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Treffalls RN, Stonko DP, DeMartino RR, Morrison JJ. Acute management of mesenteric emergencies: Tailoring the solution to the problem. Semin Vasc Surg 2023; 36:234-249. [PMID: 37330237 DOI: 10.1053/j.semvascsurg.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/10/2023] [Accepted: 04/17/2023] [Indexed: 06/19/2023]
Abstract
Acute mesenteric ischemia (AMI) constitutes a life-threatening problem that can result in death, multiorgan failure, and severe nutritional disability. Although AMI is a rare cause of acute abdominal emergencies, ranging between 1 and 2 individuals per 10,000, the morbidity and mortality rates are high. Arterial embolic etiology composes nearly one-half of AMIs, with a sudden onset of severe abdominal pain considered the most common symptom. Arterial thrombosis is the second most common cause of AMI, which presents similarly to arterial embolic AMI, although often more severe due to anatomic differences. Veno-occlusive causes of AMI are the third most common and are associated with an insidious onset of vague abdominal pain. Each patient is unique, and the treatment plan should be tailored to their individual needs. This may include considering the patient's age, comorbidities, and overall health, as well as their preferences and personal circumstances. A multidisciplinary approach involving specialists from different fields, such as surgeons, interventional radiologists, and intensivists, is recommended for the best possible outcome. Potential challenges in tailoring an optimal treatment plan for AMI may include delayed diagnosis, limited availability of specialized care, or patient factors that make some interventions less feasible. Addressing these challenges requires a proactive and collaborative approach, with regular review and adjustment of the treatment plan as needed to ensure the best possible outcome for each patient.
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Affiliation(s)
- Rebecca N Treffalls
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - David P Stonko
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Randall R DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
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Intra-abdominal hypertension and abdominal compartment syndrome. Curr Probl Surg 2021; 58:100971. [PMID: 34836571 DOI: 10.1016/j.cpsurg.2021.100971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 02/10/2021] [Indexed: 11/21/2022]
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Skelhorne-Gross G, Nantais J, Ditkofsky N, Gomez D. Massive traumatic abdominal wall hernia with significant tissue loss: challenges in management. BMJ Case Rep 2021; 14:14/5/e242609. [PMID: 33952570 PMCID: PMC8103389 DOI: 10.1136/bcr-2021-242609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 41-year-old woman presented to our trauma centre following a high-speed motor vehicle collision with a seatbelt pattern of injury resulting in extensive rupture of her abdominal wall musculature and associated hollow viscus injuries. The abdominal wall had vertical separation between transected rectus, bilateral transverse abdominis and oblique muscles allowing evisceration of small and large bowel into the flanks without skin rupture. Intraoperatively, extensive liquefaction and tissue loss of the abdominal wall was found with significant retraction of the remaining musculature. Initial operative management focused on repair of concomitant intra-abdominal injuries with definitive repair performed in delayed, preplanned stages including bridging with absorbable mesh and placement of an overlying split-thickness skin graft. The patient was discharged from hospital and underwent extensive rehabilitation. One year later, the abdominal wall was definitively repaired with components separation and biological mesh underlay. This stepwise repair process provided her with a robust and enduring abdominal wall reconstruction.
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Affiliation(s)
- Graham Skelhorne-Gross
- Department of Surgery, Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Nantais
- Department of Surgery, Division of General Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Noah Ditkofsky
- Department of Radiology, Division of Emergency, Trauma and Acute Care Imaging, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - David Gomez
- Department of Surgery, Division of General Surgery, University of Toronto, Unity Health Toronto, Toronto, Ontario, Canada
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Wu X, Wu J, Wang P, Fang X, Yu Y, Tang J, Xiao Y, Wang M, Li S, Zhang Y, Hu B, Ma T, Li Q, Wang Z, Wu A, Liu C, Dai M, Ma X, Yi H, Kang Y, Wang D, Han G, Zhang P, Wang J, Yuan Y, Wang D, Wang J, Zhou Z, Ren Z, Liu Y, Guan X, Ren J. Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons. Clin Infect Dis 2021; 71:S337-S362. [PMID: 33367581 DOI: 10.1093/cid/ciaa1513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The Chinese guidelines for IAI presented here were developed by a panel that included experts from the fields of surgery, critical care, microbiology, infection control, pharmacology, and evidence-based medicine. All questions were structured in population, intervention, comparison, and outcomes format, and evidence profiles were generated. Recommendations were generated following the principles of the Grading of Recommendations Assessment, Development, and Evaluation system or Best Practice Statement (BPS), when applicable. The final guidelines include 45 graded recommendations and 17 BPSs, including the classification of disease severity, diagnosis, source control, antimicrobial therapy, microbiologic evaluation, nutritional therapy, other supportive therapies, diagnosis and management of specific IAIs, and recognition and management of source control failure. Recommendations on fluid resuscitation and organ support therapy could not be formulated and thus were not included. Accordingly, additional high-quality clinical studies should be performed in the future to address the clinicians' concerns.
