0 Cystogastrostomy Sepsis

0 Vagotomy and Fistula + pyloroplasty sepsis + 3 gastroentero- stomy

0 Distal Fistula + oesophagectomy sepsis + 2 total oesophagectomy and proximal gastrectom y + 19 laparotomy for sepsis

0 Sigmoid Fistula + colectomy sepsis

0 Small bowel resection + 12 right hemi- and sigmoid colectomy with anastomosis

0 Hartmann procedure + 14 Drainage pelvic abscess + 22 peritonitis, bowel resection and anastomosis

Nil

0 Total pancreatectomy and transverse colectomy + 1 laparotomy for bleeding

0 Laparotomy for peritonitis + 14 laparotomy for bleeding

0 Drain subphrenic abscess and intubation of perforation + 5 laparotomy for bleeding

Fistula + sepsis

Fistula+ sepsis

Primary procedure

Bile leak + sepsis

Fistula + sepsis

Sepsis + recurrent bleeding

22

22

26

10

25

17

18

19

11

9

21

8

17

18

Upper transverse No A&W Yes and split Dis. +265 +325 colostomy + 56

C-shaped incision No into upper and lower abdominal abscesses + 25

Upper transverse 21 and drainage of pancreatic and subphrenic abscess + 14

Upper transverse No and drainage of subphrenic abscess + 24

Upper transverse No and drainage of abscess +20

Upper midline and No intubation of fistulae +21

Upper transverse, excising stomach remnant +51

C-shaped, left hemi-colectomy and colostomy. Abdomen left open +150

Midline incision re-opened exposing fistulae +21

Midline incision re-opened exposing fistulae + 40

Rooftop incision. Pancreatic necrosectomy Re-opening of rooftop incision, exposing fistula + 5

Rooftop incision exposing fistula + 42

Re-opening of midline with left transverse extension + 15

2

3

No

No

24

I

5

1

A&W No Dis. + 5 5

Died No + 30

Died No +64

Died No + 270

Died No + 46

A&W Yes +110 +485

A&W No Dis. +210

* No

* Yes Dis. +160 +140

Died No + 60

A&W No Dis. +lOO

A&W Yes Dis. +60 + lo0

A&W Yes Dis. +80 +75

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Table 1 (continued)

Primary Case Sex Age disease

15 F

16 F

17 F

18 F

45 Pancreatic abscess

59 Crohn's

30 Gallstones

33 Chronic peptic ulcer

Previous surgery Indication for laparostomy

0 Drainage of abscess

Multiple bowel resections with fistulation

0 cholecystectomy ECBD and sphincteroplasty + 10 drain pancreatic abscess and transverse colectomy + 24 reanastomosis

Residual sepsis

Fistula+ sepsis

Fistula + sepsis

6 operations in 10 years, last operation: sepsis total gastrectomy

Fistula t

Laparostomy Sepsis incision Ventilation Reconstructive scorez3 and procedure (days) Outcome surgery __ 17

12

15

19

Rooftop, 5 A&W No necrosectomy Dis. +49 cholecystostom y + 25

Lower midline, No pelvic cavity left open Upper transverse No + 56

A&W No Dis. +270

A&W No Dis. +SO

Long midline, 1 A&W Yes complete exposure I/P + 130 of peritoneal cavity and fistulae +64

For timing of events initial operation is day 0; ECBD, exploration ofcommon bile duct; A&W, alive and well; Dis., discharged; I/P, in-patient;emergency operations in italics. * Died of carcinomatosis after recovering from laparostomy

Figure 1 CTscan showing a pancreatic abscess (outlined) in case I I

extensions to incisions were made with impunity for the drainage of complex and unusually situated collections.

The abdominal cavity was entered by careful dissection to avoid creating new fistulae. In patients with sepsis secondary to anastomotic leakage, an abscess cavity discharging gastrointestinal contents was commonly found between the leaking viscus and the cutaneous opening. If possible, abscesses were opened without disturbing the rest of the peritoneum. When a large solitary collection was discovered, confirming pre-operative tests, no further exploration was performed. However, in patients with complex, multilocular collections, or in those with signs of diffuse peritonitis, a full laparotomy was performed. Apart from the subphrenic spaces and the pelvic cavity, which are routinely explored in the search for pus, we have noted a number of other sites of predilection. These include the lesser sac, the paracolic spaces, particularly around the colic flexures, between loops of small bowel and also in the retroperitoneal tissues, particularly the perirenal spaces.

