Temporary abdominal vacuum-packing closure in the neonatal intensive care unit

Comparison of the Surgical Outcomes in Neonates with Left-sided Congenital Diaphragmatic Hernia with Only Skin Closure versus Abdominal Muscle Closure

Aim

This study aims to compare the outcome of neonatal left congenital diaphragmatic hernia (CDH, Bochdalek type) repair through laparotomy with and without abdominal muscle closure.

Materials and Methods

This retrospective study was conducted between January 2012 and May 2021 at a neonatal surgical unit of a Tertiary Care Center. Demographic details, preoperative management, Two-dimensional-echo, intra-operative findings, postoperative course, and follow-up data were collected and analyzed.

Results

The study group comprised 50 neonates with a mean standard deviation (SD) age at admission: 4.44 (5.12) days, male: female ratio of 3:2, and mean (SD) weight: 2.73 (0.51) kg. Following repair of the diaphragmatic defect through laparotomy, 26 (52%) underwent skin closure alone, whereas 24 (48%) underwent abdominal muscle closure. Postoperatively, there was a significant fall in the level of platelets (P = 0.021), increase in pressure support by at least 4-5 cm H2O (P = 0.027), and increase in the blood urea (P < 0.001), creatinine (P = 0.005), lactate (P = 0.019), and acidosis (P = 0.048) in the muscle closure group. Although not statistically significant, there was a fall in the urine output and blood pressure in this group. There was no significant difference in the duration of inotropes. Mortality was 8 (32%) in the skin closure group, and 14 (61%) in the muscle closure group (P = 0.05).

Conclusions

Neonates undergoing left CDH repair through the abdominal route with skin closure alone, had better survival, as well as hematological, renal, and ventilatory parameters than those who underwent muscle closure. It is a useful surgical modification to improve outcome in centers with limited facilities.

Congenital diaphragmatic hernia repair analysis in relation to postoperative abdominal compartment syndrome and delayed abdominal closure

AIM

Limited abdominal space in congenital diaphragmatic hernia (CDH) might result in abdominal compartment syndrome (ACS) and require delayed abdominal closure (DAC). This study reviewed outcomes in pediatric ACS/DAC after CDH repair.

METHODS

Medline/PubMed, Scopus, Web of Science, Ovid and Lilacs databases were reviewed. Data from studies published in English/Spanish/Portuguese between 1990-2020 was collected. Results are presented as descriptive statistics.

RESULTS

Sixteen reports offered 118 children, 112 (94.9%) being neonates. There were six ACS (5.1%) and 112 DAC (94.9%). Regarding ACS, the diagnosis was made clinically (n = 4; 66.7%), using Doppler scans (n = 1; 16.7%) or bladder pressure measurement (n = 1; 16.7%). There was one (16.7%) lethal outcome. The rationale to perform DAC was not clearly stated, and measurement of abdominal pressure was not mentioned in all reports. Silo was the preferred approach in 36 children (32.1%), followed by skin closure only (n = 16; 14.3%), vacuum (n = 10; 8.9%), fascia patch and skin closure (n = 5; 4.5%), fascia patch and vacuum dressing (n = 1; 0.9%), fasciotomy (n = 1; 0.9%); with no DAC technique reported in 43 patients (38.4%). Complications after DAC were reported in nine children (8.1%). One DAC using vacuum dressing that was clinically diagnosed with ACS required silo placement. There were 19 (17%) lethal outcomes.

CONCLUSIONS

ACS/DAC after CDH repair are reported more frequently in neonates (112/118; 94.9%). There is no clear rationale stated behind the decision to perform DAC, with the silo being the preferred approach. Criteria need to be worked for DAC in CDH with large herniated content and small volume abdomen to prevent ACS.

Negative-Pressure Wound Therapy in Infants and Children: A Population-Based Study

BACKGROUND

Although the safety and benefits of negative-pressure wound therapy (NPWT) have been clearly demonstrated in the adult population, studies evaluating the safety and describing the use of NPWT in the pediatric population have been limited. Given this paucity, the goals of this study were to (1) evaluate the literature dedicated to NPWT use in infants and children and (2) leverage a population-level analysis to describe the experience of NPWT use in the pediatric population.

