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Comparison of Outcomes between Early Fascial Closure and Delayed Abdominal Closure in Patients with Open Abdomen: A Systematic Review and Meta-Analysis. Gastroenterol Res Pract 2014; 2014:784056. [PMID: 24987411 PMCID: PMC4060535 DOI: 10.1155/2014/784056] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 05/15/2014] [Indexed: 01/08/2023] Open
Abstract
Up to the present, the optimal time to close an open abdomen remains controversial. This study was designed to evaluate whether early fascial abdominal closure had advantages over delayed approach for open abdomen populations. Medline, Embase, and Cochrane Library were searched until April 2013. Search terms included “open abdomen,” “abdominal compartment syndrome,” “laparostomy,” “celiotomy,” “abdominal closure,” “primary,” “delayed,” “permanent,” “fascial closure,” and “definitive closure.” Open abdomen was defined as “fail to close abdominal fascia after a laparotomy.” Mortality, complications, and length of stay were compared between early and delayed fascial closure. In total, 3125 patients were included for final analysis, and 1942 (62%) patients successfully achieved early fascial closure. Vacuum assisted fascial closure had no impact on pooled fascial closure rate. Compared with delayed abdominal closure, early fascial closure significantly reduced mortality (12.3% versus 24.8%, RR, 0.53, P < 0.0001) and complication incidence (RR, 0.68, P < 0.0001). The mean interval from open abdomen to definitive closure ranged from 2.2 to 14.6 days in early fascial closure groups, but from 32.5 to 300 days in delayed closure groups. This study confirmed clinical advantages of early fascial closure over delayed approach in treatment of patients with open abdomen.
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Libberecht K, Colpaert SDM, Van Hee R, Jadoul JL, De Clercq S, Sonneville T. New developments in abdominal wall reconstruction after abdominal compartment syndrome decompression. Acta Clin Belg 2014; 62 Suppl 1:220-4. [PMID: 24881723 DOI: 10.1179/acb.2007.62.s1.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The acute abdominal compartment syndrome (ACS) is most often treated with surgical abdominal decompression. After the acute phase, primary closure of the abdominal wall may not be possible, due to tissue loss and retraction of the abdominal wall and its musculofascial components. This article gives an update of the reconstructive ladder for abdominal wall defects. Because of improved intensive care treatment and wound dressing, reconstruction can usually be delayed until infection and oedema have settled. Recent developments in bioprosthetics and new surgical techniques like component separation make better results with less donor site morbidity possible. However, there is still a place for local and distant flaps.
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Bjarnason T, Montgomery A, Ekberg O, Acosta S, Svensson M, Wanhainen A, Björck M, Petersson U. One-year follow-up after open abdomen therapy with vacuum-assisted wound closure and mesh-mediated fascial traction. World J Surg 2014; 37:2031-8. [PMID: 23703638 DOI: 10.1007/s00268-013-2082-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Open abdomen (OA) therapy frequently results in a giant planned ventral hernia. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) enables delayed primary fascial closure in most patients, even after prolonged OA treatment. Our aim was to study the incidence of hernia and abdominal wall discomfort 1 year after abdominal closure. METHODS A prospective multicenter cohort study of 111 patients undergoing OA/VAWCM was performed during 2006-2009. Surviving patients underwent clinical examination, computed tomography (CT), and chart review at 1 year. Incisional and parastomal hernias and abdominal wall symptoms were noted. RESULTS The median age for the 70 surviving patients was 68 years, 77 % of whom were male. Indications for OA were visceral pathology (n = 40), vascular pathology (n = 22), or trauma (n = 8). Median length of OA therapy was 14 days. Among 64 survivors who had delayed primary fascial closure, 23 (36 %) had a clinically detectable hernia and another 19 (30 %) had hernias that were detected on CT (n = 18) or at laparotomy (n = 1). Symptomatic hernias were found in 14 (22 %), 7 of them underwent repair. The median hernia widths in symptomatic and asymptomatic patients were 7.3 and 4.8 cm, respectively (p = 0.031) with median areas of 81.0 and 42.9 cm(2), respectively (p = 0.025). Of 31 patients with a stoma, 18 (58 %) had a parastomal hernia. Parastomal hernia (odds ratio 8.9; 95 % confidence interval 1.2-68.8) was the only independent factor associated with an incisional hernia. CONCLUSIONS Incisional hernia incidence 1 year after OA therapy with VAWCM was high. Most hernias were small and asymptomatic, unlike the giant planned ventral hernias of the past.
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Kobayashi L, Coimbra R. Planned re-laparotomy and the need for optimization of physiology and immunology. Eur J Trauma Emerg Surg 2014; 40:135-42. [PMID: 26815893 DOI: 10.1007/s00068-014-0396-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 03/10/2014] [Indexed: 12/31/2022]
Abstract
Planned re-laparotomy or damage control laparotomy (DCL), first described by Dr. Harlan Stone in 1983, has become a widely utilized technique in a broad range of patients and operative situations. Studies have validated the use of DCL by demonstrating decreased mortality and morbidity in trauma, general surgery and abdominal vascular catastrophes. Indications for planned re-laparotomy include severe physiologic derangements, coagulopathy, concern for bowel ischemia, and abdominal compartment syndrome. The immunology of DCL patients is not well described in humans, but promising animal studies suggest a benefit from the open abdomen (OA) and several human trials on this subject are currently underway. Optimal critical care of patients with OA's, including sedation, paralysis, nutrition, antimicrobial and fluid management strategies have been associated with improved closure rates and recovery.
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Affiliation(s)
- L Kobayashi
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego, 200 W. Arbor Dr. #8896, San Diego, CA, 92103-8896, USA.
| | - R Coimbra
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego, 200 W. Arbor Dr. #8896, San Diego, CA, 92103-8896, USA.
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Godat L, Kobayashi L, Costantini T, Coimbra R. Abdominal damage control surgery and reconstruction: world society of emergency surgery position paper. World J Emerg Surg 2013; 8:53. [PMID: 24341602 PMCID: PMC3878509 DOI: 10.1186/1749-7922-8-53] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/10/2013] [Indexed: 12/02/2022] Open
Abstract
Damage control laparotomy was first described by Dr. Harlan Stone in 1983 when he suggested that patients with severe trauma should have their primary procedures abbreviated when coagulopathy was encountered. He recommended temporizing patients with abdominal packing and temporary closure to allow restoration of normal physiology prior to returning to the operating room for definitive repair. The term damage control in the trauma setting was coined by Rotondo et al., in 1993. Studies in subsequent years have validated this technique by demonstrating decreased mortality and immediate post-operative complications. The indications for damage control laparotomy have evolved to encompass abdominal compartment syndrome, abdominal sepsis, vascular and acute care surgery cases. The perioperative critical care provided to these patients, including sedation, paralysis, nutrition, and fluid management strategies may improve closure rates and recovery. In the rare cases of inability to primarily close the abdomen, there are a number of reconstructive strategies that may be used in the acute and chronic phases of abdominal closure.