Ideally, the laparostomy opening was made large enough to facilitate easy changeofpacks and to ensure healing from thedepths ofthe wound. Solitary fistulae distal to the duodenojejunal flexure, a rare situation in this series. were excised and the bowel ends exteriorized. Multiple fistulae were usually left undisturbed at the base of the cavity (Figure 2). We considered this to be safer than excising a mass of bowel without

Figure 2 fistulae in its base (case 18)

Healing laparostomy wound showing multiple small bowel

knowledge of the. anatomy of the fistulae or the length of bowel remaining after previous operations. At the end of the procedure, the cavity was copiously washed with saline and packed with moist 6inch gauze rolls.

Laparostomy in itself was never an indication for mechanical

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Figure 3 Healing laparostomy wound (case 14). The skin is protected by closefitting sheets of Stomahesive (Squibb). Thefirst part ofthe duodenum has been left open and sutures controlling a tressel in aposterior ulcer can be clearly seen

Figure 4 Postage stamp grafts are a satisfactory way epithelializing a granulating laparostomy wound (case 8)

ventilation. All patients. received total parenteral nutrition using an appropriate combination of dextrose, amino acids (Synthamin, Travenol) and fat (Intralipid, KabiVitrum) as dictated by the basal metabolic rate and nitrogen output. Antibiotics were used only for treating septicaemic episodes.

Following laparostomy, the packs werechanged regularly, usually at intervals of 24-48 h. The cavity was examined on each occasion and any loculi carefully broken down with the finger. General anaesthesia was only required for the first two or three changes, subsequent changes being facilitated by intravenous analgesia or Entonox. Whether general anaesthesia or analgesia alone was used, packs were changed in the operating room on the first few occasions since bleeding from disturbance of vessels in the depths of the wound was not uncommon, and was sometimes dramatic, particularly from the pancreatic bed.

Rigorous skin care was an important aspect of management of the laparostomy. Fistula discharges were kept off the skin by the application of close fitting sheets of Stomahesive (Squibb) to the skin surrounding the wound and by an appropriately positioned sump drain connected to low power suction (Figure 3). As the serosal surfaces of the bowel granulated, split skin grafts were applied in the form of ‘postage stamps’. We were gratified by a consistently high rate of ‘take’ of the grafts in such adverse conditions (Figure 4). The wound was considered to be healed when, by a combination of skin grafting and wound contracture. complete skin cover had been achieved or, in the case of a fistula, when a stoma appliance could be fitted.

Results Morbidity and mortality Five patients (28 per cent) died following laparostomy. Two of the 13 survivors died of carcinomatosis at 2 and 6 months after recovering from laparostomy, during which time they had a reasonable quality of life.

All five deaths were attributable to the primary condition or complications of subsequent treatment. In terms of median age, sepsis score at presentation, primary pathology and the proportion whose initial condition was such as to require an emergency operation, the 5 patientswho died were similar to the 13 who survived (Table 2). Whereas 4 (44 per cent) of the first 9 patients treated with laparostomy died, only one (1 1 per cent) of the following 9 did not survive the procedure. There was no significant difference ( P > 0.05, Wilcoxon’s rank sum test) in the median sepsis score between the first 9 (19, range 1&26) and the subsequent 9 patients (17, range 8-21). The primary pathology was acute pancreatitis in 3 of the 5 who died. In two of these (cases 5 and 1 l), post-mortem examination revealed extensive sepsis, although interestingly, not in the pancreatic bed - one patient had pulmonary abscesses and the other had widespread metastatic abscesses and endocarditis. Clinically, the remaining three also died of sepsis although two of these (cases 4 and 6) were elderly.

Despite leaving the abdominal cavity open, evisceration did not occur. Mechanical ventilation was only required in 9 patients (50 per cent), and then only for a median duration of 5 days (range 1-24 days). Renal failure occurred in only one patient (case 11) . This particular patient was in renal failure before operation, but following pancreatic necrosectomy and laparostomy his renal function returned to normal. No patient developed renal failure following laparostomy. Despite laparostomy, one patient developed a perirenal abscess which was drained percutaneously and 4 others required antibiotics for episodes of septicaemia. There were no complications directly attributable to packing. Although ‘new’ fistulae appeared in one case, it is unlikely that these were caused by packing.

