modern management of peritonitis · • appendiceal flegmon: recurrence rate 7.4%, the risk of...

Modern Management of Peritonitis

Surgical Principles: Evidence Based Medicine About New &

Old Maneuvers

Korhan Taviloglu Department of Surgery

Florence Nightingale Hospital, Istanbul, Turkey

www.taviloglu.com 1 www.taviloglu.com

Intra-abdominal infection •  Intra-abdominal infection (IAI) is an

important cause of morbidity and mortality. •  It is the 2nd most commonly identified

cause of severe sepsis in the ICU. •  IAI= peritoneal inflammation in response

to microorganisms, resulting in purulence in the peritoneal cavity. IAI are classified as uncomplicated or complicated based on the extent of infection.

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•  Involve intra- mural inflammation of the GI tract without anatomic disruption.

•  They are often simple to treat; however, when treatment is delayed or inappropriate, or the infection involves a more virulent nosocomial microbe, the risk of progression into a complicated abdominal infection becomes significant

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Uncomplicated abdominal infections

•  Extend beyond the source organ into the peritoneal space. They cause peritoneal inflammation, and are associated with localized or diffuse peritonitis.

•  Localized peritonitis often manifests as an abscess with tissue debris, bacteria, neutrophils, macrophages, and exudative fluid contained in a fibrous capsule. Diffuse peritonitis is categorized as primary, secondary or tertiary peritonitis.

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Complicated abdominal infections

Classification of peritonitis

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Mazuski J, Solomkin JS. Surg Clin N Am 89 (2009) 421–437

Primary peritonitis •  White blood cell count (WBC) > 500 cells/ mm3 •  High lactate •  Low glucose levels Secondary peritonitis •  Microbial contamination through a perforation,

laceration, or necrotic segment of the GI tract. •  Definitive diagnosis is based on clinical examination

and history, and specific diagnoses can be confirmed by radiographic imaging (CT, US).

•  Infections associated with secondary peritonitis are commonly polymicrobial.

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Tertiary peritonitis

•  Infection that is persistent or recurrent at least 48 hours after appropriate management of primary or secondary peritonitis.

•  Common among critically ill or immunocompromised patients.

•  Because of the poor host defenses, it is also often associated with less virulent organisms, such as Enterococcus, Candida, Staphylococcus epidermidis & Enterobacter.

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Peritonitis sources

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Peritonitis defense mechanisms

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Peritonitis – the Eastern experience

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Gupta S, Kaushik R. WJES 2006, 1:13

Drainage •  Following initial fluid resuscitation, the goal

of drainage is to evacuate purulent, contaminated fluid, or to control drainage of ongoing enteric contamination.

•  Percutaneous or open surgical intervention. •  However, percutaneous drainage is unlikely

to result in adequate source control in cases of frank bowel perforation with ongoing contamination, or if there is a significant amount of necrotic tissue present. In these cases, surgery is the treatment of choice.


Intra-abdominal lavage •  Intra-abdominal lavage is a subject of ongoing

controversy. •  Proponents of peritoneal lavage reason that

contamination is both removed and diluted by lavage volumes > 10 L, additionally, by adding antibiotics bacterial pathogens can be specifically targeted.

•  Sugimoto (1995), has suggested that lavage with volumes of approximately 20 L reduces infectious complications in blunt traumatic small bowel perforation.

•  However, its application with or without antibiotics in abdominal sepsis is largely unsubstantiated; at this time there is minimal evidence in the literature to support its use.


Whiteside OJ. Ann R Coll Surg Engl, 2005. Schein M. Arch Surg, 1990.

Algorithm for differentiating primary & secondary peritonitis


Appendicitis •  Most common intra-abdominal surgical emergency.

•  Lifetime approximate risk: 7-9%. •  Imaging is recommended for all patients suspected of

having appendicitis except men < 40 years of age. •  CT scan: sensitivity: 87-100%, specificity 91-98% •  Ultrasound: sensitivity: 76-96%, specificity 91-100% •  MRI: sensitivity: 100%, specificity 94% •  Success rate for conservative management 88-95%;

recurrence rate of 35% •  Appendiceal flegmon: recurrence rate 7.4%, the risk

of malignancy 1.2%


Appendicitis •  Operative intervention for acute, nonperforated

appendicitis is the treatment of choice. Nonoperative management of patients with acute, nonperforated appendicitis can be considered if there is a marked improvement in the patient’s condition prior to operation. Recommendation 1 A

•  Open & laparoscopic approaches to appendectomy are both appropriate. Recommendation 1 A

•  Patients with perforated appendicitis should undergo urgent intervention. Recommendation 1 C


Sartelli et al. WSES 2011: 6:2

Appendicitis •  Patients with a periappendiceal abscess can be managed

with percutaneous image-guided drainage. Appendectomy is generally deferred in such patients. Recommendation 1 A

•  The use of interval appendectomy after percutaneous abscess drainage or nonoperative management of perforated appendicitis is controversial. Recommendation 2 C

•  A questionairre by Corfield (2007) revealed that 53 % of surgeons performed routine interval appendectomy because they worried about recurrence.

