Sequential abdominal reexploration with the zipper technique

Negative pressure wound therapy for managing the open abdomen in non-trauma patients

BACKGROUND

Management of the open abdomen is a considerable burden for patients and healthcare professionals. Various temporary abdominal closure techniques have been suggested for managing the open abdomen. In recent years, negative pressure wound therapy (NPWT) has been used in some centres for the treatment of non-trauma patients with an open abdomen; however, its effectiveness is uncertain.

OBJECTIVES

To assess the effects of negative pressure wound therapy (NPWT) on primary fascial closure for managing the open abdomen in non-trauma patients in any care setting.

SEARCH METHODS

In October 2021 we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL EBSCO Plus. To identify additional studies, we also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports. There were no restrictions with respect to language, date of publication, or study setting.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared NPWT with any other type of temporary abdominal closure (e.g. Bogota bag, Wittmann patch) in non-trauma patients with open abdomen in any care setting. We also included RCTs that compared different types of NPWT systems for managing the open abdomen in non-trauma patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection process, risk of bias assessment, data extraction, and GRADE assessment of the certainty of evidence.

MAIN RESULTS

We included two studies, involving 74 adults with open abdomen associated with various conditions, predominantly severe peritonitis (N = 55). The mean age of the participants was 52.8 years; the mean proportion of women was 39.2%. Both RCTs were carried out in single centres and were at high risk of bias. Negative pressure wound therapy versus Bogota bag We included one study (40 participants) comparing NPWT with Bogota bag. We are uncertain whether NPWT reduces time to primary fascial closure of the abdomen (NPWT: 16.9 days versus Bogota bag: 20.5 days (mean difference (MD) -3.60 days, 95% confidence interval (CI) -8.16 to 0.96); very low-certainty evidence) or adverse events (fistulae formation, NPWT: 10% versus Bogota: 5% (risk ratio (RR) 2.00, 95% CI 0.20 to 20.33); very low-certainty evidence) compared with the Bogota bag. We are also uncertain whether NPWT reduces all-cause mortality (NPWT: 25% versus Bogota bag: 35% (RR 0.71, 95% CI 0.27 to 1.88); very low-certainty evidence) or length of hospital stay compared with the Bogota bag (NPWT mean: 28.5 days versus Bogota bag mean: 27.4 days (MD 1.10 days, 95% CI -13.39 to 15.59); very low-certainty evidence). The study did not report the proportion of participants with successful primary fascial closure of the abdomen, participant health-related quality of life, reoperation rate, wound infection, or pain. Negative pressure wound therapy versus any other type of temporary abdominal closure There were no randomised controlled trials comparing NPWT with any other type of temporary abdominal closure. Comparison of different negative pressure wound therapy devices We included one study (34 participants) comparing different types of NPWT systems (Suprasorb CNP system versus ABThera system). We are uncertain whether the Suprasorb CNP system increases the proportion of participants with successful primary fascial closure of the abdomen compared with the ABThera system (Suprasorb CNP system: 88.2% versus ABThera system: 70.6% (RR 0.80, 95% CI 0.56 to 1.14); very low-certainty evidence). We are also uncertain whether the Suprasorb CNP system reduces adverse events (fistulae formation, Suprasorb CNP system: 0% versus ABThera system: 23.5% (RR 0.11, 95% CI 0.01 to 1.92); very low-certainty evidence), all-cause mortality (Suprasorb CNP system: 5.9% versus ABThera system: 17.6% (RR 0.33, 95% CI 0.04 to 2.89); very low-certainty evidence), or reoperation rate compared with the ABThera system (Suprasorb CNP system: 100% versus ABThera system: 100% (RR 1.00, 95% CI 0.90 to 1.12); very low-certainty evidence). The study did not report the time to primary fascial closure of the abdomen, participant health-related quality of life, length of hospital stay, wound infection, or pain.

AUTHORS' CONCLUSIONS

Based on the available trial data, we are uncertain whether NPWT has any benefit in primary fascial closure of the abdomen, adverse events (fistulae formation), all-cause mortality, or length of hospital stay compared with the Bogota bag. We are also uncertain whether the Suprasorb CNP system has any benefit in primary fascial closure of the abdomen, adverse events, all-cause mortality, or reoperation rate compared with the ABThera system. Further research evaluating these outcomes as well as participant health-related quality of life, wound infection, and pain outcomes is required. We will update this review when data from the large studies that are currently ongoing are available.

Should Negative Pressure Therapy Replace Any Other Temporary Abdominal Closure Device in Open-Abdomen Management of Secondary Peritonitis?

AIM

To clarify the advantages of negative pressure therapy (NPT) compared to other methods of temporary abdominal closure (TAC) in the management of secondary peritonitis.

METHODS

We retraced the history of known methods of TAC, and analyzed their advantages and disadvantages. We evaluated as the NPT mechanisms, both from the macroscopic that bio-molecular point of view, well suits to manage this difficult condition.

