Postoperative care and complications of damage control surgery

Negative pressure wound therapy for the treatment of the open abdomen and incidence of enteral fistulas: a retrospective bicentre analysis

Introduction. The open abdomen (OA) is often associated with complications. It has been hypothesized that negative pressure wound therapy (NPWT) in the treatment of OA may provoke enteral fistulas. Therefore, we analyzed patients with OA and NPWT with special regard to the occurrence of intestinal fistulas. Methods. The present study included all consecutive patients with OA treated with NWPT from April 2010 to August 2011 in two hospitals. Patients' demographics, indications for OA, risk factors, complications, outcome and incidence of fistulas before, during and after NPWT were recorded. Results. Of 81 patients with OA, 26 had pre-existing fistulas and 55 were free from a fistula at the beginning of NPWT. Nine of the 55 patients developed fistulas during (n = 5) or after NPWT (n = 4). Seventy-five patients received ABThera therapy, 6 patients other temporary abdominal closure devices. Only diverticulitis seemed to be a significant predisposing factor for fistulas. Mortality was slightly lower for patients without fistulas. Conclusion. The present study revealed no correlation between occurrence of fistulas before, during, and after NWPT, with diverticulitis being the only risk factor. Fistula formation during NPWT was comparable to reports from literature. Prospective studies are mandatory to clarify the impact of NPWT on fistula formation.

Treatment of small-bowel fistulae in the open abdomen with topical negative-pressure therapy

BACKGROUND

An open abdomen (OA) can result from surgical management of trauma, severe peritonitis, abdominal compartment syndrome, and other abdominal emergencies. Enteroatmospheric fistulae (EAF) occur in 25% of patients with an OA and are associated with high mortality.

METHODS

We report our experience with topical negative pressure (TNP) therapy in the management of EAF in an OA using the VAC (vacuum asisted closure) device (KCI Medical, San Antonio, TX). Nine patients with 17 EAF in an OA were treated with topical TNP therapy from January 2006 to January 2009. Surgery with enterectomy and abdominal closure was planned 6 to 10 weeks later.

RESULTS

Three EAF closed spontaneously. The median time from the onset of fistulization to elective surgical management was 51 days. No additional fistulae occurred during VAC therapy. One patient with a short bowel died as a result of persistent leakage after surgery.

CONCLUSIONS

Although previously considered a contraindication to TNP therapy, EAF can be managed successfully with TNP therapy. Surgical closure of EAFs is possible after several weeks.

Can vacuum-assisted closure and instillation therapy (VAC-Instill therapy) play a role in the treatment of the infected open abdomen?

Severe superimposed infection during open abdomen treatment with development of intra-abdominal sepsis is a challenging complication associated with high mortality rates. We report our experience with VAC-Instill therapy (KCI, San Antonio, USA) used for treatment of an infected open abdomen following pancreatic surgery. A literature search revealed no analogous case reports using VAC-Instill therapy for treatment of an infected laparostomy. The encouraging result of the case presented seems to indicate that VAC-Instill therapy could be used as adjunctive treatment in the management of the infected open abdomen when traditional therapy fails to control the infection.

Damage control in trauma and abdominal sepsis

Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.

Management of Enteroatmospheric Fistulae in the Open Abdomen

There are few complications dreaded more by the general surgeon than the development of an enteroatmospheric fistula in the face of the open abdomen. The open abdomen has become a valuable tool in the treatment of trauma and complex surgical patients. The development of enteroatmospheric fistulae leads to increased cost, morbidity, and mortality. In our case series, we describe the use of Malecot catheters and early mobilization of skin and subcutaneous tissue flaps to manage enteroatmospheric fistulae. All of our patients were discharged from the hospital and did not develop any complications from the procedure. All of our patients’ fistulae ultimately closed. This procedure could lead to decreased cost and morbidity.

The risk of local infective complications after damage control procedures for femoral shaft fracture

OBJECTIVES

To determine infection rates after damage control orthopaedics (DCO) and primary intramedullary nailing (1' IMN) in multiply injured patients with femoral shaft fracture.

DESIGN

Retrospective case analysis.

SETTING

Level I trauma center.

PATIENTS

All patients with New Injury Severity Score (NISS) >20 and femoral shaft fracture (AO 32-) treated in our unit between 1996 and 2002.

INTERVENTION

Damage control orthopaedics, defined as primary external fixation of the femoral shaft fracture and subsequent conversion to an intramedullary nail, or primary IMN.

MAIN OUTCOME MEASUREMENTS

Rates of infection classified as contamination (positive swabs with no clinical change), superficial, deep (requiring surgery), and removal of hardware (those requiring removal of femoral instrumentation or amputation).

RESULTS

A total of 173 patients with 192 fractures were included; 111 fractures were treated by DCO and 81 by primary IMN. Mean follow-up was 19.1 months [median, 16.7, range, 1 (patient died)-67 months]. DCO patients had a significantly higher NISS and more grade III open fractures (P<0.001). IMN procedures took a median of 150 minutes compared with 85 minutes for DCO (P<0.0001). Although wound contamination (including contaminated pin sites) was more common in the DCO group (P<0.05), the risk of infectious complications was equivalent (P=0.86). Contamination was significantly more likely when conversion to IMN occurred after more than 14 days (P<0.05); however, this did not lead to more clinically relevant infections. Logistic regression analysis showed that although a DCO approach was not associated with infection, delay before conversion in the DCO group might be [P=0.002 for contamination and removal of hardware, P=0.065 for serious infection (deep or worse), not significant for other infection outcomes]. Grade III open injury also was significantly associated with serious infection in all patients (P<0.05).

