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Pepe G, Chiarello MM, Bianchi V, Fico V, Altieri G, Tedesco S, Tropeano G, Molica P, Di Grezia M, Brisinda G. Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy. J Clin Med 2024; 13:1279. [PMID: 38592102 PMCID: PMC10932196 DOI: 10.3390/jcm13051279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients' quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas.
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Affiliation(s)
- Gilda Pepe
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Maria Michela Chiarello
- General Surgery Operative Unit, Department of Surgery, Provincial Health Authority, 87100 Cosenza, Italy;
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Gaia Altieri
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Silvia Tedesco
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Perla Molica
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Marta Di Grezia
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Giuseppe Brisinda
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
- Department of Medicine and Surgery, Catholic School of Medicine “Agostino Gemelli”, Largo Francesco Vito 1, 00168 Rome, Italy
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Roberts DJ, Leppäniemi A, Tolonen M, Mentula P, Björck M, Kirkpatrick AW, Sugrue M, Pereira BM, Petersson U, Coccolini F, Latifi R. The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review. BJS Open 2023; 7:zrad084. [PMID: 37882630 PMCID: PMC10601091 DOI: 10.1093/bjsopen/zrad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/28/2023] [Accepted: 07/28/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery. METHODS A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen. RESULTS The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible. CONCLUSION Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ari Leppäniemi
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matti Tolonen
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Andrew W Kirkpatrick
- TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group, Calgary, Alberta, Canada
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael Sugrue
- Department of Surgery Letterkenny, University Hospital Donegal, Donegal, Ireland
| | - Bruno M Pereira
- Department of Surgery, Masters Program in Health Applied Sciences, Vassouras University, Vassouras, Rio de Janeiro, Brazil
- Department of Surgery, Campinas Holy House General Surgery Residency Program Director, Campinas, Sao Paulo, Brazil
| | - Ulf Petersson
- Department of Surgery, Skane University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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Habeeb TAAM, Hussain A, Shelat V, Chiaretti M, Bueno-Lledó J, García Fadrique A, Kalmoush AE, Elnemr M, Safwat K, Raafat A, Wasefy T, Heggy IA, Osman G, Abdelhady WA, Mawla WA, Fiad AA, Elaidy MM, Amr W, Abdelhamid MI, Abdou AM, Ibrahim AIA, Baghdadi MA. A prospective multicentre study evaluating the outcomes of the abdominal wall dehiscence repair using posterior component separation with transversus abdominis muscle release reinforced by a retro-muscular mesh: filling a step. World J Emerg Surg 2023; 18:15. [PMID: 36869364 PMCID: PMC9985288 DOI: 10.1186/s13017-023-00485-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 02/22/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND This study aimed to evaluate the results of posterior component separation (CS) and transversus abdominis muscle release (TAR) with retro-muscular mesh reinforcement in patients with primary abdominal wall dehiscence (AWD). The secondary aims were to detect the incidence of postoperative surgical site occurrence and risk factors of incisional hernia (IH) development following AWD repair with posterior CS with TAR reinforced by retromuscular mesh. METHODS Between June 2014 and April 2018, 202 patients with grade IA primary AWD (Björck's first classification) following midline laparotomies were treated using posterior CS with TAR release reinforced by a retro-muscular mesh in a prospective multicenter cohort study. RESULTS The mean age was 42 ± 10 years, with female predominance (59.9%). The mean time from index surgery (midline laparotomy) to primary AWD was 7 ± 3 days. The mean vertical length of primary AWD was 16 ± 2 cm. The median time from primary AWD occurrence to posterior CS + TAR surgery was 3 ± 1 days. The mean operative time of posterior CS + TAR was 95 ± 12 min. No recurrent AWD occurred. Surgical site infections (SSI), seroma, hematoma, IH, and infected mesh occurred in 7.9%, 12.4%, 2%, 8.9%, and 3%, respectively. Mortality was reported in 2.5%. Old age, male gender, smoking, albumin level < 3.5 gm%, time from AWD to posterior CS + TAR surgery, SSI, ileus, and infected mesh were significantly higher in IH. IH rate was 0.5% and 8.9% at two and three years, respectively. In multivariate logistic regression analyses, the predictors of IH were time from AWD till posterior CS + TAR surgical intervention, ileus, SSI, and infected mesh. CONCLUSION Posterior CS with TAR reinforced by retro-muscular mesh insertion resulted in no AWD recurrence, low IH rates, and low mortality of 2.5%. Trial registration Clinical trial: NCT05278117.
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Affiliation(s)
- Tamer A A M Habeeb
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt.
| | | | - Vishal Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Massimo Chiaretti
- Department of General Surgery, Surgical Specialities and Organ Transplantation "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Jose Bueno-Lledó
- Unit of Abdominal Wall Surgery, Department of General Surgery, Hospital Universitari i Politècnic la Fe, Valencia, Spain
| | | | | | - Mohamed Elnemr
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Khaled Safwat
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Ahmed Raafat
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Tamer Wasefy
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Ibrahim A Heggy
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Gamal Osman
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Waleed A Abdelhady
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Walid A Mawla
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Alaa A Fiad
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Mostafa M Elaidy
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Wessam Amr
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Mohamed I Abdelhamid
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
| | - Ahmed Mahmoud Abdou
- Obstetrics and Gynecology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Abdelaziz I A Ibrahim
- Obstetrics and Gynecology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Muhammad Ali Baghdadi
- Department of General Surgery, Faculty of Medicine, Zagazig University, 1 Faculty of Medicine Street, Zagazig, Egypt
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Maze Y, Tokui T, Kawaguchi T, Murakami M, Inoue R, Hirano K, Sato K, Tamura Y. Open abdominal management after ruptured abdominal aortic aneurysm repair: from a single-center study in Japan. Surg Today 2022; 53:420-427. [PMID: 35984520 PMCID: PMC10042970 DOI: 10.1007/s00595-022-02574-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/24/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE We investigated the utility of the open abdominal management (OA) technique for ruptured abdominal aortic aneurysm (rAAA). METHODS Between January 2016 and August 2021, 33 patients underwent open surgery for rAAA at our institution. The patients were divided into OA (n = 12) and non-OA (n = 21) groups. We compared preoperative characteristics, operative data, and postoperative outcomes between the two groups. The intensive care unit management and abdominal wall closure statuses of the OA group were evaluated. RESULTS The OA group included significantly more cases of a preoperative shock than the non-OA group. The operation time was also significantly longer in the OA group than in the non-OA group. The need for intraoperative fluids, amount of bleeding, and need for blood transfusion were significantly higher in the OA group than in the non-OA group. Negative pressure therapy (NPT) systems are useful in OA. In five of the six survivors in the OA group, abdominal closure was able to be achieved using components separation (CS) technique. CONCLUSIONS NPT and the CS technique may increase the abdominal wall closure rate in rAAA surgery using OA and are expected to improve outcomes.
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Affiliation(s)
- Yasumi Maze
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan.
| | - Toshiya Tokui
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Teruhisa Kawaguchi
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Masahiko Murakami
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Ryosai Inoue
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Koji Hirano
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital, 1-471-2 Funae, Ise, Mie, 516-8512, Japan
| | - Keita Sato
- Department of Surgery, Ise Red Cross Hospital, Ise, Mie, Japan
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Fung S, Ashmawy H, Krieglstein C, Halama T, Schilawa D, Fuckert O, Hees A, Kröpil F, Rehders A, Lehwald-Tywuschik NC, Knoefel WT. Vertical traction device prevents abdominal wall retraction and facilitates early primary fascial closure of septic and non-septic open abdomen. Langenbecks Arch Surg 2022; 407:2075-2083. [PMID: 35147749 PMCID: PMC8832079 DOI: 10.1007/s00423-021-02424-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/23/2021] [Indexed: 12/04/2022]
Abstract
Purpose One of the major challenges in the management of patients with septic and non-septic open abdomen (OA) is to control abdominal wall retraction. The aim of this study was to evaluate the impact of a novel vertical traction device (VTD) on primary fascial closure (PFC) and prevention of fascial retraction. Methods Twenty patients treated with OA were included in this retrospective multicenter study. All patients were initially stabilized with laparostomy and the abdomen temporarily sealed either with a Bogotá bag or a negative pressure wound therapy system (NPWT). Results The mean duration of OA and fascia-to-fascia distance (FTF) prior to the VTD application were 3 days and 15 cm, respectively. At relook laparotomy 48 h after VTD implementation, the mean FTF distance significantly decreased to 10 cm (p = 0.0081). In all cases, PFC was achieved after a mean period of 7 days. Twelve patients received the VTD in combination with a NPWT, whereas in eight patients, the device was combined with an alternative temporary abdominal closure system (TAC). Although not statistically significant, the FTF distance remarkably decreased in both groups at relook laparotomy 48 h following the device implementation. The mean periods of PFC for patients with septic and non-septic OA were comparable (7.5 vs. 7 days). During follow-up, two patients developed an incisional hernia. Conclusion Vertical traction device prevents fascial retraction and facilitates early PFC in OA. In combination with NPWT, rapid fascial closure of large abdominal defects can be achieved.
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Affiliation(s)
- Stephen Fung
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Hany Ashmawy
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Christian Krieglstein
- Department of Surgery, St. Elisabeth Krankenhaus Köln, Werthmannstr. 1, 50935 Cologne, Germany
| | - Thomas Halama
- Department of Surgery, St. Vinzenz-Hospital, Merheimer Str. 221-223, 50733 Cologne, Germany
| | - Dustin Schilawa
- Department of Surgery, St. Rochus Krankenhaus, Glückaufstraße 10, 44575 Castrop-Rauxel, Germany
| | - Oliver Fuckert
- Department of Surgery, Lukas Krankenhaus, Hindenburgstraße 56, 32257 Bünde, Germany
| | - Anita Hees
- Department of Surgery, St.-Marien Krankenhaus, Kampenstraße 51, 57072 Siegen, Germany
| | - Feride Kröpil
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Alexander Rehders
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Nadja C. Lehwald-Tywuschik
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
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Akashi Y, Ogawa K, Sasaki K, Kim J, Enomoto T, Hisakura K, Ohara Y, Owada Y, Takahashi K, Shimomura O, Hashimoto S, Sekido M, Oda T. Delayed primary fascia closure of Björck grade 4 open abdomen with enteroatmospheric fistulas after repeated surgery for adhesive small bowel obstruction: a case report. BMC Surg 2021; 21:333. [PMID: 34452624 PMCID: PMC8394647 DOI: 10.1186/s12893-021-01329-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An open abdomen with frozen adherent bowels is classified as grade 4 in Björck's open abdomen classification, and skin grafting after wound granulation is a typical closure option. We achieved delayed primary fascia closure for a patient who developed open abdomen with enteroatmospheric fistulas due to severe adherent small bowel obstruction. We present here the details of his management. CASE PRESENTATION A 52-year-old man suffered acute abdominal pain during a flight and received an emergency laparotomy due to adhesive small bowel obstruction. Repeated laparotomies were required, and later open abdomen and proximal site jejunostomy were selected. After negative pressure wound therapy, he was transferred to our institution. Two enteroatmospheric fistulas emerged on the exposed intestine, and we diagnosed the condition as a Björck grade 4 open abdomen. After 8 months of wound care and parenteral nutrition, we decided to attempt primary wound closure because the patient required permanent oral restriction and total parenteral nutrition due to short bowel syndrome. A circular incision along the circumference of the exposed bowel allowed us to take a safe approach into the abdominal cavity. We removed the intestinal adhesions completely and resected the bowels, including the fistulas and anastomosed parts. Finally, the abdominal wall defect was reconstructed using the component separation technique, and the patient was discharged without an ostomy. CONCLUSIONS Primary fascia closure for grade 4 open abdomen is hard, but leaving a long interval before radical surgery and applying pertinent wound management may help solve this adverse situation.
