Open Abdomen Treatment after Aortic Aneurysm Repair with Vacuum-assisted Wound Closure and Mesh-mediated Fascial Traction

Increasing Use of Prophylactic Open Abdomen Therapy With Vacuum Assisted Wound Closure and Mesh Mediated Fascial Traction After Repair of Ruptured Abdominal Aortic Aneurysm

OBJECTIVE

Open abdomen therapy (OAT) is commonly used to prevent or treat abdominal compartment syndrome (ACS) in patients with ruptured abdominal aortic aneurysms (rAAAs). This study aimed to evaluate the incidence, treatment, and outcomes of OAT after rAAA from 2006 to 2021. Investigating data on resuscitation fluid, weight gain, and cumulative fluid balance could provide a more systematic approach to determining the timing of safe abdominal closure.

METHODS

This was a single centre observational cohort study. The study included all patients treated for rAAA followed by OAT from October 2006 to December 2021.

RESULTS

Seventy-two of the 244 patients who underwent surgery for rAAA received OAT. The mean age was 72 ± 7.85 years, and most were male (n = 61, 85%). The most frequent comorbidities were cardiac disease (n = 31, 43%) and hypertension (n = 31, 43%). Fifty-two patients (72%) received prophylactic OAT, and 20 received OAT for ACS (28%). There was a 25% mortality rate in the prophylactic OAT group compared with the 50% mortality in those who received OAT for ACS (p = .042). The 58 (81%) patients who survived until closure had a median of 12 (interquartile range [IQR] 9, 16.5) days of OAT and 5 (IQR 4, 7) dressing changes. There was one case of colocutaneous fistula and two cases of graft infection. All 58 patients underwent successful abdominal closure, with 55 (95%) undergoing delayed primary closure. In hospital survival was 85%. Treatment trends over time showed the increased use of prophylactic OAT (p ≤ .001) and fewer ACS cases (p = .03) assessed by Fisher's exact test. In multivariable regression analysis fluid overload and weight reduction predicted 26% of variability in time to closure.

CONCLUSION

Prophylactic OAT after rAAA can be performed safely, with a high rate of delayed primary closure even after long term treatment.

Open abdominal management after ruptured abdominal aortic aneurysm repair: from a single-center study in Japan

PURPOSE

We investigated the utility of the open abdominal management (OA) technique for ruptured abdominal aortic aneurysm (rAAA).

METHODS

Between January 2016 and August 2021, 33 patients underwent open surgery for rAAA at our institution. The patients were divided into OA (n = 12) and non-OA (n = 21) groups. We compared preoperative characteristics, operative data, and postoperative outcomes between the two groups. The intensive care unit management and abdominal wall closure statuses of the OA group were evaluated.

RESULTS

The OA group included significantly more cases of a preoperative shock than the non-OA group. The operation time was also significantly longer in the OA group than in the non-OA group. The need for intraoperative fluids, amount of bleeding, and need for blood transfusion were significantly higher in the OA group than in the non-OA group. Negative pressure therapy (NPT) systems are useful in OA. In five of the six survivors in the OA group, abdominal closure was able to be achieved using components separation (CS) technique.

CONCLUSIONS

NPT and the CS technique may increase the abdominal wall closure rate in rAAA surgery using OA and are expected to improve outcomes.

Adjuncts to the Management of Graft Aorto-Enteric Erosion and Fistula with in situ Reconstruction

OBJECTIVE

The objective of this retrospective single centre study was to determine whether different enteric reconstruction methods and adjuncts confer a benefit after in situ reconstructions (ISRs) of graft aorto-enteric erosion (AEnE) and fistula (AEnF).

METHODS

Primary endpoints were in hospital mortality and AEnE/F recurrence. Survival was estimated using the Kaplan-Meier method and explanatory factors were searched for using uni- ± multivariable Cox regression analysis. In 2013, a multidisciplinary team meeting was convened and since then the primary operator has always been a senior surgeon.

