Comparison of on-demand vs planned relaparotomy for treatment of severe intra-abdominal infections.

AIM: To compare morbidity and mortality of patients with severe intra-abdominal infections after two types of surgical treatment, on-demand ("wait and see") relaparotomy and modified planned relaparotomy. METHODS: We prospectively analyzed the outcomes of 65 patients with severe peritonitis surgically treated in two Croatian hospitals. In one hospital, 34 patients were treated on-demand, and in another hospital 31 patients were treated by planned relaparotomy. We compared severe postoperative complications, mortality, and length of hospital stay in the two groups of patients. RESULTS: Severity of patient's disease, as measured from preoperative group-average Acute Physiology and Chronic Health Evaluation (APACHE) II scores, was comparable in both on-demand and planned relaparotomy groups. The mortality rate was higher in patients operated on-demand (59% vs 29%, P=0.024). In nonadjusted model, the relative risk of dying was 2.5-fold higher for patients treated by on-demand operation in comparison with planned relaparatomy (P=0.030). However, after the adjustment of the survival data for individual patient's sex and APACHE II scores, the difference in the relative risk became non-significant (P=0.178). The patients who died had higher APACHE II scores (26.1+/-8.9 vs 19.7+/-5.9, P=0.009). Relative risk of dying per 5-point increase in APACHE II score was 1.24 (95% confidence interval, 1.01-1.51; P=0.039), irrespective of the surgical technique. CONCLUSIONS: Patients with severe peritonitis treated with planned relaparotomy seemed to have lower mortality. However, the relative risk of dying was not statistically different between the on-demand and planned relaparotomy groups after adjustment for preoperative APACHE II scores. The severity of disease rather than surgical approach plays more important role in survival of these patients.

Long-term benefits of laparoscopic appendectomy for chronic abdominal pain in fertile women.

AIM: To assess long-term benefit of laparoscopic appendectomy for chronic abdominal pain of unknown origin in fertile women. METHOD: The study included 70 fertile women aged 29.2+/-13.1 years who had undergone diagnostic laparoscopy for recurrent abdominal pain at our Department between 1996 and 2000. In December 2002, a questionnaire with symptom-specific questions and procedure-specific questions was sent to all the patients. The response rate was 76% (53 out of 70). RESULTS: According to intraoperative findings there were 8 patients with adhesions, 12 with gynecological origin of pain, 27 with chronic inflammation or narrowed lumen of the appendix, and 6 with normal laparoscopic findings and innocent appendix. The most common intervention was appendectomy, performed in 41 out of 53 cases; cysts fenestration in 10 cases; and lysis of adhesions in 8. The average hospital stay was 3.6+/-2.6 days. Postoperative complications occurred in 10/53 patients. A serious complication involving bladder injury after lysis of adhesions occurred in a single patient. There was no mortality. 3 out of 53 patients were readmitted 1, 3, and 9 months postoperatively because of residual abdominal pain. Two of them had appendectomy. Long-term follow up showed that there were no differences in the overall satisfaction with diagnostic laparoscopy in the patients with (n=41) and without appendectomy (n=12). There was no difference in overall satisfaction between the patients having inflamed appendix (n=22) and those without inflamed appendix (n=19). CONCLUSION: Diagnostic laparoscopy is a diagnostic and therapeutic option in most fertile women with chronic abdominal right iliac fossa pain of unknown origin. Our results showed low postoperative complications and no mortality rate with laparoscopic appendectomy indicate removal of appendix as a part of diagnostic laparoscopy when the origin of pain is unknown. In some cases of persistent pain, the removal of appendix is beneficial by eliminating appendicitis in differential diagnosis.