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Fernandez CA. Damage Control Surgery and Transfer in Emergency General Surgery. Surg Clin North Am 2023; 103:1269-1281. [PMID: 37838467 DOI: 10.1016/j.suc.2023.06.004] [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] [Indexed: 10/16/2023]
Abstract
Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.
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Affiliation(s)
- Carlos A Fernandez
- Department of Surgery, Creighton University Medical Center, 7710 Mercy Road, Suite 2000, Omaha, NE 68124, USA.
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2
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Rajabaleyan P, Jensen RO, Möller S, Qvist N, Ellebaek MB. Primary anastomosis and suturing combined with vacuum-assisted abdominal closure in patients with secondary peritonitis due to perforation of the small intestine: a retrospective study. BMC Surg 2023; 23:280. [PMID: 37715227 PMCID: PMC10503050 DOI: 10.1186/s12893-023-02179-0] [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: 01/17/2023] [Accepted: 08/31/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Intestinal resection and a proximal stoma is the preferred surgical approach in patients with severe secondary peritonitis due to perforation of the small intestine. However, proximal stomas may result in significant nutritional problems and long-term parenteral nutrition. This study aimed to assess whether primary anastomosis or suturing of small intestine perforation is feasible and safe using the open abdomen principle with vacuum-assisted abdominal closure (VAC). METHODS Between January 2005 and June 2018, we performed a retrospective chart review of 20 patients (> 18 years) with diffuse faecal peritonitis caused by small intestinal perforation and treated with primary anastomosis/suturing and subsequent open abdomen with VAC. RESULTS The median age was 65 years (range: 23-90 years). Twelve patients were female (60%). Simple suturing of the small intestinal perforation was performed in three cases and intestinal resection with primary anastomosis in 17 cases. Four patients (20%) died within 90-days postoperatively. Leakage occurred in five cases (25%), and three patients developed an enteroatmospheric fistula (15%). Thirteen of 16 patients (83%) who survived were discharged without a stoma. The rest had a permanent stoma. CONCLUSIONS Primary suturing or resection with anastomosis and open abdomen with VAC in small intestinal perforation with severe faecal peritonitis is associated with a high rate of leakage and enteroatmospheric fistula formation. TRIAL REGISTRATION The study was approved by the Danish Patient Safety Authority (case number 3-3013-1555/1) and the Danish Data Protection Agency (file number 18/28,404). No funding was received.
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Affiliation(s)
- Pooya Rajabaleyan
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
| | - Rie Overgaard Jensen
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient data Explorative Network, Department of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Niels Qvist
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Mark Bremholm Ellebaek
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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3
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Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023; 47:1850-1880. [PMID: 37277507 PMCID: PMC10241558 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA 9110 USA
| | - Nicholas P. Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104 USA
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Rajabaleyan P, Michelsen J, Tange Holst U, Möller S, Toft P, Luxhøi J, Buyukuslu M, Bohm AM, Borly L, Sandblom G, Kobborg M, Aagaard Poulsen K, Schou Løve U, Ovesen S, Grant Sølling C, Mørch Søndergaard B, Lund Lomholt M, Ritz Møller D, Qvist N, Bremholm Ellebæk M. Vacuum-assisted closure versus on-demand relaparotomy in patients with secondary peritonitis-the VACOR trial: protocol for a randomised controlled trial. World J Emerg Surg 2022; 17:25. [PMID: 35619144 PMCID: PMC9137120 DOI: 10.1186/s13017-022-00427-x] [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: 02/10/2022] [Accepted: 05/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Secondary peritonitis is a severe condition with a 20–32% reported mortality. The accepted treatment modalities are vacuum-assisted closure (VAC) or primary closure with relaparotomy on-demand (ROD). However, no randomised controlled trial has been completed to compare the two methods potential benefits and disadvantages. Methods This study will be a randomised controlled multicentre trial, including patients aged 18 years or older with purulent or faecal peritonitis confined to at least two of the four abdominal quadrants originating from the small intestine, colon, or rectum. Randomisation will be web-based to either primary closure with ROD or VAC in blocks of 2, 4, and 6. The primary endpoint is peritonitis-related complications within 30 or 90 days and one year after index operation. Secondary outcomes are comprehensive complication index (CCI) and mortality after 30 or 90 days and one year; quality of life assessment by (SF-36) after three and 12 months, the development of incisional hernia after 12 months assessed by clinical examination and CT-scanning and healthcare resource utilisation. With an estimated superiority of 15% in the primary outcome for VAC, 340 patients must be included. Hospitals in Denmark and Europe will be invited to participate. Discussion There is no robust evidence for choosing either open abdomen with VAC treatment or primary closure with relaparotomy on-demand in patients with secondary peritonitis. The present study has the potential to answer this important clinical question. Trial Registration The study protocol has been registered at clinicaltrials.gov (NCT03932461). Protocol version 1.0, 9 January 2022. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00427-x.
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Affiliation(s)
- Pooya Rajabaleyan
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark. .,University of Southern Denmark, Odense, Denmark.
| | - Jens Michelsen
- Research Unit for Anaesthesiology, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Uffe Tange Holst
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient Data Explorative Network, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Palle Toft
- Research Unit for Anaesthesiology, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Jan Luxhøi
- Surgical Department, Hospital of Southwest Jutland, Esbjerg, Denmark
| | - Musa Buyukuslu
- Surgical Department, Hospital of Southwest Jutland, Esbjerg, Denmark
| | | | - Lars Borly
- Surgical Department, Holbæk Hospital, Holbæk, Denmark
| | | | | | - Kristian Aagaard Poulsen
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | | | - Sophie Ovesen
- Surgical Department, Viborg Hospital, Viborg, Denmark
| | | | | | | | | | - Niels Qvist
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Mark Bremholm Ellebæk
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
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5
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Cheng Y, Wang K, Gong J, Liu Z, Gong J, Zeng Z, Wang X. Negative pressure wound therapy for managing the open abdomen in non-trauma patients. Cochrane Database Syst Rev 2022; 5:CD013710. [PMID: 35514120 PMCID: PMC9073087 DOI: 10.1002/14651858.cd013710.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Management of the open abdomen is a considerable burden for patients and healthcare professionals. Various temporary abdominal closure techniques have been suggested for managing the open abdomen. In recent years, negative pressure wound therapy (NPWT) has been used in some centres for the treatment of non-trauma patients with an open abdomen; however, its effectiveness is uncertain. OBJECTIVES To assess the effects of negative pressure wound therapy (NPWT) on primary fascial closure for managing the open abdomen in non-trauma patients in any care setting. SEARCH METHODS In October 2021 we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL EBSCO Plus. To identify additional studies, we also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports. There were no restrictions with respect to language, date of publication, or study setting. SELECTION CRITERIA We included all randomised controlled trials (RCTs) that compared NPWT with any other type of temporary abdominal closure (e.g. Bogota bag, Wittmann patch) in non-trauma patients with open abdomen in any care setting. We also included RCTs that compared different types of NPWT systems for managing the open abdomen in non-trauma patients. