Comparison of Continuous Albumin Infusion, Bolus Albumin, and Crystalloid Fluid Administration in Open-Abdomen Surgical-Trauma Patients

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.

Antibiotics for Patients With a Planned Re-Laparotomy for Intra-Abdominal Infection

Background: Appropriate antimicrobial therapy for the management of intra-abdominal infection (IAI) continues to evolve based on available literature. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial provided evidence to support four days of antibiotic agents in IAI post-source control but excluded patients with a planned re-laparotomy. This study aimed to determine the short- and long-term recurrent infection risk in this population. Patients and Methods: This is a single-center, retrospective, observational study of adult patients admitted to a quaternary medical center between January 1, 2016, and August 1, 2022, with IAI requiring planned laparotomy. Patients were designated as receiving five or less days of antibiotic agents (short course) or more than five days (long course) after source control. The primary outcome was IAI recurrence within 30 days. Results: Of the 104 patients who met inclusion criteria, 78 were included in analysis. Average age was 57 ± 13.3 years, 56% were male, 94% Caucasian, with a mean Acute Physiology and Chronic Health Evaluation (APACHE) II score of 17 ± 7.09. All other baseline characteristics and clinical severity markers were similar between the two groups. Regarding the primary outcome of IAI recurrence, there was no difference when comparing those who received short course versus those who received long course therapy (41.2% vs. 44.4%; p = 0.781). No differences were found between groups with respect to secondary outcomes. Conclusions: In patients admitted with IAI managed with planned re-laparotomy those who received short course antimicrobial therapy were not found to have an increase in IAI recurrence compared to those with longer courses of therapy.

A method for treatment of deep and superficial enteroatmospheric fistulas in an open abdomen, ChimneyVAC: Ten years experience

BACKGROUND

Leakage of intestinal fluid is a challenging event when it appears in an open abdomen (OA) and surgical deviation does not seem possible. Intestinal contents in the abdominal cavity maintain inflammation and drainage is there for essential. We have developed a method, ChimneyVAC, to treat both deep and superficial enteroatmospheric fistulas (EAF) AIMS: To describe this innovative surgical technique and our 10-year experience.

MATERIAL & METHODS

This single-center observational cohort study included all 16 consecutive patients treated with ChimneyVAC. Seven women and 9 men; median age: 47; (interquartile range [IQR]:39-63) years, 15 with a small bowel fistula and 1 with a large bowel fistula. All except of the colonic fistula were classified as a high output fistula; 14 were deep and 2 superficial. In this technique, a negative-pressure source is applied directly above the fistula opening, in addition to negative pressure wound therapy for the OA. This controls the leakage of intestinal fluid by direct drainage into a vacuum system, thereby avoiding contamination of the abdomen. A controlled enterocutaneous fistula (ECF) then forms as the traction from the ChimneyVAC brings the fistula opening to skin level.

RESULTS

In 14 patients, an ECF formed after a median of 42 (IQR:28-55) days and 12 (IQR:7-16) dressing changes. The median length of hospitalization was 103 (IQR:58-143) days. Two patients died of multiorgan failure and 14 initially survived.

DISCUSSION

This study showed that 14 out of 16 patients survived the initial treatment for enteric leakage with the ChimneyVAC method. The outcome of ChimneyVAC treatment is a controlled ECF, which was then corrected after a median of six months. However, hospitalization is lengthy, the patients undergo several dressing changes and many needs additional parenteral nutrition until intestinal continuity is reestablished.

CONCLUSION

ChimneyVAC is a feasible method for treatment of EAF in an OA, with favorable survival.

Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy

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.

A Cost-Effectiveness Analysis of Wittmann Patch-Assisted Abdominal Closure Compared to Planned Ventral Hernia in Management of the Open Abdomen

BACKGROUND

Inability to achieve primary fascial closure after damage control laparotomy is a frequently encountered problem by acute care and trauma surgeons. This study aims to compare the cost-effectiveness of Wittmann patch-assisted closure to the planned ventral hernia closure.

METHODS

A literature review was performed to determine the probabilities and outcomes for Wittmann patch-assisted primary closure and planned ventral hernia closure techniques. Average utility scores were obtained by a patient-administered survey for the following: rate of successful surgeries (uncomplicated abdominal wall closure), surgical site infection, wound dehiscence, abdominal hernia and enterocutaneous fistula. A visual analogue scale (VAS) was utilized to assess the survey responses and then converted to quality-adjusted life years (QALYs). Total cost for each strategy was calculated using Medicare billing codes. A decision tree was generated with rollback and incremental cost-utility ratio (ICUR) analyses. Sensitivity analyses were performed to account for uncertainty.

RESULTS

Wittmann patch-assisted closure was associated with higher clinical effectiveness of 19.43 QALYs compared to planned ventral hernia repair (19.38), with a relative cost reduction of US$7777. Rollback analysis supported Wittmann patch-assisted closure as the more cost-effective strategy. The resulting negative ICUR of -156,679.77 favored Wittmann patch-assisted closure. Monte Carlo analysis demonstrated a confidence of 96.8% that Wittmann patch-assisted closure was cost-effective.

CONCLUSIONS

This study demonstrates using the Wittmann patch-assisted closure strategy as a more cost-efficient management of the open abdomen compared to the planned ventral hernia approach.

Establishment and evaluation of an improved rat model of open abdomen

INTRODUCTION

This study aimed to establish an animal model of open abdomen (OA) through temporary abdominal closure via different techniques.

METHODS

Adult male Sprague-Dawley rats were randomly divided into three groups: group A (OA with polypropylene mesh alone); group B (OA with polypropylene mesh combined with a patch); and group C (OA with polypropylene mesh and a sutured patch). Vital signs, pathophysiological changes, and survival rates were closely monitored in the rats for 7 days after surgery. Abdominal X-rays and histopathological examinations were performed to assess abdominal organ changes and wound healing.

RESULTS

The results showed no significant difference in mortality rates among the three groups (p > 0.05). However, rats in group B exhibited superior overall condition, cleaner wounds, and a higher rate of wound healing compared to the other groups (p < 0.05). Abdominal X-rays indicated that varying degrees of distal intestinal obstruction in all groups. Histopathological examinations revealed fibrous hyperplasia, inflammatory cell infiltration, neovascularization, and collagen deposition in all groups. Group B demonstrated enhanced granulation tissue generation, neovascularization, and collagen deposition compared to the other groups (p < 0.05).

CONCLUSIONS

Polypropylene mesh combined with patches is the most suitable method for establishing an animal model of OA. This model successfully replicated the pathological and physiological changes in postoperative patients with OA, specifically the progress of abdominal skin wound healing. It provides a practical and reliable animal model for OA research.

A 5 + 1-Axis 3D Printing Platform for Producing Customized Intestinal Fistula Stents

Tailored intestinal fistula stents with a hollow bent pipe structure prepared by using a three-axis bio-printing platform are often unsuitable due to low printing efficiency and quality caused by the unavoidable need for a supporting structure. Herein, a 5 + 1-axis 3D printing platform was built and developed for producing support-free intestinal fistula stents. A 3D model of the target stent shape and dimensions was treated by a dynamic slicing algorithm, which was then used to prepare a motion control code. Our printing method showed improved printing efficiency, superior stent surface properties and structure and ideal elasticity and mechanical strength to meet the mechanical requirements of the human body. Static simulations showed the importance of axial printing techniques, whereas the stent itself was shown to have excellent biocompatibility with wettability and cell proliferation tests. We present a customizable, efficient, and high-quality method with the potential for preparing bespoke stents for treating intestinal fistulas.

National Open Abdomen Audit (NOAA) - protocol for an observational audit of the use and management of the open abdomen in secondary care across Great Britain and Ireland

AIM

Use of open abdomen (OA) remains an important life-saving manoeuvre in the management of trauma and the abdominal catastrophe. The National Open Abdomen Audit (NOAA) is an audit project investigating the indications, management, and subsequent outcomes of OA treatment throughout the UK. The aim is to generate a snapshot of practice which will inform the management of future patients and potentially reduce the significant harm that can be associated with OA.

