AVAS Best Clinical Resident Award (Tied): management and outcomes of the open abdomen in nontrauma patients

Laparostomy and temporary abdominal closure outcomes in emergency non-trauma surgery and parameters affecting early definite primary fascial closure

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.

Incisional hernia repair with plication and utilization of Botox injections: First case report from Saudi Arabia for a 19-year-old female

This article reports on the use of Botox preoperatively for the treatment of a complex ventral hernia which would have typically been treated with component separation technique. The case demonstrates that using the recently developed technique can aid in performing a tension-free hernia repair with potentially lower complication and recurrence rates.

Intensive care and health outcomes of open abdominal treatment: long-term results of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM)

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).

Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis

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.

Outcomes of primary fascial closure after open abdomen for nontrauma emergency general surgery patients

BACKGROUND

Emergency general surgery patients are increasingly being managed with an open abdomen (OA). Factors associated with complications after primary fascial closure (PFC) are unknown.

METHODS

Demographic and operative variables for all emergency general surgery patients managed with OA at an academic medical center were prospectively examined from June to December 2013. Primary outcome was complication requiring reoperation.

RESULTS

Of 58 patients, 37 managed with OA achieved PFC. Of these, 14 needed re-exploration for dehiscence, compartment syndrome, infection, or other. Complications after PFC were not associated with age, type of operative intervention, time to closure, re-explorations, comorbidities, or mortality. Complications correlated with higher body mass index (P = .02), skin closure (P = .04), plasma infusion (P = .01), and less intraoperative bleeding (P = .05). Deep surgical site infection correlated with fascial dehiscence (P = .02).

CONCLUSIONS

Reoperation after PFC was more likely in obese and nonhemorrhagic patients. Recognition of these factors and strategies to reduce surgical site infection may improve outcomes.

Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients

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.

Identifying patients at risk for high-grade intra-abdominal hypertension following trauma laparotomy

BACKGROUND

Abdominal Compartment Syndrome (ACS) is an uncommon but deleterious complication after trauma laparotomy. Early recognition of patients at risk of developing ACS is crucial for their outcome. The aim of this study was to compare the characteristics of patients who developed high-grade intra-abdominal hypertension (IAH) (i.e., grade III or IV; intra-abdominal pressure, IAP >20 mm Hg) following an injury-related laparotomy versus those who did not (i.e., IAP ≤20 mm Hg).

METHODS

A retrospective analysis of consecutive trauma patients admitted to a level 1 trauma centre in Australia between January 1, 1995 and January 31, 2010 was performed. A comparison was made between characteristics of patients who developed high-grade IAH following trauma laparotomy versus those who did not.

RESULTS

A total of 567 patients (median age 31 years) were included in this study. Of these patients 10.2% (58/567) developed high-grade IAH of which 51.7% (30/58) developed ACS. Patients with high-grade IAH were older (p<0.001), had a higher Injury Severity Score (p<0.001), larger base deficit (p<0.001) and lower temperature at admission (p=0.011). In the first 24h of admission, patients with high-grade IAH received larger volumes of crystalloids (p<0.001), larger volumes of colloids (p<0.001) and more units of packed red blood cells (p<0.001). Following surgery prolonged prothrombin (p<0.001) and partial thromboplastin times (p<0.001) were seen. The patients with high-grade IAH suffered higher mortality rates (25.9% (15/58) vs. 12.2% (62/509); p=0.012).

CONCLUSION

Of all patients who underwent a trauma laparotomy, 10.2% developed high-grade IAH, which increases the risk of mortality. Patients with acidosis, coagulopathy, and hypothermia were especially at risk. In these patients, the abdomen should be left open until adequate resuscitation has been achieved, allowing for definitive surgery.

LEVEL OF EVIDENCE

This is a level III retrospective study.

Primary fascial closure after damage control laparotomy: sepsis vs haemorrhage

OBJECTIVE

To compare the outcomes of patients undergoing damage control laparotomy (DCL) for intra-abdominal sepsis vs intra abdominal haemorrhage. We hypothesize that patients undergoing DCL for sepsis will have a higher rate of septic complications and a lower rate of primary fascial closure.

SETTINGS AND PATIENTS

Retrospective study of patients undergoing DCL from December 2006 to November 2009. Data are presented as medians and percentages where appropriate.