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Affiliation(s)
- Yoshimasa Akashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan.
| | - Koichi Ogawa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Kaoru Sasaki
- Department of Plastic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Jaejeong Kim
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Katsuji Hisakura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Yusuke Ohara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Yohei Owada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Kazuhiro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Osamu Shimomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Shinji Hashimoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Mitsuru Sekido
- Department of Plastic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
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7
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Sobocki J, Jackowski M, Dziki A, Tarnowski W, Banasiewicz T, Kunecki M, Słodkowski M, Stanisławski M, Zaczek Z, Richer P, Matyja A, Frączek M, Wallner G. Clinical guidelines for the management of gastrointestinal fistula
– developed by experts of the Polish Surgical Society. POLISH JOURNAL OF SURGERY 2021. [DOI: 10.5604/01.3001.0015.0499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction: Gastrointestinal fistula is one of the most difficult problems in gastrointestinal surgery. It is associated with high morbidity and mortality, numerous complications, prolonged hospitalization, and high cost of treatment. </br>Aim: This project aimed to develop recommendations for the treatment of gastrointestinal fistulas, based on evidence-based medicine and best clinical practice to reduce treatment-related mortality and morbidity. </br>Material and methods: The preparation of these recommendations is based on a review of the literature from the PubMed, Medline, and Cochrane Library databases from 1.01.2010 to 31.12.2020, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations in the form of a directive were formulated and assessed using the Delphi method. </br>Results and conclusions: Nine recommendations were presented along with a discussion and comments of experts. Treatment should be managed by a multidisciplinary team (surgeon, anesthetist, clinical nutritionist/dietician, nurse, pharmacist, endoscopist).
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Affiliation(s)
- Jacek Sobocki
- Department of General Surgery and Clinical Nutrition, Postgraduate Medical Education Center, Warsaw, Poland; Head: Jacek Sobocki MD PhD, CMPK Professor
| | - Marek Jackowski
- Department of General Surgery, Gastrointestinal Surgery and Surgical Oncology, Collegium Mediucm at the Nicolaus Copernicus University in Torun, Poland; Head: prof. Marek Jackowski MD PhD
| | - Adam Dziki
- Department of General and Colorectal Surgery, Medical University of Lodz, Poland; Head: prof. Adam Dziki MD PhD
| | - Wiesław Tarnowski
- Department of General Surgery, Gastrointestinal Surgery and Surgical Oncology, Postgraduate Medical Education Center, Warsaw, Poland; Head: prof. Wiesław Tarnowski MD PhD
| | - Tomasz Banasiewicz
- Department of General Surgery, Endocrine Surgery and Gastrointestinal Oncology, Institute of Surgery, Poznan University of Medical Sciences, Poland; Head: prof. Tomasz Banasiewicz MD PhD
| | - Marek Kunecki
- General and Vascular Surgery Unit, Center for Nutritional Therapy, M. Pirogow Regional Specialist Hospital, Lodz, Poland; Head: Marek Kunecki MD PhD
| | - Maciej Słodkowski
- Department of General Surgery, Gastrointestinal Surgery and Surgical Oncology, Medical University of Warsaw, Poland; Head: Maciej Słodkowski MD PhD
| | - Michał Stanisławski
- Department of General Surgery and Clinical Nutrition, Postgraduate Medical Education Center, Warsaw, Poland; Head: Jacek Sobocki MD PhD, CMPK Professor
| | - Zuzanna Zaczek
- Department of General Surgery and Clinical Nutrition, Postgraduate Medical Education Center, Warsaw, Poland; Head: Jacek Sobocki MD PhD, CMPK Professor
| | - Piotr Richer
- Department and Clinical Unit of General Surgery, Gastrointestinal Surgery and Transplantology, Jagiellonian University Medical College, Cracow, Poland; Head: prof. Piotr Richter MD PhD
| | - Andrzej Matyja
- II Department of Surgery, Clinical Unit of General Surgery, Surgical Oncology, Metabolic Surgery and Emergency Surgery, Jagiellonian University Medical College, Cracow, Poland; Head: prof. Andrzej Matyja, MD PhD
| | - Mariusz Frączek
- II Department and Clinic of General Surgery, Vascular Surgery and Surgical Oncology at the Medical University of Warsaw, Poland; Head: prof. Mariusz Frączek MD PhD
| | - Grzegorz Wallner
- II Department and Clinic of General Surgery, Gastrointestinal Surgery and Gastrointestinal Neoplasia, Medical University of Lublin, Poland; Head: prof. Grzegorz Wallner MD PhD
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8
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Should Negative Pressure Therapy Replace Any Other Temporary Abdominal Closure Device in Open-Abdomen Management of Secondary Peritonitis? Surg Technol Int 2021. [PMID: 33844240 DOI: 10.52198/21.sti.38.gs1386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To clarify the advantages of negative pressure therapy (NPT) compared to other methods of temporary abdominal closure (TAC) in the management of secondary peritonitis. METHODS We retraced the history of known methods of TAC, and analyzed their advantages and disadvantages. We evaluated as the NPT mechanisms, both from the macroscopic that bio-molecular point of view, well suits to manage this difficult condition. RESULTS The ideal TAC technique should be quick to apply, easy to change, protect and contain the abdominal viscera, decrease bowel edema, prevent loss of domain and abdominal compartment syndrome, limit contamination, allow egress of peritoneal fluid (and its estimation) and not result in adhesions. It should also be cost-effective, minimize the number of dressing changes and the number of surgical revisions, and ensure a high rate of early closure with a low rate of complications (especially entero-atmospheric fistula). For NPT, the reported fistula rate is 7%, primary fascial closure ranges from 33 to 100% (average 60%) and the mortality rate is about 20%. With the use of NPT as TAC, it may be possible to extend the window of time to achieve primary fascial closure (for up to 20-40 days). CONCLUSION NPT has several potential advantages in open-abdomen (OA) management of secondary peritonitis and may make it possible to achieve all the goals suggested above for an ideal TAC system. Only trained staff should use NPT, following the manufacturer's instructions when commercial products are used. Even if there was a significant evolution in OA management, we believe that further research into the role of NPT for secondary peritonitis is necessary.
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9
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Berrevoet F, Lampaert S, Singh K, Jakipbayeva K, van Cleven S, Vanlander A. Early Initiation of a Standardized Open Abdomen Treatment With Vacuum Assisted Mesh-Mediated Fascial Traction Achieves Best Results. Front Surg 2021; 7:606539. [PMID: 33634162 PMCID: PMC7900519 DOI: 10.3389/fsurg.2020.606539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/10/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Complete fascial closure is an essential treatment objective and can be achieved by the use of different dynamic closure techniques. Both surgical technique and-decision making are essential for optimal patient outcome in terms of fascial closure. The aim of this study was to analyse patients' outcome after the use of mesh-mediated fascial traction (MMFT) associated with negative pressure wound therapy (NPWT) and identify important factors that negatively influenced final fascial closure. Methods: A single center ambispective analysis was performed including all patients treated for an open abdomen in a tertiary referral center from 3/2011 till 2/2020. All patients with a minimum survival >24 h after initiation of treatment were analyzed. The data concerning patient management was collected and entered into the Open Abdomen Route of the European Hernia Society (EHS). Patient basic characteristics considering OA indication, primary fascial closure, as well as important features in surgical technique including time after index procedure to start mesh mediated fascial traction, surgical closure techniques and patients' long-term outcomes were analyzed. Results: Data were obtained from 152 patients who underwent open abdomen therapy (OAT) in a single center study. Indications for OAT as per-protocol analysis were sepsis (33.3%), abdominal compartment syndrome (31.6%), followed by peritonitis (24.2%), abdominal trauma (8.3%) and burst abdomen (2.4%). Overall fascial closure rate was 80% as in the per-protocol analysis. When patients that started OA management with MMFT and NPWT from the initial surgery a significantly better fascial closure rate was achieved compared to patients that started 3 or more days later (p < 0.001). An incisional hernia developed in 35.8% of patients alive with a median follow-up of 49 months (range 6-96 months). Conclusion: Our main findings emphasize the importance of a standardized treatment plan, initiated early on during management of the OA. The use of vacuum assisted closure in combination with MMFT showed high rates of fascial closure. Absence of initial intraperitoneal NPWT as well as delayed start of MMFT were risk factors for non-fascial closure. Initiation of OA with VACM should not be unnecessary delayed.
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Affiliation(s)
- Frederik Berrevoet
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Silvio Lampaert
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Kashika Singh
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Kamilya Jakipbayeva
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Stijn van Cleven
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Aude Vanlander
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
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10
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Auer T, Sauseng S, Delcev P, Kohek P. Effect of Negative Pressure Therapy on Open Abdomen Treatments. Prospective Randomized Study With Two Commercial Negative Pressure Systems. Front Surg 2021; 7:596056. [PMID: 33614699 PMCID: PMC7894571 DOI: 10.3389/fsurg.2020.596056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/29/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction: The use of negative pressure dressings for open abdominal therapy has made a great impact on strategies for open abdominal treatment. Observed intestinal damage and developement of fistula formation raises questions about safety of commonly used systems (AB-Thera). The most common used system uses foils for shielding intestines directly from negative pressure. As an alternative a system with open pore dressing in double layer film was introduced (Suprasorb CNP) and proved to safe in animal studies. We compared the effects of this two systems on patients requiring open abdominal treatment. Materials and methods: Patients with secondary peritonitis in at least two abdominal quadrants were included in this randomized study. Inclusion criteria were secondary peritonitis (ACS), abdominal compartment syndrome, and abdominal trauma combined with ACS and/or contaminated abdomen. Patients with active bleeding and pancreatitis were not included. We examined Mannheim peritonitis Index (MPI), bloodcount, PCT, amount of fluid collected, and morphological changes on the bowel. Data were collected on day 2, 4, 7, 14, 21, and 28. Primary end point was fascial closure. Examination was terminated in case of death and damage to the abdominal organs. Groups were compared using Mann Whitney U-test and chi square test. Trend evaluation was evaluated using an one way repeated measure analysis of variance. P-values below 0.05 was considered significat. Results: Thirty four patients were included between August 2010 and September 2012. There were no significant difference between two groups in MPI, age, and gender. Mean duration of treatment, WBC, CRP, and abdominal closure rate were not significantly different between groups. Suprasorb CNP System collected twice more fluid than AB-Thera and decreased PCT on significantly faster rate than AB-Thera. Four patients died (11%) and four patients developed enteric fistula (11%). Closure rate was achieved in 27 out of 34 Patients (79.5%). Closure rate was not significantly different between groups. Conclusion: The use of both systems proved to be efficient and safe. The application of well-dosed, moderate negative pressure on contaminated areas of the abdomen seems to have a lot of potential and it is worth directing greater research potential in this direction.
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Affiliation(s)
- Thomas Auer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Siegfried Sauseng
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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11
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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12
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Hofmann AT, May C, Glaser K, Fortelny RH. Delayed Closure of Open Abdomen in Septic Patients Treated With Negative Pressure Vacuum Therapy and Dynamic Sutures: A 10-Years Follow-Up on Long-Term Complications. Front Surg 2021; 7:611905. [PMID: 33521047 PMCID: PMC7844391 DOI: 10.3389/fsurg.2020.611905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/07/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction: Patients with open abdomen after surgical interventions associated with the complication of secondary peritonitis are successfully treated with negative pressure wound therapy. The use of dynamic fascial sutures reduces fascial lateralization and increases successful delayed fascial closure after open abdomen treatment. Methods: In 2017 we published the follow-up results of 38 survivors out of 87 open abdomen patients treated with negative pressure wound therapy and dynamic fascial sutures between 2007 and 2012. In our current study we present the 10-years follow-up results regarding long-term complications with the focus on incisional hernias and pain. Since 2017 seven more patients have died, hence 31 patients were included in the current study. The patients were asked to answer questions about specific long-term complications of OA treatment including pain, the presence of incisional hernias and subsequent surgical interventions. Demographic data and data regarding fascial closure after open abdomen treatment were collected. All results were analyzed quantitatively. The follow-up period was 8–13 years. Results: The median age was 69 (30–90) years, and 15 (48.4%) were females. Twenty-four patients (77.4%) responded to the questionnaire: Three patients (12.5%) suffered from pain in the original operating field, all three at rest but not during exercise. None of the patients required analgesic treatment. Eleven patients (45.8%) were found to have incisional hernias. Five out of 11 hernias (45.5%) were treated by surgery and did not declare any pain in the operating field. Among the patients with incisional hernias lower MPI (Mannheimer Peritonitis Index) at the time of primary surgery but more reoperations and treatment days were found. The technique of fascial closure was heterogenic and no differences in the occurrence of incisional hernia could be detected. Conclusion: The incidence of incisional hernias after open abdomen treatment is still high, but are associated with little pain in the original operating field. Further studies are required to investigate methods for fascial closure techniques after OA treatment.