METHODS AND ANALYSIS

NOAA is a collaborative, prospective observational audit recruiting patients from across Great Britain and Ireland. The study will open from July 2023 with rolling recruitment across participating sites. All adult patients who leave theatre with an OA will be included and followed-up for 90 days. The primary objective is to prospectively audit the national variability in the management of the OA. Secondary outcomes include the treatment modality used for OA, indication, outcome of treatment and complications, including mortality and development of intestinal failure. All data will be recorded and managed using the secure REDCap electronic data capture and analysed using Stata (version 16.1). Results will be reported in accordance with the STROBE statement.

CONCLUSION

Results will be used to formulate a practical clinical guideline on when to implement an OA along with a stepwise management plan once initiated to reduce the associated morbidity and mortality. It is hoped that participation in this study will facilitate education of surgeons with a "trickle down" effect on all members of the surgical team and remove variability in the management.

Vacuum assisted closure with mesh mediated fascial traction of open abdominal wounds and acute fascial dehiscence, a single institution experience

BACKGROUNDS

Laparostomy is a common means of managing surgical catastrophes, but often results in large ventral hernias which prove difficult to repair. It is also associated with high rates of enteric fistula formation. Dynamic methods of managing the open abdomen have been shown to result in higher rates of fascial closure and fewer complications. Recent publications have suggested the addition of chemical components relaxation with botulinum toxin has an added advantage over prior methods.

METHODS

We report on a series of emergent cases managed by the combination of Botulinum toxin A (BTA) mediated chemical relaxation with a modified method of mesh-mediated fascial traction (MMFT) and negative pressure wound therapy (NPWT).

RESULTS

Thirteen cases (nine laparostomies and four fascial dehiscence) were successfully closed in a median of 12 days, using a median of 4 'tightenings', with no clinical herniation detected at follow up so far (median 183 days, IQR 123-292). There were no procedure-related complications, but one death from the underling pathology.

CONCLUSIONS

We report further cases of vacuum assisted mesh-mediated fascial traction (VA-MMFT) utilizing BTA in successfully managing laparostomy and abdominal wound dehiscence and continues the known high rate of successful fascial closure seen when applied in treating the open abdomen.

Assessment of Risk Factors for Enteric Fistula and Intra-Abdominal Sepsis in Patients with Open Abdomen in Trauma: An Original Research

Introduction

In emergency surgeries, open abdomen or laparostomy, especially with perforated viscus, has been used primarily to prevent delayed ventral hernia, burst abdomen, and abdominal compartment syndrome. In the present study, the clinical and resuscitative factors that are linked with open abdomen morbidity are evaluated.

Material and Methods

A retrospective analysis was done for all the subjects who were admitted at the tertiary care center between May 2020 and May 2022 for the open abdomen surgeries. These patients were examined to see whether they needed more postoperative care than usual, including the need for resuscitative treatments and other critical clinical indicators. Patients were evaluated if they had any complications. The data that were collected were analysed for any variance using analysis of variance considering P <.05 as significant.

Results

A total of 100 subjects were analysed in this study. Forty nine patients had intra-abdominal sepsis of the 100 cases examined from historical case records and 1 had entero-cutaneous fistulas. These patients did not necessitate additional actions for intensive care unit care, resuscitation, an chest infection, extended hospital stay, or any disabilities compared to those who did not undergo laparotomy during the same period. In this group of patients with open abdomens, the immediate postoperative period was not linked to an increase in resuscitation efforts or a load on clinical staff. Once patients are stabilized, early definitive abdominal closure is advised to prevent problems associated to laparostomies.

Conclusion

The quantity of initial fluid revival and the coagulation factors at the time of admission are not related to intra-abdominal sepsis and enteric fistula following laparostomy after significant abdominal injuries.

Severe Acute Pancreatitis Treated with Negative Pressure Wound Therapy System: Influence of Laboratory Markers

(1) Background: An open abdomen is a serious medical condition that requires prompt and effective treatment to prevent complications and improve patient outcomes. Negative pressure therapy (NPT) has emerged as a viable therapeutic option for temporary closure of the abdomen, offering several benefits over traditional methods. (2) Methods: We included 15 patients with pancreatitis who were hospitalized in the I-II Surgery Clinic of the Emergency County Hospital "St. Spiridon" from Iasi, Romania, between 2011-2018 and received NPT. (3) Results: Preoperatively, the mean IAP level was 28.62 mmHg, decreasing significantly postoperatively to 21.31 mmHg. The mean level of the highest IAP value recorded in pancreatitis patients treated with VAC did not differ significantly by lethality (30.31 vs. 28.50; p = 0.810). In vacuum-treated pancreatitis patients with a IAP level > 12, the probability of survival dropped below 50% during the first 7 days of stay in the ICU, so that after 20 days the probability of survival was approximately 20%. IAP enters the determinism of surgery with a sensitivity of 92.3% and a specificity of 99%, the cut-off value of IAP being 15 mmHg. (4) Conclusions: The timing of surgical decompression in abdominal compartment syndrome is very important. Consequently, it is vital to identify a parameter, easy to measure, within the reach of any clinician, so that the indication for surgical intervention can be made judiciously and without delay.

How to isolate a high output enteroatmospheric fistula in the open abdomen with negative pressure therapy: an institution's step by step guide to the VAC donut

There is multiple evidence to suggest that isolation techniques of high output enteroatmospheric fistulas (EAF) in open abdomens can be advantageous in controlling fistula effluent while allowing time for abdominal wall to granulate. The large loss of proteins, electrolytes and fluid, and the distressing nature of the open abdomen for both patients and doctors, make managing these EAFs a clinical challenge. We present our experience with a high output mucosal protruding EAF and the creation of a 'VAC donut' allowing a successful diversion of the enteric content whilst promoting granulation of the tissue bed.

[Surgical wound closure in advanced peritonitis]

To date, mortality in widespread peritonitis is still high (15-20%) and increased up to 70-80% in case of septic shock. Surgeons actively discuss wound closure technique in these patients considering intraoperative findings and severity of illness. The authors present scientific data and opinions of national and foreign surgeons regarding the methods of laparotomy closure. There are still no generally accepted criteria for choosing the method of laparotomy closure in secondary widespread peritonitis. Indications and clinical efficacy of each procedure require additional research.

Retrospective Study of Indications and Outcomes of Open Abdomen with Negative Pressure Wound Therapy Technique for Abdominal Sepsis in a Tertiary Referral Centre

In patients with advanced sepsis from abdominal disease, the open abdomen (OA) technique as part of a damage control surgery (DCS) approach enables relook surgery to control infection, defer intestinal anastomosis, and prevent intra-abdominal hypertension. Limited evidence is available on key outcomes, such as mortality and rate of definitive fascial closure (DFC), which are needed for surgeons to select patients and adequate therapeutic strategies. Abdominal closure with negative pressure wound therapy (NPWT) has shown rates of DFC around 90%. We conducted a retrospective study to evaluate in-hospital survival and factors associated with mortality in acute, non-trauma patients treated using the OA technique and NPWT for sepsis from abdominal disease. Fifty consecutive patients treated using the OA technique and NPWT between February 2015 and July 2022 were included. Overall mortality was 32%. Among surviving patients, 97.7% of cases reached DFC, and the overall complication rate was 58.8%, with one case of entero-atmospheric fistula. At univariable analysis, age (p = 0.009), ASA IV status (<0.001), Mannheim Peritonitis Index > 30 (p = 0.001) and APACHE II score (p < 0.001) were associated with increased mortality. At multivariable analysis, higher APACHE II was a predictor of in-hospital mortality (OR 2.136, 95% CI 1.08−4.22; p = 0.029). Although very resource-intensive, DCS and the OA technique are valuable tools to manage patients with advanced abdominal sepsis, allowing reduced mortality and high DFC rates.

Open abdomen: is a dedicated emergency surgery team needed? A single center retrospective study on 141 consecutive patients

BACKGROUND

Open Abdomen (OA) is widely used when facing a catastrophic abdomen. Still, no indication is validated by a strong and high quality of evidence. The study reports the 5 year experience of a dedicated emergency general surgery (EGS) team.

METHODS

Retrospective observational cohort study. Patients undergoing OA management from 2/01/2015 to 19/07/2020 for trauma, non-traumatic emergencies or rescue surgery.