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Affiliation(s)
| | | | | | - Raul Coimbra
- Division of Trauma, Surgical Critical Care, and Burns, University of California, San Diego, 200 West Arbor Dr,, #8896, San Diego CA 92103-8896, United States of America.
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Negative pressure wound therapy for the treatment of the open abdomen and incidence of enteral fistulas: a retrospective bicentre analysis. Gastroenterol Res Pract 2013; 2013:730829. [PMID: 24285953 PMCID: PMC3830879 DOI: 10.1155/2013/730829] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 09/06/2013] [Indexed: 11/22/2022] Open
Abstract
Introduction. The open abdomen (OA) is often associated with complications. It has been hypothesized that negative pressure wound therapy (NPWT) in the treatment of OA may provoke enteral fistulas. Therefore, we analyzed patients with OA and NPWT with special regard to the occurrence of intestinal fistulas. Methods. The present study included all consecutive patients with OA treated with NWPT from April 2010 to August 2011 in two hospitals. Patients' demographics, indications for OA, risk factors, complications, outcome and incidence of fistulas before, during and after NPWT were recorded. Results. Of 81 patients with OA, 26 had pre-existing fistulas and 55 were free from a fistula at the beginning of NPWT. Nine of the 55 patients developed fistulas during (n = 5) or after NPWT (n = 4). Seventy-five patients received ABThera therapy, 6 patients other temporary abdominal closure devices. Only diverticulitis seemed to be a significant predisposing factor for fistulas. Mortality was slightly lower for patients without fistulas. Conclusion. The present study revealed no correlation between occurrence of fistulas before, during, and after NWPT, with diverticulitis being the only risk factor. Fistula formation during NPWT was comparable to reports from literature. Prospective studies are mandatory to clarify the impact of NPWT on fistula formation.
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Cheesborough JE, Park E, Souza JM, Dumanian GA. Staged management of the open abdomen and enteroatmospheric fistulae using split-thickness skin grafts. Am J Surg 2013; 207:504-11. [PMID: 24315380 DOI: 10.1016/j.amjsurg.2013.07.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 06/27/2013] [Accepted: 07/08/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Management of the open abdomen with polyglactin 910 mesh followed by split-thickness skin grafts allows safe, early closure of abdominal wounds. This technique can be modified to manage enteroatmospheric fistulae. Staged ventral hernia is performed in a less inflamed surgical field. METHODS A retrospective review was performed of 59 consecutive patients who underwent abdominal skin grafting for open abdominal wounds from 2001 to 2011. RESULTS The median length of follow-up was 215 days. Thirty-one percent of patients presented with preexisting enteroatmospheric fistulae, and 41% required polyglactin 910 mesh placement before skin grafting. Partial or complete skin graft failure occurred in 7 patients. Four patients required repeat skin grafting. All patients ultimately achieved abdominal wound closure, and none developed de novo fistulae. CONCLUSIONS With proper technique, skin grafting of the open abdomen with a planned ventral hernia repair is a safe and effective alternative to delayed primary closure.
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Affiliation(s)
- Jennifer E Cheesborough
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, 675 N St Clair, Suite 19-250, Chicago, IL 60611, USA
| | - Eugene Park
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, 675 N St Clair, Suite 19-250, Chicago, IL 60611, USA
| | - Jason M Souza
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, 675 N St Clair, Suite 19-250, Chicago, IL 60611, USA
| | - Gregory A Dumanian
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, 675 N St Clair, Suite 19-250, Chicago, IL 60611, USA.
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Kreis BE, de Mol van Otterloo AJ, Kreis RW. Open abdomen management: a review of its history and a proposed management algorithm. Med Sci Monit 2013; 19:524-33. [PMID: 23823991 PMCID: PMC3706408 DOI: 10.12659/msm.883966] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 05/10/2013] [Indexed: 12/13/2022] Open
Abstract
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.
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60
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Commentary on "predictors of failed primary abdominal closure in the trauma patient with an open abdomen". South Med J 2013; 106:332-3. [PMID: 23644643 DOI: 10.1097/smj.0b013e318292440f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Haddock C, Konkin DE, Blair NP. Management of the open abdomen with the Abdominal Reapproximation Anchor dynamic fascial closure system. Am J Surg 2013; 205:528-33; discussion 533. [DOI: 10.1016/j.amjsurg.2013.01.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 01/12/2013] [Accepted: 01/17/2013] [Indexed: 11/30/2022]
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Abstract
Few descriptions of temporary abdominal closure for planned relaparotomy have been reported in burned patients. The purpose of this study is to describe our experience and outcomes in the management of burned patients with an open abdomen. The authors performed a retrospective review of all admissions to our burn center from March 2003 to June 2008, identifying patients treated by laparotomy with temporary abdominal closure. The authors collected data on patient demographics, indication for laparotomy, methods of temporary and definitive abdominal closure, and outcomes. Of 2,104 patients admitted, 38 underwent a laparotomy with temporary abdominal closure. Their median TBSA was 55%, and the incidence of inhalation injury was 58%. Abdominal compartment syndrome was the most common indication for laparotomy (82%) followed by abdominal trauma (16%). The in-hospital mortality associated with an open abdomen was 68%. Temporary abdominal closure was performed most commonly using negative pressure wound therapy (90%). Fascial closure was performed in 21 patients but was associated with a 38% rate of failure requiring reexploration. Of 12 survivors, fascial closure was achieved in seven patients and five were managed with a planned ventral hernia. Burned patients who necessitate an open abdomen management strategy have a high morbidity and mortality. Fascial closure was associated with a high rate of failure but was successful in a select group of patients. Definitive abdominal closure with a planned ventral hernia was associated with no increased mortality and remains an option when "tension-free" fascial closure cannot be achieved.
