Damage control with abdominal vacuum therapy (VAC) to manage perforated diverticulitis with advanced generalized peritonitis--a proof of concept

Current concept of abdominal sepsis: WSES position paper

Although sepsis is a systemic process, the pathophysiological cascade of events may vary from region to region.

Abdominal sepsis represents the host’s systemic inflammatory response to bacterial peritonitis.

It is associated with significant morbidity and mortality rates, and is the second most common cause of sepsis-related mortality in the intensive care unit.

The review focuses on sepsis in the specific setting of severe peritonitis.

Damage control surgery for abdominal emergencies

BACKGROUND

Damage control surgery is a management sequence initiated to reduce the risk of death in severely injured patients presenting with physiological derangement. Damage control principles have emerged as an approach in non-trauma abdominal emergencies in order to reduce mortality compared with primary definitive surgery.

METHODS

A PubMed/MEDLINE literature review was conducted of data available over the past decade (up to August 2013) to gain information on current understanding of damage control surgery for abdominal surgical emergencies. Future directions for research are discussed.

RESULTS

Damage control surgery facilitates a strategy for life-saving intervention for critically ill patients by abbreviated laparotomy with subsequent reoperation for delayed definitive repair after physiological resuscitation. The six-phase strategy (including damage control resuscitation in phase 0) is similar to that for severely injured patients, although non-trauma indications include shock from uncontrolled haemorrhage or sepsis. Minimal evidence exists to validate the benefit of damage control surgery in general surgical abdominal emergencies. The collective published experience over the past decade is limited to 16 studies including a total of 455 (range 3-99) patients, of which the majority are retrospective case series. However, the concept has widespread acceptance by emergency surgeons, and appears a logical extension from pathophysiological principles in trauma to haemorrhage and sepsis. The benefits of this strategy depend on careful patient selection. Damage control surgery has been performed for a wide range of indications, but most frequently for uncontrolled bleeding during elective surgery, haemorrhage from complicated gastroduodenal ulcer disease, generalized peritonitis, acute mesenteric ischaemia and other sources of intra-abdominal sepsis.

CONCLUSION

Damage control surgery is employed in a wide range of abdominal emergencies and is an increasingly recognized life-saving tactic in emergency surgery performed on physiologically deranged patients.

A systematic review of stercoral perforation

AIM

Stercoral perforation is a rarely suspected life-threatening condition. Early diagnosis is difficult but essential. A comprehensive systematic review was performed to evaluate its presentation, diagnosis and treatment.

METHOD

A systematic review was carried out of Embase, MEDLINE, PubMed and Cochrane databases for all articles published between 1998 and 2011. Only studies describing stercoral perforation were included.

RESULTS

Twenty-four relevant articles were found including 137 patients (median age = 62 years) with stercoral perforation, of whom 81% had chronic constipation. Stercoral perforation was diagnosed by CT scan in 90% of 31 patients, with the commonest findings being a combination of faecal impaction (84%) and subphrenic (90%) or extraluminal air (61%). The commonest site of perforation was the sigmoid colon (50%) followed by the rectosigmoid junction (24%). The overall mortality was 34%.

CONCLUSION

Stercoral perforation should be suspected in elderly and chronically constipated patients with unexplained abdominal pain and investigated appropriately with a CT scan to allow timely and optimal treatment.

Open abdomen management: a review of its history and a proposed management algorithm

In this review we look into the historical development of open abdomen management. Its indication has spread in 70 years from intra-abdominal sepsis to damage control surgery and abdominal compartment syndrome. Different temporary abdominal closure techniques are essential to benefit the potential advantages of open abdomen management. Here, we discuss the different techniques and provide a new treatment strategy, based on available evidence, to facilitate more consistent decision making and further research on this complicated surgical topic.

Treatment of Hinchey stage III-IV diverticulitis: a systematic review and meta-analysis

BACKGROUND

This manuscript is a review of different surgical techniques to manage perforated colon diverticulitis.

OBJECTIVE

This study was conducted to compare the benefits and disadvantages of different surgical treatments for Hinchey III or IV type of colon diverticulitis.

METHODS

A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, and the Science Citation Index (1990 and 2011). A total of 1,809 publications were identified and 14 studies with 1,041 patients were included in the study. Any surgical treatment was considered in this review. Mortality was considered the primary outcome, whereas hospital stay and reoperation rate were considered secondary outcomes.

RESULTS

Primary resection with anastomosis has a significant advantage in terms of lower mortality rate with respect to Hartmann's procedure (P = 0.02). The postoperative length of hospitalization was significantly shorter in the resection with anastomosis group (P < 0.001). Different findings have emerged from studies of patients with the primary resection with anastomosis vs laparoscopic peritoneal lavage and subsequent resection: overall surgical morbidity and hospital stay were lower in the laparoscopic peritoneal lavage group compared to the primary resection and anastomosis group (P < 0.001).

CONCLUSIONS

Despite numerous published articles on operative treatments for patients with generalized peritonitis from perforated diverticulitis, we found a marked heterogeneity between included studies limiting the possibility to summarize in a metanalytical method the data provided and make difficult to synthesize data in a quantitative fashion. The advantages in the group of colon resection with primary anastomosis in terms of lower mortality rate and postoperative stay should be interpreted with caution because of several limitations. Future randomized controlled trials are needed to further evaluate different surgical treatments for patients with generalized peritonitis from perforated diverticulitis.