RESULTS

The ideal TAC technique should be quick to apply, easy to change, protect and contain the abdominal viscera, decrease bowel edema, prevent loss of domain and abdominal compartment syndrome, limit contamination, allow egress of peritoneal fluid (and its estimation) and not result in adhesions. It should also be cost-effective, minimize the number of dressing changes and the number of surgical revisions, and ensure a high rate of early closure with a low rate of complications (especially entero-atmospheric fistula). For NPT, the reported fistula rate is 7%, primary fascial closure ranges from 33 to 100% (average 60%) and the mortality rate is about 20%. With the use of NPT as TAC, it may be possible to extend the window of time to achieve primary fascial closure (for up to 20-40 days).

CONCLUSION

NPT has several potential advantages in open-abdomen (OA) management of secondary peritonitis and may make it possible to achieve all the goals suggested above for an ideal TAC system. Only trained staff should use NPT, following the manufacturer's instructions when commercial products are used. Even if there was a significant evolution in OA management, we believe that further research into the role of NPT for secondary peritonitis is necessary.

Intraabdominal continuous negative pressure therapy for secondary peritonitis: an observational trial in a maximum care center

Background: Acute secondary peritonitis is afflicted with a high morbidity and mortality. Intensive care therapy, antibiotics and surgical procedures are mandatory. Continuous negative pressure therapy (cNPT) seems to be beneficial but it is unclear which patients will benefit most from this procedures.Methods: We performed a prospective observational trial including all patients that needed to undergo an exploratory laparotomy for the suspicion of acute secondary peritonitis and were treated with cNPT in one year.Results: Thirty nine patients fitted the criteria. Median hospitalization length was 40 days. The vacuum therapy treatment was applied for a median of 4 days. The subgroup analysis between patients, who received the cNPT-dressing for one time (Group A) and patients, in whom the cNPT was continued after first relaparotomy (Group B) showed no differences concerning patients' characteristics. The Mannheimer Peritonitis Index (MPI) during the first operation was significantly correlated with the number of dressing changes (Spearman's rho 0.518, p = .002).Conclusions: Fast acting in acute secondary peritonitis for elimination of the source, abdominal lavage, derivation of the exsudat and interdisciplinary treatment is the treatment of choice. The MPI could be beneficial for the decision process of using cNPT.

[The treatment of acute secondary peritonitis : A retrospective analysis of the use of continuous negative pressure therapy]

BACKGROUND

Patients with acute secondary peritonitis often need relaparotomies and open abdominal lavages. Continuous negative pressure therapy seems to be beneficial.

OBJECTIVES

Does the efficacy of the therapy depend on the continuous negative pressure system used?

MATERIALS AND METHODS

A retrospective analysis was performed in the Chirurgische Klinik der Universitätsmedizin Berlin, Charité Campus Mitte, including all patients who underwent abdominal vacuum therapy between December 2013 and February 2015. Two different systems (ABThera®, KCI Medizinprodukte GmbH and Suprasorb® CNP Drainagefolie, Lohmann & Rauscher GmbH) were available for treatment.

RESULTS

During the 14 month study period, 33 patients with acute secondary peritonitis were treated with abdominal negative pressure therapy. Vacuum therapy treatment was applied for a median of 4 days (range 0-22 days). Eight patients (24%) died during hospitalisation. After completion of intraabdominal vacuum therapy, direct fascial closure was feasible in 26 patients (79%). There were no differences concerning patient characteristics, duration of abdominal vacuum therapy, the possibility of direct fascial closure or morbidity and mortality with the two different systems used.

CONCLUSIONS

Acute secondary peritonitis is associated with high morbidity. We achieved a lower mortality rate compared to prospective clinical trials using intraabdominal continuous negative pressure therapy. The effectiveness and cost efficiency of different therapy systems should be the topic of further research.

Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis

Temporary abdominal closure (TAC) techniques are routinely used in the open abdomen. Ideally, they should prevent evisceration, aid in removal of unwanted fluid from the peritoneal cavity, facilitate in achieving safe definitive fascial closure, as well as prevent the development of intra-abdominal complications. TAC techniques used in the open abdomen were compared with negative pressure wound therapy (NPWT) to identify which was superior. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines involving Medline, Excerpta Medica, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Clinicaltrials.gov. All studies describing TAC technique use in the open abdomen were eligible for inclusion. Data were analyzed per TAC technique in the form of a meta-analysis. A total of 225 articles were included in the final analysis. A meta-analysis involving only randomized controlled trials showed that NPWT with continuous fascial closure was superior to NPWT alone for definitive fascial closure [mean difference (MD): 35% ± 23%; P = 0.0044]. A subsequent meta-analysis involving all included studies confirmed its superiority across outcomes for definitive fascial closure (MD: 19% ± 3%; P < 0.0001), perioperative (MD: -4.0% ± 2.4%; P = 0.0013) and in-hospital (MD: -5.0% ± 2.9%; P = 0.0013) mortality, entero-atmospheric fistula (MD: 22.0% ± 1.8%; P = 0.0041), ventral hernia (MD: -4.0% ± 2.4%; P = 0.0010), and intra-abdominal abscess (MD: -3.1% ± 2.1%; P = 0.0044). Therefore, it was concluded that NPWT with continuous fascial traction is superior to NPWT alone.

Delayed primary closure in open abdomen with stoma using dynamic closure system

BACKGROUND

The situation of abdominal sepsis secondary to colonic perforation sometimes forces treat the patient with multiple interventions in the open abdomen (OA) context. Correct management of OA is important to restore the patient's clinical situation and to avoid further complications of the abdominal wall. Delayed primary closure of the abdomen using a dynamic and progressive traction is a relatively new technique for treating the OA.