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Affiliation(s)
- Anna Theresa Hofmann
- Department of General, Visceral and Oncological Surgery, Klinik Ottakring, Vienna, Austria
| | - Christopher May
- Department of General, Visceral and Oncological Surgery, Klinik Ottakring, Vienna, Austria
| | - Karl Glaser
- Department of General, Visceral and Oncological Surgery, Klinik Ottakring, Vienna, Austria
| | - René H Fortelny
- Department of General, Visceral and Oncological Surgery, Klinik Ottakring, Vienna, Austria.,Medical Faculty, Sigmund Freud Private University, Vienna, Austria
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13
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Willms AG, Schwab R, von Websky MW, Berrevoet F, Tartaglia D, Sörelius K, Fortelny RH, Björck M, Monchal T, Brennfleck F, Bulian D, Beltzer C, Germer CT, Lock JF. Factors influencing the fascial closure rate after open abdomen treatment: Results from the European Hernia Society (EuraHS) Registry : Surgical technique matters. Hernia 2020; 26:61-73. [PMID: 33219419 PMCID: PMC8881440 DOI: 10.1007/s10029-020-02336-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/02/2020] [Indexed: 01/09/2023]
Abstract
Purpose Definitive fascial closure is an essential treatment objective after open abdomen treatment and mitigates morbidity and mortality. There is a paucity of evidence on factors that promote or prevent definitive fascial closure. Methods A multi-center multivariable analysis of data from the Open Abdomen Route of the European Hernia Society included all cases between 1 May 2015 and 31 December 2019. Different treatment elements, i.e. the use of a visceral protective layer, negative-pressure wound therapy and dynamic closure techniques, as well as patient characteristics were included in the multivariable analysis. The study was registered in the International Clinical Trials Registry Platform via the German Registry for Clinical Trials (DRK00021719). Results Data were included from 630 patients from eleven surgical departments in six European countries. Indications for OAT were peritonitis (46%), abdominal compartment syndrome (20.5%), burst abdomen (11.3%), abdominal trauma (9%), and other conditions (13.2%). The overall definitive fascial closure rate was 57.5% in the intention-to-treat analysis and 71% in the per-protocol analysis. The multivariable analysis showed a positive correlation of negative-pressure wound therapy (odds ratio: 2.496, p < 0.001) and dynamic closure techniques (odds ratio: 2.687, p < 0.001) with fascial closure and a negative correlation of intra-abdominal contamination (odds ratio: 0.630, p = 0.029) and the number of surgical procedures before OAT (odds ratio: 0.740, p = 0.005) with DFC. Conclusion The clinical course and prognosis of open abdomen treatment can significantly be improved by the use of treatment elements such as negative-pressure wound therapy and dynamic closure techniques, which are associated with definitive fascial closure. Electronic supplementary material The online version of this article (10.1007/s10029-020-02336-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A G Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - R Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - M W von Websky
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital of Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - F Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - D Tartaglia
- Emergency Surgery Unit, Cisanello University Hospital, Via Paradisa 1, 56124, Pisa, Italy
| | - K Sörelius
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - R H Fortelny
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, 1160, Vienna, Austria.,Medical Faculty, Sigmund Freud University of Vienna, 1020, Vienna, Austria
| | - M Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, SE 751 85, Uppsala, Sweden
| | - T Monchal
- Department of General Surgery, Sainte Anne Military Hospital, 2 Boulevard Sainte-Anne, 83000, Toulon, France
| | - F Brennfleck
- Department of Surgery, Regensburg University Hospital, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - D Bulian
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - C Beltzer
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Hospital of Ulm, Oberer Eselsberg, Ulm, Germany
| | - C T Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - J F Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
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14
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Freund MR, Reissman P, Spira RM, Topaz M. Innovative approach to open abdomen: converting an enteroatmospheric fistula into an easily manageable stoma. BMJ Case Rep 2020; 13:13/8/e234207. [PMID: 32847870 PMCID: PMC7451951 DOI: 10.1136/bcr-2019-234207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
A 52-year-old super morbidly obese patient underwent elective laparoscopic conversion of a failed silastic ring vertical gastroplasty to a Roux-en-Y gastric bypass. Following surgery, she developed an anastomotic leak which required emergent laparotomy. The patient then suffered from a complex postoperative course during which she developed an intestinal fistula which freely drained into the wound and gradually led to its complete dehiscence. Her course was further complicated by the surfacing of an enteroatmospheric fistula. This devastating complication was managed by employing the TopClosure Tension Relief system. Using the inverse maturation technique, further described in this report, we were able to progressively approximate and invert the edges of the skin around the enteroatmospheric fistula, thereby facilitating its conversion to an easily manageable stoma. Using this technique, we were able to achieve delayed primary wound closure of a grade 4 open abdomen complicated by an enteroatmospheric fistula in just under 5 weeks' time.
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Affiliation(s)
- Michael Ron Freund
- Department of General Surgery, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Petachia Reissman
- Department of General Surgery, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Ram M Spira
- Department of General Surgery, Shaare Zedek Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
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15
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Clark JM, Cheatham ML, Safcsak K, Alban RF. Effects of Race and Insurance on Outcomes of the Open Abdomen. Am Surg 2020. [DOI: 10.1177/000313481307900932] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent studies have suggested improved outcomes in surgical patients with healthcare insurance, whereas several others have noted disparities in access to health care, the care provided, and the aftercare of uninsured patients. Several different strategies exist in the management and prevention of the open abdomen secondary to abdominal compartment syndrome. To date, no study has evaluated the effects of race and insurance in patients with an open abdomen (OA). A retrospective review from our OA database was queried. All patients with an OA from January 2002 to December 2010 were included for analysis. Data analyzed included patients’ demographics, race, insurance status, hospital charges, Injury Severity Scores, and outcomes. Insured patients were identified and compared with their uninsured counterparts. A total of 720 patients were treated for an OA during the study period. Of these, 273 (37.9%) died within their hospital stay. Patients who died were noted to be older and sicker with higher Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiologic Scores (27.6 vs 18.2, P < 0.001 and 54.6 vs 38.5, P < 0.001, respectively). Logistic regression analysis revealed that age, APACHE II, and Injury Severity Scores were independently associated with mortality. From our categorical variables, race was not associated with worse outcomes. In addition, being uninsured was significantly associated with increased mortality (odds ratio, 1.67; 95% confidence interval, 1.1 to 2.6; P = 0.05). “Self-pay” status was associated with increased mortality even after adjusting for severity of illness. Further studies incorporating baseline comorbidities need to be undertaken to further assess the reasons for these disparities.
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Affiliation(s)
- Jason M. Clark
- From Orlando Health–Surgical Education, Orlando, Florida
| | | | - Karen Safcsak
- From Orlando Health–Surgical Education, Orlando, Florida
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16
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Li X, Wei J, Zhang Y, Wang W, Wu G, Zhao Q, Li X. Open abdomen treatment for complicated intra-abdominal infection patients with gastrointestinal fistula can reduce the mortality. Medicine (Baltimore) 2020; 99:e19692. [PMID: 32311946 PMCID: PMC7220662 DOI: 10.1097/md.0000000000019692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
To evaluate the effect of the open abdomen (OA) and closed abdomen (CA) approaches for treating intestinal fistula with complicated intra-abdominal infection (IFWCIAI), and analyze the risk factors in OA treatment.IFWCIAI is associated with high mortality rates and healthcare costs, as well as longer postoperative hospital stay. However, OA treatment has also been linked with increased mortality and development of secondary intestinal fistula.A total of 195 IFWCIAI patients who were operated over a period of 7 years at our hospital were retrospectively analyzed. These patients were divided into the OA group (n = 112) and CA group (n = 83) accordingly, and the mortality rates, hospital costs, and hospital stay duration of both groups were compared. In addition, the risk factors in OA treatment were also analyzed.OA resulted in significantly lower mortality rates (9.8% vs 30.1%, P < .001) and hospital costs ($11721.40 ± $9368.86 vs $20365.36 ± $21789.06, P < .001) compared with the CA group. No incidences of secondary intestinal fistula was recorded and the duration of hospital stay was similar for both groups (P = .151). Delayed OA was an independent risk factor of death following OA treatment (hazard ratio [HR] = 1.316; 95% confidence interval [CI] = 1.068-1.623, P = .010), whereas early enteral nutrition (EN) exceeding 666.67 mL was a protective factor (HR = 0.996; 95% CI = 0.993-0.999, P = .018). In addition, Acinetobacter baumannii, Pseudomonas aeruginosa, and Candida albicans were the main pathogens responsible for the death of patients after OA treatment.OA decreased mortality rates and hospital costs of IFWCIAI patients, and did not lead to any secondary fistulas. Early OA and EN also reduced mortality rates.
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Affiliation(s)
- Xuzhao Li
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University
- Department of General surgery, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, 750002, Ningxia Hui Autonomous Region, China
| | - Jiangpeng Wei
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University
| | - Ying Zhang
- Department of Radiotherapy, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi
| | - Weizhong Wang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University
| | - Guosheng Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University
| | - Qingchuan Zhao
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University
| | - Xiaohua Li
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University
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17
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Gross DJ, Smith MC, Zangbar-Sabegh B, Chao K, Chang E, Boudourakis L, Muthusamy M, Roudnitsky V, Schwartz T. Challenge of uncontrolled enteroatmospheric fistulas. Trauma Surg Acute Care Open 2020; 4:e000381. [PMID: 32072014 PMCID: PMC6996786 DOI: 10.1136/tsaco-2019-000381] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/18/2019] [Accepted: 12/08/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction With the popularization of damage control surgery and the use of the open abdomen, a new permutation of fistula arose; the enteroatmospheric fistula (EAF), an opening of exposed intestine spilling uncontrollably into the peritoneal cavity. EAF is the most devastating complication of the open abdomen. We describe and analyze a single institution’s experience in controlling high-output EAFs in patients with peritonitis. Methods We analyzed 189 consecutive procedures to achieve and maintain definitive control of 24 EAFs in 13 patients between 2006 and 2017. EAFs followed surgery for either trauma (seven patients) or non-traumatic abdominal conditions (six patients). All procedures were mapped onto an operative timeline and analyzed for: success in achieving definitive control, number of reoperations, and feasibility of bedside procedures in the surgical intensive care unit. The end point was controlled enteric drainage through a healed abdominal wound. Results There was a mean delay of 8.5 days (range 2–46 days) from the index operation until the EAF was identified. Most EAFs required several attempts (mean: 2.7 per patient, range 1–7) until definitive control was achieved. Multiple reoperations were then required to maintain control (mean: 13). While the most effective techniques were endoscopic (1) and proximal diversion (1), these were applicable only in select circumstances. A ‘floating stoma’ where the fistula edges are sutured to an opening in a temporary closure device, while technically effective, required multiple reoperations. Tube drainage through a negative pressure dressing (tube vac) required the most maintenance usually through bedside procedures. Primary closure almost always failed. Twelve of the 13 patients survived. Conclusion An EAF is a highly complex surgical challenge. Successful source control of the potentially lethal ongoing peritonitis requires tenacity and tactical flexibility. The appropriate control technique is often found by trial and error and must be creatively tailored to the individual circumstances of the patient.
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Affiliation(s)
- Daniel Jonathan Gross
- Surgery, State University of New York Downstate Medical Center, Brooklyn, New York, USA
| | - Michael C Smith
- Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Kenneth Chao
- Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, New York, USA
| | - Erin Chang
- Surgery, State University of New York Downstate Medical Center, Brooklyn, New York, USA
| | | | | | | | - Tim Schwartz
- Surgery, Kings County Hospital Center, Brooklyn, New York, USA
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Dynamic closure techniques for treatment of an open abdomen: an update. Hernia 2020; 24:325-331. [PMID: 32020342 DOI: 10.1007/s10029-020-02130-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/27/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain as it is associated with a high incidence of complications and poor outcomes. The objective is to perform a systematic review on dynamic closure techniques for fascial closure during open abdomen management. METHODS An electronic database search was conducted involving 4 different databases (MEDLINE (PubMed), SCOPUS, WEB OF SCIENCE (WOS) and EMBASE). All studies that described dynamic closure techniques in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest. RESULTS Thirteen studies were included in the final synthesis. Overall methodological quality was low with a high number of retrospective observational studies and low number of patients. All included studies are observational cohort studies. No studies reported on the use of either Wittmann patch, dynamic retention sutures or ABRA system. Two studies reported on the ABRA system in combination with Negative Pressure Wound Therapy (NPWT), while 9 reported on mesh-mediated fascial traction (MMFT) combined with NPWT. Other types of fascial traction, either by dynamic suture lines or by a self-made silastic tube system, and NPWT were reported in 2 studies. Overall closure rates are 93.2% for the ABRA system + NPWT versus 72.0% for the mesh-mediated fascial traction + NPWT. CONCLUSION Careful selection and good management of OA patients will avoid prolonged treatment and facilitate early fascial closure. Future research should focus on comparison of different temporary dynamic closure techniques to evolve toward best treatment options, in terms of both fascial closure rates and long-term incisional hernia rates.
