Comparison of on-demand and planned relaparotomy for secondary peritonitis

Objective: To compare patient outcomes, healthcare utilization and costs of on-demand and planned relaparotomy in patients with severe secondary peritonitis. Design: Randomized, nonblinded controlled trial. Setting: Two academic and 5 regional teaching hospitals in The Netherlands. Patients: A total of 232 patients with a diagnosis of peritonitis, confirmed during an index laparotomy, and an acute physiology and chronic health evaluation (APACHE II) score of greater than 11. Intervention: The planned relaparotomy (n = 116) was performed every 36–48 hours after the index laparotomy to inspect, drain, lavage and perform other necessary abdominal interventions for residual peritonits or new infections. The sequence of planned relaparotomy was terminated when negative findings were found macroscopically. On-demand relaparotomy (n = 116) was only performed in patients with clinical deterioration or lack of improvement with a likely intra-abdominal cause. Deterioration was considered if there was an increase of more than 4 points in the multiple organ dysfunction score or a prespecified surgical emergency (e.g., abdominal compartment syndrome, intra-abdominal bleeding with decrease in hemoglobin despite replacement and hemodynamic instability, burst abdomen, perforation of visceral organ, anastomotic leak, intra-abdominal abscess that cannot be drained percutaneously, ischemia/necrosis of a visceral organ). Primary outcome: A combination of all-cause mortality and major disease-related morbidity in surviving patients within the 12 month follow-up period after the index laparotomy. Secondary outcomes included health care utilization and direct medical costs during the followup period. Results: Comparing on-demand with planned relaparotomy, there was no significant difference in the primary outcome (57% v. 65%, p = 0.25), in mortality alone (29% v. 36%, p = 0.22), or in morbidity alone (40% v. 44%, p = 0.58). A total of 42% of patients in the on-demand group had a relaparotomy compared with 94% of patients in the planned relaparotomy group. Thirty-one percent of first relaparotomies were negative in the on-demand group compared with 66% in the planned relaparotomy group (p < 0.001). Patients in the on-demand group had shorter stays in the intensive care unit than those in the planned relaparotomy group (median 7 v. 11 d, p = 0.001) in addition to shorter stays in hospital (median 27 v. 35 d, p = 0.008). The medical costs for patients in the on-demand group were 23% lower than those for patients in the planned relaparotomy group. Conclusion: Patients in the ondemand group did not have significantly lower mortality or major peritonitis-related morbidity than those in the planned relaparotomy group, but did have fewer relaparotomies and a substantial reduction in health care utilization and medical costs.