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Affiliation(s)
- Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jie Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,BenQ Medical Center, Nanjing Medical University, Nanjing, China
| | - Peige Wang
- Department of Emergency Medicine, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xueling Fang
- Department of Critical Care Medicine, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianguo Tang
- Department of Emergency Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Yonghong Xiao
- Department of Infectious Diseases, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Shikuan Li
- Department of Emergency Medicine, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Bijie Hu
- Department of Infectious Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Qiang Li
- Department of General Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhiming Wang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Anhua Wu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Chang Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Menghua Dai
- Department of Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Huimin Yi
- Department of Critical Care Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Daorong Wang
- Department of General Surgery, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Gang Han
- Department of Gastroenterology, Second Hospital of Jilin University, Changchun, China
| | - Ping Zhang
- Department of General Surgery, First Hospital of Jilin University, Changchun, China
| | - Jianzhong Wang
- Department of Gastroenterology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yufeng Yuan
- Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dong Wang
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China
| | - Jian Wang
- Department of Biliary and Pancreatic Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zheng Zhou
- Department of General Surgery, First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Zeqiang Ren
- Department of General Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yuxiu Liu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiangdong Guan
- Department of Critical Care Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Wang Y, Alnumay A, Paradis T, Beckett A, Fata P, Khwaja K, Razek T, Grushka J, Deckelbaum DL. Management of Open Abdomen After Trauma Laparotomy: A Comparative Analysis of Dynamic Fascial Traction and Negative Pressure Wound Therapy Systems. World J Surg 2020; 43:3044-3050. [PMID: 31506714 DOI: 10.1007/s00268-019-05166-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Management of the post-traumatic open abdomen (OA) using negative pressure wound therapy (NPWT) alone is associated with low rates of primary fascial closure. The abdominal reapproximation anchor (ABRA) system exerts dynamic medial fascial traction and may work synergistically with NPWT to facilitate primary fascial closure. METHODS Patients with an OA following trauma laparotomy between 2009 and 2018 were identified from a prospectively maintained institutional database. Patients treated with ABRA in conjunction with NPWT (ABRA) versus NPWT alone (NPWT) were compared in terms of primary fascial closure rate, number of surgeries to closure, tracheostomy duration, length of stay and incidence of entero-atmospheric fistula. Multivariable linear regression was performed to identify predictors of tracheostomy duration. RESULTS We identified 48 patients [ABRA, 12 and NPWT, 36]. The ABRA group was significantly younger (25 vs. 37 years, p = 0.027) and included a lower proportion of males (58% vs. 89%, p = 0.032). Groups were similar with respect to the incidence of hollow viscus injury, injury severity score and abdominal abbreviated injury score. Compared to the NPWT group, the ABRA group had a significantly higher rate of primary fascial closure (100% vs. 28%, p < 0.001), fewer surgeries to abdominal closure (2 vs. 2.5, p = 0.023) and shorter duration of tracheostomy (15.5 vs. 36 days, p = 0.008). There were no differences in length of stay or incidence of entero-atmospheric fistula. On multivariable linear regression, ABRA placement was an independent predictor of shorter tracheostomy duration, after adjusting for covariates (β = - 0.294, p = 0.036). CONCLUSION For the post-traumatic OA, ABRA coupled with NPWT achieves a higher rate of primary fascial closure compared to NPWT alone, while requiring fewer surgeries and a shorter duration of tracheostomy.
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Affiliation(s)
- Yifan Wang
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Abdulaziz Alnumay
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Tiffany Paradis
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Andrew Beckett
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Paola Fata
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Kosar Khwaja
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Tarek Razek
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada.,Centre for Global Surgery, McGill University, Montreal, QC, Canada
| | - Jeremy Grushka
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada
| | - Dan L Deckelbaum
- Division of Trauma Surgery, McGill University Health Centre, McGill University, 1650 Cedar Avenue, L9-411, Montreal, QC, H3G 1A4, Canada. .,Centre for Global Surgery, McGill University, Montreal, QC, Canada.
