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Lagazzi E, Nzenwa IC, Rafaqat W, Panossian VS, Hoekman AH, Arnold S, Ghaddar KA, Parks JJ, Paranjape CN, Velmahos GC, Kaafarani HMA, Hwabejire JO. Debunking the "Obesity Paradox": Obesity Is Associated With Adverse Outcomes in Emergency General Surgery. J Surg Res 2024; 301:95-102. [PMID: 38917579 DOI: 10.1016/j.jss.2024.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 06/27/2024]
Abstract
INTRODUCTION Obesity is increasingly prevalent both nationwide and in the emergency general surgery (EGS) population. While previous studies have shown that obesity may be protective against mortality following EGS procedures, the association between body mass index (BMI) and postoperative outcomes, as well as intraoperative decision-making, remains understudied. METHODS The National Surgical Quality Improvement Program 2015-2019 database was used to identify all adult patients undergoing an open abdominal or abdominal wall procedure for EGS conditions. Our outcomes included 30-d postoperative mortality, composite 30-d morbidity, delayed fascial closure, reoperation, operative time, and hospital length of stay (LOS). Multivariable logistic regression models were used to explore the association between BMI and each outcome of interest while adjusting for patient demographics, comorbidities, laboratory tests, preoperative and intraoperative variables. RESULTS We identified 78,578 patients, of which 3121 (4%) were categorized as underweight, 23,661 (30.1%) as normal weight, 22,072 (28.1%) as overweight, 14,287 (18.2%) with class I obesity, 7370 (9.4%) with class II obesity, and 8067 (10.3%) with class III obesity. Class III obesity was identified as a risk factor for 30-d postoperative morbidity (adjusted odds ratio 1.14, 95% CI, 1.03-1.26, P < 0.01). An increase in obesity class was also associated with a stepwise increase in the risk of undergoing delayed fascial closure, experiencing a prolonged operative time, and having an extended LOS. CONCLUSIONS Obesity class was associated with an increase in delayed fascial closure, longer operative time, higher reoperation rates, and extended hospital LOS. Further studies are needed to explore how a patient's BMI impacts intraoperative factors, influences surgical decision-making, and contributes to hospital costs.
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Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Ikemsinachi C Nzenwa
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Vahe S Panossian
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Anne H Hoekman
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Suzanne Arnold
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen A Ghaddar
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts.
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Nguyen D, Tan J, Bialowas C. Modified Application of the Abdominal Re-Approximation Anchor Device in the Closure of Septic Open Abdomen in a Patient With Class III Obesity. Cureus 2024; 16:e58749. [PMID: 38779286 PMCID: PMC11110945 DOI: 10.7759/cureus.58749] [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] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
The Abdominal Re-Approximation Anchor (ABRA®) is a pivotal dynamic wound closure system utilized for achieving primary fascial closure in patients undergoing open abdomen surgeries. However, its efficacy can be hindered in patients with class III obesity due to anatomical complexities and compromised tissue characteristics. Here, we present the unique case of a 25-year-old woman with class III obesity (body mass index (BMI) ≥ 40 kg/m2) who required primary abdominal closure following complications of an ileostomy repair. Traditional placement of the ABRA device was not feasible due to thick subcutaneous tissue layers. Consequently, a modified application of ABRA was decided based on clinical judgment, whereby the ABRA button anchors were strategically placed internally under the subcutaneous tissue instead of externally on the skin surface. The patient completed six intraoperative tightenings of the ABRA device via this novel technique and was treated with washouts over the course of two months until complete resolution was achieved. The presented case demonstrates a successful modification of the ABRA wound closure device to suit an open abdomen patient with class III obesity.
