Inflammatory response in peritoneal exudate and plasma of patients undergoing planned relaparotomy for severe secondary peritonitis

R. G. Holzheimer, M. Schein and D. H. Wittmann
Department of Surgery, University of Wurzburg, Germany.

OBJECTIVE: To study the pattern of intraperitoneal cytokine release in secondary peritonitis and its correlation with plasma levels and prognosis. DESIGN: Noncomparative descriptive case series. SETTING: Department of surgery in a university hospital. PATIENTS: Seventeen consecutive patients undergoing planned relaparotomy for severe intra-abdominal infection (Acute Physiological and Chronic Health Evaluation [APACHE II] score > 10; mean score, 17.5). INTERVENTIONS: The following were measured at the first and last serial operations in the peritoneal exudate and plasma: endotoxin, tumor necrosis factor alpha (TNF-alpha), interleukin-1 (IL-1), interleukin-6 (IL-6), elastase, and neopterin. MAIN OUTCOME MEASURES: Survival and death. RESULTS: Six patients died. Peritoneal endotoxin levels were significantly higher than in the plasma and were significantly higher in the nonsurvivors. Plasma TNF-alpha, IL-6, elastase, and neopterin levels remained elevated in the nonsurvivors prior to death. Levels of TNF-alpha, IL-6, elastase, and endotoxin were 19, 993, 239, and 7 times higher, respectively, in the peritoneal exudate than in plasma, all significant differences. Elastase and TNF-alpha levels decreased in survivors during the operative treatment but remained elevated in the nonsurvivors. CONCLUSIONS: Secondary peritonitis is associated with a significant cytokine-mediated inflammatory response that is compartmentalized in the peritoneal cavity and indicates an adverse prognosis. Levels of cytokines in the exudate of peritonitis may be used to better stratify the severity of peritonitis and, in future, to guide local therapy.

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