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Betancourt AS, Milagros GC, Sibaja P, Fernandez L, Norwood S. Cost evaluation of temporary abdominal closure methods in abdominal sepsis patients successfully treated with an open abdomen. Should we take temporary abdominal closure methods at face value? Health economic evaluation. Ann Med Surg (Lond) 2020; 56:11-16. [PMID: 32566220 PMCID: PMC7296327 DOI: 10.1016/j.amsu.2020.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 12/03/2022] Open
Abstract
Background Many commercial and artisanal devices are utilized for temporary abdominal closure in patients being managed with an open abdomen for abdominal sepsis. The costs of materials required to treat patients with an open abdomen varies drastically. In Costa Rica, due to the lack of accurate information relating to the actual cost to manage a patient entails that the method with the least expensive materials is usually selected. Study design A single-center retrospective review of 46 patients diagnosed with abdominal sepsis and successfully treated with an open abdomen and one of the three temporary abdominal closure methods during the year 2018 in a tertiary hospital was evaluated using a gross-cost pricing model developed by the authors. The three temporary abdominal closure methods were a locally manufactured Bogota Bag, and commercial abdominal negative pressure therapy dressing and negative pressure therapy with 0.9% saline solution instillation. The per-unit-costs were hospital day and intensive care day, number of surgical procedures per patient, cost negative pressure therapy kits. Results Statistically significant cost reduction was observed in the cohort treated with negative pressure therapy with instillation as compared to the other temporary abdominal closure methods. The reduction of hospital length of stay, as well as fewer number of surgeries were the main contributing factors in diminishing costs. On average, the costs to treat a patient utilizing negative pressure therapy with instillation was nearly 50% lower than using the other two temporary abdominal closure methods. Conclusions The costs relating to managing abdominal sepsis in the septic open abdomen vary greatly according to the temporary abdominal closure utilized. If the hospital length of stay, intensive care unit length of stay and number of surgeries required are the main parameters used in determining costs, the use of negative pressure therapy with 0.9% saline solution instillation reduces costs by nearly 50% in comparison to conventional negative pressure wound therapy and Bogota Bag. In this instance, the more expensive method at first glance, obtained a considerable cost reduction when compared to therapies that utilize less expensive materials. The costs of materials required to treat patients with an OA varies drastically. In Costa Rica, due to the lack of accurate information relating to the actual cost to manage a patient entails that the method with the least expensive materials is usually selected. Statistically significant cost reduction was observed in the cohort treated with negative pressure therapy with instillation as compared to the other TAC methods. On average, the costs to treat a patient utilizing negative pressure therapy with instillation was up to 50% lower than using the other two TAC methods.
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Affiliation(s)
- Alfredo Sanchez Betancourt
- Centro de Investigación Clínica de Oriente, Universidad Estatal a Distancia, Sabanilla, Escazú, San Jose, Costa Rica
- Corresponding author.
| | - Gonzalez Cole Milagros
- Centro de Investigación Clínica de Oriente, Universidad Estatal a Distancia, Sabanilla, Escazú, San Jose, Costa Rica
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Wang Y, Stanek A, Grushka J, Fata P, Beckett A, Khwaja K, Razek T, Deckelbaum DL. Incidence and factors associated with development of heterotopic ossification after damage control laparotomy. Injury 2018; 49:51-55. [PMID: 29191669 DOI: 10.1016/j.injury.2017.11.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 11/12/2017] [Accepted: 11/25/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The incidence of heterotopic ossification (HO) following damage control laparotomy (DCL) is unknown. Abdominal wall reconstruction may prove more challenging in patients with HO. This study examines the incidence and factors associated with HO in patients with an open abdomen following DCL. METHODS A retrospective review of all patients with an open abdomen after DCL at a level 1 trauma centre from 2009 to 2015 was conducted. Demographics and peri-operative outcomes of patients with and without HO were compared. Univariate and multivariable binary logistic regression models were used to determine the association of peri-operative factors with the development of HO. RESULTS 68 patients were included, of which 36 (53%) developed HO. On univariate analysis, development of HO was significantly associated with hollow viscus injury (OR, 3.89; CI 1.42-10.7), greater number of abdominal surgeries prior to definitive closure (OR, 1.84; CI, 1.10-3.05), non-fascial closure (OR, 4.33; CI, 1.44-13.1) and higher peak ALP (OR 1.01; CI, 1.00-1.02). The presence of a hollow viscus injury remained an independent predictor of HO on multivariable analysis after adjusting for covariates (OR, 3.77; CI, 1.22-11.6). CONCLUSION Heterotopic ossification develops in a high proportion of trauma patients following damage control laparotomy, particularly in the presence of hollow viscus injury. Its impact on delayed abdominal wall reconstruction and the efficacy of prophylaxis strategies merit further investigation.