MATERIALS AND METHODS

We performed a literature review and analyzed the Truven Health Analytics MarketScan Commercial Claims Databases from 2006 to 2014 to identify infants and children treated with NPWT. We evaluated patient characteristics, indications, complications before and after NPWT placement, and health care utilization within 30 d of NPWT placement.

RESULTS

We identified 457 articles, 11 of which fit our inclusion criteria. Most studies (65.2%) were case reports or series with less than 10 patients. In addition, we identified 3184 patients aged younger than of 18 y who were treated with NPWT between 2006 and 2014. Serious incident complications within 30 d after NPWT placement were rare (bleeding 0.6%, septicemia 0.5%, and sepsis 0.5%).

CONCLUSIONS

Despite the lack of robust studies, NPWT is widely used for many indications and across different ages and providers. Given the low incidence of serious complications, we conclude that NPWT use in infants and children is safe and can be effectively used by different providers spanning surgical and nonsurgical disciplines.

Negative pressure wound therapy in pediatric surgery: How and when to use

INTRODUCTION

Negative pressure wound therapy (NPWT) has been widely adopted to treat laparostomy, abdominal compartment syndrome (ACS) and complicated wounds associated with tissue loss. The method presents specific aspects, advantages and indications in Pediatrics. Our aim is to review the evidence available about NPWT in children.

METHODS

Active search for papers about NPWT in Pediatric patients. Papers referring to orthopedic problems, wound complications after Cardiac Surgery or burns were excluded.

RESULTS

The method shows good results to treat ACS, complicated wounds and abdominal wall malformations in neonates, including prematures. Periwound skin protection, monitoring of fluid losses and fine tuning of negative pressure levels according to age are necessary. Less pain, quicker recovery, less frequent dressing changes, possible recovery of exposed surgical hardware, granulation and shrinkage of the wound are advantages of the method over other kinds of dressing. NPWT is contraindicated over blood vessels and exposed nerves. Debridement is needed before usage over necrotic areas. Enteric fistulae are not contraindications. Complications are rare, mainly foam retention and dermatitis/skin maceration. The possibility of fistulae being caused by NPWT remains debatable.

CONCLUSION

NPWT is widely used in Pediatrics, including neonates and premature, but the evidence available about the method is scarce and low quality. Complications are uncommon and mostly manageable. A possible causal relationship between NPWY and enteric fistula remains unclear. Adult devices and parameters have been adapted to children's use. Extra care is needed to protect the delicate tissues of Pediatric patients. Comparative research to define differential costs, indications and advantages of the method, specific indications and limits of NWTP in Pediatrics is needed.

TYPE OF STUDY

Review.

EVIDENCE LEVEL

IV.

Delayed abdominal closure after congenital diaphragmatic hernia repair

PURPOSE

We present our experience with CDH patients who required delayed abdominal closure following CDH repair.

METHODS

A retrospective review of all CDH repairs from 2004 to 2014 was performed.

RESULTS

233 patients underwent CDH repair, of which 21 required delayed abdominal closure defined as the inability to close the abdominal fascia at the time of CDH repair. The incidence of delayed closure was higher in those undergoing CDH repair on ECMO vs. not on ECMO (40% [17/43] vs. 2% [4/190]; P<0.001). The abdominal wound was temporarily covered by skin only (n=2), skin+prosthetic mesh sutured to the fascia (n=3), preformed silo (n=9), or vacuum assisted closure (VAC®) device (n=7). The mean time to fascial closure was 14.5±7 and 6±3days for patients repaired on ECMO and not on ECMO, respectively. In patients repaired on ECMO, the "primary closure" and "delayed closure" groups were not different in prenatal predictors (liver up, lung-to-head ratio [LHR]), total days on ECMO, ECMO days prior to CDH repair, and survival. In patients repaired on ECMO, the "delayed closure" group had a significantly higher requirement for blood transfusions compared to the "primary closure" group (mean 87±35 vs. 62±27ml of packed RBCs per ECMO day; P=0.01).

