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Gómez Garnica DG, Rey Chaves CE, Barco-Castillo C, Gutierrez JA, Falla A. Negative Pressure Wound Therapy After Intestinal Anastomosis: A Risk Factor Analysis for Dehiscence. J Surg Res 2024; 296:223-229. [PMID: 38286101 DOI: 10.1016/j.jss.2024.01.003] [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: 09/20/2023] [Revised: 12/18/2023] [Accepted: 01/02/2024] [Indexed: 01/31/2024]
Abstract
INTRODUCTION Negative pressure wound therapy (NPWT) is part of the temporary abdominal closure in the treatment of patients with traumatic, inflammatory, or vascular disease. However, the use of NPWT when performing an intestinal anastomosis has been controversial. This study aimed to describe the patients managed with NPWT therapy and identify the risk factors for anastomotic dehiscence when intestinal anastomosis was performed. METHODS A single-center cohort study with prospectively collected databases was performed. Patients who required NPWT therapy from January 2014 to December 2018 were included. Patients were stratified according to the performance of intestinal anastomosis and according to the presence of dehiscence. Bivariate and multivariate analyses were performed for anastomotic dehiscence and mortality. RESULTS A total of 97 patients were included. Median age was 52 y old [interquartile range 24.5-70]. Male patients corresponded to 75.6% (n = 34) of the population. Delayed fascial closure was performed in 80% (n = 36). The risk of anastomotic dehiscence was higher in females (odds ratio (OR) 11.52 [confidence interval (CI) 1.29-97.85], P = 0.030), delayed fascial closure (OR 18.18 [CI 2.02-163.5], P = 0.010) and use of vasopressors (OR 12.04 [CI 1.22-118.47], P = 0.033). NPWT pressures >110 mmHg were evidenced in the dehiscence group with statistically significant value (OR 1.2 [0.99-2.26] p 0.04) CONCLUSIONS: There is still controversy in the use of NPWT when performing intestinal anastomosis. According to our data, the risk of dehiscence is higher in females, delayed fascial closure, use of vasopressors, and NPWT pressures >110 MMHG.
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Affiliation(s)
- David Guillermo Gómez Garnica
- Department of General Surgery, Hospital Militar Central, Bogotá DC, Colombia; Universidad Militar Nueva Granada School of Medicine, Bogotá DC, Colombia; Cirugía General, Profesor Asistente, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Carlos Eduardo Rey Chaves
- Estudiante de Posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Bogotá, Colombia.
| | - Catalina Barco-Castillo
- Universidad Militar Nueva Granada School of Medicine, Bogotá DC, Colombia; Department of Urology, Hospital Militar Central, Bogotá DC, Colombia
| | - Jorge Andrés Gutierrez
- Department of General Surgery, Hospital Militar Central, Bogotá DC, Colombia; Universidad Militar Nueva Granada School of Medicine, Bogotá DC, Colombia; Cirugía General, Profesor Asistente, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Andrés Falla
- Department of General Surgery, Hospital Militar Central, Bogotá DC, Colombia; Universidad Militar Nueva Granada School of Medicine, Bogotá DC, Colombia
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Pepe G, Chiarello MM, Bianchi V, Fico V, Altieri G, Tedesco S, Tropeano G, Molica P, Di Grezia M, Brisinda G. Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy. J Clin Med 2024; 13:1279. [PMID: 38592102 PMCID: PMC10932196 DOI: 10.3390/jcm13051279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients' quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas.
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Affiliation(s)
- Gilda Pepe
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Maria Michela Chiarello
- General Surgery Operative Unit, Department of Surgery, Provincial Health Authority, 87100 Cosenza, Italy;
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Gaia Altieri
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Silvia Tedesco
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Perla Molica
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Marta Di Grezia
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Giuseppe Brisinda
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
- Department of Medicine and Surgery, Catholic School of Medicine “Agostino Gemelli”, Largo Francesco Vito 1, 00168 Rome, Italy
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Yamamoto R, Kuramoto S, Shimizu M, Shinozaki H, Miyake T, Sadakari Y, Sekine K, Kaneko Y, Kurosaki R, Koizumi K, Shibusawa T, Sakurai Y, Wakahara S, Sasaki J. Optimal tentative abdominal closure for open abdomen: a multicenter retrospective observational study (OPTITAC study). Int J Surg 2023; 109:4049-4056. [PMID: 37678286 PMCID: PMC10720862 DOI: 10.1097/js9.0000000000000687] [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: 06/02/2023] [Accepted: 08/07/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Primary fascia closure is often difficult following an open abdomen (OA). While negative-pressure wound therapy (NPWT) is recommended to enhance successful primary fascia closure, the optimal methods and degree of negative pressure remain unclear. This study aimed to elucidate optimal methods of NPWT as a tentative abdominal closure for OA to achieve primary abdominal fascia closure. MATERIALS AND METHODS A multicenter, retrospective, cohort study of adults who survived OA greater than 48 h was conducted in 12 institutions between 2010 and 2022. The achievement of primary fascia closure and incidence of enteroatmospheric fistula were examined based on methods (homemade, superficial NPWT kit, or open-abdomen kit) or degrees of negative pressure (<50, 50-100, or >100 mmHg). A generalized estimating equation was used to adjust for age, BMI, comorbidities, etiology for laparotomy requiring OA, vital signs, transfusion, severity of critical illness, and institutional characteristics. RESULTS Of the 279 included patients, 252 achieved primary fascia closure. A higher degree of negative pressure (>100 mmHg) was associated with fewer primary fascia closures than less than 50 mmHg [OR, 0.18 (95% CI: 0.50-0.69), P =0.012] and with more frequent enteroatmospheric fistula [OR, 13.83 (95% CI: 2.30-82.93)]. The methods of NPWT were not associated with successful primary fascia closure. However, the use of the open-abdomen kit was related to a lower incidence of enteroatmospheric fistula [OR, 0.02 (95% CI: 0.00-0.50)]. CONCLUSION High negative pressure (>100 mmHg) should be avoided in NPWT during tentative abdominal closure for OA.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo
| | - Shunsuke Kuramoto
- Department of Acute Care Surgery, Shimane University Faculty of Medicine, Shimane
| | - Masayuki Shimizu
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Kanagawa
| | | | - Tasuku Miyake
- Department of Acute Care Surgery, Shimane University Faculty of Medicine, Shimane
| | | | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo
| | - Yasushi Kaneko
- Department of Emergency Medicine, Hiratsuka City Hospital, Kanagawa
| | - Ryo Kurosaki
- Department of Surgery, Japanese Red Cross Maebashi Hospital, Gunma
| | - Kiyoshi Koizumi
- Department of Cardiovascular Surgery, Ashikaga Red Cross Hospital, Tochigi
| | - Takayuki Shibusawa
- Department of Emergency and Critical Care Medicine, National Hospital Organization Tokyo Medical Center, Tokyo
| | | | - Sota Wakahara
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo
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Fernández LG. Treatment of Complex Thoracic and Abdominal Trauma Patients: A Review of Literature and Negative Pressure Wound Therapy Treatment Options. Adv Wound Care (New Rochelle) 2023. [PMID: 37672527 DOI: 10.1089/wound.2023.0113] [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: 09/08/2023] Open
Abstract
Significance: In trauma care, extensive surgical intervention may be required. Damage control surgery (DCS) is applicable to patients with life or limb-threatening conditions that are incapable of tolerating a traditional surgical approach. Recent Advances: The current resuscitation strategy for complex trauma patients includes limiting crystalloid fluids, balanced mass transfusion protocols, permissive hypotension, and damage control resuscitation. Recent technological advancements in surgical critical care have improved outcomes in these critically ill patients. Critical Issues: DCS, which is often required in patients with trauma injuries, is typically followed by surgical correction of the injury once the immediate patient survival procedures have been completed. However, DCS and the subsequent injury repair procedures have a high risk for postsurgical complication development. Future Directions: Negative pressure therapy modalities can offer clinicians additional adjunctive and cost-effective tools for the management of the trauma care patient, as these systems can be utilized during both the DCS and the postoperative injury management phases of trauma care.
