Infection (2010) 38:255260

DOI 10.1007/s15010-010-0021-4

CLINICAL AND EPIDEMIOLOGICAL STUDY

Prognostic factors of the mortality of postoperative

intraabdominal infections
N. Torer K. Yorganci D. Elker I. Sayek

Received: 13 August 2009 / Accepted: 17 March 2010 / Published online: 15 April 2010
Urban & Vogel 2010

Abstract
Purpose We investigated the relationship between the
prognostic factors of postoperative peritonitis and
mortality.
Methods Data from 56 patients re-operated for postoperative secondary peritonitis in our hospital between 1991
and 2001 were collected retrospectively. Demographic
features, comorbidity, malignancy, organ failure, type and
timing of the primary operation, intraoperative findings,
etiology of postoperative peritonitis, number of relaparotomies, source control failure, Mannheim peritonitis index
(MPI), and mortality were noted. The time intervals
between the first operation and relaparotomy, and between
symptom onset and the second operation were also noted.
Results The overall mortality rate was 32% (n = 18).
Organ failure (p = 0.001), time elapse between symptoms
and the second operation (p = 0.046), severity of peritonitis (p = 0.035), source control failure (0.047), and MPI
scores (p = 0.032) were significantly related with the
mortality of postoperative peritonitis in a univariate analysis. MPI score [30 had a higher mortality rate.
Conclusion Delaying relaparotomy for more than 24 h
and presence of organ failure result in higher mortality.
Keywords

Mortality
Peritonitis

N. Torer (&)
K. Yorganci
D. Elker
I. Sayek

Department of General Surgery, Faculty of Medicine,
Hacettepe University, Ankara, Turkey
e-mail: ntorer@yahoo.com.tr

Introduction
Intraabdominal infections are one of the most important
problems in general surgery, and still carry a significant
morbidity and mortality. The mortality from intraabdominal infections is in the range of 1130% [1, 2].
Secondary peritonitis is the most common type and is
classified as acute, postoperative, or posttraumatic peritonitis. Postoperative peritonitis is caused by intraperitoneal
contamination with intestinal contents secondary to a leak
from an anastomosis or primary suture line in the gastrointestinal tract, unrecognized injury to a hollow viscus, or
persistence of intraabdominal pathology. The mortality rate
from postoperative peritonitis is reported to be the highest
among causes of secondary peritonitis [2]. Although the
prognostic parameters of secondary peritonitis and the
benefit of early approach have been well studied [2], there
are only a few reports studying the prognostic parameters
of postoperative peritonitis.
Independent of the etiology, source control, appropriate
antibiotic therapy, and supplementary treatment are
important factors for the treatment of secondary peritonitis.
Wittman and associates [3] clearly defined four main
principles of surgical treatment for secondary peritonitis as
(1) accurate repair and source control; (2) elimination of
pus, debris, and foreign materials; (3) control of intraabdominal pressure by decompression; and (4) rigorous
control for persistent infection.
Although these principles are indisputable, type of surgical options remain controversial. Several prognostic
parameters have been defined and some scoring systems
have been developed. The Mannheim peritonitis index
(MPI) is one of the most popular scoring systems for
peritonitis. The MPI is used to evaluate both preoperative (age, sex, presence of organ failure, presence of

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N. Torer et al.

malignancy, elapsed time between operations) and intraoperative (source of infection, spread of peritonitis, type of
exudates) criteria of the patients. The MPI is reported to be
effective for predicting the mortality from secondary
peritonitis and to help to guide decision for early surgery
[4, 5].
The aim of this study was to investigate the prognostic
factors of postoperative peritonitis (subgroup of secondary
peritonitis) related to mortality and the predictivity of the
MPI for postoperative peritonitis.

Materials and methods

Data of 56 patients operated for postoperative secondary
peritonitis in our hospital between 1991 and 2001 were
collected retrospectively. Demographic features, postoperative hospital stay, comorbidity, malignancy, organ failure
(as defined by the Goris organ failure score [6]), type
(source of infection) and timing (emergency or elective) of
primary operation, intraoperative findings, etiology of
postoperative peritonitis, number of relaparotomies, failure
for source control, MPI score, and mortality were noted.
The time period between beginning of the symptoms and
second operation were also noted.
The Goris scoring system is calculated as evaluation of
the seven organ systems on a 14-point scale graduated
from 0 to 2 (no organ failure, moderately severe organ
failure, and severe organ failure): lung, heart, kidney,
liver, blood, gastrointestinal (GI) tract, and central nervous system (CNS). MPI score is calculated as the sum of
the preoperative and intraoperative parameters as shown
in Table 1.
Definition of source control was as follows: drainage of
infected fluids, debridement of infected soft tissues, removal
of infected devices or foreign bodies, and finally, definite

