Abdominal infections can be one of the most challenging scenarios for the general surgeon. Even the most simple appendicitis can become a complicated infection, due to an uncontrolled peritonitis, a multi-resistant bacteria, associated comorbidities, etc.
It can be difficult to define what a complex abdominal infection is: a diffuse peritonitis? Is it technically difficult to manage? Is it life threatening for the patient? Or is it a tertiary/nosocomial peritonitis in a critically ill patient? In many cases it can be a combination of all these factors, and we will have to tailor the approach.
The best approach will be the one that considers all variables related to the patient as a whole, and not just the type or location of infection. Clinical risk factors, hemodynamic situation, early and appropriate therapy and source control, are all important if we are to deliver the best possible treatment. Most guidelines and consensus such as the newly updated SIS Guidelines (Mazuskiet al. Surg Infect 2017) and worldwide initiatives such as the Surviving Sepsis Campaign stress the importance of this. Specific severity scores such as the one developed by the World Society of Emergency Surgery (WSES) can be useful to predict mortality in patients with complicated abdominal infections.
Source control is one of the most important measures that a surgeon can apply: an appropriate source control is essential to increase survival, and it should always be as definitive as possible at the time of the index procedure. Minimally invasive techniques, including drainage and laparoscopy, have demonstrated to be as efficient as laparotomy in some cases, increasing the surgeon’s options. The optimal approach is to achieve adequate source control using the least aggressive technique, following the principles of the ‘step-up approach’ used in pancreatitis. However, in some cases it is inevitable to perform extreme interventions, including leaving the abdomen open. Although this is still an option in very critical patients with infections, evidence has shown that indications should be very limited in this context. There is no place anymore for planned re-laparotomy in complex patients, and indications should be considered to be ‘on-demand’.