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Kalaiselvan R, Slade DAJ, Soop M, Burnett H, Lees NP, Anderson ID, Lal S, Carlson GL. Impact of negative pressure wound therapy on enteroatmospheric fistulation in the septic open abdomen. Colorectal Dis 2023; 25:111-117. [PMID: 36031878 DOI: 10.1111/codi.16318] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/10/2022] [Accepted: 08/14/2022] [Indexed: 02/02/2023]
Abstract
AIM The effect of negative pressure wound therapy (NPWT) on the pathogenesis and outcome of enteroatmospheric fistulation (EAF) in the septic open abdomen (OA) is unclear. This study compares the development and outcome of EAF following NPWT with that occurring in the absence of NPWT. METHODS Consecutive patients admitted with EAF following abdominal sepsis at a National Reference Centre for intestinal failure between 01 January 2005 and 31 December 2015 were included in this study. Patients were divided into two groups based on those that had been treated with NPWT and those that had not (non-NPWT) and characteristics of their fistulas compared. Clinical outcomes concerning nutritional autonomy at 4 years and time to fistula development, size of abdominal wall defect and complete fistula closure were compared between groups. RESULTS A total of 160 patients were admitted with EAF following a septic abdomen (31-NPWT and 129-non-NPWT). Median (range) time taken to fistulation after OA was longer with NPWT (18 [5-113] vs. 8 [2-60] days, p = 0.004); these patients developed a greater number of fistulas (3 [2-21] vs. 2 [1-10], p = 0.01), involving a greater length of small bowel (42.5 [15-100] cm vs. 30 [3.5-170] cm, p = 0.04) than those who did not receive NPWT. Following reconstructive surgery, nutritional autonomy was similar in both groups (77% vs. 72%) and a comparable number of patients were also fistula-free (100% vs. 97%). CONCLUSIONS Negative pressure wound therapy appears to be associated with more complex and delayed intestinal fistulation, involving a greater length of small intestine in the septic OA. This did not, however, appear to adversely affect the overall outcome of intestinal and abdominal wall reconstruction in this study.
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Affiliation(s)
- Ramya Kalaiselvan
- Department of Surgery, National Reference Centre for Intestinal Failure, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Dominic A J Slade
- Department of Surgery, National Reference Centre for Intestinal Failure, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Mattias Soop
- Department of Surgery, National Reference Centre for Intestinal Failure, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Hugh Burnett
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Nicholas P Lees
- Department of Surgery, National Reference Centre for Intestinal Failure, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Iain D Anderson
- Department of Surgery, National Reference Centre for Intestinal Failure, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Simon Lal
- Department of Surgery, National Reference Centre for Intestinal Failure, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Gordon L Carlson
- Department of Surgery, National Reference Centre for Intestinal Failure, Salford Royal NHS Foundation Trust, Manchester, UK
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Retrospective Study of Indications and Outcomes of Open Abdomen with Negative Pressure Wound Therapy Technique for Abdominal Sepsis in a Tertiary Referral Centre. Antibiotics (Basel) 2022; 11:antibiotics11111498. [PMID: 36358153 PMCID: PMC9686976 DOI: 10.3390/antibiotics11111498] [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: 09/21/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
In patients with advanced sepsis from abdominal disease, the open abdomen (OA) technique as part of a damage control surgery (DCS) approach enables relook surgery to control infection, defer intestinal anastomosis, and prevent intra-abdominal hypertension. Limited evidence is available on key outcomes, such as mortality and rate of definitive fascial closure (DFC), which are needed for surgeons to select patients and adequate therapeutic strategies. Abdominal closure with negative pressure wound therapy (NPWT) has shown rates of DFC around 90%. We conducted a retrospective study to evaluate in-hospital survival and factors associated with mortality in acute, non-trauma patients treated using the OA technique and NPWT for sepsis from abdominal disease. Fifty consecutive patients treated using the OA technique and NPWT between February 2015 and July 2022 were included. Overall mortality was 32%. Among surviving patients, 97.7% of cases reached DFC, and the overall complication rate was 58.8%, with one case of entero-atmospheric fistula. At univariable analysis, age (p = 0.009), ASA IV status (<0.001), Mannheim Peritonitis Index > 30 (p = 0.001) and APACHE II score (p < 0.001) were associated with increased mortality. At multivariable analysis, higher APACHE II was a predictor of in-hospital mortality (OR 2.136, 95% CI 1.08−4.22; p = 0.029). Although very resource-intensive, DCS and the OA technique are valuable tools to manage patients with advanced abdominal sepsis, allowing reduced mortality and high DFC rates.