RESULTS

One hundred and forty-one patients. Age 66.9 ± 15.1. Male 58.2%.9.3% OA for trauma, 64.5% for non-traumatic emergencies and 26.2% for rescue surgery. 40.4% performed by the EGS team 52.4% indication for surgery was a severe intra-abdominal infection. TAC device: commercial negative pressure wound therapy (NPWT) (83%), Sandwich VAC (12%), commercial NPWT with polypropylene mesh (5%) for pregressive fascial traction. Enteroatmospheric fistula (EAF) in 3 patients. OA duration 5.3 days (1-25). A 1.8 revision surgeries (0-12) required for definitive closure; ICU stay 9.9 days (0-78). 30-day mortality 23.5%. Overall and 1-year mortality were 47.5% and 43.3%. Overall survival 9.9 months. An increased one-year mortality rate was found in the >65 group (P = 0.01).

CONCLUSIONS

We reported a wide use of OA in septic abdomen (90% of cases). We had a low rate of EAF, short ICU stay and OA duration. These results are related to the fact that patients were treated by a dedicated EGS team, suggesting that OA management should be cared for as much as possible by trained and experienced surgeons. Prospective studies with more accurate patient selection are needed to prove our conclusions.

Open abdomen technique used in complications of major gynecological oncology surgery

OBJECTIVE

To evaluate the open abdomen technique (laparostomy) used in complications of major gynecological oncology surgery.

METHODS

We analyzed retrospectively the surgical database of all patients who had undergone major open surgery by the same gynecologic oncologist over a 5-year period. All patients who had had open abdomen procedure were identified; demographic data and indications of primary surgery, temporary abdominal closure procedure details, fascia closure and morbidity, mortality rates were evaluated. Intraabdominal infection and intraoperative massive hemorrhage were the major indications for all open abdomen cases. Mannheim Peritonitis Index was used perioperatively to determine open abdomen decision in intraabdominal infections. Vacuum Assisted Abdominal Closure system and Bogota Bag were used for temporary abdominal closure techniques.

RESULTS

Out of the total 560 patients who had undergone major oncological surgery, 19 patients (3.3%) had open abdomen procedure due to surgical complications. Eleven patients had intraabdominal infection, six patients had hemodynamic instability due to peri and postoperative hemorrhage, two patients had gross fecal contamination during posterior pelvic exenteration surgery. The fascia was closed totally in 15 (78%), partially in 3 (15%) and could not be closed in 1 patient who had died secondary to multiorgan failure. Total morbidity and mortality rates were 26% (5/19) (two intrabdominal abscess, one pulmonary embolism, one skin necrosis, one enteroatmospheric fistula) and 5.2% (1/19) respectively.

CONCLUSION

Open abdomen is a life-saving procedure when applied with correct indications and timing. Gynecological oncologic surgeries are candidates to serious complications and gynecologic oncologists dealing with such surgery should be as experienced as general surgeons in this regard.

Open Abdomen after Two Trauma Laparotomies: Do Diuretics Help?

Data are lacking regarding the use of diuretics in facilitating closure of the open abdomen (OA). For patients with an OA after 2 laparotomies, we hypothesized that diuretic use was associated with a higher rate of primary fascial closure than no diuretic use. A retrospective review of patients with trauma laparotomies over 7 years was performed. Primary fascial closure (PFC) was defined as apposition of fascial edges without interposition mesh. Of 321 patients, 30 (9%) remained with an OA after 2 laparotomies. Prior to the third laparotomy, median cumulative fluid balance was +12.6 L. Thirteen (43%) received diuretics. Primary fascial closure rates were similar for diuretic use vs no diuretic (38% vs 59%, P = .46). Primary fascial closure was not associated with age (P = .2), gender (P = 0.7), cumulative fluid balance (P = .3), or units of packed cells (P = .4). Diuretic use in trauma patients with an OA after 2 laparotomies was not associated with successful PFC.

Intra-abdominal hypertension and abdominal compartment syndrome in critically ill patients: A narrative review of past, present, and future steps

BACKGROUND AND OBJECTIVE

Intra-abdominal hypertension is frequently present in critically ill patients and is an independent predictor for mortality. In this narrative review, we aim to provide a comprehensive overview of current insights into intra-abdominal pressure monitoring, intra-abdominal hypertension, and abdominal compartment syndrome. The focus of this review is on the pathophysiology, risk factors and outcome of intra-abdominal hypertension and abdominal compartment syndrome, and on therapeutic strategies, such as non-operative management, surgical decompression, and management of the open abdomen. Finally, future steps are discussed, including propositions of what a future guideline should focus on.

CONCLUSIONS

Pathological intra-abdominal pressure is a continuum ranging from mild intra-abdominal pressure elevation without clinically significant adverse effects to substantial increase in intra-abdominal pressure with serious consequences to all organ systems. Intra-abdominal pressure monitoring should be performed in all patients at risk of intra-abdominal hypertension. Although continuous intra-abdominal pressure monitoring is feasible, this is currently not standard practice. There are a number of effective non-operative medical interventions that may be performed early in the patient's course to reduce intra-abdominal pressure and decrease the need for surgical decompression. Abdominal decompression can be life-saving when abdominal compartment syndrome is refractory to non-operative treatment and should be performed expeditiously. The objectives of open abdomen management are to prevent fistula and to achieve delayed fascial closure at the earliest possible time. There is still a lot to learn and change. The 2013 World Society of Abdominal Compartment Syndrome guidelines should be updated and multicentre studies should evaluate the effect of intra-abdominal hypertension treatment on patient outcome.

The implementation of a pathway and care bundle for the management of acute occlusive arterial mesenteric ischemia reduced mortality

BACKGROUND

Acute mesenteric ischemia (AMI) is a disease with high mortality and requires a multidisciplinary approach for effective management. A pathway and care bundle were developed and implemented with the objective to reduce mortality. The aim of this retrospective comparative study was to analyze the effects of the pathway on patient management and outcome.

METHODS

All consecutive patients operated in a secondary and tertiary referral center because of occlusive arterial AMI were identified between 2014 and April 2020. The pathway aimed to increase overall awareness, and hasten and improve diagnostics and management. Patients treated before implementation of the pathway (pregroup, years 2014-2017) were compared with patients treated using the pathway (postgroup, May 2018 to April 2020). Univariate and multivariate analyses were used to compare the groups.

RESULTS

There were 78 patients in the pregroup and 67 patients in the postgroup with comparable baseline characteristics and disease acuity. The postgroup was more often diagnosed with contrast-enhanced computed tomography (58 [74%] vs. 63 [94%], p = 0.001) and had shorter mean in-hospital delay to operating room (7 hours [interquartile range, 3.5-12.5] vs. 3 hours [interquartile range, 2-11], p = 0.023). Revascularization was done more often in the postgroup (53 [68%] vs. 56 [84%], p = 0.030) especially using endovascular treatment (26 [33%] vs. 43 [64%], p < 0.001). Thirty-day mortality was lower in the postgroup (23 [51%] vs. 17 [25%], p = 0.001). Being managed in the postgroup remained as a protective factor (odds ratio, 0.32; 95% confidence interval, 0.14-0.75; p = 0.008) for 30-day mortality in the multivariate analysis.

CONCLUSION

Implementing a pathway and care bundle resulted in enhanced regional and in-hospital awareness of AMI, more appropriate computed tomography imaging, shorter in-hospital delays, increased number of revascularizations, and, hence, lower mortality.

LEVEL OF EVIDENCE

Therapeutic/Care Management, level IV.