Wound healing and reconstructive surgery

The median time for wounds to heal was 10 weeks (range 3-26 weeks). Six patients have gone on to have definitive surgery 2-15 months after laparostomy (median 6 months). The procedures were: reanastomosis of formally exteriorized bowel (case I), resection of fistulae and reanastomosis (cases 10 and 18), oesophageal reconstruction using colon (case 7), Roux loop to duodenal fistula (case 13) and Polya gastrectomy (case 14). In most cases definitive surgery was performed without undue difficulty and with excellent results. Remarkably few adhesions were encountered in the majority of cases. Only two (cases 13 and 17) of the 1 1 survivors developed incisional hernias. Two representative cases are described below.

Case 7 A 33-year-old man was transferred to our care with an enterocutaneous fistula following elective distal oesophagectomy for a Barrett’s ulcer. Three days following the initial operation, re-exploration was required because of anastomotic dehiscence. The proximal stomach, which was found to be necrotic, was excised together with the remaining intrathoracic oesophagus leaving the patient with a gastrostomy and a cervical oesophagostomy. Two weeks later another laparotomy was performed for gastrointestinal bleeding and a duodenal ulcer was undersewn following which the patient developed a duodenal fistula and

Table 2 A comparison of survivors with those dying afer laparostomy

Dead Alive Statistical n=5 n = 1 3 significance

Age (years) Median 54 45 P > 0.05(n.s.)* Range (31-78) (3&64)

Sepsis scorez3 Median 21 17 P > 0.05(n.s.)* Range (1C26) (8-22)

Initial operation as 2/5 5/13 P = l.O(n.s.)t emergency

pancreatitis Primary pathology 3/5 211 I P =0.78(n.s.)?

* Wilcoxon’s rank sum test; t Fisher’s test of exact probability

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asymptomatic. Five days before presenting with severe abdominal pain, he had been crushed against a wall by a cow, sustaining what he considered to be a trivial injury. On admission, he had signs of upper abdominal peritonitis with a raised serum amylase level of 2500 units/l. Laparotomy was performed revealing biliary peritonitis with two duodenal perforations and an oedematous pancreas. After peritoneal lavage, drains were placed adjacent to the duodenum and the abdomen closed. Two weeks later a second laparotomy was performed for severe gastrointestinal bleeding at which a large duodenal ulcer was undersewn and the patient transferred to our unit. Parenteral nutrition was commenced and, because he was extremely toxic (sepsis score 171, the upper abdomen was explored through a rooftop incision. A large left subphrenic collection was drained, and the duodenal stump, which was found to be completely open was left undisturbed and the wound packed. Mechanical ventilation was required for 5 days. The patient made a steady recovery and the wound healed sufficiently over the next two months to allow the application of a stoma bag around the duodenal fistula. He resumed adequate oral nutrition and was discharged home with a low output duodenal fistula and readmitted 6 weeks later for reconstructive surgery at which the duodenal stump was drained into a Roux loop. Remarkably few intraperitoneal adhesions were encountered at this operation.

Figure 5 Case 7. Upper abdominal laparostomy

Discussion As far as we can ascertain, the term ‘laparostomy’ was first used by Professor J. N. Maillard of Paris ten years ago (Professor L. F. Hollender, personal communication). We have found this technique very effective in the management of intra-abdominal sepsis in which the abscesses are too extensive or their contents too thick for treatment by interventional radiological or conventional surgical techniques. The mortality of 28 per cent in a group of critically ill patients, the majority of whom had already had more than one operation for intra-abdominal sepsis

Figure 6 parenteral nutrition

Case 7. Healed laparostomy wound before discharge on home

continued to deteriorate from persistent sepsis. On his admission to our unit, parenteral nutrition was commenced and laparostomy was performed using a transverse upper abdominal incision. A large abscess was found in association with a gangrenous stomach remnant which was excised. A sump drain was placed into the duodenum and the wound packed (Figure 5). He recovered steadily and was discharged a month later on home parenteral nutrition (Figure 6). Intestinal continuity was restored a year later using the right colon with uneventful recovery and a very satisfactory functional result (Figure 7).