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Tartaglia D, Marin JN, Nicoli AM, De Palma A, Picchi M, Musetti S, Cremonini C, Salvadori S, Coccolini F, Chiarugi M. Predictive factors of mortality in open abdomen for abdominal sepsis: a retrospective cohort study on 113 patients. Updates Surg 2021; 73:1975-1982. [PMID: 33683639 PMCID: PMC8500907 DOI: 10.1007/s13304-021-01012-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/22/2021] [Indexed: 11/26/2022]
Abstract
Over the past few years, the open abdomen (OA) as a part of Damage Control Surgery (DCS) has been introduced as a surgical strategy with the intent to reduce the mortality of patients with severe abdominal sepsis. Aims of our study were to analyze the OA effects on patients with abdominal sepsis and identify predictive factors of mortality. Patients admitted to our institution with abdominal sepsis requiring OA from 2010 to 2019 were retrospectively analyzed. Primary outcomes were mortality, morbidity and definitive fascial closure (DFC). Comparison between groups was made via univariate and multivariate analyses. On 1474 patients operated for abdominal sepsis, 113 (7.6%) underwent OA. Male gender accounted for 52.2% of cases. Mean age was 68.1 ± 14.3 years. ASA score was > 2 in 87.9%. Mean BMI, APACHE II score and Mannheim Peritonitis Index were 26.4 ± 4.9, 15.3 ± 6.3, and 22.6 ± 7.3, respectively. A negative pressure wound system technique was used in 47% of the cases. Overall, mortality was 43.4%, morbidity 76.6%, and DFC rate was 97.8%. Entero-atmospheric fistula rate was 2.2%. At multivariate analysis, APACHE II score (OR 1.18; 95% CI 1.05-1.32; p = 0.005), Frailty Clinical Scale (OR 4.66; 95% CI 3.19-6.12; p < 0.0001) and ASA grade IV (OR 7.86; 95% CI 2.18-28.27; p = 0.002) were significantly associated with mortality. OA seems to be a safe and reliable treatment for critically ill patients with severe abdominal sepsis. Nonetheless, in these patients, co-morbidity and organ failure remain the major obstacles to a better prognosis.
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Affiliation(s)
- Dario Tartaglia
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy.
| | - Jacopo Nicolò Marin
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Alice Maria Nicoli
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Andrea De Palma
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Martina Picchi
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Serena Musetti
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Camilla Cremonini
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Stefano Salvadori
- Consiglio Nazionale delle Ricerche Area della Ricerca di Pisa, Pisa, Toscana, Italy
| | - Federico Coccolini
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Massimo Chiarugi
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
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Should Negative Pressure Therapy Replace Any Other Temporary Abdominal Closure Device in Open-Abdomen Management of Secondary Peritonitis? Surg Technol Int 2021. [PMID: 33844240 DOI: 10.52198/21.sti.38.gs1386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To clarify the advantages of negative pressure therapy (NPT) compared to other methods of temporary abdominal closure (TAC) in the management of secondary peritonitis. METHODS We retraced the history of known methods of TAC, and analyzed their advantages and disadvantages. We evaluated as the NPT mechanisms, both from the macroscopic that bio-molecular point of view, well suits to manage this difficult condition. RESULTS The ideal TAC technique should be quick to apply, easy to change, protect and contain the abdominal viscera, decrease bowel edema, prevent loss of domain and abdominal compartment syndrome, limit contamination, allow egress of peritoneal fluid (and its estimation) and not result in adhesions. It should also be cost-effective, minimize the number of dressing changes and the number of surgical revisions, and ensure a high rate of early closure with a low rate of complications (especially entero-atmospheric fistula). For NPT, the reported fistula rate is 7%, primary fascial closure ranges from 33 to 100% (average 60%) and the mortality rate is about 20%. With the use of NPT as TAC, it may be possible to extend the window of time to achieve primary fascial closure (for up to 20-40 days). CONCLUSION NPT has several potential advantages in open-abdomen (OA) management of secondary peritonitis and may make it possible to achieve all the goals suggested above for an ideal TAC system. Only trained staff should use NPT, following the manufacturer's instructions when commercial products are used. Even if there was a significant evolution in OA management, we believe that further research into the role of NPT for secondary peritonitis is necessary.
