Specialist registrar Rie Overgaard Jensen Department of Surgery, Odense University Hospital
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Is primary anastomosis and open abdomen with VAC a viable treatment for peritonitis caused by intestinal perforation?
Intestinal perforation or anastomotic leaks with fecal peritonitis is a life-threatening condition requiring acute surgery. The preferred operation is resection of the involved bowel segment and forming of a proximal ostomy, as experience tells that there is a high risk of leakage when attempting primary anastomosis by intraperitoneal contamination. However, in recent years, the vacuum processing with open abdomen has gained more ground and attempts have been made to perform the primary anastomosis during open abdomen, thus avoiding the stoma. This study aims to assess the results of these operations in our department.
Peritonitis caused by intestinal perforation is a major reason for sepsis in abdominal surgery. It is a serious condition with a mortality rate up to 30%. Relevant surgical treatment is crucial with control and elimination of the infectious focus to avoid further complications. To achieve this, the principle of damage control surgery, before mainly employed in trauma patients, has been adopted by general surgeons in the treatment of secondary peritonitis. The preferred surgical method is intestinal resection and a proximal diverting stoma with either a closure of the distal intestinal segment or placement of a distal stoma. Another possible procedure is primary anastomosis with a protective diverting loop-ileostomy in cases of colon resection. The drawback is a permanent stoma or a later reverse to restore intestinal continuity, which carries a relative high rate of leakage and a mortality rate up to 5-10%. Therefore, reversal procedure is denied in many comorbid patients, leaving permanent colostomy in 35-50%. Performing primary anastomosis carries a relative high risk of leakage because of the physiological compromising conditions from peritonitis and sepsis. However, if at the same time the abdomen is left open with vacuum assisted closure (VAC®) and planned re-laparotomy a primary anastomosis may be safe since anastomotic leakage will be discovered early and dealt properly. Another advantage of open abdomen is prevention of abdominal compartment syndrome (ACS), a serious risk due to tissue inflammation. The benefit of planned re-laparotomy versus on demand re-laparotomy is debated. At a planned re-laparotomy it is possible to drain and perform lavage of the abdominal cavity and to inspect intestines and perform procedures to prevent serious complications. The drawback is unnecessary laparotomy in a critically ill patient, which is associated with risk of medical and surgical complications. Significant differences in mortality between planned re-laparotomy and on demand re-laparotomy has not been found. Open abdomen and planned relaparotomy had widely been used in the most severe cases of secondary peritonitis as damage control, allowing the patient to stabilise, receive antibiotic load and fluid resuscitation before final surgery. Major complications linked to the use of open abdomen are fistula formation, infection and inability to obtain fascia closure.
The aim of this study is to assess whether primary anastomosis is feasible and safe in patients with peritonitis when using the open abdomen principle by VAC.\n
Description of the cohort
Patients with peritonitis caused by intestinal perforation, which have been treated at the Department of Surgery, Odense University Hospital with primary anastomosis as well as VAC and open abdomen in the period 2005-2015.
Data and biological material
Data retrieved from the journal entries associated with hospitalization for treatment of the abovementioned process.