What is the treatment approach for extensive peritoneal disease?

Treatment Approach for Extensive Peritoneal Disease

Patients with extensive peritoneal disease and diffuse peritonitis require emergency surgical intervention as soon as possible, even while continuing resuscitative measures, as delayed source control significantly increases mortality. 1

Immediate Resuscitation and Stabilization

Fluid Resuscitation:

• Begin rapid restoration of intravascular volume immediately upon diagnosis, with aggressive fluid therapy for patients with septic shock starting the moment hypotension is identified 1
• For patients without volume depletion, initiate intravenous fluids when intra-abdominal infection is first suspected 1
• Monitor lactate clearance and central venous oxygen saturation as indicators of adequate perfusion 1
• Use caution with large-volume crystalloid infusion to avoid abdominal compartment syndrome while optimizing bowel perfusion 1

Antimicrobial Therapy:

• Administer broad-spectrum antibiotics immediately once peritoneal infection is diagnosed or suspected 1
• For septic shock patients, give antibiotics as soon as possible, ideally within 1 hour 1, 2
• For non-shock patients, start antimicrobials in the emergency department 1
• Maintain satisfactory drug levels during source control procedures, which may require additional dosing just before surgery 1, 2
• For complicated intra-abdominal infections, meropenem 1 gram IV every 8 hours is appropriate empiric coverage 3

Diagnostic Evaluation

Imaging:

• CT scan with IV contrast is unnecessary in patients with obvious diffuse peritonitis who require immediate surgery 1
• For patients not undergoing immediate laparotomy, CT abdomen/pelvis is the imaging modality of choice to determine infection source and extent 1

Surgical Management

Emergency Surgery Indications:

• Patients with diffuse peritonitis must undergo emergency surgical procedure without delay, continuing physiologic stabilization concurrently during the operation 1, 2
• Do not wait for complete physiologic stabilization before surgery, as this delay increases mortality 2

Surgical Goals:

• Drain infected foci and control ongoing peritoneal contamination 1
• Resect or divert sources of contamination 1
• Restore anatomic and physiological function to the extent feasible 1

Operative Approach:

• Perform midline laparotomy for direct assessment of disease extent and bowel viability 1
• Resect all frankly necrotic tissue while preserving viable bowel 1
• Consider damage control techniques in critically ill patients with acidosis, hypothermia, and coagulopathy 1
• For perforated viscus, options include simple closure with omental patch for small perforations or resection with anastomosis when appropriate 2

Postoperative Considerations:

• Mandatory or scheduled relaparotomy is NOT recommended unless there is intestinal discontinuity, inability to close abdominal fascia, or intra-abdominal hypertension 1
• Second-look laparotomy at 24-48 hours may be considered for patients with extensive bowel involvement to reassess viability 1

Special Considerations for Malignant Peritoneal Disease

For Peritoneal Carcinomatosis (Selected Patients Only):

• Systemic chemotherapy alone is the standard approach for most patients with malignant peritoneal disease 1
• Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) should only be considered for highly selected patients with: 1
  • Low Peritoneal Cancer Index (PCI ≤10) 1
  • Complete cytoreduction achievable 1
  • No extraperitoneal metastases 1
  • Good performance status 1
  • Limited small bowel involvement 1
• Patients must receive systemic therapy for minimum 3 months before considering CRS/HIPEC, with restaging to confirm stable or improved disease 1
• This approach is experimental outside clinical trials and should only be performed in specialized high-volume centers 1

Critical Pitfalls to Avoid

Timing Errors:

• Never delay emergency surgery for complete physiologic stabilization in diffuse peritonitis—this significantly increases mortality 1, 2
• Do not wait for imaging in patients with obvious peritonitis requiring immediate surgery 1

Antibiotic Management:

• Avoid inadequate antimicrobial coverage during the perioperative period 2
• Ensure therapeutic drug levels are maintained throughout source control procedures 1

Surgical Decision-Making:

• Do not perform routine scheduled relaparotomy without specific indications (intestinal discontinuity, fascial loss, or intra-abdominal hypertension) 1
• Avoid inappropriate patient selection for CRS/HIPEC—only patients with complete cytoreduction potential and low disease burden benefit 1