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Rasilainen SK, Mentula PJ, Leppäniemi AK. Vacuum and mesh-mediated fascial traction for primary closure of the open abdomen in critically ill surgical patients. Br J Surg 2012; 99:1725-32. [PMID: 23034811 DOI: 10.1002/bjs.8914] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2012] [Indexed: 01/26/2023]
Abstract
BACKGROUND Several temporary abdominal closure techniques have been used in the management of open abdomen. Failure to achieve delayed primary fascial closure results in a large ventral hernia. This retrospective analysis evaluated whether the use of vacuum-assisted closure and mesh-mediated fascial traction (VACM) as temporary abdominal closure improved the delayed primary fascial closure rate compared with non-traction methods. METHODS Patients treated with an open abdomen between 2004 and 2010 were analysed. RESULTS Among 50 patients treated with VACM and 54 using non-traction techniques (control group), the delayed primary fascial closure rate was 78 and 44 per cent respectively (P < 0·001); rates among those who survived to abdominal closure were 93 and 59 per cent respectively. Independent predictors of delayed primary fascial closure in multivariable logistic regression analysis were the use of VACM (odds ratio (OR) 4·43, 95 per cent confidence interval 1·64 to 11·99) and diagnosis other than peritonitis, severe acute pancreatitis or ruptured abdominal aortic aneurysm (OR 3·45, 1·07 to 11·04), which represented the main diagnoses. Prophylactic open abdomen was used to inhibit the development of intra-abdominal hypertension more frequently in the VACM group (28 versus 7 per cent; P = 0·008). Twelve per cent of patients in the VACM group developed an enteroatmospheric fistula compared with 19 per cent of control patients. Among survivors, three of 31 treated with VACM and 17 of 36 controls were left with a planned ventral hernia (P = 0·001). CONCLUSION The indication for open abdomen contributed to the probability of delayed primary fascial closure. VACM resulted in a higher fascial closure rate and lower planned hernia rate than methods that did not provide fascial traction.
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Affiliation(s)
- S K Rasilainen
- Department of Abdominal Surgery, Helsinki University Central Hospital, Finland.
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65
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Burlew CC. The open abdomen: practical implications for the practicing surgeon. Am J Surg 2012; 204:826-35. [PMID: 23000185 DOI: 10.1016/j.amjsurg.2012.04.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 04/23/2012] [Accepted: 04/23/2012] [Indexed: 12/13/2022]
Abstract
The open abdomen is a necessary sequela after damage-control surgery or abdominal compartment syndrome. Management of the patient in the intensive care unit continues to evolve, with considerations of fluid resuscitation, enteral nutrition, and supportive care. Management of the abdominal contents incorporates several basic techniques and considerations: appropriate temporary covering, enteric injury repair in most patients, placement of an anastomosis in an area of the abdomen with minimal manipulation without exposure to the atmosphere, acquiring enteral access for initiation of enteral nutrition, and ultimate abdominal closure. An understanding of these complex factors is instrumental for the practicing surgeon.
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Affiliation(s)
- Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO, USA.
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Quyn AJ, Johnston C, Hall D, Chambers A, Arapova N, Ogston S, Amin AI. The open abdomen and temporary abdominal closure systems--historical evolution and systematic review. Colorectal Dis 2012; 14:e429-38. [PMID: 22487141 DOI: 10.1111/j.1463-1318.2012.03045.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM Several techniques for temporary abdominal closure have been developed. We systematically review the literature on temporary abdominal closure to ascertain whether the method can be tailored to the indication. METHOD Medline, Embase, the Cochrane Central Register of Controlled Trials and relevant meeting abstracts until December 2009 were searched using the following headings: open abdomen, laparostomy, VAC (vacuum assisted closure), TNP (topical negative pressure), fascial closure, temporary abdominal closure, fascial dehiscence and deep wound dehiscence. The data were analysed by closure technique and aetiology. The primary end-points included delayed fascial closure and in-hospital mortality. The secondary end-points were intra-abdominal complications. RESULTS The search identified 106 papers for inclusion. The techniques described were VAC (38 series), mesh/sheet (30 series), packing (15 series), Wittmann patch (eight series), Bogotá bag (six series), dynamic retention sutures (three series), zipper (15 series), skin only and locking device (one series each). The highest facial closure rates were seen with the Wittmann patch (78%), dynamic retention sutures (71%) and VAC (61%). CONCLUSION Temporary abdominal closure has evolved from simple packing to VAC based systems. In the absence of sepsis Wittmann patch and VAC offered the best outcome. In its presence VAC had the highest delayed primary closure and the lowest mortality rates. However, due to data heterogeneity only limited conclusions can be drawn from this analysis.
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Affiliation(s)
- A J Quyn
- Department of General Surgery, Victoria Hospital, Fife NHS Trust, Kirkcaldy, UK.
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Abstract
Since the mid-1990s the surgical community has seen a surge in the prevalence of open abdomens (OAs) reported in the surgical literature and in clinical practice. The OA has proven to be effective in decreasing mortality and immediate postoperative complications; however, it may come at the cost of delayed morbidity and the need for further surgical procedures. Indications for leaving the abdomen open have broadened to include damage control surgery, abdominal compartment syndrome, and abdominal sepsis. The surgical options for management of the OA are now more diverse and sophisticated, but there is a lack of prospective randomized controlled trials demonstrating the superiority of any particular method. Additionally, critical care strategies for optimization of the patient with an OA are still being developed. Review of the literature suggests a bimodal distribution of primary closure rates, with early closure dependent on postoperative intensive care management and delayed closure more affected by the choice of the temporary abdominal closure technique. Invariably, a small fraction of patients requiring OA management fail to have primary fascial closure and require some form of biologic fascial bridge with delayed ventral hernia repair in the future.
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Shah SK, Jimenez F, Letourneau PA, Walker PA, Moore-Olufemi SD, Stewart RH, Laine GA, Cox CS. Strategies for modulating the inflammatory response after decompression from abdominal compartment syndrome. Scand J Trauma Resusc Emerg Med 2012; 20:25. [PMID: 22472164 PMCID: PMC3352320 DOI: 10.1186/1757-7241-20-25] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 04/03/2012] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Management of the open abdomen is an increasingly common part of surgical practice. The purpose of this review is to examine the scientific background for the use of temporary abdominal closure (TAC) in the open abdomen as a way to modulate the local and systemic inflammatory response, with an emphasis on decompression after abdominal compartment syndrome (ACS). METHODS A review of the relevant English language literature was conducted. Priority was placed on articles published within the last 5 years. RESULTS/CONCLUSION Recent data from our group and others have begun to lay the foundation for the concept of TAC as a method to modulate the local and/or systemic inflammatory response in patients with an open abdomen resulting from ACS.