Case 13 A 43-year-old, previously fit farmer was transferred to our unit following two emergencyoperations. Thirteen years previously he had had a Polya gastrectomy for duodenal ulcer following which he had been Figure 7 Case 7. The abdomen one year after oesophagealreconstruction

Br. J. Surg., Vol. 73, No. 4, April 1986 257

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Table 3 Mortality of luparostomy in previous studies

Reference Number of Mortality number Author(s) Year patients (Percentage)

10 11 12 18 13 19 20 14 21 16 15 22

17

Champault et a / . Guivarc’h er a/ . Hay et ul. Steinberg Fagniez et a / . Duff and Moffat Maetani and Tobe Doutre e t a / . Anderson et a/ . Broome et a/ . Hollender et a / . Bradley and Fulenwider

Guthy

1979 27 1979 16 1979 64 1979 14 1980 32 1981 18 1981 13 1982 29 1983 20 1983 30 1983 22 1984 21

1984 100

48 25 52 7

56 38 8

51 60 47 32 14

50-60

is better than the 42percent mortality in 33 patients with abdominal sepsis treated by closed laparotomy in our unitz4. Following laparostomy, recurrent sepsis is rare and healing rapid, permitting definitive surgery when required, any time from 10 weeks onwards. Curiously, incisional hernias are uncommon, confirming the experience of others” with this technique. We believe this to be due to healing of the cavities by contracture, ultimately resulting in the apposition of the musculo-aponeurotic margins of the wound.

The principal cause of death following surgery for peritonitis is failure to control the initial infection or the recurrence of sepsis. Septicaemia, gastrointestinal bleeding, renal failure and respiratory problems are well known causes of death following peritonitis. Although often attributed to the ‘poor general condition of the patient’ these complications are, in reality, merely manifestations of the syndrome of multi-organ failure which characterizes severe sepsisz6.

Beforecomparing the different methods of dealing with intra- abdominal sepsis, it is important to distinguish between ‘first time’ peritonitis due, for example, t o perforated duodenal ulcer, postoperative peritonitis due to anastomotic dehiscence, and deep seated intra-abdominal collections of pus such as subphrenic or pancreatic abscesses. These distinctions are important because the management of first time peritonitis which has a mortality of up t o 20 per cent’ is different from that of postoperative intra-abdominal sepsis due to anastomotic dehiscence or pancreatic abscesses which carry a mortality of over 50 per The higher mortality in the latter situation is due to the fact that both the accurate localization of sepsis and the necessary operations are often difficult, and the patient may be compromised already as a result of chest infection, malnutrition, etc.

Postoperative peritoneal lavage for a period of48-72 h, with’ or without6 antibiotics has been shown to reduce the mortality of peritonitis. Hudspeth advocates radical peritoneal debridement for diffuse peritonitis7. However, a prospective controlled trial of the technique, which involves the meticulous removal from the peritoneal cavity of all pus and detritus including fibrinous exudate from the serosal aspect of the bowel, has failed to show any advantage over conventional surgery and indeed carried a high mortality in the elderly’.

Clearly, neither postoperative lavage nor radical peritoneal debridement are applicable in the type of patient described in our series. The former because much of the peritoneal cavity is often walled-off by adhesions from previous surgery and the latter because it would be technically impossible.

In a prospective study of septic shock (mainly of gastrointestinal origin), a significant reduction in mortality has been shown by the routine exploration of patients failing to respond to intensive resuscitation within a few hoursz7. On this basis, some workers have advocated planned re-laparotomies for severe peritonitis’. In a retrospective study of 42 patients

with severe generalized peritonitis, Penninckx and associates showed a reduction in mortality from 79 per cent in those managed by ‘on-demand’ laparotomies to 29 per cent in those subjected to laparotomy every 2 to 3 days until the abdominal cavity was clean. The authors d o not explain why it was necessary to re-suture the abdomen after each operation.

