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Faecal Peritonitis John Hartley M62 Course March 2007.

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Presentation on theme: "Faecal Peritonitis John Hartley M62 Course March 2007."— Presentation transcript:

1 Faecal Peritonitis John Hartley M62 Course March 2007

2 Faecal peritonitis Definitions  The clinical sequela of free contamination of the peritoneal cavity with faecal material  Differs from other forms of peritonitis in magnitude and speed of systemic disturbance

3 Faecal peritonitis Causes  Perforated diverticular disease  Anastomotic failure  Stercoral perforation  Perforation of a “threatened caecum” - left sided obstruction - pseudoobstruction  Perforated toxic megacolon  Trauma

4 The classification of perforated diverticular disease  Stage I:Localised pericolic or mesenteric abscess  Stage II:Confined pelvic abscess  Stage III:Generalised purulent peritonitis from ruptured abscess  Stage IV:Faecal peritonitis from free colonic perforation Hinchey EJ et al Adv Surg 1978;12:85-109

5 Faecal peritonitis - pathophysiology

6 Faecal peritonitis-definitions  SIRS: 2 or more of: Temperature > 38°C or < 36°C Heart rate > 90 bpm Resp rate > 20 breaths.min -1 or PaCO2 < 4.3kPa (32mmg) WBCs > 12 or 10% immature forms)

7 Faecal peritonitis-definitions  Sepsis = SIRS with documented infection site  Severe Sepsis Sepsis + organ dysfunction, hypoperfusion or hypotension  Septic Shock Severe sepsis (SBP < 90mmHg) despite adequate fluid resuscitation

8 Faecal peritonitis Clinical features  Peritonitis + some degree of the SIRS pathway:  Septic shock  Multiple organ failure

9 Faecal peritonitis Investigations  FBC, BCP, Amylase  Erect CXR  AXR  Think before CT scan please

10 Faecal peritonitis Principles of Management  Rapid resuscitation to enable  Source control followed by  Physiological support until recovery (or death)

11 Faecal peritonitis Management  Vigorous resuscitation in the appropriate setting - Oxygen - Adequate volume - Monitor response - +/- inotropes - Antibiotics

12 Faecal peritonitis The goals of resuscitation  MAP >65mmHg  CVP 8-12mmHg  Urine output >0.5ml/kg/hr  Within the first 6 hrs  What to do with non-responders? Early Goal Directed Therapy in the Treatment of Severe Sepsis. Rivers et al NEJM 2001; 345:

13 Faecal peritonitis Operative management  Generous access  Remove particulate matter  Generous lavage  Identify source

14 Faecal peritonitis-operative management Source control  Resect or exteriorise the perforation - Hartmann’s - TAC and end ileostomy  Avoid primary anastomosis  Occasionally - drainage, lavage, proximal diversion

15 Faecal peritonitis – importance of source control No. of reops NPlanned reops Mortality (%) From Christou et al 1993

16 Faecal peritonitis-operative management  Primary anastomosis (or laparoscopic lavage) versus Hartmann’s procedure for complicated diverticular disease  Primary anastomosis in 61 of 127 pts undergoing emergency surgery, 3% mortality and 2% anastomotic leak rate Biondo S et al Br J Surg 2001;88:1419  Probably not relevant in faecal peritonitis

17 Faecal peritonitis – operative management Hartmann’s procedure  Excise the perforation  Intraperitoneal rectal stump vs mucous fistula vs buried stump  +/- Drainage  A viable colostomy

18 Faecal peritonitis – operative management The difficult colostomy  Adequate mobilisation  Use the upper abdomen  Stoma through the wound  Stapled off blind end and proximal loop

19 Faecal peritonitis Closure versus laparostomy  Consider laparostomy when - Can’t close the abdomen - Concern over source control - Concern over ischaemia  Beware abdominal compartment syndrome

20 Faecal peritonitis – reasonable expectations? (www.riskprediction.org.uk) Physiological parameters Age<61>80 Cardiac failureNo/mildModerate Systolic BP <90mmHg Pulse rate >120 Hb13-16 Urea<10 >15 Operative parameters Operation typeMajor Peritoneal contamination Free bowel content MalignancyNo cancer CEPODEmergency Predicted mortality 13%70%92%

21 Faecal peritonitis Planned re-laparotomy versus laparotomy on demand?  No randomised studies  Non-significant reduction in mortality with the latter approach  Little role for scheduled re-laparotomies  Clear source at first operation

22 Faecal peritonitis Aftercare  ICU support  Steady improvement or:  Failure to progress  +/- Signs ongoing sepsis  Progressive MOF  Usually not a surgically remediable cause - CT scan +/- percutaneous drainage - Re-laparotomy

23 Faecal peritonitis Summary  Prompt resuscitation  Initial source control  Avoid primary anastomosis  Close abdomen where possible  ICU support  Re-laparotomy on demand  High mortality

24 Faecal peritonitis Conclusions  Recognition of the problem, and  Primary source control by surgeons  Physiological support in a multidisciplinary setting  Outcome should be determined by the response to sepsis rather than ongoing sepsis

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26 Faecal peritonitis More definitions:  SIRS  Sepsis  Septic shock


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