title: Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial.
abstract: BACKGROUND
  In patients with severe secondary peritonitis, there are 2 surgical treatment strategies following an initial emergency laparotomy: planned relaparotomy and relaparotomy only when the patient's condition demands it ("on-demand"). The on-demand strategy may reduce mortality, morbidity, health care utilization, and costs. However, randomized trials have not been performed.
  
  
  OBJECTIVE
  To compare patient outcome, health care utilization, and costs of on-demand and planned relaparotomy.
  
  
  METHODS
  Randomized, nonblinded clinical trial at 2 academic and 5 regional teaching hospitals in the Netherlands from November 2001 through February 2005. Patients had severe secondary peritonitis and an Acute Physiology and Chronic Health Evaluation (APACHE-II) score of 11 or greater.
  
  
  METHODS
  Random allocation to on-demand or planned relaparotomy strategy.
  
  
  METHODS
  The primary end point was death and/or peritonitis-related morbidity within a 12-month follow-up period. Secondary end points included health care utilization and costs.
  
  
  RESULTS
  A total of 232 patients (116 on-demand and 116 planned) were randomized. One patient in the on-demand group was excluded due to an operative diagnosis of pancreatitis and 3 in each group withdrew or were lost to follow-up. There was no significant difference in primary end point (57% on-demand [n = 64] vs 65% planned [n = 73]; P = .25) or in mortality alone (29% on-demand [n = 32] vs 36% planned [n = 41]; P = .22) or morbidity alone (40% on-demand [n = 32] vs 44% planned [n = 32]; P = .58). A total of 42% of the on-demand patients had a relaparotomy vs 94% of the planned relaparotomy group. A total of 31% of first relaparotomies were negative in the on-demand group vs 66% in the planned group (P <.001). Patients in the on-demand group had shorter median intensive care unit stays (7 vs 11 days; P = .001) and shorter median hospital stays (27 vs 35 days; P = .008). Direct medical costs per patient were reduced by 23% using the on-demand strategy.
  
  
  CONCLUSIONS
  Patients in the on-demand relaparotomy group did not have a significantly lower rate of death or major peritonitis-related morbidity compared with the planned relaparotomy group but did have a substantial reduction in relaparotomies, health care utilization, and medical costs.
  
  
  BACKGROUND
  http://isrctn.org Identifier: ISRCTN51729393.
authors: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors: Oddeke
authors: O
authors: van Ruler
authors: Cecilia W
authors: CW
authors: Mahler
authors: Kimberly R
authors: KR
authors: Boer
authors: E Ascelijn
authors: EA
authors: Reuland
authors: Hein G
authors: HG
authors: Gooszen
authors: Brent C
authors: BC
authors: Opmeer
authors: Peter W
authors: PW
authors: de Graaf
authors: Bas
authors: B
authors: Lamme
authors: Michael F
authors: MF
authors: Gerhards
authors: E Philip
authors: EP
authors: Steller
authors: J W Olivier
authors: JW
authors: van Till
authors: Corianne J A M
authors: CJ
authors: de Borgie
authors: Dirk J
authors: DJ
authors: Gouma
authors: Johannes B
authors: JB
authors: Reitsma
authors: Marja A
authors: MA
authors: Boermeester
mesh_terms: D018806:APACHE; D000368:Aged; D004630:Emergencies; D005260:Female; D017048:Health Care Costs; D006296:Health Services / Q000706:statistics & numerical data; D006801:Humans; D007813:Laparotomy / Q000009:adverse effects / Q000191:economics / Q000592:standards; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D009426:Netherlands; D010043:Outcome and Process Assessment, Health Care; D010538:Peritonitis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D012086:Reoperation / Q000009:adverse effects / Q000191:economics / Q000592:standards; D016019:Survival Analysis