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Affiliation(s)
- Daryn Nguyen
- Department of Plastic and Reconstructive Surgery, Albany Medical College, Albany, USA
| | - Jiali Tan
- Department of Plastic and Reconstructive Surgery, Albany Medical College, Albany, USA
| | - Christie Bialowas
- Department of Plastic and Reconstructive Surgery, Albany Medical Center, Albany, USA
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De Waele JJ, Coccolini F, Lagunes L, Maseda E, Rausei S, Rubio-Perez I, Theodorakopoulou M, Arvanti K. Optimized Treatment of Nosocomial Peritonitis. Antibiotics (Basel) 2023; 12:1711. [PMID: 38136745 PMCID: PMC10740749 DOI: 10.3390/antibiotics12121711] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/24/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
This comprehensive review aims to provide a practical guide for intensivists, focusing on enhancing patient care associated with nosocomial peritonitis (NP). It explores the epidemiology, diagnosis, and management of NP, a significant contributor to the mortality of surgical patients worldwide. NP is, per definition, a hospital-acquired condition and a consequence of gastrointestinal surgery or a complication of other diseases. NP, one of the most prevalent causes of sepsis in surgical Intensive Care Units (ICUs), is often associated with multi-drug resistant (MDR) bacteria and high mortality rates. Early clinical suspicion and the utilization of various diagnostic tools like biomarkers and imaging are of great importance. Microbiology is often complex, with antimicrobial resistance escalating in many parts of the world. Fungal peritonitis and its risk factors, diagnostic hurdles, and effective management approaches are particularly relevant in patients with NP. Contemporary antimicrobial strategies for treating NP are discussed, including drug resistance challenges and empirical antibiotic regimens. The importance of source control in intra-abdominal infection management, including surgical and non-surgical interventions, is also emphasized. A deeper exploration into the role of open abdomen treatment as a potential option for selected patients is proposed, indicating an area for further investigation. This review underscores the need for more research to advance the best treatment strategies for NP.
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Affiliation(s)
- Jan J. De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, 9000 Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, 56124 Pisa, Italy;
| | - Leonel Lagunes
- Vall d’Hebron Institut de Recerca CRIPS, 08035 Barcelona, Spain;
- Facultad de Medicina, Universidad Autónoma de San Luis Potosi, 78210 San Luis Potosi, Mexico
| | - Emilio Maseda
- Department of Anesthesia and Critical Care, Hospital Quironsalud Valle del Henares, 28850 Madrid, Spain;
- Department of Pharmacology and Toxicology, Complutense University of Madrid, 28040 Madrid, Spain
| | - Stefano Rausei
- General Surgery Unit, Department of Surgery, Cittiglio-Angera Hospital, ASST SetteLaghi, 21100 Varese, Italy;
| | - Ines Rubio-Perez
- Colorectal Surgery Unit, Department of General Surgery, Hospital Universitario La Paz, 28029 Madrid, Spain;
- Hospital La Paz Institute for Health Research (Idipaz), 28029 Madrid, Spain
- Universidad Autonoma de Madrid, 28029 Madrid, Spain
| | - Maria Theodorakopoulou
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 10675 Athens, Greece;
| | - Kostoula Arvanti
- Department of Intensive Care Medicine, Papageorgiou Hospital, 54646 Thessaloniki, Greece;
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Yamamoto R, Kuramoto S, Shimizu M, Shinozaki H, Miyake T, Sadakari Y, Sekine K, Kaneko Y, Kurosaki R, Koizumi K, Shibusawa T, Sakurai Y, Wakahara S, Sasaki J. Optimal tentative abdominal closure for open abdomen: a multicenter retrospective observational study (OPTITAC study). Int J Surg 2023; 109:4049-4056. [PMID: 37678286 PMCID: PMC10720862 DOI: 10.1097/js9.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/07/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Primary fascia closure is often difficult following an open abdomen (OA). While negative-pressure wound therapy (NPWT) is recommended to enhance successful primary fascia closure, the optimal methods and degree of negative pressure remain unclear. This study aimed to elucidate optimal methods of NPWT as a tentative abdominal closure for OA to achieve primary abdominal fascia closure. MATERIALS AND METHODS A multicenter, retrospective, cohort study of adults who survived OA greater than 48 h was conducted in 12 institutions between 2010 and 2022. The achievement of primary fascia closure and incidence of enteroatmospheric fistula were examined based on methods (homemade, superficial NPWT kit, or open-abdomen kit) or degrees of negative pressure (<50, 50-100, or >100 mmHg). A generalized estimating equation was used