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection process, risk of bias assessment, data extraction, and GRADE assessment of the certainty of evidence. MAIN RESULTS We included two studies, involving 74 adults with open abdomen associated with various conditions, predominantly severe peritonitis (N = 55). The mean age of the participants was 52.8 years; the mean proportion of women was 39.2%. Both RCTs were carried out in single centres and were at high risk of bias. Negative pressure wound therapy versus Bogota bag We included one study (40 participants) comparing NPWT with Bogota bag. We are uncertain whether NPWT reduces time to primary fascial closure of the abdomen (NPWT: 16.9 days versus Bogota bag: 20.5 days (mean difference (MD) -3.60 days, 95% confidence interval (CI) -8.16 to 0.96); very low-certainty evidence) or adverse events (fistulae formation, NPWT: 10% versus Bogota: 5% (risk ratio (RR) 2.00, 95% CI 0.20 to 20.33); very low-certainty evidence) compared with the Bogota bag. We are also uncertain whether NPWT reduces all-cause mortality (NPWT: 25% versus Bogota bag: 35% (RR 0.71, 95% CI 0.27 to 1.88); very low-certainty evidence) or length of hospital stay compared with the Bogota bag (NPWT mean: 28.5 days versus Bogota bag mean: 27.4 days (MD 1.10 days, 95% CI -13.39 to 15.59); very low-certainty evidence). The study did not report the proportion of participants with successful primary fascial closure of the abdomen, participant health-related quality of life, reoperation rate, wound infection, or pain. Negative pressure wound therapy versus any other type of temporary abdominal closure There were no randomised controlled trials comparing NPWT with any other type of temporary abdominal closure. Comparison of different negative pressure wound therapy devices We included one study (34 participants) comparing different types of NPWT systems (Suprasorb CNP system versus ABThera system). We are uncertain whether the Suprasorb CNP system increases the proportion of participants with successful primary fascial closure of the abdomen compared with the ABThera system (Suprasorb CNP system: 88.2% versus ABThera system: 70.6% (RR 0.80, 95% CI 0.56 to 1.14); very low-certainty evidence). We are also uncertain whether the Suprasorb CNP system reduces adverse events (fistulae formation, Suprasorb CNP system: 0% versus ABThera system: 23.5% (RR 0.11, 95% CI 0.01 to 1.92); very low-certainty evidence), all-cause mortality (Suprasorb CNP system: 5.9% versus ABThera system: 17.6% (RR 0.33, 95% CI 0.04 to 2.89); very low-certainty evidence), or reoperation rate compared with the ABThera system (Suprasorb CNP system: 100% versus ABThera system: 100% (RR 1.00, 95% CI 0.90 to 1.12); very low-certainty evidence). The study did not report the time to primary fascial closure of the abdomen, participant health-related quality of life, length of hospital stay, wound infection, or pain. AUTHORS' CONCLUSIONS Based on the available trial data, we are uncertain whether NPWT has any benefit in primary fascial closure of the abdomen, adverse events (fistulae formation), all-cause mortality, or length of hospital stay compared with the Bogota bag. We are also uncertain whether the Suprasorb CNP system has any benefit in primary fascial closure of the abdomen, adverse events, all-cause mortality, or reoperation rate compared with the ABThera system. Further research evaluating these outcomes as well as participant health-related quality of life, wound infection, and pain outcomes is required. We will update this review when data from the large studies that are currently ongoing are available.
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Affiliation(s)
- Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Ke Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Junhua Gong
- Organ Transplant Center, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zhong Zeng
- Organ Transplant Center, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xiaomei Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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The Significance of Visceral Protection in Preventing Enteroatmospheric Fistulae During Open Abdomen Treatment in Patients With Secondary Peritonitis: A Propensity Score-matched Case-control Analysis. Ann Surg 2021; 273:1182-1188. [PMID: 31318792 DOI: 10.1097/sla.0000000000003440] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the influence of a visceral protective layer (VPL) on the formation of enteroatmospheric fistulae (EAF) in open abdomen treatment (OAT) for peritonitis. BACKGROUND EAF formation is a severe complication of OAT. Despite the widespread use of OAT, there are no robust evidence-based recommendations for preventing EAF. METHODS A total of 120 peritonitis patients with secondary peritonitis as a result of a perforation of a hollow viscus or anastomotic insufficiency who had undergone OAT were included, and 14 clinical parameters were recorded in prospective OAT databases at 2 tertiary referral centers. For this analysis, patients with a VPL were assigned to the treatment group and those without a VPL to the control group. Propensity Score (PS) matching was performed. Known risk factors in OAT such as malignant disease, mortality, emergency operation, OAT duration, and fascial closure were matching variables. The influence of VPL on EAF formation was statistically evaluated using logistic regression analysis. RESULTS With 34 patients in each group, no notable differences were identified with regard to age, sex, underlying disease, mortality, emergency operation, fascial closure, and OAT duration. Overall, a mortality rate of 22.1% for OAT due to peritonitis was observed. Mean OAT duration was approximately 9 days, and secondary fascial closure was achieved in more than two-thirds of all patients. Fascial traction was used in more than 75% of cases. EAF formation was significantly more frequent in the control group (EAF formation: VPL group 2.9% vs control 26.5%; P = 0.00). In the final regression analysis, the use of VPL resulted in a significant reduction in the risk of EAF formation (odds ratio 0.08; 95% confidence interval 0.01-0.71, P = 0.02), which translates to a relative risk reduction of 89.1%. CONCLUSION VPL effectively prevents EAF formation during OAT in patients with peritonitis. We recommend the consistent use of VPL as part of a standardized OAT treatment algorithm.
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Gasser E, Rezaie D, Gius J, Lorenz A, Gehwolf P, Perathoner A, Öfner D, Kafka-Ritsch R. Lessons Learned in 11 Years of Experience With Open Abdomen Treatment With Negative-Pressure Therapy for Various Abdominal Emergencies. Front Surg 2021; 8:632929. [PMID: 34150837 PMCID: PMC8212035 DOI: 10.3389/fsurg.2021.632929] [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: 11/24/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Open abdomen (OA) treatment with negative-pressure therapy (NPT) was initiated for perforated diverticulitis and subsequently extended to other abdominal emergencies. The aim of this retrospective study was to analyze the indications, procedures, duration of NPT, and the outcomes of all our patients. Methods: All consecutive patients treated with intra-abdominal NPT from January 1, 2008 to December 31, 2018 were retrospectively analyzed. Results: A total of 438 patients (44% females) with a median (range) age of 66 (12-94) years, BMI of 25 (14-48) kg/m2, and ASA class I, II, III, and IV scores of 36 (13%), 239 (55%), 95 (22%), and 3(1%), respectively, were treated with NPT. The indication for surgery was primary bowel perforation in 163 (37%), mesenteric ischemia in 53 (12%), anastomotic leakage in 53 (12%), ileus in 53 (12%), postoperative bowel perforation/leakage in 32 (7%), abdominal compartment in 15 (3%), pancreatic fistula in 13 (3%), gastric perforation in 13 (3%), secondary peritonitis in 11 (3%), burst abdomen in nine (2%), biliary leakage in eight (2%), and other in 15 (3%) patients. A damage control operation without reconstruction in the initial procedure was performed in 164 (37%) patients. The duration of hospital and intensive care stay were, median (range), 28 (0-278) and 4 (0-214) days. The median (range) duration of operation was 109 (22-433) min and of NPT was 3(0-33) days. A trend to shorter duration of NPT was observed over time and in the colonic perforation group. The mean operating time was shorter when only blind ends were left in situ, namely 110 vs. 133 min (p = 0.006). The mortality rates were 14% at 30 days, 21% at 90 days, and 31% at 1 year. An entero-atmospheric fistula was observed in five (1%) cases, most recently in 2014. Direct fascia closure was possible in 417 (95%) patients at the end of NPT, but least often (67%, p = 0.00) in patients with burst abdomen. During follow-up, hernia repair was observed in 52 (24%) of the surviving patients. Conclusion: Open abdomen treatment with NPT is a promising concept for various abdominal emergencies, especially when treated outside normal working hours. A low rate of entero-atmospheric fistula formation and a high rate of direct fascia closure were achieved with dynamic approximation of the fascia edges. The authors recommend an early-in and early-out strategy as the prolongation of NPT by more than 1 week ends up in a frozen abdomen and does not improve abdominal sepsis.