•  However; the recurrence rate of appendicitis (10%-25%) and the complication rate of interval appendectomy (23%) are similar.

•  Interval appendectomy is unnecessary in 75-90% cases.

www.taviloglu.com 16 Sartelli et al. WSES 2011: 6:2

Gastroduodenal perforation •  2nd common complication of gastro-duodenal

ulcers, following bleeding. •  Previously, ulcer perforation was treated by

excision and vagotomy. The current standard of care is simple ulcer excision and primary repair of the defect, or omental patch and subsequent H. pylori eradication, with little or no role for antisecretory ulcer surgery. Recommendation 1 A

•  Laparoscopic surgery is associated with significantly less pain, but downfalls include longer operative times, and potentially inadequate repair of large perforations. Recommendation 1 A



Gastroduodenal perforation •  In the case of a perforated peptic ulcer,

surgery is the treatment of choice. •  In selected cases (patients younger than 70

years old, no shock, no peritonitis, lack of spillage of the water-soluble contrast medium at gastroduodenogram) nonoperative management may be attempted.

•  After initial non operative management, no improvement of conditions within 24 hours is and indication to surgery. Recommendation 1 A



Langell JT, et al. Med Clin N Am 92 (2008) 599–625



Summary of previously reported series of gastroduodenal perforations



Summary of previously reported series of small intestinal perforations


Diverticulitis •  At autopsy > 50% of people over 80 years old are

affected. •  The lifetime prevalence of diverticulitis among patients

with diverticulosis is 10-25%. •  The standard treatment for uncomplicated diverticulitis is

bowel rest and antibiotics. Two studies found that patients who did not respond to antibiotics within 48 hours were more likely to require prolonged hospital stays for antibiotics & surgical intervention (Evans 2008, Sra 2009).

•  Diverticulitis can be complicated by phlegmon, abscess, or free perforation and is generally classified according to modified Hinchey criteria (Kaiser 2005).

•  Approximately 15-20% of cases are associated with abscesses. In small abscesses < 4 cm, antibiotics + percutaneous drainage = 90 % success.


Diverticulitis •  Surgery in large, multiloculated, or inaccessible, as well as in

cases of free perforation, or diffuse peritonitis. •  Non-operative treatment, with bowel rest and antibiotics, is

suggested in patients with uncomplicated diverticulitis Recommendation 1 C - Sartelli et al. WSES 2011: 6:2

•  However, the Hartmann’s procedure is associated with significant morbidity and mortality, and while it can be reversed in 3-6 months, 30-70% of patients never undergo reversal.

•  Recently, it has been suggested that primary resection and anastomosis should be preferred (Salem 2004, Richter 2006, McCafferty 2007).

•  Laparoscopic resections for complicated diverticulitis have also been shown to be safe; and, in spite of longer operative times, they are associated with fewer major complications, less pain, and shorter hospital stays.


Diverticulitis •  The decision to recommend elective sigmoid colectomy after recovery from acute diverticulitis should be made on a

case-by-case basis Recommendation 1 C •  Systemic antibiotic treatment alone is usually the most

appropriate treatment for patients with a small (4 cm in diameter) one. Recommendation 2 B

•  When a colectomy for diverticular disease is performed, a laparoscopic approach is appropriate in selected patients. Recommendation 1 B

•  Urgent operation is required for patients with diffuse peritonitis or for those who fail non-operative management of acute diverticulitis. Recommendation 1 B




Antibiotics for peritonitis


Risk factors for poor outcomes

Oral antibiotic regimens


< 24 hour antibiotic therapy



Clinical factors predicting failure of source control for intra-abdominal infections

Solomkin JS, Mazuski J. Infect Dis Clin N Am 23 (2009) 593–608

Thank you!

Korhan Taviloglu Department of Surgery

Florence Nightingale Hospital, Istanbul, Turkey

www.taviloglu.com 30 www.taviloglu.com

modern management of peritonitis · • appendiceal flegmon: recurrence rate 7.4%, the risk of...

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