Table 1 Parameters and their points to calculate the MPI score

Parameters

Point

Patients age [50 years

Female gender

Presence of organ failure

Presence of malignancy

Elapsed time between two operation [24 h

Non colonic sepsis

Diffuse generalized peritonitis

4
6

Type of exudates
Clear
Purulent
Fecal

0
6
12

measures to correct anatomic derangement resulting in

ongoing microbial contamination and to restore optimal
function [7].
All postoperative peritonitis patients who were operated are included. Patients with localized postoperative
peritonitis were treated with percutaneous drainage.
Patients with multiple abscesses, and on whom failure or
inability to safely perform percutaneous drainage were
treated with laparotomy. Patients treated with percutaneous intervention were excluded. Source control was
achieved by means of closure, resection, exteriorization,
or drainage depending on the condition as discussed in
the report of Bohnen [8].
Intraoperative findings of the secondary operation were
classified as (1) severity of peritonitis [localized or generalized (at least two quadrants of the abdomen)], (2) the
source (colonic or non-colonic), (3) characteristic of exudates (clear, purulent, or fecal).
Statistical analyses were performed with the SPSS 9.0
for Windows. A v2 test was used to analyze categorical
variables, and a Students t test and MannWhitney U test
were used to analyze continuous parametric and nonparametric variables, respectively. A logistic regression model
was constructed for assessing the independent effects on
mortality. All variables associated with mortality with a
p values \0.2 in the univariate analysis were included in
the multivariate analysis to detect confounders. The results
are presented as prevalence odd ratios (OR) and their 95%
confidence intervals.

Results
Fifty-six patients were evaluated retrospectively. The
ratio of males to females was 1.66 and the median age
was 47 years (1683). General characteristics of patients
are summarized in Table 2. The source of infection and
the rate of source control achievement are shown in
Table 3.
Overall mortality rate was 32% (n = 18). In a univariate analysis; organ failure, time elapsed between
symptoms and re-operation, severity of peritonitis, source
control failure, and MPI scores were significantly related
with the mortality of the postoperative peritonitis
(Table 4). The results of logistic regression analysis are
shown in Table 5. Organ failure and delay in relaparotomy more than 24 h were the most prominent factors
(OR: 1081.87, OR: 121.88, respectively) among the
variables that of their probability values \0.2 in univariate analysis.
Fourteen patients required more than one relaparotomy
to achieve source control. Three patients had two and two
patients had three more relaparotomies.

Mortality of postoperative intraabdominal infection

257

Table 2 General characteristics of patients

Median age

47 (1683)

Gender (male/female ratio)

35/21

Table 4 Relation of mortality and characteristics of patients with

postoperative peritonitis

Postoperative hospital stay (median days)

21 (1180)

Comorbidities (present/absent)a

21/35

Gender

Malignancy (present/absent)

25/31

Male

Organ failure (present/absent)

11/45

Source of infection

Non survivor/total
(n)

% of non
survivors

9/35

25.7

Female
Source of infection

9/21

42.9
42.9

Gastroduodenal

Gastroduodenal

3/7

Small intestine

Small intestine

2/5

40.0

Colonic

27

Colonic

9/27

33.3

Hepatobiliary

HPB

0/6

0.0

Gynecologic

Gynecologic

1/3

33.3

Appendectomy

Appendectomy

2/6

33.3

Others

Others

1/2

50.0

Timing of first operation (elective/emergency)

Etiology of postoperative peritonitis

27/29

Intraabdominal abscess

8/26

30.8

26

Anastomotic leakage

9/25

44.6

Anastomotic leakage

25

Othersa

1/5

20.0

Peptic ulcer perforation

0.696

0.486

Comorbidities

Mesenteric vascular occlusion

Present

10/21

47.6

Cecal volvulus

8/35

22.9

Pancreatic abscess

Absent
Malignancy

Source control (achieved/failed)

48/8

Present

11/25

44.0

Mortality

18

Absent

7/31

22.6

Comorbidities coronary artery disease, congestive heart failure,

chronic obstructive pulmonary disease, renal diseases, chronic active
hepatitis, cerebrovascular diseases

0.184

Etiology

Intraabdominal abscess

0.055

0.088

Organ failure
Present

8/11

72.7

Absent

10/45

22.6

Emergency

8/29

22.6

Elective

10/27

37.0

0.001

Time of first operation

Table 3 Achievement of source control according to the source of
infection
The source of infection