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Affiliation(s)
| | | | - Johanna Gius
- Medical University Innsbruck, Innsbruck, Austria
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8
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Schaaf S, Schwab R, Willms A. Quality of Life After Open Abdominal Treatment With Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction. Mil Med 2021; 186:452-457. [PMID: 33499462 DOI: 10.1093/milmed/usaa336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/04/2020] [Accepted: 09/03/2020] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Little is known about the long-term outcome of open abdomen treatment with vacuum-assisted wound closure and mesh-3. Therefore, this study's purpose is to evaluate this with a particular focus on incisional hernia development and quality of life (QoL). MATERIALS AND METHODS Fifty-five patients who underwent vacuum-assisted wound closure and mesh-mediated fascial traction at our institution from 2006 to 2013 were prospectively enrolled in this study. After a median follow-up period of 3.8 years, 34 patients attended a follow-up examination, including the SF-36 QoL questionnaire. RESULTS The fascial closure rate was 74% (intention-to-treat) and 89% (per-protocol). Enteroatmospheric fistulae occurred in 1.8%. In-hospital mortality was 16.4%, and during the follow-up period, it was 27.4%. Incisional hernias developed in 35% of the cases.The SF-36 physical role (54.6 ± 41.0 (0-100), P < 0.01), physical functioning (68.4 ± 29.5 (0-100), P = 0.01), and physical component summary (41.6 ± 13.0 (19-62), P = 0.01) scores for the patient population were significantly lower than normative scores. The mental dimensions of QoL showed no differences.A subgroup analysis revealed that the lower scores for physical role, physical functioning, and physical component summary only existed in the subgroup of incisional hernia patients. In contrast, physical and mental SF-36 scores of patients without incisional hernias did not differ from the normative scores. CONCLUSIONS Vacuum-assisted wound closure and mesh-mediated fascial traction seems to result in low complication rates. However, incisional hernias occur in 35%, which are the leading cause of reduced QoL. Measures to further improve this rate, such as prophylactic meshes, have to be evaluated.
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Affiliation(s)
- Sebastian Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Rhineland-Palatinate, Koblenz, 56072, Germany
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Rhineland-Palatinate, Koblenz, 56072, Germany
| | - Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Rhineland-Palatinate, Koblenz, 56072, Germany
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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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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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11
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Rezende-Neto JB, Camilotti BG. New non-invasive device to promote primary closure of the fascia and prevent loss of domain in the open abdomen: a pilot study. Trauma Surg Acute Care Open 2020; 5:e000523. [PMID: 33225070 PMCID: PMC7661352 DOI: 10.1136/tsaco-2020-000523] [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: 05/25/2020] [Revised: 09/10/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023] Open
Abstract
Background Primary closure of the fascia at the conclusion of a stage laparotomy can be a challenging task. Current techniques to medialize the fascial edges in open abdomens entail several trips to the operating room and could result in fascial damage. We conducted a pilot study to investigate a novel non-invasive device for gradual reapproximation of the abdominal wall fascia in the open abdomen. Methods Mechanically ventilated patients ≥16 years of age with the abdominal fascia deliberately left open after a midline laparotomy for trauma and acute care surgery were randomized into two groups. Control group patients underwent standard care with negative pressure therapy only. Device group patients were treated with negative pressure therapy in conjunction with the new device for fascial reapproximation. Exclusion criteria: pregnancy, traumatic hernias, pre-existing ventral hernias, burns, and body mass index ≥40 kg/m2. The primary outcome was successful fascial closure by direct suture of the fascia without mesh or component separation. Secondary outcomes were abdominal wall complications. Results Thirty-eight patients were investigated, 20 in the device group and 18 in the control group. Primary closure of the fascia by direct suture without mesh or component separation was achieved in 17 patients (85%) in the device group and only 10 patients (55.6%) in the control group (p=0.0457). Device group patients were 53% more likely to experience primary fascial closure by direct suture than control group patients. Device group showed gradual reduction (p<0.005) in the size of the fascial defects; not seen in control group. There were no complications related to the device. Conclusions The new device applied externally on the abdominal wall promoted reapproximation of the fascia in the midline, preserved the integrity of the fascia, and improved primary fascial closure rate compared with negative pressure therapy system only. Level of evidence I, randomized controlled trial.
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Affiliation(s)
- Joao Baptista Rezende-Neto
- Surgery, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada.,General Surgery, St Michael's Hospital, Toronto, Ontario, Canada
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12
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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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13
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Müller V, Piper SK, Pratschke J, Raue W. Intraabdominal continuous negative pressure therapy for secondary peritonitis: an observational trial in a maximum care center. Acta Chir Belg 2020; 120:179-185. [PMID: 30947631 DOI: 10.1080/00015458.2019.1576448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Acute secondary peritonitis is afflicted with a high morbidity and mortality. Intensive care therapy, antibiotics and surgical procedures are mandatory. Continuous negative pressure therapy (cNPT) seems to be beneficial but it is unclear which patients will benefit most from this procedures.Methods: We performed a prospective observational trial including all patients that needed to undergo an exploratory laparotomy for the suspicion of acute secondary peritonitis and were treated with cNPT in one year.Results: Thirty nine patients fitted the criteria. Median hospitalization length was 40 days. The vacuum therapy treatment was applied for a median of 4 days. The subgroup analysis between patients, who received the cNPT-dressing for one time (Group A) and patients, in whom the cNPT was continued after first relaparotomy (Group B) showed no differences concerning patients' characteristics. The Mannheimer Peritonitis Index (MPI) during the first operation was significantly correlated with the number of dressing changes (Spearman's rho 0.518, p = .002).Conclusions: Fast acting in acute secondary peritonitis for elimination of the source, abdominal lavage, derivation of the exsudat and interdisciplinary treatment is the treatment of choice. The MPI could be beneficial for the decision process of using cNPT.
