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Okidi R, Sambo VDC, Okello I, Ekwem DA, Ekwang S, Obalim F, Kyegombe W. Associated factors of mortality and morbidity in emergency and elective abdominal surgery: a two-year prospective cohort study at lacor hospital, Uganda. BMC Surg 2024; 24:144. [PMID: 38730310 PMCID: PMC11088035 DOI: 10.1186/s12893-024-02433-z] [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: 02/22/2023] [Accepted: 05/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND The mortality rate associated with open abdominal surgery is a significant concern for patients and healthcare providers. This is particularly worrisome in Africa due to scarce workforce resources and poor early warning systems for detecting physiological deterioration in patients who develop complications. METHODS This prospective cohort study aimed to follow patients who underwent emergency or elective abdominal surgery at Lacor Hospital in Uganda. The participants were patients who underwent abdominal surgery at the hospital between April 27th, 2019 and July 07th, 2021. Trained research staff collected data using standardized forms, which included demographic information (age, gender, telephone contact, and location), surgical indications, surgical procedures, preoperative health status, postoperative morbidity and mortality, and length of hospital stay. RESULTS The present study involved 124 patients, mostly male, with an average age of 35 years, who presented with abdominal pain and varying underlying comorbidities. Elective cases constituted 60.2% of the total. The common reasons for emergency and elective surgery were gastroduodenal perforation and cholelithiasis respectively. The complication rate was 17.7%, with surgical site infections being the most frequent. The mortality rate was 7.3%, and several factors such as preoperative hypotension, deranged renal function, postoperative use of vasopressors, and postoperative assisted ventilation were associated with it. Elective and emergency-operated patients showed no significant difference in survival (P-value = 0.41) or length of hospital stay (P-value = 0.17). However, there was a significant difference in morbidity (p < 0.001). CONCLUSION Cholelithiasis and gastroduodenal perforation were key surgical indications, with factors like postoperative ventilation and adrenaline infusion linked to mortality. Emergency surgeries had higher complication rates, particularly surgical site infections, despite similar hospital stay and mortality rates compared to elective surgeries.
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Affiliation(s)
- Ronald Okidi
- Department of Surgery, Lacor Hospital, P.O. Box 180, Gulu, Uganda.
- Faculty of Medicine, Gulu University, Gulu, Uganda.
| | | | - Isaac Okello
- Department of Surgery, Lacor Hospital, P.O. Box 180, Gulu, Uganda
| | | | - Solomon Ekwang
- Department of Surgery, Lacor Hospital, P.O. Box 180, Gulu, Uganda
| | - Fiddy Obalim
- Department of Surgery, Lacor Hospital, P.O. Box 180, Gulu, Uganda
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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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Schaaf S, Schwab R, Wöhler A, Muysoms F, Lock JF, Sörelius K, Fortelny R, Keck T, Berrevoet F, Stavrou GA, von Websky M, Tartaglia D, Bulian D, Willms A. Use of a visceral protective layer prevents fistula development in open abdomen therapy: results from the European Hernia Society Open Abdomen Registry. Br J Surg 2023; 110:1607-1610. [PMID: 37311688 PMCID: PMC10638526 DOI: 10.1093/bjs/znad163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 06/15/2023]
Affiliation(s)
- Sebastian Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Aliona Wöhler
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Filip Muysoms
- Department of Surgery, Maria Middelares Hospital, Ghent, Belgium
| | - Johan F Lock
- Department of General-, Visceral-, Transplant-, Vascular- and Paediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Karl Sörelius
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rene Fortelny
- Department of General, Visceral and Oncological Surgery, Vienna, Austria
- Medical Faculty, Sigmund Freud University of Vienna, Vienna, Austria
| | - Tobias Keck
- Department of Surgery, University Hospital Schleswig-Holstein (UKSH), Lübeck, Germany
| | - Frederik Berrevoet
- Department of General and Hepatopancreatobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Gregor A Stavrou
- Department of General, Visceral and Thoracic Surgery, Surgical Oncology, Klinikum Saarbrücken, Saarbrücken, Germany
| | - Martin von Websky
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Dario Tartaglia
- General, Emergency and Trauma Surgery Unit, Pisa University Hospital, Pisa, Italy
| | - Dirk Bulian
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Centre, Witten/Herdecke University, Cologne, Germany
| | - Arnulf Willms
- Department of General, Visceral and Vascular Surgery, German Armed Forces Hospital Hamburg, Hamburg, Germany
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Theodorou A, Banysch M, Gök H, Deerenberg EB, Kalff JC, von Websky MW. Don't fear the (small) bite: A narrative review of the rationale and misconceptions surrounding closure of abdominal wall incisions. Front Surg 2022; 9:1002558. [PMID: 36504582 PMCID: PMC9727106 DOI: 10.3389/fsurg.2022.1002558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/11/2022] [Indexed: 11/24/2022] Open
Abstract
Background The most common complications related to the closure of abdominal wall incisions are surgical site infections, wound dehiscence and the development of an incisional hernia. Several factors relating to the surgical technique and the materials used have been identified and analysed over the years, as mirrored in the current recommendations of the European Hernia Society, but some misconceptions still remain that hinder wide implementation. Method A literature search was performed in the PubMed and GoogleScholar databases on 15 July 2021 and additionally on 30 March 2022 to include recent updates. The goal was to describe the scientific background behind the optimal strategies for reducing incisional hernia risk after closure of abdominal wall incisions in a narrative style review. Results An aponeurosis alone, small bites/small steps continuous suture technique should be used, using a slowly resorbable USP 2/0 or alternatively USP 0 suture loaded in a small ½ circle needle. The fascial edges should be properly visualised and tension should be moderate. Conclusion Despite the reproducibility, low risk and effectiveness in reducing wound complications following abdominal wall incisions, utilisation of the recommendation of the guidelines of the European Hernia Society remain relatively limited. More work is needed to clear misconceptions and disseminate the established knowledge and technique especially to younger surgeons.