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Affiliation(s)
- Shinil K Shah
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, Texas, USA
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Webb LH, Patel MB, Dortch MJ, Miller RS, Gunter OL, Collier BR. Use of a furosemide drip does not improve earlier primary fascial closure in the open abdomen. J Emerg Trauma Shock 2012; 5:126-30. [PMID: 22787341 PMCID: PMC3391835 DOI: 10.4103/0974-2700.96480] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Accepted: 08/31/2011] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The furosemide drip (FD), in addition to improving volume overload respiratory failure, has been used to decrease fluid in attempts to decrease intra-abdominal and abdominal wall volumes to facilitate fascial closure. The purpose of this study is to evaluate the FD and the associated rate of primary fascial closure following trauma damage control laparotomy (DCL). MATERIALS AND METHODS From January 2004 to September 2008, a retrospective review from a single institution Trauma Registry of the American College of Surgeons dataset was performed. All DCLs greater than 24 h who had a length of stay for 3 or more days were identified. The study group (FD+) and control group (FD-) were compared. Demographic data including age, sex, probability of survival, red blood cell transfusions, initial lactate, and mortality were collected. Primary outcomes included primary fascial closure and primary fascial closure within 7 days. Secondary outcomes included total ventilator days and LOS. RESULTS A total of 139 patients met inclusion criteria: 25 FD+ and 114 FD-. The 25 FD+ patients received the drug at a median 4 days post DCL. Demographic differences between the groups were not significantly different, except that initial lactate was higher for FD- (1.7 vs 4.0; P=0.03). No differences were noted between groups regarding successful primary fascial closure (FD+ 68.4% vs FD- 64.0%; P=0.669), or closure within 7 days (FD+13.2% vs FD- 28.0%; P=0.066) of original DCL. FD+ patients suffered more open abdomen days (4 [2-7] vs 2 [1-4]; P=0.001). FD+ did not demonstrate an association with primary fascial closure [Odds ratio (OR) 1.5, 95% confidence interval (CI) 0.260-8.307; P=0.663]. FD+ patients had more ventilator days and longer Intensive Care Unit (ICU)/hospital LOS (P<0.01). CONCLUSION FD use may remove excess volume; however, forced diuresis with an FD is not associated with an increased rate of primary closure after DCL. Further studies are warranted to identify ICU strategies to facilitate fascial closure in DCL.
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Affiliation(s)
- Leland H Webb
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mayur B Patel
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
- Veterans Affairs (VA) Tennessee Valley Healthcare System, Nashville VA Medical Center, Surgical Service, 1310, 24 Avenue South Nashville, TN 37212, USA
| | - Marcus J Dortch
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard S Miller
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oliver L Gunter
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bryan R Collier
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
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Gutierrez IM, Gollin G. Negative pressure wound therapy for children with an open abdomen. Langenbecks Arch Surg 2012; 397:1353-7. [DOI: 10.1007/s00423-012-0923-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 02/06/2012] [Indexed: 10/28/2022]
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Verdam FJ, Dolmans DEJGJ, Loos MJ, Raber MH, de Wit RJ, Charbon JA, Vroemen JPAM. Delayed primary closure of the septic open abdomen with a dynamic closure system. World J Surg 2012; 35:2348-55. [PMID: 21850603 PMCID: PMC3170463 DOI: 10.1007/s00268-011-1210-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The major challenge in the management of patients with an infected open abdomen (OA) is to control septic peritonitis and intra-abdominal fluid secretion, and to facilitate repeated abdominal exploration, while preserving the fascia for delayed primary closure. We here present a novel method for closure of the infected OA, based on continuous dynamic tension, in order to achieve re-approximation of the fascial edges of the abdominal wall. Methods Eighteen cases with severe peritonitis of various origin (e.g., gastrointestinal perforations, anastomotic leakage) were primarily stabilized by laparostomy, sealed with either the vacuum-assisted closure abdominal dressing or the Bogotá bag. After hemodynamic stabilization and control of the sepsis, the Abdominal Re-approximation Anchor System (ABRA; Canica Design, Almonte, Ontario, Canada) was applied. This system approximates the wound margins through dynamic traction exerted by transfascial elastomers. Before ABRA application, 5/18 patients had a grade 2B, 2/18 a grade 3, and 11/18 a grade or 4 status according to the open abdomen classification of Björck. Results In this severely ill population the mean time before ABRA system application was 12 days (range: 2–39 days). Two of 18 patients died of non-ABRA-related causes within three weeks. In 14 of the remaining 16 patients (88%) primary abdominal closure of the midline was accomplished in 15 days (range: 7–30 days). The other two patients needed a component separation technique according to Ramirez to reach closure. However, secondary wound dehiscence occurred in both these patients. Two thirds of patients (12/18) developed pressure sores to the skin and/or dermis, but all healed without further complications. During outpatient clinic follow-up, 4/14 successfully closed patients still developed a midline hernia. Conclusions Delayed primary closure of OA in septic patients could be achieved in 88% with this new approximation system. However, the risk of hernia development remained. We consider this system a useful tool in the treatment of septic patients with an open abdomen. Electronic supplementary material The online version of this article (doi:10.1007/s00268-011-1210-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Froukje J Verdam
- Department of General Surgery, Amphia Hospital, P.O. Box 90158, 4800 RK Breda, The Netherlands.
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Franklin ME, Alvarez A, Russek K. Negative pressure therapy: a viable option for general surgical management of the open abdomen. Surg Innov 2012; 19:353-63. [PMID: 22228757 DOI: 10.1177/1553350611429693] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Management of the open abdomen (OA) is challenging for surgeons and requires experienced medical teamwork. The need for improvements in temporary abdominal closure methods has led to the development of a negative-pressure therapy (NPT; ABThera OA NPT, KCI USA, Inc, San Antonio, TX). METHOD The authors present a 19-patient case series documenting their use of NPT for OA management in nontraumatic surgery. All received NPT until the fascia was considered ready for closure. RESULTS Of 19 patients, 17 (89.5%) achieved fascial closure with a Kaplan-Meier (KM) median time to closure of 6 days. Mean hospital and intensive care unit stays were 32.1 and 26.6 days, respectively. During their hospitalization, 5 patients (26.3%) died, with a KM median time to mortality of 53 days. CONCLUSION These findings demonstrate effective use of NPT for managing the OA in critically ill patients, and this has led the authors to use it in their general surgery practice.
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74
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One hundred percent fascial approximation can be achieved in the postinjury open abdomen with a sequential closure protocol. J Trauma Acute Care Surg 2012; 72:235-41. [DOI: 10.1097/ta.0b013e318236b319] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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75
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Denadai R. Some considerations on "Synthesis of large wounds of the body wall with rubber elastic band". ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2012. [PMID: 22569986 DOI: 10.1590/s0102-67202012000100018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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76
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Papavramidis TS, Marinis AD, Pliakos I, Kesisoglou I, Papavramidou N. Abdominal compartment syndrome - Intra-abdominal hypertension: Defining, diagnosing, and managing. J Emerg Trauma Shock 2011; 4:279-91. [PMID: 21769216 PMCID: PMC3132369 DOI: 10.4103/0974-2700.82224] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Accepted: 06/26/2010] [Indexed: 12/31/2022] Open
Abstract
Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) are increasingly recognized as potential complications in intensive care unit (ICU) patients. ACS and IAH affect all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. ACS/IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of ACS/IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. We start this article with a brief historic review on ACS/IAH. Then, we present the definitions concerning parameters necessary in understanding ACS/IAH. Finally, pathophysiology aspects of both phenomena are presented, prior to exploring the various facets of ACS/IAH management.