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Affiliation(s)
- V. Müller
- Department of Surgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - S. K. Piper
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - J. Pratschke
- Department of Surgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - W. Raue
- Clinic of General-, Visceral- and Thoracic Surgery, AKH Celle, Celle, Germany
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14
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Zosimas D, Lykoudis PM, Ivanov B, Hepworth C. Laparostomy and temporary abdominal closure outcomes in emergency non-trauma surgery and parameters affecting early definite primary fascial closure. MINERVA CHIR 2020; 75:419-425. [PMID: 32456399 DOI: 10.23736/s0026-4733.20.08320-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The open abdomen or laparostomy is a great advance of surgery based on the concept of damage control surgery. Aim of the study is to review the laparostomy outcomes of non-trauma emergency surgery patients in a district general hospital and identify parameters affecting early definite primary fascial closure. METHODS The records of all non-trauma emergency surgical patients who underwent laparostomy in a three-year period in a single institute were studied retrospectively. Outcomes included length of stay, morbidity, mortality, readmission rates, number of re-look operations, rate of definite primary fascial closure and time to closure. RESULTS Thirty-two patients were included. Morbidity was 84.4% and mortality rates were 21.9% (in-hospital), 18.8% (30-day) and 46.9% (overall). Median length of hospital stay was 22 days. Rate of primary fascial closure was 87.5% and median time to closure was two days. The number of relook operations was the only independent prognostic factor of definite early primary fascial closure, with higher rates of closure in patients with 1-2 relooks. CONCLUSIONS Although the open abdomen has been demonstrated to improve survival, the precise role in abdominal sepsis has not been elucidated. Current consensus does not support use of open abdomen routinely, however in selected situations it becomes unavoidable. Laparostomy is a valid option in non-trauma emergency surgery and can be managed safely in a district hospital. High closure rates can be achieved if one or two re-look operations are performed with an early attempt for closure.
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Affiliation(s)
- Dimitrios Zosimas
- Department of General Surgery, Queen's Hospital, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK -
| | - Panagis M Lykoudis
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Bogdan Ivanov
- Department of General Surgery, Queen's Hospital, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK
| | - Clive Hepworth
- Department of General Surgery, Queen's Hospital, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK
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15
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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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16
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Martin-Loeches I, Timsit JF, Leone M, de Waele J, Sartelli M, Kerrigan S, Azevedo LCP, Einav S. Clinical controversies in abdominal sepsis. Insights for critical care settings. J Crit Care 2019; 53:53-58. [DOI: 10.1016/j.jcrc.2019.05.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/27/2022]
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17
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Apelqvist J, Willy C, Fagerdahl AM, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Vowden P. EWMA Document: Negative Pressure Wound Therapy. J Wound Care 2019; 26:S1-S154. [PMID: 28345371 DOI: 10.12968/jowc.2017.26.sup3.s1] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.1 NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4-6 dehisced sternal wounds following cardiac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.11 While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.
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Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, 205 02 Malmö, Sweden and Division for Clinical Sciences, University of Lund, 221 00 Lund, Sweden
| | - Christian Willy
- Department of Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Bundeswehr Hospital Berlin, Research and Treatment Center for Complex Combat Injuries, Federal Armed Forces of Germany, 10115 Berlin, Germany
| | - Ann-Mari Fagerdahl
- Department of Clinical Science and Education, Karolinska Institutet, and Wound Centre, Södersjukhuset AB, SE-118 83 Stockholm, Sweden
| | - Marco Fraccalvieri
- Plastic Surgery Unit, ASO Città della Salute e della Scienza of Turin, University of Turin, 10100 Turin, Italy
| | | | - Alberto Piaggesi
- Department of Endocrinology and Metabolism, Pisa University Hospital, 56125 Pisa, Italy
| | - Astrid Probst
- Kreiskliniken Reutlingen GmbH, 72764 Reutlingen, Germany
| | - Peter Vowden
- Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
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18
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Suzuki M, Matsushima H, Uehara K, Saiki T, Hayamizu A, Kamisasanuki T, Sugiki D. Stomal stenosis during gradual closure of a traumatic abdominal wall hernia. Int J Surg Case Rep 2019; 60:284-286. [PMID: 31265988 PMCID: PMC6609734 DOI: 10.1016/j.ijscr.2019.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 11/16/2022] Open
Abstract
Stomal stenosis can develop after repair of a traumatic abdominal wall hernia. Abdominal wall repair with negative-pressure wound therapy may be effective. Stomal patency must be evaluated during the abdominal wall hernia repair.
Introduction Traumatic abdominal wall hernias are often accompanied by intra-abdominal injuries, and a stoma may be required. Although rare, stomal stenosis can develop after the repair of a traumatic abdominal wall hernia. Presentation of case A 65-year-old woman was in a head-on collision with a truck and was brought by ambulance to our facility. The findings of a physical examination and computed tomography scan suggested bowel perforation for which exploratory surgery was performed. The lacerated small bowel and sigmoid colon were resected and an ileostomy and colostomy were created. Abdominal wall reconstruction was impossible because of the large defect size. Repair of the abdominal wall was achieved by gradual closure of the fascia after surgery in combination with negative pressure wound therapy. Stenosis of the ileostomy occurred during this process and was surgically repaired. Discussion We reconstructed the abdominal wall using negative pressure wound therapy in combination with sutures while minimizing the risk of abdominal compartment syndrome. This approach did not increase the intra-abdominal pressure, but it deformed the abdominal wall, resulting in unexpected stenosis of the ostomy. Conclusion Gradual postoperative closure of a traumatic abdominal wall hernia with an ostomy in place may result in stomal stenosis. Stomal patency must be carefully evaluated during this process.
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Affiliation(s)
- Mitsuhiro Suzuki
- Department of Emergency and Critical Care Medicine, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan.
| | - Hisao Matsushima
- Department of Emergency and Critical Care Medicine, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Katsuki Uehara
- Department of Emergency and Critical Care Medicine, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Tatsuhiko Saiki
- Department of Emergency and Critical Care Medicine, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Atsuki Hayamizu
- Department of Emergency and Critical Care Medicine, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Toshirou Kamisasanuki
- Department of Emergency and Critical Care Medicine, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Daisuke Sugiki
- Department of Emergency and Critical Care Medicine, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
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López-Cano M, García-Alamino JM, Antoniou SA, Bennet D, Dietz UA, Ferreira F, Fortelny RH, Hernandez-Granados P, Miserez M, Montgomery A, Morales-Conde S, Muysoms F, Pereira JA, Schwab R, Slater N, Vanlander A, Van Ramshorst GH, Berrevoet F. EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen. Hernia 2018; 22:921-939. [DOI: 10.1007/s10029-018-1818-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 08/21/2018] [Indexed: 12/22/2022]
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20
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Abstract
Due to the abundant and lax tissue of the abdominal wall, most ventral trunk defects are amenable to local soft tissue closure. However, when abdominal defects are accompanied by a lack of soft tissue, the surgeon faces a more complex subset of reconstructions. Three important principles guide the reconstruction of these wounds: timing of closure, careful assessment of the true extent of the wound, and the components of the defect. This article focuses on these three guiding principles and suggests the authors' preferred technique for these difficult defects.
