Staged management of the open abdomen and enteroatmospheric fistulae using split-thickness skin grafts

Damage control surgery in emergency general surgery: What you need to know

ABSTRACT

Damage-control surgery (DCS) is a strategy adopted to limit initial operative interventions in the unstable surgical patient, delaying definitive repairs and abdominal wall closure until physiologic parameters have improved. Although this concept of "physiology over anatomy" was initially described in the management of severely injured trauma patients, the approaches of DCS have become common in the management of nontraumatic intra-abdominal emergencies.While the utilization of damage-control methods in emergency general surgery (EGS) is controversial, numerous studies have demonstrated improved outcomes, making DCS an essential technique for all acute care surgeons. Following a brief history of DCS and its indications in the EGS patient, the phases of DCS will be discussed including an in-depth review of preoperative resuscitation, techniques for intra-abdominal source control, temporary abdominal closure, intensive care unit (ICU) management of the open abdomen, and strategies to improve abdominal wall closure.

How to do mesh-mediated fascial traction for delayed primary closure of the open abdomen

The open abdomen can be a life-saving resuscitative manoeuvre in patients with catastrophic abdominal pathologies, however, can lead to the need for delayed primary closure. The most recent guidelines released from the European Hernia Society and World Society for Emergency Surgery both suggest mesh-mediated fascial traction in conjunction with negative pressure wound therapy as the preferred method in this situation. We present a detailed 'how to do it' on this technique.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Management of ventral hernia defect during enterocutaneous fistula takedown: practice patterns and short-term outcomes from the Abdominal Core Health Quality Collaborative

BACKGROUND

An enterocutaneous fistula (ECF) with an associated large hernia defect poses a significant challenge for the reconstructive surgeon. We aim to describe operative details and 30-day outcomes of elective hernia repair with an ECF when performed by surgeons participating in the Abdominal Core Health Quality Collaborative (ACHQC).

STUDY DESIGN

Patients undergoing concomitant hernia and ECF elective repair were identified within the ACHQC. Outcomes of interest were operative details and 30-day rates of surgical site infections (SSI), surgical site occurrences requiring procedural intervention (SSOPI), medical complications, and mortality.

RESULTS

170 patients were identified (mean age 60 years, 52.4% females, mean BMI 32.3 kg/m²). 106 patients (62%) had small-bowel ECFs, mostly managed with resection without diversion. 30 patients (18%) had colonic ECFs, which were managed with resection without diversion (14%) or resection with diversion (6%). 100 (59%) had a prior mesh in place, which was removed in 90% of patients. Hernias measured 14 cm ± 7 in width, and 68 (40%) had a myofascial release performed (41 TARs). Mesh was placed in 115 cases (68%), 72% as a sublay, and more frequently of biologic (44%) or permanent synthetic (34%) material. 30-day SSI was 18% (37% superficial, 40% deep), and 30-day SSOPI was 21%. 19 patients (11%) were re-operated: 8 (8%) due to a wound complication and 4 (2%) due to a missed enterotomy. Two infected meshes were removed, one biologic and one synthetic.

CONCLUSIONS

Surgeons participating in the ACHQC predominantly resect ECFs and repair the associated hernias with sublay mesh with or without a myofascial release. Morbidity remains high, most closely related to wound complications, as such, concomitant definitive repairs should be entertained with caution.

Unusual techniques in the management of enteroatmospheric fistula. Report of a case

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Enteroatmospheric fistula is a difficult complication to manage.

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One of the essential elements in managing patients with Enteroatmospheric fistula is to protect the skin and control the effluent from the Enteroatmospheric fistula.

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Multidisciplinary teams are required to manage these patients successfully.

Introduction

Enteroatmospheric fistula (EAF) is one of the most challenging postoperative complications following gastrointestinal surgery. Different techniques have been reported for managing the open abdomen and controlling the effluent released from an EAF.

Presentation of a case

We herein report the case of a patient who underwent bowel resection, complicated by the failure of the staple line, in the setting of an open abdomen. A male external catheter was anastomosed to the EAF opening to control the effluent and divert it away from the wound. In addition, Teflon pledgets were used to successfully patch a second, small EAF opening.

Discussion

An essential element in managing EAFs is wound care and controlling the effluent from the EAF to protect the wound. Different innovative techniques have been described to manage an EAF in the setting of an open abdomen. Anastomosing the male external catheter to the EAF opening is a simple and quick technique to control the EAF effluent. Other techniques can be applied at the same time to manage the wound.

Conclusion

EAF is a very challenging complication. We presented a simple and effective technique to control the EAF effluent. Multidisciplinary teams are required to manage these patients successfully.

Reconstructive operations for enteric and colonic fistulas: Low mortality and recurrence in a single-surgeon series with long follow-up

BACKGROUND

The aim of the study was to evaluate the outcomes of 100 consecutive patients undergoing reconstructive operation for enteric and colonic fistulas. These fistulas cause dramatic morbidity and profoundly diminish quality of life. Fistula takedown has been associated with high rates of recurrence.

METHODS

Consecutive patients undergoing definitive fistula reconstruction by a single surgeon were reviewed retrospectively. Major adverse outcomes included bowel leak, fistula recurrence, death, total parenteral nutrition dependence, and incidence of new stomas.