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Auer T, Sauseng S, Delcev P, Kohek P. Effect of Negative Pressure Therapy on Open Abdomen Treatments. Prospective Randomized Study With Two Commercial Negative Pressure Systems. Front Surg 2021; 7:596056. [PMID: 33614699 PMCID: PMC7894571 DOI: 10.3389/fsurg.2020.596056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/29/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction: The use of negative pressure dressings for open abdominal therapy has made a great impact on strategies for open abdominal treatment. Observed intestinal damage and developement of fistula formation raises questions about safety of commonly used systems (AB-Thera). The most common used system uses foils for shielding intestines directly from negative pressure. As an alternative a system with open pore dressing in double layer film was introduced (Suprasorb CNP) and proved to safe in animal studies. We compared the effects of this two systems on patients requiring open abdominal treatment. Materials and methods: Patients with secondary peritonitis in at least two abdominal quadrants were included in this randomized study. Inclusion criteria were secondary peritonitis (ACS), abdominal compartment syndrome, and abdominal trauma combined with ACS and/or contaminated abdomen. Patients with active bleeding and pancreatitis were not included. We examined Mannheim peritonitis Index (MPI), bloodcount, PCT, amount of fluid collected, and morphological changes on the bowel. Data were collected on day 2, 4, 7, 14, 21, and 28. Primary end point was fascial closure. Examination was terminated in case of death and damage to the abdominal organs. Groups were compared using Mann Whitney U-test and chi square test. Trend evaluation was evaluated using an one way repeated measure analysis of variance. P-values below 0.05 was considered significat. Results: Thirty four patients were included between August 2010 and September 2012. There were no significant difference between two groups in MPI, age, and gender. Mean duration of treatment, WBC, CRP, and abdominal closure rate were not significantly different between groups. Suprasorb CNP System collected twice more fluid than AB-Thera and decreased PCT on significantly faster rate than AB-Thera. Four patients died (11%) and four patients developed enteric fistula (11%). Closure rate was achieved in 27 out of 34 Patients (79.5%). Closure rate was not significantly different between groups. Conclusion: The use of both systems proved to be efficient and safe. The application of well-dosed, moderate negative pressure on contaminated areas of the abdomen seems to have a lot of potential and it is worth directing greater research potential in this direction.
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Affiliation(s)
- Thomas Auer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Siegfried Sauseng
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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Poillucci G, Podda M, Russo G, Perri SG, Ipri D, Manetti G, Lolli MG, De Angelis R. Open abdomen closure methods for severe abdominal sepsis: a retrospective cohort study. Eur J Trauma Emerg Surg 2020; 47:1819-1825. [PMID: 32377924 DOI: 10.1007/s00068-020-01379-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 04/24/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE The open abdomen (OA) procedure as part of damage control surgery represents a significant surgical advance in severe intra-abdominal infections. Major techniques used for OA are negative pressure wound therapy (NPWT) and non-NPWT. The aim of this retrospective study is to evaluate the effects of different abdominal closure methods and their outcomes in patients presenting with abdominal sepsis treated with OA. MATERIALS AND METHODS We retrospectively analyzed clinical outcomes of patients affected by severe intra-abdominal sepsis treated with OA. Demographic features, mortality prediction score, abdominal closure methods, length of hospital stay, complications and mortality rates of patients were determined and compared. RESULTS This study included 106 patients, of whom 77 underwent OA with NPWT and 29 with non-NPWT. OA duration was longer in NPWT patients (p = 0.007). In-hospital mortality rates in NPWT and in non-NPWT patients were 40.3% and 51.7%, respectively (p = 0.126), with an overall 30-day mortality rate of 18.2% and 51.7%, respectively (p = 0.0002). After emergency colorectal surgery, patients who underwent OA with NPWT had a lower rate of colostomy (p = 0.025). CONCLUSIONS NPWT is the best temporary abdominal closure technique to decrease mortality and colostomy rates in patients managed with OA for severe intra-abdominal infections.