Lessons Learned in 11 Years of Experience With Open Abdomen Treatment With Negative-Pressure Therapy for Various Abdominal Emergencies

Introduction: Open abdomen (OA) treatment with negative-pressure therapy (NPT) was initiated for perforated diverticulitis and subsequently extended to other abdominal emergencies. The aim of this retrospective study was to analyze the indications, procedures, duration of NPT, and the outcomes of all our patients. Methods: All consecutive patients treated with intra-abdominal NPT from January 1, 2008 to December 31, 2018 were retrospectively analyzed. Results: A total of 438 patients (44% females) with a median (range) age of 66 (12-94) years, BMI of 25 (14-48) kg/m², and ASA class I, II, III, and IV scores of 36 (13%), 239 (55%), 95 (22%), and 3(1%), respectively, were treated with NPT. The indication for surgery was primary bowel perforation in 163 (37%), mesenteric ischemia in 53 (12%), anastomotic leakage in 53 (12%), ileus in 53 (12%), postoperative bowel perforation/leakage in 32 (7%), abdominal compartment in 15 (3%), pancreatic fistula in 13 (3%), gastric perforation in 13 (3%), secondary peritonitis in 11 (3%), burst abdomen in nine (2%), biliary leakage in eight (2%), and other in 15 (3%) patients. A damage control operation without reconstruction in the initial procedure was performed in 164 (37%) patients. The duration of hospital and intensive care stay were, median (range), 28 (0-278) and 4 (0-214) days. The median (range) duration of operation was 109 (22-433) min and of NPT was 3(0-33) days. A trend to shorter duration of NPT was observed over time and in the colonic perforation group. The mean operating time was shorter when only blind ends were left in situ, namely 110 vs. 133 min (p = 0.006). The mortality rates were 14% at 30 days, 21% at 90 days, and 31% at 1 year. An entero-atmospheric fistula was observed in five (1%) cases, most recently in 2014. Direct fascia closure was possible in 417 (95%) patients at the end of NPT, but least often (67%, p = 0.00) in patients with burst abdomen. During follow-up, hernia repair was observed in 52 (24%) of the surviving patients. Conclusion: Open abdomen treatment with NPT is a promising concept for various abdominal emergencies, especially when treated outside normal working hours. A low rate of entero-atmospheric fistula formation and a high rate of direct fascia closure were achieved with dynamic approximation of the fascia edges. The authors recommend an early-in and early-out strategy as the prolongation of NPT by more than 1 week ends up in a frozen abdomen and does not improve abdominal sepsis.

Case Report: Delayed Primary Wound Closure After Extensive Abdominal Wall Resection for Infection and Malignancy Using TopClosure®

The closure of a massive abdominal wall defect is illustrated using a novel dynamic closure technique - the TopClosure® tension relief system. This system attaches to the abdominal wall immediately after laparotomy and allows for early approximation of the skin, avoiding an open abdomen and the complications associated with this. The technique in this case was employed after extensive resection of the abdominal wall for infected skin metastases of colonic adenocarcinoma and circumvented post-operative ventilation and open abdomen. Early recovery after such extensive surgery is important in terms of patient morbidity and mortality. In this case, primary surgery may not have been an acceptable risk to undertake without the option of Top Closure of the abdomen. We illustrate the technique of abdominal wall closure through a series of images of the procedure.

Open abdomen in the management of complicated diaphragmatic hernia: a case report

Diaphragmatic hernia (DH) can be congenital or acquired. DH is a potentially life-threatening condition and the management in emergency setting remain unclear. Nonspecific symptoms can delay the diagnosis. We report a case of a 63-year-old man admitted for abdominal pain and nausea. He was successfully treated with damage control surgery.

Closing Difficult Laparostomies With the Aid of Botulinum Toxin A: An Audit of 12 Cases

Background

Obtaining primary fascial closure following laparostomy can be difficult; especially with fascial retraction or large pre-existing fascial defects. Various techniques have been described in the literature which attempt to improve reapproximation rates. Most techniques described comprise the use of adjuncts including Bogota Bags, negative pressure dressings, anchor devices and various types of mesh. While most techniques achieve primary closure, less achieve primary fascial closure. Botulinum toxin A (BTA) has proven a beneficial adjunct in repairing large ventral herniae. While there is limited research in the use of BTA in the acute setting of laparostomy closure its benefits in elective repair may prove transferrable with the appropriate protocols.

Method

This retrospective study reviewed 12 cases where BTA was used as an adjunct to close laparostomy. It compared primary fascial closure rates to historical controls at the same institution. 

Results

Seven males and five females. Median age 63.5 years. Median BMI 32.95. Median days from BTA injection to primary fascial closure 9.5. Median 18 days from primary operation to primary fascial closure. 83% of patients achieved primary fascial closure with the rest achieving partial closure with the residual defect bridged with biological mesh. At the time of review, there was only one resulting ventral hernia in a patient with a BMI of 51.7 at the time of surgery.

Conclusion

While BTA does not guarantee primary fascial closure in laparostomy this study would indicate it improves primary fascial closure rates and can be added to any other existing method for managing the open abdomen. As BTA can be injected via the open abdomen or with ultrasound guidance it can be performed by any appropriately trained surgeon, anaesthetist or radiologist making its use widely achievable. Retrospectively registered.

Intraoperative Fascia Tension as an Alternative to Component Separation. A Prospective Observational Study

Incisional hernias are common late complications of abdominal surgery, with a 1-year post-laparotomy incidence of about 20%. A giant hernia is often preceded by severe peritonitis of various causes. The Fasciotens® Abdomen device is used to stretch the fascia in a measurably controlled manner during surgery to achieve primary tension-free abdominal closure. This prospective observational study aims to clarify the extent to which this traction method can function as an alternative to component separation (CS) methods. Methods: We included data of 21 patients treated with intraoperative fascia stretching in seven specialized hernia centers between November 2019 and August 2020. Results: Intraoperatively-measured fascial distance averaged 17.3 cm (range 8.5-44 cm). After application of diagonal-anterior traction >10 kg for an average duration of 32.3 min (range 30-40 min), the fascial distance decreased by 9.8 cm (1-26 cm) to an average 7.5 cm (range 2-19 cm), which is a large effect (r = 0.62). The fascial length increase (average 9.8 cm) after applied traction was highly significant. All hernias were closed under moderate tension after the traction phase. In 19 patients, this closure was reinforced with mesh using a sublay technique. Conclusion: This method allows primary closure of complex (LOD) hernias and is potentially less prone to complications than component separation (CS) methods.

Early Initiation of a Standardized Open Abdomen Treatment With Vacuum Assisted Mesh-Mediated Fascial Traction Achieves Best Results

Background: The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Complete fascial closure is an essential treatment objective and can be achieved by the use of different dynamic closure techniques. Both surgical technique and-decision making are essential for optimal patient outcome in terms of fascial closure. The aim of this study was to analyse patients' outcome after the use of mesh-mediated fascial traction (MMFT) associated with negative pressure wound therapy (NPWT) and identify important factors that negatively influenced final fascial closure. Methods: A single center ambispective analysis was performed including all patients treated for an open abdomen in a tertiary referral center from 3/2011 till 2/2020. All patients with a minimum survival >24 h after initiation of treatment were analyzed. The data concerning patient management was collected and entered into the Open Abdomen Route of the European Hernia Society (EHS). Patient basic characteristics considering OA indication, primary fascial closure, as well as important features in surgical technique including time after index procedure to start mesh mediated fascial traction, surgical closure techniques and patients' long-term outcomes were analyzed. Results: Data were obtained from 152 patients who underwent open abdomen therapy (OAT) in a single center study. Indications for OAT as per-protocol analysis were sepsis (33.3%), abdominal compartment syndrome (31.6%), followed by peritonitis (24.2%), abdominal trauma (8.3%) and burst abdomen (2.4%). Overall fascial closure rate was 80% as in the per-protocol analysis. When patients that started OA management with MMFT and NPWT from the initial surgery a significantly better fascial closure rate was achieved compared to patients that started 3 or more days later (p < 0.001). An incisional hernia developed in 35.8% of patients alive with a median follow-up of 49 months (range 6-96 months). Conclusion: Our main findings emphasize the importance of a standardized treatment plan, initiated early on during management of the OA. The use of vacuum assisted closure in combination with MMFT showed high rates of fascial closure. Absence of initial intraperitoneal NPWT as well as delayed start of MMFT were risk factors for non-fascial closure. Initiation of OA with VACM should not be unnecessary delayed.

Abdominal wall heterotopic ossification following damage control laparotomy: an unusual bone to pick

BACKGROUND

Heterotopic ossification (HO) refers to the development of extra-skeletal bone in muscle and soft tissues, following tissue insult secondary to surgery or trauma. This pathological process is considered as the result of severe inflammatory cell cascade initiated after local trauma and subsequent attempt at tissue repair involving resident mesenchymal cells. We present a series of 12 cases of abdominal HO (AHO), over 8 years, following damage control laparotomies (DCLs).