to adjust for age, BMI, comorbidities, etiology for laparotomy requiring OA, vital signs, transfusion, severity of critical illness, and institutional characteristics. RESULTS Of the 279 included patients, 252 achieved primary fascia closure. A higher degree of negative pressure (>100 mmHg) was associated with fewer primary fascia closures than less than 50 mmHg [OR, 0.18 (95% CI: 0.50-0.69), P =0.012] and with more frequent enteroatmospheric fistula [OR, 13.83 (95% CI: 2.30-82.93)]. The methods of NPWT were not associated with successful primary fascia closure. However, the use of the open-abdomen kit was related to a lower incidence of enteroatmospheric fistula [OR, 0.02 (95% CI: 0.00-0.50)]. CONCLUSION High negative pressure (>100 mmHg) should be avoided in NPWT during tentative abdominal closure for OA.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo
| | - Shunsuke Kuramoto
- Department of Acute Care Surgery, Shimane University Faculty of Medicine, Shimane
| | - Masayuki Shimizu
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Kanagawa
| | | | - Tasuku Miyake
- Department of Acute Care Surgery, Shimane University Faculty of Medicine, Shimane
| | | | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo
| | - Yasushi Kaneko
- Department of Emergency Medicine, Hiratsuka City Hospital, Kanagawa
| | - Ryo Kurosaki
- Department of Surgery, Japanese Red Cross Maebashi Hospital, Gunma
| | - Kiyoshi Koizumi
- Department of Cardiovascular Surgery, Ashikaga Red Cross Hospital, Tochigi
| | - Takayuki Shibusawa
- Department of Emergency and Critical Care Medicine, National Hospital Organization Tokyo Medical Center, Tokyo
| | | | - Sota Wakahara
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo
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Sibilla MG, Cremonini C, Portinari M, Carcoforo P, Tartaglia D, Cicuttin E, Musetti S, Strambi S, Sartelli M, Radica MK, Catena F, Chiarugi M, Coccolini F, Salvetti F, Negoi I, Zese M, Occhionorelli S, Shlyapnikov S, Sugrue M, Demetrashvili Z, Dondossola D, Ioannidis O, Novelli G, Frattini C, Nacoti M, Khor D, Inaba K, Demetriades D, Kaussen T, Jusoh AC, Ghannam W, Sakakushev B, Guetta O, Dogjani A, Costa S, Singh S, Damaskos D, Isik A, Yuan KC, Trotta F, Rausei S, Martinez-Perez A, Bellanova G, Fonseca VC, Hernández F, Marinis A, Fernandes W, Quiodettis M, Bala M, Vereczkei A, Curado R, Fraga GP, Pereira BM, Gachabayov M, Chagerben GP, Arellano ML, Ozyazici S, Costa G, Tezcaner T, Porta M, Li Y, Karateke F, Manatakis D, Mariani F, Lora F, Sahderov I, Atanasov B, Zegarra S, Fattori L, Ivatury R, Xiao J, Ben-Ishay O, Zharikov A, Dubuisson V. Patients with an Open Abdomen in Asian, American and European Continents: A Comparative Analysis from the International Register of Open Abdomen (IROA). World J Surg 2023; 47:142-151. [PMID: 36326921 PMCID: PMC9726668 DOI: 10.1007/s00268-022-06733-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND International register of open abdomen (IROA) enrolls patients from several centers in American, European, and Asiatic continent. The aim of our study is to compare the characteristics, management and clinical outcome of adult patients treated with OA in the three continents. MATERIAL AND METHODS A prospective analysis of adult patients enrolled in the international register of open abdomen (IROA). TRIAL REGISTRATION NCT02382770. RESULTS 1183 patients were enrolled from American, European and Asiatic Continent. Median age was 63 years (IQR 49-74) and was higher in the European continent (65 years, p < 0.001); 57% were male. The main indication for OA was peritonitis (50.6%) followed by trauma (15.4%) and vascular emergency (13.5%) with differences among the continents (p < 0.001). Commercial NPWT was preferred in America and Europe (77.4% and 52.3% of cases) while Barker vacuum pack (48.2%) was the preferred temporary abdominal closure technique in Asia (p < 0.001). Definitive abdominal closure was achieved in 82.3% of cases in America (fascial closure in 90.2% of cases) and in 56.4% of cases in Asia (p < 0.001). Prosthesis were mostly used in Europe (17.3%, p < 0.001). The overall entero-atmospheric fistula rate 2.5%. Median open abdomen duration was 4 days (IQR 2-7). The overall intensive care unit and hospital length-of-stay were, respectively, 8 and 11 days (no differences between continents). The overall morbidity and mortality rates for America, Europe, and Asia were, respectively, 75.8%, 75.3%, 91.8% (p = 0.001) and 31.9%, 51.6%, 56.9% (p < 0.001). CONCLUSION There is no uniformity in OA management in the different continents. Heterogeneous adherence to international guidelines application is evident. Different temporary abdominal closure techniques in relation to indications led to different outcomes across the continents. Adherence to guidelines, combined with more consistent data, will ultimately allow to improving knowledge and outcome.