RESULTS

Among the 100 patients, median follow-up was 2.7 years. A total of 11 patients had postoperative leaks that evolved to 5 fistula recurrences. Of these patients 3 underwent successful secondary or tertiary takedown. The 30-day mortality rate was 1%, and the combined postoperative and fistula-related mortality rate at follow-up was 3%. New postoperative total parenteral nutrition dependence occurred in 2 patients (2%), and 9 (9%) had placement of a new stoma. Leaks were more frequent for patients who had a history of open abdomen than for patients who did not.

CONCLUSIONS

With minimal patient selection and a methodic approach to evaluation and management, we achieved a 96% fistula-free survival rate. Few patients acquired new total parenteral nutrition dependence or a new stoma. These results compare favorably with outcomes published elsewhere.

Meta-analysis and Systematic Review of Skin Graft Donor-site Dressings with Future Guidelines

Background:

Many types of split-thickness skin graft (STSG) donor-site dressings are available with little consensus from the literature on the optimal dressing type. The purpose of this systematic review was to analyze the most recent outcomes regarding moist and nonmoist dressings for STSG donor sites.

Methods:

A comprehensive systematic review was conducted across PubMed/MEDLINE, EMBASE, and Cochrane Library databases to search for comparative studies evaluating different STSG donor-site dressings in adult subjects published between 2008 and 2017. The quality of randomized controlled trials was assessed using the Jadad scale. Data were collected on donor-site pain, rate of epithelialization, infection rate, cosmetic appearance, and cost. Meta-analysis was performed for reported pain scores.

Results:

A total of 41 articles were included comparing 44 dressings. Selected studies included analysis of donor-site pain (36 of 41 articles), rate of epithelialization (38 of 41), infection rate (25 of 41), cosmetic appearance (20 of 41), and cost (10 of 41). Meta-analysis revealed moist dressings result in lower pain (pooled effect size = 1.44). A majority of articles (73%) reported better reepithelialization rates with moist dressings.

Conclusion:

The literature on STSG donor-site dressings has not yet identified an ideal dressing. Although moist dressings provide superior outcomes with regard to pain control and wound healing, there continues to be a lack of standardization. The increasing commercial availability and marketing of novel dressings necessitates the development of standardized research protocols to design better comparison studies and assess true efficacy.

Surgical Critical Care: Gastrointestinal Complications

Critical illness and injury affect the gastrointestinal tract almost uniformly. Complications include the sequelae of direct intestinal injury and repair, impaired motility, intra-abdominal hypertension, and ulceration, among others. Contemporary clinical practice has incorporated many advances in the prevention and treatment of gastrointestinal complications during critical illness. This article discusses the epidemiology, risk factors, means of diagnosis, treatment, and prevention of some of these compilations.

An Innovative Way to Separate Gastrointestinal and Abdominal Wall Reconstruction after Complex Abdominal Trauma

Despite advances in trauma care, a subset of patients surviving damage control cannot achieve fascial closure and require split-thickness skin grafting (STSG) of their open abdomen. Controversy exists as to whether reconstruction of the gastrointestine (GI) should be staged or performed at the time of abdominal wall reconstruction (AWR). Many surgeons do not believe that operations through the STSG can be completed safely or without loss of graft. This series reviews the outcomes of operations for GI reconstruction performed through the elevated healed STSG. Concurrent series on all patients undergoing abdominal operation through the STSG. The technique involves elevating the STSG, lysing adhesions only as needed, avoid detaching underlying omentum or viscera to avoid devascularization, and then reattaching the elevated STSG to the abdominal wall with simple sutures. From 1995 to 2017, 27 patients underwent 40 distinct procedures during 36 separate abdominal reoperations (89% GI) through the elevated STSG approach at three Level I trauma centers at a mean interval of 11 months from application of the STSG. One STSG was lost (patient closed with skin flaps), one patient had 30 per cent loss of the STSG (regrafted), and one patient had 10 per cent loss of the STSG (allowed to granulate). One patient required a small bowel resection for intraoperative enterotomy during a difficult operative dissection. There were no GI complications, intraabdominal infections, or deaths, and all patients were deemed fit to undergo AWR after three months. Major intraabdominal reoperations can be readily and safely accomplished through the elevated STSG approach with a <4 per cent need for regrafting. This staged approach significantly simplifies and increases the safety of a second stage AWR.

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.

Open abdomen in trauma patients: a double-edged sword

The use of open abdomen (OA) as a technique in the treatment of exsanguinating trauma patients was first described in the mid-19(th) century. Since the 1980s, OA has become a relatively new and increasingly common strategy to manage massive trauma and abdominal catastrophes. OA has been proven to help reduce the mortality of trauma. Nevertheless, the OA method may be associated with terrible and devastating complications such as enteroatmospheric fistula (EAF). As a result, OA should not be overused, and attention should be given to critical care as well as special management. The temporary abdominal closure (TAC) technique after abbreviated laparotomy was used to improve wound healing and facilitate final fascial closure of OA. Negative pressure therapy (NPT) is the most commonly used TAC method.

The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper

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.