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Affiliation(s)
- Theodossis S Papavramidis
- 3 Department of Surgery, AHEPA University Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
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77
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Eastern Association for the Surgery of Trauma: a review of the management of the open abdomen--part 2 "Management of the open abdomen". ACTA ACUST UNITED AC 2011; 71:502-12. [PMID: 21825951 DOI: 10.1097/ta.0b013e318227220c] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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78
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Moore LJ, Moore FA. Early Diagnosis and Evidence-Based Care of Surgical Sepsis. J Intensive Care Med 2011; 28:107-17. [DOI: 10.1177/0885066611408690] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sepsis continues to be a common and serious problem among surgical patients. It is a leading cause of both morbidity and mortality in the perioperative period. The early identification of sepsis and the early implementation of evidence-based care can improve outcomes. This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of sepsis, severe sepsis, and septic shock in the surgical patients.
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Affiliation(s)
- Laura J. Moore
- Department of Surgery, The University of Texas Health Science Center, Houston, USA
| | - Frederick A. Moore
- Department of Surgery, The University of Texas Health Science Center, Houston, USA
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79
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Parmeggiani D, Gubitosi A, Ruggiero R, Docimo G, Atelli PF, Avenia N. The abdominal compartment syndrome: review, experience report and description of an innovative biological mesh application. Updates Surg 2011; 63:271-5. [PMID: 21710331 DOI: 10.1007/s13304-011-0083-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 05/24/2011] [Indexed: 12/13/2022]
Abstract
Intra abdominal hypertension (IAH) is defined as an intra-abdominal pressure (IAP) >12 mmHg. Abdominal compartment syndrome (ACS) is defined as an IAP above 20 mmHg with evidence of organ dysfunction/failure. The real incidence of the ACS is not clear, because there are few perspective studies. The origin of ACS can be divided into retroperitoneal, intraperitoneal, parietal and intestinal, and the diagnostic algorithm includes base and toxicological laboratory examinations, thorax X-ray, abdomen X-ray, abdomen TC, peritoneal washing, abdomen ultrasonography, diagnostic laparoscopy, and measurement of IAP. To allow a suitable decompression and avoid the damages to the abdominal organs, abdominal wall normally is not sutured primarily but secondarily and there are many methods of temporary closing: absorbable net, non-absorbable nets, 'Bogota bag', 'vacuum pack ice', gradual approximation of side cutaneous edges on the half-way line with permanence of an ample ventral hernia that could be subsequently repaired, and the use of 'skin expanders'. Since January 2000, until December 2008, eight patients were submitted to laparostomy, four of them for re-laparotomy, with mortality incidence of 37.5%. The defective size to fill was on the average 300 cm as reported by Bradley and Bradley (J Clin Invest 26:1010-1015, 1947). The abdominal wall reconstruction was performed using ample muscle edges derived from the slip in medial sense of the rectus muscle of the abdomen 'unmoored' through an incision 1 cm distant from semi-lunar line, and using absorbable prosthesis to cover the solution of continuity, thus allowing the closing of defects over 30 cm. We have found median post surgical hernia in one patient corrected in accordance with the time using polypropylene prosthesis. In one patient with parietal disaster and multiple traumatic splanchnic ruptures, we have used a pure pork-derived acellular collagen mesh (Permacol(®)) to close the wound, leaving enough space between fascia extremities, to solve the IAP. The employment of ample muscle edges represents the ideal solution in the reconstruction of the abdominal walls after laparotomic operations, offering a valid dynamic support preferable in comparison with the employment of alloplastic material. In consideration of the limits of this technique in the enormous parietal disaster-ACS treatment, we describe a new kind of innovative mesh application (Permacol(®)), most often used for parietal disaster or enormous incisional hernias, which can easily be preferred to dual mesh prosthesis, having a better biological profile and no capacity to produce intestinal adherences.
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Affiliation(s)
- Domenico Parmeggiani
- Dipartimento di Scienze Anestesiologiche, Chirurgiche e dell'Emergenza Seconda Università di Napoli, Via A. Falcone 290/A, 80128, Naples, Italy.
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80
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Current Use of Damage-Control Laparotomy, Closure Rates, and Predictors of Early Fascial Closure at the First Take-Back. ACTA ACUST UNITED AC 2011; 70:1429-36. [DOI: 10.1097/ta.0b013e31821b245a] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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81
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Al-Mufarrej F, Abell LM, Chawla LS. Understanding Intra-Abdominal Hypertension. J Intensive Care Med 2011; 27:145-60. [PMID: 21525112 DOI: 10.1177/0885066610396156] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Received November 10, 2009. Received Revised June 17, 2010. Submitted June 21, 2010. Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are highly morbid conditions that are common and underrecognized in the intensive care unit. Intra-abdominal hypertension affects the critically ill patient population and is not solely limited to the trauma and surgical subgroups. The recognition of IAH and ACS as distinct clinical states has become more apparent. Extensive bench and clinical research has shed significant light into the definition, incidence, etiology, physiology, clinical manifestations, and treatment strategies. Although further research into this morbid condition is needed, improvement in recognition is a critical first step. This review aims to scrutinize the basic science and clinical literature available on this condition in a surgically focused, organ-system-based approach.
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Affiliation(s)
- Faisal Al-Mufarrej
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Lynn M. Abell
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
- Department of Surgery and Critical Care, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, Washington, DC, USA
| | - Lakhmir S. Chawla
- Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, Washington, DC, USA
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, DC, USA
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82
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Gabriel A, Kirk J, Jones J, Rauen B, Fritzsche SD. Navigating new technologies in negative pressure wound therapy. Plast Surg Nurs 2011; 31:65-74. [PMID: 21633272 DOI: 10.1097/psn.0b013e318219778b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Plastic surgeons and their support staff are tasked with proficient management of a wide variety of complex wounds. Since its introduction, negative pressure wound therapy (NPWT) has increasingly been used within the plastic surgery specialty to improve and simplify wound management. Increased usage of the therapy has prompted the development of a myriad of new NPWT systems. While an expanded product selection allows greater choice to maximize patient outcomes, sound decision-making also requires a clear understanding of the characteristics of various NPWT systems and applications. Wound-specific NPWT systems of varying size are available for low- to moderate-severity wounds, clean closed incisions, and acute abdominal wounds. Wound size and severity, amount of exudate, and patient mobility issues have become important considerations when choosing an NPWT device. The purpose of this article is to familiarize the reader with the latest sophistications in NPWT systems to guide decision making and usage.
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Affiliation(s)
- Allen Gabriel
- Southwest Washington Medical Center, Department of Surgery, Vancouver, WA, USA.