CASE PRESENTATION

We report the case of a 50 year old woman with history of malnutrition and chronic obstructive pulmonary disease, affects for an OA after several surgical interventions. Two previous interventions (right colectomy, ileostomy and laparotomy with Bogotá bag) for disseminated peritonitis and abdominal compartment syndrome were performed. Six days after the Bogota bag the of the dynamic closure system ABRA(®) system was placed to delayed primary closure of the abdomen with excellent result results of the contingency of the abdominal wall.

DISCUSSION

The most common technique in the current management of OA is the placement of vacuum-assisted closure or the use of a mesh. These systems generally require several operations to restore the integrity of the abdominal wall. However, the dynamic closure of the abdominal wall makes it possible to restore it into the same process.

CONCLUSIONS

ABRA system allows delayed primary closure of the abdominal wall in an OA by sepsis secondary to colonic perforation. The stoma was not a problem with this technique. The final closure of the abdomen was at 16 days after the ABRA placement. The abdominal wall has not alterations in the follow up after 3 years.

Temporary abdominal closure with zipper-mesh device for management of intra-abdominal sepsis

OBJECTIVE: to present our experience with scheduled reoperations in 15 patients with intra-abdominal sepsis. METHODS: we have applied a more effective technique consisting of temporary abdominal closure with a nylon mesh sheet containing a zipper. We performed reoperations in the operating room under general anesthesia at an average interval of 84 hours. The revision consisted of debridement of necrotic material and vigorous lavage of the involved peritoneal area. The mean age of patients was 38.7 years (range, 15 to 72 years); 11 patients were male, and four were female. RESULTS: forty percent of infections were due to necrotizing pancreatitis. Sixty percent were due to perforation of the intestinal viscus secondary to inflammation, vascular occlusion or trauma. We performed a total of 48 reoperations, an average of 3.2 surgeries per patient. The mesh-zipper device was left in place for an average of 13 days. An intestinal ostomy was present adjacent to the zipper in four patients and did not present a problem for patient management. Mortality was 26.6%. No fistulas resulted from this technique. When intra-abdominal disease was under control, the mesh-zipper device was removed, and the fascia was closed in all patients. In three patients, the wound was closed primarily, and in 12 it was allowed to close by secondary intent. Two patients developed hernia; one was incisional and one was in the drain incision. CONCLUSION: the planned reoperation for manual lavage and debridement of the abdomen through a nylon mesh-zipper combination was rapid, simple, and well-tolerated. It permitted effective management of severe septic peritonitis, easy wound care and primary closure of the abdominal wall.

Comparison of Outcomes between Early Fascial Closure and Delayed Abdominal Closure in Patients with Open Abdomen: A Systematic Review and Meta-Analysis

Up to the present, the optimal time to close an open abdomen remains controversial. This study was designed to evaluate whether early fascial abdominal closure had advantages over delayed approach for open abdomen populations. Medline, Embase, and Cochrane Library were searched until April 2013. Search terms included “open abdomen,” “abdominal compartment syndrome,” “laparostomy,” “celiotomy,” “abdominal closure,” “primary,” “delayed,” “permanent,” “fascial closure,” and “definitive closure.” Open abdomen was defined as “fail to close abdominal fascia after a laparotomy.” Mortality, complications, and length of stay were compared between early and delayed fascial closure. In total, 3125 patients were included for final analysis, and 1942 (62%) patients successfully achieved early fascial closure. Vacuum assisted fascial closure had no impact on pooled fascial closure rate. Compared with delayed abdominal closure, early fascial closure significantly reduced mortality (12.3% versus 24.8%, RR, 0.53, P < 0.0001) and complication incidence (RR, 0.68, P < 0.0001). The mean interval from open abdomen to definitive closure ranged from 2.2 to 14.6 days in early fascial closure groups, but from 32.5 to 300 days in delayed closure groups. This study confirmed clinical advantages of early fascial closure over delayed approach in treatment of patients with open abdomen.

Open abdomen management: a review of its history and a proposed management algorithm

In this review we look into the historical development of open abdomen management. Its indication has spread in 70 years from intra-abdominal sepsis to damage control surgery and abdominal compartment syndrome. Different temporary abdominal closure techniques are essential to benefit the potential advantages of open abdomen management. Here, we discuss the different techniques and provide a new treatment strategy, based on available evidence, to facilitate more consistent decision making and further research on this complicated surgical topic.

The Value of Vacuum-Assisted Closure in Septic Patients Treated with Laparostomy

The ideal method of temporary abdominal closure (TAC) should allow rapid closure, easy maintenance, and wound repair with minimal tissue damage. The aim of this retrospective study is to compare open abdomen outcomes between patients managed with vacuum-assisted closure (VAC), and patients managed with other methods of TAC, when septic abdomen is present. Two groups of patients with septic open abdomen: 27 treated with VAC versus 31 treated with other techniques of TAC. We studied open abdomen duration, number of dressing changes, re-exploration rate, successful abdominal closure rate, overall mortality, and development of enteroatmospheric fistulas. The VAC device demonstrated its superiority concerning open abdomen duration ( P < 0.001), number of dressing changes ( P < 0.001), re-exploration rate ( P < 0.002), successful abdominal closure rate ( P < 0.0001), and development of enteroatmospheric fistulas ( P < 0.00001). Compared with other methods of TAC, our experience with the VAC device demonstrated its advantages concerning clinical feasibility. The high rates of direct fascia closure with an acceptable rate of ventral hernias are further benefits of this technique.

