In patients with severe secondary peritonitis, there are 2 surgical treatment strategies following an initial emergency laparoscopy.
The first is planned relaparotomy and the second strategy was relaparotomy only when the patient's condition demands it, referred to as ‘on-demand'.
On-demand strategy may reduce mortality, morbidity, health care utilization, and costs.
However, randomized trials have not been performed.
Dr Oddeke van Ruler and colleagues from the Netherlands compared patient outcome, health care utilization, costs of on-demand, and planned relaparotomy.
The team undertook a randomized, nonblinded clinical trial at 2 academic, and 5 regional teaching hospitals in the Netherlands from 2001 through 2005.
Patients had severe secondary peritonitis and an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 11 or greater.
The team randomized 232 patients to on-demand or planned relaparotomy strategy.
|Mortality alone occurred in 29% of the on-demand group|
|The Journal of the American Medical Association|
The primary end point was death and/or peritonitis-related morbidity within a 12-month follow-up period.
Secondary end points included health care utilization and costs.
The team reported that 1 patient in the on-demand group was excluded due to an operative diagnosis of pancreatitis.
A further 3 patients in each group withdrew or were lost to follow-up.
There was no significant difference in primary end point, occurring in 57% of the on-demand group vs 65% of the planned relaparotomy group.
Mortality alone occurred in 29% of patients in the on-demand group vs 36% of the planned relaparotomy group.
The research team found that morbidity alone occurred in 40% of the on-demand group vs 44% of the planned relaparotomy group.
The team found that a total of 42% of the on-demand patients had a relaparotomy vs 94% of the planned relaparotomy group.
A total of 31% of first relaparotomies were negative in the on-demand group vs 66% in the planned relaparotomy group.
The research team observed that patients in the on-demand group had shorter median intensive care unit stays, and shorter median hospital stays.
Direct medical costs per patient were reduced by 23% using the on-demand strategy.
Dr van Ruler's team concluded, "Patients in the on-demand relaparotomy group did not have a significantly lower rate of death."
"Or major peritonitis-related morbidity compared with the planned relaparotomy group but did have a substantial reduction in relaparotomies, health care utilization, and medical costs."