Laparostomy would appear to be a rational method of dealing with peritoneal sepsis after previous surgery, particularly when there are multiple fistulae which cannot be easily exteriorized, and also for the primary treatment of pancreatic abscesses which often contain debris that cannot easily pass down a drain.

The previously reported mortality of laparostomy ranges from 7 per cent t o 60 per cent with an average of 38 per cent (Table 3). The results of laparostomy seem to depend, among other things, on the indications for its use and the subsequent management of the wound. The lowest mortality of 7 per cent for its use in diffuse peritonitis was reported by Steinberg”. It is clear that the patients in Steinberg’s series were not as ill as those discussed in the present study. Twelve (86 per cent) of the 14 patients in his series presented with ‘first time’ peritonitis and the abdomen was formally closed in all cases in 48-72 h. Similarly, the low mortality of 14percent for the open drainage of pancreatic abscesses reported by Bradley and FulenwiderZZ was in patients who had had no previous attempts a t drainage of sepsis. Furthermore, their series did not include patients with necrotizing pancreatitis. Our patients and methods are comparable to those of Maetani and Tobe, who reported a mortality of only 8 per cent”. We havenearly achieved the same rate of success in the last 9 patients treated by laparostomy.

The highest mortality was reported by Anderson and colleagues’’. In 20 patients treated by open packing of the abdomen, of whom half had postoperative peritonitis, they recorded a mortality of 60 per cent compared with 33 per cent in conventionally treated historical controls. These disappointing results may have been due to the inappropriate use of laparostomy in half the patients, who in fact had first-time, diffuse peritonitis. Nearly three-quarters of the patients developed severe respiratory problems during the course of their illness, almost certainly a consequence of the use of prolonged mechanical ventilation in all patients undergoing laparostomy.

As the majority of our cases had adhesions from previous operations and because laparostomy rarely resulted in total exposure of the peritoneal cavity, mechanical ventilation was never specifically required to prevent evisceration. Nearly half of our patients were therefore spared the potential complications of prolonged mechanical ventilation.

Like othersI5, we have found that patients with fulminant pancreatitis, irrespective of their age, do badly. Three of the four patients in our series who underwent surgery for necrotizing pancreatitis or pancreatitic abscess died. Although others have reported a mortality as low as 14 per cent following the open drainage of pancreatic abscesses”, the patient groups are not strictly comparable. Two of our three patients with pancreatitis who died (cases 3 and 5) were referred to us at a late stage after failure of primary surgery. It is interesting that all three of our patients with pancreatitis who died had a sepsis score above 20, confirming the findings of Elebute and Stonerz3, who noted a 90 per cent mortality in patients with a sepsis score exceeding 20. A rising score is a grave prognostic sign and a signal that urgent surgery is needed in patients with suspected intra-abdominal sepsis and fulminant pancreatitis.

We d o not regard laparostomy as a first line procedure for intra-abdominal sepsis other than in exceptional circumstances such as huge rnultilocular pancreatic abscesses. At least one previous study” has shown that the over-enthusiastic use of laparostomy can be disastrous. In a series of 137 patients with diffuse peritonitis, Hollender and colleagues only used laparostomy in 22 cases (16 per cent).

At the turn of the century, Yates concluded from his experimental studies that ‘drainage of the general peritoneal cavity is physically and physiologically impossible’28. His

258 Br. J. Surg.. Vol. 73, No. 4, April 1986

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Guivarc’h M, Roullet-Audy JC, Chapmann A. La non-fermeture parittale dans la chirurgie itkrative des peritonites. Chirurgie 1979;

