The number of operations negatively influences fascia closure in open abdomen management

Sedation and paralytic use in open abdomen patients-results from the EAST SLEEP Survey

BACKGROUND

Patients with an open abdomen after trauma or emergency surgery may benefit from reduced sedation and chemical paralysis. We studied the effect of attending surgeon experience on sedation depth and paralytic use, as well as enteral nutrition and time between laparotomies.

METHODS

We performed an institutional review board-approved survey (Sedation Level after Emergent ExLap without Primary Fascial Closure) of the senior and active Eastern Association for the Surgery of Trauma membership using Qualtrics (Qualtrics, Inc, Provo, UT). We obtained 393/1,655 responses (23.7%). Spearman's rho was used for ordinal data, and multivariate logistic regression was used to adjust for trauma center level and presence of trainees in the relationship between surgeon experience and use of deep sedation.

RESULTS

Surgeon experience was associated with deep sedation (Richmond Agitation and Sedation Score ≤-3, P = .001) and chemical paralysis (P = .001). Surgeon experience was associated with less concern about delirium and more concern for evisceration as the reason for sedation depth (P = .001) and for paralysis (P = .001). Using multivariate logistic regression, surgeon experience was associated with deep sedation (odds ratio 3.6 [95% confidence interval 1.3, 10.4], P = .017 for ≥20 years; odds ratio 3.5 [95% confidence interval 1.1, 10.4], P = .025 for 15-20 years). Trauma center level was also significant (odds ratio 7.2 for Richmond Agitation and Sedation Score ≤-3 [95% confidence interval 1.7, 31.0], P = .008 for level III/IV versus level I/II). Increased surgeon experience was associated with delay of commencement of enteral feeds until return of bowel function (P = .013). Few respondents indicated willingness to extubate or mobilize open abdomen patients. Experienced surgeons were likely to wait for a defined time rather than for normalization of resuscitation markers to perform the first takeback laparotomy (P = .047) and waited longer between subsequent laparotomies (P = .004).

CONCLUSION

There were significant variations in practice among respondents based on the length of time since their last residency or fellowship, including variations that deviate from current best practice for management of patients with an open abdomen.

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.

Management of open abdomen: single center experience

Aim. The authors reviewed their experience in the management of open abdomen using the vacuum-assisted closure (VAC), in order to assess its morbidity, and the outcome of abdominal wall integrity. Methods. A retrospective review was performed using the trauma registry to identify patients undergoing temporary abdominal closure (TAC) either using Bogota Bag (BB) or VAC, from January 2006 to December 2012. Inclusion criteria were TAC and survival to definitive abdominal closure. Data collected included age, indication for TAC, number of operating room procedures, primary fascial closure rate, and complications. Results. During the study period, 156 patients required one type of TAC. Mean number of operations required in BB group was 3.04 as compared to 1.96 in VAC group (P = 0.006). Survival was significantly increased in the VAC group (P < 0.001). The difference in primary closure rates did not reach statistical significance (25% vs. 55%; P = 0.074). Complications were observed less frequently in the VAC group (P = 0.047). The mean time for fascial closure was 21 (±12) days in the BB group, as opposed to 6 (±3) days in the VAC group (P < 0.001). Conclusion. The vacuum assisted closure (VAC) has a significantly faster rate of closure, requires less number of operations, and is associated with a lower complication rate.

Long-term consequences of open abdomen management

Background

There is little data on the long-term results of the open abdomen technique regarding subsequent bowel obstruction, enterocutaneous fistula and ventral hernia rates. This study represents our follow-up of these complications.

Methods

A retrospective review of patients undergoing open abdomen management was performed. Patient demographics and development of subsequent ventral hernia, enteric fistula and/or bowel obstruction were evaluated.

Results

Seventy-three men and 47 women with a mean age of 51 underwent open abdomen management; 85 for inflammatory conditions and 35 for haemorrhagic conditions. Only 27 patients did not achieve definitive fascial closure and were left open for secondary closure or had a biologic mesh bridge; 13 patients had component separation to achieve fascial closure. With a mean follow-up of 21 months, 30 patients (25%) developed a ventral hernia, 13 patients (11%) experienced an enterocutaneous fistula and two patients developed bowel obstruction. Ventral hernias and enterocutaneous fistulae occurred in 78% and 41%, respectively, of patients not definitively closed compared with 10% and 2%, respectively, of patients closed primarily at initial management ( p < 0.05).

Conclusions

There is a high incidence of ventral hernia and enterocutaneous fistula when open abdomen management necessitates leaving the abdomen open or using a biologic mesh bridge. Strategies for primary fascia closure including component separation should be employed.