The open abdomen and temporary abdominal closure systems--historical evolution and systematic review

AIM

Several techniques for temporary abdominal closure have been developed. We systematically review the literature on temporary abdominal closure to ascertain whether the method can be tailored to the indication.

METHOD

Medline, Embase, the Cochrane Central Register of Controlled Trials and relevant meeting abstracts until December 2009 were searched using the following headings: open abdomen, laparostomy, VAC (vacuum assisted closure), TNP (topical negative pressure), fascial closure, temporary abdominal closure, fascial dehiscence and deep wound dehiscence. The data were analysed by closure technique and aetiology. The primary end-points included delayed fascial closure and in-hospital mortality. The secondary end-points were intra-abdominal complications.

RESULTS

The search identified 106 papers for inclusion. The techniques described were VAC (38 series), mesh/sheet (30 series), packing (15 series), Wittmann patch (eight series), Bogotá bag (six series), dynamic retention sutures (three series), zipper (15 series), skin only and locking device (one series each). The highest facial closure rates were seen with the Wittmann patch (78%), dynamic retention sutures (71%) and VAC (61%).

CONCLUSION

Temporary abdominal closure has evolved from simple packing to VAC based systems. In the absence of sepsis Wittmann patch and VAC offered the best outcome. In its presence VAC had the highest delayed primary closure and the lowest mortality rates. However, due to data heterogeneity only limited conclusions can be drawn from this analysis.

Strategies for modulating the inflammatory response after decompression from abdominal compartment syndrome

BACKGROUND

Management of the open abdomen is an increasingly common part of surgical practice. The purpose of this review is to examine the scientific background for the use of temporary abdominal closure (TAC) in the open abdomen as a way to modulate the local and systemic inflammatory response, with an emphasis on decompression after abdominal compartment syndrome (ACS).

METHODS

A review of the relevant English language literature was conducted. Priority was placed on articles published within the last 5 years.

RESULTS/CONCLUSION

Recent data from our group and others have begun to lay the foundation for the concept of TAC as a method to modulate the local and/or systemic inflammatory response in patients with an open abdomen resulting from ACS.

Temporary abdominal closure: long-term outcomes

BACKGROUND

Temporary abdominal closure (TAC) is an invaluable tool in the armamentarium of surgeons caring for critically ill and injured patients. The objective of this study was to determine the incidence of abdominal wall hernias and intestinal obstructions in patients who underwent TAC.

METHODS

A retrospective review of the medical records of patients who underwent TAC from September 2000 to December 2007 was completed. Patients were stratified by technique and indication for TAC. Statistical analysis included analysis of variance, χ(2), Fisher's exact test, Wilcoxon rank sum test, Kruskal-Wallis test, and Kaplan-Meier analysis.

RESULTS

One hundred seventeen patients underwent TAC during the study period. Nine patients were excluded from the analysis. For the remaining 108 patients, 30-day mortality was 17%. Definitive fascial closure was accomplished in 91% of patients. Median time to closure was 3 days. Seventy-six (70%) patients survived ≥6 months after definitive fascial or skin-only closure. Median follow-up was 34.5 months. Intestinal obstructions developed in 11% of patients. Abdominal wall hernias developed in 30% of patients with definitive fascial closure. No differences were observed for rates of abdominal wall hernias or intestinal obstructions based on preoperative body mass index, TAC indication, or TAC technique (temporary skin, bridge, or vacuum-assisted device closure).

CONCLUSION

Successful definitive fascial closure was achieved in 91% of patients after TAC. Abdominal wall hernias and intestinal obstructions were associated with longer median time to closure and increased ventilator days. No associations with indications for TAC, temporary closure techniques, or definitive closure methods were demonstrated.

Short- and long-term outcome of laparostomy following intra-abdominal sepsis

AIM

This study reports the short- and long-term outcomes of laparostomy for intra-abdominal sepsis.

METHOD

Twenty-nine sequential patients with intra-abdominal sepsis treated with a laparostomy over 6 years were included.

RESULTS

The median age of the patients was 51 years, postoperative intensive care unit stay was 8 days, postoperative length of hospital stay was 87 days and follow up was 2 years. The expected mortality of 25% was insignificantly different from the observed mortality of 33% (P = 0.35). Seven per cent of patients required percutaneous drainage of intra-abdominal collections. An enterocutaneous fistula developed in 31% of all patients and in 15% of those treated with vacuum dressings. Component-separation fascial reconstruction was successful and uncomplicated in 83% of recipients compared with 25% of mesh repairs.

CONCLUSION

Laparostomy does not significantly reduce mortality from the expected rate and commits the patient to a prolonged recovery with a high risk of enterocutaneous fistulation. Component-separation fascial reconstruction has a better outcome than mesh repair.