RESULTS

Sixty-six patients were treated for AEnE (n = 38) and AEnF (n = 28, 42%) from 2004 to 2020. All patients with AEnF presented with gastrointestinal bleeding (vs. 0 for AEnE; p < .001). Signs of infection were seen in 50 patients (76% [37 for AEnE vs. 13 for AEnF]; p < .001). Referrals for endograft infection increased over time (n = 15, 23%; one before 2013 vs. 14 after; p = .002). Most patients underwent complete graft excision (n = 52, 79%) with increasing suprarenal cross clamping (n = 21, 32%; four before 2013 vs. 17 after; p = .015). Complex visceral reconstructions decreased over time (n = 31, 47%; 17 before 2013 vs. 14 after; p = .055), while "open abdomens" (OAs) increased (one before 2013 vs. 22 after; p < .001), reducing operating time (p = .012). In hospital mortality reached 42% (n = 28). Estimated survival reached 47.6% (95% confidence interval [CI] 35.0 - 59.1) at one year and 45.6% (95% CI 33.0 - 57.3) at three years and was higher for AEnE than for AEnF (log rank p = .029). AEnE/F recurrence was noted in 12 patients (18%). Older age predicted in hospital mortality in multivariable analysis (p = .034). AEnE/F recurrence decreased with the presence of a primary senior surgeon (vs. junior; p = .003) and OA (1 [4.4%] vs. 11 [26%] for primary fascial closure; p = .045) in univariable analysis.

CONCLUSION

Mortality and recurrence rates remain high after ISR of AEnE/F. Older age predicted in hospital mortality. Primary closure of enteric defects ≤ 2 cm in diameter reduced operating time without increasing the recurrence of AEnF.

Comparative outcomes of open abdominal therapy after ruptured abdominal aortic aneurysm via open and endovascular approaches

BACKGROUND

Open abdomen therapy is sometimes a necessary lifesaving procedure after repair of ruptured abdominal aortic aneurysm (rAAA). OAT aims to prevent or treat abdominal compartment syndrome (ACS). This study aims to evaluate our experience with open abdomen therapy (OAT) after repair of ruptured abdominal aortic aneurysms (rAAAs).

DESIGN

Retrospective cohort study METHODS: Medical records were retrieved for ruptured abdominal aortic aneurysm patients who underwent open surgical repair (OS) or endovascular aneurysm repair (EVAR) between January 1, 2008 and December 12, 2015 from a single center. Univariate and multivariate analysis were performed with statistical significance.

RESULTS

The study included 171 patients. Thirty-three patients (19.3%) required OAT. A smaller percentage of patients required OAT after EVAR (9.8%) compared to OS (23.3%) (P = 0.05). Patients with OAT also had a significantly longer operation (257 vs. 202.7 minutes; P < 0.05), required more intra-operative fluids (15,700 vs. 8,050 mL; P < 0.05), had a longer hospital stay (20 vs. 8.5 days; P < 0.05), and had a higher peri-operative mortality rate (48.5% vs 25.4%; P < 0.05). On multivariate logistic regression analysis, a lower preoperative SBP (OR 0.9, P = 0.01) and history of hypertension (OR 0.3, P = 0.02) were protective against OAT, while longer operative duration increased the risk of OAT (OR: 1.27, P = 0.05). Mean duration of OAT prior to closure was 4.76 days. Comparing OS patients (transperitoneal and retroperitoneal) that underwent OAT closure, patients who had a retroperitoneal repair received less intra-operative fluids (13.79 vs. 19.11 L; P = 0.212), had earlier return of bowel function (10 vs. 16.9 days; P = 0.08), and a shorter hospital stay (19.9 vs. 32.2 days; P = 0.03).

CONCLUSIONS

OAT is a lifesaving procedure that is associated with higher morbidity and mortality following OS and EVAR for rAAA. Patients with longer operations and extensive fluid resuscitation are at higher risk for OAT following rAAAs. Preoperative permissive hypotension may be protective against OAT. OAT following the RP approach to rAAA is associated with earlier abdominal wall closure, earlier bowel recovery, and shorter hospital stay.

