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; 345:1368- 77

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 (%) 0156027 1462543 215740 310630 45540 57757 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 BP100-170 <90mmHg Pulse rate101-120 >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

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