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Affiliation(s)
- Margaret S Roubaud
- Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Donald P Baumann
- Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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21
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Jakob MO, Schwarz C, Haltmeier T, Zindel J, Pinworasarn T, Candinas D, Starlinger P, Beldi G. Mesh-augmented versus direct abdominal closure in patients undergoing open abdomen treatment. Hernia 2018; 22:785-792. [PMID: 30027445 PMCID: PMC6153946 DOI: 10.1007/s10029-018-1798-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/13/2018] [Indexed: 01/29/2023]
Abstract
Background Open abdomen (OA) may be required in patients with abdominal trauma, sepsis or compartment syndrome. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) is a widely used approach for temporary abdominal closure to close the abdominal wall. However, this method is associated with a high incidence of re-operations in short term and late sequelae such as incisional hernia. The current study aims to compare the results of surgical strategies of OA with versus without permanent mesh augmentation. Methods Patients with OA treatment undergoing vacuum-assisted wound closure and an intraperitoneal onlay mesh (VAC-IPOM) implantation were compared to VAWCM with direct fascial closure which represents the current standard of care. Outcomes of patients from two tertiary referral centers that performed the different strategies for abdominal closure after OA treatment were compared in univariate and multivariate regression analysis. Results A total of 139 patients were included in the study. Of these, 50 (36.0%) patients underwent VAC-IPOM and 89 (64.0%) patients VAWCM. VAC-IPOM was associated with reduced re-operations (adjusted incidence risk ratio 0.48 per 10-person days; CI 95% = 0.39–0.58, p < 0.001), reduced duration of stay on intensive care unit (ICU) [adjusted hazard ratio (aHR) 0.53; CI 95% = 0.36–0.79, p = 0.002] and reduced hospital stay (aHR 0.61; CI 95% = 0.040–0.94; p = 0.024). In-hospital mortality [22.5 vs 18.0%, risk difference − 4.5; confidence interval (CI) 95% = − 18.2 to 9.3; p = 0.665] and the incidence of intestinal fistula (18.0 vs 22.0%, risk difference 4.0; CI 95% = −10.0 to 18.0; p = 0.656) did not differ between the two groups. In Kaplan–Meier analysis, hernia-free survival was significantly increased after VAC-IPOM (p = 0.041). Conclusions In patients undergoing OA treatment, intraperitoneal mesh augmentation is associated with a significantly decreased number of re-operations, duration of hospital and ICU stay and incidence of incisional hernias when compared to VAWCM. Electronic supplementary material The online version of this article (10.1007/s10029-018-1798-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M O Jakob
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - C Schwarz
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - T Haltmeier
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - J Zindel
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - T Pinworasarn
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - D Candinas
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland
| | - P Starlinger
- Department of Surgery, General Hospital, Medical University of Vienna, Vienna, Austria
| | - G Beldi
- Department of Visceral Surgery and Medicine, University Hospital, Bern, Switzerland.
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22
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Fortelny RH. Abdominal Wall Closure in Elective Midline Laparotomy: The Current Recommendations. Front Surg 2018; 5:34. [PMID: 29876355 PMCID: PMC5974102 DOI: 10.3389/fsurg.2018.00034] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 04/09/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction The risk of developing an incisional hernia after primary elective median laparotomy is reported in the literature as being between 5 and 20 percent. The goal of this systematic review was to evaluate different closure techniques for midline laparotomies and the use of additional prophylactic mesh augmentation for midline closure in high risk patients. Method A systematic literature search was performed until September 2017. The quality of the RCTs was evaluated and analysed. The data are reported in accordance with the Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results In the systematic review for closure techniques a total of 23 RCTs and 9 RCTs for the use of prophylactic mesh were included. In elective midline closure the use of a slowly absorbable suture material for continuous closure using the small bites technique results in significantly less incisional hernias than a large bites technique (OR 0.41; 95% CI 0.19, 0.86). The use of prophylactic mesh versus the suture closure of the midline achieved a significant reduction of the incisional hernia rate [OR 0.14 (95% CI 0.07-0.27)]. Conclusions Based on the currently evidence in midline closure after elective laparotomy in the small bites technique can be recommended to reduce significantly the rate of incisional hernia. The additional use of a prophylactic mesh in high risk patients can significantly reduce the occurrence of incisional hernia.
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Affiliation(s)
- René H Fortelny
- Department of General, Viszeral and Oncologic Surgery, Wilhelminenspital, Vienna, Austria.,Medical Faculty, Sigmund Freud University Vienna, Vienna, Austria
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23
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Abstract
Management of a patient with an open abdomen is difficult, and the primary closure of the fascial edges is essential to obtain the best patient outcome, regardless of the initial etiology of the open abdomen. The use of temporary abdominal closure devices is nowadays the gold standard to have the highest closure rates with mesh-mediated fascial traction as the proposed standard of care. However, the incidence of incisional hernias, although much more controlled than when leaving an abdomen open, is high and reaches up to 65%. As shown for other high-risk patient subgroups, such as obese patients, patients with an abdominal aneurysm, and patients with former -ostomy sites, the prevention of incisional hernias might be key to further optimize patient outcomes after open abdomen treatment. In this overview, current available modalities to decrease the incidence of incisional hernia are discussed. Most of these preventive options have been shown effective in giant ventral hernia repair and might work effectively in this patient cohort with open abdomen as well.
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Affiliation(s)
- Frederik Berrevoet
- Ghent University Hospital, Department of General and HPB Surgery and Liver Transplantation, Ghent, Belgium
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24
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Heise D, Eickhoff R, Kroh A, Binnebösel M, Klinge U, Klink CD, Neumann UP, Lambertz A. Elastic TPU Mesh as Abdominal Wall Inlay Significantly Reduces Defect Size in a Minipig Model. J INVEST SURG 2018; 32:501-506. [PMID: 29469618 DOI: 10.1080/08941939.2018.1436207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: The open abdomen with mesh implantation, followed by early reoperation with fascial closure, is a modern surgical approach in difficult clinical situations such as severe abdominal sepsis. As early fascial closure is not possible in many cases, mesh-mediated fascial traction is helpful for conditioning of a minimized ventral hernia after open abdomen. The aim of this study was to evaluate the clinical utilization of an innovative elastic thermoplastic polyurethane mesh (TPU) as an abdominal wall inlay in a minipig model. Methods: Ten minipigs were divided in two groups, either receiving an elastic TPU mesh or a nonelastic polyvinylidene fluoride (PVDF) mesh in inlay position of the abdominal wall. After 8 weeks, mesh expansion and abdominal wall defect size were measured. Finally, pigs were euthanized and abdominal walls were explanted for histological and immunohistochemical assessment. Results: Eight weeks after abdominal wall replacement, transversal diameter of the fascial defect in the TPU group was significantly smaller than in the PVDF group (4.5 cm vs. 7.4 cm; p = 0.047). Immunhistochemical analysis showed increased Ki67 positive cells (p = 0.003) and a higher number of apoptotic cells (p = 0.047) after abdominal wall replacement with a TPU mesh. Collagen type I/III ratio was increased in the PVDF group (p = 0.011). Conclusion: Implantation of an elastic TPU mesh as abdominal wall inlay is a promising approach to reduce the size of the ventral hernia after open abdomen by mesh-mediated traction. However, this effect was associated with a slightly increased foreign body reaction in comparison to the nonelastic PVDF.