The management of the open abdomen in trauma and emergency general surgery: part 1-damage control

BACKGROUND

The open abdomen technique, after both military and civilian trauma, emergency general or vascular surgery, has been used in some form for the past 30 years. There have been several hundred citations on the indications and the management of the open abdomen. Eastern Association for the Surgery of Trauma practice management committee convened a study group to organize the world's literature for the management of the open abdomen. This effort was divided into two parts: damage control and the management of the open abdomen. Only damage control is presented in this study. Part 1 is divided into indications for the open abdomen, temporary abdominal closure, staged abdominal repair, and nutrition support of the open abdomen.

METHODS

A literature review was performed for more than 30 years. Prospective and retrospective studies were included. The reviews and case reports were excluded. Of 1,200 articles, 95 were selected. Seventeen surgeons reviewed the articles with four defined criteria. The Eastern Association for the Surgery of Trauma primer was used to grade the evidence.

RESULTS

There was only one level I recommendation. A patient with documented abdominal compartment syndrome should undergo decompressive laparotomy.

CONCLUSION

The open abdomen technique remains a heroic maneuver in the care of the critically ill trauma or surgical patient. For the best outcomes, a protocol for the indications, temporary abdominal closure, staged abdominal reconstruction, and nutrition support should be in place.

Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen

Background

This study was designed to systematically review the literature to assess which temporary abdominal closure (TAC) technique is associated with the highest delayed primary fascial closure (FC) rate. In some cases of abdominal trauma or infection, edema or packing precludes fascial closure after laparotomy. This “open abdomen” must then be temporarily closed. However, the FC rate varies between techniques.

Methods

The Cochrane Register of Controlled Trials, MEDLINE, and EMBASE databases were searched until December 2007. References were checked for additional studies. Search criteria included (synonyms of) “open abdomen,” “fascial closure,” “vacuum,” “reapproximation,” and “ventral hernia.” Open abdomen was defined as “the inability to close the abdominal fascia after laparotomy.” Two reviewers independently extracted data from original articles by using a predefined checklist.

Results

The search identified 154 abstracts of which 96 were considered relevant. No comparative studies were identified. After reading them, 51 articles, including 57 case series were included. The techniques described were vacuum-assisted closure (VAC; 8 series), vacuum pack (15 series), artificial burr (4 series), Mesh/sheet (16 series), zipper (7 series), silo (3 series), skin closure (2 series), dynamic retention sutures (DRS), and loose packing (1 series each). The highest FC rates were seen in the artificial burr (90%), DRS (85%), and VAC (60%). The lowest mortality rates were seen in the artificial burr (17%), VAC (18%), and DRS (23%).

Conclusions

These results suggest that the artificial burr and the VAC are associated with the highest FC rates and the lowest mortality rates.

Preventing loss of domain: a management strategy for closure of the "open abdomen" during the initial hospitalization

BACKGROUND

In the management of the abdominal compartment syndrome resulting in an open abdomen, the so-called "planned ventral hernia" is considered an acceptable outcome. We describe a technique of surgical management of the abdominal wound that allows fascial closure in most cases during the initial admission.

METHODS

Consecutive trauma patients with abdominal compartment syndrome managed with an open abdomen over a 3-year period were identified. Medical records and the trauma data registry were reviewed for demographics, injury characteristics, operative treatment, timing and type of wound management, closure of the abdomen, and outcome.

RESULTS

From January 2004 to January 2007, 23 patients underwent management with an open abdomen. The mechanism of injury was blunt in 83% of patients and penetrating in 17%. All 18 survivors underwent primary fascial closure of the abdomen using a vacuum- and tie-assisted technique of wound closure. The mean time to closure was 11 +/- 4.4 days (range, 4-18 days). In all, 9 complications occurred in 7 patients, which included 1 reoperation for abscess after fascial closure. There was no dehiscence and no fistula. The Apache II score was 19.3 +/- 6.9 (range, 7-30), and the injury severity score was 32.3 + 10.6 (range, 9-50).

CONCLUSIONS

A technique of managing the open abdomen that prevents fascial retraction results in a high primary closure rate with an acceptable rate of short-term complications.

In Vitro Comparison of Intra-Abdominal Hypertension Development After Different Temporary Abdominal Closure Techniques

BACKGROUND

To compare volume reserve capacity (VRC) and development of intra-abdominal hypertension after different in vitro temporary abdominal closure (TAC) techniques.

METHODS

A model of the abdomen was designed. The abdominal wall was simulated with polychloroprene, a synthetic rubber compound. A lentil-shaped defect of 150 cm(2) was cut into the anterior aspect of the abdominal wall. TAC of this defect was performed by a zipper system (ZS), a bag silo closure (BSC), or a vacuum assisted closure (VAC) with subatmospheric pressures ranging from 0- to 200 mmHg. The model with intact abdominal wall served as reference. The model was filled with water to baseline level. The intra-abdominal pressure was increased in 2 mmHg steps from baseline level (6 mmHg) to 40 mmHg by adding volume to the system according to a standardized protocol. VRC with corresponding intra-abdominal pressure were analyzed and compared for the different TAC techniques.