METHODS

Medical records of 50 patients who underwent DCLs at Alice Springs Hospital between 2010 and 2018 were retrospectively reviewed for AHO. Demographic data were extracted. Abdominal X-rays and computed tomography scans of 47 patients were reviewed for AHO.

RESULTS

Twelve patients (25%) developed AHO of varying diversity ranging from small insignificant lesions to clinically palpable lesions in the abdominal wall. Data revealed relatively younger male preponderance. DCL for severe acute pancreatitis (SAP) was associated with AHO (P < 0.1, 90% CI). Longer periods of ventilation, intensive care unit stay and admission to hospital were strongly associated with AHO (P < 0.01, 95% CI). Occurrence of AHO with SAP was significantly higher compared to patients without SAP (relative risk 3.54, P < 0.001). Only two patients required surgical excision of HO prior to definitive closure of the abdomen.

CONCLUSION

The authors conclude that AHO occurred more frequently in younger males. DCL for SAP was a significant risk factor. Extended periods of ventilation, intensive care unit stay and hospital admission were strongly associated with the development of AHO. Preoperative detection of HO is essential prior to planning definitive closure of the abdomen.

Technique Advances in Enteroatmospheric Fistula Isolation After Open Abdomen: A Review and Outlook

Enteroatmospheric fistula (EAF) after open abdomen adds difficulties to the management and increases the morbidity and mortality of patients. As an effective measurement, reconstructing gastrointestinal tract integrity not only reduces digestive juice wasting and wound contamination, but also allows expedient restoration of enteral nutrition and intestinal homeostasis. In this review, we introduce several technologies for the temporary isolation of EAF, including negative pressure wound therapy, fistuloclysis, fistula patch, surgical covered stent, three-dimensional (3D) printing stent, and injection molding stent. The manufacture and implantation procedures of each technique with their pros and cons are described in detail. Moreover, the approach in combination with finger measurement, x-ray imaging, and computerized tomography is used to measure anatomic parameters of fistula and design appropriate 3D printer-recognizable stereolithography files for production of isolation devices. Given the active roles that engineers playing in the technology development, we call on the cooperation between clinicians and engineers and the organization of clinical trials on these techniques.

Use of Transversus Abdominis Plane (TAP) Blocks for Postoperative Pain Management in a Patient With an Open Abdomen: A Case Report and Review of Literature

In light of the superior analgesia and opioid sparing effects provided by transversus abdominis plane (TAP) blocks, numerous new techniques and applications have evolved. However, TAP blocks are still underutilized in the critical care setting, and PubMed‑listed reports on the relevance of TAP integrity for TAP block efficacy are lacking. Here, we report bilateral TAP blocks delivering quick, potent and durable pain relief to a patient with open abdomen (OA) after prior management with opioids and epidural anesthesia had failed. Extending TAP block application to OA patients even in the post‑operative setting might hence reduce opioid consumption and quicken reconvalescence.

Delayed Closure of Open Abdomen in Septic Patients Treated With Negative Pressure Vacuum Therapy and Dynamic Sutures: A 10-Years Follow-Up on Long-Term Complications

Introduction: Patients with open abdomen after surgical interventions associated with the complication of secondary peritonitis are successfully treated with negative pressure wound therapy. The use of dynamic fascial sutures reduces fascial lateralization and increases successful delayed fascial closure after open abdomen treatment.

Methods: In 2017 we published the follow-up results of 38 survivors out of 87 open abdomen patients treated with negative pressure wound therapy and dynamic fascial sutures between 2007 and 2012. In our current study we present the 10-years follow-up results regarding long-term complications with the focus on incisional hernias and pain. Since 2017 seven more patients have died, hence 31 patients were included in the current study. The patients were asked to answer questions about specific long-term complications of OA treatment including pain, the presence of incisional hernias and subsequent surgical interventions. Demographic data and data regarding fascial closure after open abdomen treatment were collected. All results were analyzed quantitatively. The follow-up period was 8–13 years.

Results: The median age was 69 (30–90) years, and 15 (48.4%) were females. Twenty-four patients (77.4%) responded to the questionnaire: Three patients (12.5%) suffered from pain in the original operating field, all three at rest but not during exercise. None of the patients required analgesic treatment. Eleven patients (45.8%) were found to have incisional hernias. Five out of 11 hernias (45.5%) were treated by surgery and did not declare any pain in the operating field. Among the patients with incisional hernias lower MPI (Mannheimer Peritonitis Index) at the time of primary surgery but more reoperations and treatment days were found. The technique of fascial closure was heterogenic and no differences in the occurrence of incisional hernia could be detected.

Conclusion: The incidence of incisional hernias after open abdomen treatment is still high, but are associated with little pain in the original operating field. Further studies are required to investigate methods for fascial closure techniques after OA treatment.

Nutrition in open abdomen

Open abdomen is known as a serious consequence of various intra-abdominal pathologies. Initially, patients often have a life-threatening condition, sepsis or septic shock. Severe stress related malnutrition, mineral and fluid imbalance develop as metabolic consequences. Intestinal fistulas also occur as a frequent complication in patients with open abdomen. In such patients, a comprehensive approach is needed, including rehabilitation, nutritional support using optimal formulas, and local care for the open abdomen. Our case report presents a patient with open abdomen and enterocutaneous fistulation. A complex nutritional approach in the course of the disease is described and its importance is discussed. Finally, a summary of nutritional care for open abdomen patients is provided based on current recommendations.

Prophylactic Onlay Mesh Implantation During Definitive Fascial Closure After Open Abdomen Therapy (PROMOAT): Absorbable or Non-absorbable? Methodical Description and Results of a Feasibility Study

Introduction: Incisional hernia development after open abdomen therapy (OAT) remains a common complication in the long run. To demonstrate the feasibility, we describe our method of prophylactic onlay mesh implantation with definitive fascial closure after open abdomen therapy (PROMOAT). To display the feasibility of this concept, we evaluated the short-term outcome after absorbable and non-absorbable synthetic mesh implantation as prophylactic onlay. Material and Methods: Ten patients were prospectively enrolled, and prophylactic onlay mesh (long-term absorbable or non-absorbable) was implanted at the definitive fascial closure operation. The cohort was followed up with a special focus on incisional hernia development and complications. Results: OAT duration was 21.0 ± 12.6 days (95% CI: 16.9-25.1). Definitive fascial closure was achieved in all cases. No incisional hernias were present during a follow-up interval of 12.4 ± 10.8 months (range 1-30 months). Two seromas and one infected hematoma occurred. The outcome did not differ between mesh types. Conclusion: The prophylactic onlay mesh implantation of alloplastic, long-term absorbable, or non-absorbable meshes in OAT showed promising results and only a few complications that were of minor concern. Incisional hernias did not occur during follow-up. To validate the feasibility and safety of prophylactic onlay mesh implantation long-term data and large-scaled prospective trials are needed to give recommendations on prophylactic onlay mesh implantation after OAT.

Damage control surgery for the treatment of perforated acute colonic diverticulitis: A systematic review

BACKGROUND

Acute colonic diverticulitis (ACD) complications arise in approximately 8% to 35% patients and the most common ones are represented by phlegmon or abscess, followed by perforation, peritonitis, obstruction, and fistula. In accordance with current guidelines, patients affected by generalized peritonitis should undergo emergency surgery. However, decisions on whether and when to operate ACD patients remain a substantially debated topic while algorithm for the best treatment has not yet been determined. Damage control surgery (DCS) represents a well-established method in treating critically ill patients with traumatic abdomen injuries. At present, such surgical approach is also finding application in non-traumatic emergencies such as perforated ACD. Thanks to a thorough systematic review of the literature, we aimed at achieving deeper knowledge of both indications and short- and long-term outcomes related to DCS in perforated ACD.

METHODS

We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Pubmed/MEDLINE, Embase, Scopus, Cochrane Library, and Web of Science databases were used to search all related literature.

RESULTS

The 8 included articles covered an approximately 13 years study period (2006-2018), with a total 359 patient population. At presentation, most patients showed III and IV American Society of Anesthesiologists (ASA) score (81.6%) while having Hinchey III perforated ACD (69.9%). Most patients received a limited resection plus vacuum-assisted closure at first-look while about half entire population underwent primary resection anastomosis (PRA) at a second-look. Overall morbidity rate, 30-day mortality rate and overall mortality rate at follow-up were between 23% and 74%, 0% and 20%, 7% and 33%, respectively. Patients had a 100% definitive abdominal wall closure rate and a definitive stoma rate at follow-up ranging between 0% and 33%.

