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Ottolino P. Managing the Open Abdomen: Selecting an Appropriate Treatment Strategy. Adv Wound Care (New Rochelle) 2024; 13:400-415. [PMID: 38963339 DOI: 10.1089/wound.2023.0121] [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] [Indexed: 07/05/2024] Open
Abstract
Significance: The laparotomy is a common surgical procedure with a wide range of indications. Ideally, once the goals of surgery were achieved, the incision edges could then be approximated and the abdomen primarily closed. However, in some circumstances, it may be impossible to achieve primary closure, and instead the abdomen is intentionally left open. This review discusses the indications and objectives for the open abdomen (OA), summarizes the most common techniques for temporary abdominal closure, and illustrates treatment algorithms grounded in the current recommendations from specialty experts. Recent Advances: Still a relatively young technique, multiple strategies, and technologies have emerged to manage the OA. So too have the recommendations evolved, based on updated classifications that take wound characteristics into account. Recent studies have also brought greater clarity on recommendations for managing infection and malnutrition to support improved clinical outcomes. Critical Issues: The status of the OA can change rapidly depending on the patient's condition, the wound quality, and many other factors. Thus, there is a significant need for comprehensive treatment strategies that can be adapted to these developing circumstances. Future Directions: Treatment recommendations should be continuously updated as new technologies are introduced and old techniques fall out of use.
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Goad NT, Alexander E, Allen C, Cha JY. Comparison of Continuous Albumin Infusion, Bolus Albumin, and Crystalloid Fluid Administration in Open-Abdomen Surgical-Trauma Patients. J Pharm Pract 2024; 37:537-545. [PMID: 36514924 DOI: 10.1177/08971900221145991] [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: 12/15/2022]
Abstract
Background: The open abdomen (OA), an intentional lack of fascial closure following abdominal cavity opening, is utilized for various indications among surgical-trauma patients. Among intravenous fluid options, administration of albumin as a continuous infusion may improve outcomes in OA. The purpose of this study is to compare the time to abdomen closure among patients with OA according to type of fluid administration. Methods: We conducted a retrospective cohort study of adults with OA from 2012 through 2018 and stratified by intravenous fluid administration into one of three groups: continuous albumin infusion, intermittent bolus albumin, or crystalloid. The primary outcome was median time to abdomen closure. Secondary outcomes included hemodynamic parameters, length of stay (LOS), and mortality. Time to final abdomen closure was analyzed by Cox proportional hazards regression. Results: Eighty-four patients were included with 28 in each cohort. Compared to crystalloids (44.2 [interquartile range, IQR, 36.3-62.9] hours), median time to abdomen closure was significantly longer in bolus albumin (79.0 [IQR, 44.5-130.8] hours; P = .002) and continuous albumin groups (63.6 [IQR, 42.9-139.6] hours; P = .001) in Cox regression analysis. The incidence of hospital mortality was highest in the bolus albumin cohort (continuous albumin: 21.4% vs bolus albumin: 50.0% vs crystalloid: 25.0%; P = .044). All other secondary outcomes were similar between groups. Conclusions: Among patients with OA, administration of intravenous crystalloid was associated with the shortest time to abdomen closure compared to bolus or continuous albumin. Further evaluation of continuous albumin infusion in patients with OA is needed.
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Affiliation(s)
- Nathan T Goad
- Department of Pharmacy Services, Cabell Huntington Hospital, Huntington, WV, USA
| | - Earnest Alexander
- Department of Pharmacy Services, Tampa General Hospital, Tampa, FL, USA
| | - Christopher Allen
- Department of Pharmacy Services, Tampa General Hospital, Tampa, FL, USA
| | - John Y Cha
- Department of Surgery, Tampa General Hospital, Tampa, FL, USA
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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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Hill A, Elke G, Weimann A. Nutrition in the Intensive Care Unit-A Narrative Review. Nutrients 2021; 13:nu13082851. [PMID: 34445010 PMCID: PMC8400249 DOI: 10.3390/nu13082851] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background: While consent exists, that nutritional status has prognostic impact in the critically ill, the optimal feeding strategy has been a matter of debate. Methods: Narrative review of the recent evidence and international guideline recommendations focusing on basic principles of nutrition in the ICU and the treatment of specific patient groups. Covered topics are: the importance and diagnosis of malnutrition in the ICU, the optimal timing and route of nutrition, energy and protein requirements, the supplementation of specific nutrients, as well as monitoring and complications of a Medical Nutrition Therapy (MNT). Furthermore, this review summarizes the available evidence to optimize the MNT of patients grouped by primarily affected organ system. Results: Due to the considerable heterogeneity of the critically ill, MNT should be carefully adapted to the individual patient with special focus on phase of critical illness, metabolic tolerance, leading symptoms, and comorbidities. Conclusion: MNT in the ICU is complex and requiring an interdisciplinary approach and frequent reevaluation. The impact of personalized and disease-specific MNT on patient-centered clinical outcomes remains to be elucidated.