CONCLUSION

Delayed abdominal closure was required in 40% of CDH repairs done on ECMO but was rarely required in CDH repairs performed off ECMO. Although associated with an increased need for blood transfusions, delayed closure following CDH repair on ECMO was not associated with increased mortality.

Abdominal compartment syndrome in children

Abdominal compartment syndrome is defined as sustained intra-abdominal pressure greater than 20 mm Hg (with or without abdominal perfusion pressure <60 mm Hg) associated with new organ failure or dysfunction. The syndrome is associated with 90% to 100% mortality if not recognized and treated in a timely manner. Nurses are responsible for accurately measuring intra-abdominal pressure in children with abdominal compartment syndrome and for alerting physicians about important changes. This article provides relevant definitions, outlines risk factors for abdominal compartment syndrome developing in children, and discusses an instructive case involving an adolescent with abdominal compartment syndrome. Techniques for measuring intra-abdominal pressure, normal ranges, and the importance of monitoring in the critical care setting for timely identification of intra-abdominal hypertension and abdominal compartment syndrome also are discussed.

Abdominal wall closure in neonates after congenital diaphragmatic hernia repair

PURPOSE

Repair of Congenital Diaphragmatic Hernia (CDH) abruptly increases intra-abdominal pressure. This study sought to characterize the incidence and significance of ACS and delayed fascial closure (DFC) after CDH repair.

METHODS

We reviewed the CAPSNet database from 2006 to 2011, identifying the subset of patients that developed ACS or required DFC. Prenatal and demographic information, operative and physiologic details, and outcomes were investigated.

RESULTS

Of 349 patients with CDH, 3 (0.8%) were diagnosed with ACS, while 43 patients (12%) had DFC at the time of CDH repair. Patients more often had right-sided defects (26% vs 13%, p=0.04) and trended toward requiring a patch repair (41% vs 31.2%, p=0.23) and having a liver lobe above the diaphragmatic rim (47% vs 32.7, p=0.09). Patients with ACS or DFC had increased length of stay (47.5 vs 33.9, p=0.01), days fasting (8.2 vs 5.8, p=0.01), days on parenteral nutrition (23.6 vs 15.5, p=0.003), and days on mechanical ventilation (16.3 vs 9.0, p=0.001).

CONCLUSIONS

While ACS in neonates after CDH repair is rare (<1%), DFC is required relatively commonly (>10%) and is associated with right-sided diaphragmatic hernias. Inability to close abdominal fascia is associated with increased morbidity. Clinicians caring for neonates with CDH should be facile with strategies to manage delayed abdominal fascia closure.

Use of negative pressure wound therapy for abdominal wounds in neonates and infants

BACKGROUND

Negative pressure wound therapy (NPWT) is an established and effective tool in the management of complicated abdominal wounds. This management approach has been used in infants, but few large series reports exist in the literature.

METHODS

The outcomes of infants with abdominal wounds receiving NPWT over the last 10 years at our institution were evaluated. Overall survival, time between initiation of NPWT, and discharge/death were examined.

RESULTS

We identified 18 infants who had abdominal wounds treated with NPWT. Diagnoses were varied, as was the duration of therapy. The median NPWT duration of treatment was 34.0 ± 92.1 days. Forty-four percent of the infants had a stoma before application of NPWT, and 22% of the infants had enterocutaneous fistulas before use of NPWT. There were only 2 cases in which a new fistula developed during the use of NPWT, and both of these omphalopagus conjoined twins had undergone the Bianchi procedure. No additional NPWT-related complications were identified. Of 18 infants, 6 died in this cohort.

CONCLUSION

Negative pressure wound therapy is an important therapeutic tool for the management of abdominal wounds in infants.