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Affiliation(s)
- D Heise
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - R Eickhoff
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - A Kroh
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - M Binnebösel
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - U Klinge
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - C D Klink
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - U P Neumann
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany.,Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - A Lambertz
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Aachen, Germany
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25
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Acosta S, Seternes A, Venermo M, Vikatmaa L, Sörelius K, Wanhainen A, Svensson M, Djavani K, Björck M. Open Abdomen Therapy with Vacuum and Mesh Mediated Fascial Traction After Aortic Repair: an International Multicentre Study. Eur J Vasc Endovasc Surg 2017; 54:697-705. [PMID: 29033336 DOI: 10.1016/j.ejvs.2017.09.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/05/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Open abdomen therapy may be necessary to prevent or treat abdominal compartment syndrome (ACS). The aim of the study was to analyse the primary delayed fascial closure (PDFC) rate and complications after open abdomen therapy with vacuum and mesh mediated fascial traction (VACM) after aortic repair and to compare outcomes between those treated with open abdomen after primary versus secondary operation. METHODS This was a retrospective cohort, multicentre study in Sweden, Finland, and Norway, including consecutive patients treated with open abdomen and VACM after aortic repair at six vascular centres in 2006-2015. The primary endpoint was PDFC rate. RESULTS Among 191 patients, 155 were men. The median age was 71 years (IQR 66-76). Ruptured abdominal aortic aneurysm (RAAA) occurred in 69.1%. Endovascular/hybrid and open repairs were performed in 49 and 142 patients, respectively. The indications for open abdomen were inability to close the abdomen (62%) at primary operation and ACS (80%) at secondary operation. Duration of open abdomen was 11 days (IQR 7-16) in 157 patients alive at open abdomen termination. The PDFC rate was 91.8%. Open abdomen initiated at primary (N=103), compared with secondary operation (N=88), was associated with less severe initial open abdomen status (p=.006), less intestinal ischaemia (p=.002), shorter duration of open abdomen (p=.007), and less renal replacement therapy (RRT, p<.001). In hospital mortality was 39.3%, and after entero-atmospheric fistula (N=9) was 88.9%. Seven developed graft infection within 6 months, 1 year mortality was 28.6%. Intestinal ischaemia (OR 3.71, 95% CI 1.55-8.91), RRT (OR 3.62, 95% CI 1.72-7.65), and age (OR 1.12, 95% CI 1.06-1.12), were independent factors associated with in hospital mortality, but not open abdomen initiated at primary versus secondary operation. CONCLUSIONS VACM was associated with a high PDFC rate after prolonged open abdomen therapy following aortic repair. Patient outcomes seemed better when open abdomen was initiated at primary, compared with secondary operation but a selection effect is possible.
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Affiliation(s)
- Stefan Acosta
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden; Vascular Centre, Department of Cardio-Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.
| | - Arne Seternes
- Department of Vascular Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leena Vikatmaa
- Department of Anaesthetics, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karl Sörelius
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Mats Svensson
- Department of Surgery, Falun Hospital, Falun, Sweden
| | | | - Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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26
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Coccolini F, Montori G, Ceresoli M, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Sartelli M, De Moya M, Velmahos G, Fraga GP, Pereira BM, Leppaniemi A, Boermeester MA, Kirkpatrick AW, Maier R, Bala M, Sakakushev B, Khokha V, Malbrain M, Agnoletti V, Martin-Loeches I, Sugrue M, Di Saverio S, Griffiths E, Soreide K, Mazuski JE, May AK, Montravers P, Melotti RM, Pisano M, Salvetti F, Marchesi G, Valetti TM, Scalea T, Chiara O, Kashuk JL, Ansaloni L. The role of open abdomen in non-trauma patient: WSES Consensus Paper. World J Emerg Surg 2017; 12:39. [PMID: 28814969 PMCID: PMC5557069 DOI: 10.1186/s13017-017-0146-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022] Open
Abstract
The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore hospital, Parma, Italy
| | | | - Rao Ivatury
- Trauma Surgery, Virginia Commonwealth University, Richmond, VA 23284 USA
| | - Walter Biffl
- Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI 96813 USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, 15213 USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, 92103 USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Marc De Moya
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | - George Velmahos
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | | | - Bruno M. Pereira
- Faculdade de Ciências Médicas (FCM) – Unicamp Campinas, São Paulo, Brazil
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | | | | | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, 98104 USA
| | - Miklosh Bala
- General Surgery Department, Hadassah Medical Centre, Jerusalem, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | | | - Manu Malbrain
- ICU and High Care Burn Unit, Ziekenhius Netwerk Antwerpen, Antwerpen, Belgium
| | | | | | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Ewen Griffiths
- Upper Gatrointestinal Surgery, Birmigham Hospital, Birmigham, UK
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University, Saint Louis, MO 63130 USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN 37232 USA
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | | | - Michele Pisano
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Francesco Salvetti
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Tino M. Valetti
- ICU Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Thomas Scalea
- Trauma Surgery department, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Osvaldo Chiara
- Emergency and Trauma Surgery department, Niguarda Hospital, Milan, Italy
| | - Jeffry L. Kashuk
- General Surgery department, Assuta Medical Centers, Tel Aviv, Israel
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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27
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Open abdomen with vacuum-assisted wound closure and mesh-mediated fascial traction in patients with complicated diffuse secondary peritonitis: A single-center 8-year experience. J Trauma Acute Care Surg 2017; 82:1100-1105. [PMID: 28338592 DOI: 10.1097/ta.0000000000001452] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Open abdomen (OA) treatment in patients with peritonitis is increasing worldwide. Various temporary abdominal closure devices are being used. This study included patients with complicated diffuse secondary peritonitis, OA, and vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). The aim of this study was to describe mortality and major morbidity in terms of delayed primary fascial closure and enteroatmospheric fistula rates. METHODS This was a single-academic-center retrospective study of consecutive patients with diffuse peritonitis, OA, and VAWCM between years 2008 and 2016. Descriptive and univariate analyses were performed. RESULTS Forty-one patients were identified and analyzed. Median age was 59 years, preoperative septic shock was diagnosed in 54% (n = 22), and 59% (n = 24) had a postoperative peritonitis. Mortality was 29% (n = 12), and 76% (n = 31) of patients were admitted in the intensive care unit. The median duration of OA was 7 days with a median of two dressing changes. Delayed primary fascial closure rate among survivors was 92% (n = 33), and enteroatmospheric fistulas developed in 7% (n = 3). In a subgroup analysis, patients with OA in the primary laparotomy for peritonitis (n = 27) were compared with patients with OA in the subsequent laparotomies (n = 14). There were no significant differences between groups. CONCLUSIONS The VAWCM technique in patients with complicated secondary diffuse peritonitis and OA yields excellent results in terms of delayed primary fascial closure rate and a low number of enteroatmospheric fistulas. It seems to be safe to close the abdomen at the index laparotomy, if possible, even if there is a risk of a need of OA later. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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28
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Montori G, Allievi N, Coccolini F, Solaini L, Campanati L, Ceresoli M, Fugazzola P, Manfredi R, Magnone S, Tomasoni M, Ansaloni L. Negative Pressure Wound Therapy versus modified Barker Vacuum Pack as temporary abdominal closure technique for Open Abdomen management: a four-year experience. BMC Surg 2017; 17:86. [PMID: 28732537 PMCID: PMC5521106 DOI: 10.1186/s12893-017-0281-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 07/11/2017] [Indexed: 12/16/2022] Open
Abstract
Background We reviewed our experience with patients presenting with trauma and peritonitis who underwent an open abdomen (OA) procedure, and compared outcomes between Negative Pressure Wound Therapy (NPWT) and a modified Barker Vacuum Pack (mBVP) technique. Methods In this descriptive study, we retrospectively analyzed data regarding all patients who underwent OA for intra-abdominal sepsis or abdominal trauma at our Centre from January 2012 to December 2015. Demographic data, co-morbidities, indications to surgery, intra-operative details and Björck classification grade were considered. Outcomes included were: time to closure in days, fascial closure rates, ICU and hospital stay, in-hospital and overall mortality, and entero-atmospheric fistula rate. Results A total of 83 cases were considered. Mean closure time was 6 days versus 6.5 days (p = 0.71) in NPWT and mBVP groups, respectively; the fascial closure rate was 75.4% versus 93.8% (p = 0.10). At multivariate analysis, in-hospital and overall mortality were significantly higher within the mBVP, as compared to NPWT (OR 3.8, 95% CI 1.1 to 13.1, p = 0.02 – OR 4.2, 95% CI 1.2 to 14.1, p = 0.01). Entero-atmospheric fistula rate was 2.6% in the two groups. Conclusions NPWT as a temporary abdominal closure technique, as compared to mBVP, appears to be associated with better outcomes in terms of mortality. Electronic supplementary material The online version of this article (doi:10.1186/s12893-017-0281-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giulia Montori
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy
| | - Niccolò Allievi
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy.
