Management of abdominal sepsis--a paradigm shift?

The abdomen is the second most common source of sepsis and secondary peritonitis. The most common causes of abdominal sepsis are perforation, ischemic necrosis or penetrating injury to the abdominal viscera. Management consists of control of the infection source, restoration of gastrointestinal tract (GI) function, systemic antimicrobial therapy and support of organ function. Mortality after secondary peritonitis is still high. Excluding patient-related factors such as age or co-morbidities that can not be influenced at the time of intervention, delay to surgical intervention and inability to obtain source control are the main determinants of outcome. In patients with severe physiological derangement or difficult intraperitoneal conditions, where a prolonged operation and complete anatomical repair may not be possible or appropriate, it is becoming increasingly popular to utilize a damage control strategy with abbreviated laparotomy and planned reoperations. The main components of damage control laparotomy for secondary peritonitis are postponing the reconstruction of intestinal anastomoses to a second operation (deferred anastomosis) and leaving the abdomen open with some form of temporary abdominal closure (TAC). Advances in the management techniques of the open abdomen and new negative pressure-based TAC-devices have significantly reduced the previously observed prohibitive morbidity associated with open abdomens. These advancements have led to current fascial closure rates after TAC approaching 90%. The cornerstones of appropriate antimicrobial therapy are the timing, spectrum and dosing of antibiotics. Enteral nutrition should be started as soon as possible in hemodynamically stable patients but withheld when the patient is on a significant dose of vasopressors or whenever GI hypoperfusion is suspected. Timely source control with appropriate use of antimicrobial agents and early intensive care offers the best chance of survival for patients with abdominal sepsis. The introduction of the concept of damage control to the management of secondary peritonitis represents a paradigm shift in the same way as in management of major trauma. Although limited and repeated surgical interventions have been shown to be safe, the actual benefits need to be demonstrated in controlled studies.