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Affiliation(s)
- Yifan Wang
- Division of Trauma Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Agatha Stanek
- Division of Diagnostic Radiology, McGill University Health Centre, Montreal, QC, Canada
| | - Jeremy Grushka
- Division of Trauma Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Paola Fata
- Division of Trauma Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Andrew Beckett
- Division of Trauma Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Kosar Khwaja
- Division of Trauma Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Tarek Razek
- Division of Trauma Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Dan L Deckelbaum
- Division of Trauma Surgery, McGill University Health Centre, Montreal, QC, Canada.
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Spillebeen AL, Robben JH, Thomas R, Kirpensteijn J, van Nimwegen SA. Negative pressure therapy versus passive open abdominal drainage for the treatment of septic peritonitis in dogs: A randomized, prospective study. Vet Surg 2017; 46:1086-1097. [PMID: 28862743 DOI: 10.1111/vsu.12703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 02/14/2017] [Accepted: 05/22/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare passive open abdominal drainage (POAD) and negative-pressure abdominal drainage (NPAD) using the ABThera™ system in the treatment of septic peritonitis. STUDY DESIGN Randomized prospective clinical trial. ANIMALS Dogs (n = 16) with septic peritonitis. METHODS Dogs with septic peritonitis were randomly assigned to one of two treatment protocols: NPAD versus POAD. Anesthesia time, operating time, duration of drainage, costs, survival, and complications were compared between techniques. Hematological and biochemical parameters in blood and abdominal fluid, and histopathological findings of omentum and abdominal wall tissue samples were compared between NPAD and POAD at time of initial surgery and at time of closure. RESULTS Overall survival was 81%. Treatment costs, anesthesia and operating time, drainage time, survival, and postoperative complications were similar between techniques. Loss of total plasma protein and decreased inflammation-related factors in abdominal fluid at time of closure were noted in all patients. Neutrophilic inflammation was greater in abdominal wall samples after NPAD. POAD patients showed discomfort during bandage changes and had frequent leakage of abdominal fluid outside of the bandage. CONCLUSION NPAD is an effective alternative to POAD for treatment of septic peritonitis, based on costs and survival. NPAD resulted in less abdominal fluid leakage, and evidence of superior healing on histological evaluation of abdominal tissues.
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Affiliation(s)
- Anneleen L Spillebeen
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, the Netherlands
| | - Joris H Robben
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, the Netherlands
| | - Rachel Thomas
- Department of Veterinary Pathology, Faculty of Veterinary Medicine, Utrecht University, the Netherlands
| | - Jolle Kirpensteijn
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, the Netherlands
| | - Sebastiaan A van Nimwegen
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, the Netherlands
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What is the effectiveness of the negative pressure wound therapy (NPWT) in patients treated with open abdomen technique? A systematic review and meta-analysis. J Trauma Acute Care Surg 2017; 81:575-84. [PMID: 27257705 DOI: 10.1097/ta.0000000000001126] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The open abdomen technique may be used in critically ill patients to manage abdominal injury, reduce the septic complications, and prevent the abdominal compartment syndrome. Many different techniques have been proposed and multiple studies have been conducted, but the best method of temporary abdominal closure has not been determined yet. Recently, new randomized and nonrandomized controlled trials have been published on this topic. We aimed to perform an up-to-date systematic review on the management of open abdomen, including the most recent published randomized and nonrandomized controlled trials, to compare negative pressure wound therapy (NPWT) with no NPWT and define if one technique has better outcomes than the other with regard to primary fascial closure, postoperative 30-day mortality and morbidity, enteroatmospheric fistulae, abdominal abscess, bleeding, and length of stay. METHODS According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions, an online literature research (until July 1, 2015) was performed on MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Library databases. The MeSH terms and free words used "vacuum assisted closure" "vac;", "open abdomen", "damage control surgery", and "temporary abdominal