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Affiliation(s)
- Luis G Fernández
- Division of Trauma Surgery/Surgical Critical Care, Department of Surgery, University of Texas Health Science Center, Tyler, Texas, USA
- School of Medicine Bill Barrett Endowed Chair in Trauma Surgery, The University of Texas-Tyler, Tyler, Texas, USA
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Nasa P, Chanchalani G, Juneja D, Malbrain MLNG. Surgical decompression for the management of abdominal compartment syndrome with severe acute pancreatitis: A narrative review. World J Gastrointest Surg 2023; 15:1879-1891. [PMID: 37901738 PMCID: PMC10600763 DOI: 10.4240/wjgs.v15.i9.1879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/20/2023] [Accepted: 08/01/2023] [Indexed: 09/21/2023] Open
Abstract
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) play a pivotal role in the pathophysiology of severe acute pancreatitis (SAP) and contribute to new-onset and persistent organ failure. The optimal management of ACS involves a multi-disciplinary approach, from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure (IAP). A targeted literature search from January 1, 2000, to November 30, 2022, revealed 20 studies and data was analyzed on the type and country of the study, patient demographics, IAP, type and timing of surgical procedure performed, post-operative wound management, and outcomes of patients with ACS. There was no randomized controlled trial published on the topic. Decompressive laparotomy is effective in rapidly reducing IAP (standardized mean difference = 2.68, 95% confidence interval: 1.19-1.47, P < 0.001; 4 studies). The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but, potentially lethal ACS. Disease-specific patient selection and the role of less-invasive decompressive measures, like subcutaneous linea alba fasciotomy or component separation techniques, is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS. This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP. However, there is a lack of high-quality evidence on patient selection, timing, and modality of surgical decompression. Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
- Department of Internal Medicine, College of Medicine and Health Sciences, Al Ain 15551, United Arab Emirates
| | - Gunjan Chanchalani
- Department of Critical Care Medicine, K.J. Somaiya Hospital and Research Centre, Mumbai 400022, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Specialty Hospital, New Delhi 110017, India
| | - Manu LNG Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin 20-954, Poland
- Executive Administration, International Fluid Academy, Lovenjoel 3360, Belgium
- Medical Data Management, Medaman, Geel 2440, Belgium
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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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Navarro AS, Gomez CM, Angeles MA, Fuzier R, Ruiz J, Picard M, Martinez A, Ferron G. Open abdominal vacuum pack technique for the management of severe abdominal complications after cytoreductive surgery in ovarian cancer. Gynecol Oncol 2023; 170:108-113. [PMID: 36681011 DOI: 10.1016/j.ygyno.2023.01.009] [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: 05/31/2022] [Revised: 12/27/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the indications and management of grade III-IV postoperative complications in patients requiring vacuum-assisted open abdomen after debulking surgery for ovarian carcinomatosis. METHODS Retrospective study of prospectively collected data from patients who underwent a cytoreductive surgery by laparotomy for an epithelial ovarian cancer that required postoperative management of an open abdomen. An abdominal vacuum-assisted wound closure (VAWC) was applied in cases of abdominal compartmental syndrome (ACS) or intra-abdominal hypertension, to prevent ACS. The fascia was closed with a suture or a biologic mesh. The primary aim was to achieve primary fascial closure. Secondary outcomes considered included complications of cytoreductive surgery (CRS) and open abdominal wounds (hernia, fistula). RESULTS Two percent of patients who underwent CRS required VAWC during the study's patient inclusion period. VAWC indications included: (i) seven cases of gastro-intestinal perforation, (ii) three necrotic enterocolitis, (iii) two intestinal ischemia, (iv) three anastomotic leakages and (v) four intra-abdominal hemorrhages. VAWC was used to treat indications (i) to (iv) (which represented 73.7% of cases), to prevent compartmental syndrome. Primary fascia closure was achieved in 100% of cases, in four cases (21.0%) a biologic mesh was used. Median hospital stay was 65 days (range: 18-153). Four patients died during hospitalization, three of these within 30 days of VAWC completion. CONCLUSION VAWC for managing open abdominal wounds is a reliable technique to treat surgical post-CRS complications in advanced ovarian cancer and reduces the early post-operative mortality in cases presenting with severe complications.
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Affiliation(s)
- Anne-Sophie Navarro
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France.
| | | | - Martina Aida Angeles
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Régis Fuzier
- Department of Anesthesia Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Jean Ruiz
- Intensive care unit, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, CHU Toulouse, Toulouse, France
| | - Muriel Picard
- Intensive care unit, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, CHU Toulouse, Toulouse, France
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Gwénaël Ferron
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
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Sibilla MG, Cremonini C, Portinari M, Carcoforo P, Tartaglia D, Cicuttin E, Musetti S, Strambi S, Sartelli M, Radica MK, Catena F, Chiarugi M, Coccolini F, Salvetti F, Negoi I, Zese M, Occhionorelli S, Shlyapnikov S, Sugrue M, Demetrashvili Z, Dondossola D, Ioannidis O, Novelli G, Frattini C, Nacoti M, Khor D, Inaba K, Demetriades D, Kaussen T, Jusoh AC, Ghannam W, Sakakushev B, Guetta O, Dogjani A, Costa S, Singh S, Damaskos D, Isik A, Yuan KC, Trotta F, Rausei S, Martinez-Perez A, Bellanova G, Fonseca VC, Hernández F, Marinis A, Fernandes W, Quiodettis M, Bala M, Vereczkei A, Curado R, Fraga GP, Pereira BM, Gachabayov M, Chagerben GP, Arellano ML, Ozyazici S, Costa G, Tezcaner T, Porta M, Li Y, Karateke F, Manatakis D, Mariani F, Lora F, Sahderov I, Atanasov B, Zegarra S, Fattori L, Ivatury R, Xiao J, Ben-Ishay O, Zharikov A, Dubuisson V. Patients with an Open Abdomen in Asian, American and European Continents: A Comparative Analysis from the International Register of Open Abdomen (IROA). World J Surg 2023; 47:142-151. [PMID: 36326921 PMCID: PMC9726668 DOI: 10.1007/s00268-022-06733-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND International register of open abdomen (IROA) enrolls patients from several centers in American, European, and Asiatic continent. The aim of our study is to compare the characteristics, management and clinical outcome of adult patients treated with OA in the three continents. MATERIAL AND METHODS A prospective analysis of adult patients enrolled in the international register of open abdomen (IROA). TRIAL REGISTRATION NCT02382770. RESULTS 1183 patients were enrolled from American, European and Asiatic Continent. Median age was 63 years (IQR 49-74) and was higher in the European continent (65 years, p < 0.001); 57% were male. The main indication for OA was peritonitis (50.6%) followed by trauma (15.4%) and vascular emergency (13.5%) with differences among the continents (p < 0.001). Commercial NPWT was preferred in America and Europe (77.4% and 52.3% of cases) while Barker vacuum pack (48.2%) was the preferred temporary abdominal closure technique in Asia (p < 0.001). Definitive abdominal closure was achieved in 82.3% of cases in America (fascial closure in 90.2% of cases) and in 56.4% of cases in Asia (p < 0.001). Prosthesis were mostly used in Europe (17.3%, p < 0.001). The overall entero-atmospheric fistula rate 2.5%. Median open abdomen duration was 4 days (IQR 2-7). The overall intensive care unit and hospital length-of-stay were, respectively, 8 and 11 days (no differences between continents). The overall morbidity and mortality rates for America, Europe, and Asia were, respectively, 75.8%, 75.3%, 91.8% (p = 0.001) and 31.9%, 51.6%, 56.9% (p < 0.001). CONCLUSION There is no uniformity in OA management in the different continents. Heterogeneous adherence to international guidelines application is evident. Different temporary abdominal closure techniques in relation to indications led to different outcomes across the continents. Adherence to guidelines, combined with more consistent data, will ultimately allow to improving knowledge and outcome.
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Affiliation(s)
- Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Camilla Cremonini
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Mattia Portinari
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Dario Tartaglia
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Enrico Cicuttin
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Serena Musetti
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Silvia Strambi
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | | | - Margherita Koleva Radica
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Fausto Catena
- Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Massimo Chiarugi
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Federico Coccolini
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124, Pisa, Italy.
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Bueno-Lledó J, Martínez-Hoed J, Pous-Serrano S. Negative pressure therapy in abdominal wall surgery. Cir Esp 2022; 100:464-471. [PMID: 35584763 DOI: 10.1016/j.cireng.2022.05.017] [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: 09/27/2021] [Accepted: 12/14/2021] [Indexed: 06/15/2023]
Abstract
Negative pressure wound therapy (NPWT) is widely known in surgical practice. The initial indications for NPWT were chronic wounds, especially diabetic foot, vascular and decubitus ulcers, and infected traumatic wounds. Nowadays, the use has been widely increased. Although in the field of abdominal wall surgery, it has mainly been used in the treatment of surgical wound complications after hernia repair, other indications have been added after years of experience in the management of NPWT. Therefore, the aim of this article is to analyze and review the main indications of NPWT in abdominal wall surgery, as well as the advantages obtained with its application.