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Novel method for delayed primary closure and incisional hernia prevention in open abdomen: COmbined and MOdified Definitive Abdominal wall closure (COMODA). Hernia 2019; 24:395-401. [PMID: 30968285 DOI: 10.1007/s10029-019-01948-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Intended open abdomen is an option in cases of trauma and non-trauma patients. Nevertheless, after primary closure, incisional hernia rate is high. We describe a novel method, called COmbined and MOdified Definitive Abdominal closure (COMODA), a delayed primary closure which prevents incisional hernia. METHODS A negative pressure wound therapy system is combined with a condensed polytetrafluoroethylene (cPTFE) mesh. TRIAL REGISTRATION ISRCTN72678033. RESULTS Ten male patients with a median age of 68.8 (43-87) years were included. Primary closure rate was 100% per protocol. The median number of procedures per patient was 5.7 (5-9). Primary closure was obtained in 20.8 (10-32) days and median hospital stay was 36.3 (18-52) days. Only one patient developed incisional hernia during a median follow-up of 27 (8-60) months. CONCLUSION COMODA method allows for a high rate of delayed primary closure. It is safe and decreases the risk for developing an incisional hernia. However, a large number of patients are needed to support this conclusion.
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Coco D, Leanza S. Systematic Review of Laparostomy/Open Abdomen to Prevent Acute Compartimental Syndrome (ACS). MAEDICA 2018; 13:179-182. [PMID: 30568736 DOI: 10.26574/maedica.2018.13.3.179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Laparostomy is defined as a surgical technique in which the peritoneal cavity is opened and left open, called "open abdomen" (OA). An open abdomen presents numerous challenges for the clinician. Specific pathologies like severe intraabdominal sepsis, trauma requiring damage control, abdominal compartment syndrome, staged abdominal repair and other complex abdominal pathologies can be managed with laparostomy. Laparostomy allows abdominal re-exploration, clearing and control of abdominal fluid of the fascia, avoiding intra-abdominal hypertension (IAH), abdominal wall closure.
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Petersson P, Montgomery A, Petersson U. Vacuum-Assisted Wound Closure and Permanent Onlay Mesh-Mediated Fascial Traction: A Novel Technique for the Prevention of Incisional Hernia after Open Abdomen Therapy Including Results From a Retrospective Case Series. Scand J Surg 2018; 108:216-226. [PMID: 30574843 DOI: 10.1177/1457496918818979] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Incisional hernia development is a frequent long-term sequel after open abdomen treatment. This report describes a novel technique, the vacuum-assisted wound closure and permanent onlay mesh-mediated fascial traction for temporary and final closure of the open abdomen, with the intention to decrease incisional hernia rates. Primary aim was to evaluate incisional hernia development and secondary aims to describe short-term complications and patient-reported outcome. MATERIALS AND METHODS The basics of the technique is an onlay mesh, applied early during open abdomen treatment by suturing to the fascia in two rows with a 3- to 4-cm overlap from the midline incision, used for traction and kept for reinforced permanent closure. A retrospective case series, including chart review, evaluation of computed tomography/ultrasound images, and an out-patient clinical examination were performed. The patients were asked to answer a modified version of the ventral hernia pain questionnaire. RESULTS A total of 11 patients were treated with vacuum-assisted wound closure and permanent onlay mesh-mediated fascial traction with median follow-up of 467 days. Fascial closure rate was 100% and 30 day mortality 0%. Two of nine patients, eligible for incisional hernia follow-up, developed a hernia. Neither of the hernias were symptomatic nor clinically detectable. Six of 10 patients eligible for short-term follow-up had a prolonged wound-healing time exceeding 3 weeks. One of seven patients eligible for patient-reported outcome have had pain during the last week. CONCLUSION The vacuum-assisted wound closure and permanent onlay mesh-mediated fascial traction is a promising new technique for open abdomen treatment and reinforced fascial closure. The results of the first 11 patients treated with this technique show a low incisional hernia rate with manageable short-term wound complications and few patient-reported disadvantages.
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Affiliation(s)
- P Petersson
- 1 Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Lund, Sweden.,2 Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - A Montgomery
- 1 Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Lund, Sweden.,2 Department of Surgery, Skåne University Hospital, Malmö, Sweden
| | - U Petersson
- 1 Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Lund, Sweden.,2 Department of Surgery, Skåne University Hospital, Malmö, Sweden
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Alvarez PS, Betancourt AS, Fernández LG. Negative Pressure Wound Therapy with Instillation in the Septic Open Abdomen Utilizing a Modified Negative Pressure Therapy System. Ann Med Surg (Lond) 2018; 36:246-251. [PMID: 30568791 PMCID: PMC6287374 DOI: 10.1016/j.amsu.2018.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 10/04/2018] [Accepted: 10/06/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Various treatment modalities are utilized to treat the open abdomen. The use of negative pressure wound therapy(NPWT)has been a great advancement and has become the preferred modality for temporary abdominal closure technique (TAC). Programmed instillation of the abdominal cavity with saline solution in conjunction with a commercial negative pressure system showed positive results in the management of severe abdominal sepsis in patients that were treated with an open abdomen. Severe abdominal sepsis continues to be an oftendifficult clinical problem for the general surgeon. The use of an open abdomen technique in this setting and the ideal TAC method continue to be debated. The failure to understand the biomechanical features/limitations of negative pressure devices are often contributing factors associated with therapeutic failures reported in the literature. OBJECTIVES To describe the underlying principles behind negative pressure wound therapy with instillation in the context of abdominal sepsis, as well as its optimal usage in these conditions. METHODS A systematic review and two retrospective cohort studies, both published and unpublished performed by some of the authors were included to provide a basis form comparison between NPWT and NPWT-I outcomes in managing abdominal sepsis. CONCLUSION Our findings suggest that this technique appears to reduce morbidity, mortality, and hospital and critical care length of stay. This communication is intended to help inform general surgeons that manage complex abdominal infections on how to optimally apply this technique.
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Does Negative-Pressure Wound Therapy for the Open Abdomen Benefit the Patient? A Retrospective Cohort Study. Adv Skin Wound Care 2018; 30:256-261. [PMID: 28520603 DOI: 10.1097/01.asw.0000516196.19330.6f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Negative-pressure wound therapy (NPWT) is the most modern and sophisticated method of temporary abdominal closure. The aim of the study was to determine the significant predictors for mortality in patients with NPWT. SETTING University Clinical Centre Maribor, Slovenia MATERIALS AND METHODS:: The authors performed a retrospective cohort study of all patients treated with NPWT between January 1, 2011, and December 31, 2014. RESULTS In the univariate analysis, the type of wound closure, more than 7 NPWT changes, the total days with NPWT, and time to wound closure were significantly associated with death of the patient. In the multivariate analysis, only the number of more than 7 NPWT changes was found as a significant predictor for death (P = .038). CONCLUSIONS Negative-pressure wound therapy is a method of choice for the treatment of open abdomen if there is a clear indication. However, clinicians should try all measures to remove the NPWT system and close the abdomen as soon as possible because prolonged use is associated with significantly higher mortality.
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Salamone G, Licari L, Guercio G, Comelli A, Mangiapane M, Falco N, Tutino R, Bagarella N, Campanella S, Porrello C, Gullo R, Cocorullo G, Gulotta G. Vacuum-Assisted Wound Closure with Mesh-Mediated Fascial Traction Achieves Better Outcomes than Vacuum-Assisted Wound Closure Alone: A Comparative Study. World J Surg 2018; 42:1679-1686. [PMID: 29147897 PMCID: PMC5934457 DOI: 10.1007/s00268-017-4354-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Open abdomen (OA) permits the application of damage control surgery principles when abdominal trauma, sepsis, severe acute peritonitis and abdominal compartmental syndrome (ACS) occur. Methods Non-traumatic patients treated with OA between January 2010 and December 2015 were identified in a prospective database, and the data collected were retrospectively reviewed. Patients’ records were collected from charts and the surgical and intensive care unit (ICU) registries. The Acosta “modified” technique was used to achieve fascial closure in vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) patients. Sex, age, simplified acute physiology score II (SAPS II), abdominal compartmental syndrome (ACS), cardiovascular disease (CVD) and surgical technique performed were evaluated in a multivariate analysis for mortality and fascial closure prediction. Results Ninety-six patients with a median age of 69 (40–78) years were included in the study. Sixty-nine patients (72%) underwent VAWCM. Forty-one patients (68%) achieved primary fascia closure: two patients (5%) were treated with VAWC (37 median days) versus 39 patients (95%) who were treated with VAWCM (10 median days) (p = 0.0003). Forty-eight patients underwent OA treatment due to ACS, and 24 patients (50%) survived compared to 36 patients (75%) from the “other reasons” group (p = 0.01). The ACS group required longer mechanical ventilator support (p = 0.006), length of stay in hospital (p = 0.005) and in ICU (p = 0.04) and had higher SAPS II scores (p = 0.0002). Conclusions The survival rate was 62%. ACS (p = 0.01), SAPS II (p = 0.004), sex (p = 0.01), pre-existing CVD (p = 0.0007) and surgical technique (VAWC vs VAWCM) (p = 0.0009) were determined to be predictors of mortality. Primary fascial closure was obtained in 68% of cases. VAWCM was found to grant higher survival and primary fascial closure rate.
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Affiliation(s)
- Giuseppe Salamone
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Leo Licari
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy.
| | - Giovanni Guercio
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Albert Comelli
- Department of Industrial and Digital Innovation, Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Mirko Mangiapane
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Nicolò Falco
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Roberta Tutino
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Noemi Bagarella
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Sofia Campanella
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Calogero Porrello
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Roberto Gullo
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Gianfranco Cocorullo
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Gaspare Gulotta
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
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Hu P, Uhlich R, Gleason F, Kerby J, Bosarge P. Impact of initial temporary abdominal closure in damage control surgery: a retrospective analysis. World J Emerg Surg 2018; 13:43. [PMID: 30237824 PMCID: PMC6139137 DOI: 10.1186/s13017-018-0204-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/03/2018] [Indexed: 02/05/2023] Open
Abstract
Background Damage control surgery has revolutionized trauma surgery. Use of damage control surgery allows for resuscitation and reversal of coagulopathy at the risk of loss of abdominal domain and intra-abdominal complications. Temporary abdominal closure is possible with multiple techniques, the choice of which may affect ability to achieve primary fascial closure and further complication. Methods A retrospective analysis of all trauma patients requiring damage control laparotomy upon admission to an ACS-verified level one trauma center from 2011 to 2016 was performed. Demographic and clinical data including ability and time to attain primary fascial closure, as well as complication rates, were recorded. The primary outcome measure was ability to achieve primary fascial closure during initial hospitalization. Results Two hundred and thirty-nine patients met criteria for inclusion. Primary skin closure (57.7%), ABThera™ VAC system (ABT) (15.1%), Bogota bag (BB) (25.1%), or a modified Barker's vacuum-packing (BVP) (2.1%) were used in the initial laparotomy. Patients receiving skin-only closure had significantly higher rates of primary fascial closure and lower hospital mortality, but also significantly lower mean lactate, base deficit, and requirement for massive transfusion. Between ABT or BB, use of ABT was associated with increased rates of fascial closure. Multivariate regression revealed primary skin closure to be significantly associated with primary fascial closure while BB was associated with failure to achieve fascial closure. Conclusions Primary skin closure is a viable option in the initial management of the open abdomen, although these patients demonstrated less injury burden in our study. Use of vacuum-assisted dressings continues to be the preferred method for temporary abdominal closure in damage control surgery for trauma.
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Affiliation(s)
- Parker Hu
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 701 19th Street South, 112 Lyons-Harrison Research Building, Birmingham, AL 35294 USA
| | - Rindi Uhlich
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Frank Gleason
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Jeffrey Kerby
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Patrick Bosarge
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
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26
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Morais M, Gonçalves D, Bessa-Melo R, Devesa V, Costa-Maia J. The open abdomen: analysis of risk factors for mortality and delayed fascial closure in 101 patients. Porto Biomed J 2018; 3:e14. [PMID: 31595244 DOI: 10.1016/j.pbj.0000000000000014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 05/09/2018] [Indexed: 11/20/2022] Open
Abstract
Introduction The core concepts of damage control and open abdomen in trauma surgery have been expanding for emergent general surgery. Temporary closures allow ease of access to the abdominal cavity for source control.The aim of the current study was to assess the outcomes of patients who underwent open abdomen management for acute abdominal conditions and evaluate risk factors for worse outcomes and inability of fascial closure during the initial hospitalization. Methods We conducted a retrospective analysis of 101 patients submitted to laparostomy in a single institution from January 2009 to March 2017. The evaluated outcomes were mortality, local morbidity, and rate of primary fascial closure. Results The most common indications for open abdomen were bowel perforation, bowel ischemia, and necrotizing pancreatitis. Global in-hospital mortality rate was 62.4%. For the 37 patients discharged from the hospital, a definitive abdominal closure was attained in 28.Multivariable logistic regression analysis revealed that people older than 60 years of age and with Acute Physiology and Chronic Health Evaluation (APACHE II) scores over 18.5 had higher in-hospital mortality rates. Definitive fascial closure was statistically associated with a lower number of re-interventions and ICU stay. Conclusions Open abdomen management may be appropriate in these critically ill patients; however, it continues to be associated with significantly high mortality, especially in elder patients and with higher APACHE II scores. Recognition of risk factors for fascia closure failure should promote the investigation for a tailored surgical approach in these patients.
