Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 142 No. 2930 (2012)

The Acute Physiology and Chronic Health Evaluation II score is helpful in predicting the need of relaparotomies in patients with secondary peritonitis of colorectal origin

  • Carsten T. Viehl
  • Rebecca Kraus
  • Manuel Zürcher
  • Thomas Ernst
  • Daniel Oertli
  • Christoph Kettelhack
Cite this as:
Swiss Med Wkly. 2012;142:w13640


BACKGROUND: Secondary peritonitis of colorectal origin has considerable morbidity and mortality. Relaparotomies are frequently neccessary in the course of the disease. The objective of this study was to evaluate several scores in terms of their predictive value, i.e. whether Mannheim Peritonitis Index (MPI), Acute Physiology And Chronic Health Evaluation (APACHE) II, or Colorectal Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (CR-POSSUM) scores can predict relaparotomies.

METHODS: Charts of 147 patients treated for secondary peritonitis of colorectal origin were retrospectively reviewed, MPI, APACHE II, and CR-POSSUM scores were calculated, and groups of patients with or without relaparotomies were compared.

RESULTS: Thirty-four percent of patients underwent one or more relaparotomies. Patients with relaparotomies showed a significantly higher APACHE II score than patients without relaparotomies (p = 0.004). MPI (p = 0.072) and CR-POSSUM score (p = 0.319) did not differ between the two groups. A high APACHE II score was also significantly associated with the need for a relaparotomy on demand (p <0.001), and for the combined outcome parameter relaparotomy and/or an interventional drainage (p = 0.046). Both other scores were not predictive for these outcomes. Overall in-hospital mortality was 21.8%. All three scores investigated were predictive for mortality. Sensitivity was 62.5%, 78.1%, and 75.0% for MPI, APACHE II score, and CR-POSSUM score, respectively.

CONCLUSION: The Acute Physiology And Chronic Health Evaluation II score might be helpful in predicting the need for relaparotomies in patients with secondary peritonitis of colorectal origin.


  1. Wacha H, Linder MM, Feldmann U, Wesch G, Grundlach E, Steifensand RA. Mannheim peritonitis index – prediction of risk of death from peritonitis: construction of a statistical and validation of an empirically based index. Theor Surg. 1987;1:169–77.
  2. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818–29.
  3. Tekkis PP, Prytherch DR, Kocher HM, Senapati A, Poloniecki JD, Stamatakis JD, et al. Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM). Br J Surg. 2004;91(9):1174–82.
  4. Senagore AJ, Warmuth AJ, Delaney CP, Tekkis PP, Fazio VW. POSSUM, p-POSSUM, and Cr-POSSUM: implementation issues in a United States health care system for prediction of outcome for colon cancer resection. Dis Colon Rectum. 2004;47(9):1435–41.
  5. van Ruler O, Kiewiet JJ, Boer KR, Lamme B, Gouma DJ, Boermeester MA, et al. Failure of available scoring systems to predict ongoing infection in patients with abdominal sepsis after their initial emergency laparotomy. BMC Surg. 2011;11(1):38.
  6. Basu A, Pai DR. Early elevation of intra-abdominal pressure after laparotomy for secondary peritonitis: a predictor of relaparotomy? World J Surg. 2008;32(8):1851–6.
  7. Boermeester MA. Surgical approaches to peritonitis. Br J Surg. 2007;94(11):1317–8.
  8. Lamme B, Boermeester MA, Belt EJ, van Till JW, Gouma DJ, Obertop H. Mortality and morbidity of planned relaparotomy versus relaparotomy on demand for secondary peritonitis. Br J Surg. 2004;91(8):1046–54.
  9. Waydhas C, Nast-Kolb D, Ruchholtz S, Schweiberer L. Practical and theoretical limits of score systems. Unfallchirurg. 1994;97(4):185–90.
  10. Anonymous. New classification of physical status. Anesthesiology. 1963;24:111.
  12. Vermeulen J, Akkersdijk GP, Gosselink MP, Hop WC, Mannaerts GH, van der Harst E, et al. Outcome after emergency surgery for acute perforated diverticulitis in 200 cases. Dig Surg. 2007;24(5):361–6.
  13. Wacha H, Hau T, Dittmer R, Ohmann C. Risk factors associated with intraabdominal infections: a prospective multicenter study. Peritonitis Study Group. Langenbecks Arch Surg. 1999;384(1):24–32.
  14. van Ruler O, Lamme B, Gouma DJ, Reitsma JB, Boermeester MA. Variables associated with positive findings at relaparotomy in patients with secondary peritonitis. Crit Care Med. 2007;35(2):468–76.
  15. Paugam-Burtz C, Dupont H, Marmuse JP, Chosidow D, Malek L, Desmonts JM, et al. Daily organ-system failure for diagnosis of persistent intra-abdominal sepsis after postoperative peritonitis. Intensive Care Med. 2002;28(5):594–8.
  16. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22(7):707–10.
  17. Koperna T, Schulz F. Relaparotomy in peritonitis: prognosis and treatment of patients with persisting intraabdominal infection. World J Surg. 2000;24(1):32–7.
  18. Bader FG, Schroder M, Kujath P, Muhl E, Bruch HP, Eckmann C. Diffuse postoperative peritonitis – value of diagnostic parameters and impact of early indication for relaparotomy. Eur J Med Res. 2009;14(11):491–6.
  19. Mulier S, Penninckx F, Verwaest C, Filez L, Aerts R, Fieuws S, et al. Factors affecting mortality in generalized postoperative peritonitis: multivariate analysis in 96 patients. World J Surg. 2003;27(4):379–84.
  20. Lamme B, Boermeester MA, Reitsma JB, Mahler CW, Obertop H, Gouma DJ. Meta-analysis of relaparotomy for secondary peritonitis. Br J Surg. 2002;89(12):1516–24.
  21. van Ruler O, Mahler CW, Boer KR, Reuland EA, Gooszen HG, Opmeer BC, et al. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA. 2007;298(8):865–72.
  22. Farjah F, Flum DR. When not being superior may not be good enough. JAMA. 2007;298(8):924–5.
  23. Lamme B, Boermeester MA, de Vos R, van Ruler O, van Till JW, Obertop H. Survey among surgeons on surgical treatment strategies for secondary peritonitis. Dig Surg. 2004;21(5-6):387–94; discussion 394–85.

Most read articles by the same author(s)