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Affiliation(s)
- José Bueno-Lledó
- Unidad de Cirugía de Pared Abdominal, Hospital Universitari i Politècnic La Fe, Universidad de Valencia, Valencia, Spain.
| | | | - Salvador Pous-Serrano
- Unidad de Cirugía de Pared Abdominal, Hospital Universitari i Politècnic La Fe, Universidad de Valencia, Valencia, Spain
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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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Akbayir O, Ulukent SC, Guraslan H, Seyhan NA, Gunkaya OS, Cingillioglu B, Akturk E, Yuksel IT. Open abdomen technique used in complications of major gynecological oncology surgery. J Obstet Gynaecol Res 2022; 48:1904-1912. [PMID: 35596265 DOI: 10.1111/jog.15296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 03/27/2022] [Accepted: 05/08/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the open abdomen technique (laparostomy) used in complications of major gynecological oncology surgery. METHODS We analyzed retrospectively the surgical database of all patients who had undergone major open surgery by the same gynecologic oncologist over a 5-year period. All patients who had had open abdomen procedure were identified; demographic data and indications of primary surgery, temporary abdominal closure procedure details, fascia closure and morbidity, mortality rates were evaluated. Intraabdominal infection and intraoperative massive hemorrhage were the major indications for all open abdomen cases. Mannheim Peritonitis Index was used perioperatively to determine open abdomen decision in intraabdominal infections. Vacuum Assisted Abdominal Closure system and Bogota Bag were used for temporary abdominal closure techniques. RESULTS Out of the total 560 patients who had undergone major oncological surgery, 19 patients (3.3%) had open abdomen procedure due to surgical complications. Eleven patients had intraabdominal infection, six patients had hemodynamic instability due to peri and postoperative hemorrhage, two patients had gross fecal contamination during posterior pelvic exenteration surgery. The fascia was closed totally in 15 (78%), partially in 3 (15%) and could not be closed in 1 patient who had died secondary to multiorgan failure. Total morbidity and mortality rates were 26% (5/19) (two intrabdominal abscess, one pulmonary embolism, one skin necrosis, one enteroatmospheric fistula) and 5.2% (1/19) respectively. CONCLUSION Open abdomen is a life-saving procedure when applied with correct indications and timing. Gynecological oncologic surgeries are candidates to serious complications and gynecologic oncologists dealing with such surgery should be as experienced as general surgeons in this regard.
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Affiliation(s)
- Ozgur Akbayir
- Department of Gynecologic Oncology, Prof. Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Suat C Ulukent
- Department of General Surgery, Gaziosmanpasa Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Hakan Guraslan
- Department of Obstetrics and Gynecology, Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Niyazi A Seyhan
- Department of Gynecologic Oncology, Aydin Adnan Menderes University, Aydin, Turkey
| | - Osman S Gunkaya
- Department of Obstetrics and Gynecology, Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Basak Cingillioglu
- Department of Obstetrics and Gynecology, Prof. Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Erhan Akturk
- Department of Obstetrics and Gynecology, Prof. Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ilkbal T Yuksel
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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Intra-Abdominal Pressure Monitoring During Negative Pressure Wound Therapy in the Open Abdomen. J Surg Res 2022; 278:100-110. [PMID: 35597024 DOI: 10.1016/j.jss.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/11/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Negative pressure wound therapy (NPWT) is commonly used in open abdomen management, where there may be a simultaneous need for prevention of abdominal hypertension, tamponade of hemorrhage, and continuous fascial tension. The regional pressure dynamics of vacuum dressings are poorly understood. METHODS Three duroc swine underwent mid-line laparotomy and application of vacuum open abdomen dressing, with and without sponge packing. Twenty-five catheters were placed throughout the abdomen to capture and record pressures in each quadrant as the vacuum system was ranged between (-75 mmHg to -200 mmHg pressure). Vital signs and ventilator pressures were measured and recorded concomitantly. RESULTS No variations in ventilatory pressures or vital signs were observed with any setting. NPWT changed pressure in seven of seventy-five catheters (9%), five of which were related to abdominal packing. When data were grouped into abdominal wall, perihepatic, perisplenic, and deep abdominal regions, there was no significant change in abdominal pressure when packing was absent. With packing, only the abdominal wall region showed a pressure change, reaching a maximum of 20% of the set vacuum pressure. CONCLUSIONS NPWT does only little to change the intraabdominal pressure, except in superficial locations in packed abdomens and does not appear to cause hemodynamic changes in a porcine open abdomen model. While NPWT may play an important role in fluid scavenging and fascial tensioning, there are likely to be few benefits or drawbacks specifically related to negative abdominal pressure in the deep abdomen.
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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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Abdominal Negative Pressure Wound Therapy Devices for Management of the Open Abdomen: A Technologic Analysis. J Wound Ostomy Continence Nurs 2022; 49:124-127. [PMID: 35255062 DOI: 10.1097/won.0000000000000862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this technologic analysis was to analyze technologic features of abdominal negative pressure wound therapy (NPWT). APPROACH Published literature regarding abdominal negative pressure wound therapy (aNPWT) devices was reviewed. A summary of management approaches for the open abdomen provides a foundation for understanding the benefits of aNPWT. Safety information regarding aNPWT was derived from the Manufacturer and User Facility Device Experience (MAUDE) Database. CONCLUSIONS The open abdomen approach with temporary abdominal closure may be employed for patients with a variety of conditions. Specialized abdominal NPWT devices, either singly or in combination with other approaches, may contribute to improved outcomes in this high-risk patient population. Manufacturer recommendations and clinical guidelines should be followed to minimize patient risk.
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Fung S, Ashmawy H, Krieglstein C, Halama T, Schilawa D, Fuckert O, Hees A, Kröpil F, Rehders A, Lehwald-Tywuschik NC, Knoefel WT. Vertical traction device prevents abdominal wall retraction and facilitates early primary fascial closure of septic and non-septic open abdomen. Langenbecks Arch Surg 2022; 407:2075-2083. [PMID: 35147749 PMCID: PMC8832079 DOI: 10.1007/s00423-021-02424-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/23/2021] [Indexed: 12/04/2022]
Abstract
Purpose One of the major challenges in the management of patients with septic and non-septic open abdomen (OA) is to control abdominal wall retraction. The aim of this study was to evaluate the impact of a novel vertical traction device (VTD) on primary fascial closure (PFC) and prevention of fascial retraction. Methods Twenty patients treated with OA were included in this retrospective multicenter study. All patients were initially stabilized with laparostomy and the abdomen temporarily sealed either with a Bogotá bag or a negative pressure wound therapy system (NPWT). Results The mean duration of OA and fascia-to-fascia distance (FTF) prior to the VTD application were 3 days and 15 cm, respectively. At relook laparotomy 48 h after VTD implementation, the mean FTF distance significantly decreased to 10 cm (p = 0.0081). In all cases, PFC was achieved after a mean period of 7 days. Twelve patients received the VTD in combination with a NPWT, whereas in eight patients, the device was combined with an alternative temporary abdominal closure system (TAC). Although not statistically significant, the FTF distance remarkably decreased in both groups at relook laparotomy 48 h following the device implementation. The mean periods of PFC for patients with septic and non-septic OA were comparable (7.5 vs. 7 days). During follow-up, two patients developed an incisional hernia. Conclusion Vertical traction device prevents fascial retraction and facilitates early PFC in OA. In combination with NPWT, rapid fascial closure of large abdominal defects can be achieved.
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Affiliation(s)
- Stephen Fung
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Hany Ashmawy
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Christian Krieglstein
- Department of Surgery, St. Elisabeth Krankenhaus Köln, Werthmannstr. 1, 50935 Cologne, Germany
| | - Thomas Halama
- Department of Surgery, St. Vinzenz-Hospital, Merheimer Str. 221-223, 50733 Cologne, Germany
| | - Dustin Schilawa
- Department of Surgery, St. Rochus Krankenhaus, Glückaufstraße 10, 44575 Castrop-Rauxel, Germany
| | - Oliver Fuckert
- Department of Surgery, Lukas Krankenhaus, Hindenburgstraße 56, 32257 Bünde, Germany
| | - Anita Hees
- Department of Surgery, St.-Marien Krankenhaus, Kampenstraße 51, 57072 Siegen, Germany
| | - Feride Kröpil
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Alexander Rehders
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Nadja C. Lehwald-Tywuschik
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
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Willms A, Güsgen C, Schwab R, Lefering R, Schaaf S, Lock J, Kollig E, Jänig C, Bieler D. Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®. Langenbecks Arch Surg 2021; 407:805-817. [PMID: 34611749 DOI: 10.1007/s00423-021-02344-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma. METHODS Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene. RESULTS The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004). CONCLUSION DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.
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Affiliation(s)
- Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Christoph Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany.
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Sebastian Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Johan Lock
- Department of General, Transplantation, Vascular and Paediatric Surgery, University Hospital of Würzburg, VisceralWürzburg, Germany
| | - Erwin Kollig
- Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery, and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany
| | - Christoph Jänig
- Department of Anesthesiology and Intensive Care, German Armed Forces Central Hospital, Koblenz, Germany
| | - Dan Bieler
- Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery, and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany.,Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Medical School, Düsseldorf, Germany
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Smit M, van Meurs M, Zijlstra JG. Intra-abdominal hypertension and abdominal compartment syndrome in critically ill patients: A narrative review of past, present, and future steps. Scand J Surg 2021; 111:14574969211030128. [PMID: 34605332 DOI: 10.1177/14574969211030128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Intra-abdominal hypertension is frequently present in critically ill patients and is an independent predictor for mortality. In this narrative review, we aim to provide a comprehensive overview of current insights into intra-abdominal pressure monitoring, intra-abdominal hypertension, and abdominal compartment syndrome. The focus of this review is on the pathophysiology, risk factors and outcome of intra-abdominal hypertension and abdominal compartment syndrome, and on therapeutic strategies, such as non-operative management, surgical decompression, and management of the open abdomen. Finally, future steps are discussed, including propositions of what a future guideline should focus on. CONCLUSIONS Pathological intra-abdominal pressure is a continuum ranging from mild intra-abdominal pressure elevation without clinically significant adverse effects to substantial increase in intra-abdominal pressure with serious consequences to all organ systems. Intra-abdominal pressure monitoring should be performed in all patients at risk of intra-abdominal hypertension. Although continuous intra-abdominal pressure monitoring is feasible, this is currently not standard practice. There are a number of effective non-operative medical interventions that may be performed early in the patient's course to reduce intra-abdominal pressure and decrease the need for surgical decompression. Abdominal decompression can be life-saving when abdominal compartment syndrome is refractory to non-operative treatment and should be performed expeditiously. The objectives of open abdomen management are to prevent fistula and to achieve delayed fascial closure at the earliest possible time. There is still a lot to learn and change. The 2013 World Society of Abdominal Compartment Syndrome guidelines should be updated and multicentre studies should evaluate the effect of intra-abdominal hypertension treatment on patient outcome.
