Clinical Health Updates

For severe secondary peritonitis, on-demand relaparotomy > planned relaparotomy

Clinical Question:
In patients with secondary peritonitis who undergo initial emergent laparotomy, does planned relaparotomy reduce morbidity, mortality, and costs over on-demand relaparotomy?

Bottom Line:
Mortality rates did not differ between the 2 approaches, but on-demand laparotomy resulted in reduced intensive care unit (ICU) length of stay, reduced overall hospital length of stay, and decreased costs.

Reference:
van Ruler O, Mahler CW, Boer KR, et al, for the Dutch Peritonitis Study Group. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis. JAMA 2007;298:865-873.

Study Design:
Randomized controlled trial (nonblinded)

Synopsis:
In patients with severe secondary peritonitis, there are 2 surgical treatment strategies following an initial emergency laparotomy:
1. planned relaparotomy
2. relaparotomy

Only when the patient’s condition demands it (“on-demand”). The on-demand strategy may reduce mortality, morbidity, health care utilization, and costs. However, randomized trials have not been performed.

The investigators compared
1. patient outcome
2. health care utilization
3. costs of on-demand and planned relaparotomy.

They did a randomized, nonblinded clinical trial of patients who had severe secondary peritonitis and an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 11 or greater
1. 2 academic teaching hospitals in the Netherlands from November 2001 through February 2005
2. 5 regional teaching hospitals in the Netherlands from November 2001 through February 2005

End Points are.
1. The primary end point was death and/or peritonitis-related morbidity within a 12-month follow-up period.
2. Secondary end points included health care utilization and costs.

A total of 232 patients (116 on-demand and 116 planned) were randomized. One patient in the on-demand group was excluded due to an operative diagnosis of pancreatitis and 3 in each group withdrew or were lost to follow-up. There was no significant difference in primary end point (57% on-demand [n = 64] vs 65% planned [n = 73]; P = .25) or in mortality alone (29% on-demand [n = 32] vs 36% planned [n = 41]; P = .22) or morbidity alone (40% on-demand [n = 32] vs 44% planned [n = 32]; P = .58). 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 group (P <.001). Patients in the on-demand group had shorter median intensive care unit stays (7 vs 11 days; P = .001) and shorter median hospital stays (27 vs 35 days; P = .008). Direct medical costs per patient were reduced by 23% using the on-demand strategy.