Is sclerosing peritonitis a foreign body response? This week I (plus two colleagues) operated a case of sclerosing peritonitis. It is an unusual entity of which I have previously operated 3 or 4 cases. Viewing it as a graded disease I think I have operated more with partial disease.
This patient had an inadvertent diathermy injury of small bowel during a gyn lap procedure last December. A couple days postop she developed a bowel leak with peritonitis which was operated with resection of the site of leakage with anastomosis. The course was essentially uneventful but she had mild protracted systemic inflammation and bowel function never became normal. She was discharged with slight delay. She wasted about 8 kg over the next couple of months with progressing symptoms of chronic bowel malfunction (obstruction). A small bowel follow through showed delayed transit and mildly dilated bowel loops. Symptoms progressed and she was re-admitted to hospital unable to support herself by oral feeding.
On physical exam one could palpate what seemed to be a diffuse induration inside the abdomen.
At operation the whole small bowel was encapsulated by a 2-3 mm thick fibrous envelop producing a package of all small bowel exept 40 cm of terminal ileum which was free but encapsulated in a fibrous tube and much narrowed.
It took two hours to free the package of bowel from the abdominal wall such that the whole package could be delivered out of the abdomen.
The interface between bowel loops was almost invisible and one must make a guess where to cut in between the loops. We reasoned that we either stop here and hope that mother nature does something sensible about the problem, or we free the bowel loops and hope that the process is not returning, and that freeing can be accomplished with not too much bowel damage.
We choose the latter. It took another four hours during which we meticoulsly cut free loop after loop. It is mainly an encapsulation so once inside it the adherences between the loops are not so difficult. The tric is to get inside, work with the reasonable adherences inside towards the surface which will give you better chance of understanding the margin of intersection between loops at the surface. We had three inadvertent holes of the bowel.
I learnt something new from the terminal ileum. The loops were free from the beginning but it was all encapsulated in a thick tube which restricted the bowel. I cut into the tube thinking I saw mucosa buldge out. But it wasn’t. The serosal surface was intact. As seemed the bowel wall to be normal. It all behaved like scarification of third degree burns or when incising the fascia in a compartment syndrome. It was not possible to remove the fibrous capsule but it was possible to incise the capsule at many sites to break it open.
I do not know why sclerosing peritonitis occurs. It is rare and certainly something different from the common postop adherences, even when they are very difficult. This patient had been operated with talc-free gloves. We see many patients with peritonitis and they do not develop this condition. I have seen a patient being operated and reoperated 3 or 4 times and then suddenly developed it.
The findings of the terminal ileum, in my mind clearly demonstrates that the disease is not a bowel disease, i.e. it is not the bowel wall or the peritoneum viscerale that produces the fibrous capsule. My guess is that the parietal peritoneum is the culprit. It seems as if the parietal peritoneum recognizes the bowel as a foreign body and encapulates it with a thick fibrous scar. You have all seen this sort of capsule, and its process, around various inplants, such as osteosynthesis, venous access ports, pacemakers, etc.
We left the abdomen open for several reasons, Leaving it open might change conditions for recurrence, oedema after this 6 hour plus operation might cause abdominal compartment syndrome, and there were bowel damages which might leak in the postop period in which case the open abdomen would immediately diagnose and control the leak.
Since nearly a year I experiment with a modification of the Bogota bag. Instead of suturing a piece of an infusion bag (or some other material) to the abdominal wall or the skin, I now take a 3M plastic bag designed for keeping the small bowel moist during aortic procedures. It is large enough to be spread over the bowel and be tacked in between the bowel and abdominal wall deep to the sides, (like one makes a bed). If one tacks in pieces of gause just a few centimetres between the abdominal wall and the plastic covered bowel the plastic will be kept in place. No suturing. This is very simple and takes much less time. One can remove the plastic and inspect and treat the abdominal cavity at convenience, and replace the plastic.
The procedure makes sure that there will be no adherences between bowel and abdominal wall. An emergency patient the other week, with grossly distended and swollen bowel had her abdomen closed on the seventh day easily when oedema was gone and the bowel had sunk into the abdominal cavity.
Most of the patients treated this way have been closed, a higher sucess rate than with the traditional Bogota bag in my experience. Another remarkable observation (though preliminary) is that the multiple organ failure syndrome and death from these terrible abdomens seems to disappear from the ICU, at least in postop cases. Another service in my hospital is not using planned open abdomen, and I have their cases as controls and reminder about what it used to be. I am sorry Moshe, this is level 5 evidence, fragmentary and observer biased, but it makes my mind work on the problem of abdominal pressure syndrome.
The lady with sclerosing peritonitis woke up on the ventilator and we could talk to her and explain the situation. She had been warned preoperatively that this might happen. She was doing fine, no fever, and no antibiotics.
Yesterday, two days postop, she was still doing fine, but now she had bowel contents under the plastic. I found a 2 mm hole in a part of bowel with serosal damage. I sutured the hole, and replaced the plastic. The hole is likely to result in a fistula but I may gain more time.
This lady had no fever, despite the bowel hole, her white cells had increased from 7 to 13. She is awake and no organ dysfunction. She had been given the single dose prophylactic antibiotic we use. Why should I reinstitute antibiotics now? Because of a bowel leak which is controlled and did not cause SIRS in a patient who seems responsive? Well, I gave in to pressure and she was put on imipenem.
I have never heard that antibiotics prevent bowel injuries, nor heals them, and I do not believe that antibiotics are necessary for contamination of open wounds, or for the treatment of bowel fistula.
However, everybody gives antibiotics for bacteria in the abdomen despite it does not make a leaking abdomen sterile. A closed abdomen with leakage is disastrous but is something totally different in an open abdomen.