Source control

Total

Achieved

Not achieved

Gastroduodenal

6 (85.7%)

1 (14.3%)

7 (12.5%)

Small Intestine

3 (60.0%)

2 (40.0%)

5 (8.9%)

Colonic

25 (92.6%)

2 (7.4%)

27 (48.2%)

Hepatobiliary

5 (83.3%)

1 (16.7%)

6 (10.7%)

Gynecologic

2 (66.7%)

1 (33.3%)

3 (5.4%)

Appendectomy

6 (100.0%)

0 (0%)

6 (10.7%)

Others

1 (50.0%)

1 (50.0%)

2 (3.6%)

Total

48 (85.7%)

8 (14.3%)

56 (100%)

0.449

Time period between symptoms and 2nd operation

\24 h

1/12

21.4

[24 h

17/44

38.6

0.046

Type of peritonitis
Generalized

18/48

37.5

Localized

0/8

0.0

Type of source
Colonic

8/26

30.0

Non-colonic

10/30

33.3

Clear

0/3

0.0

Purulent

16/42

38.1

Fecal

2/11

11.1

Only one

13/42

31.0

More than one

5/14

25.7

Achieved

13/48

27.1

Not achieved

5/8

62.5

0.035

0.838

Type of exudates

0.214

Relaparotomy

Median postoperative hospital stay was 21 (1180) days.

Mean MPI score of survivors was 23.66 and that of nonsurvivors were 38.72 (Fig. 1). Receiver-operator characteristic (ROC) curve of MPI/mortality is shown in Fig. 2. The
area under the curve was calculated as 0.762 (p = 0.001,
lower bound: 0.638, upper bound: 0.900). For a threshold

0.741

Source control
0.047

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N. Torer et al.
1,0

Table 4 continued
Non survivor/total
(n)

% of non
survivors

010

0/3

1120

3/18

16.7

2130

6/20

30.0

[31

9/15

60.0

MPI

0.032

HPB hepatopancreatobiliary, MPI Mannheim peritonitis index

Sensitivity

,8

,5

Other etiologic factors were two peptic ulcer perforations, one

mesenteric vascular occlusion, one cecal volvulus and one pancreatic
abscess

,3

Table 5 Results of logistic regression analyses

OR
Gender (female)
Having Malignancy
Having Organ failure

95.0% CI

14.67 1.18183.02

0.037

20.33 1.19346.92

0.037

1081.87 7.8214963.01 0.005

Source control not achieved

14.84 0.73301.05

0.079

121.88 3.244584.37

0.009

Having Comorbidities

2.04 0.2814.80

0.482

Generalized peritonitis
MPI [ 31

23.15 0.511059.08
10.32 0.58183.53

0.107
0.112

Time period between symptoms and

2nd Operation [24 h

40

0,0
0,0

,3

,5

,8

1,0

1 - Specificity
Fig. 2 Receiver-operator characteristic (ROC) curve of MPI/mortality

Table 6 Sensitivity, Specificity, Positive and Negative Predictive

Values of some MPI scores
Threshold
point of
MPI

Sensitivity
(%)

20

100

Specificity
(%)

Positive
predictive
value (%)

Negative
predictive
value (%)
100

31.6

40.9

25

72.2

55.3

43.3

80.8

30

55.5

84.2

62.5

80.0

MPI Mannheim peritonitis index

30

MPI

Discussion
20

10

0
N=

38

18

survivor

non-survivor

Mortality
Fig. 1 Mean MPI score of survivors and non-survivors

index score of 20, 25, and 30 points, sensitivity, specificity,

positive, and negative predictive values for mortality are
shown in Table 6.

The choice of surgical treatment for intraabdominal

infection is still controversial. For many years, surgeons
used to perform relaparotomy on demand depending on
the clinical condition. In the last decade, open abdomen
(laparostomy), planned relaparotomy, or staged abdominal
repair have been performed more commonly [2, 9, 10]. All
these methods have their own advantages and disadvantages. Although there are some prospective studies evaluating the type of surgery, a recently published study with
the same intention was stopped due to ethical problems
[11]. Scoring systems have been used to determine the
prognosis and thus to decide on the type and the extent of
surgical intervention. The most well known and popular
scoring system is the APACHE II score, which is commonly used to predict mortality in patients in the intensive
care unit [12]. More specifically, MPI and the Peritonitis
_
Index of Altona (PIA-II)
are used as scoring systems for