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Affiliation(s)
- Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Camilla Cremonini
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Mattia Portinari
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Dario Tartaglia
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Enrico Cicuttin
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Serena Musetti
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Silvia Strambi
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | | | - Margherita Koleva Radica
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Fausto Catena
- Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Massimo Chiarugi
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Federico Coccolini
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124, Pisa, Italy.
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Proaño-Zamudio JA, Gebran A, Argandykov D, Dorken-Gallastegi A, Saillant NN, Fawley JA, Onyewadume L, Kaafarani HMA, Fagenholz PJ, King DR, Velmahos GC, Hwabejire JO. Delayed fascial closure in nontrauma abdominal emergencies: A nationwide analysis. Surgery 2022; 172:1569-1575. [PMID: 35970609 DOI: 10.1016/j.surg.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Initially used in trauma management, delayed abdominal closure endeavors to decrease operative time during the index operation while still being lifesaving. Its use in emergency general surgery is increasing, but the data evaluating its outcome are sparse. We aimed to study the association between delayed abdominal closure, mortality, morbidity, and length of stay in an emergency surgery cohort. METHODS The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program database was examined for patients undergoing emergency laparotomy. The patients were classified by the timing of abdominal wall closure: delayed fascial closure versus immediate fascial closure. Propensity score matching was performed based on preoperative covariates, wound classification, and performance of bowel resection. The outcomes were then compared by univariable analysis. RESULTS After matching, both the delayed fascial closure and immediate fascial closure groups consisted of 3,354 patients each. Median age was 65 years, and 52.6% were female. The delayed fascial closure group had a higher in-hospital mortality (35.3% vs 25.0%, P < .001), a higher 30-day mortality (38.6% vs 29.0%, P < .001), a higher proportion of acute kidney injury (9.5% vs 6.6%, P < .001), a lower proportion of postoperative sepsis (11.8% vs 15.6%, P < .001), and a lower proportion of surgical site infection (3.4% vs 7.0%, P < .001). CONCLUSION Compared with immediate fascial closure, delayed fascial closure is associated with an increased mortality in the patients matched based on comorbidities and surgical site contamination. In emergency general surgery, delaying abdominal closure may not have the presumed overarching benefits, and its indications must be further defined in this population.