CONCLUSION

DCS application to ACD patients seems to offer good outcomes with a lower percentage of patients with definitive ostomy, if compared to Hartmann's procedure. However, correct definition of DCS eligible patients is paramount in avoiding overtreatment. In accordance to 2016 WSES (World Society of Emergency Surgery) Guidelines, DCS remains an effective surgical strategy in critically ill patients affected by sepsis/septic shock and hemodynamical unstability.

Dynamic Fascial Closure With Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction (VAWCM) Treatment of the Open Abdomen-An Updated Systematic Review

Introduction: Several different temporary abdominal closure techniques are described in the context of open abdomen treatment. Techniques based on dynamic fascial closure combined with negative pressure therapy have gained popularity and seem to result in the highest fascial closure rates without increased complications and are highlighted in recent guidelines and recommendations. One dynamic closure technique is the vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) technique, first described in 2007. The aim of this systematic review was to evaluate the VAWCM technique regarding a number of short- and long-term results.

Materials and Methods: A systematic literature search was performed in PubMed, EMBASE, and Cochrane Library databases for articles published between January 1, 2006 and May 8, 2020. The review was independently performed by the two authors according to the PRISMA statements for reporting systematic reviews and meta-analyses. Results were pooled for presentation of weighted means when applicable.

Results: A total of 220 articles were screened by title and abstract. Thirty-two articles were assessed for eligibility by full-text review and 15 articles finally remained for review. A total of 600 patients treated with VAWCM were included. The pooled weighted means were as follows: fascial closure, 83.5%; enteroatmospheric fistula, 5.6%; planned ventral hernia, 6.2%; in-hospital survival, 72%; and incisional hernia incidence, 40.5%. Long-term survival ranged between 22 and 72%. Quality of life (SF-36) was reported in two studies showing lower scores than the population mean especially in physical domains. Incisional hernia resulted in lower scores in one but not in the other study.

Discussion: The results of 600 VAWCM-treated patients from 15 studies were evaluated in this systematic review. Earlier findings with high fascial closure rates, low enteroatmospheric fistula, and planned ventral hernia rates as well as high incisional hernia incidences were underlined. Permanent mesh for efficient fascial traction and reinforcement at fascial closure seem to be the next step in evolving an optimal temporary closure technique in open abdomen treatment.

The Abdominal Re-Approximation Anchor device (ABRA®) has the potential to be useful in both emergency and elective dynamic temporary fascial closure

BACKGROUND

The management of an open abdomen (OA) remains an evolving field because of its relative rarity. Many techniques to achieve temporary abdominal closure exist, but often require multiple returns to the operating theatre and usually do not address the issue of lateral fascial retraction and do not achieve primary fascial closure (PFC). The ensuing incisional hernias result in a significant surgical challenge affecting both the physical and mental health of the patient. We describe our experience with the Abdominal Re-approximation Anchor (ABRA) device, which addresses some of these issues.

METHODS

The records of patients with an OA managed by a single surgeon using the ABRA device at Princess Alexandra Hospital, Queensland, Australia, between December 2014 and April 2020 were analysed retrospectively.

RESULTS

Six patients with OA were managed with the ABRA. All patients required an OA for the ramification of intraabdominal sepsis. Three patients were managed with the ABRA device electively and three in the acute setting. 100% of patients achieved PFC. Average follow-up was 40 months with three developing incisional hernias that were subsequently repaired.

CONCLUSION

The OA in critically ill surgical patients remains one of the most challenging problems in general surgery. The ABRA device is simple to use and has shown positive outcomes in both the acute and elective setting. Our use has resulted in 100% PFC, which demonstrates that the ABRA device is an important tool for the general surgeon in managing these complex cases.

The Need for Emergency Laparotomy With Open Abdomen Therapy in the Course of ECMO-A Retrospective Analysis of Course and Outcome

Background: Abdominal compartment syndrome (ACS) can occur in patients placed on extra corporeal membrane oxygenation (ECMO). This implies the necessity of decompressive laparotomy followed by an open abdomen (OA) to prevent complications such as multi-organ-failure or death.

Methods: We searched for ECMO patients in our hospital database between July 2015 and April 2020 and selected those with an emergency laparotomy and OA therapy. Of these, we analyzed only patients who were treated with an OA after establishing the ECMO regarding patient-related parameters like sex, age, height, weight, and indications for ECMO as well as outcome parameters like complete fascial closure rate, mortality, length of stay in intensive care unit (ICU), length and kind of OA therapy, number of surgical procedures, dressing changes concerning negative pressure wound therapy (NPWT), and number of surgical revisions.

Results: In eight out of 421 patients (1.9%), a laparostoma had to be created during ECMO support. For temporary closure, either NPWT, abdominal packing, or both were used. The median length of OA therapy was 17 days, and the median length of stay in ICU was 42 days in total. The median number of surgical procedures and NPWT dressing changes was seven. In three of the eight patients, a surgical revision was necessary. The total mortality rate was 50%. In 75%, the fascia could be closed. Two patients died before final closure. In all deceased patients, an abdominal packing was necessary during the course of treatment; in the survivors, only once. No enteroatmospheric fistula or abscesses occurred.

Conclusions: ACS in patients placed on ECMO is a very rare condition with a considerable mortality rate but high secondary closure rate of the fascia. A necessary abdominal packing due to a severe bleeding seems to be a risk factor with a potentially fatal outcome.

Open abdomen in acute mesenteric ischemia

In acute mesenteric ischemia, early diagnosis should optimally be followed by either open or endovascular intestinal revascularization. All too often, diagnosis is delayed and diagnosis and treatment are performed at the same time during explorative laparotomy. The majority of patients will be diagnosed when transmural intestinal infarction has developed and at this time point damage control strategies involving intestinal revascularization, bowel resection, open abdomen and second look may be necessary to salvage the patient. This review outlines the principles of the damage control surgery approach in acute mesenteric ischemia and the rationale for temporary open abdomen. In patients in need of long-term open abdomen therapy, negative pressure wound therapy with continuous fascial traction is a preferred technique achieving a high delayed fascial closure rate.

Perioperative Factors Associated With Respiratory Complications Following Open Abdomen Management

BACKGROUND

Postoperative respiratory complications are often severe and associated with a high risk of mortality in patients who undergo open abdomen (OA) management following emergency damage-control surgery. The causes of postoperative respiratory complications remain unknown. Therefore, we evaluated postoperative factors associated with respiratory complications in nontrauma patients who had undergone OA management using propensity score matching, with a focus on OA-related risk factors.

METHODS

This retrospective analysis included subjects who underwent OA management during a 4-y study period. Age, body mass index, and smoking history were selected as covariates. After propensity score matching, we compared postoperative factors (ie, first operative time, duration of OA, initial 3-d fluid balance, length of ICU stay, and in-hospital mortality) in 2 groups of subjects: those who had post-OA respiratory complications (PORCs) and those who did not.

RESULTS

60 subjects (33 men and 27 women) were identified; 38.3% of these subjects had PORCs. After propensity score matching, 18 subjects were matched. The 3-d fluid balance was significantly higher in subjects with PORCs than in those without PORCs (3,513 mL vs 1,087 mL; P = .03).

CONCLUSIONS

To our knowledge, this is the first study to examine factors associated with respiratory complications following OA in nontrauma subjects. After adjusting for known co-factors associated with postoperative respiratory complications, the 3-d fluid balance was identified as a significant risk factor for PORCs in subjects who had undergone OA. Clinicians should pay attention to the incidence of PORCs in OA subjects with a positive fluid balance after emergency abdominal surgery.

