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One Surgery Often Enough for Peritonitis

Study questions usefulness of secondary procedures

TUESDAY, Aug. 21 (HealthDay News) -- Patients with a serious gastrointestinal infection known as peritonitis may not automatically need to undergo more operations beyond the first one, new research suggests.

In the United States, most surgeons choose to wait and see if they think patients need the extra surgery, said Dr. David Flum, a gastrointestinal surgeon at the University of Washington, who wrote a commentary about the study.

Until now, however, "there hasn't been a lot of evidence to guide that decision," he said.

The findings are published in the Aug. 22/29 issue of the Journal of the American Medical Association.

Peritonitis occurs when a hole develops in the intestines -- such as when the appendix bursts -- and allows bacteria to spill into the abdominal cavity, Flum said. Severe infection can result.

There's a high risk of death even after surgeons plug up the hole, he said, because bacteria remains and creates problems.

One approach has been to operate and then "keep taking them back to the operating room and washing out the abdominal cavity until they improve," Flum said. "Another strategy is to re-operate when the patient's body is giving you signs that it needs an operation."

In the new study, Dutch researchers at the Academic Medical Center, Amsterdam, examined the impact of each strategy on 225 patients. Only 42 percent of those in the "non-automatic-surgery" group actually went on to have a secondary operation, compared to 94 percent in the automatic-surgery group.

About a third of the patients in both groups died, and the researchers said there was no "significant difference" between their mortality rates.

However, patients who only underwent a second surgery when their doctors thought it necessary spent an average of seven days in intensive care versus 11 days for the other group. They also spent an average of 27 days in the hospital versus 35 days in the automatic-surgery cohort.

Meanwhile, "direct medical costs" were 23 percent less among those who didn't automatically have a subsequent surgery.

"It doesn't like look there's a huge difference in survival," Flum said. "But the approach with fewer operations and less cost would be the preferred one."

Dr. E. Patchen Dellinger, chief of the division of general surgery at the University of Washington, Seattle, said he hopes that questions about the validity of automatic re-operation are now settled.

"An area that could use study is how long antibiotics should be continued in the treatment of peritonitis," said Dellinger, who also wrote a journal commentary on the Dutch study. "Currently, I believe that many [peritonitis] patients get antibiotics for far longer than needed."

More information

There's more on peritonitis at the University of Maryland.

SOURCES: David R. Flum, M.D., associate professor, surgery and surgical outcomes and gastrointestinal surgeon, University of Washington, Seattle; E. Patchen Dellinger, M.D., professor and vice chairman, department of surgery, and chief, division of general surgery, University of Washington, Seattle; Aug. 22/29, 2007, Journal of the American Medical Association

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