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Affiliation(s)
- Aileen Hill
- Department of Intensive Care and Anesthesiology, University Hospital RWTH Aachen University, D-52074 Aachen, Germany
- Correspondence: (A.H.); (A.W.); Tel.: +49-(0)241-80-38166 (A.H.); +49-(0)341-909-2200 (A.W.)
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany;
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Surgical Intensive Care Unit, Klinikum St. Georg, D-04129 Leipzig, Germany
- Correspondence: (A.H.); (A.W.); Tel.: +49-(0)241-80-38166 (A.H.); +49-(0)341-909-2200 (A.W.)
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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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Briganti V, Tursini S, Gulia C, Ruggeri G, Gargano T, Lima M. Bogotà bag for pediatric Open Abdomen. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Chen AM, Isidan A, Vega C, Saglam K, Mihaylov P, Fridell JA, Kubal CA, Mangus RS, Ekser B. Complex Abdominal Wound Healing After Multivisceral Retransplant: A Case Report on the Importance of Nutrition. Transplant Proc 2020; 52:2839-2843. [PMID: 32576477 DOI: 10.1016/j.transproceed.2020.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intestinal transplantation (ITx) is performed as an isolated ITx or as a part of multivisceral transplantation for intestinal failure secondary to short gut syndrome, inflammatory bowel disease, trauma, and sequelae of chronic parenteral nutrition dependence. Wound complications after ITx are very common, and abdominal wound closure cannot be immediately achieved in half of cases. CASE PRESENTATION A 25-year-old man sustained an abdominal crush injury causing complete loss of his small intestine, requiring an isolated ITx in March 2016. He lost his graft because of early exfoliative rejection in November 2016. Five months after enterectomy and the immunosuppression-free period, he underwent multivisceral retransplantation in April 2017. His post-transplant course was complicated by wound healing problems that improved with treatment of his malnutrition, quantified by increasing albumin, total protein, prealbumin, weight, body mass index, and total psoas muscle area over a period of 19 months after retransplant. CONCLUSION To our knowledge, this is the first case described of long-term wound follow-up after a multivisceral (re)transplantation, with corresponding nutrition information and images of the wound.
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Affiliation(s)
- Angela M Chen
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Abdulkadir Isidan
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Carlos Vega
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kutay Saglam
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Plamen Mihaylov
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan A Fridell
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chandrashekhar A Kubal
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Richard S Mangus
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Burcin Ekser
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
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Goh EL, Chidambaram S, Segaran E, Garnelo Rey V, Khan MA. A meta-analysis of the outcomes following enteral vs parenteral nutrition in the open abdomen in trauma patients. J Crit Care 2019; 56:42-48. [PMID: 31837600 DOI: 10.1016/j.jcrc.2019.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 10/23/2019] [Accepted: 12/02/2019] [Indexed: 11/16/2022]
Affiliation(s)
- En Lin Goh
- Faculty of Medicine, Imperial College London, South Kensington, London SW7 2AZ, United Kingdom.
| | - Swathikan Chidambaram
- Faculty of Medicine, Imperial College London, South Kensington, London SW7 2AZ, United Kingdom.
| | - Ella Segaran
- Department of Surgery and Trauma, Imperial College London, St Mary's Hospital, W2 1NY London, United Kingdom.
| | - Vanesa Garnelo Rey
- Department of Surgery and Trauma, Imperial College London, St Mary's Hospital, W2 1NY London, United Kingdom.
| | - Mansoor Ali Khan
- Department of Surgery and Trauma, Imperial College London, St Mary's Hospital, W2 1NY London, United Kingdom.