closure". No language restriction was made. RESULTS The initial systematic literature search yielded 452 studies. After a careful assessment of the titles and of the full text was obtained, eight articles fulfilled inclusion criteria. We analyzed 1,225 patients, of whom 723 (59%) underwent NPWT and 502 (41%) did not undergo NPWT, and performed four subgroups: VAC versus Bogota bag technique (two studies, 106 participants), VAC versus mesh-foil laparostomy (two studies, 159 participants), VAC versus laparostomy (adhesive impermeable with midline zip) (one study, 106 participants), and NPWT versus no NPWT techniques (three studies, 854 participants) in which it is not possible to perform an analysis of the different types of treatment. Comparing the NPWT group and the group without NPWT, there was no statistically significant difference in fascial closure (63.5% vs 69.5%; odds ratio [OR], 0.74; 95% confidence interval [CI], 0.27-2.06; p = 0.57), postoperative 30-day overall morbidity (p = 0.19), postoperative enteroatmospheric fistulae rate (2.1% vs 5.8%; OR, 0.63; 95% CIs, 0.12-3.15; p = 0.57), in the postoperative bleeding rate (5.7% vs 14.9%; OR, 0.58; 95% CIs, 0.05-6.84; p = 0.87), and postoperative abdominal abscess rate (2.4% vs 5.6%; OR, 0.42; 95% CI, 0.13-1.34; p = 0.14). On the other hand, statistical significance was found between the NPWT group and the group without NPWT in the postoperative mortality rate (28.5% vs 41.4%; OR, 0.46; 95% CI, 0.23-0.91; p = 0.03) and in the length of stay in the intensive care unit (mean difference, -4.53; 95% CI, -5.46 to 3.60; p < 0.00001). CONCLUSION The limitations of the present analysis might be related to the lack of randomized controlled trials, so there is a risk of selection bias favoring NPWT. For several outcomes, there were few studies, confidence intervals were wide, and inconsistency was high, suggesting that although there were no statistically significant differences between the groups, there was insufficient evidence to show that the outcomes were similar. We can conclude from the current available data that NPWT seems to be associated with a trend toward better outcomes compared to the use of no NPWT. It does reflect the evidence presented in the current systematic review; however, the data should be interpreted with substantial caution given a number of weaknesses (in particular, the lack of statistical significance and heterogeneity between studies, i.e., small sample size of the included studies, high variability between studies). We highlight the need for randomized controlled trials having homogeneous inclusion criteria to assess the use of NPWT for the management of open abdomen. LEVEL OF EVIDENCE Systemic review/meta-analysis, level III.
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10
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Application of a Silicone Sheet in Negative-Pressure Wound Therapy to Treat an Abdominal Wall Defect after Necrotizing Fasciitis. Arch Plast Surg 2017; 44:76-79. [PMID: 28194352 PMCID: PMC5300929 DOI: 10.5999/aps.2017.44.1.76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 10/13/2016] [Accepted: 10/18/2016] [Indexed: 11/08/2022] Open
Abstract
Necrotizing fasciitis (NF) is an aggressive soft-tissue infection involving the deep fascia and is characterized by extensive deterioration of the surrounding tissue. Immediate diagnosis and intensive treatment, including debridement and systemic antibiotics, represent the most important factors influencing the survival of NF patients. In this report, we present a case of NF in the abdomen due to an infection caused by a perforated small bowel after abdominal liposuction. It was successfully treated using negative-pressure wound therapy, in which a silicone sheet functioned as a barrier between the sponge and internal organs to protect the small bowel.
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11
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Cristaudo A, Jennings S, Gunnarsson R, Decosta A. Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis. Am Surg 2017. [DOI: 10.1177/000313481708300220] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Adam Cristaudo
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Scott Jennings
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Ronny Gunnarsson
- James Cook University, School of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Alan Decosta
- James Cook University, School of Medicine, Cairns Hospital, Cairns, Queensland, Australia
- Department of Surgery, Cairns Hospital, Cairns, Queensland, Australia
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Abstract
BACKGROUND A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. METHODS The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. RESULTS OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). CONCLUSION OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.