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Affiliation(s)
- Gaetano Poillucci
- Department of General and Specialized Surgery "Paride Stefanini", Policlinico Universitario Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Mauro Podda
- Department of General, Emergency and Minimally Invasive Surgery, Policlinico Universitario "D. Casula", University of Cagliari, Monserrato, Italy
| | - Giulia Russo
- Department of General Surgery, San Camillo De Lellis Hospital, Rieti, Italy
| | | | - Domenico Ipri
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Gabriele Manetti
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Maria Giulia Lolli
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Renato De Angelis
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
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7
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López-Cano M, García-Alamino JM, Antoniou SA, Bennet D, Dietz UA, Ferreira F, Fortelny RH, Hernandez-Granados P, Miserez M, Montgomery A, Morales-Conde S, Muysoms F, Pereira JA, Schwab R, Slater N, Vanlander A, Van Ramshorst GH, Berrevoet F. EHS clinical guidelines on the management of the abdominal wall in the context of the open or burst abdomen. Hernia 2018; 22:921-939. [DOI: 10.1007/s10029-018-1818-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 08/21/2018] [Indexed: 12/22/2022]
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Sun X, Wu S, Xie T, Zhang J. Combing a novel device and negative pressure wound therapy for managing the wound around a colostomy in the open abdomen: A case report. Medicine (Baltimore) 2017; 96:e9370. [PMID: 29384913 PMCID: PMC6392989 DOI: 10.1097/md.0000000000009370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE An open abdomen complicated with small-bowel fistulae becomes a complex wound for local infection, systemic sepsis and persistent soiling irritation by intestinal content. While controlling the fistulae drainage, protecting surrounding skin, healing the wound maybe a challenge. PATIENT CONCERNS In this paper we described a 68-year-old female was admitted to emergency surgery in general surgery department with severe abdomen pain. Resection part of the injured small bowel, drainage of the intra-abdominal abscess, and fashioning of a colostomy were performed. DIAGNOSES She failed to improve and ultimately there was tenderness and lot of pus under the skin around the fistulae. The wound started as a 3-cm lesion and progressed to a 6 ×13 (78 cm) around the stoma. INTERVENTIONS In our case we present a novel device for managing colostomy wound combination with negative pressure wound therapy. OUTCOMES This tube allows for an effective drainage of small-bowel secretion and a safe build-up of granulation tissue. Also it could be a barrier between the bowel suction point and foam. LESSONS Management of open abdomen wound involves initial dressing changes, antibiotic use and cutaneous closure. When compared with traditional dressing changes, the NPWT offers several advantages including increased granulation tissue formation, reduction in bacterial colonization, decreased of bowel edema and wound size, and enhanced neovascularization.