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Choi JH, Luo-Owen X, Brooks SE, Turay D, O'Bosky KR, Mukherjee K. Sedation and paralytic use in open abdomen patients-results from the EAST SLEEP Survey. Surgery 2019; 166:1111-1116. [PMID: 31500906 DOI: 10.1016/j.surg.2019.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/11/2019] [Accepted: 07/24/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patients with an open abdomen after trauma or emergency surgery may benefit from reduced sedation and chemical paralysis. We studied the effect of attending surgeon experience on sedation depth and paralytic use, as well as enteral nutrition and time between laparotomies. METHODS We performed an institutional review board-approved survey (Sedation Level after Emergent ExLap without Primary Fascial Closure) of the senior and active Eastern Association for the Surgery of Trauma membership using Qualtrics (Qualtrics, Inc, Provo, UT). We obtained 393/1,655 responses (23.7%). Spearman's rho was used for ordinal data, and multivariate logistic regression was used to adjust for trauma center level and presence of trainees in the relationship between surgeon experience and use of deep sedation. RESULTS Surgeon experience was associated with deep sedation (Richmond Agitation and Sedation Score ≤-3, P = .001) and chemical paralysis (P = .001). Surgeon experience was associated with less concern about delirium and more concern for evisceration as the reason for sedation depth (P = .001) and for paralysis (P = .001). Using multivariate logistic regression, surgeon experience was associated with deep sedation (odds ratio 3.6 [95% confidence interval 1.3, 10.4], P = .017 for ≥20 years; odds ratio 3.5 [95% confidence interval 1.1, 10.4], P = .025 for 15-20 years). Trauma center level was also significant (odds ratio 7.2 for Richmond Agitation and Sedation Score ≤-3 [95% confidence interval 1.7, 31.0], P = .008 for level III/IV versus level I/II). Increased surgeon experience was associated with delay of commencement of enteral feeds until return of bowel function (P = .013). Few respondents indicated willingness to extubate or mobilize open abdomen patients. Experienced surgeons were likely to wait for a defined time rather than for normalization of resuscitation markers to perform the first takeback laparotomy (P = .047) and waited longer between subsequent laparotomies (P = .004). CONCLUSION There were significant variations in practice among respondents based on the length of time since their last residency or fellowship, including variations that deviate from current best practice for management of patients with an open abdomen.
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Affiliation(s)
- Jee Hwan Choi
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Xian Luo-Owen
- Division of Acute Care Surgery, Loma Linda University Medical Center, CA
| | - Steven E Brooks
- Division of Trauma and Surgical Critical Care, Texas Tech University Health Sciences Center, Lubbock, TX
| | - David Turay
- Division of Acute Care Surgery, Loma Linda University Medical Center, CA
| | | | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Medical Center, CA.
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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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Abstract
BACKGROUND The purpose of this study was to characterize associations among serum proteins, negative-pressure wound therapy (NPWT) fluid loss, and primary fascial closure (PFC) following emergent laparotomy and temporary abdominal closure (TAC). We hypothesized that high levels of C-reactive protein (CRP) and NPWT output would be associated with hypoalbuminemia and failure to achieve PFC. METHODS We performed a retrospective analysis of 233 patients managed with NPWT TAC. Serum proteins and resuscitation indices were assessed on admission, initial laparotomy, and then at 48 hours, 96 hours, 7 days, and discharge. Correlations were assessed by Pearson coefficient. Multivariable regression was performed to identify predictors of PFC with cutoff values for continuous variables determined by Youden index. RESULTS Patients who failed to achieve PFC (n = 55) had significantly higher CRP at admission (249 vs. 148 mg/L, p = 0.003), initial laparotomy (237 vs. 154, p = 0.002), and discharge (124 vs. 72, p = 0.003), as well as significantly lower serum albumin at 7 days (2.3 vs. 2.5 g/dL, p = 0.028) and discharge (2.5 vs. 2.8, p = 0.004). Prealbumin (in milligrams per deciliter) was similar between groups at each time point. There was an inverse correlation between nadir serum albumin and total milliliters of NPWT output (r = -0.33, p < 0.001). Exogenous albumin administration (in grams per day) correlated with higher serum albumin levels at each time point: 48 hours: r = 0.26 (p = 0.002), 96 hours: r = 0.29 (p = 0.002), 7 days: r = 0.40 (p < 0.001). Albumin of less than 2.6 g/dL was an independent predictor of failure to achieve PFC (odds ratio, 2.59; 95% confidence interval, 1.02-6.61) in a multivariate model including abdominal sepsis, body mass index of greater than 40 kg/m, and CRP of greater than 250 mg/L. CONCLUSIONS Early and persistent systemic inflammation and high NPWT output were associated with hypoalbuminemia, which was an independent predictor of failure to achieve PFC. The utility of exogenous albumin following TAC requires further study. LEVEL OF EVIDENCE Prognostic study, level III; Therapeutic study, level IV.