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83
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Abstract
BACKGROUND Over the last 15 years, negative-pressure wound therapy has become commonly used for treatment of a wide variety of complex wounds. There are now several systems marketed, and additional products will be available in the near future. Many clinicians have noted a dramatic response when negative-pressure wound therapy technology has been used, prompting a number of scientific investigations related to its mechanism of action and clinical trials determining its efficacy. METHODS The peer-reviewed literature within the past 5 years was reviewed, using an evidence-based approach. RESULTS Negative-pressure wound therapy works through mechanisms that include fluid removal, drawing the wound together, microdeformation, and moist wound healing. Several randomized clinical trials support the use of negative-pressure wound therapy in certain wound types. Serious complications, including bleeding and infection, have recently been reported by the U.S. Food and Drug Administration in a small number of patients. CONCLUSIONS Negative-pressure wound therapy has dramatically changed the way complex wounds are treated. The rapid introduction of this technology has occurred faster than large-scale randomized controlled studies or registry studies have been conducted. Further clinical studies and basic science studies will help surgeons to better understand the evidence and use this technology in the future.
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84
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Prichayudh S, Sriussadaporn S, Samorn P, Pak-Art R, Sriussadaporn S, Kritayakirana K, Capin A. Management of open abdomen with an absorbable mesh closure. Surg Today 2010; 41:72-8. [PMID: 21191694 DOI: 10.1007/s00595-009-4202-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 11/19/2009] [Indexed: 11/25/2022]
Abstract
PURPOSE To examine the methods and results of treatment in patients with an open abdomen (OA) at a single institution where an absorbable mesh closure (AMC) is most commonly used. METHODS A retrospective study was performed in OA patients from January 2001 to June 2007. Outcomes were analyzed in terms of enteroatmospheric fistula (EAF) formation and survival. RESULTS There were 73 OA patients receiving definitive closures (40 trauma and 33 nontrauma). Twenty-four patients were able to undergo a delayed primary fascial closure (DPFC) after initial vacuum pack closure (DPFC rate 33%). The DPFC rate was significantly lower in patients with an associated infection or contamination (9% vs 44%, P = 0.002). The EAF and mortality rates of the DPFC group were 0% and 13%, respectively. Absorbable mesh closure was used in 41 of 49 patients who failed DPFC (84%). There were 9 patients who had EAF (overall EAF rate 12%), 6 of whom were in the AMC group (EAF rate 15%). The overall and AMC group mortality rates were 29% and 37%, respectively. CONCLUSION Absorbable mesh closure carries high EAF and mortality rates. Therefore, DPFC should be considered as the primary closure method. Absorbable mesh closure should be reserved for patients who fail DPFC, especially those with peritonitis or contamination.
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85
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Kamamoto F, Batista BN, Tokeshi F. New technique for dynamic closure of the abdominal wall. Rev Col Bras Cir 2010; 37:376-8. [PMID: 21181005 DOI: 10.1590/s0100-69912010000500012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 07/20/2010] [Indexed: 11/22/2022] Open
Abstract
Advances in care of trauma patients and severe abdominal infections are responsible for an increasing number of laparostomies. The management of this entity is complex and several techniques have been described for its treatment. Recently the concept of dynamic closure of the abdominal wall was introduced in the literature with high success rates. The objective of this report is to serve as a foreword for a new approach for the treatment of laparostomy developed at the University Hospital of the University of São Paulo. This is a simple and low cost method, easily performed by a general surgeon. The procedure was also used prophylactically as reinforcement in tight abdominal closures. It is described in detail as well as the results in the first patients. Although promising, refinements and further studies are needed to validate the technique.
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Affiliation(s)
- Fabio Kamamoto
- Departamento de Cirurgia, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brazil
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86
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Padalino P, Dionigi G, Minoja G, Carcano G, Rovera F, Boni L, Dionigi R. Fascia-to-Fascia Closure with Abdominal Topical Negative Pressure for Severe Abdominal Infections: Preliminary Results in a Department of General Surgery and Intensive Care Unit. Surg Infect (Larchmt) 2010; 11:523-8. [DOI: 10.1089/sur.2010.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Pietro Padalino
- Department of General Surgery, University of Milano, Monza, Italy
| | | | - Giulio Minoja
- Department of Intensive Care, Ospedale Macchi Varese, Varese, Italy
| | - Giulio Carcano
- Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Francesca Rovera
- Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Luigi Boni
- Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Renzo Dionigi
- Department of Surgical Sciences, University of Insubria, Varese, Italy
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87
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De Waele J, Desender L, De Laet I, Ceelen W, Pattyn P, Hoste E. Abdominal decompression for abdominal compartment syndrome in critically ill patients: a retrospective study. Acta Clin Belg 2010; 65:399-403. [PMID: 21268953 DOI: 10.1179/acb.2010.65.6.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The abdominal compartment syndrome (ACS) refers to organ dysfunction that may occur as a result of increased intra-abdominal pressure (IAP). Successful management may require abdominal decompression and temporary abdominal closure (TAC). The aim of this study was to analyze the characteristics of patients requiring abdominal decompression, to describe the methods used for TAC, and to study the outcome of these patients. METHODS A series of critically ill patients who required abdominal decompression for ACS between January 2000 and March 2007 were reviewed retrospectively. Age, gender, severity of organ dysfunction before decompression and the cause of ACS as well as the type of abdominal closure system and length of ICU-stay were recorded. Definitive abdominal closure and in-hospital mortality were the main outcome parameters. RESULTS Eighteen patients with primary ACS and 6 with secondary ACS required decompressive Laparotomy. Patients' ages ranged from 18 to 89 years (mean 50.7). The median preoperative IAP was 26 mmHg, and IAP decreased to 13 mmHg after decompressive laparotomy. Organ function, as quantified by the SOFA scoring system, improved significantly after the intervention. Eight patients had immediate primary fascial closure after the decompressive procedure and 16 patients required TAC. The majority of the survivors underwent planned ventral hernia repair at a later stage. The mean length of stay in the ICU was 23 (+/- 16) days. Overall, fifteen patients survived (63%). CONCLUSIONS Decompressive Laparotomy was effective in reducing IAP and was associated with an improvement in organ function. In most of the patients, the abdomen could not be closed after decompression, and fascial repair was delayed.