Factors influencing the fascial closure rate after open abdomen treatment: Results from the European Hernia Society (EuraHS) Registry : Surgical technique matters

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.

Open surgery and endovascular repair for mycotic aortic aneurysms: Benefits beyond survival

OBJECTIVE

Endovascular techniques have been increasingly used to treat mycotic aortic aneurysms. However, apart from survival, the potential benefits of open surgery and endovascular repair for mycotic aortic aneurysms are poorly understood. The aim of this study was to evaluate the short- and mid-term outcomes after open surgery versus endovascular repair for mycotic aortic aneurysms.

METHODS

All patients treated for mycotic aortic aneurysms at Peking University People's Hospital between 2001 and 2017 were identified. Survival was analyzed using Kaplan-Meier analysis and log-rank tests. The reoperation rate was analyzed using a competing-risk analysis.

RESULTS

Forty-three patients were identified. The mean follow-up time was 41 months (median, 29; range, 1-135 months). The 30-day mortality in the open surgery group was 8.7% (2/23) versus 5% (1/20) in the endovascular repair group (P = .999). The overall survival for open surgery and endovascular repair was 78% versus 75%, respectively, at 1 year, and 69% versus 41% (P = .210), respectively, at 5 years. But during the follow-up, the open surgery group demonstrated multiple benefits, including a shorter length of hospital stay (26.80 ± 14.1 days vs 42.73 ± 21.22 days, P = .026), fewer readmissions (mean 0.61 vs 1.30, P = .037), and lower infection-related reoperations (P = .018) than endovascular repair at 3 years. Subgroup analysis revealed better survival for open surgery in patients with a periaortic mass less than 20 mm (P = .03).

CONCLUSIONS

There were no significant differences between endovascular repair and open surgery in survival. However, in the mid-term, the potential benefits of open surgery are favorable compared with endovascular repair, including lower infection-related reoperation rates and reduced medical burden.

Successful abdominal wound closure for treatment of severe peritonitis using negative pressure wound therapy with continuous mesh fascial traction: a case report

Background

Surgery for severe peritonitis often entails difficult wound closure and may require open abdominal management due to gut edema and/or concern of abdominal compartment syndrome. Negative pressure wound therapy (NPWT) is known to have good outcomes for wound closure after surgery for severe peritonitis. NPWT with continuous mesh fascial traction may result in even better outcomes, especially for fascial closure.

Case presentation

An 81-year-old man was hospitalized for abdominal pain. At admission, computed tomography (CT) demonstrated multiple liver metastases and a tumor perforating the sigmoid colon. Acute peritonitis due to perforated sigmoid colon cancer was diagnosed, and emergency peritonitis surgery and Hartmann’s operation were performed. However, at the end of the operation, the surgical abdominal wound could not be closed due to gut edema and concern of abdominal compartment syndrome. Thus, the abdominal wound was left open and NPWT was performed in the primary operation. In the second and subsequent operations, NPWT with mesh fascial traction was performed. The wound was ultimately closed in the fifth operation, which took place 9 days after the primary operation.

Conclusions

Treatment of severe peritonitis requires that gastroenterological surgeons learn some form of open abdominal management. This case suggests that NPWT with fascial mesh traction is a suitable solution. Furthermore, it does not require any special materials, and surgeons will find it easy to perform. In sum, NPWT with fascial mesh traction may be the preferred method of open abdominal management over other techniques currently available.

Prevention of Incisional Hernias after Open Abdomen Treatment

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.

Open Abdomen Treated with Negative Pressure Wound Therapy: Indications, Management and Survival

BACKGROUND

Open abdomen treatment (OAT) is a significant burden for patients and is associated with considerable mortality. The primary aim of this study was to report survival and cause of mortality after OAT. Secondary aims were to evaluate length of stay (LOS) in intensive care unit (ICU) and in hospital, time to abdominal closure and major complications.