Hay JM, Duchatelle P, Elman A, Flamant Y, Maillard JN. Les ventres laisses ouverts. Chirurgie 1979; 105: 508-10. Fagniez PL, Villet R, LeGall JR, Salvat A, Germain A. La non fermeture parietale dans la chirurgie iterative des +ritonites. Chirurgie 1980; 106: 293-6. Doutre LP, Perissat J, Saric J et a/. La laparostomie: Method d’exception dans la traitement des pkritonites gravissimes. Ann Chir 1982; 3 6 433-6. Hollender LF, Bur F, Schwenck D, Pigache P. Das ‘Offengenlassene abdomen’ Technik, indikation und resultate. Chirurgie 1983: 54 316-9. Broom6 A, Hansson L, Lundgren F, Smedberg S. Open treatment of abdominal septic catastrophies. World J Surg 1983; 7: 792-6. Guthy E. Surgical aspects in the management of peritonitis. Scand J Gastroent 1984; 100: 49-52. Steinberg D. On leaving the peritoneal cavity open in acute generalised suppurative peritonitis. Am J Surg 1979; 137: 216-20. Duff JH, Moffat J. Abdominal sepsis managed by leaving abdomen open. Surgery 1981; 90: 774-6. Maetani S, Tobe T. Open peritoneal drainage as effective treatment of advanced peritonitis. Surgery 1981; 9 0 804-9. Anderson ED, Mandelbaum DM, Ellison EC, Carey LC, Cooperman M. Open packing of the peritoneal cavity in generalised bacterial peritonitis. Am J Surg 1983; 145 131-3. Bradley EL, Fulenwider JT. Open treatment of pancreatic abscess. Surg Gynecol Obstet 1984; 159 509-13. Elebute EA, Stoner HB. The grading of sepsis. Br J Surg 1983; 7 0

Irving M, White R, Tresadern J. Three years’ experience with an intestinal failure unit. Ann R Coll Surg Eng 1985; 67: 2-5. Mohn HP. Beitrag zur postoperativen sepsis in der Bauchchirurgie. Eine Auswertung von 104 Fallen. Dissertation Universtat Berne 1980. Quoted by Aeberhard P and Casey PA (Reference 2 above). Polk HC, Shields CL. Remote organ failure: A valid sign of occult intra-abdominal infection. Surgery 1977; 81: 31Ck3. Ledingham I McA, McArdle CS. Prospective study of the treatment of septic shock. Lancet 1978; i 1194-7. Yates JL. An experimental study of the local effects of peritoneal drainage. Surg Gynecol Obstet 1905; 1: 473-92.

105 287-90.

29-3 1.

remarks are probably still relevant to the drainage of a closed abdomen, but if the peritoneal cavity is packed open and allowed to heal by granulation, then we believe that satisfactory drainage can be achieved. That this sort of treatment is possible is in large measure due to the feasibility of total parenteral nutrition and advances in stoma care. The successful management of the patient with a laparostomy hinges on expert nursing care and the capability of maintaining complication-free long term parenteral nutrition. It is an advantage to treat such patients in specialized centres with a pool of the necessary skills, facilities and experiencez4. However, this should not dissuade one from using this life-saving technique appropriately; laparostomy may stabilize a critically ill patient who can then be referred to a specialist centre.

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Stephen MA, Loewenthal J. Generalized infective peritonitis. Surg Gynecol Obstet 1978; 147 2314. Aeberhard P, Casey PA. Re-operation for Abdominal Sepsis. Berne, Stuttgart: Hans Huber, 1983. Ranson JHC, Spencer FC. Prevention, diagnosis and treatment of pancreatic abscess. Surgery 1977; 82: 99-106. Stewart DJ, Matheson NA. Peritoneal lavage in appendicular peritonitis. Br J Surg 1978; 65: 54-6. McKenna JP, Currie DJ, MacDonald JA et a/. The use of continuous postoperative peritoneal lavage in the management of diffuse peritonitis. Surg Gynecol Obstet 1970; 130: 254-8. Jennings WC, Wood CD, Guernsey JM. Continuous postoperative lavage in the treatment of peritoneal sepsis. Dis Colon Rectum 1982; 25 641-3. Hudspeth AS. Radical surgical debridement in the treatment of advanced generalised peritonitis. Arch Surg 1974; 110 1233-36. Polk HC, Fry DE. Radical peritoneal debridement for established peritonitis. The results of a prospective randomised clinical trial. Arch Surg 1980; 192 35G5. Penninckx FM, Kerremans RP, Lauwers PM. Planned relaparotomies in the surgical treatment of severe generalised peritonitis from intestinal origin. Wortd J Surg 1983; 7 762-6. Champault G, Magnier M, Psalmon F, Patel JC. Discussion en cours: la non-fermeture pariltale dans la chirurgie iterative des peritonites. Chirurgie 1979; 105: 866-9.

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Paper accepted 5 November 1985

Br. J. Surg.. Vol. 73, No. 4. April 1986 259