Long-term survival in generalized peritonitis: the impact of early critical periods in major emergency abdominal surgery

BACKGROUND: Generalized peritonitis is a severe intra-abdominal infection associated with high morbidity and mortality in patients undergoing major emergency abdominal surgery. While short-term outcomes are well documented, long-term survival and prognostic factors remain less explored. This study investigated four-year survival and conditional survival to assess the impact of generalized peritonitis on long-term outcomes. METHODS: This was a retrospective study based on prospectively collected data from 2017 to 2020, including patients aged ≥ 18 years who underwent major emergency abdominal surgery. All patients were treated within a high-quality, multidisciplinary standardized protocol. The primary outcome was four-year overall survival stratified according to the degree of peritonitis. Secondary outcomes were conditional survival, in which time at risk began on postoperative days 30 and 90 and included only patients alive beyond these time points. Associations between survival and risk factors were assessed using Cox regression analyses. RESULTS: A total of 966 patients were included, of whom 21% (203/966) were found perioperatively to have generalized peritonitis. The four-year overall survival rate was 66% (95% CI: 62.38-69.12%) in patients without generalized peritonitis and 53% (95% CI: 46.52-60.39%) in patients with generalized peritonitis, with the log-rank test showing a significant difference in survival (P = 0.00014). Among patients alive 30 days after surgery, generalized peritonitis was still associated with significantly lower survival (log-rank test, P = 0.028). However, this association was no longer observed among patients surviving beyond 90 days after surgery (log-rank test, P = 0.51). Furthermore, age > 70 years, ASA ≥ 3, intra-abdominal malignancy, and generalized peritonitis were significantly associated with poor survival, whereas among patients surviving beyond 90 days, generalized peritonitis was no longer associated with four-year survival. CONCLUSION: Generalized peritonitis was independently associated with significantly worse four-year overall survival. Although this survival disadvantage remained significant among 30-day survivors, it was no longer observed beyond 90 days postoperatively, suggesting that the prognostic impact of generalized peritonitis is primarily confined to the early postoperative period.