METHODS

Retrospective review of prospectively registered patients undergoing OAT between October 2006 and June 2014 at Trondheim University Hospital, Norway.

RESULTS

The 118 patients with OAT had a median age of 63 (20-88) years. OAT indications were abdominal compartment syndrome (ACS) (n = 53), prophylactic (n = 29), abdominal contamination/second look laparotomy (n = 22), necrotizing fasciitis (n = 7), hemorrhage packing (n = 4) and full-thickness wound dehiscence (n = 3). Eight percent were trauma patients. Vacuum-assisted wound closure (VAWC) with mesh-mediated traction (VAWCM) was used in 92 (78 %) patients, the remaining 26 (22 %) had VAWC only. Per-protocol primary fascial closure rate was 84 %. Median time to abdominal closure was 12 days (1-143). LOS in the ICU was 15 (1-89), and in hospital 29 (1-246) days. Eighty-one (68 %) patients survived the hospital stay. Renal failure requiring renal replacement therapy (RRT) (OR 3.9, 95 % CI 1.37-11.11), ACS (OR 3.1, 95 % CI 1.19-8.29) and advanced age (OR 1.045, 95 % CI 1.004-1.088) were independent predictors of mortality in multivariate analysis. The nine patients with an entero-atmospheric fistula (EAF) survived.

CONCLUSION

Two-thirds of the patients treated with OAT survived. Renal failure with RRT, ACS and advanced age were predictors of mortality, whereas EAF was not associated with increased mortality.

Open Abdomen Therapy with Vacuum and Mesh Mediated Fascial Traction After Aortic Repair: an International Multicentre Study

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.

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

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.

Improved Outcomes for Ruptured Abdominal Aortic Aneurysms Using Integrated Management Involving Endovascular Clamping, Endovascular Replacement, and Open Abdominal Decompression

Objective: Endovascular repair has become the treatment of choice for ruptured abdominal aortic aneurysms (RAAAs). To improve surgical outcomes, preoperative management is important. In 2011, we introduced integrated management, which involves endovascular aneurysm repair, stabilization of hemodynamics by endovascular clamping, and open abdominal decompression to address abdominal compartment syndrome (ACS). Methods: To evaluate the efficacy of this management strategy, 62 patients who had undergone emergency surgery for an RAAA were analyzed retrospectively: group A (n=39), where an old strategy was used, and group B (n=23), where integrated management was introduced. Patient characteristics and 30-day mortality rates were compared between the two groups. Results: The average patient age was 67.7 years and 74.7 years for groups A and B, respectively (P=0.032). Group B patients required more frequent use of vasopressors (P=0.035). Other patient characteristics did not differ between the two groups. The duration of surgery was significantly shorter in group B than in group A (P=0.001). The total amount of transfused blood did not differ between the two groups. No patients showed symptoms of ACS. Early mortality rates were 12.8% and 8.7% in groups A and B, respectively. The number of wound infections was significantly fewer in group B than in group A. Conclusion: Although group B patients were significantly older and had a higher rate of vasopressor use, early mortality was improved in both groups. Morbidity was significantly better in group B with respect to the duration of surgery and number of wound infections than in group A.

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.

Negative-pressure wound therapy for prevention and treatment of surgical-site infections after vascular surgery

BACKGROUND

Indications for negative-pressure wound therapy (NPWT) in vascular surgical patients are expanding. The aim of this review was to outline the evidence for NPWT on open and closed wounds.

METHODS

A PubMed, EMBASE and Cochrane Library search from 2007 to June 2016 was performed combining the medical subject headings terms 'wound infection', 'abdominal aortic aneurysm (AAA)', 'fasciotomy', 'vascular surgery' and 'NPWT' or 'VAC'.