Abdominal decompression in children

Abdominal compartment syndrome (ACS) increases the risk for mortality in critically ill children. It occurs in association with a wide variety of medical and surgical diagnoses. Management of ACS involves recognizing the development of intra-abdominal hypertension (IAH) by intra-abdominal pressure (IAP) monitoring, treating the underlying cause, and preventing progression to ACS by lowering IAP. When ACS is already present, supporting dysfunctional organs and decreasing IAP to prevent new organ involvement become an additional focus of therapy. Medical management strategies to achieve these goals should be employed but when medical management fails, timely abdominal decompression is essential to reduce the risk of mortality. A literature review was performed to understand the role and outcomes of abdominal decompression among children with ACS. Abdominal decompression appears to have a positive effect on patient survival. However, prospective randomized studies are needed to fully understand the indications and impact of these therapies on survival in children.

Vacuum drainage in the management of complicated abdominal wound dehiscence in children

PURPOSE

The aim of the study was to report the outcomes of the vacuum dressing method (vacuum-assisted closure [VAC]) in the management of "complicated" abdominal wounds in a selected group of children including neonates.

METHODS

All children with vacuum (VAC) dressing-assisted closure of a complex abdominal wound (defined as complete/partial wound dehiscence combined with at least one of stoma, anastomosis, tube enterostomy, or infected patch abdominoplasty) were included in a 2-year study that took place in a single tertiary referral hospital. Retrospective case note analysis was used to determine premorbid diagnosis, management, illness severity markers, morbidity, and outcome.

RESULTS

Nine children (neonate to 16 years) required 11 continuous episodes of VAC therapy. Abdominal wall dehiscence was complete in 7 and partial in 4 episodes. These were complicated by stomas (8), anastomoses (3), enterocutaneous fistulae (3), tube enterostomy (1), and infected patch abdominoplasty (2). Illness severity was assessed by the following proxy physiologic markers: American Society of Anesthesiologists status 3 or more (10), intensive care unit (ICU) (7), inotropes (4), ventilation (7), septic (C-reactive protein >100 and blood culture-positive) (3), liver impairment (aspartate transaminase >58 and alanine transaminase >36) (4), coagulopathy (international normalized ratio >1.3) (4), proinflammatory state (platelet count >450) (5), and nutritional impairment (albumin <37) (9). The median VAC treatment time was 32 days (range, 9-101 days). Of the changes, 70% required a general anesthetic or sedation on ICU. Control of 10 of 11 complex abdominal wounds (including 3 established enterocutaneous fistulae) was achieved using VAC therapy. Complications included nonreduction of laparostomy (1), failure of anastomosis (1), and failure of tube enterostomy diversion (1). Four children died of unrelated causes, 2 of them more than 3 months after VAC therapy.

CONCLUSIONS

In our experience with a small series of patients, VAC therapy is both safe and effective in complex pediatric abdominal wounds in severely ill children. It appears to promote wound closure, controls local sepsis, and can be used to manage established fistulae. However, our results suggest that recent bowel anastomoses may be compromised using VAC, which in this circumstance, should be used with caution.

Vacuum-assisted closure for complicated neonatal abdominal wounds

BACKGROUND

Neonatal experience in vacuum-assisted closure (VAC) for complex abdominal wounds remains scant.

METHODS

A neonatal VAC protocol was instituted in 2004. The medical records of patients treated with this protocol for the ensuing 3 years were retrospectively reviewed. Continuous data are reported as mean +/- SD (range).

RESULTS

Ten VAC applications occurred in 8 neonates for a 3-year period. Gestational age and age at VAC application were 30 +/- 6.9 (24-40) weeks and 84.5 +/- 51 (21-165) days, respectively. Birth weight and weight at VAC application were 1495 +/- 1118 (615-3415) g and 3515 +/- 2118 (989-7965) g, respectively. All wound complications occurred after laparotomies (7 elective, 3 emergent). Three wounds included intestinal stomas, and 3 included enterocutaneous fistulae. Average wound area at VAC initiation was 13.6 +/- 6.0 (8.5-25) cm(2). Duration of VAC use was 19.1 +/- 15.3 (7-60) days. Vacuum-assisted closure resulted in complete wound closure in all cases and did not result in any local or systemic complications. Five patients (63%) survived to discharge.

CONCLUSIONS

Vacuum-assisted closure for complicated abdominal wounds is safe and successful in neonates of any gestational age and birth weight. It provides effective wound management, even in the presence of stomas or enterocutaneous fistulae.