CONCLUSIONS

Infection rates after DCO for femoral fractures are comparable to those after primary IMN. We see no contraindication to the implementation of a damage control approach for severely injured patients with femoral shaft fracture where appropriate. Pin-site contamination was more common where the fixator was in place for more than 2 weeks. For patients treated by using a DCO approach, conversion to definitive fixation should be performed in a timely fashion.

Use of a Vacuum-Assisted Device to Facilitate Abdominal Closure

The inability for abdominal closure in critically ill surgical patients provides a complex problem. Often, these patients are left with a large ventral hernia, which requires readmission for abdominal wall repair. We are reporting on the use of a vacuum-assisted device (VAD) to facilitate abdominal wall closure. Fifteen patients were enrolled for placement of a VAD. Selection was based on the diagnosis of abdominal compartment syndrome, the inability for abdominal closure at the initial operation, or the inability to close the abdomen upon re-exploration. Ten (67%) patients were successfully closed within 11 days using the VAD. Predictors of successful closure were the duration of VAD placement (<12 days, P < 0.001), the total amount of VAD output (<3 L, P < 0.04), the patient's cumulative fluid balance within the first 2 weeks (<2 L, P < 0.002), or the presence of a systemic infection at the time of attempted closure (P < 0.001). After 6 months, there have been no complications in patients successfully closed with this device. There have been a few recent reports describing VAD abdominal closures. While not successful for every case, the majority of our patients were able to have their abdominal wall closed primarily. We plan to use this technique to help shorten hospital stay and prevent readmission for hernia repair.

Análise dos indicadores de hemorragia letal em vítimas de trauma penetrante de tronco admitidas em choque: um método objetivo para selecionar os candidatos ao "controle de danos"

OBJETIVO: Identificar os indicadores de hemorragia letal em vítimas de trauma penetrante de tronco, admitidas com hipotensão arterial sistêmica e analisar sua aplicabilidade na seleção dos candidatos ao "controle de danos". MÉTODO: Foram analisadas informações sobre 74 vítimas de ferimentos penetrantes exclusivamente de tronco, admitidas com hipotensão arterial sistêmica secundária à hemorragia, que sobreviveram até o tratamento definitivo. Os dados foram coletados prospectivamente durante dois anos. A média etária foi 29,5 + 8 anos, e 62 (83%) pacientes eram do sexo masculino. Trinta e nove (52%) foram vítimas de ferimentos de instrumentos perfurocortantes e 35 (47%), de ferimentos por projéteis de arma de fogo. Houve 23 óbitos (31%), 19 por hemorragia (82,6%). Os que faleceram por hemorragia foram incluídos no grupo H e os outros no grupo O. Foram comparadas diversas variáveis entre os grupos, utilizando-se o teste t de Student (controlado pelo teste de Levene) e a correlação de Spearman, considerando p<0,05 como significativo. RESULTADOS: As variáveis de maior correlação com hemorragia letal foram a pressão arterial sistólica no início da operação (<110mmHg), o pH arterial no início da operação (<7,25), a resposta à infusão endovenosa de líquidos à admissão (choque persistente) e o volume de concentrados de hemácias transfundido durante a operação (>1.200ml). Através de um modelo de regressão logística foi possível calcular o risco de morte por hemorragia baseado na pressão arterial no início da operação e volume de concentrados de hemácias transfundido. CONCLUSÃO: A análise dos indicadores de hemorragia letal fornece dados objetivos para a indicação do "controle de danos".

[Damage control: a tactical alternative for the management of exanguinating trauma patients]

BACKGROUND

Despite the advances in the treatment of exanguinating patients, hemorrhage remains as the leading cause of early deaths. A great deal of attention has been given to "damage control" as a therapeutic alternative in this scenario.

AIM

To appraise the definition, indications, operative techniques and results of damage control for the treatment of exanguinating trauma patients.

METHOD

Bibliographic review.

RESULTS

Damage control introduces the concept of breaking the vicious cycle of metabolic acidosis, hypothermia and coagulopathy which results from hemorrhagic shock. Thus, the operation has to be interrupted before this irreversible stage, even if the injured organs were not given the definitive treatment at this moment. So, damage control involves three steps: an abbreviated operation, a recovering period in the intensive care unit, and the reoperation for the definitive treatment. At the abbreviated operation, operative techniques as stapling intestinal injuries or packing liver wounds are applied, allowing rapid control of the bleeding and spillage. In the intensive care unit, the patient is warmed, oxygen delivery and consumption are restored and coagulation factors administered. As soon as the hemodynamic stability, ideal body temperature and coagulation status are reached, the definitive operation is carried out. Damage control is a helpful option if correctly used. However, there are also severe complications that can occur. Therefore, it should be employed only in centers that could provide optimum resources.

CONCLUSION

Damage control is an important tactical alternative for the treatment of exanguinating trauma patients.

Damage control surgery--concepts and practice

The results of prolonged and extensive procedures in the critically injured are poor, even in experienced hands. The operating theatre is a hostile and physiologically unfavourable environment for the severely injured patient. Laparotomy for major trauma involves dissipation of heat and massive blood loss requiring replacement. The result is a vicious cycle of hypothermia, acidosis and coagulopathy leading to death from an irreversible physiological insult (62). The damage control concept places surgery as an integral part of the resuscitative process, rather than an end in itself, and recognises that outcomes after major trauma are determined by the physiological limits of the patient, rather than by efforts of anatomical restoration by the surgeon. All those involved in the care of wounded patients should be familiar with this concept and its surgical and logistical implications.