RESULTS

NPWT of open infected groin wounds was associated with shorter duration of wound healing by 47 days, and was more cost-effective than alginate dressings in one RCT. In one RCT and six observational studies, NPWT-related major bleeding and graft preservation rates were 0-10 and 83-100 per cent respectively. One retrospective comparative study showed greater wound size reduction per day, fewer dressing changes, quicker wound closure and shorter hospital stay with NPWT compared with gauze dressings for lower leg fasciotomy. NPWT and mesh-mediated fascial traction after AAA repair and open abdomen was associated with high primary fascial closure rates (96-100 per cent) and low risk of graft infection (0-7 per cent). One retrospective comparative study showed a significant reduction in surgical-site infection, from 30 per cent with standard wound care to 6 per cent with closed incisional NPWT.

CONCLUSION

NPWT has a central role in open and infected wounds after vascular surgery; the results of prophylactic care of closed incisions are promising.

Quality of life and hernia development 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction

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.

Editor's Choice - Abdominal Compartment Syndrome After Surgery for Abdominal Aortic Aneurysm: A Nationwide Population Based Study

OBJECTIVE/BACKGROUND

The understanding of abdominal compartment syndrome (ACS), and its importance for outcome, has increased over time. The aim was to investigate the incidence and clinical consequences of ACS after open (OR) and endovascular repair (EVAR) for ruptured and intact infrarenal abdominal aortic aneurysm (rAAA and iAAA, respectively).

METHODS

In 2008, ACS and decompression laparotomy (DL) were introduced as variables in the Swedish vascular registry (Swedvasc), offering an opportunity to study this complication in a prospective, population based design. Operations carried out in the period 2008-13 were analysed. Of 6,612 operations, 1,341 (20.3%) were for rAAA (72.0% OR) and 5,271 (79.7%) for iAAA (41.9% OR). In all, 3,171 (48.0%) were operated on by OR and 3,441 by EVAR. Prophylactic open abdomen (OA) treatment was validated through case records. Cross-matching with the national population registry secured valid mortality data.

RESULTS

After rAAA repair, ACS developed in 6.8% after OR versus 6.9% after EVAR (p = 1.0). All major complications were more common after ACS (p < .001). Prophylactic OA was performed in 10.7% of patients after OR. For ACS, DL was performed in 77.3% after OR and 84.6% after EVAR (p = .433). The 30 day mortality rate was 42.4% with ACS and 23.5% without ACS (p < .001); at 1 year it was 50.7% versus 31.8% (p < .001). After iAAA repair, ACS developed in 1.6% of patients after OR versus 0.5% after EVAR (p < .001). Among those with ACS, DL was performed in 68.6% after OR and in 25.0% after EVAR (p = .006). Thirty day mortality was 11.5% with ACS versus 1.8% without it (p < .001); at 1 year it was 27.5% versus 6.3% (p < .001). When ACS developed, renal failure, multiple organ failure, intestinal ischaemia, and prolonged intensive care were much more frequent (p < .001). Morbidity and mortality were similar, regardless of primary surgical technique (OR/EVAR/iAAA/rAAA).

CONCLUSION

ACS and OA were common after treatment for rAAA. ACS is a devastating complication after surgery for rAAA and iAAA, irrespective of operative technique, emphasizing the importance of prevention.

Decompressive laparotomy for abdominal compartment syndrome

Background

The effect of decompressive laparotomy on outcomes in patients with abdominal compartment syndrome has been poorly investigated. The aim of this prospective cohort study was to describe the effect of decompressive laparotomy for abdominal compartment syndrome on organ function and outcomes.

Methods

This was a prospective cohort study in adult patients who underwent decompressive laparotomy for abdominal compartment syndrome. The primary endpoints were 28‐day and 1‐year all‐cause mortality. Changes in intra‐abdominal pressure (IAP) and organ function, and laparotomy‐related morbidity were secondary endpoints.