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Affiliation(s)
- Marije Smit
- Department of Critical Care, University Medical Center Groningen, University of Groningen, BA 49, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan G Zijlstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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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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Should Negative Pressure Therapy Replace Any Other Temporary Abdominal Closure Device in Open-Abdomen Management of Secondary Peritonitis? Surg Technol Int 2021. [PMID: 33844240 DOI: 10.52198/21.sti.38.gs1386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To clarify the advantages of negative pressure therapy (NPT) compared to other methods of temporary abdominal closure (TAC) in the management of secondary peritonitis. METHODS We retraced the history of known methods of TAC, and analyzed their advantages and disadvantages. We evaluated as the NPT mechanisms, both from the macroscopic that bio-molecular point of view, well suits to manage this difficult condition. RESULTS The ideal TAC technique should be quick to apply, easy to change, protect and contain the abdominal viscera, decrease bowel edema, prevent loss of domain and abdominal compartment syndrome, limit contamination, allow egress of peritoneal fluid (and its estimation) and not result in adhesions. It should also be cost-effective, minimize the number of dressing changes and the number of surgical revisions, and ensure a high rate of early closure with a low rate of complications (especially entero-atmospheric fistula). For NPT, the reported fistula rate is 7%, primary fascial closure ranges from 33 to 100% (average 60%) and the mortality rate is about 20%. With the use of NPT as TAC, it may be possible to extend the window of time to achieve primary fascial closure (for up to 20-40 days). CONCLUSION NPT has several potential advantages in open-abdomen (OA) management of secondary peritonitis and may make it possible to achieve all the goals suggested above for an ideal TAC system. Only trained staff should use NPT, following the manufacturer's instructions when commercial products are used. Even if there was a significant evolution in OA management, we believe that further research into the role of NPT for secondary peritonitis is necessary.
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21
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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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22
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Laurens JR, Foster A, Hardley A. Closing Difficult Laparostomies With the Aid of Botulinum Toxin A: An Audit of 12 Cases. Cureus 2021; 13:e14066. [PMID: 33898149 PMCID: PMC8059676 DOI: 10.7759/cureus.14066] [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] [Indexed: 11/26/2022] Open
Abstract
Background Obtaining primary fascial closure following laparostomy can be difficult; especially with fascial retraction or large pre-existing fascial defects. Various techniques have been described in the literature which attempt to improve reapproximation rates. Most techniques described comprise the use of adjuncts including Bogota Bags, negative pressure dressings, anchor devices and various types of mesh. While most techniques achieve primary closure, less achieve primary fascial closure. Botulinum toxin A (BTA) has proven a beneficial adjunct in repairing large ventral herniae. While there is limited research in the use of BTA in the acute setting of laparostomy closure its benefits in elective repair may prove transferrable with the appropriate protocols. Method This retrospective study reviewed 12 cases where BTA was used as an adjunct to close laparostomy. It compared primary fascial closure rates to historical controls at the same institution. Results Seven males and five females. Median age 63.5 years. Median BMI 32.95. Median days from BTA injection to primary fascial closure 9.5. Median 18 days from primary operation to primary fascial closure. 83% of patients achieved primary fascial closure with the rest achieving partial closure with the residual defect bridged with biological mesh. At the time of review, there was only one resulting ventral hernia in a patient with a BMI of 51.7 at the time of surgery. Conclusion While BTA does not guarantee primary fascial closure in laparostomy this study would indicate it improves primary fascial closure rates and can be added to any other existing method for managing the open abdomen. As BTA can be injected via the open abdomen or with ultrasound guidance it can be performed by any appropriately trained surgeon, anaesthetist or radiologist making its use widely achievable. Retrospectively registered.
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Affiliation(s)
- Jason R Laurens
- General Surgery, Fiona Stanley and Fremantle Hospital Group, Perth, AUS.,General Surgery, Joondalup Health Campus, Perth, AUS
| | - Amanda Foster
- General Surgery, Fiona Stanley and Fremantle Hospital Group, Perth, AUS
| | - Andrew Hardley
- General Surgery, Fiona Stanley and Fremantle Hospital Group, Perth, AUS
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23
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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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24
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Ramser M, Glauser PM, Glass TR, Weixler B, Grapow MTR, Hoffmann H, Kirchhoff P. Abdominal Decompression after Cardiac Surgery: Outcome of 42 Patients with Abdominal Compartment Syndrome. World J Surg 2021; 45:1242-1251. [PMID: 33481080 DOI: 10.1007/s00268-020-05917-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Up to 50% of patients in intensive care units develop intraabdominal hypertension (IAH) in the course of medical treatment. If not detected on time and treated adequately, IAH may develop into an abdominal compartment syndrome (ACS) which is associated with a high mortality rate. Patients undergoing cardiac surgery are especially prone to develop ACS due to several risk factors including intraoperative hypothermia, fluid resuscitation and acidosis. We investigated patients who developed ACS after cardiac surgery and analyzed potential risk factors, treatment and outcome. METHODS From 2011 to 2016, patients with ACS after cardiac surgery requiring decompressive laparotomy were prospectively recorded. Patient characteristics, details on the cardiac surgery, mortality rate and type of treatment of the open abdomen were analyzed. RESULTS Incidence of ACS in cardiac surgery patients was 1.0% (n = 42/4128), with a mortality rate of 57%. Ejection fraction, Euroscore2 as well as the perfusion time are independent risk factors for the development of ACS. The outcome of patients with ACS was independent of elective versus emergency surgery, gender, age, BMI or ASA score. In the 18 surviving patients, fascial closure was achieved in 72% after a median of 9 days. CONCLUSION Abdominal compartment syndrome is a rare but serious complication after cardiac surgery with a high mortality rate. Independent risk factors for ACS were identified. Negative pressure wound therapy seems to promote and allow early fascia closure of the abdomen and represents therefore a likely benefit for the patient.
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Affiliation(s)
- Michaela Ramser
- Department of Surgery, University Hospital Basel, Basel, Switzerland. .,Department of Surgery, Solothurner Spitäler, Kantonsspital Olten, Olten, Switzerland.
| | - Philippe M Glauser
- Department of Surgery, University Hospital Basel, Basel, Switzerland.,Department of Surgery, Solothurner Spitäler, Spital Dornach, Dornach, Switzerland
| | - Tracy R Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Benjamin Weixler
- University of Basel, Basel, Switzerland.,Department of Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Martin T R Grapow
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland.,Hirslanden Klinik Zürich, HerzZentrum, Zürich, Switzerland
| | - Henry Hoffmann
- University of Basel, Basel, Switzerland.,Center for Hernia Surgery & Proctology, ZweiChirurgen, Basel, Switzerland
| | - Philipp Kirchhoff
- University of Basel, Basel, Switzerland.,Center for Hernia Surgery & Proctology, ZweiChirurgen, Basel, Switzerland
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25
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Ehlers-Danlos syndrome type IV: a case report of a rare cause of spontaneous sigmoid perforation and enteroatmospheric fistulae in a child. Surg Case Rep 2020; 6:312. [PMID: 33289853 PMCID: PMC7724010 DOI: 10.1186/s40792-020-01051-0] [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: 07/07/2020] [Accepted: 10/16/2020] [Indexed: 01/04/2023] Open
Abstract
Background Ehlers–Danlos syndrome (EDS) type IV is a rare subtype of EDS, but has important surgical implications. Case presentation Here, we present a case of a spontaneous sigmoid perforation in a 14-year-old boy. He was initially treated with laparotomy, oversew of the sigmoid perforation and a diverting ileostomy. He developed a complete wound dehiscence and enteroatmospheric fistulae. These were managed with a combination of negative pressure wound therapy and Eakin (TG Eakin™) pouch changes. We discuss the clinical features and presentation of EDS type IV, the surgical implications of managing patients with the condition, and the challenges in management of enteroatmospheric fistulae in children. Conclusions Ehlers–Danlos syndrome type IV should be considered as a cause of any spontaneous colonic perforation in children.