Open abdomen treatment for complicated intra-abdominal infection patients with gastrointestinal fistula can reduce the mortality

To evaluate the effect of the open abdomen (OA) and closed abdomen (CA) approaches for treating intestinal fistula with complicated intra-abdominal infection (IFWCIAI), and analyze the risk factors in OA treatment.IFWCIAI is associated with high mortality rates and healthcare costs, as well as longer postoperative hospital stay. However, OA treatment has also been linked with increased mortality and development of secondary intestinal fistula.A total of 195 IFWCIAI patients who were operated over a period of 7 years at our hospital were retrospectively analyzed. These patients were divided into the OA group (n = 112) and CA group (n = 83) accordingly, and the mortality rates, hospital costs, and hospital stay duration of both groups were compared. In addition, the risk factors in OA treatment were also analyzed.OA resulted in significantly lower mortality rates (9.8% vs 30.1%, P < .001) and hospital costs ($11721.40 ± $9368.86 vs $20365.36 ± $21789.06, P < .001) compared with the CA group. No incidences of secondary intestinal fistula was recorded and the duration of hospital stay was similar for both groups (P = .151). Delayed OA was an independent risk factor of death following OA treatment (hazard ratio [HR] = 1.316; 95% confidence interval [CI] = 1.068-1.623, P = .010), whereas early enteral nutrition (EN) exceeding 666.67 mL was a protective factor (HR = 0.996; 95% CI = 0.993-0.999, P = .018). In addition, Acinetobacter baumannii, Pseudomonas aeruginosa, and Candida albicans were the main pathogens responsible for the death of patients after OA treatment.OA decreased mortality rates and hospital costs of IFWCIAI patients, and did not lead to any secondary fistulas. Early OA and EN also reduced mortality rates.

Population Pharmacokinetic Study of the Suitability of Standard Dosing Regimens of Amikacin in Critically Ill Patients with Open-Abdomen and Negative-Pressure Wound Therapy

The aim was to assess the appropriateness of recommended regimens for empirical MIC coverage in critically ill patients with open-abdomen and negative-pressure therapy (OA/NPT). Over a 5-year period, every critically ill patient who received amikacin and who underwent therapeutic drug monitoring (TDM) while being treated by OA/NPT was retrospectively included. A population pharmacokinetic (PK) modeling was performed considering the effect of 10 covariates (age, sex, total body weight [TBW], adapted body weight [ABW], body surface area [BSA], modified sepsis-related organ failure assessment [SOFA] score, vasopressor use, creatinine clearance [CL_CR], fluid balance, and amount of fluids collected by the NPT over the sampling day) in patients who underwent continuous renal replacement therapy (CRRT) or did not receive CRRT. Monte Carlo simulations were employed to determine the fractional target attainment (FTA) for the PK/pharmacodynamic [PD] targets (maximum concentration of drug [C _max]/MIC ratio of ≥8 and a ratio of the area under the concentration-time curve from 0 to 24 h [AUC_0-24]/MIC of ≥75). Seventy critically ill patients treated by OA/NPT (contributing 179 concentration values) were included. Amikacin PK concentrations were best described by a two-compartment model with linear elimination and proportional residual error, with CL_CR and ABW as significant covariates for volume of distribution (V) and CL_CR for CL. The reported V) in non-CRRT and CRRT patients was 35.8 and 40.2 liters, respectively. In Monte Carlo simulations, ABW-adjusted doses between 25 and 35 mg/kg were needed to reach an FTA of >85% for various renal functions. Despite an increased V and a wide interindividual variability, desirable PK/PD targets may be achieved using an ABW-based loading dose of 25 to 30 mg/kg. When less susceptible pathogens are targeted, higher dosing regimens are probably needed in patients with augmented renal clearance (ARC). Further studies are needed to assess the effect of OA/NPT on the PK parameters of antimicrobial agents.

LapVac - a laparoscopic approach for negative pressure wound therapy application in open abdomen management: a porcine animal model

Introduction

Negative pressure wound therapy (NPWT) in the open abdomen (OA) is recognized as a gold standard management method. Currently minimally invasive procedures are implemented in many clinical scenarios.

Aim

To demonstrate the feasibility of using negative pressure wound therapy in a laparoscopic approach for OA management in a porcine model termed as a laparoscopic vacuum (LapVac).

Material and methods

An adult female swine underwent a laparoscopic procedure. Briefly, a small incision was made and secured with a wound protector, pneumoperitoneum was created and two additional ports were placed. Then, a non-adhesive layer was precisely placed within the abdominal cavity.

Results

Finally, polyurethane foam and adhesive drape were applied. A volume of 200 ml of saline solution was instilled and drained completely within 30 min. We did not observe any technical problems with NPWT application.

Conclusions

This study confirmed the technical feasibility of NPWT application in the laparoscopic approach. LapVac seems to be a promising technique which may minimize the trauma and lead to better outcomes.

Are the Benefits of Rapid Source Control Laparotomy Realized after Acute Colonic Perforation?

Background: The indications for damage-control laparotomy (DCL) in patients with intra-abdominal injuries have evolved from its use in trauma patients with hypothermia, coagulopathy, and acidosis to use in general surgical patients with acute intestinal perforations. Whereas some patients may be acidotic, most are not hypothermic or afflicted with coagulopathies. Recent study suggests the benefits to patients of rapid source-control laparotomy (RSCL) are not realized in patients with acute abdominal emergencies. Methods: Three years of data (2014-2016) from The American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) were assessed. The patient populations were separated into RSCL patients who had their fascia left open after the initial source control operation and those who had primary fascial closure (PFC). The principal outcome of interest in this study was death within thirty days. A secondary analysis was performed evaluating complications and length of stay. Results: Of the 1,381 patients who qualified for the study, 396 (28.7%) were managed with RSCL and the remaining 985 patients had PFC. After a univariable analysis, propensity score matching was performed. The median hospital length of stay was 20 days (95% confidence interval [CI] 18-22) versus 14 (95% CI 13-16; p < 0.001) in RSCL and PFC, respectively. A larger number of patients having RSCL went to a rehabilitation facility than those having PFC (18.7%; versus 11.2%; p = 0.014). The 30-day mortality rate in patients in the RSCL group was significantly higher than in the PFC group ((32.6% versus 16.9%; p < 0.001). Conclusion: These data provide strong evidence that RSCL may not be beneficial for routine use in perforated colon surgery.

Prevention of Entero-Atmospheric Fistula: The Initial Closure of the Abdomen

Background and Aims

The “Open Abdomen” technique for difficult conditions such as trauma, necrotizing pancreatitis, severe peritonitis, reoperations and transplantations have become a very useful way to save patients. The more severe complication of this method are the enteroatmospheric fistulae with a frequency of 5–75% and a mortality up to 42%. So any effort to prevent these is very essential. The aim of this paper is to present methods of the initial (temporary) closure of the abdomen for the prevention of this catastrophe, when early approximation of the abdominal wall is not feasible.

Methods and Materials

We present two representative case reports and we describe the use of full thickness or split skin grafts as first step for abdominal closure.

Results and Conclusions

The outcome of our patients by using tissues for temporary abdominal closure seems to have fewer problems than other methods with synthetic materials. We think that this is a reasonable option for the cases where we cannot achieve approximation of the abdominal wall edges in the early days of an open abdomen.

Abdominal Compartment Syndrome: Improving Outcomes With A Multidisciplinary Approach - A Narrative Review

Abdominal compartment syndrome (ACS) refers to a severe increase in intra-abdominal pressure associated with single or multiorgan failure. ACS with specific pathophysiological processes and detrimental outcomes may occur in a variety of clinical conditions. Patients with ACS are predominantly managed in critical care settings, however, a wide range of multidisciplinary interventions are frequently required from medical, surgical, radiological and nursing specialties. The medical management, aiming to prevent the progression of intra-abdominal hypertension to ACS, is extensively reviewed. Timing and techniques of surgical decompression techniques, as well as management of open abdomen, are outlined. In summary, the current narrative review provides data on history, definitions, epidemiology and pathophysiology of the syndrome and highlights the importance of multidisciplinary approach in the management of ACS in adults.