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Affiliation(s)
| | - Shaohan Wu
- Department of General Surgery, The Second Hospital Affiliated to Jiaxing University, Jiaxing, Zhejiang, China
| | - Ting Xie
- Wound Healing Department, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China, 200011
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Coccolini F, Montori G, Ceresoli M, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Sartelli M, De Moya M, Velmahos G, Fraga GP, Pereira BM, Leppaniemi A, Boermeester MA, Kirkpatrick AW, Maier R, Bala M, Sakakushev B, Khokha V, Malbrain M, Agnoletti V, Martin-Loeches I, Sugrue M, Di Saverio S, Griffiths E, Soreide K, Mazuski JE, May AK, Montravers P, Melotti RM, Pisano M, Salvetti F, Marchesi G, Valetti TM, Scalea T, Chiara O, Kashuk JL, Ansaloni L. The role of open abdomen in non-trauma patient: WSES Consensus Paper. World J Emerg Surg 2017; 12:39. [PMID: 28814969 PMCID: PMC5557069 DOI: 10.1186/s13017-017-0146-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022] Open
Abstract
The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore hospital, Parma, Italy
| | | | - Rao Ivatury
- Trauma Surgery, Virginia Commonwealth University, Richmond, VA 23284 USA
| | - Walter Biffl
- Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI 96813 USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, 15213 USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, 92103 USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Marc De Moya
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | - George Velmahos
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | | | - Bruno M. Pereira
- Faculdade de Ciências Médicas (FCM) – Unicamp Campinas, São Paulo, Brazil
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | | | | | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, 98104 USA
| | - Miklosh Bala
- General Surgery Department, Hadassah Medical Centre, Jerusalem, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | | | - Manu Malbrain
- ICU and High Care Burn Unit, Ziekenhius Netwerk Antwerpen, Antwerpen, Belgium
| | | | | | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Ewen Griffiths
- Upper Gatrointestinal Surgery, Birmigham Hospital, Birmigham, UK
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University, Saint Louis, MO 63130 USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN 37232 USA
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | | | - Michele Pisano
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Francesco Salvetti
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Tino M. Valetti
- ICU Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Thomas Scalea
- Trauma Surgery department, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Osvaldo Chiara
- Emergency and Trauma Surgery department, Niguarda Hospital, Milan, Italy
| | - Jeffry L. Kashuk
- General Surgery department, Assuta Medical Centers, Tel Aviv, Israel
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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10
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Giudicelli G, Rossetti A, Scarpa C, Buchs NC, Hompes R, Guy RJ, Ukegjini K, Morel P, Ris F, Adamina M. Prognostic Factors for Enteroatmospheric Fistula in Open Abdomen Treated with Negative Pressure Wound Therapy: a Multicentre Experience. J Gastrointest Surg 2017; 21:1328-1334. [PMID: 28536807 DOI: 10.1007/s11605-017-3453-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 05/10/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reductions in mortality were reported with negative pressure wound therapy for laparostomy. However, some authors have voiced concern over an increased risk of enteroatmospheric fistulae. In this retrospective study, we hypothesized that surgical and metabolic derangements could increase the incidence of enteroatmospheric fistulae. We aimed to assess our experience and report long-term outcomes. METHODS A multicentre review of all patients with a laparostomy managed with negative pressure wound therapy between 2005 and 2015 was undertaken. Features associated with enteroatmospheric fistulae were included in multivariate logistic regression. RESULTS Fifty-seven patients were treated according to uniform protocol. Fourteen per cent (8/57) presented enteroatmospheric fistulae. Mesenteric ischaemia and preoperative arterial serum lactate >3.5 mmol/L were associated with a significantly increased risk of enteroatmospheric fistulae. Preoperative arterial serum lactate >3.5 mmol/L was an independent predictor of enteroatmospheric fistulae with an odds ratio of 12.41 (95% CI 1.54-99.99). All mesenteric ischaemia patients with anastomosis (5/15) presented enteroatmospheric fistulae. In-hospital mortality was 26.3% (15/57). One-year mortality was 33.3% (19/57). Incisional hernia rate was 5.2% (2/38) after 14.2 (2.4-56.3) months of follow-up. DISCUSSION Mesenteric ischaemia increases the risk of enteroatmospheric fistulae. Anastomosis should only be created in revascularized patients. When mesenteric vascularization is not restored, diversion is advised.