| | - Federico Coccolini
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy
| | - Leonardo Solaini
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy
| | - Luca Campanati
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy
| | - Marco Ceresoli
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy
| | - Paola Fugazzola
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy
| | - Roberto Manfredi
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy
| | - Stefano Magnone
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy
| | - Matteo Tomasoni
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy
| | - Luca Ansaloni
- Unit of General Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24127, Bergamo, Italy
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29
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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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30
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Willms A, Schaaf S, Schwab R, Richardsen I, Jänig C, Bieler D, Wagner B, Güsgen C. Intensive care and health outcomes of open abdominal treatment: long-term results of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). Langenbecks Arch Surg 2017; 402:481-492. [PMID: 28382564 DOI: 10.1007/s00423-017-1575-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/08/2017] [Indexed: 01/31/2023]
Abstract
PURPOSE The study's purpose is to evaluate the long-term outcome after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) and to identify predictors of quality of life associated with intensive care. METHODS Fifty-five patients who underwent open abdomen management at our institution from 2006 to 2013 were prospectively enrolled in this study. After a median follow-up period of 3.8 years, 27 patients completed the 36-Item Short Form Survey (SF-36) quality of life questionnaire. As this is a report solely focused on quality of life, direct treatment-related outcome measures like mortality, closure rates, and incisional hernia development of this study cohort have been reported previously. RESULTS = 0.50, β = -0.70, p = 0.02). CONCLUSIONS Despite high short-term mortality and morbidity rates for these critically ill patients, open abdomen treatment using VAWCM allows patients to recover to an acceptable long-term quality of life. The complex intensive care score can be used as a surrogate parameter for the global severity of illness and was the only predictor of physical functioning (SF-36).
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Affiliation(s)
- A Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany.
| | - S Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - R Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - I Richardsen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - C Jänig
- Department of Anesthesiology and Intensive Care, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - D Bieler
- Department of Trauma Surgery and Orthopedics, Plastic and Reconstructive Surgery, and Hand Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - B Wagner
- Support Division of the Directorate-General for Strategy and Operations, Federal Ministry of Defense, Berlin, Germany
| | - C Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
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Cristaudo A, Jennings S, Gunnarsson R, Decosta A. Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis. Am Surg 2017. [DOI: 10.1177/000313481708300220] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Temporary abdominal closure (TAC) techniques are routinely used in the open abdomen. Ideally, they should prevent evisceration, aid in removal of unwanted fluid from the peritoneal cavity, facilitate in achieving safe definitive fascial closure, as well as prevent the development of intra-abdominal complications. TAC techniques used in the open abdomen were compared with negative pressure wound therapy (NPWT) to identify which was superior. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines involving Medline, Excerpta Medica, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Clinicaltrials.gov. All studies describing TAC technique use in the open abdomen were eligible for inclusion. Data were analyzed per TAC technique in the form of a meta-analysis. A total of 225 articles were included in the final analysis. A meta-analysis involving only randomized controlled trials showed that NPWT with continuous fascial closure was superior to NPWT alone for definitive fascial closure [mean difference (MD): 35% ± 23%; P = 0.0044]. A subsequent meta-analysis involving all included studies confirmed its superiority across outcomes for definitive fascial closure (MD: 19% ± 3%; P < 0.0001), perioperative (MD: -4.0% ± 2.4%; P = 0.0013) and in-hospital (MD: -5.0% ± 2.9%; P = 0.0013) mortality, entero-atmospheric fistula (MD: 22.0% ± 1.8%; P = 0.0041), ventral hernia (MD: -4.0% ± 2.4%; P = 0.0010), and intra-abdominal abscess (MD: -3.1% ± 2.1%; P = 0.0044). Therefore, it was concluded that NPWT with continuous fascial traction is superior to NPWT alone.