Application of Negative Pressure Wound Therapy with Instillation and Dwell Time of the Open Abdomen: Initial Experience

Recent therapeutic advances in the management of severe abdominal sepsis (SAS) have improved patient mortality and morbidity. However, SAS and its impact on multiple organ failure remain a serious, life-threatening condition with a high mortality rate. The open abdomen (OA) technique has become an effective alternative to repeat laparotomy. The use of OA negative pressure wound therapy (OA NPWT) has been a significant advancement in the management of the open abdomen. Similarly, negative pressure wound therapy (NPWT) with instillation and dwell time (NPWT-i) has been used in patients with multiple comorbidities, with an American Society of Anesthesiology Classification ≥ 2, severe traumatic wounds, diabetic foot infections, and wounds complicated by invasive infection or extensive biofilm. Controlled instillation of saline during NPWT-i may further enhance healing by facilitating automatic and contained volumetric wound irrigation and cleansing and diluting local levels of inflammatory cytokines, improving the local as well as the systemic response to infection. Although the soft tissue and intra-abdominal compartments differ anatomically, they share very similar biologic responses to infections. Therefore, from a biologic and physiologic aspect, intraperitoneal instillation therapy may play a role as an adjunctive treatment of abdominal compartment inflammation from trauma or infection. The addition of saline solution instillation to OA NPWT (OAI) in a programmed, controlled manner may offer the clinician an effective adjunctive therapy for the treatment of the complex septic abdomen. The technical aspects of instillation into the OA and a pooled multicenter case study cohort utilizing OAI with saline solution, bacitracin, or hypochlorous acid in the management of the septic abdomen is presented.

The difficult abdominal closure after paediatric intestinal transplantation: Use of abdominal rectus muscle fascia and literature review

Primary abdominal wall closure after intestinal and multivisceral transplantation may not be possible because of loss of abdominal domain and/or graft size/abdominal cavity mismatch. Traditional closure techniques for the open abdomen may not be valid in these circumstances because of severe scarring of the abdominal wall from multiple previous surgeries in this particular group of patients. We present our initial experience with the use of non-vascularized abdominal rectus muscle fascia in two patients who underwent deceased donation and living-related combined liver and small bowel transplantation, respectively, and who could not be closed primarily. The donor fascia was attached to the recipient fascia in both patients. In either case, there was not enough skin cover for closure, the wound was left open, and a negative pressure dressing was applied. In both cases, over a period of 6 months after placement of the non-vascularized abdominal rectus muscle fascia, the wound contracted, granulation tissue gradually covered the wound, and healing occurred, giving an intact abdominal wall. The abdominal rectus muscle fascia from a deceased donor can be used in a definite procedure for closure of the abdominal wall either at the time of transplant or later when a suitable rectus muscle fascia graft becomes available.

A preliminary prospective study of patients who underwent vacuum-assisted and mesh-mediated fascial traction techniques for open abdomen management with negative fluid therapy: An observational study

It is unclear whether strategies targeting negative fluid balance are associated with facilitated early fascial closure. The present study investigated the effects of fluid removal therapy on early facial closure of open abdomen patients.A prospective study was conducted in patients who underwent open abdomen management with vacuum-assisted and mesh-mediated fascial traction technique. Therapeutic diuresis with torasemide was applied to cause negative fluid balance in the treatment group. The study and follow-up periods were 7 and 180 days, respectively. The observational indices included the intra-abdominal pressure, the number of days to closure, the type of closure, the septic complications, the duration of ventilation support, the duration of initial hospital stay, and the duration of intensive care unit (ICU) stay.A total of 27 patients were divided into the treatment (16 patients) and control (11 patients) groups. The median intra-abdominal pressure (IAP) of the patients of the control and the treatment groups was significantly lower at day 7 compared with the baseline value (P < .0001). IAP was lower in the treatment group compared with that noted in the control group, following day 4 of the fluid removal therapy (P < .05). The percentage weight loss in the treatment group was between 4.80% and 10.88%. The early closure rates were significantly higher in the treatment group compared with those in the control group (75.0% vs 18.2%, P = .0063).Fluid removal therapy combined with vacuum-assisted and mesh-mediated fascial traction provided a high early fascial closure rate for open abdomen patients.

Serial abdominal closure with Gore-tex mesh and Rives-Stoppa for an open abdomen secondary to intra-abdominal hypertension in burns

Intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) commonly occurs in major burns. To relieve the excess pressure, decompressive laparotomy is done which can lead to an open abdomen. Closure of the abdomen after a decompressive laparotomy is very difficult with bowel oedema. We describe our technique of closing the open abdomen in such situations with a combination of serial abdominal wall closure with a layered mesh and the Rives-Stoppa component separation technique.

Advantages of Damage Control Strategy With Abdominal Negative Pressure and Instillation in Patients With Diffuse Peritonitis From Perforated Diverticular Disease

Purpose. To evaluate the results of Damage Control Strategy (DCS) in the treatment of generalized peritonitis from perforated diverticular disease in patients with preoperative severe systemic diseases. Methods. All the patients with diffuse peritonitis (Hinchey 3 and 4) and the American Society of Anesthesiologists (ASA) score ≥3 were included and underwent DCS consisting of a 2-step procedure. The first was peritoneal lavage, perforated colon-stapled resection, and temporary abdominal closure with negative pressure wound therapy combined with instillation. The second step, 48 hours later, included the possibility of restoring intestinal continuity basing on local and general patients' conditions. Results. Thirty patients (18 [60%] women and 12 [40%] men, median age 68.5 [range = 35-84] years) were included (18 [60%] ASA III, 11 [36.7%] ASA IV, and 1 [0.03%] ASA V). Seven patients (23.3%) showed sepsis and 1 (3.33%) septic shock. At second surgery, 24 patients (80%) received a colorectal anastomosis and 6 patients (20%) underwent a Hartmann's procedure. Median hospital stay was 18 days (range = 12-62). Postoperative morbidity rate was 23.3% (7/30) and included 1 anastomotic leak treated with Hartmann's procedure. Consequently, at discharge from hospital, 23 patients (76.6%) were free of stoma. Primary fascial closure was possible in all patients. Conclusions. DCS with temporary abdominal closure by negative pressure wound therapy combined with instillation in patients with diffuse peritonitis from complicated diverticulitis could represent a feasible surgical option both in hemodynamically stable and no stable patients, showing encouraging results including a low stoma rate and an acceptable morbidity rate.

Effect of Neuromuscular Blocking Agents on Sedation Requirements in Trauma Patients with an Open Abdomen

The appropriate level of sedation in patients with an open abdomen following damage control laparotomy (DCL) is debated. Chemical paralysis with neuromuscular blocking agents (NMBAs) has been used to decrease time to abdominal closure. We sought to evaluate the effect of NMBA use on sedation requirements in patients with an open abdomen and to determine the effect of sedation on patient outcomes. A retrospective cohort study was conducted at an American College of Surgeons' verified level 1 trauma center. Adult trauma patients who underwent DCL between 2009 and 2015 were included. Patients with an intensive care unit length of stay of less than 48 hours and those who died before abdominal closure were excluded. The NMBA+ group received continuous NMBA within 24 hours of DCL; the NMBA- group did not. The primary outcome was cumulative sedation dose during the 7 days following DCL. Secondary outcomes included Richmond Agitation-Sedation Scale (RASS) score, mechanical ventilation-free days, and delirium-coma-free days. Delirium-coma-free days were analyzed with linear regression. A total of 222 patients were included (NMBA+ 125; NMBA- 97). Demographics were similar between groups including age, Injury Severity Score, and mechanism of injury. The median time to closure in the overall cohort was 2 days (interquartile range [IQR] 1-2 days). Propofol and fentanyl were the primary sedatives used. The NMBA+ group received higher cumulative doses of propofol (NMBA+ 5405 mg, IQR 3103-10,573 mg; NMBA- 3601 mg, IQR 1605-6887 mg; p=0.007), but not of fentanyl. Time to abdominal closure, but not NMBA use, was associated with a higher cumulative propofol dose on multivariate analysis. The NMBA+ group had significantly lower RASS scores on the first 3 days following DCL. Mechanical ventilation-free days (NMBA+ 20 days vs NMBA- 18 days, p=0.960) and delirium-coma-free days (NMBA+ 18 days vs NMBA- 18 days, p=0.610) were similar between the groups. On linear regression, cumulative propofol dose was associated with fewer delirium-coma-free days (β-coefficient -0.007, 95% confidence interval -0.015 to -0.003). In trauma patients managed with DCL, higher cumulative sedative doses were administered in patients who received adjunctive NMBA, although NMBA therapy was not associated with a higher cumulative propofol dose on multivariate analysis. Consideration must be given to the potential effect of sedation on delirium and awakening following DCL.