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26
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Lembo F, Cecchino LR, Parisi D, Portincasa A. Protocol Management of Wide Abdominal Wound Dehiscence Following Gynecology Laparotomies in Obese Women. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2020.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Fedele Lembo
- Azienda Ospedaliero Universitaria Ospedali Riuniti–Foggia, Foggia, Italy
| | | | - Domenico Parisi
- Azienda Ospedaliero Universitaria Ospedali Riuniti–Foggia, Foggia, Italy
| | - Aurelio Portincasa
- Azienda Ospedaliero Universitaria Ospedali Riuniti–Foggia, Foggia, Italy
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27
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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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Gu Y, Wang P, Li H, Tian W, Tang J. Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction. Am J Surg 2020; 222:86-98. [PMID: 33239177 DOI: 10.1016/j.amjsurg.2020.11.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common. DATA SOURCES With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results. CONCLUSIONS This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.
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Affiliation(s)
- Yan Gu
- Hernia and Abdominal Wall Disease Center, Shanghai Jiao Tong University, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
| | - Ping Wang
- Department of Hernia Surgery, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Hangyu Li
- Department of General Surgery, Fourth Hospital of China Medical University, Shenyang, 110000, China
| | - Wen Tian
- Department of General Surgery, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
| | - Jianxiong Tang
- Department of General Surgery, Huadong Hospital, Fudan University, Shanghai, 200040, China.
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Prevention of Fascial Retraction in the Open Abdomen with a Novel Device. Case Rep Surg 2020; 2020:8254804. [PMID: 33145116 PMCID: PMC7599407 DOI: 10.1155/2020/8254804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 08/29/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022] Open
Abstract
The open abdomen requires intensive and specific treatment efforts. Long hospital admissions, treatment duration, high mortality rates, deferred and delayed wound closures with alloplastic materials or elaborate closure techniques, and the need for subsequent surgical procedures justify and call for implementation of new therapy options. The case presented here demonstrates the use of a new product (Fasciotens Abdomen) to prevent fascial retraction in the open abdomen of an extubated, conscious patient with four-quadrant peritonitis after perforated appendicitis. Controlled, anteriorly directed fascial traction of 50-60 Newtons prevented fascial retraction during open treatment of the abdomen. Once edema was reduced, abdominal closure was completed without difficulty. This new form of therapy was well tolerated by the patient and led to a markedly more rapid abdominal closure without mesh or abdominal wall reconstruction.
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30
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Wulfert CH, Müller CT, Abdel-Kawi AF, Schulze W, Schmidt-Seithe H, Borstelmann S, Loske G. Intrauterine negative-pressure therapy (IU-NPT) to treat peritonitis after caesarean section. Innov Surg Sci 2020; 5:67-73. [PMID: 33506096 PMCID: PMC7798308 DOI: 10.1515/iss-2020-0014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022] Open
Abstract
Objectives We describe the first application of intrauterine negative-pressure therapy (IU-NPT) for an early rupture of a uterine suture after a third caesarean section with consecutive peritonitis and sepsis. Because all four quadrants were affected by peritonitis, a laparotomy was performed on the 15th day after caesarean section. Abdominal negative-pressure wound therapy (A-NPWT) of the open abdomen was initiated. During the planned relaparotomy, a suture defect of the anterior uterine wall was identified and sutured. In the second relaparotomy, the suture appeared once more insufficient. Case presentation For subsequent IU-NPT, we used an open-pore film drainage (OFD) consisting of a drainage tube wrapped in the double-layered film. The OFD was inserted into the uterine cavity via the uterine defect and IU-NPT was established together with A-NPT. With the next relaparotomy, local inflammation and peritonitis had been resolved completely. IU-NPT was continued transvaginally, the uterine defect was sutured, and the abdomen was closed. Vaginal IU-NPT was also discontinued after another eight days. Conclusions By using IU-NPT, local infection control of the septic focus was achieved. The infectious uterine secretions were completely evacuated and no longer discharged into the abdominal cavity. As a result of the applied suction, the uterine cavity collapsed around the inlaid OFD. The total duration of IU-NPT was 11 days. The uterine defect was completely closed, and a hysterectomy was avoided. The patient was discharged four days after the end of IU-NPT. IU-NPT follows the same principles as those described for endoscopic negative-pressure wound therapy of the gastrointestinal tract.
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Affiliation(s)
| | - Christian Theodor Müller
- Department for General, Abdominal, Thoracic and Vascular Surgery, Kath. Marienkrankenhaus Hamburg, Hamburg, Germany
| | | | - Wolfgang Schulze
- Department for General, Abdominal, Thoracic and Vascular Surgery, Kath. Marienkrankenhaus Hamburg, Hamburg, Germany
| | - Henning Schmidt-Seithe
- Department for General, Abdominal, Thoracic and Vascular Surgery, Kath. Marienkrankenhaus Hamburg, Hamburg, Germany
| | - Sonko Borstelmann
- Department of Obstetrics, Kath. Marienkrankenhaus Hamburg, Hamburg, Germany
| | - Gunnar Loske
- Department for General, Abdominal, Thoracic and Vascular Surgery, Kath. Marienkrankenhaus Hamburg, Hamburg, Germany
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31
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Petersen S, Deder A, Prause A, Pohland C, Richter D, Mansfeld T, Puhl G. Transverse vs. median laparotomy in peritonitis and staged lavage: a single center case series. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc07. [PMID: 32973421 PMCID: PMC7492753 DOI: 10.3205/000283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/22/2020] [Indexed: 12/02/2022]
Abstract
Background: Staged lavage was first introduced in the 1970s and now serves as a therapeutic option for septic patients with peritonitis. A central aspect of this treatment concept is leaving the abdomen open after a wide incision. To evaluate the influence of transverse vs. median access to the abdomen in staged lavage, data from the authors’ patients were analyzed. Methods: To evaluate patients with peritonitis, prospective intensive care data were examined together with data on the surgical details. The main aspects covered here were the surgical details of the lavage (namely, transverse vs. median laparotomy), number of lavages, fascia closure, wound-healing disorders, and observed lethality, in combination with the preoperatively evaluated SAPS-II score, expected hospital lethality, patient age, and the Mannheim Peritonitis Index. Results: Between January 2008 and December 2018, 522 patients were treated with open abdomen and staged lavage. The mean age of the patients was 66.0 years (standard deviation (SD) 15.9 years). A median incision was used in 140 cases, and transverse laparotomy was performed in 382. The mean SAPS-II score was 46.5 (SD 15.7), expected lethality was 39.6% (SD 26.3%), and observed lethality was 19.9%. On average, two lavages were performed after the index operation. Transverse incision was significantly less likely to cause wound-healing disorder (p=0.03), and fascial dehiscence was observed less frequently in the transverse laparotomies group than in median incisions in the statistical trend (p=0.06). Conclusion: In summary, staged lavage reduced expected lethality in patients with peritonitis. Transverse incision caused wound-healing disorders and fascial dehiscence less often. Therefore, the indication for transverse laparotomy should be generous, as this form of treatment is advantageous in case of peritonitis.
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Affiliation(s)
- Sven Petersen
- Department of General, Visceral and Vascular Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - Alice Deder
- Department of General, Visceral and Vascular Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - Axel Prause
- Department of Anesthesia, Intensive Care & Emergency, Asklepios Hospital Altona, Hamburg, Germany
| | - Christopher Pohland
- Department of General, Visceral and Vascular Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - Dominik Richter
- Department of General, Visceral and Vascular Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - Thomas Mansfeld
- Department of Surgery, Westklinikum Hamburg Rissen, Hamburg, Germany
| | - Gero Puhl
- Department of General, Visceral and Vascular Surgery, Asklepios Hospital Altona, Hamburg, Germany
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Oliveira MDC, Andrade AYTD, Turrini RNT, Poveda VDB. Negative pressure wound therapy in the treatment of surgical site infection in cardiac surgery. Rev Bras Enferm 2020; 73:e20190331. [PMID: 32609220 DOI: 10.1590/0034-7167-2019-0331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 10/12/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to describe the relationship between epidemiological and clinical characteristics of postoperative cardiac surgery patients undergoing negative pressure wound therapy for the treatment of surgical site infection. METHODS an observational, cross-sectional analytical study including a convenience sample consisting of medical records of patients undergoing sternal cardiac surgery with surgical site infection diagnosed in medical records treated by negative pressure wound therapy. RESULTS medical records of 117 patients, mainly submitted to myocardial revascularization surgery and with deep incisional surgical site infection (88; 75.2%). Negative pressure wound therapy was used on mean for 16 (±9.5) days/patient; 1.7% had complications associated with therapy and 53.8% had discomfort, especially pain (93.6%). The duration of therapy was related to the severity of SSI (p=0.010) and the number of exchanges performed (p=0.045). CONCLUSIONS negative pressure wound therapy has few complications, but with discomfort to patients.