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Affiliation(s)
- Marina Morais
- Department of General Surgery, Sao Joao Medical Center, Porto Medical School, Porto, Portugal
| | - Diana Gonçalves
- Department of General Surgery, Sao Joao Medical Center, Porto Medical School, Porto, Portugal
| | - Renato Bessa-Melo
- Department of General Surgery, Sao Joao Medical Center, Porto Medical School, Porto, Portugal
| | - Vítor Devesa
- Department of General Surgery, Sao Joao Medical Center, Porto Medical School, Porto, Portugal
| | - José Costa-Maia
- Department of General Surgery, Sao Joao Medical Center, Porto Medical School, Porto, Portugal
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Jakob MO, Spari D, Zindel J, Pinworasarn T, Candinas D, Beldi G. Prophylactic, Synthetic Intraperitoneal Mesh Versus No Mesh Implantation in Patients with Fascial Dehiscence. J Gastrointest Surg 2018; 22:2158-2166. [PMID: 30039450 PMCID: PMC6244924 DOI: 10.1007/s11605-018-3873-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/03/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Primary closure of post-operative facial dehiscence (FD) is associated with a high incidence of recurrence, revisional surgery, and incisional hernia. This retrospective study compares outcomes of implantation of non-absorbable intra-abdominal meshes with primary closure of FD. The outcomes of different mesh materials were assessed in subgroup analysis. METHODS A total of 119 consecutive patients with FD were operated (70 mesh group and 49 no mesh group) between 2001 and 2015. Primary outcome parameter was hernia-free survival. Secondary outcome parameters include re-operations of the abdominal wall, intestinal fistula, surgical site infections (SSI), and mortality. Kaplan-Meier analysis for hernia-free survival, adjusted Poisson regression analysis for re-operations and adjusted regression analysis for chronic SSI was performed. RESULTS Hernia-free survival was significantly higher in the mesh group compared to the no mesh group (P = 0.005). Fewer re-operations were necessary in the mesh group compared to the no mesh group (adjusted incidence risk ratio 0.44, 95% confidence interval [CI] 0.20-0.93, P = 0.032). No difference in SSI, intestinal fistula, and mortality was observed between groups. Chronic SSI was observed in 7 (10%) patients in the mesh group (n = 3 [6.7%] with polypropylene mesh and 4 [28.6%] with polyester mesh). The risk for chronic SSI was significantly higher if a polyester mesh was used when compared to a polypropylene mesh (adjusted odds ratio 8.69, 95% CI 1.30-58.05, P = 0.026). CONCLUSION Implantation of a polypropylene but not polyester-based mesh in patients with FD decreases incisional hernia with a low rate of mesh-related morbidity.
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Affiliation(s)
- Manuel O Jakob
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Daniel Spari
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Joel Zindel
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Tawan Pinworasarn
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland.
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Ahmed N, Hassan MU, Tahira M, Samad A, Rana HN. Intra-Operative Predictors of difficult cholecystectomy and Conversion to Open Cholecystectomy - A New Scoring System. Pak J Med Sci 2018; 34:62-66. [PMID: 29643880 PMCID: PMC5857031 DOI: 10.12669/pjms.341.13302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 01/24/2018] [Accepted: 01/27/2018] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To evaluate the intra-operative scoring system to predict difficult cholecystectomy and conversion to open surgery. METHODS This descriptive study was conducted from March 2016 to August, 2016 in the Department of Surgery, Shalimar Hospital. The study recruited 120 patients of either gender, age greater than 18 years and indicated for laparoscopic cholecystectomy (LC). Intra-operatively all patients were evaluated using the new scoring system. The scoring system included five aspects; appearance and adhesion of Gall Bladder (GB), distension or contracture degree of GB, ease in access, local or septic complications, and time required for cystic artery and duct identification. The scoring system ranges from 0 to 10, classified as score of <2 being considered easy, 2 to 4 moderate, 5-7 very difficult, and 8 to 10, extreme. Patient demographic data (i.e. age, gender), co-morbidities, intra-operative scores using the scoring system and conversion to open were recorded. The data was analysed using statistical analysis software SPSS (IBM). RESULTS Among one hundred and twenty participants, sixty seven percent were females and the mean age (years) was 43.05 ± 14.16. Co-morbidities were present in twenty percent patients with eleven diagnosed with diabetes, six with hypertension and five with both hypertension and diabetes. The conversion rate to open surgery was 6.7%. The overall mean intra-operative scores were 3.52 ± 2.23; however significant difference was seen in mean operative score of converted to open and those not converted to open (8.00 ± 0.92 Vs. 3.20 V 1.92; p-value = 0.001). Among eight cases converted to open, three (37.5%) were in very difficult category while five (62.5%) were in extreme category. Moreover, age greater than 40 years and being diabetic were also the risk factors for conversion to open surgery. CONCLUSION The new intra-operative scoring system is a valuable assessment tool to predict difficult laparoscopic cholecystectomy and conversion parameters to open surgery and its utility could improve patient's clinical outcome indicated for laparoscopic cholecystectomy.
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Affiliation(s)
- Nauman Ahmed
- Nauman Ahmed, Consultant General & Laproscopic Surgeon, Surgical Unit II, Shalamar Institute of Health Sciences, Lahore, Pakistan
| | - Maaz ul Hassan
- Maaz ul Hassan, Assistant Professor, Surgical Unit II, Shalamar Institute of Health Sciences, Lahore, Pakistan
| | - Maham Tahira
- Maham Tahira, Medical Officer, Surgical Unit II, Shalamar Institute of Health Sciences, Lahore, Pakistan
| | - Abdul Samad
- Abdul Samad, Shaheen Research Group, Karachi, Pakistan
| | - Hamad Naeem Rana
- Hamad Naeem Rana, Professor of Surgery, Surgical Unit II, Shalamar Institute of Health Sciences, Lahore, Pakistan
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Seternes A, Rekstad LC, Mo S, Klepstad P, Halvorsen DL, Dahl T, Björck M, Wibe A. Open Abdomen Treated with Negative Pressure Wound Therapy: Indications, Management and Survival. World J Surg 2017; 41:152-161. [PMID: 27541031 DOI: 10.1007/s00268-016-3694-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Open abdomen treatment (OAT) is a significant burden for patients and is associated with considerable mortality. The primary aim of this study was to report survival and cause of mortality after OAT. Secondary aims were to evaluate length of stay (LOS) in intensive care unit (ICU) and in hospital, time to abdominal closure and major complications. METHODS Retrospective review of prospectively registered patients undergoing OAT between October 2006 and June 2014 at Trondheim University Hospital, Norway. RESULTS The 118 patients with OAT had a median age of 63 (20-88) years. OAT indications were abdominal compartment syndrome (ACS) (n = 53), prophylactic (n = 29), abdominal contamination/second look laparotomy (n = 22), necrotizing fasciitis (n = 7), hemorrhage packing (n = 4) and full-thickness wound dehiscence (n = 3). Eight percent were trauma patients. Vacuum-assisted wound closure (VAWC) with mesh-mediated traction (VAWCM) was used in 92 (78 %) patients, the remaining 26 (22 %) had VAWC only. Per-protocol primary fascial closure rate was 84 %. Median time to abdominal closure was 12 days (1-143). LOS in the ICU was 15 (1-89), and in hospital 29 (1-246) days. Eighty-one (68 %) patients survived the hospital stay. Renal failure requiring renal replacement therapy (RRT) (OR 3.9, 95 % CI 1.37-11.11), ACS (OR 3.1, 95 % CI 1.19-8.29) and advanced age (OR 1.045, 95 % CI 1.004-1.088) were independent predictors of mortality in multivariate analysis. The nine patients with an entero-atmospheric fistula (EAF) survived. CONCLUSION Two-thirds of the patients treated with OAT survived. Renal failure with RRT, ACS and advanced age were predictors of mortality, whereas EAF was not associated with increased mortality.
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Affiliation(s)
- A Seternes
- Departments of Vascular Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway. .,Departments of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway. .,Departments of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), 7006, Trondheim, Norway.
| | - L C Rekstad
- Departments of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway
| | - S Mo
- Departments of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway
| | - P Klepstad
- Departments of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway.,Departments of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), 7006, Trondheim, Norway
| | - D L Halvorsen
- Departments of Urologic Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway
| | - T Dahl
- Departments of Vascular Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway.,Departments of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), 7006, Trondheim, Norway
| | - M Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, 751 85, Uppsala, Sweden
| | - A Wibe
- Departments of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway.,Departments of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway
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Giudicelli G, Rossetti A, Scarpa C, Buchs NC, Hompes R, Guy RJ, Ukegjini K, Morel P, Ris F, Adamina M. Prognostic Factors for Enteroatmospheric Fistula in Open Abdomen Treated with Negative Pressure Wound Therapy: a Multicentre Experience. J Gastrointest Surg 2017; 21:1328-1334. [PMID: 28536807 DOI: 10.1007/s11605-017-3453-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 05/10/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reductions in mortality were reported with negative pressure wound therapy for laparostomy. However, some authors have voiced concern over an increased risk of enteroatmospheric fistulae. In this retrospective study, we hypothesized that surgical and metabolic derangements could increase the incidence of enteroatmospheric fistulae. We aimed to assess our experience and report long-term outcomes. METHODS A multicentre review of all patients with a laparostomy managed with negative pressure wound therapy between 2005 and 2015 was undertaken. Features associated with enteroatmospheric fistulae were included in multivariate logistic regression. RESULTS Fifty-seven patients were treated according to uniform protocol. Fourteen per cent (8/57) presented enteroatmospheric fistulae. Mesenteric ischaemia and preoperative arterial serum lactate >3.5 mmol/L were associated with a significantly increased risk of enteroatmospheric fistulae. Preoperative arterial serum lactate >3.5 mmol/L was an independent predictor of enteroatmospheric fistulae with an odds ratio of 12.41 (95% CI 1.54-99.99). All mesenteric ischaemia patients with anastomosis (5/15) presented enteroatmospheric fistulae. In-hospital mortality was 26.3% (15/57). One-year mortality was 33.3% (19/57). Incisional hernia rate was 5.2% (2/38) after 14.2 (2.4-56.3) months of follow-up. DISCUSSION Mesenteric ischaemia increases the risk of enteroatmospheric fistulae. Anastomosis should only be created in revascularized patients. When mesenteric vascularization is not restored, diversion is advised.
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Affiliation(s)
- Guillaume Giudicelli
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.
| | - A Rossetti
- Department of Visceral Surgery, Cantonal Hospital Sankt Gallen, Sankt Gallen, Switzerland
| | - C Scarpa
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - N C Buchs
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - R J Guy
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - K Ukegjini
- Department of Visceral Surgery, Cantonal Hospital Sankt Gallen, Sankt Gallen, Switzerland
| | - P Morel
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - F Ris
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - M Adamina
- Division of Visceral and Thoracic Surgery, Department of Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
- University of Basel, Basel, Switzerland
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Zhang PH, Liu Z, Ren LC, Zeng JZ, Huang GW, Xiao MZ, Zhou J, Liang PF, Zhang MH, Huang XY. Early laparotomy and timely reconstruction for patients with abdominal electrical injury: Five Case Reports and Literature Review. Medicine (Baltimore) 2017; 96:e7437. [PMID: 28723751 PMCID: PMC5521891 DOI: 10.1097/md.0000000000007437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION High-tension electricity can cause devastating injuries that may result in abdominal wall loss, visceral damage, and sometimes major threat to life. The visceral organ may be exposed after debridement and require flap cover, but the tensile strength of abdominal wall may be lack even if flap transplanted. METHODS From April 2007 through May 2015, 5 patients with severe abdominal electrical injury were treated at our hospital. Exploratory laparotomy was performed based on their clinical manifestations and debridement findings of abdominal wall at early stage, and decision regarding technique for reconstruction of abdominal wall was based on an assessment of the location and extent of the defect. Medical records were reviewed for these data. RESULTS Clinical evaluation and debridement findings of the abdomen revealed 4 patients with suspicious visceral damage. Laparotomy was performed in 4 cases, and revealed obvious lesion in 3 cases, including segmental necrosis of small intestine, partial necrosis of diaphragm, left liver and gastric wall, and greater omentum. Five patients underwent abdominal wall reconstruction using island retrograde latissimus dorsi myocutaneous flap or free/island composite anterolateral thigh myocutaneous flap. All flaps survived, abdominal bulging occurred in 3 cases after follow-up of 12 to 36 months. CONCLUSIONS The clinical manifestations and wound features of abdomen collectively suggest a possible requirement of laparotomy for severe abdominal electrical burns. Retrograde latissimus dorsi myocutaneous flap or composite anterolateral thigh myocutaneous flap is an effective option for reconstruction of abdominal wall loss, the long-term complication of abdominal bulging, however, remains a significant clinical challenge.