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Affiliation(s)
- Guillaume Giudicelli
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland.
| | - A Rossetti
- Department of Visceral Surgery, Cantonal Hospital Sankt Gallen, Sankt Gallen, Switzerland
| | - C Scarpa
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - N C Buchs
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - R Hompes
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - R J Guy
- Department of Colorectal Surgery, Churchill Hospital, Oxford University Hospitals, Oxford, UK
| | - K Ukegjini
- Department of Visceral Surgery, Cantonal Hospital Sankt Gallen, Sankt Gallen, Switzerland
| | - P Morel
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - F Ris
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Gabrielle-Perret-Gentil 4, 1211, Geneva 14, Switzerland
| | - M Adamina
- Division of Visceral and Thoracic Surgery, Department of Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
- University of Basel, Basel, Switzerland
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11
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[The treatment of acute secondary peritonitis : A retrospective analysis of the use of continuous negative pressure therapy]. Med Klin Intensivmed Notfmed 2017; 113:299-304. [PMID: 28555442 DOI: 10.1007/s00063-017-0309-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 04/23/2017] [Accepted: 05/04/2017] [Indexed: 10/19/2022]
Abstract
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.
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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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High risk of fistula formation in vacuum-assisted closure therapy in patients with open abdomen due to secondary peritonitis—a retrospective analysis. Langenbecks Arch Surg 2016; 401:619-25. [DOI: 10.1007/s00423-016-1443-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/26/2016] [Indexed: 02/02/2023]
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14
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Rasilainen SK, Viljanen M, Mentula PJ, Leppäniemi AK. Enteroatmospheric fistulae in open abdomen: Management and outcome – Single center experience. INTERNATIONAL JOURNAL OF SURGERY OPEN 2016. [DOI: 10.1016/j.ijso.2016.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Techniques for Abdominal Wall Closure after Damage Control Laparotomy: From Temporary Abdominal Closure to Early/Delayed Fascial Closure-A Review. Gastroenterol Res Pract 2015; 2016:2073260. [PMID: 26819597 PMCID: PMC4706912 DOI: 10.1155/2016/2073260] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 09/27/2015] [Indexed: 12/11/2022] Open
Abstract
Open abdomen (OA) has been an effective treatment for abdominal catastrophes in traumatic and general surgery. However, management of patients with OA remains a formidable task for surgeons. The central goal of OA is closure of fascial defect as early as is clinically feasible without precipitating abdominal compartment syndrome. Historically, techniques such as packing, mesh, and vacuum-assisted closure have been developed to assist temporary abdominal closure, and techniques such as components separation, mesh-mediated traction, bridging fascial defect with permanent synthetic mesh, or biologic mesh have also been attempted to achieve early primary fascial closure, either alone or in combined use. The objective of this review is to present the challenges of these techniques for OA with a goal of early primary fascial closure, when the patient's physiological condition allows.
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Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients. World J Surg 2015; 39:912-25. [PMID: 25446477 DOI: 10.1007/s00268-014-2883-6] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Several challenging clinical situations in patients with peritonitis can result in an open abdomen (OA) and subsequent temporary abdominal closure (TAC). Indications and treatment choices differ among surgeons. The risk of fistula development and the possibility to achieve delayed fascial closure differ between techniques. The aim of this study was to review the literature on the OA and TAC in peritonitis patients, to analyze indications and to assess delayed fascial closure, enteroatmospheric fistula and mortality rate, overall and per TAC technique. METHODS Electronic databases were searched for studies describing the OA in patients of whom 50% or more had peritonitis of a non-traumatic origin. RESULTS The search identified 74 studies describing 78 patient series, comprising 4,358 patients of which 3,461 (79%) had peritonitis. The overall quality of the included studies was low and the indications for open abdominal management differed considerably. Negative pressure wound therapy (NPWT) was the most frequent described TAC technique (38 of 78 series). The highest weighted fascial closure rate was found in series describing NPWT with continuous mesh or suture mediated fascial traction (6 series, 463 patients: 73.1%, 95% confidence interval 63.3-81.0%) and dynamic retention sutures (5 series, 77 patients: 73.6%, 51.1-88.1%). Weighted rates of fistula varied from 5.7% after NPWT with fascial traction (2.2-14.1%), 14.6% (12.1-17.6%) for NPWT only, and 17.2% after mesh inlay (17.2-29.5%). CONCLUSION Although the best results in terms of achieving delayed fascial closure and risk of enteroatmospheric fistula were shown for NPWT with continuous fascial traction, the overall quality of the available evidence was poor, and uniform recommendations cannot be made.
