COMPARISON OF PRE-OPERATIVE PERITONEAL WASH AND DRAINAGE VERSUS URGENT LAPAROTOMY STRATEGY IN PATIENTS WITH LATE STAGE PERFORATION PERITONITIS. A RANDOMIZED CONTROLLED TRIAL

Abstract

Peritonitis is inflammation of peritoneum which is most commonly due to generalized or localized infection. Secondary peritonitis is the commonest form and a large percent of them is due to perforation or impending gastrointestinal perforation. The prognosis depends on multiple factors by which Mannheim Peritonitis Index (MPI) appears to be more practical. This study aimed to assess the value of pre-operative aspiration of peritoneal fluid followed by peritoneal wash and drainage before proceeding to definitive surgery in patients with MPI score>20. This prospective study was conducted in Al-Hussein Teaching Hospital in Al Nasserya city and Basrah Teaching Hospital in Basrah city from October 2003 to July 2014. Each patient admitted to the emergency department in these hospitals with the provisional diagnosis of perforation peritonitis was evaluated with MPI score. If the score was less than 20; the patient managed with resuscitation and broad spectrum antibiotics for 2-3 hours then by definitive surgery while those with MPI more than 20 were randomly divided into two groups; the first were managed with 2-3 hours resuscitation with intra-venous fluid resuscitation and antibiotics followed by urgent surgical exploration (USE). The second group were managed with percutaneous peritoneal drainage (PPD) with aspiration of the fluid and then irrigation of the peritoneal cavity with isotonic saline and followed by a drainage with aid of the gravity through another catheter located in the right ileac fossa. Sixty two patients included in this study who fulfilled the criteria of perforation peritonitis and MPI score more than 20. Around half of them the score was between 26-30. Perforated peptic ulcer is the commonest etiology. The most common cause of their high MPI score is the late presentation and the evidence of organ failure. Renal failure is the most prevalent organ failed in both groups. The overall mortality is decreased in (PPD) group. Those with urgent surgical exploration(USE) showed no improvements in the pre-operative vital signs, prolonged operation time and a higher mortality and more severe post-operative complication than PPD group. In conclusion, the pre-operative percutaneous peritoneal aspiration of the fluid followed by peritoneal irrigation and drainage in patients with advanced stage perforation peritonitis is associated with a significant improvement in the pre-operative pulse rate and blood pressure, decrease in the operation time, a decrease in the overall mortality and deep seated wound infection and dehiscence but it is associated with a higher mortality in the first post-operative day. Introduction P eritonitis is inflammation of peritoneum which is most commonly due to generalized or localized infection. Secondary peritonitis is the commonest form. A large percentage of secondary peritonitis is due to perforation which if not treated surgically causes considerable mortality. Mortality of perforation peritonitis was as high as 90% in the early twentieth century and is still high despite advances in antibiotics, surgical technique, radiographic imaging, and Bas J Surg, December, 24, 2018 67 Comparison of pre-operative peritoneal wash and drainage versus urgent laparotomy Salah Kadhim Muslim resuscitation therapy. The contamination with the peritoneal cavity can lead to a cascade of infection , sepsis , multi system-organ failure (MSOF) and death if not treated in a timely manner. Many scoring systems was used to assess the severity of perforation peritonitis like Acute Physiology And Chronic Health Evaluation score(APACHEII), Simplified Acute Physiology Score (SAPS). In 1983; Wacha and Linder developed a scoring system consist of twenty risk factors on which eight of them proved to be of prognostic relevance. This system called Mannheim Peritonitis Index (MPI) (Table I). It appears to be more practical than other scoring systems. Mortality increases with increasing range of the score, adopting three cut-off ranges from less than 20, from 20 to 30 and more than 30 growing the mortality from 0% to 28% up to 81% respectively. Table I: The Mannheim peritonitis index Risk factor score