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Coccolini F, Perrina D, Ceresoli M, Kluger Y, Kirkpatrick A, Sartelli M, Ansaloni L, Catena F. Open abdomen and age; results from IROA (International Register of Open Abdomen). Am J Surg 2020; 220:229-236. [DOI: 10.1016/j.amjsurg.2019.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/03/2019] [Accepted: 11/10/2019] [Indexed: 01/22/2023]
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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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The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy. J Trauma Acute Care Surg 2020; 86:670-678. [PMID: 30562327 DOI: 10.1097/ta.0000000000002170] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. STUDY DESIGN We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n = 60) to recent historic controls (n = 78) who would have met protocol inclusion criteria. The protocol includes low-volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure. RESULTS Baseline characteristics, including age, American Society of Anesthesiologists class, and postoperative lactate levels, were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p = 0.044) and exhibited higher serum osmolarity (303 vs. 293 mOsm/kg, p = 0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p = 0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p = 0.045, number needed to treat = 8.3). Complication rates were similar between groups. CONCLUSIONS Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations, and higher fascial closure rates with no difference in complications. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Poillucci G, Podda M, Russo G, Perri SG, Ipri D, Manetti G, Lolli MG, De Angelis R. Open abdomen closure methods for severe abdominal sepsis: a retrospective cohort study. Eur J Trauma Emerg Surg 2020; 47:1819-1825. [PMID: 32377924 DOI: 10.1007/s00068-020-01379-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 04/24/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE The open abdomen (OA) procedure as part of damage control surgery represents a significant surgical advance in severe intra-abdominal infections. Major techniques used for OA are negative pressure wound therapy (NPWT) and non-NPWT. The aim of this retrospective study is to evaluate the effects of different abdominal closure methods and their outcomes in patients presenting with abdominal sepsis treated with OA. MATERIALS AND METHODS We retrospectively analyzed clinical outcomes of patients affected by severe intra-abdominal sepsis treated with OA. Demographic features, mortality prediction score, abdominal closure methods, length of hospital stay, complications and mortality rates of patients were determined and compared. RESULTS This study included 106 patients, of whom 77 underwent OA with NPWT and 29 with non-NPWT. OA duration was longer in NPWT patients (p = 0.007). In-hospital mortality rates in NPWT and in non-NPWT patients were 40.3% and 51.7%, respectively (p = 0.126), with an overall 30-day mortality rate of 18.2% and 51.7%, respectively (p = 0.0002). After emergency colorectal surgery, patients who underwent OA with NPWT had a lower rate of colostomy (p = 0.025). CONCLUSIONS NPWT is the best temporary abdominal closure technique to decrease mortality and colostomy rates in patients managed with OA for severe intra-abdominal infections.
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Affiliation(s)
- Gaetano Poillucci
- Department of General and Specialized Surgery "Paride Stefanini", Policlinico Universitario Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Mauro Podda
- Department of General, Emergency and Minimally Invasive Surgery, Policlinico Universitario "D. Casula", University of Cagliari, Monserrato, Italy
| | - Giulia Russo
- Department of General Surgery, San Camillo De Lellis Hospital, Rieti, Italy
| | | | - Domenico Ipri
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Gabriele Manetti
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Maria Giulia Lolli
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Renato De Angelis
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
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Population Pharmacokinetic Study of the Suitability of Standard Dosing Regimens of Amikacin in Critically Ill Patients with Open-Abdomen and Negative-Pressure Wound Therapy. Antimicrob Agents Chemother 2020; 64:AAC.02098-19. [PMID: 31964795 DOI: 10.1128/aac.02098-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/07/2020] [Indexed: 02/02/2023] Open
Abstract
The aim was to assess the appropriateness of recommended regimens for empirical MIC coverage in critically ill patients with open-abdomen and negative-pressure therapy (OA/NPT). Over a 5-year period, every critically ill patient who received amikacin and who underwent therapeutic drug monitoring (TDM) while being treated by OA/NPT was retrospectively included. A population pharmacokinetic (PK) modeling was performed considering the effect of 10 covariates (age, sex, total body weight [TBW], adapted body weight [ABW], body surface area [BSA], modified sepsis-related organ failure assessment [SOFA] score, vasopressor use, creatinine clearance [CLCR], fluid balance, and amount of fluids collected by the NPT over the sampling day) in patients who underwent continuous renal replacement therapy (CRRT) or did not receive CRRT. Monte Carlo simulations were employed to determine the fractional target attainment (FTA) for the PK/pharmacodynamic [PD] targets (maximum concentration of drug [C max]/MIC ratio of ≥8 and a ratio of the area under the concentration-time curve from 0 to 24 h [AUC0-24]/MIC of ≥75). Seventy critically ill patients treated by OA/NPT (contributing 179 concentration values) were included. Amikacin PK concentrations were best described by a two-compartment model with linear elimination and proportional residual error, with CLCR and ABW as significant covariates for volume of distribution (V) and CLCR for CL. The reported V) in non-CRRT and CRRT patients was 35.8 and 40.2 liters, respectively. In Monte Carlo simulations, ABW-adjusted doses between 25 and 35 mg/kg were needed to reach an FTA of >85% for various renal functions. Despite an increased V and a wide interindividual variability, desirable PK/PD targets may be achieved using an ABW-based loading dose of 25 to 30 mg/kg. When less susceptible pathogens are targeted, higher dosing regimens are probably needed in patients with augmented renal clearance (ARC). Further studies are needed to assess the effect of OA/NPT on the PK parameters of antimicrobial agents.
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Gök MA, Kafadar MT, Yeğen SF. Comparison of negative-pressure incision management system in wound dehiscence: A prospective, randomized, observational study. J Med Life 2019; 12:276-283. [PMID: 31666831 PMCID: PMC6814883 DOI: 10.25122/jml-2019-0033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Wound dehiscence is a significant problem faced by surgeons after major abdominal surgery. In this study, it was aimed to select the best incision management system to keep the incision edges together and prevent wound opening, and infection by protecting the incision. In this study, 60 patients who underwent abdominal surgery were evaluated regarding their risk of wound dehiscence. In our clinic, high-risk cases of abdominal surgery are performed, the risk factors being ischemia along the incision line, dirty and contaminated wound, obesity, tension on the suture line, traumatization of the wound site, age at onset (> 65), body mass index (BMI) > 30, diabetes mellitus, chronic obstructive pulmonary disease (COPD), immunosuppressive drug users. A prospective study protocol was planned after ASA (American Society of Anesthesiologists) physical status class assignment. Patients were divided into three groups: patients who underwent a postoperative negative-pressure therapy dressing, patients who underwent subcutaneous aspiration drainage, and patients who received standard dressing. The aim of this study was to evaluate the decompensation, surgical site infection, seroma, hospital stay and costs and to evaluate the results in the postoperative period. Sixty patients were randomized (n = 20, for each group). Thirty-one (51%) of the patients were male, and the mean age was 64.3 ± 8.9 (46-85). The mean BMI was 30.45 ± 7.2. There was no statistically significant difference (p≥0.05) between groups in terms of sex, age, and BMI. The ASA score and surgical interventions were similar between the groups. Wound dehiscence rate was 25% (n = 8), 20% (n = 6) and 3% (n = 1) for the Standard Dressing (SD), Aspiration Drainage (AD) and Negative-Pressure (NP) groups, respectively (p <0.017). Duration of hospitalization was 16.45 ± 6.6, 14.3 ± 7.4 and 8.95 ± 2.8 days (p <0.001) for SD, AD and NP groups, respectively. No statistically significant difference was found between the groups regarding other variables (p≥0.05 for all variables). Negative-pressure wound treatment is an easy, fast and practical technique which reduces lateral tension and swelling. It provides perfusion support and helps to protect the surgical field against external sources of infection.
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Affiliation(s)
- Mehmet Ali Gök
- Clinic of General Surgery, Health Sciences University, Derince Training and Research Hospital, Kocaeli, Turkey
| | - Mehmet Tolga Kafadar
- Clinic of General Surgery, Health Sciences University, Mehmet Akif İnan Training and Research Hospital, Şanlıurfa, Turkey
| | - Serkan Fatih Yeğen
- Clinic of General Surgery, Ali Osman Sönmez Oncology Hospital, Bursa, Turkey
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Popivanov G, Kjossev K, Mutafchiyski V. The open abdomen - still a challenge for the surgeons. Which is the best technique for temporary abdominal closure? A focus on negative pressure wound therapy. G Chir 2019; 38:267-272. [PMID: 29442056 DOI: 10.11138/gchir/2017.38.6.267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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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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Eickhoff R, Guschlbauer M, Maul AC, Klink CD, Neumann UP, Engel M, Hellmich M, Sterner-Kock A, Krieglstein CF. A new device to prevent fascial retraction in the open abdomen - proof of concept in vivo. BMC Surg 2019; 19:82. [PMID: 31286901 PMCID: PMC6615246 DOI: 10.1186/s12893-019-0543-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 06/24/2019] [Indexed: 12/11/2022] Open
Abstract
Background An open abdomen is often necessary for survival of patients after peritonitis, compartment syndrome, or in damage control surgery. However, abdominal wall retraction relieves delays and complicates abdominal wall closure. The principle of the newly fascia preserving device (FPD) is the application of anteriorly directed traction on both fascial edges over an external support through a longitudinal beam to relieve increased abdominal pressure and prevent fascial retraction. Methods Twelve pigs were randomly divided into two groups. Both groups underwent midline laparotomy under general anesthesia. Group one was treated with the new device, group two served as controls. The tension for closing the abdominal fascia was measured immediately after laparotomy as well as at 24 and 48 h. Vital parameters and ventilation pressure were recorded. Post mortem, all fascial tissues were histologically examined. Results All pigs demonstrated increases in abdominal circumference. In both groups, forces for closing the abdomen increased over the observation period. Concerning the central closing force after 24 h we saw a significant lower force in the FPD group (14.4 ± 3 N) vs. control group (21.6 ± 5.7 N, p < 0.001). By testing the main effects using an ANOVA analysis we found a significant group related effect concerning closing force and abdominal circumference of the FDP-group vs. control group (p < 0.001; p < 0.001). The placement of the device on chest and pelvis did not influence vital parameters and ventilation pressure. Histologic exam detected no tissue damage. Conclusions This trial shows the feasibility to prevent fascial retraction during the open abdomen by using the new device. Thus, it is expected that an earlier closure of the abdominal wall will be possible, and a higher rate of primary closure will be attained.