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Beltzer C, Eisenächer A, Badendieck S, Doll D, Küper M, Lenz S, Krapohl BD. Retrospective analysis of a VACM (vacuum-assisted closure and mesh-mediated fascial traction) treatment manual for temporary abdominal wall closure - results of 58 consecutive patients. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2016; 5:Doc19. [PMID: 27547691 PMCID: PMC4977375 DOI: 10.3205/iprs000098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: The optimal treatment concept for temporary abdominal closure (TAC) in critically ill visceral surgery patients with open abdomen (OA) continues to be unclear. The VACM (vacuum-assisted closure and mesh-mediated fascial traction) therapy seems to permit higher delayed primary fascial closure rates (FCR) than other TAC procedures. Material and methods: Patients of our clinic (n=58) who were treated by application of a VAC/VACM treatment manual in the period from 2005 to 2008 were retrospectively analysed. Results: The overall FCR of all patients was 48.3% (95% confidence interval: 34.95–61.78). An FCR of 61.3% was achieved in patients who had a vicryl mesh implanted at the fascial level (VACM therapy) in the course of treatment. Mortality among patients treated with VACM therapy was 45.2% (95% CI: 27.32–63.97). Conclusions: The results of our own study confirm the results of previous studies which showed an acceptable FCR among non-trauma patients who were treated with VACM therapy. VACM therapy currently appears to be the treatment regime of choice for patients with OA requiring TAC.
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Affiliation(s)
- Christian Beltzer
- Bundeswehr Hospital Ulm, Department of General, Visceral and Thorax Surgery, Ulm, Germany
| | - Alexander Eisenächer
- Bundeswehr Hospital Berlin, Department of General, Visceral and Thorax Surgery, Berlin, Germany
| | - Steffen Badendieck
- Bundeswehr Hospital Berlin, Department of General, Visceral and Thorax Surgery, Berlin, Germany
| | - Dietrich Doll
- St. Marienhospital, Vechta, Department of Colorectal Surgery, Vechta, Germany
| | - Markus Küper
- Bundeswehr Hospital Berlin, Department of General, Visceral and Thorax Surgery, Berlin, Germany
| | - Stefan Lenz
- Klinikum Nauen, Department of General and Visceral Surgery, Nauen, Germany
| | - Björn Dirk Krapohl
- St. Marien-Krankenhaus, Berlin, Department of Plastic and Hand Surgery, Berlin, Germany
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Suarez-Grau JM, Guadalajara Jurado JF, Gómez Menchero J, Bellido Luque JA. Delayed primary closure in open abdomen with stoma using dynamic closure system. SPRINGERPLUS 2015; 4:519. [PMID: 26405639 PMCID: PMC4573745 DOI: 10.1186/s40064-015-1316-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 09/07/2015] [Indexed: 11/10/2022]
Abstract
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.
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Montori G, Coccolini F, Manfredi R, Ceresoli M, Campanati L, Magnone S, Pisano M, Poiasina E, Nita G, Catena F, Ansaloni L. One year experience of swine dermal non-crosslinked collagen prostheses for abdominal wall repairs in elective and emergency surgery. World J Emerg Surg 2015; 10:28. [PMID: 26136817 PMCID: PMC4487506 DOI: 10.1186/s13017-015-0023-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/22/2015] [Indexed: 02/08/2023] Open
Abstract
Introduction The approach to the abdominal wall surgical repair is dramatically changed in the last years. This study evaluates our institutional outcomes about the usage of biological meshes for abdominal wall repair in different setting: in elective surgery, in emergency surgery and in abdominal wall repair following open abdomen (OA) procedure. Methods A database was prospectively conducted (January–December 2014) and data were reviewed for patients who underwent to an abdominal wall reconstruction with swine dermal non-cross linked collagens prostheses either in elective or emergency setting, and following OA/laparostomy procedure. Demographic data, co-morbidities, indications for surgery, intra-operative details, post-operative complications and outcome (peri-operative, 3, 6, 9-months) were analyzed. Results A total of 30 cases were reported: 9 in elective surgery (Group 1), 4 in emergency surgery (Group 2) and 17 with abdominal wall closure following OA management (Group 3). Two meshes were removed: 1 in the Group 1 and 1 in the Group 3. During follow-up only one patient in the Group 3 had a recurrence of the incisional hernia. Mortality rate was 11.1 % at 3 months in Group 1, 0 % in the Group 2, and 29.4 % in peri-operative period in the Group 3. Conclusions The use of non-cross linked biological meshes can be safe and versatile in different situations from elective to emergency surgery, and also for the reconstruction of the abdominal wall after OA procedure, with an acceptable recurrence and mortality rate.
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Affiliation(s)
- Giulia Montori
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Federico Coccolini
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Roberto Manfredi
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Marco Ceresoli
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Luca Campanati
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Magnone
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Michele Pisano
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Elia Poiasina
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Gabriela Nita
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Fausto Catena
- General surgery department, Ospedale Maggiore, Parma, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
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