The influence of lavage on peritonitis

Abstract

Lavage was adopted by surgeons around the turn of the century for managing patients with peritonitis. In 1906, Franz Torek from the New York PostGraduate Medical School described how “the salt water is poured into all recesses” and “the hand, by some gentle to-and-fro motions, assists it in washing all parts” and pus was “dipped out, rather than wiped out, as the latter procedure would be more likely to injure the peritoneum.” Over the years, support for its use has fluctuated, depending largely on opinions rather than evidence. Lavage is currently widely used in the treatment of patients with peritonitis either from bowel perforation or from acute pancreatitis. Early opponents of the use of lavage claimed that it served to spread infection. In the first half of this century, Rodney Maingot commented that, “Irrigation of the peritoneal cavity for cleansing purposes is, in my opinion, never justified, even in the presence of gross fecal contamination.” Burnett and coworkers in 1957 reintroduced peritoneal lavage as a treatment option in patients with peritonitis in association with high concentrations of antibiotics. He commented that “lavage removes large quantities of toxins from a great absorptive area and many bacteria which would have otherwise have to be dealt with by the body’s defenses.” The primary role of the surgeon in managing patients with peritonitis is to control the source of contamination. Failure to do so results in septicemia and a universally poor prognosis. Secondary treatment aims include reducing the bacterial load in the peritoneal cavity by lavage, antibiotics, or both. Lavage is claimed to remove not only bacteria but also material that may promote bacterial proliferation (eg, blood) and proinflammatory cytokines that may enhance local inflammation. The objective of this article is, first, to give an overview of peritoneal defense mechanisms and how lavage may influence the resolution of peritonitis; and second, to review the relevant surgical literature and to perform a combined analysis of available randomized prospective clinical trials, to evaluate whether lavage influences mortality and morbidity in patients with bacterial peritonitis.