RESULTS

VRC was the highest after BSC at all pressure levels studied (P < 0.05). VAC and ZS resulted in significantly lower VRC compared with BSC and reference (P < 0.05). The magnitude of negative pressure on the VAC did not significantly influence the VRC.

CONCLUSIONS

In the present in vitro model, BSC demonstrated the highest VRC of all evaluated TAC techniques. Different levels of subatmospheric pressures applied to the VAC did not affect VRC. The results for ZS and VAC indicate that these TAC techniques may increase the risk for recurrent intra-abdominal hypertension and should therefore not be used in high-risk patients during the initial phase after abdominal decompression.

[Abdominal vacuum device with open abdomen]

BACKGROUND

For the treatment of peritonitis or abdominal compartment syndrome, an open abdomen can be required. Because of the high complication rate associated with this method, different technical modifications were developed that are now being applied. Abdominal vacuum-assisted closure is increasingly favoured. We analyse our experience with this device in a distinct group of patients from gastrointestinal cancer surgery.

PATIENTS AND METHOD

From June 2003 to December 2005, 36 patients were treated with 151 double-layer abdominal vacuum devices. Indications for applying this device were peritonitis (n = 22), abdominal compartment syndrome (n = 11), and necrotising fasciitis (n = 3). Thirty-four patients gave anamneses of malignoma.

RESULTS

Overall, the vacuum therapy treatment lasted a median of 13 days (range 3-48). With it, four enteric fistulas (11%) and four abdominal wall bleedings (11%) occurred. In our patient group, no new intra-abdominal abscesses were observed. Four patients died during treatment with the vacuum-assisted device and four afterward because of multiple organ failure in acute sepsis (in-hospital mortality 22%). Twenty-six patients (72%) underwent direct fascial closure after a median treatment duration of 10 days. Six patients (17%) required synthetic mesh for fascial closure. After a median follow-up of 100 days, two patients developed ventral hernias and two others showed ossification of the scar.

CONCLUSION

Compared with other methods of temporary abdominal closure, our experience with the vacuum-assisted device demonstrates its advantages concerning clinical feasibility and the relatively low complication rate. The high rate of direct fascial closure with an acceptable rate of ventral hernias following vacuum-assisted abdominal closure are further benefits of this technique.

Vacuum-assisted fascial closure for patients with abdominal trauma

BACKGROUND

Massive fluid resuscitation often is required for patients with intraabdominal trauma. Subsequently, fascial closure is not always possible in this subset of patients. Under these circumstances, an initial step can be the use of a temporary abdominal closure method. The authors currently use a vacuum-assisted closure to manage the open abdomen for some of their trauma patients. They present their experience over the past 3 years.

METHODS

From January 2000 to December 2002, 48 trauma patients were treated with temporary abdominal closure using a vacuum-assisted dressing. The ultimate management of the abdominal defect, the serum lactate levels measured in the emergency department, and the fluid balance at the last attempt to accomplish fascial closure were reviewed.

RESULTS

Delayed fascial closure was achieved in 23 (71.9%) of 32 patients who survived to discharge (26 of 48, 54.2%). Of the 32 patients who survived to discharge, 9 (28.1%) required an alternative closure, most often a split-thickness skin graft. Of the 16 patients who died before discharge, 8 died within 24 hours after admission. Whereas 5 of the 16 deaths occurred after delayed abdominal closure, 11 patients died without abdominal closure. Emergency department serum lactate levels above 8 mg/dL show a positive correlation with in-hospital mortality (6 of 16 patients; 38%; p = 0.001) and mortality within 24 hours of admission (6 of 8 patients; 75%; p = 0.003). Admission lactate levels were not associated with the type of closure achieved. However, primary closure was associated with a significant decrease in lactate levels during the first 12 hours. Complications included five abdominal abscesses, two enterocutaneous fistulas, and one split-thickness skin graft failure.

CONCLUSIONS

Patients requiring temporary abdominal closure have a significant in-hospital mortality rate of 33%. Delayed primary closure with vacuum assistance was achieved for 71.9% of the surviving patients. Maintaining a negative or total positive fluid balance of less than 20 L before the last attempted fascial closure improves successful closure rates, as seen in 19 of 22 patients (86.4%). The vacuum-assisted closure technique also enabled successful primary closure for two patients with extreme delay (>8 days). Elevated serum lactate levels are significantly correlated with early and in-hospital mortality. A significant decrease in lactate level during the first 12 hours is associated with achievement of primary closure.

Intra-abdominal hypertension and the abdominal compartment syndrome

The pressure within the abdominal cavity is normally little more than atmospheric pressure. However, even small increases in intra-abdominal pressure can have adverse effects on renal function, cardiac output, hepatic blood flow, respiratory mechanics, splanchnic perfusion and intracranial pressure. Although intra-abdominal pressure can be measured directly, this is invasive and bedside measurement of intra-abdominal pressure is usually achieved via the urinary bladder. This cheap, easy approach has been shown to produce results that correlate closely with directly measured abdominal pressures. Significant increases in intra-abdominal pressure are seen in a wide variety of conditions commonly encountered in the intensive care unit, such as ruptured aortic aneurysm, abdominal trauma and acute pancreatitis. Abdominal compartment syndrome describes the combination of increased intra-abdominal pressure and end-organ dysfunction. This syndrome has a high mortality, most deaths resulting from sepsis and multi-organ failure. Detection of abdominal compartment syndrome requires close surveillance of intra-abdominal pressure in patients thought to be at risk of developing intra-abdominal hypertension. The only available treatment for established abdominal compartment syndrome is decompressive laparotomy. Prevention of abdominal compartment syndrome after laparotomy by adoption of an open abdomen approach may be preferable in the patient at significant risk of developing intra-abdominal hypertension, but this has not been demonstrated in any large trials. Most surgeons prefer to adopt a 'wait and see' policy, only intervening when clinical deterioration is associated with a significant increase in intra-abdominal pressure.