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Affiliation(s)
- Roman Eickhoff
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Maria Guschlbauer
- Center for Experimental Medicine, University of Cologne, Robert-Koch-Str. 10 Building No. 51A, 50931, Cologne, Germany.,Decentral Animal Facility, University Hospital of Cologne, Gleueler Str. 24, 50931, Cologne, Germany
| | - Alexandra C Maul
- Center for Experimental Medicine, University of Cologne, Robert-Koch-Str. 10 Building No. 51A, 50931, Cologne, Germany
| | - Christian D Klink
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ulf P Neumann
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Michael Engel
- Department of Surgery, Marienhospital Brühl GmbH, Mühlenstraße, 21-25 50321, Brühl, Germany
| | - Martin Hellmich
- IMSB, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Anja Sterner-Kock
- Center for Experimental Medicine, University of Cologne, Robert-Koch-Str. 10 Building No. 51A, 50931, Cologne, Germany
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Novel method for delayed primary closure and incisional hernia prevention in open abdomen: COmbined and MOdified Definitive Abdominal wall closure (COMODA). Hernia 2019; 24:395-401. [PMID: 30968285 DOI: 10.1007/s10029-019-01948-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Intended open abdomen is an option in cases of trauma and non-trauma patients. Nevertheless, after primary closure, incisional hernia rate is high. We describe a novel method, called COmbined and MOdified Definitive Abdominal closure (COMODA), a delayed primary closure which prevents incisional hernia. METHODS A negative pressure wound therapy system is combined with a condensed polytetrafluoroethylene (cPTFE) mesh. TRIAL REGISTRATION ISRCTN72678033. RESULTS Ten male patients with a median age of 68.8 (43-87) years were included. Primary closure rate was 100% per protocol. The median number of procedures per patient was 5.7 (5-9). Primary closure was obtained in 20.8 (10-32) days and median hospital stay was 36.3 (18-52) days. Only one patient developed incisional hernia during a median follow-up of 27 (8-60) months. CONCLUSION COMODA method allows for a high rate of delayed primary closure. It is safe and decreases the risk for developing an incisional hernia. However, a large number of patients are needed to support this conclusion.
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Hypertonic saline resuscitation after emergent laparotomy and temporary abdominal closure. J Trauma Acute Care Surg 2019; 84:350-357. [PMID: 29140948 DOI: 10.1097/ta.0000000000001730] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Our objective was to establish the safety of 3% hypertonic saline (HTS) resuscitation for trauma and acute care surgery patients undergoing emergent laparotomy and temporary abdominal closure (TAC) with the hypothesis that HTS administration would be associated with hyperosmolar hypercholoremic acidosis, lower resuscitation volumes, and higher fascial closure rates, without adversely affecting renal function. METHODS We performed a retrospective cohort analysis of 189 trauma and acute care surgery patients who underwent emergent laparotomy and TAC, comparing patients with normal baseline renal function who received 3% HTS at 30 mL/h (n = 36) to patients with standard resuscitation (n = 153) by baseline characteristics, resuscitation parameters, and outcomes including primary fascial closure and Kidney Disease: Improving Global Outcomes stages of acute kidney injury. RESULTS The HTS and standard resuscitation groups had similar baseline illness severity and organ dysfunction, though HTS patients had lower serum creatinine at initial laparotomy (1.2 mg/dL vs. 1.4 mg/dL; p = 0.078). Forty-eight hours after TAC, HTS patients had significantly higher serum sodium (145.8 mEq/L vs. 142.2 mEq/L, p < 0.001), chloride (111.8 mEq/L vs. 106.6 mEq/L, p < 0.001), and osmolarity (305.8 mOsm/kg vs. 299.4 mOsm/kg; p = 0.006), and significantly lower arterial pH (7.34 vs. 7.38; p = 0.011). The HTS patients had lower intravenous fluid (IVF) volumes within 48 hours of TAC (8.5 L vs. 11.8 L; p = 0.004). Serum creatinine, urine output, and kidney injury were similar between groups. Fascial closure was achieved for 92% of all HTS patients and 77% of all standard resuscitation patients (p = 0.063). Considering all 189 patients, higher IVF resuscitation volumes within 48 hours of TAC were associated with decreased odds of fascial closure (odds ratio, 0.90; 95% confidence interval, 0.83-0.97; p = 0.003). CONCLUSION Hypertonic saline resuscitation was associated with the development of a hypernatremic, hyperchloremic, hyperosmolar acidosis, and lower total IVF resuscitation volumes, without adversely affecting renal function. These findings may not be generalizable to patients with baseline renal dysfunction and susceptibility to hyperchloremic acidosis-induced kidney injury. LEVEL OF EVIDENCE Prognostic study, level II.
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Li Y, Li PY, Sun SJ, Yao YZ, Li ZF, Liu T, Yang F, Zhang LY, Bai XJ, Huo JS, He WB, Ouyang J, Peng L, Hu P, Zhu YA, Jin P, Shao QF, Wang YF, Dai RW, Hu PY, Chen HM, Wang GF, Wang YG, Jin HX, Zhu CJ, Zhang QY, Shao B, Sang XG, Yin CL. Chinese Trauma Surgeon Association for management guidelines of vacuum sealing drainage application in abdominal surgeries-Update and systematic review. Chin J Traumatol 2019; 22:1-11. [PMID: 30850324 PMCID: PMC6529401 DOI: 10.1016/j.cjtee.2018.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/12/2018] [Accepted: 01/12/2019] [Indexed: 02/07/2023] Open
Abstract
Vacuum sealing drainage (VSD) is frequently used in abdominal surgeries. However, relevant guidelines are rare. Chinese Trauma Surgeon Association organized a committee composed of 28 experts across China in July 2017, aiming to provide an evidence-based recommendation for the application of VSD in abdominal surgeries. Eleven questions regarding the use of VSD in abdominal surgeries were addressed: (1) which type of materials should be respectively chosen for the intraperitoneal cavity, retroperitoneal cavity and superficial incisions? (2) Can VSD be preventively used for a high-risk abdominal incision with primary suture? (3) Can VSD be used in severely contaminated/infected abdominal surgical sites? (4) Can VSD be used for temporary abdominal cavity closure under some special conditions such as severe abdominal trauma, infection, liver transplantation and intra-abdominal volume increment in abdominal compartment syndrome? (5) Can VSD be used in abdominal organ inflammation, injury, or postoperative drainage? (6) Can VSD be used in the treatment of intestinal fistula and pancreatic fistula? (7) Can VSD be used in the treatment of intra-abdominal and extra-peritoneal abscess? (8) Can VSD be used in the treatment of abdominal wall wounds, wound cavity, and defects? (9) Does VSD increase the risk of bleeding? (10) Does VSD increase the risk of intestinal wall injury? (11) Does VSD increase the risk of peritoneal adhesion? Focusing on these questions, evidence-based recommendations were given accordingly. VSD was strongly recommended regarding the questions 2-4. Weak recommendations were made regarding questions 1 and 5-11. Proper use of VSD in abdominal surgeries can lower the risk of infection in abdominal incisions with primary suture, treat severely contaminated/infected surgical sites and facilitate temporary abdominal cavity closure.