Mortality of postoperative intraabdominal infection

peritonitis [4, 5]. In addition, MPI, SAPS II and APACHE

II have recently been shown to predict the development of
postoperative peritonitis among patients with secondary
peritonitis [13].
Causes of secondary peritonitis have changed during the
last century. In 1920, according to Kirshners report,
appendicitis was the most common cause of secondary
peritonitis, but in 1990, colonic [14] and gastroduodenal
[15] pathologies became more common causes of secondary peritonitis. As reported before, between 1987 and 1996,
34% of secondary peritonitis was caused by gastroduodenal
pathologies. In that report, 84.0% of surgically treated
secondary peritonitis cases were acute secondary peritonitis and 15.9% of them were postoperative secondary peritonitis [16]. In this present report, we studied particularly
the postoperative secondary peritonitis. The leading source
of postoperative secondary peritonitis in our present study
was colonic surgery (48.2%).
The mortality rate of our study was higher with gastroduodenal surgery when compared to colonic surgery
(42.9 vs. 33.3%). The difference between these two groups
was not significant. This is most probably related to the
small number of patients when subgroups are evaluated. In
the literature, mortality rate in secondary peritonitis is
expected to be higher in gastroduodenal surgery than
colonic surgery, which may be related to a higher output of
the gastroduodenal secretion. Furthermore, the source
control may be more difficult to achieve in relation to the
anatomical location of the gastrointestinal tract. Altunbay
and associates [17] similarly reported that mortality of
postoperative peritonitis caused by a gastroduodenal source
was 67% and that caused by a colonic source was 32%
without any statistical significance.
There are many prognostic parameters defined for secondary peritonitis. Female sex, older age, and malignancy
are defined as poor prognostic factors [1821]. In our
series, the mortality in female patients and in patients with
malignancy was higher but the difference is not statistically
significant. A relation between age and mortality was not
observed in this study. The absence of significance for
these factors may be due to the small number of cases.
The type of the first surgical intervention, whether
emergency or elective, did not affect the mortality significantly. Grunau [22] as well in his study did not show any
difference.
Patients with generalized peritonitis have a higher
mortality, as expected [17]. The mortality increased significantly (p \ 0.05) if the peritonitis was generalized. This
may be due to the severity of peritonitis and probably the
increase in the systemic response of the patient.
Time period elapsed between the beginning of the
symptoms and the surgical intervention were important
prognostic factors. This has been previously reported in

259

other studies [2]. Delaying the operation may worsen the

patients condition. As we have shown with multivariate
analysis, delaying a relaparotomy for more than 24 h
results in higher mortality.
Achievement of source control was significantly related
with the mortality. When the source control could not be
achieved in the first re-operation, early planned relaparotomy has been shown to decrease the mortality significantly
than laparotomy on demand [2]. Early relaparotomy could
prevent delay in source control.
Organ failure is an important parameter for most scoring
systems [18, 23, 24]. Most authors agree that patients with
at least one organ failure before relaparotomy have a higher
mortality rate. As in our study, patients with postoperative
peritonitis with failure of one or more organs have a higher
mortality. Decision for relaparotomy should be made
before organ failure occurs and delays for any intervention
may further increase the rate of organ failure. As shown by
Mulier previously, planned relaparotomy may be considered for those without effective source control achieved or
those with higher MPI.
MPI predicts mortality in intraabdominal infections in
most reports [18]. In a recent study, Biondo et al. [25]
have shown that MPI and the Peritonitis Severity Score
are valuable scoring systems to be used for left colonic
peritonitis. Although in a logistic regression model MPI
was not related with mortality, MPI would be a suitable
method for predicting the mortality of postoperative
peritonitis. The reason for insignificance may be the
small number of cases for each group. There was no
optimal cutoff point for the same reason; however, 30
points would be a cutoff with the highest positive predictive value. Patients with MPI [30 points have a high
mortality risk and may be considered candidates for
relaparotomy.
The main limitation of our study was the small number
of cases. Therefore, the absence of significance in some
comparisons should be cautiously interpreted. Additionally
the wide confidence interval of the significant parameters
should be taken into consideration and multivariate analysis may be unreliable because of a too small sample size.
Prospective randomized clinical trials are needed to
compare the effectiveness of treatment strategies. However, it is not easy to standardize the patient groups with
different etiologies and conditions of peritonitis. Therefore,
MPI may be used to compare the groups.
In conclusion, delaying relaparotomy for more than 24 h
may worsen the patients condition and result in higher
mortality of postoperative peritonitis and MPI could predict mortality in postoperative peritonitis.
Acknowledgments We would like to thank to Assoc. Prof. Dr.
Guls ah Seydaoglu for her contribution in the statistical analysis.

260
Conflict of interest statement

N. Torer et al.
None.

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