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Mukherjee K, Kavalukas SL, Barbul A. Nutritional Aspects of Gastrointestinal Wound Healing. Adv Wound Care (New Rochelle) 2016; 5:507-515. [PMID: 27867755 DOI: 10.1089/wound.2015.0671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/23/2015] [Indexed: 02/07/2023] Open
Abstract
Significance: Although the wound healing cascade is similar in many tissues, in the gastrointestinal tract mucosal healing is critical for processes such as inflammatory bowel disease and ulcers and healing of the mucosa, submucosa, and serosal layers is needed for surgical anastomoses and for enterocutaneous fistula. Failure of wound healing can result in complications including infection, prolonged hospitalization, critical illness, organ failure, readmission, new or worsening enterocutaneous fistula, and even death. Recent Advances: Recent advances are relevant for the role of specific micronutrients, such as vitamin D, trace elements, and the interplay between molecules with pro- and antioxidant properties. Our understanding of the role of other small molecules, genes, proteins, and macronutrients is also rapidly changing. Recent work has elucidated relationships between oxidative stress, nutritional supplementation, and glucose metabolism. Thresholds have also been established to define adequate preoperative nutritional status. Critical Issues: Further work is needed to establish standards and definitions for measuring the extent of wound healing, particularly for inflammatory bowel disease and ulcers. In addition, a mounting body of evidence has determined the need for adequate preoperative nutritional supplementation for elective surgical procedures. Future Directions: A large portion of current work is restricted to model systems in rodents. Therefore, additional clinical and translational research is needed in this area to promote gastrointestinal wound healing in humans, particularly those suffering from critical illness, patients with enterocutaneous fistula, inflammatory bowel disease, and ulcers, and those undergoing surgical procedures.
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Affiliation(s)
- Kaushik Mukherjee
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandra L. Kavalukas
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adrian Barbul
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Abstract
BACKGROUND A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. METHODS The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. RESULTS OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). CONCLUSION OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.
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Du Toit A. Nutritional management of a complicated surgical patient by means of fistuloclysis. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2016. [DOI: 10.1080/16070658.2014.11734515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Du Toit A. SASPEN Case Study: Nutritional management of a patient with an open abdomen. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2016. [DOI: 10.1080/16070658.2014.11734502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Classification, prevention and management of entero-atmospheric fistula: a state-of-the-art review. Langenbecks Arch Surg 2016; 401:1-13. [PMID: 26867939 DOI: 10.1007/s00423-015-1370-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/22/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Entero-atmospheric fistula (EAF) is an enteric fistula occurring in the setting of an open abdomen, thus creating a communication between the GI tract and the external atmosphere. Management and nursing of patients suffering EAF carries several challenges, and prevention of EAF should be the first and best treatment option. PURPOSE Here, we present a novel modified classification of EAF and review the current state of the art in its prevention and management including nutritional issues and feeding strategies. We also provide an overview on surgical management principles, highlighting several surgical techniques for dealing with EAF that have been reported in the literature throughout the years. CONCLUSIONS The treatment strategy for EAF should be multidisciplinary and multifaceted. Surgical treatment is most often multistep and should be tailored to the single patient, based on the type and characteristics of the EAF, following its correct identification and classification. The specific experience of surgeons and nursing staff in the management of EAF could be enhanced, applying distinct simulation-based ex vivo training models.