Results

Thirty‐three patients were included in the study (20 men). Twenty‐seven patients were surgical admissions treated for abdominal conditions. The median (i.q.r.) Acute Physiology And Chronic Health Evaluation (APACHE) II score was 26 (20–32). Median IAP was 23 (21–27) mmHg before decompressive laparotomy, decreasing to 12 (9–15), 13 (8–17), 12 (9–15) and 12 (9–14) mmHg after 2, 6, 24 and 72 h. Decompressive laparotomy significantly improved oxygenation and urinary output. Survivors showed improvement in organ function scores, but non‐survivors did not. Fourteen complications related to the procedure developed in eight of the 33 patients. The abdomen could be closed primarily in 18 patients. The overall 28‐day mortality rate was 36 per cent (12 of 33), which increased to 55 per cent (18 patients) at 1 year. Non‐survivors were no different from survivors, except that they tended to be older and on mechanical ventilation.

Conclusion

Decompressive laparotomy reduced IAP and had an immediate effect on organ function. It should be considered in patients with abdominal compartment syndrome.

Improves organ function

Techniques for Abdominal Wall Closure after Damage Control Laparotomy: From Temporary Abdominal Closure to Early/Delayed Fascial Closure-A Review

Open abdomen (OA) has been an effective treatment for abdominal catastrophes in traumatic and general surgery. However, management of patients with OA remains a formidable task for surgeons. The central goal of OA is closure of fascial defect as early as is clinically feasible without precipitating abdominal compartment syndrome. Historically, techniques such as packing, mesh, and vacuum-assisted closure have been developed to assist temporary abdominal closure, and techniques such as components separation, mesh-mediated traction, bridging fascial defect with permanent synthetic mesh, or biologic mesh have also been attempted to achieve early primary fascial closure, either alone or in combined use. The objective of this review is to present the challenges of these techniques for OA with a goal of early primary fascial closure, when the patient's physiological condition allows.

Temporary Abdominal Closure After Abdominal Aortic Aneurysm Repair: A Systematic Review of Contemporary Observational Studies

OBJECTIVES

The aim of this paper was to review the literature on temporary abdominal closure (TAC) after abdominal aortic aneurysm (AAA) repair.

METHODS

This was a systematic review of observational studies. A PubMed, EMBASE and Cochrane search from 2007 to July 2015 was performed combining the Medical Subject Headings "aortic aneurysm" and "temporary abdominal closure", "delayed abdominal closure", "open abdomen", "abdominal compartment syndrome", "negative pressure wound therapy", or "vacuum assisted wound closure".

RESULTS

Seven original studies were found. The methods used for TAC were the vacuum pack system with (n = 1) or without (n = 2) mesh bridge, vacuum assisted wound closure (VAWC; n = 1) and the VAWC with mesh mediated fascial traction (VACM; n = 3). The number of patients included varied from four to 30. Three studies were exclusively after open repair, one after endovascular aneurysm repair, and three were mixed series. The frequency of ruptured AAA varied from 60% to 100%. The primary fascial closure rate varied from 79% to 100%. The median time to closure of the open abdomen was 10.5 and 17 days in two prospective studies with a fascial closure rate of 100% and 96%, respectively; the inclusion criterion was an anticipated open abdomen therapy time ≥5 days using the VACM method. The graft infection rate was 0% in three studies. No patient with long-term open abdomen therapy with the VACM in the three studies was left with a planned ventral hernia. The in hospital survival rate varied from 46% to 80%.

CONCLUSIONS

A high fascial closure rate without planned ventral hernia is possible to achieve with VACM, even after long-term open abdomen therapy. There are, however, few publications reporting specific results of open abdomen treatment after AAA repair, and there is a need for randomized controlled trials to determine the most efficient and safe TAC method during open abdomen treatment after AAA repair.

Microbial colonization of open abdomen in critically ill surgical patients

Introduction

This study was designed to describe the time-course and microbiology of colonization of open abdomen in critically ill surgical patients and to study its association with morbidity, mortality and specific complications of open abdomen. A retrospective cohort analysis was done.