Prospective evaluation of vacuum-assisted fascial closure after open abdomen: planned ventral hernia rate is substantially reduced

OBJECTIVE

The goal of this report is to examine the success of vacuum-assisted fascial closure (VAFC) under a carefully applied protocol in abdominal closure after open abdomen.

SUMMARY BACKGROUND DATA

With the development of damage control techniques and the understanding of abdominal compartment syndrome, the open abdomen has become commonplace in trauma patients. If the abdomen is not closed in the early postoperative period, the combination of adhesions and fascial retraction frequently make primary fascial closure impossible and creation of a planned ventral hernia is required. We have previously reported our experience with the development of a technique for VAFC that allowed for closure of the fascia in many such patients long after initial operation. During this previous study, during which the technique was being developed, VAFC was successful in 69% of patients in whom it was applied, and 22 patients were successfully closed at > or = 9 days after initial surgery (range, 9 to 49 days). A protocol for the use of VAFC in patients with open abdomen was developed on the basis of these data and has been employed since October 2001. The outcome of this protocol's use is examined.

METHODS

This is a prospective evaluation of all trauma patients admitted to Wake Forest University Baptist Medical Center over a 19-month period who required management with an open abdomen. VAFC employs suction applied to a large polyurethane sponge under an occlusive dressing in the wound and allows for constant medial traction of the abdominal fascia. It is attempted in all patients in whom the rectus muscles and fascia are intact. Studied variables include fascial closure rate, time to closure, incidence of wound dehiscence, and hernia development after closure.

RESULTS

From November 1, 2001, through May 31, 2003, 212 laparotomies were performed in injured patients; 53 (25%) of these patients required open abdomen management. Mean injury severity score for the group was 34, with an average abdominal abbreviated injury score of 2.9. Forty-five (78%) survived until abdominal closure. Vacuum dressings were used in all 45 but VAFC was not attempted in 2 patients (1 due to development of enterocutaneous fistula, 1 because a rectus flap was used for another wound). Closure rate in those undergoing VAFC was 88% (38), with mean time to closure being 9.5 days. This is significantly higher than the 69% rate of fascial closure during the time in which the technique was developed (P = 0.03). Twenty-one patients (48%) were closed at > or =9 days (range, 9 to 21 days). Two patients (4.6%) developed wound dehiscence and underwent successful reclosure. One patient (2.3%) developed a ventral hernia on follow-up, which has since been repaired

CONCLUSIONS

The use of VAFC under a carefully defined protocol has resulted in significantly higher fascial closure rates, obviating the need for subsequent hernia repair in most patients. The utility of this technique is not limited to the early postoperative period, but it can be successful as much as 3 to 4 weeks after initial operation.

Late fascial closure in lieu of ventral hernia: the next step in open abdomen management

BACKGROUND

The use of open abdomen techniques in damage control laparotomy and abdominal compartment syndrome has led to development of several methods of temporary abdominal closure. All of these methods require creation of a planned hernia with later reconstruction in patients unable to undergo fascial closure in the early postoperative period. We review a method of late primary fascial closure, thus eliminating the need for delayed reconstruction in some patients.

METHODS

The records of all patients managed with open abdomens over a 5-year period at a Level I trauma center were reviewed for injury characteristics, operative treatment, final abdominal closure type and timing, and outcome. Patients requiring open abdomen who were unable to undergo fascial closure in the early postoperative period were managed with a vacuum-assisted fascial closure (VAFC) technique. This allows for constant tension on the wound edges and facilitates late fascial closure. Patients managed with planned hernia (HERNIA group) were compared with those undergoing fascial closure > or = 9 days after initial laparotomy (LATE group) for injury severity, fistula rate, and mortality. All patients in the LATE group underwent VAFC.

RESULTS

From September 1996 to October 2001, 148 patients required management with an open abdomen. Fifty-nine underwent fascial closure, 37 of these before postoperative day 9 and 22 on or after day 9. Mean time to closure in the LATE group was 21 days (range, 9-49 days). Injury Severity Scores were similar in the HERNIA and LATE groups (26 vs. 30, p = 0.28), as were admission base deficit (-8.8 vs. -9.5, p = 0.71), number of fistulas (1 vs. 0, p = 0.99), and mortality (17% vs. 14%, p = 0.99).

CONCLUSION

VAFC enables late fascial closure in open abdomen patients up to a month after initial laparotomy. Complication rates do not differ from patients with planned hernia, and the need for future abdominal wall reconstruction is avoided.

Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients

BACKGROUND

Temporary abdominal wound closure after celiotomy for trauma is often desirable. The ideal method of temporary closure should allow rapid closure, easy maintenance, and allow reexploration and wound repair with minimal tissue damage. Over the past 7 years, we have successfully used a vacuum closure system (the vacuum pack) for temporary management of the open abdomen.

METHODS

Medical records of trauma patients undergoing exploratory celiotomy from April of 1992 to February of 1999 were reviewed. Demographic data as well as indications for open-abdominal management and complications of open-abdominal management were collected.

RESULTS

Two hundred sixteen vacuum packs were performed in 112 trauma patients. Of the 216 vacuum packs placed, 2.8% were placed for increased intra-abdominal pressure, 5.3% for inability to achieve tension-free fascial closure, 20% for damage control, 55% for reexploration, and 16.7% for a combination of factors. Sixty-two patients (55.4%) went on to primary closure and 25 patients (22.3%) underwent polyglactin mesh repair of the defect followed by wound granulation and eventual skin grafting. Twenty-two patients (19.6%) died before abdominal closure was attempted. Five patients (4.5%) developed enterocutaneous fistulae. Five patients (4.5%) developed intra-abdominal abscesses. There were no eviscerations. Three patients (2.7%) required further explorations after abdominal closure. Overall mortality rate was 25.9%, none related to the vacuum pack.

CONCLUSIONS

The vacuum pack is the temporary abdominal wound closure of choice in patients undergoing open abdominal management at our institution. Primary closure is achieved in the majority of patients with a low rate of complication. The technique is simple and easily mastered. Technical complications are rare and easily repaired.

Interventional and surgical treatment of pancreatic abscess

Pancreatic abscess is one of the infectious complications of acute pancreatitis. It is a collection principally containing pus, but it may also contain variable amounts of semisolid necrotic debris. Most of these abscesses evolve from the progressive liquefaction of necrotic pancreatic and peripancreatic tissues, but some arise from infection of peripancreatic fluid or collections elsewhere in the peritoneal cavity. Included also are abscesses found after surgical débridement and drainage of pancreatic necrosis. Although open surgical treatment of infected necrosis is the established treatment of choice, percutaneous drainage of abscesses is successful in some circumstances. We used percutaneous catheter drainage in 39 patients during 1987-1995. Only 9 of 29 (31%) attempts at primary therapy were successful; 2 patients died, and 18 required subsequent surgical drainage. On the other hand, 14 of 14 patients with recurrent or residual abscesses after surgical drainage were successfully drained percutaneously. Percutaneous catheter drainage of pancreatic abscesses may be useful for initial stabilization of septic patients, drainage of further abscesses after surgical intervention (especially when access for reoperation will be difficult), associated abscesses remote from the pancreas, and selected unilocular collections at a sufficient interval after necrotizing pancreatitis to have allowed essentially complete liquefaction.

Acute renal failure as a complication of acute pancreatitis

To assess the prevalence of acute renal failure (ARF) in patients with acute pancreatitis, as well as the factors predictive of a lethal outcome, we retrospectively studied the data of all patients admitted to our hospital over a 5-year period. Between 1989 and 1993, 554 patients presented with acute pancreatitis, of which 24 (4.4%) subsequently developed ARF. Death occurred in 14/24 (58%) of patients with ARF, and was associated with an increased incidence of multiorgan failure. There was no statistically significant difference in the age, admission blood pressure, or admission pulse rate of the patients who survived and those who died. In contrast, death was associated with a higher Ranson score, and the increased prevalence of multiorgan failure. The length of hospitalization of the nonsurviving group was significantly shorter. Acute renal failure is not a common finding in patients with acute pancreatitis. However, when it occurs, it is associated with a poor prognosis, and is predicted by a higher Ranson score and the presence of multiorgan failure.

Prevalence and prediction of multiple organ system failure and mortality in acute pancreatitis

We studied the prevalence of multiple organ system failure (MOSF), the relations between age, pre-existing chronic conditions, local complications, systemic infection, organ system failure, and mortality in patients with acute pancreatitis. During the study period, 267 consecutive patients were admitted to a tertiary hospital with acute pancreatitis. Multivariate analyses were used to identify factors predictive of MOSF occurrence and mortality. Using a previously developed MOSF scoring system at our center, MOSF (> or = 2 organ systems) was found to occur in 63 (24%) of the patients. Cardiovascular, pulmonary, renal, and hepatic failure predominated. Advanced age (> 55 yr) and chronic disease were related to local complications and systemic infection (both, P < .001). Local complications and systemic infection occurred in 68% and 75% of patients, respectively. In multiple logistic regression, advanced age, chronic disease, local complications, and systemic infection independently contributed to the development of MOSF. Overall mortality was 19%. MOSF accounted for 96% of deaths; mortality increased from 1% to 79% in patients without and with MOSF, respectively. In multiple logistic regression, advanced age, chronic disease, local complications, failure of the cardiovascular, renal, hepatic, gastrointestinal, and neurological systems independently contributed to mortality prediction. Advanced age and prior chronic disease may reflect diminished physiological reserve and predispose to local complications, systemic infection, and MOSF. Although local complications and systemic infection are important predisposing factors for MOSF, a host-dependent response to unknown specific or nonspecific factors may have a role in the pathogenesis of the syndrome in 25% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)