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Abstract
The use of open abdomen (OA) as a technique in the treatment of exsanguinating trauma patients was first described in the mid-19(th) century. Since the 1980s, OA has become a relatively new and increasingly common strategy to manage massive trauma and abdominal catastrophes. OA has been proven to help reduce the mortality of trauma. Nevertheless, the OA method may be associated with terrible and devastating complications such as enteroatmospheric fistula (EAF). As a result, OA should not be overused, and attention should be given to critical care as well as special management. The temporary abdominal closure (TAC) technique after abbreviated laparotomy was used to improve wound healing and facilitate final fascial closure of OA. Negative pressure therapy (NPT) is the most commonly used TAC method.
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Affiliation(s)
- Yu-Hua Huang
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002 China
| | - You-Sheng Li
- Department of General Surgery, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002 China
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Griggs C, Butler K. Damage Control and the Open Abdomen: Challenges for the Nonsurgical Intensivist. J Intensive Care Med 2015; 31:567-76. [PMID: 26180038 DOI: 10.1177/0885066615594352] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 06/10/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND As strategies in acute care surgery focus on damage control to restore physiology, intensivists spanning all disciplines care for an increasing number of patients requiring massive transfusion, temporary abdominal closures, and their sequelae. OBJECTIVE To equip the nonsurgical intensivist with evidence-based management principles for patients with an open abdomen after damage control surgery. DATA SOURCE Search of PubMed database and manual review of bibliographies from selected articles. DATA SYNTHESIS AND CONCLUSIONS Temporary abdominal closure improves outcomes in patients with abdominal compartment syndrome, hemorrhagic shock, and intra-abdominal sepsis but creates new challenges with electrolyte derangement, hypovolemia, malnutrition, enteric fistulas, and loss of abdominal wall domain. Intensive care of such patients mandates attention to resuscitation, sepsis control, and expedient abdominal closure.
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Affiliation(s)
| | - Kathryn Butler
- Division of Trauma Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
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Blair SG, Fayard NJ, Ahmed N, Rogers EA, Simmons JD. Early Use of Split-thickness Skin Graft Allows Separation of the Wound into Different Compartments Facilitating the Collection of Enteroatmospheric Fistulae Output. Am Surg 2015. [DOI: 10.1177/000313481508100303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Scott G. Blair
- Division of Trauma, Burn, Acute Care Surgery & Surgical Critical Care The University of South Alabama Medical Center Mobile, Alabama
| | - Nicholas J. Fayard
- Division of Trauma and Surgical Critical Care University of Mississippi Medical Center Jackson, Mississippi
| | - Naveed Ahmed
- Division of Trauma and Surgical Critical Care University of Mississippi Medical Center Jackson, Mississippi
| | - Emily A. Rogers
- Division of Trauma and Surgical Critical Care University of Mississippi Medical Center Jackson, Mississippi
| | - Jon D. Simmons
- Division of Trauma, Burn, Acute Care Surgery & Surgical Critical Care The University of South Alabama Medical Center Mobile, Alabama
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Lambertz A, Mihatsch C, Röth A, Kalverkamp S, Eickhoff R, Neumann U, Klink C, Junge K. Fascial closure after open abdomen: Initial indication and early revisions are decisive factors – A retrospective cohort study. Int J Surg 2015; 13:12-16. [DOI: 10.1016/j.ijsu.2014.11.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 10/24/2014] [Accepted: 11/23/2014] [Indexed: 12/20/2022]
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Chen J, Ren JA, Han G, Gu GS, Wang GF, Wu XW, Zhou B, Hu D, Wu Y, Zhao YZ, Li JS. Polymorphism of heat shock protein 70-2 and enterocutaneous fistula in Chinese population. World J Gastroenterol 2014; 20:12559-65. [PMID: 25253958 PMCID: PMC4168091 DOI: 10.3748/wjg.v20.i35.12559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/08/2014] [Accepted: 06/20/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate whether the heat shock protein 70-2 (HSP70-2) polymorphism is associated with enterocutaneous fistulas in a Chinese population. METHODS This study included 131 patients with enterocutaneous/enteroatmospheric fistulas. Patients with inflammatory bowel disease or other autoimmune diseases were excluded