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Affiliation(s)
- J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
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88
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Velmahos GC. Commentary on "vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: a clinical trial". Surgery 2010; 148:954. [PMID: 20951863 DOI: 10.1016/j.surg.2010.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 03/26/2010] [Indexed: 10/18/2022]
Affiliation(s)
- George C Velmahos
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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89
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Abouassaly CT, Dutton WD, Zaydfudim V, Dossett LA, Nunez TC, Fleming SB, Cotton BA. Postoperative neuromuscular blocker use is associated with higher primary fascial closure rates after damage control laparotomy. ACTA ACUST UNITED AC 2010; 69:557-61. [PMID: 20838126 DOI: 10.1097/ta.0b013e3181e77ca4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Failure to achieve fascial primary closure after damage control laparotomy (DCL) is associated with increased morbidity, higher healthcare expenditures, and a reduction in quality of life. The use of neuromuscular blocking agents (NMBA) to facilitate closure remains controversial and poorly studied. The purpose of this study was to determine whether exposure to NMBA is associated a higher likelihood of primary fascial closure. METHODS All adult trauma patients admitted between January 2002 and May 2008 who (1) went directly to the operating room, (2) were managed initially by DCL, and (3) survived to undergo a second laparotomy. Study group (NMBA+): those receiving NMBA in the first 24 hours after DCL. Comparison group (NMBA-): those not receiving NMBA in the first 24 hours after DCL. Primary fascial closure defined as fascia-to-fascia approximation by hospital day 7. RESULTS One hundred ninety-one patients met inclusion (92 in NMBA+ group, 99 in NMBA- group). Although the NMB+ patients were younger (31 years vs. 37 years, p = 0.009), there were no other differences in demographics, severity of injury, or lengths of stay between the groups. However, NMBA+ patients achieved primary closure faster (5.1 days vs. 3.5 days, p = 0.046) and were more likely to achieve closure by day 7 (93% vs. 83%, p = 0.023). After controlling for age, gender, race, mechanism, and severity of injury, logistic regression identified NMBA use as an independent predictor of achieving primary fascial closure by day 7 (OR, 3.24, CI: 1.15-9.16; p = 0.026). CONCLUSIONS Early NMBA use is associated with faster and more frequent achievement of primary fascial closure in patients initially managed with DCL. Patients exposed to NMBA had a three times higher likelihood of achieving primary fascial closure by hospital day 7.
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Affiliation(s)
- Chadi T Abouassaly
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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90
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Abstract
Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.
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91
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Goodman MD, Pritts TA, Tsuei BJ. Development of a novel method of progressive temporary abdominal closure. Surgery 2010; 148:799-805; discussion 805-6. [PMID: 20727561 DOI: 10.1016/j.surg.2010.07.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 07/13/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND This paper describes our experience with a novel method of temporary abdominal closure that permits frequent reassessment of the abdominal contents and progressive reapproximation of the fascial edges without compromising definitive fascial closure outcomes. METHODS We developed a novel method of temporary abdominal closure, which we have named the frequent assessment temporary abdominal closure (FASTAC). The records of patients who underwent planned relaparotomy during 5 years were reviewed. The data collected included patient demographics, indication for operation, number of operations, duration of temporary abdominal closure placement, hospital duration of stay, method of definitive abdominal closure, and subsequent ventral hernia repair. RESULTS One hundred and thirty-three patients underwent 308 temporary abdominal closure placements, including 16 patients who had a FASTAC placed for open abdomen management. FASTAC remained in place for a significantly greater time with more frequent reassessment. Fascial closure techniques were not different in FASTAC patients. FASTAC patients had a significantly greater duration of stay, which suggests selective placement in a more complicated patient population. The materials for frequent assessment temporary abdominal closure cost only $38 compared with $350 for a large piece of Silastic. CONCLUSION FASTAC is a novel, cost-effective method of temporary abdominal closure that allows for frequent bedside intra-abdominal surveillance, maintains abdominal domain, and does not compromise abdominal closure outcomes in the management of the open abdomen.
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Affiliation(s)
- Michael D Goodman
- Department of Surgery, Division of Trauma and Critical Care, University of Cincinnati, Cincinnati, OH 45267, USA.
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92
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Early results after treatment of open abdomen after aortic surgery with mesh traction and vacuum-assisted wound closure. Eur J Vasc Endovasc Surg 2010; 40:60-4. [PMID: 20359914 DOI: 10.1016/j.ejvs.2010.02.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 02/25/2010] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study aimed to describe the use of vacuum-assisted wound closure (VAWC) and mesh traction to repair an open abdomen after aortic surgery. DESIGN Prospective clinical study. MATERIAL AND METHODS From October 2006 to April 2009, nine consecutive patients were treated; seven of the patients received laparostomy following abdominal compartment syndrome (ACS), while two wounds were left open initially. The indication for laparostomy was intra-abdominal pressure (IAP) > 20 mmHg or abdominal perfusion pressure (APP) < 60 mmHg and development of organ failure. V.A.C. therapy (KCI, San Antonio, TX, USA) was initiated with the laparostomy, and supplemented with a fascial mesh after 2 days. The wound was then closed stepwise with mesh traction and VAWC. RESULTS All wounds could be closed following a median interval of 10.5 (range: 6-19) days after laparostomy. A median of four (range: 2-7) dressing changes were performed. One patient died on the seventh postoperative day. Two other patients died 38 and 50 days after final closure, respectively. Left colonic necrosis was seen in two patients while incisional hernia was observed in two patients. Mean follow-up duration was 17 (range: 2-36) months. CONCLUSION VAWC with mesh traction was successful in terms of early delayed primary closure and is a useful tool in the treatment of open abdomen after aortic surgery.
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93
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Pliakos I, Papavramidis TS, Mihalopoulos N, Koulouris H, Kesisoglou I, Sapalidis K, Deligiannidis N, Papavramidis S. Vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: a clinical trial. Surgery 2010; 148:947-53. [PMID: 20227097 DOI: 10.1016/j.surg.2010.01.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2009] [Accepted: 01/21/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Multiple techniques have been introduced to obtain fascial closure for the open abdomen to minimize morbidity and cost of care. We hypothesized that a modification of the vacuum-assisted closure (VAC) technique that provides constant fascial tension and prevents abdominis rectis retraction would facilitate primary fascial closure and reduce morbidity. METHODS In all, 53 patients with severe abdominal sepsis were allocated randomly into 2 groups, and 30 patients were analyzed. In the VAC group, we included patients managed only with the VAC device, whereas the retentions sutured sequential fascial closure (RSSFC) group included patients to whom RSSFC was performed. RESULTS The abdomen was left open for 12 days (P = .0001) with 4.4 ± 1.35 changes per patient for the VAC group (P = .001) and 8 days with 2.87 ± 0.74 dressing changes per patient for the RSSFC group, respectively. Abdominal closure was possible in only 6 patients in the VAC group, whereas for the RSSFC group, abdominal closure was achieved in 14 patients (P = .005). Planned hernia was exclusively decided in patients in the VAC group (P = .001). The hospital stay was 17.53 ± 4.59 days for the VAC group and 11.93 ± 2.05 days for the RSSFC group (P = .0001). The median initial intra-abdominal pressure (IAP) was 12 mm Hg for the VAC group and 16 mm Hg for the RSSFC group (P < .0001). CONCLUSION We demonstrated the superiority of RSSFC compared with the single use of the VAC device. In our opinion, sequential fascial closure can immediately begin when abdominal sepsis is controlled.