RESULTS

111 patients were identified (55 men), 79 with sepsis and 32 with haemorrhage. There was no difference in age (63 vs 62 years), body mass index (BMI, 27 vs 28), diabetes mellitus (13% vs 9%), or duration of initial operation (125 vs 117 min). Patients with sepsis presented with a lower serum lactate (2.2 vs 4.7 mmol/L, p<0.01), base deficit (4.0 vs 8.0, p ≤ 0.01) and ASA score (3.0 vs 4.0, p<0.01). There was no statistical difference in overall morbidity (81% vs 66), mortality (19% vs 22%), intra-abdominal abscess (18% vs 16%), deep wound infection (9% vs 9%), enterocutaneous fistula (ECF) (8% vs 6%) and primary fascial closure (58% vs 59%). Multivariable analysis demonstrated that intra-abdominal abscess (OR 4.26, 95% CI 1.06-19.32), higher base deficit (OR 1.14, 95% CI 1.00-1.31) and more abdominal explorations (OR 1.54, 95% CI 1.23-2.07) were associated with lack of primary fascial closure, but BMI (OR 1.00, 95% CI 0.94-1.07), ECF (OR 2.02, 95% CI 0.23-19.98), wound infection (OR 0.93, 95% CI 0.15-5.27), amount of crystalloids infused within the first 24h (OR 1.00, 95% CI 0.99-1.00) and intra-abdominal sepsis (OR 1.14, 95% CI 0.35-3.80) were not.

CONCLUSIONS

There was an equivalent rate of septic complications and primary fascial closure rates regardless of cause for DCL. Intra-abdominal abscess, worse base deficit and higher number of abdominal explorations were independently associated with the lack of primary fascial closure.

Early repair of open abdomen with a tailored two-component mesh and conditioning vacuum packing: a safe alternative to the planned giant ventral hernia

Purpose

Once open abdomen therapy has succeeded, the problem of closing the abdominal wall must be addressed. We present a new four-stage procedure involving the application of a two-component mesh and vacuum conditioning for abdominal wall closure of even large defects. The aim is to prevent the development of a giant ventral hernia and the eventual need for the repair of the abdominal wall.

Methods

Nineteen of 62 patients treated by open abdomen over a two-year period could not receive primary abdominal wall closure. To achieve closure in these patients, we applied the following four-stage procedure: stage 1: abdominal damage control and conditioning of the abdominal wall; stage 2: attachment of a tailored two-component mesh of polyglycolic acid (PGA) and large pore polypropylene (PP) in intraperitoneal position (IPOM) plus placement of a vacuum bandage; stage 3: vacuum therapy for 3–4 weeks to allow granulation of the mesh and optimization of dermatotraction; stage 4: final skin suture. During stage 3, eligible patients were weaned from respirator and mobilized.

Results

The abdominal wall gap in the 19 patients ranged in size from 240 cm² to more than 900 cm². An average of 3.44 vacuum dressing changes over 19 days were required to achieve 60–100 % granulation of the surface area, so final skin suture could be made. Already in stage 3, 14 patients (73.68 %) could be weaned from respirator an average of 6.78 days after placement of the two-component mesh; 6 patients (31.57 %) could be mobilized on the edge of the bed and/or to a bedside chair after an average of 13 days. No mesh-related hematomas, seromas, or intestinal fistulas were observed.

Conclusion

The four-stage procedure presented here is a viable option for achieving abdominal wall closure in patients treated with open abdomen, enabling us to avoid the development of planned giant ventral hernias. It has few complications and has the special advantage of allowing mobilization of the patients before final skin closure. Long-term course in a large number of patients must still confirm this result.

Outcomes of damage control laparotomy with open abdomen management in the octogenarian population

BACKGROUND

Controversy surrounds the role of abbreviated laparotomy and open abdomen (OA) in the octogenarian population in the acute care surgery model based on concern that the initial insult, combined with its sequelae, is beyond the physiologic reserve of these patients. As the population ages further, this dilemma will arise more frequently, requiring the analysis of futility or utility of OA in this demographic.

METHODS

The institutional review board approval was obtained to analyze retrospectively patients aged 80 years or older with OA from 1997 to 2009. Univariate, multivariate, and Kaplan-Meier analyses were used to evaluate the effects that demographics, comorbidities, and clinical factors had on in-hospital mortality and overall survival.

RESULTS

Sixty-seven patients (32 men and 35 women) were identified. Acute general surgery (including vascular procedures) was the most common indication for laparotomy (94%) with trauma a distant second (6%). Early definitive closure was obtained in 52% of patients with a 34% planned ventral hernia rate. Overall complication rate was 62% and overall in-hospital mortality was 37%. Multivariate analysis revealed congestive heart failure (odds ratio, 11.4; 95% confidence interval, 1.01-128.03) and acute renal failure (odds ratio, 11.8; 95% confidence interval, 2.00-69.12) correlated with in-hospital mortality. Of those surviving to hospital dismissal, 2-year survival was 66% with a 17-month median follow-up (range, 1-125 months).

CONCLUSION

There is utility in octogenarians undergoing aggressive surgical management that requires OA. These patients have high mortality rates, but long-term survival can be better than their peers with other chronic diseases if they survive the surgical insult. Patient selection should be based on preexisting comorbidities such as congestive heart failure and the development of acute renal failure. Despite the adequate long-term survival, most patients will leave the hospital with a hernia.