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Affiliation(s)
| | - Zan Liu
- Department of Burns and Reconstructive Surgery
| | | | | | | | | | - Jie Zhou
- Department of Burns and Reconstructive Surgery
| | | | | | - Xiao-Yuan Huang
- Institute of Burn Research, Xiangya Hospital, Central South University, Changsha, Hunan Province, P.R. China
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Hofmann AT, Gruber-Blum S, Lechner M, Petter-Puchner A, Glaser K, Fortelny R. Delayed closure of open abdomen in septic patients treated with negative pressure wound therapy and dynamic fascial suture: the long-term follow-up study. Surg Endosc 2017; 31:4717-4724. [PMID: 28424908 DOI: 10.1007/s00464-017-5547-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 03/28/2017] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Negative pressure wound therapy (NPWT) is widely used in the treatment of open abdomen (OA). The use of dynamic fascial sutures (DFS) increases the rate of successful delayed closure by reducing fascial lateralization. We recently published a prospective controlled trial including 87 patients undergoing abdominal surgery for secondary peritonitis between 2007 and 2012. Patients were treated with NPWT and DFS for approximation of fascial edges. The present study represents a follow-up assessment of these patients 5-9 years after OA treatment with NPWT and DFS. METHODS The 39 patients still alive were included in the recent study according to the protocol of our last study in 2013. All patients received a questionnaire regarding long-term complications after OA treatment between 2007 and 2012. Mean follow-up was 5-9 years. Analyzed parameters included pain, the presence of incisional hernia, and subsequent surgical interventions. Results were analyzed quantitatively. RESULTS One patient had deceased since the last publication in 2013, and hence 38 patients were included in the current study. The median age was 60.9 (25.2-86.1) years, and 17 (44.7%) were females. Overall 56.3% of the original 87 patients had died during the long-term follow-up period. 21 patients (55.3%) answered the questionnaire. Six (28.6%) declared that they suffered from pain in the previous operating field, five (23.8%) at rest, and three (14.3%) during exercise. In five patients (23.8%), pain lasted for more than 3 months. One patient (4.8%) still requires analgesic treatment. Among the 21 patients, seven (33.3%) were found to have incisional hernias. Three hernias (42.9%) were treated by surgery. CONCLUSION Incisional hernia rates after OA treatment remain high, but are accompanied by little pain. The ideal technique of fascial closure after NPWT should be investigated in further research.
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Affiliation(s)
- Anna Theresa Hofmann
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Montleartstrasse 37, 1160, Vienna, Austria.
| | - Simone Gruber-Blum
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Montleartstrasse 37, 1160, Vienna, Austria
| | - Michael Lechner
- Department of Surgery, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020, Salzburg, Austria
| | - Alexander Petter-Puchner
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Montleartstrasse 37, 1160, Vienna, Austria
| | - Karl Glaser
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Montleartstrasse 37, 1160, Vienna, Austria
| | - René Fortelny
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, Montleartstrasse 37, 1160, Vienna, Austria.,Sigmund Freud University, Freudplatz 1, 1020, Vienna, Austria
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Muresan M, Muresan S, Brinzaniuc K, Voidazan S, Sala D, Jimborean O, Hussam AH, Bara T, Popescu G, Borz C, Neagoe R. How much does decompressive laparotomy reduce the mortality rate in primary abdominal compartment syndrome?: A single-center prospective study on 66 patients. Medicine (Baltimore) 2017; 96:e6006. [PMID: 28151898 PMCID: PMC5293461 DOI: 10.1097/md.0000000000006006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 11/26/2022] Open
Abstract
Contribution of decompressive laparotomy within the framework of the complex therapeutic algorithm of abdominal compartment syndrome (ACS) is cited with an extremely heterogeneous percentage in terms of survival. The purpose of this study was to present new data regarding contribution of each therapeutic step toward decreasing the mortality of this syndrome.This is a longitudinal prospective study including 134 patients with risk factors for ACS. The intra-abdominal pressure was measured every hour indirectly based on transvesical approach and the appearance of organ dysfunction. Specific therapy for ACS was based on the 2013 World Society of Abdominal Compartment Syndrome guidelines, which include laparotomy decompression. Management of the temporarily open abdomen included an assisted vacuum wound therapy.Of 134 patients, 66 developed ACS. The average intra-abdominal pressure significantly decreased after therapy and decompression surgery. The overall rate of mortality was 27.3% with statistical significance in necrotizing infected pancreatitis. Surgical decompression performed within the first 24 hours after the onset of ACS had a protective role against mortality (odds ratio <1). The average time after which laparotomy decompression was performed was 16.23 hours. The complications occurred during TAC were 2 wound suppurations and 1 intestinal obstruction. Wound suppurations evolved favorably by using vacuum wound-assisted therapy associated with the general treatment, whereas for occlusion, resurgery was performed after which adhesions dissolved. The final closure of the abdomen was performed at a mean of 11.7 days (min. = 9, max. = 14). The closure type was primary suture of the musculoaponeurotic edges in 4 cases, and the use of dual mesh in the other 11 cases.The highest mortality rate in the study group was registered in patients with necrotizing pancreatitis and the lowest in trauma group. Surgical decompression within the framework of the complex algorithm treatment of ACS contributed to the reduction of mortality by 8.7%. It is extremely important that the elapsed time since the initiation of the ACS until the surgical decompression is minimal (under 24 hours).
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Affiliation(s)
| | | | | | | | | | | | - Al Husseim Hussam
- Cardiovascular Surgery Clinic, University of Medicine and Pharmacy of Tirgu Mures, Tirgu Mures, Romania
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Beltzer C, Eisenächer A, Badendieck S, Doll D, Küper M, Lenz S, Krapohl BD. Retrospective analysis of a VACM (vacuum-assisted closure and mesh-mediated fascial traction) treatment manual for temporary abdominal wall closure - results of 58 consecutive patients. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2016; 5:Doc19. [PMID: 27547691 PMCID: PMC4977375 DOI: 10.3205/iprs000098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: The optimal treatment concept for temporary abdominal closure (TAC) in critically ill visceral surgery patients with open abdomen (OA) continues to be unclear. The VACM (vacuum-assisted closure and mesh-mediated fascial traction) therapy seems to permit higher delayed primary fascial closure rates (FCR) than other TAC procedures. Material and methods: Patients of our clinic (n=58) who were treated by application of a VAC/VACM treatment manual in the period from 2005 to 2008 were retrospectively analysed. Results: The overall FCR of all patients was 48.3% (95% confidence interval: 34.95–61.78). An FCR of 61.3% was achieved in patients who had a vicryl mesh implanted at the fascial level (VACM therapy) in the course of treatment. Mortality among patients treated with VACM therapy was 45.2% (95% CI: 27.32–63.97). Conclusions: The results of our own study confirm the results of previous studies which showed an acceptable FCR among non-trauma patients who were treated with VACM therapy. VACM therapy currently appears to be the treatment regime of choice for patients with OA requiring TAC.
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Affiliation(s)
- Christian Beltzer
- Bundeswehr Hospital Ulm, Department of General, Visceral and Thorax Surgery, Ulm, Germany
| | - Alexander Eisenächer
- Bundeswehr Hospital Berlin, Department of General, Visceral and Thorax Surgery, Berlin, Germany
| | - Steffen Badendieck
- Bundeswehr Hospital Berlin, Department of General, Visceral and Thorax Surgery, Berlin, Germany
| | - Dietrich Doll
- St. Marienhospital, Vechta, Department of Colorectal Surgery, Vechta, Germany
| | - Markus Küper
- Bundeswehr Hospital Berlin, Department of General, Visceral and Thorax Surgery, Berlin, Germany
| | - Stefan Lenz
- Klinikum Nauen, Department of General and Visceral Surgery, Nauen, Germany
| | - Björn Dirk Krapohl
- St. Marien-Krankenhaus, Berlin, Department of Plastic and Hand Surgery, Berlin, Germany
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Rezende-Neto J, Rice T, Abreu ES, Rotstein O, Rizoli S. Anatomical, physiological, and logistical indications for the open abdomen: a proposal for a new classification system. World J Emerg Surg 2016; 11:28. [PMID: 27307788 PMCID: PMC4908692 DOI: 10.1186/s13017-016-0083-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/10/2016] [Accepted: 06/09/2016] [Indexed: 12/21/2022] Open
Abstract
Background A systematic approach to the appropriate use of the open abdomen strategy has not been described. We propose three fundamental reasons for the use of this strategy, anatomical, physiological and logistical. Anatomical reasons pertain to the inability to bring the fascial edges together including soft tissue defects. Physiological reasons relate to features of systemic dysfunction. Logistical reasons involve any anticipated abdominal re-intervention while preserving fascia. These categories occur either as a single reason or in any combination. Methods A single-center prospective observational study of patients with open abdomens in trauma and acute abdomen. Surgeons were asked to select from the three reasons (single or any combination of) their motivation for using the open abdomen upon completion of the initial operation. Patients were compared using the non-parametric Wilcoxon two-sample test or Kruskal-Wallis test. Chi-square or Fisher’s exact test was used for categorical variables; Statistical significance set at P-value ≤ 0.05. Results Forty-five consecutive patients with open abdomens were evaluated (Jan. 1- Dec. 31, 2012). Mean age was 38.8 years, 32 were male, 39 (86.7 %) sustained trauma. The most common single reason for the open abdomen was physiological (24.4 %), 33 patients had multiple reasons, the most common combination being anatomical and physiological (22.2 %). A physiological reason was linked to: lower pH, higher lactate, and lower systolic blood pressure on admission (p < 0.05). A logistical reason was associated with earlier primary fascial closure, intra-operative packing, and bowel left in discontinuity. Logistic regression and adjusted odds ratio of primary fascial closure was: physiological (0.08, 95 % CI, 0.01–0.92, p = 0.043); logistical (6.03, 95 % CI, 1.13–32.29, p = 0.036); and anatomical (0.83, 95 % CI, 0.16–4.18, p = 0.816). Conclusion We defined three basic indications for the use of the open abdomen, anatomical physiological and logistical. These indications establish a practical and comprehensive terminology that could help to promote appropriate use of the open abdomen.