Incisional hernia rate after open abdomen treatment with negative pressure and delayed primary fascia closure

PURPOSE

Various techniques for delayed primary fascia closure have been published in patients treated with open abdomen (OA) and application of negative pressure, but to date, no data are available on incisional hernia (IH) rate. The aim of this retrospective analysis was to investigate the long-term outcome of this patient population with special interest in IH development.

METHODS

Two hundred and nine consecutive patients, 90(43 %) female, were treated at our institution for various abdominal emergencies involving OA from June 2006 to June 2011. Mean age was 63(16-92) years. The indication was abdominal sepsis in 155(74 %) patients, ischemia in 24(12 %) and other reasons in 30(14 %). Hospital mortality was 21 %(n = 44); and planned ventral hernia was 7 %(n = 15); and mortality until follow-up was 16 %(n = 25), and 9 %(n = 13) patients were lost to follow-up, leaving 112 patients for evaluation of IH development.

RESULTS

The rate of IH for patients with OA and delayed primary fascia closure was overall 35 % at a median (range) follow-up time of 26(12-81) months. Mean time for development of a ventral hernia was 11 months; 21(57 %) patients underwent surgery for symptomatic hernia (2 emergency operations for incarceration). Kaplan-Meier estimate for 5 years gave a 66 % IH rate. BMI, small bowel as source of infection and rapid adsorbable interrupted suture were identified risk factors.

CONCLUSION

The rate of IH after open abdomen treatment with delayed primary fascia closure is high with a running suture with slow absorbable suture material showing the best results.

Open abdomen treatment with dynamic sutures and topical negative pressure resulting in a high primary fascia closure rate

BACKGROUND

Open abdomen (OA) treatment with negative-pressure therapy is a novel treatment option for a variety of abdominal conditions. We here present a cohort of 160 consecutive OA patients treated with negative pressure and a modified adaptation technique for dynamic retention sutures.

METHODS

From May 2005 to October 2010, a total of 160 patients--58 women (36 %); median age 66 years (21-88 years); median Mannheim peritonitis index 25 (5-43) underwent emergent laparotomy for diverse abdominal conditions (abdominal sepsis 78 %, ischemia 16 %, other 6 %).

RESULTS

Hospital mortality was 21 % (13 % died during OA treatment); delayed primary fascia closure was 76 % in the intent-to-treat population and 87 % in surviving patients. Six patients required reoperation for abdominal abscess and five patients for anastomotic leakage; enteric fistulas were observed in five (3 %) patients. In a multivariate analysis, factors correlating significantly with high fascia closure rate were limited surgery at the emergency operation and a Björk index of 1 or 2; factors correlating significantly with low fascia closure rate were male sex and generalized peritonitis.

CONCLUSIONS

With the aid of initially placed dynamic retention sutures, OA treatment with negative pressure results in high rates of delayed primary fascia closure. OA therapy with the technical modifications described is thus considered a suitable treatment option in various abdominal emergencies.

Damage control surgery with abdominal vacuum and delayed bowel reconstruction in patients with perforated diverticulitis Hinchey III/IV

OBJECTIVE

With the use of abdominal vacuum therapy, we have developed a damage control concept for patients with perforated diverticulitis and generalized peritonitis. The primary aim of this concept was to enhance recovery and allow bowel reconstruction in a second-look operation.

METHODS

A total of 51 patients (28 female, 55%) with a median (range) age of 69 (28-87) years, with perforated diverticulitis Hinchey III (n = 40, 78%) or Hinchey IV (n = 11, 22%) and a median (range) Mannheim peritonitis index of 26 (12-39), admitted between October 2006 and September 2011, were prospectively enrolled in the study. At initial operation, limited resection of the diseased segment, lavage, and application of abdominal vacuum-assisted closure dressing was performed. After patient resuscitation, a second look was performed in an elective setting.

RESULTS

Hospital mortality rate was 9.8%; 35 (76%) of patients were discharged with reconstructed colon, and 93% of patients live without a stoma at follow-up. Risk factors for mortality were American Society of Anesthesiologist score (p = 0.01), organ failure at initial presentation (p = 0.03), cardiac comorbidity (p = 0.05), and a Hartmann procedure at second look (p = 0.00).

CONCLUSION

With this abdominal vacuum-based damage control concept, an acceptable hospital mortality rate and a high rate of bowel reconstruction at second look were achieved in patients with perforated diverticulitis and generalized peritonitis.

The Use of Vacuum-Assisted Closure in the Management of Septic Peritonitis in Six Dogs

The purpose of this study was to describe the appropriate surgical technique, postoperative monitoring, and complications encountered with use of vacuum-assisted closure (VAC) in six dogs with confirmed septic peritonitis. Initial diagnosis of septic peritonitis was performed by measuring either the blood-to-fluid lactate ratio and glucose concentration differences or cytologic verification of intracellular bacteria. After appropriate surgical procedures were performed to manage the primary cause of peritoneal sepsis, a VAC was performed. Serum and abdominal fluid protein levels were measured, and all complications were noted during the postoperative period. Three of the six dogs (50%) survived to the secondary closure and were subsequent discharged, which is similar to previous studies where the abdomen was either closed primarily or treated with open abdominal drainage. No major complications occurred with bandage management during hospitalization. The results of this study support VAC as a feasible technique for managing septic peritonitis.