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Rasilainen SK, Juhani MP, Kalevi LA. Microbial colonization of open abdomen in critically ill surgical patients. World J Emerg Surg 2015; 10:25. [PMID: 26136816 PMCID: PMC4487573 DOI: 10.1186/s13017-015-0018-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 06/19/2015] [Indexed: 01/16/2023] Open
Abstract
Introduction This study was designed to describe the time-course and microbiology of colonization of open abdomen in critically ill surgical patients and to study its association with morbidity, mortality and specific complications of open abdomen. A retrospective cohort analysis was done. Methods One hundred eleven consecutive patients undergoing vacuum-assisted closure with mesh as temporary abdominal closure method for open abdomen were analyzed. Microbiological samples from the open abdomen were collected. Statistical analyses were performed using Fisher’s exact test for categorical variables. Mann-Whitney U test was used when comparing number of temporary abdominal closure changes between colonized and sterile patients. Kaplan-Meier analysis was done to calculate cumulative estimates for colonization. Cox regression analyses were performed to analyze risk factors for colonization. Results Microbiological samples were obtained from 97 patients. Of these 76 (78 %) were positive. Sixty-one (80 %) patients were colonized with multiple micro-organisms and 27 (36 %) were cultured positive for candida species. The duration of open abdomen treatment adversely affected the colonization rate. Thirty-three (34 %) patients were colonized at the time of laparostomy. After one week of open abdomen treatment 69, and after two weeks 76 patients were colonized with cumulative colonization estimates of 74 % and 89 %, respectively. Primary fascial closure rate was 80 % (61/76) and 86 % (18/21) for the colonized and sterile patients, respectively. The rate of wound complications did not significantly differ between these groups. Conclusions Microbial colonization of open abdomen is associated with the duration of open abdomen treatment. Wound complications are common after open abdomen, but colonization does not seem to have significant effect on these. The high colonization rate described herein should be taken into account when primarily sterile conditions like acute pancreatitis and aortic aneurysmal rupture are treated with open abdomen.
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Affiliation(s)
| | - Mentula Panu Juhani
- Department of Abdominal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Leppäniemi Ari Kalevi
- Department of Abdominal Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Willms A, Güsgen C, Schaaf S, Bieler D, von Websky M, Schwab R. Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction. Langenbecks Arch Surg 2014; 400:91-9. [PMID: 25128414 DOI: 10.1007/s00423-014-1240-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 08/08/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The open abdomen has become an accepted treatment option of critically ill patients with severe intra-abdominal conditions. Fascial closure is a particular challenge in patients with peritonitis. This study investigates whether fascial closure rates can be increased in peritonitis patients by using an algorithm that combines vacuum-assisted wound closure and mesh-mediated fascial traction. Moreover, fascial closure rates for patients with peritonitis, trauma or abdominal compartment system (ACS) are compared. METHODS Data were collected prospectively from all patients who underwent open abdomen management at our institution from 2006 to 2012. All patients were treated under a standardised algorithm that combines vacuum-assisted closure and mesh placement at the fascial level. RESULTS During the study period, 53 patients (mean age 53 years) underwent open abdomen management for a mean duration of 15 days. Indications for leaving the abdomen open were peritonitis (51 %), trauma (26 %), and ACS or abdominal wall dehiscence (23 %). The fascial closure rate was 79 % in an intention-to-treat analysis and 89 % in a per-protocol analysis. Mortality was 13 %. No patient developed an enteroatmospheric fistula or abdominal wall dehiscence after closure. The mean duration of treatment was significantly longer in peritonitis patients (20 days) than in patients without peritonitis (10 days) (p = 0.03). There were no significant differences in fascial closure rates between patients with peritonitis (87 %), trauma (85 %), and ACS or abdominal wall dehiscence (100 %) (p = 0.647). CONCLUSIONS Regardless of the underlying pathology, high fascial closure rates can be achieved using a combination of vacuum-assisted closure and mesh-mediated fascial traction.