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Affiliation(s)
- Ioannis Pliakos
- 3rd Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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94
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Stevens P. Vacuum-assisted closure of laparostomy wounds: a critical review of the literature. Int Wound J 2010; 6:259-66. [PMID: 19719522 DOI: 10.1111/j.1742-481x.2009.00614.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Vacuum-assisted closure (VAC) reduces the burden for carers of laparostomy wounds but evidence from randomised trials is lacking. This review analyses the evidence for the VAC abdominal wound management system (KCI, San Antonio, TX) in the open abdomen. Three prospective studies provide level III evidence that VAC allows delayed primary fascial closure in the majority of these wounds up to 21 days after occurrence, but not where duration of VAC was less than 9 days or if vacuum pack techniques were used in place of VAC. Fistulae occurred in a minority of wounds complicated by multi-organ failure or sepsis and could not be attributed to VAC itself. Two retrospective analyses suggested VAC may reduce re-operation rate and length of stay in complex wounds. Whilst randomised controlled trials remain the gold standard of evidence for effectiveness of health care interventions, contemporaneous level III evidence supports the hypothesis that VAC increases the rate of primary fascial closure. Whilst enterocutaneous fistula formation is reported in the most complex of these wounds, there is no more evidence that these are consequential to as opposed to coincident with VAC use.
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Affiliation(s)
- Philip Stevens
- MRCS(Royal College of Surgeons of England), Department of General Surgery, Nevill Hall Hospital, Abergavenny, UK.
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95
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Temporary implantation of vacuum-assisted closure dressing beneath flaps: a novel adjunctive technique for staged lower extremity wound closure in chronic wounds. CURRENT ORTHOPAEDIC PRACTICE 2010. [DOI: 10.1097/bco.0b013e3181b67500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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96
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Kashuk JL, Cothren CC, Moore EE, Johnson JL, Biffl WL, Barnett CC. Primary repair of civilian colon injuries is safe in the damage control scenario. Surgery 2009; 146:663-8; discussion 668-70. [DOI: 10.1016/j.surg.2009.06.042] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Accepted: 06/06/2009] [Indexed: 11/16/2022]
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97
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Gourgiotis S, Villias C, Benetatos C, Tsakiris A, Parisis C, Aloizos S, Salemis NS. TNP-assisted fascial closure in a patient with acute abdomen and abdominal compartment syndrome. J Wound Care 2009; 18:65-7. [PMID: 19418783 DOI: 10.12968/jowc.2009.18.2.38745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Topical negative pressure was applied to prevent abdominal compartment syndrome in a patient following surgery for an acute abdomen. It delayed fascial closure, protected the underlying bowel and facilitated abdominal re-entry.
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Affiliation(s)
- S Gourgiotis
- Second Surgical Department, 401 General Army Hospital of Athens, Greece.
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98
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Treatment of the open abdomen with the commercially available vacuum-assisted closure system in patients with abdominal sepsis: low primary closure rate. World J Surg 2009; 32:2724-9. [PMID: 18836762 DOI: 10.1007/s00268-008-9762-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Abdominal Vacuum-Assisted Closure (V.A.C.) systems for treatment of open abdomens have been predominantly used for trauma patients with a high primary fascial closure rate. Use of the V.A.C. technique in abdominal sepsis is less well established. METHODS All patients with abdominal sepsis and treatment with the abdominal V.A.C. system between 2004 and 2007 were prospectively assessed. End points were fascial closure, V.A.C.-related morbidity, and quality of life score (SF-36) at follow-up. RESULTS Thirty patients with abdominal sepsis were included in the study. Primary fascial closure was feasible in 10, partial closure in 4, and no closure in 16 patients. Median number of V.A.C. changes was 3 (range, 1-10). Nine patients died. V.A.C.-related morbidity was as follows: two fistulas, three fascial edge necroses, one skin blister, and four prolapses of small bowel between the fascia and foam. Univariate analysis showed no variables influencing primary closure rate or V.A.C.-related morbidity. Mortality was significantly influenced by age (P < 0.001), respiratory failure (P = 0.01), and pneumonia (P = 0.03). At follow-up, V.A.C. patients scored lower in the physical health scores and similar in the mental health scores compared with the normal population. CONCLUSIONS Treatment of the open abdomen in patients with abdominal sepsis with the abdominal V.A.C. system is safe with good long-term quality of life. Primary closure rate in these patients is substantially lower than in trauma patients. Stepwise closure of the fascia during V.A.C. changes should be attempted to avoid additional lateral retraction of fascial edges. V.A.C.-related complications may be avoided with careful surgical technique.
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99
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Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen. World J Surg 2009; 33:199-207. [PMID: 19089494 PMCID: PMC3259401 DOI: 10.1007/s00268-008-9867-3] [Citation(s) in RCA: 189] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background This study was designed to systematically review the literature to assess which temporary abdominal closure (TAC) technique is associated with the highest delayed primary fascial closure (FC) rate. In some cases of abdominal trauma or infection, edema or packing precludes fascial closure after laparotomy. This “open abdomen” must then be temporarily closed. However, the FC rate varies between techniques. Methods The Cochrane Register of Controlled Trials, MEDLINE, and EMBASE databases were searched until December 2007. References were checked for additional studies. Search criteria included (synonyms of) “open abdomen,” “fascial closure,” “vacuum,” “reapproximation,” and “ventral hernia.” Open abdomen was defined as “the inability to close the abdominal fascia after laparotomy.” Two reviewers independently extracted data from original articles by using a predefined checklist. Results The search identified 154 abstracts of which 96 were considered relevant. No comparative studies were identified. After reading them, 51 articles, including 57 case series were included. The techniques described were vacuum-assisted closure (VAC; 8 series), vacuum pack (15 series), artificial burr (4 series), Mesh/sheet (16 series), zipper (7 series), silo (3 series), skin closure (2 series), dynamic retention sutures (DRS), and loose packing (1 series each). The highest FC rates were seen in the artificial burr (90%), DRS (85%), and VAC (60%). The lowest mortality rates were seen in the artificial burr (17%), VAC (18%), and DRS (23%). Conclusions These results suggest that the artificial burr and the VAC are associated with the highest FC rates and the lowest mortality rates.
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100
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Intra-Abdominal Pressure Development After Different Temporary Abdominal Closure Techniques in a Porcine Model. ACTA ACUST UNITED AC 2009; 66:1118-24. [DOI: 10.1097/ta.0b013e3181820d94] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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