from this study. All patients with enterocutaneous/enteroatmospheric fistulas were followed up for three months to observe disease recurrence. In addition, a total of 140 healthy controls were also recruited from the Jinling Hospital, matched according to the sex and age of the patient population. Genomic DNA was extracted from peripheral blood from each participant. The HSP70-2 restriction fragment length polymorphism related to the polymorphic PstI site at position 1267 was characterized by polymerase chain reaction (PCR). First PCR amplification was carried out, and then PCR products were digested with PstI restriction enzyme. The DNA lacking the polymorphic PstI site within HSP70-2 generates a product of 1117 bp in size (allele A), whereas the HSP70-2 PstI polymorphism produces two fragments of 936 bp and 181 bp in size (allele B). RESULTS The frequency of the HSP70-2 PstI polymorphism did not differ between patients and controls; however, the A allele was more predominant in patients with enterocutaneous fistulas than in controls (60.7% vs 51.4%, P = 0.038, OR = 1.425, 95%CI: 1.019-1.994). Sixty-one patients were cured by a definitive operation, drainage operation, or percutaneous drainage while 52 patients were cured by nonsurgical treatment. There was no significant difference in the frequency of the HSP70-2 PstI polymorphism between the patients who had surgery compared to those who did not (P = 0.437, OR = 1.237, 95%CI: 0.723-2.117). Moreover, 11 patients refused any treatment for economic reasons or tumor burden, and 7 patients with enterocutaneous fistulas (5.8%) died during the follow-up period. However, there was no significant difference in the frequency of the HSP70-2 PstI polymorphism between the patients who survived compared to those who died (P = 0.403, OR = 0.604, 95%CI: 0.184-1.986). CONCLUSION The A allele of the HSP70-2 PstI polymorphism was associated with enterocutaneous fistulas in this Chinese population.
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López-Cano M, Pereira JA, Armengol-Carrasco M. “Acute postoperative open abdominal wall”: Nosological concept and treatment implications. World J Gastrointest Surg 2013; 5:314-320. [PMID: 24392182 PMCID: PMC3879415 DOI: 10.4240/wjgs.v5.i12.314] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 08/02/2013] [Accepted: 10/16/2013] [Indexed: 02/06/2023] Open
Abstract
The so-called “burst abdomen” has been described for many years and is a well-known clinical condition, whereas the concept of the “open abdomen” is relatively new. In clinical practice, both nosological entities are characterized by a complex spectrum of symptoms apparently disconnected, which in many cases poses a great challenge for surgical repair. In order to assess the management of these disorders in a more comprehensive and integral fashion, the concept of “acute postoperative open abdominal wall” (acute POAW) is presented, which in turn can be divided into “intentional” or planned acute POAW and “unintentional” or unplanned POAW. The understanding of the acute POAW as a single clinical process not only allows a better optimization of the therapeutic approach in the surgical repair of abdominal wall-related disorders, but also the stratification and collection of data in different patient subsets, favoring a better knowledge of the wide spectrum of conditions involved in the surgical reconstruction of the abdominal wall.
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Nutritional support in patients following damage control laparotomy with an open abdomen. Eur J Trauma Emerg Surg 2013; 39:243-8. [PMID: 26815230 DOI: 10.1007/s00068-013-0287-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 04/01/2013] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Damage control laparotomy (DCL) and the open abdomen have been well accepted following either severe abdominal trauma or emergency surgical disease. As DCL is increasingly utilized as a therapeutic option, appropriate management of the post-DCL patient is important. Early caloric support by enteral nutrition (EN) in the critically ill patient improves wound healing and decreases septic complications, lung injury, and multi-system organ failure. However, following DCL, nutritional strategies can be challenging and, at times, even daunting. CONCLUSIONS Even though limited data exist, the use of early EN following DCL seems safe, provided that the patient is not undergoing active resuscitation or the bowel is not in discontinuity. It is unknown as to whether EN in the open abdomen reduces septic complications, prevents enterocutaneous fistula (ECF), or alters the timing of definitive abdominal wall closure. Future investigation in a prospective manner may help elucidate these important questions.
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