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Affiliation(s)
- Yang Li
- Trauma Center of PLA, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Pei-Yuan Li
- Trauma Center of PLA, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Shi-Jing Sun
- Trauma Center of PLA, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Yuan-Zhang Yao
- Trauma Center of PLA, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Zhan-Fei Li
- Trauma Center/Department of Emergency and Trauma Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Tao Liu
- Trauma Center/Department of Emergency and Trauma Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Fan Yang
- Trauma Center/Department of Emergency and Trauma Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Lian-Yang Zhang
- Trauma Center of PLA, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China.
| | - Xiang-Jun Bai
- Trauma Center/Department of Emergency and Trauma Surgery, Tongji Hospital of Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China.
| | - Jing-Shan Huo
- Foshan Hospital of Traditional Chinese Medicine, Foshan, Guangzhou Province, China
| | - Wu-Bing He
- Fujian Provincial Hospital, Fuzhou, China
| | - Jun Ouyang
- Emergency Surgery of the First Affiliated Hospital, Shihezi University School of Medicine, Shihezi, Xinjiang Autonomous Region, China
| | - Lei Peng
- The First Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Ping Hu
- Chongqing Emergency Medical Center, Chongqing, China
| | - Yan-An Zhu
- Taizhou Hospital of Zhejiang Province, Taizhou, Zhejiang Province, China
| | - Ping Jin
- Yuyao People's Hospital of Zhejiang Province, Yuyao, Zhejiang Province, China
| | - Qi-Feng Shao
- Ninth People's Hospital of Zhengzhou, Zhengzhou, China
| | | | - Rui-Wu Dai
- Chengdu Military General Hospital, Chengdu, China
| | - Pei-Yang Hu
- Tiantai County People's Hospital, Tiantai, Zhejiang, China
| | - Hai-Ming Chen
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ge-Fei Wang
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yong-Gao Wang
- Department of Surgery, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Hong-Xu Jin
- Shenyang Military General Hospital, Shenyang, China
| | - Chang-Ju Zhu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qi-Yong Zhang
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Biao Shao
- The First People's Hospital of Kunming, Kunming, China
| | | | - Chang-Lin Yin
- The First Affiliated Hospital of Third Military Medical University, Chongqing, China
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The Difficult Abdominal Wound: Management Tips. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-0156-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Does Negative-Pressure Wound Therapy for the Open Abdomen Benefit the Patient? A Retrospective Cohort Study. Adv Skin Wound Care 2018; 30:256-261. [PMID: 28520603 DOI: 10.1097/01.asw.0000516196.19330.6f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Negative-pressure wound therapy (NPWT) is the most modern and sophisticated method of temporary abdominal closure. The aim of the study was to determine the significant predictors for mortality in patients with NPWT. SETTING University Clinical Centre Maribor, Slovenia MATERIALS AND METHODS:: The authors performed a retrospective cohort study of all patients treated with NPWT between January 1, 2011, and December 31, 2014. RESULTS In the univariate analysis, the type of wound closure, more than 7 NPWT changes, the total days with NPWT, and time to wound closure were significantly associated with death of the patient. In the multivariate analysis, only the number of more than 7 NPWT changes was found as a significant predictor for death (P = .038). CONCLUSIONS Negative-pressure wound therapy is a method of choice for the treatment of open abdomen if there is a clear indication. However, clinicians should try all measures to remove the NPWT system and close the abdomen as soon as possible because prolonged use is associated with significantly higher mortality.
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Salamone G, Licari L, Guercio G, Comelli A, Mangiapane M, Falco N, Tutino R, Bagarella N, Campanella S, Porrello C, Gullo R, Cocorullo G, Gulotta G. Vacuum-Assisted Wound Closure with Mesh-Mediated Fascial Traction Achieves Better Outcomes than Vacuum-Assisted Wound Closure Alone: A Comparative Study. World J Surg 2018; 42:1679-1686. [PMID: 29147897 PMCID: PMC5934457 DOI: 10.1007/s00268-017-4354-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Open abdomen (OA) permits the application of damage control surgery principles when abdominal trauma, sepsis, severe acute peritonitis and abdominal compartmental syndrome (ACS) occur. Methods Non-traumatic patients treated with OA between January 2010 and December 2015 were identified in a prospective database, and the data collected were retrospectively reviewed. Patients’ records were collected from charts and the surgical and intensive care unit (ICU) registries. The Acosta “modified” technique was used to achieve fascial closure in vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) patients. Sex, age, simplified acute physiology score II (SAPS II), abdominal compartmental syndrome (ACS), cardiovascular disease (CVD) and surgical technique performed were evaluated in a multivariate analysis for mortality and fascial closure prediction. Results Ninety-six patients with a median age of 69 (40–78) years were included in the study. Sixty-nine patients (72%) underwent VAWCM. Forty-one patients (68%) achieved primary fascia closure: two patients (5%) were treated with VAWC (37 median days) versus 39 patients (95%) who were treated with VAWCM (10 median days) (p = 0.0003). Forty-eight patients underwent OA treatment due to ACS, and 24 patients (50%) survived compared to 36 patients (75%) from the “other reasons” group (p = 0.01). The ACS group required longer mechanical ventilator support (p = 0.006), length of stay in hospital (p = 0.005) and in ICU (p = 0.04) and had higher SAPS II scores (p = 0.0002). Conclusions The survival rate was 62%. ACS (p = 0.01), SAPS II (p = 0.004), sex (p = 0.01), pre-existing CVD (p = 0.0007) and surgical technique (VAWC vs VAWCM) (p = 0.0009) were determined to be predictors of mortality. Primary fascial closure was obtained in 68% of cases. VAWCM was found to grant higher survival and primary fascial closure rate.
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Affiliation(s)
- Giuseppe Salamone
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Leo Licari
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy.
| | - Giovanni Guercio
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Albert Comelli
- Department of Industrial and Digital Innovation, Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Mirko Mangiapane
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Nicolò Falco
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Roberta Tutino
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Noemi Bagarella
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Sofia Campanella
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Calogero Porrello
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Roberto Gullo
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Gianfranco Cocorullo
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
| | - Gaspare Gulotta
- General and Emergency Surgery - Policlinico P. Giaccone, University of Palermo, Via Liborio Giuffré 5, 90127, Palermo, Italy
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Piccoli M, Agresta F, Attinà GM, Amabile D, Marchi D. "Complex abdominal wall" management: evidence-based guidelines of the Italian Consensus Conference. Updates Surg 2018; 71:255-272. [PMID: 30255435 PMCID: PMC6647889 DOI: 10.1007/s13304-018-0577-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 08/03/2018] [Indexed: 11/29/2022]
Abstract
To date, there is no shared consensus on a definition of a complex abdominal wall in elective surgery and in the emergency, on indications, technical details, complications, and follow-up. The purpose of the conference was to lay the foundations for a homogeneous approach to the complex abdominal wall with the primary intent being to attain the following objectives: (1) to develop evidence-based recommendations to define “complex abdominal wall”; (2) indications in emergency and in elective cases; (3) management of “complex abdominal wall”; (4) techniques for temporary abdominal closure. The decompressive laparostomy should be considered in a case of abdominal compartment syndrome in patients with critical conditions or after the failure of a medical treatment or less invasive methods. In the second one, beyond different mechanism, patients with surgical emergency diseases might reach the same pathophysiological end point of trauma patients where a preventive “open abdomen” might be indicated (a temporary abdominal closure: in the case of a non-infected field, the Wittmann patch and the NPWT had the best outcome followed by meshes; in the case of an infected field, NPWT techniques seem to be the preferred). The second priority is to create optimal both general as local conditions for healing: the right antimicrobial management, feeding—preferably by the enteral route—and managing correctly the open abdomen wall. The use of a mesh appears to be—if and when possible—the gold standard. There is a lot of enthusiasm about biological meshes. But the actual evidence supports their use only in contaminated or potentially contaminated fields but above all, to reduce the higher rate of recurrences, the wall anatomy and function should be restored in the midline, with or without component separation technique. On the other site has not to be neglected that the use of monofilament and macroporous non-absorbable meshes, in extraperitoneal position, in the setting of the complex abdomen with contamination, seems to have a cost effective role too. The idea of this consensus conference was mainly to try to bring order in the so copious, but not always so “evident” literature utilizing and exchanging the expertise of different specialists.
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Affiliation(s)
- Micaela Piccoli
- Department of General Surgery, General Surgery Unit, New Sant'Agostino Hospital, Via Pietro Giardini, 1355, 41126, Modena, Italy
| | - Ferdinando Agresta
- Department of General Surgery, ULSS19 Veneto, Piazzale degli Etruschi 9, 45011, Adria, Italy
| | - Grazia Maria Attinà
- Department of General Surgery, General Surgery Unit, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152, Rome, Italy.
| | - Dalia Amabile
- Department of General Surgery, General Surgery 1, Saint Chiara Hospital, Largo Medaglie D'oro, 9, 38122, Trento, Italy
| | - Domenico Marchi
- Department of General Surgery, General Surgery Unit, New Sant'Agostino Hospital, Via Pietro Giardini, 1355, 41126, Modena, Italy
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Abstract
The open abdomen technique and temporary abdominal closure after damage control surgery is fast becoming the standard of care for managing intra-abdominal bleeding and infectious or ischemic processes in critically ill patients. Expansion of this technique has evolved from damage control surgery in severely injured trauma patients to use in patients with abdominal compartment syndrome due to acute pancreatitis and other disorders. Subsequent therapies after use of the open abdomen technique and temporary abdominal closure are resuscitation in the intensive care unit and planned reoperation to manage the underlying cause of bleeding, infection, or ischemia. Determining the need for this potentially lifesaving intervention and managing the wound after the open abdomen has been created are all within the realm of critical care nurses. Case studies illustrate the implementation of the open abdomen technique and patient management strategies.
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Affiliation(s)
- Eleanor R Fitzpatrick
- Eleanor R. Fitzpatrick is a clinical nurse specialist for surgical critical care at the Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
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Salzedas Netto A, Silva P, Vicentine F, Takamatsu F, Gonzalez A, Martins J. Use of vacuum peritoneostomy as an alternative to the silo in the treatment of gastroschisis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2018. [DOI: 10.1016/j.epsc.2018.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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