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Affiliation(s)
- Joao Rezende-Neto
- Department of Surgery Division of General Surgery, University of Toronto, St. Michael's Hospital, 30 Bond Street, Rm 3-074 Donnelly Wing, Toronto, ON M5B 1 W8 Canada
| | - Timothy Rice
- Department of Surgery Division of General Surgery, University of Toronto, St. Michael's Hospital, 30 Bond Street, Rm 3-074 Donnelly Wing, Toronto, ON M5B 1 W8 Canada
| | - Emanuelle Savio Abreu
- Hospital Risoleta Tolentino Neves, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Ori Rotstein
- Department of Surgery Division of General Surgery, University of Toronto, St. Michael's Hospital, 30 Bond Street, Rm 3-074 Donnelly Wing, Toronto, ON M5B 1 W8 Canada
| | - Sandro Rizoli
- Department of Surgery Division of General Surgery, University of Toronto, St. Michael's Hospital, 30 Bond Street, Rm 3-074 Donnelly Wing, Toronto, ON M5B 1 W8 Canada
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High risk of fistula formation in vacuum-assisted closure therapy in patients with open abdomen due to secondary peritonitis—a retrospective analysis. Langenbecks Arch Surg 2016; 401:619-25. [DOI: 10.1007/s00423-016-1443-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/26/2016] [Indexed: 02/02/2023]
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Bobkiewicz A, Walczak D, Smoliński S, Kasprzyk T, Studniarek A, Borejsza-Wysocki M, Ratajczak A, Marciniak R, Drews M, Banasiewicz T. Management of enteroatmospheric fistula with negative pressure wound therapy in open abdomen treatment: a multicentre observational study. Int Wound J 2016; 14:255-264. [PMID: 27000995 DOI: 10.1111/iwj.12597] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/11/2016] [Accepted: 02/24/2016] [Indexed: 12/11/2022] Open
Abstract
The management of enteroatmospheric fistula (EAF) in open abdomen (OA) therapy is challenging and associated with a high mortality rate. The introduction of negative pressure wound therapy (NPWT) in open abdomen management significantly improved the healing process and increased spontaneous fistula closure. Retrospectively, we analysed 16 patients with a total of 31 enteroatmospheric fistulas in open abdomen management who were treated using NPWT in four referral centres between 2004 and 2014. EAFs were diagnosed based on clinical examination and confirmed with imaging studies and classified into low (<200 ml/day), moderate (200-500 ml/day) and high (>500 ml/day) output fistulas. The study group consisted of five women and 11 men with the mean age of 52·6 years [standard deviation (SD) 11·9]. Since open abdomen management was implemented, the mean number of re-surgeries was 3·7 (SD 2·2). There were 24 EAFs located in the small bowel, while four were located in the colon. In three patients, EAF occurred at the anastomotic site. Thirteen fistulas were classified as low output (41·9%), two as moderate (6·5%) and 16 as high output fistulas (51·6%). The overall closure rate was 61·3%, with a mean time of 46·7 days (SD 43·4). In the remaining patients in whom fistula closure was not achieved (n = 12), a protruding mucosa was present. Analysing the cycle of negative pressure therapy, we surprisingly found that the spontaneous closure rate was 70% (7 of 10 EAFs) using intermittent setting of negative pressure, whereas in the group of patients treated with continuous pressure, 57% of EAFs closed spontaneously (12 of 21 EAFs). The mean number of NPWT dressing was 9 (SD 3·3; range 4-16). In two patients, we observed new fistulas that appeared during NPWT. Three patients died during therapy as a result of multi-organ failure. NPWT is a safe and efficient method characterised by a high spontaneous closure rate. However, in patients with mucosal protrusion of the EAFs, spontaneous closure appears to be impossible to achieve.
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Affiliation(s)
- Adam Bobkiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Dominik Walczak
- Department of General Surgery, John Paul II Memorial Hospital, Belchatow, Poland
| | - Szymon Smoliński
- Department of Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Kasprzyk
- Department of General, Vascular and Oncologic Surgery, Regional Specialistic Hospital, Słupsk, Poland
| | - Adam Studniarek
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Maciej Borejsza-Wysocki
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrzej Ratajczak
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Ryszard Marciniak
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Michal Drews
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Banasiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
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Björck M, Kirkpatrick AW, Cheatham M, Kaplan M, Leppäniemi A, De Waele JJ. Amended Classification of the Open Abdomen. Scand J Surg 2016; 105:5-10. [PMID: 26929286 DOI: 10.1177/1457496916631853] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 01/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2009, a classification system for the open abdomen was introduced. The aim of such a classification is to aid the (1) description of the patient's clinical course; (2) standardization of clinical guidelines for guiding open abdomen management; and (3) facilitation of comparisons between studies and heterogeneous patient populations, thus serving as an aid in clinical research. METHODS As part of the revision of the definitions and clinical guidelines performed by the World Society of the Abdominal Compartment Syndrome, this 2009 classification system was amended following a review of experiences in teaching and research and published as part of updated consensus statements and clinical practice guidelines in 2013. Among 29 articles citing the 2009 classification system, nine were cohort studies. They were reviewed as part of the classification revision process. A total of 542 patients (mean: 60, range: 9-160) had been classified. Two problems with the previous classification system were identified: the definition of enteroatmospheric fistulae, and that an enteroatmospheric fistula was graded less severe than a frozen abdomen. RESULTS The following amended classification was proposed: Grade 1, without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization), subdivided as follows: 1A, clean; 1B, contaminated; and 1C, with enteric leak. An enteric leak controlled by closure, exteriorization into a stoma, or a permanent enterocutaneous fistula is considered clean. Grade 2, developing fixation, subdivided as follows: 2A, clean; 2B, contaminated; and 2C, with enteric leak. Grade 3, frozen abdomen, subdivided as follows: 3A clean and 3B contaminated. Grade 4, an established enteroatmospheric fistula, is defined as a permanent enteric leak into the open abdomen, associated with granulation tissue. CONCLUSIONS The authors believe that, with these changes, the requirements on a functional and dynamic classification system, useful in both research and training, will be fulfilled. We encourage future investigators to apply the system and report on its merits and constraints.
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Affiliation(s)
- M Björck
- Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - A W Kirkpatrick
- Regional Trauma Services, Foothills Medical Centre, Calgary, AB, Canada
| | - M Cheatham
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - M Kaplan
- Albert Einstein Medical Center, Philadelphia, PA, USA
| | - A Leppäniemi
- Abdominal Center, Meilahti Hospital, University of Helsinki, Helsinki, Finland
| | - J J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
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Classification, prevention and management of entero-atmospheric fistula: a state-of-the-art review. Langenbecks Arch Surg 2016; 401:1-13. [PMID: 26867939 DOI: 10.1007/s00423-015-1370-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/22/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Entero-atmospheric fistula (EAF) is an enteric fistula occurring in the setting of an open abdomen, thus creating a communication between the GI tract and the external atmosphere. Management and nursing of patients suffering EAF carries several challenges, and prevention of EAF should be the first and best treatment option. PURPOSE Here, we present a novel modified classification of EAF and review the current state of the art in its prevention and management including nutritional issues and feeding strategies. We also provide an overview on surgical management principles, highlighting several surgical techniques for dealing with EAF that have been reported in the literature throughout the years. CONCLUSIONS The treatment strategy for EAF should be multidisciplinary and multifaceted. Surgical treatment is most often multistep and should be tailored to the single patient, based on the type and characteristics of the EAF, following its correct identification and classification. The specific experience of surgeons and nursing staff in the management of EAF could be enhanced, applying distinct simulation-based ex vivo training models.
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Rasilainen SK, Viljanen M, Mentula PJ, Leppäniemi AK. Enteroatmospheric fistulae in open abdomen: Management and outcome – Single center experience. INTERNATIONAL JOURNAL OF SURGERY OPEN 2016. [DOI: 10.1016/j.ijso.2016.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Yetisir F, Sarer AE, Acar HZ, Aygar M. Delayed Closure of 61 Open Abdomen Patients Based on an Algorithm. Indian J Surg 2015; 79:38-44. [PMID: 28331265 DOI: 10.1007/s12262-015-1422-5] [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: 10/05/2015] [Accepted: 12/08/2015] [Indexed: 10/22/2022] Open
Abstract
Hemodynamic resuscitation, source control, and delayed abdominal closure are the three fundamental steps for open abdomen (OA) management. When to start delayed abdominal closure and how to determine which delayed closure method should be applied to each OA patient are not clarified in the literature. We evaluated an algorithm that was developed to address these two questions. A retrospective chart review was conducted for OA patients treated for according to the algorithm. When hemodynamic stabilization and source control using negative pressure therapy resulted in regression of sepsis and decreased procalcitonin levels, patients were assigned to either the skin-only or fascial closure groups according to their Björck scores and open abdominal fascial closure (OAFC) scores. The novel OAFC scoring system was created by adding age and malignancy to the sequential organ failure assessment (SOFA) score. For skin-only closure, skin flaps and skin grafts were used; for fascial closure, an abdominal re-approximation anchor system (ABRA) or ABRA plus biologic mesh was applied. From January 2008 through September 2014, 108 OA patients were managed based on the algorithm; 61 were included in this study. Abdominal closure rate was 90.2 % (55/61). Overall hospital mortality rate was 11.4 % (7/61). Small hernias developed in only 12.5 % (4/32) of the fascial closure group. In this retrospective study, the algorithm with the novel OAFC score provided practical and valid guidance to clarify when to start delayed abdominal closure and which delayed closure method to use for each OA patient.
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Affiliation(s)
- Fahri Yetisir
- General Surgery Department, Atatürk Research and Training Hospital, Ankara, Turkey
| | - A Ebru Sarer
- Anesthesiology and Reanimation Department, Atatürk Research and Training Hospital, Ankara, Turkey
| | - Hasan Zafer Acar
- Natomed Private Hospital General Surgery Department, Ankara, Turkey
| | - Muhittin Aygar
- General Surgery Department, Atatürk Research and Training Hospital, Ankara, Turkey
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Temporary Abdominal Closure After Abdominal Aortic Aneurysm Repair: A Systematic Review of Contemporary Observational Studies. Eur J Vasc Endovasc Surg 2015; 51:371-8. [PMID: 26652956 DOI: 10.1016/j.ejvs.2015.10.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 10/18/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The aim of this paper was to review the literature on temporary abdominal closure (TAC) after abdominal aortic aneurysm (AAA) repair. METHODS This was a systematic review of observational studies. A PubMed, EMBASE and Cochrane search from 2007 to July 2015 was performed combining the Medical Subject Headings "aortic aneurysm" and "temporary abdominal closure", "delayed abdominal closure", "open abdomen", "abdominal compartment syndrome", "negative pressure wound therapy", or "vacuum assisted wound closure". RESULTS Seven original studies were found. The methods used for TAC were the vacuum pack system with (n = 1) or without (n = 2) mesh bridge, vacuum assisted wound closure (VAWC; n = 1) and the VAWC with mesh mediated fascial traction (VACM; n = 3). The number of patients included varied from four to 30. Three studies were exclusively after open repair, one after endovascular aneurysm repair, and three were mixed series. The frequency of ruptured AAA varied from 60% to 100%. The primary fascial closure rate varied from 79% to 100%. The median time to closure of the open abdomen was 10.5 and 17 days in two prospective studies with a fascial closure rate of 100% and 96%, respectively; the inclusion criterion was an anticipated open abdomen therapy time ≥5 days using the VACM method. The graft infection rate was 0% in three studies. No patient with long-term open abdomen therapy with the VACM in the three studies was left with a planned ventral hernia. The in hospital survival rate varied from 46% to 80%. CONCLUSIONS A high fascial closure rate without planned ventral hernia is possible to achieve with VACM, even after long-term open abdomen therapy. There are, however, few publications reporting specific results of open abdomen treatment after AAA repair, and there is a need for randomized controlled trials to determine the most efficient and safe TAC method during open abdomen treatment after AAA repair.
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Hecker A, Hecker B, Hecker M, Riedel JG, Weigand MA, Padberg W. Acute abdominal compartment syndrome: current diagnostic and therapeutic options. Langenbecks Arch Surg 2015; 401:15-24. [PMID: 26518567 DOI: 10.1007/s00423-015-1353-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/22/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND If untreated, the abdominal compartment syndrome (ACS) has a mortality of nearly 100 %. Thus, its early recognition is of major importance for daily rounds on surgical intensive care units. Intraabdominal hypertension (IAH) is a poorly recognized entity, which occurs if intraabdominal pressure arises >12 mmHg. Measurement of the intravesical pressure is the gold standard to diagnose IAH, which can be detected in about one fourth of surgical intensive care patients. PURPOSE The aim of this manuscript is to outline the current diagnostic and therapeutic options for IAH and ACS. While diagnosis of IAH and ACS strongly depends on clinical experience, new diagnostic markers could play an important role in the future. Therapy of IAH/ACS consists of five treatment "columns": intraluminal evacuation, intraabdominal evacuation, improvement of abdominal wall compliance, fluid management, and improved organ perfusion. If conservative therapy fails, emergency laparotomy is the most effective therapeutic approach to achieve abdominal decompression. Thereafter, patients with an open abdomen require intensive care and are permanently threatened by the quadrangle of fluid loss, muscle proteolysis, heat loss, and an impaired immune function. As a consequence, complication rate dramatically increases after 8 days of open abdomen therapy. CONCLUSION Despite many efforts, the mortality of patients with ACS remains unacceptably high. Permanent clinical education and surgical trials will be necessary to improve the outcome of our critically ill surgical patients.