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Affiliation(s)
- Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/eljefe_md
| | - Anthony Gebran
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/AnthonyGebran
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/argandykov
| | - Ander Dorken-Gallastegi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/AnderDorken
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/MGHSurgery
| | - Jason A Fawley
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/fawley85
| | - Louisa Onyewadume
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/TraumaMGH
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/hayfaarani
| | - Peter J Fagenholz
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - David R King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. http://
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Retrospective Study of Indications and Outcomes of Open Abdomen with Negative Pressure Wound Therapy Technique for Abdominal Sepsis in a Tertiary Referral Centre. Antibiotics (Basel) 2022; 11:antibiotics11111498. [PMID: 36358153 PMCID: PMC9686976 DOI: 10.3390/antibiotics11111498] [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: 09/21/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
In patients with advanced sepsis from abdominal disease, the open abdomen (OA) technique as part of a damage control surgery (DCS) approach enables relook surgery to control infection, defer intestinal anastomosis, and prevent intra-abdominal hypertension. Limited evidence is available on key outcomes, such as mortality and rate of definitive fascial closure (DFC), which are needed for surgeons to select patients and adequate therapeutic strategies. Abdominal closure with negative pressure wound therapy (NPWT) has shown rates of DFC around 90%. We conducted a retrospective study to evaluate in-hospital survival and factors associated with mortality in acute, non-trauma patients treated using the OA technique and NPWT for sepsis from abdominal disease. Fifty consecutive patients treated using the OA technique and NPWT between February 2015 and July 2022 were included. Overall mortality was 32%. Among surviving patients, 97.7% of cases reached DFC, and the overall complication rate was 58.8%, with one case of entero-atmospheric fistula. At univariable analysis, age (p = 0.009), ASA IV status (<0.001), Mannheim Peritonitis Index > 30 (p = 0.001) and APACHE II score (p < 0.001) were associated with increased mortality. At multivariable analysis, higher APACHE II was a predictor of in-hospital mortality (OR 2.136, 95% CI 1.08−4.22; p = 0.029). Although very resource-intensive, DCS and the OA technique are valuable tools to manage patients with advanced abdominal sepsis, allowing reduced mortality and high DFC rates.
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Coccolini F, Gubbiotti F, Ceresoli M, Tartaglia D, Fugazzola P, Ansaloni L, Sartelli M, Kluger Y, Kirkpatrick A, Amico F, Catena F, Chiarugi M. Open Abdomen and Fluid Instillation in the Septic Abdomen: Results from the IROA Study. World J Surg 2020; 44:4032-4040. [PMID: 32833107 PMCID: PMC7599169 DOI: 10.1007/s00268-020-05728-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 02/05/2023]
Abstract
Background Open abdomen (OA) is a surgical option that can be used in patients with severe peritonitis. Few evidences exist to recommend the use of intraperitoneal fluid instillation associated with OA in managing septic abdomen. Materials and methods A prospective analysis of adult patients enrolled in the International Register of Open Abdomen (trial registration: NCT02382770) was performed. Results A total of 387 patients were enrolled in two groups: 84 with peritoneal fluid instillation (FI) and 303 without (NFI). The groups were homogeneous for baseline characteristics. Overall complications were 92.9% in FI and 86.3% in NFI (p = 0.106). Complications during OA were 72.6% in FI and 59.9% in NFI (p = 0.034). Complications after definitive closure were 70.8% in FI and 61.1% in NFI (p = 0.133). Entero-atmospheric fistula was 13.1% in FI and 12% in NFI (p = 0.828). Fascial closure was 78.6% in FI and 63.7% in NFI (p = 0.02). Analysis of FI in negative pressure wound therapy (NPWT) showed: Overall morbidity in NPWT was 94% and in non-NPWT 91.2% (p = 0.622) and morbidity during OA was 68% and 79.4% (p = 0.25), respectively. Definitive fascial closure in NPWT was 87.8% and 96.8% in non-NPWT (p = 0.173). Overall mortality was 40% in NPWT and 29.4% in non-NPWT (p = 0.32) and morality during OA period was 18% and 8.8% (p = 0.238), respectively. Conclusion We found intraperitoneal fluid instillation during open abdomen in peritonitic patients to increase the complication rate during the open abdomen period, with no impact on mortality, entero-atmospheric fistula rate and opening time. Fascial closure rate is increased by instillation. Fluid instillation is feasible even when associated with nonnegative pressure temporary abdominal closure techniques.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 1, 56124, Pisa, Italy.
| | | | - Marco Ceresoli
- General and Emergency Surgery Department, Milano-Bicocca University Hospital, Monza, Italy
| | - Dario Tartaglia
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 1, 56124, Pisa, Italy
| | - Paola Fugazzola
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Massimo Sartelli
- General and Emergency Surgery Department, Macerata Hospital, Macerata, Italy
| | - Yoram Kluger
- General Surgery Department, Rambam Medical Centre, Tel Aviv, Israel
| | | | - Francesco Amico
- Department of Surgery, Trauma Service, John Hunter Hospital, University of Newcastle, Newcastle, Australia
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Massimo Chiarugi
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 1, 56124, Pisa, Italy
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