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Affiliation(s)
- Adam Cristaudo
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Scott Jennings
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Ronny Gunnarsson
- James Cook University, School of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Alan Decosta
- James Cook University, School of Medicine, Cairns Hospital, Cairns, Queensland, Australia
- Department of Surgery, Cairns Hospital, Cairns, Queensland, Australia
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Boele van Hensbroek P, Atema JJ, Herrle F, Dijkgraaf MGW, Goslings JC. Negative pressure wound therapy for managing the open abdomen after midline laparotomy. Hippokratia 2016. [DOI: 10.1002/14651858.cd011356.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Pieter Boele van Hensbroek
- Academic Medical Center; Department of Surgery; Meibergdreef 9 PO Box 22660 Amsterdam Netherlands 1100 DD
| | - Jasper J Atema
- Academic Medical Centre; Department of Surgery; Meibergdreef 9 PO Box 22660 Amsterdam Netherlands 1100 DD
| | - Florian Herrle
- University Medical Centre Mannheim, University of Heidelberg; Department of Surgery; Theodor-Kutzer-Ufer 1-3 Mannheim Germany D-68167
| | - Marcel GW Dijkgraaf
- Academic Medical Center; Clinical Epidemiology, Biostatistics and Bioinformatics; P.O. Box 22660 Amsterdam Netherlands 1100DD
| | - J Carel Goslings
- Academic Medical Center; Trauma Unit, Department of Surgery; Meibergdreef 9 Amsterdam Netherlands 1105 AZ
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Willms A, Schaaf S, Schwab R, Richardsen I, Bieler D, Wagner B, Güsgen C. Abdominal wall integrity after open abdomen: long-term results of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). Hernia 2016; 20:849-858. [PMID: 27601035 DOI: 10.1007/s10029-016-1534-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 08/28/2016] [Indexed: 01/30/2023]
Abstract
PURPOSE The open abdomen has become a standard technique in the management of critically ill patients undergoing surgery for severe intra-abdominal conditions. Negative pressure and mesh-mediated fascial traction are commonly used and achieve low fistula rates and high fascial closure rates. In this study, long-term results of a standardised treatment approach are presented. METHODS Fifty-five patients who underwent OA management for different indications at our institution from 2006 to 2013 were enrolled. All patients were treated under a standardised algorithm that uses a combination of vacuum-assisted wound closure and mesh-mediated fascial traction. Structured follow-up assessments were offered to patients and included a medical history, a clinical examination and abdominal ultrasonography. The data obtained were statistically analysed. RESULTS The fascial closure rate was 74 % in an intention-to-treat analysis and 89 % in a per-protocol analysis. The fistula rate was 1.8 %. Thirty-four patients attended follow-up. The median follow-up was 46 months (range 12-88 months). Incisional hernias developed in 35 %. Patients with hernias needed more operative procedures (10.3 vs 3.4, p = 0.03) than patients without hernia formation. A Patient Observer Scar Assessment Scale (POSAS) of 31.1 was calculated. Patients with symptomatic hernias (NAS of 2-10) had a significantly lower mean POSAS score (p = 0.04). CONCLUSIONS Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) seem to result in low complication rates and high fascial closure rates. Abdominal wall reconstruction, which is a challenging and complex procedure and causes considerable patient discomfort, can thus be avoided in the majority of cases. Available results are based on studies involving only a small number of cases. Multi-centre studies and registry-based data are therefore needed to validate these findings.
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Affiliation(s)
- A Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Strasse 170, 56072, Koblenz, Germany.
| | - S Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Strasse 170, 56072, Koblenz, Germany
| | - R Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Strasse 170, 56072, Koblenz, Germany
| | - I Richardsen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Strasse 170, 56072, Koblenz, Germany
| | - D Bieler
- Department of Trauma Surgery and Orthopaedics, Plastic and Reconstructive Surgery, and Hand Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - B Wagner
- Directorate-General for Strategy and Operations, Federal Ministry of Defence, Berlin, Germany
| | - C Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Strasse 170, 56072, Koblenz, Germany
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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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Quality of life and hernia development 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction. Hernia 2016; 20:755-64. [PMID: 27324880 DOI: 10.1007/s10029-016-1516-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 06/09/2016] [Indexed: 12/29/2022]
Abstract
PURPOSE To report incisional hernia (IH) incidence, abdominal wall (AW) discomfort and quality of life (QoL) 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). METHODS Five-year follow-up of patients included in a prospective study 2006-2009. The protocol included physical examination, patient interview, chart review, questionnaires on abdominal wall and stoma complaints and the SF-36 questionnaire. RESULTS Fifty-five (12 women, 43 men; median age 70 years) of 111 included patients were alive. Follow-up rate was 91 %. Cumulative IH incidence during the whole study was 62 %. One-third of the IHs was repaired. At 5-year follow-up 59 % of IHs were clinically detectable. AW symptoms were equivalent in patients with (15/23) and without (11/21) IH (p = 0.541). SF-36 scores were lower than population mean for component scores and all subscales except bodily pain. Patients with major co-morbidity had lower physical component score [31.6 (95 %, CI 25.6-37.4)] compared to those without [48.9 (95 %, CI 46.2-51.4)]. Major co-morbidity was not associated with IH (p = 0.56), AW symptoms (p = 0.54) or stoma (p = 0.10). Patients with IH or other AW symptoms had similar SF-36 results compared to those without, whereas patients with a stoma had >5 point lower mean scores for general health, social function and physical component score compared to those without. CONCLUSIONS VAWCM treatment results in high incidence of IH. However, at five years, there was no detectable difference in abdominal wall complaints and QoL in patients with IH compared to those without. Lower QoL appeared mainly to be associated with the presence of major co-morbidity.
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36
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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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Jiménez-Rodríguez RM, Ciuró FP, Cruzado VDM, Cortes MF, Bernal FL, Padillo J. A new technique to close open abdomen using negative pressure therapy and elastic gums. Injury 2016; 47:979-82. [PMID: 26952333 DOI: 10.1016/j.injury.2016.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 02/12/2016] [Indexed: 02/02/2023]
Affiliation(s)
| | | | | | | | | | - Javier Padillo
- Department of Surgery, Hospital Universitario Virgen del Rocío, Spain
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38
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Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg 2015; 39:912-25. [PMID: 25446477 DOI: 10.1007/s00268-014-2883-6] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Several challenging clinical situations in patients with peritonitis can result in an open abdomen (OA) and subsequent temporary abdominal closure (TAC). Indications and treatment choices differ among surgeons. The risk of fistula development and the possibility to achieve delayed fascial closure differ between techniques. The aim of this study was to review the literature on the OA and TAC in peritonitis patients, to analyze indications and to assess delayed fascial closure, enteroatmospheric fistula and mortality rate, overall and per TAC technique. METHODS Electronic databases were searched for studies describing the OA in patients of whom 50% or more had peritonitis of a non-traumatic origin. RESULTS The search identified 74 studies describing 78 patient series, comprising 4,358 patients of which 3,461 (79%) had peritonitis. The overall quality of the included studies was low and the indications for open abdominal management differed considerably. Negative pressure wound therapy (NPWT) was the most frequent described TAC technique (38 of 78 series). The highest weighted fascial closure rate was found in series describing NPWT with continuous mesh or suture mediated fascial traction (6 series, 463 patients: 73.1%, 95% confidence interval 63.3-81.0%) and dynamic retention sutures (5 series, 77 patients: 73.6%, 51.1-88.1%). Weighted rates of fistula varied from 5.7% after NPWT with fascial traction (2.2-14.1%), 14.6% (12.1-17.6%) for NPWT only, and 17.2% after mesh inlay (17.2-29.5%). CONCLUSION Although the best results in terms of achieving delayed fascial closure and risk of enteroatmospheric fistula were shown for NPWT with continuous fascial traction, the overall quality of the available evidence was poor, and uniform recommendations cannot be made.
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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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Abstract
Negative pressure wound therapy (NPWT) is becoming recognized in veterinary medicine as a viable option for the management of complex wounds. NPWT has many advantages over traditional wound care and results in quicker and improved wound healing in many instances. This article discusses the art and science of NPWT, as well as the many current indications, complications, advantages and disadvantages, and future directions of NPWT in small animal veterinary medicine. This therapy will likely have a growing role in veterinary medical practice for complicated wound management and other usages in coming years.
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Affiliation(s)
- Lisa M Howe
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843-4474, USA.
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41
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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: 94] [Impact Index Per Article: 10.4] [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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Petter-Puchner AH, Fortelny RH. The heart of darkness. Hernia 2014; 19:195-6. [DOI: 10.1007/s10029-014-1336-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 12/10/2014] [Indexed: 10/24/2022]
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