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Affiliation(s)
- A Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.
| | - B Hecker
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Hecker
- Medical Clinic II, Pulmonary and Critical Care Medicine, University Hospital of Giessen, Giessen, Germany
| | - J G Riedel
- Department of General and Thoracic Surgery, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - M A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - W Padberg
- Department of General and Thoracic Surgery, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
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Montori G, Coccolini F, Manfredi R, Ceresoli M, Campanati L, Magnone S, Pisano M, Poiasina E, Nita G, Catena F, Ansaloni L. One year experience of swine dermal non-crosslinked collagen prostheses for abdominal wall repairs in elective and emergency surgery. World J Emerg Surg 2015; 10:28. [PMID: 26136817 PMCID: PMC4487506 DOI: 10.1186/s13017-015-0023-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/22/2015] [Indexed: 02/08/2023] Open
Abstract
Introduction The approach to the abdominal wall surgical repair is dramatically changed in the last years. This study evaluates our institutional outcomes about the usage of biological meshes for abdominal wall repair in different setting: in elective surgery, in emergency surgery and in abdominal wall repair following open abdomen (OA) procedure. Methods A database was prospectively conducted (January–December 2014) and data were reviewed for patients who underwent to an abdominal wall reconstruction with swine dermal non-cross linked collagens prostheses either in elective or emergency setting, and following OA/laparostomy procedure. Demographic data, co-morbidities, indications for surgery, intra-operative details, post-operative complications and outcome (peri-operative, 3, 6, 9-months) were analyzed. Results A total of 30 cases were reported: 9 in elective surgery (Group 1), 4 in emergency surgery (Group 2) and 17 with abdominal wall closure following OA management (Group 3). Two meshes were removed: 1 in the Group 1 and 1 in the Group 3. During follow-up only one patient in the Group 3 had a recurrence of the incisional hernia. Mortality rate was 11.1 % at 3 months in Group 1, 0 % in the Group 2, and 29.4 % in peri-operative period in the Group 3. Conclusions The use of non-cross linked biological meshes can be safe and versatile in different situations from elective to emergency surgery, and also for the reconstruction of the abdominal wall after OA procedure, with an acceptable recurrence and mortality rate.
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Affiliation(s)
- Giulia Montori
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Federico Coccolini
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Roberto Manfredi
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Marco Ceresoli
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Luca Campanati
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Magnone
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Michele Pisano
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Elia Poiasina
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Gabriela Nita
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Fausto Catena
- General surgery department, Ospedale Maggiore, Parma, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
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Sugrue M, Sahebally SM, Ansaloni L, Zielinski MD. Grading operative findings at laparoscopic cholecystectomy- a new scoring system. World J Emerg Surg 2015; 10:14. [PMID: 25870652 PMCID: PMC4394404 DOI: 10.1186/s13017-015-0005-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 02/09/2015] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Variation in outcomes from surgery is a major challenge and defining surgical findings may help set benchmarks, which currently do not exist in laparoscopic cholecystectomy. This study outlines a new surgical scoring system incorporating key operative findings. METHODS English language studies (from January 1965 to July 2014) pertaining to severity scoring and predictors of difficult laparoscopic cholecystectomy were searched for in PubMed, Embase and Cochrane databases using the search terms 'Laparoscopic cholecystectomy or Lap chole' and/or 'Scoring Index or Grading system or Prediction of difficulty or Conversion to open' in various combinations. Cross-referencing from papers retrieved in the original search identified additional articles. RESULTS Sixteen published papers report a gallbladder (GB) scoring system, but all relate to pre-operative clinical and imaging findings, rather than operative findings. The current scoring system, using operative findings incorporates the appearance of the GB, presence of GB distension, ease of access, potential biliary complications and time taken to identify cystic duct and artery. A score of <2 would imply mild difficulty, 2-4 moderate, 5-7 severe and 8-10 extreme. CONCLUSION This paper reports one of the first operative classifications of findings at laparoscopic cholecystectomy. It has the potential to allow benchmarks for international collaboration of operative and patient outcomes in patients undergoing laparoscopic cholecystectomy.
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Affiliation(s)
- Michael Sugrue
- Department of Surgery, Letterkenny Hospital and Donegal Clinical Research Academy, National University Ireland Galway, Letterkenny, Donegal Ireland
| | - Shaheel M Sahebally
- Department of Surgery, Letterkenny Hospital and Donegal Clinical Research Academy, National University Ireland Galway, Letterkenny, Donegal Ireland
| | - Luca Ansaloni
- Department of Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Mutafchiyski VM, Popivanov GI, Kjossev KT, Chipeva S. Open abdomen and VAC® in severe diffuse peritonitis. J ROY ARMY MED CORPS 2015; 162:30-4. [PMID: 25712560 DOI: 10.1136/jramc-2014-000386] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Currently, the open abdomen technique is the widely recognised method for treatment of life-threatening trauma, intra-abdominal sepsis, abdominal compartment syndrome and wound dehiscence. The techniques for temporary closure using negative pressure have gained increasing popularity. Although negative pressure wound therapy has been proved as an effective method in trauma, the results in diffuse peritonitis are contradictory. METHODS Overall, 108 patients with diffuse peritonitis and open abdomen were prospectively enrolled from January 2006 to December 2013--69 treated with mesh-foil laparostomy without negative pressure and 49 with vacuum-assisted closure (VAC(®)) The primary endpoints were the rate of primary fascial closure and mortality. The secondary outcomes were the rate of complications--enteroatmospheric fistulas, intra-abdominal abscesses, wound infection and necrotising fasciitis, intensive care unit (ICU) and overall hospital stay. RESULTS VAC was associated with higher overall (73% vs 53%) and late primary fascial closure rates (31% vs 7%), lower rates of necrotising fasciitis (2% vs 15%, p=0.012), intra-abdominal abscesses (10% vs 20%), enteroatmospheric fistulas (8% vs 19%), overall mortality (31% vs 53%, p<0.05), shorter ICU (6.1 vs 10.6 days, p=0.002) and hospital stay (15.1 vs 25.9 days, p=0.000). CONCLUSIONS The results clearly suggest the obvious advantage of VAC in comparison to the temporary abdominal closure without negative pressure in the cases with severe diffuse peritonitis. However, to a large extent, our results might be attributed to the combination of VAC with dynamic fascial closure.
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Affiliation(s)
- Ventsislav M Mutafchiyski
- Department of Military Surgery, Clinic of Endoscopic, Endocrine surgery and Coloproctology, Military Medical Academy, Sofia, Bulgaria
| | - G I Popivanov
- Clinic of Endoscopic, Endocrine surgery and Coloproctology, Military Medical Academy, Sofia, Bulgaria
| | - K T Kjossev
- Clinic of Abdominal Surgery, Military Medical Academy, Sofia, Bulgaria
| | - S Chipeva
- Department of Statistics and Econometrics, University of National and World Economy, Sofia, Bulgaria
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Mukhi AN, Minor S. Management of the open abdomen using combination therapy with ABRA and ABThera systems. Can J Surg 2015; 57:314-9. [PMID: 25265104 DOI: 10.1503/cjs.026613] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The open abdomen is an increasingly used technique that is applied in a wide variety of clinical situations. The ABThera Open Abdomen Negative Pressure Therapy System is one of the most common and successful temporary closure systems, but it has limited ability to close the fascia in approximately 30% of patients. The abdominal reapproximation anchor system (ABRA) is a dynamic closure system that seems ideal to manage patients who may not achieve primary fascial closure with ABThera alone. We report on the use of the ABRA in conjunction with the ABThera in patients with an open abdomen. METHODS We retrospectively analyzed patients with an open abdomen managed with the ABThera and ABRA between January 2007 and December 2012 at the Halifax Infirmary, QEII Health Science Centre, Halifax, Nova Scotia. RESULTS Sixteen patients had combination therapy using the ABRA and ABThera systems for treatment of the open abdomen. After removing patients who died prior to closure, primary fascial closure was achieved in 12 of 13 patients (92%). CONCLUSION We observed a high rate of primary fascial closure in patients with an open abdomen managed with the ABThera system in conjuction with the ABRA. Applying mechanical traction in addition to the ABThera should be considered in patients predicted to be at high risk for failure to achieve primary fascial closure.
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Terzi C, Egeli T, Canda AE, Arslan NC. Management of enteroatmospheric fistulae. Int Wound J 2015; 11 Suppl 1:17-21. [PMID: 24851732 DOI: 10.1111/iwj.12288] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 03/24/2014] [Accepted: 03/30/2014] [Indexed: 12/14/2022] Open
Abstract
A small-bowel enteroatmospheric fistula (EAF) is an especially challenging complication for patients with open abdomens (OAs) and their surgeons. Manipulation of the bowel during treatment (e.g. dressing changes) is one of the risk factors for developing these openings between the atmosphere and the gastrointestinal tract. Unlike enterocutaneous fistulae, EAFs have neither overlying soft tissue nor a real fistula tract, which reduces the likelihood of their spontaneous closure. Surgical closure is necessary but not always easy to do in the OA environment. Negative pressure wound therapy (NPWT) has been used successfully as an adjunct therapy to heal the wound around EAFs. This review discusses many aspects of managing EAFs in patients with OAs, and presents techniques that have been developed to isolate the fistula and divert effluent while applying NPWT to the surrounding wound bed.
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Affiliation(s)
- Cem Terzi
- Department of Surgery, Dokuz Eylul University Hospital, Izmir, Turkey
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Surgical Tips in Frozen Abdomen Management: Application of Coliseum Technique. Case Rep Surg 2015; 2015:309290. [PMID: 26064759 PMCID: PMC4442005 DOI: 10.1155/2015/309290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 04/25/2015] [Indexed: 12/01/2022] Open
Abstract
Wound dehiscence is a serious postoperative complication, with an incidence of 0.5–3% after primary closure of a laparotomy incision, and represents an acute mechanical failure of wound healing. Relatively recently the concept of “intentional open abdomen” was described and both clinical entities share common pathophysiological and clinical pathways (“postoperative open abdominal wall”). Although early reconstruction is the target, a significant proportion of patients will develop adhesions between abdominal viscera and the anterolateral abdominal wall, a condition widely recognized as “frozen abdomen,” where delayed wound closure appears as the only realistic alternative. We report our experience with a patient who presented with frozen abdomen after wound dehiscence due to surgical site infection and application of the “Coliseum technique” for its definitive surgical management. This novel technique represents an innovative alternative to abdominal exploration, for cases of “malignant” frozen abdomen due to peritoneal carcinomatosis. Lifting the edges of the surgical wound upwards and suspending them under traction by threads from a retractor positioned above the abdomen facilitates approach to the peritoneal cavity, optimizes exposure of intra-abdominal organs, and prevents operative injury to the innervation and blood supply of abdominal wall musculature, a crucial step for subsequent hernia repair.
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Sartelli M, Abu-Zidan FM, Ansaloni L, Bala M, Beltrán MA, Biffl WL, Catena F, Chiara O, Coccolini F, Coimbra R, Demetrashvili Z, Demetriades D, Diaz JJ, Di Saverio S, Fraga GP, Ghnnam W, Griffiths EA, Gupta S, Hecker A, Karamarkovic A, Kong VY, Kafka-Ritsch R, Kluger Y, Latifi R, Leppaniemi A, Lee JG, McFarlane M, Marwah S, Moore FA, Ordonez CA, Pereira GA, Plaudis H, Shelat VG, Ulrych J, Zachariah SK, Zielinski MD, Garcia MP, Moore EE. The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper. World J Emerg Surg 2015; 10:35. [PMID: 26269709 PMCID: PMC4534034 DOI: 10.1186/s13017-015-0032-7] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/03/2015] [Indexed: 02/07/2023] Open
Abstract
The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Walter L. Biffl
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, USA
| | - Fausto Catena
- Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca’ Granda Hospital, Milan, Italy
| | | | - Raul Coimbra
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego Health Science, San Diego, USA
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Demetrios Demetriades
- Trauma, Emergency Surgery, Surgical Critical Care, University of Southern California, Los Angeles, USA
| | - Jose J. Diaz
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | | | - Gustavo P. Fraga
- Division of Trauma Surgery, Hospital de Clinicas, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Wagih Ghnnam
- Department of Surgery Mansoura, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Sanjay Gupta
- Department of Surgery Government Medical College and Hospital, Chandigarh, India
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | | | - Victor Y. Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, Republic of South Africa
| | - Reinhold Kafka-Ritsch
- Department of Visceral, Thorax and Transplant Surgery, University of Innsbruck, Innsbruck, Austria
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Rifat Latifi
- Department of Surgery, Trauma Research Institute, University of Arizona, Tucson, AZ USA
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Michael McFarlane
- Department of Surgery, University Hospital of the West Indies, Kingston, Jamaica
| | - Sanjay Marwah
- Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | | | - Carlos A. Ordonez
- Department of Surgery, Fundación Valle del Lili, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
| | - Gerson Alves Pereira
- Division of Emergency and Trauma Surgery, Ribeirão Preto Medical School, Ribeirão Preto, Brazil
| | - Haralds Plaudis
- Department of General and Emergency Surgery, Riga East Clinical University Hospital “Gailezers”, Riga, Latvia
| | - Vishal G. Shelat
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jan Ulrych
- 1st Surgical Department of First Faculty of Medicine, General University Hospital, Prague Charles University, Prague, Czech Republic
| | | | | | - Maria Paula Garcia
- Centro de investigaciones clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, USA
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