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Affiliation(s)
- Alexis Theodorou
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany,Correspondence: Alexis Theodorou
| | - Mark Banysch
- Department of Surgery, St. Bernhard Hospital Kamp-Lintfort, Kamp-Lintfort, Germany
| | - Hakan Gök
- Hernia Istanbul, Hernia Istanbul®, Hernia Surgery Center, Istanbul, Turkey
| | - Eva B. Deerenberg
- Department of Surgery, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Joerg C. Kalff
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Martin W. von Websky
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
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Nikoupour H, Theodorou A, Arasteh P, Lurje G, Kalff JC, von Websky MW. Update on surgical management of enteroatmospheric fistulae in intestinal failure patients. Curr Opin Organ Transplant 2022; 27:137-143. [PMID: 35232927 DOI: 10.1097/mot.0000000000000960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The surgical management of enteroatmospheric fistula (EAF) in patients with intestinal failure represents a major challenge for a surgical team and requires proficiency in sepsis management, nutritional support and prehabilitation, beside expertise in visceral and abdominal wall surgery. This review provides an update on the current recommendations and evidence. RECENT FINDINGS Reconstructive surgery should be performed at a minimum of 6-12 months after last laparotomy. Isolation techniques and new occlusion devices may accelerate spontaneous EAF closure in selected cases. Chyme reinfusion supports enteral and parenteral nutrition. Stapler anastomosis and failure to close the fascia increase the risk of EAF recurrence. Posterior component separation, intraoperative fascial tension and biological meshes may be used to accommodate fascial closure. SUMMARY Timing of reconstructive surgery and previous optimal conservative treatment is vital for favorable outcomes. Wound conditions, nutritional support and general patient status should be optimal before attempting a definitive fistula takedown. Single stage procedures with autologous gut reconstruction and abdominal wall reconstruction can be complex but well tolerated.
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Affiliation(s)
- Hamed Nikoupour
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Peyman Arasteh
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Georg Lurje
- Department of Surgery, Charité Berlin, Berlin, Germany
| | - Joerg C Kalff
- Department of Surgery, University Hospital of Bonn, Bonn
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Management of the patient with the open abdomen. Curr Opin Crit Care 2021; 27:726-732. [PMID: 34561356 DOI: 10.1097/mcc.0000000000000879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to outline the management of the patient with the open abdomen. RECENT FINDINGS An open abdomen approach is used after damage control laparotomy, to decrease risk for postsurgery intra-abdominal hypertension, if reoperation is likely and after primary abdominal decompression.Temporary abdominal wall closure without negative pressure is associated with higher rates of intra-abdominal infection and evisceration. Negative pressure systems improve fascial closure rates but increase fistula formation. Definitive abdominal wall closure should be considered once oedema has subsided and the patient has stabilized. Delayed abdominal closure after trauma (>24-48 h) is associated with less achievement of fascial closure and more complications. Protective lung ventilation should be employed early, particularly if respiratory compromise is evident. Conservative fluid management and less sedation may decrease delirium and increase definitive abdominal closure rates. Extubation may be performed before definitive abdominal closure in selected patients. Antibiotic therapy should be brief, targeted and guideline concordant. Survival depends on the underlying disease, the closure method and the course of hospitalization. SUMMARY Changes in the treatment of patients with the open abdomen include negative temporary closure, conservative fluid management, early protective lung ventilation, decreased sedation and extubation before abdominal closure in selected patients.
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