Methods

One hundred eleven consecutive patients undergoing vacuum-assisted closure with mesh as temporary abdominal closure method for open abdomen were analyzed. Microbiological samples from the open abdomen were collected. Statistical analyses were performed using Fisher’s exact test for categorical variables. Mann-Whitney U test was used when comparing number of temporary abdominal closure changes between colonized and sterile patients. Kaplan-Meier analysis was done to calculate cumulative estimates for colonization. Cox regression analyses were performed to analyze risk factors for colonization.

Results

Microbiological samples were obtained from 97 patients. Of these 76 (78 %) were positive. Sixty-one (80 %) patients were colonized with multiple micro-organisms and 27 (36 %) were cultured positive for candida species. The duration of open abdomen treatment adversely affected the colonization rate. Thirty-three (34 %) patients were colonized at the time of laparostomy. After one week of open abdomen treatment 69, and after two weeks 76 patients were colonized with cumulative colonization estimates of 74 % and 89 %, respectively. Primary fascial closure rate was 80 % (61/76) and 86 % (18/21) for the colonized and sterile patients, respectively. The rate of wound complications did not significantly differ between these groups.

Conclusions

Microbial colonization of open abdomen is associated with the duration of open abdomen treatment. Wound complications are common after open abdomen, but colonization does not seem to have significant effect on these. The high colonization rate described herein should be taken into account when primarily sterile conditions like acute pancreatitis and aortic aneurysmal rupture are treated with open abdomen.

Management of abdominal compartment syndrome and the open abdomen

OBJECTIVES

The management of the abdominal compartment syndrome (ACS) and the open abdomen (OA) are important to improve survival after major vascular surgery, in particular ruptured abdominal aortic aneurysm (RAAA). The aim is to summarize contemporary knowledge in this field.

METHODS

The consensus definitions of the World Society of the Abdominal Compartment Syndrome (WSACS) that were published in 2006 and the clinical practice guidelines published in 2007 were updated in 2013. Structured clinical questions were formulated (modified Delphi method), and the evidence base to answer those questions was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines.

RESULTS

Most of the previous definitions were kept untouched, or were slightly modified. Four new definitions were added, including a definition of OA and of lateralization of the abdominal wall, an important clinical problem to approach during prolonged OA treatment. A classification system of the OA was added. Seven recommendations were formulated, in summary: Trans-bladder intra-abdominal pressure (IAP) should be monitored in patients at risk. Protocolized monitoring and management are recommended, and decompression laparotomy if ACS. When OA, protocolized efforts to obtain an early abdominal fascial closure, and strategies utilizing negative pressure wound therapy should be used, versus not. In most cases the evidence was graded as weak or very weak. In six of the structured clinical questions, no recommendation could be made.

CONCLUSION

This review summarizes changes in definitions and management guidelines of relevance to vascular surgery, and data on the incidence of ACS after open and endovascular aortic surgery.

Modern treatment of acute mesenteric ischaemia

BACKGROUND

Diagnosis of acute mesenteric ischaemia in the early stages is now possible with modern computed tomography (CT), using intravenous contrast enhancement and imaging in the arterial and/or portal venous phase. The availability of CT around the clock means that more patients with acute mesenteric ischaemia may be treated with urgent intestinal revascularization.

METHODS

This was a review of modern treatment strategies for acute mesenteric ischaemia.

RESULTS

Endovascular therapy has become an important alternative, especially in patients with acute thrombotic superior mesenteric artery (SMA) occlusion, where the occlusive lesion can be recanalized either antegradely from the femoral or brachial artery, or retrogradely from an exposed SMA after laparotomy, and stented. Aspiration embolectomy, thrombolysis and open surgical embolectomy, followed by on-table angiography, are the treatment options for embolic SMA occlusion. Endovascular therapy may be an option in the few patients with mesenteric venous thrombosis who do not respond to anticoagulation therapy. Laparotomy is needed to evaluate the extent and severity of visceral organ ischaemia, which is treated according to the principles of damage control surgery.

CONCLUSION

Modern treatment of acute mesenteric ischaemia involves a specialized approach that considers surgical and, increasingly, endovascular options for best outcomes.