Indications for relaparotomy and its results

For the recent six years 6855 operations on abdominal organs have been performed which were followed by relaparotomies in 104 patients (1.5%). The authors show that the greatest amount of relaparotomies followed operations for ulcer disease, tumors and cholecystitis. The main causes of relaparotomies were peritonitis, intestinal obstructions and bleedings. The group of greater risk consisted of men aged 50-60. The amount of relaparotomies can be reduced due to unification of medical tactics, strict observation of the operation technique and responsible management of the patients in the postoperative period.     

Indications for relaparotomy in acute postoperative intestinal obstruction]

For the period of 1977-1987, operations on the abdominal organs were performed in 13,306 patients. Of them, 115 (0.86%) developed 1 to 21 days after the operation acute ileus requiring the performance of emergency relaparotomy. Lethality in this complication was 33.9%. A retrospective analysis of 103 case records and observations on 12 patients who underwent at the early postoperative period emergency laparotomy for acute ileus were performed. The data were entered on a formalized card. The material was processed by means of a computer. The integral criteria for diagnosis of acute postoperative ileus which permitted to predict with an accuracy of 99% the complication serving an indication for relaparotomy were developed.     

Early relaparotomy

An analysis of 14565 operations on organs of the abdominal cavity has shown that main causes of early relaparotomies were peritonites (47,4%), intestinal obstruction (33,3%), eventration of the abdominal organs (16,0%) and hemoperitoneum (3,3%). The highest lethality was after postoperative peritonitis (54,1%). For the recent 10 years the total lethality has become 31,6% lower due to better diagnosis and early relaparotomies.     

Mortality and morbidity of planned relaparotomy versus relaparotomy on demand for secondary peritonitis

BACKGROUND: Planned relaparotomy (PR) and relaparotomy on demand (ROD) are both frequently used in the treatment of secondary peritonitis. The aim of this study was to evaluate the mortality, morbidity and long-term outcome associated with PR compared with ROD in patients with secondary peritonitis admitted to a university hospital. METHOD: This retrospective study included 278 consecutive patients who underwent emergency laparotomy for secondary peritonitis between January 1994 and January 2000. Outcome was analysed based on the decision made by the surgeon during the first operation to perform either ROD (197 patients) or PR (81). RESULTS: The Acute Physiology And Chronic Health Evaluation II score was comparable in ROD and PR groups (10.8 versus 11.7; P = 0.222). The in-hospital mortality rate was significantly lower with ROD than PR (21.8 versus 36 per cent; P = 0.016). Two-year survival(s.e.) was 65.8(3.4) per cent in the ROD group and 55.5(5.5) per cent in the PR group (P = 0.031). CONCLUSION: The in-hospital and long-term survival rates were higher in patients with secondary peritonitis treated by ROD than in those with disease of comparable severity treated by PR. Choice of treatment strategy was an independent predictor of survival.     

Early urgent relaparotomy

We analyzed the indications for and implications of reoperation in 113 patients who required early urgent relaparotomy. Infection with intact organs was the most common indication, causing the most diagnostic difficulties, and presenting the most varied findings. Suture-line leaks and dehiscence were next in frequency. Bleeding caused the earliest relaparotomies and obstruction, the latest. In seven patients a technical error at the primary laparotomy was identified, and in 56 patients an error of some sort was presumed. High-mortality categories were identified, including the elderly, who were particularly susceptible if bleeding or after an emergency primary laparotomy. An aggressive policy of reoperation resulted in 59 survivors and seems to be the only practical approach in the treatment of these usually desperately ill patients.     

Meta-analysis of relaparotomy for secondary peritonitis

BACKGROUND: Planned relaparotomy and relaparotomy on demand are two frequently employed surgical treatment strategies for patients with abdominal sepsis. METHODS: The available literature was evaluated to compare the efficacy of both surgical treatment strategies. A systematic search for studies comparing planned and on-demand relaparotomy strategies in adult patients with secondary peritonitis was employed. Studies were reviewed independently for design features, inclusion and exclusion criteria, and outcomes. The primary outcome measure was in-hospital mortality. RESULTS: No randomized studies were found; eight observational studies with a total of 1266 patients (planned relaparotomy, 286; relaparotomy on demand, 980) met the inclusion criteria and were included in the meta-analysis. These eight studies were heterogeneous on clinical and statistical grounds (chi2= 40.7, d.f. = 7, P < 0.001). Using a random-effects approach, the combined odds ratio for in-hospital mortality was 0.70 (95 per cent confidence interval 0.27 to 1.80) in favour of the on-demand strategy. CONCLUSION: The combined results of observational studies show a statistically non-significant reduction in mortality for the on-demand relaparotomy strategy compared with the planned relaparotomy strategy when corrected for heterogeneity in a random-effects model. Owing to the non-randomized nature of the studies, the limited number of patients per study, and the heterogeneity between studies, the overall evidence generated by the eight studies was inconclusive.     

Emergency relaparotomy in children

Early relaparotomies following operations on organs of the abdominal cavity were shown by the authors to be necessary in 1,3% of the patients operated on due to developing intraperitoneal complications. The main causes of repeated operations were: intestinal obstruction, diffuse peritonitis, intestinal eventration, limited purulent processes in the abdominal cavity and intraperitoneal bleedings. Postoperative lethality proved to be high (23,5%).     

Programmed relaparotomy in peritonitis

Statistical analysis of the clinical picture, history data, intraoperative findings and outcomes of treatment in 214 patients with generalized purulent peritonitis provided an algorithm for defining of indications for programmed relaparotomy. The algorithm allowed errors to decrease from 25.2 to 2.4% in the choice of surgical policy for peritonitis and to decrease mortality from 21.0 to 16.7%.     

Psychological aspects of relaparotomy

The authors analyse the importance of the psychological barrier in the choice of the method of treatment in performing relaparotomy. Proceeding from the fact that the surgeon's psychological barrier is an objective factor aggravating the results of management of postoperative complications, the authors suggest that the indications for relaparotomy should be considered collectively. They believe that the second operation should be carried out by another, more experienced surgeon of the department. The surgeon who performed the first operation acts as an assistant during the relaparotomy.     

Non-directed relaparotomy for intra-abdominal sepsis. A futile procedure

Over a 50-month period, 2,657 primary laparotomies were performed; 192 patients underwent urgent relaparotomy for complications of primary laparotomy. Forty-seven relaparotomies were performed for Type I intra-abdominal sepsis (IAS-1) with a 12.8 per cent mortality, and 46 for Type 2 IAS with a 82.6 per cent mortality (P less than 0.001). Of the 46 IAS-2 patients, 31 relaparotomies were "directed" by positive peritoneal signs (CAT/ultrasound/PIPIDA examinations) with 94 per cent (29/31) yielding positive findings. Fifteen were "non-directed" in an effort to uncover an occult source of continuing sepsis of MOSF and yielded a 13 per cent (2/15) positive rate (P less than 0.001), and a 93 per cent (14/15) mortality. Relaparotomy for sepsis directed by positive radiologic or clinical findings can be reliably expected to demonstrate a surgical focus whose correction may yield patient survival; non-directed relaparotomy, however, seldom demonstrates a focus and does not contribute to survival.