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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