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Affiliation(s)
- A Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Ruebenacher Strasse 170, 56072, Koblenz, Germany,
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De Siqueira J, Tawfiq O, Garner J. Managing the open abdomen in a district general hospital. Ann R Coll Surg Engl 2014; 96:194-8. [PMID: 24780782 DOI: 10.1308/003588414x13814021678556] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The need to manage an open abdomen is becoming more common in general surgical practice and a variety of methods of temporary abdominal closure (TAC) are available. The evidence for the efficacy of the various forms of TAC as well as the subsequent definitive fascial closure (DFC) rates and complications comes mainly from large trauma series in the US, which represent a different patient population to those in the UK in whom TAC is usually required. METHODS All cases of open abdomen management in our hospital over a five-year period were reviewed to ascertain the methods of TAC used, our success in achieving DFC and the applicability of managing such cases in a district hospital environment. RESULTS Nineteen patients underwent TAC, with two deaths (10.5%) and an overall DFC rate at hospital discharge of 12/17 (70.6%). The median lengths of critical care and hospital stays were 19.5 and 38.0 days respectively. Thirteen out of seventeen survivors had at least one significant complication. CONCLUSIONS The management of the open abdomen can be achieved safely in a district general hospital setting with acceptable outcomes for the non-trauma patients commonly seen in UK practice but it is a resource intensive and expensive undertaking.
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Rausei S, Dionigi G, Boni L, Rovera F, Minoja G, Cuffari S, Dionigi R. Open Abdomen Management of Intra-Abdominal Infections: Analysis of a Twenty-Year Experience. Surg Infect (Larchmt) 2014; 15:200-6. [DOI: 10.1089/sur.2012.180] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Stefano Rausei
- Department of Surgery, University of Insubria, Varese, Italy
| | | | - Luigi Boni
- Department of Surgery, University of Insubria, Varese, Italy
| | | | - Giulio Minoja
- Department of Critical Care Medicine, University of Insubria, Varese, Italy
| | | | - Renzo Dionigi
- Department of Surgery, University of Insubria, Varese, Italy
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Slade DAJ, Carlson GL. Takedown of Enterocutaneous Fistula and Complex Abdominal Wall Reconstruction. Surg Clin North Am 2013; 93:1163-83. [DOI: 10.1016/j.suc.2013.06.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Carlson GL, Patrick H, Amin AI, McPherson G, MacLennan G, Afolabi E, Mowatt G, Campbell B. Management of the open abdomen: a national study of clinical outcome and safety of negative pressure wound therapy. Ann Surg 2013; 257:1154-9. [PMID: 23478532 DOI: 10.1097/sla.0b013e31828b8bc8] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine clinical outcome of open abdomen therapy and assess the influence of negative pressure wound therapy on outcome. BACKGROUND Leaving the abdomen open (laparostomy) is an option following laparotomy for severe abdominal sepsis or trauma. Negative pressure wound therapy (NPWT) has become a popular means of managing laparostomy wounds. It may facilitate nursing care and delayed primary wound closure but the evidence to support its use is poor and concern has arisen about the risk of intestinal fistulation from exposed bowel, leading to an increased risk of death. METHODS Prospective observational study of 578 patients treated with an open abdomen in 105 hospitals in the United Kingdom between January 1, 2010, and June 30, 2011. Propensity analysis was used to compare adverse outcomes (fistulation, death, intestinal failure, bleeding requiring intervention) and delayed primary closure rates in patients who did and did not receive NPWT. FINDINGS The most common indication for an open abdomen (n = 398, 68.9%) was abdominal sepsis. Overall hospital mortality was 28.2%. The majority of patients (n = 355, 61.4%) were treated with NPWT. Intestinal fistulation [relative risk (RR) = 0.83, 95% confidence interval (CI): 0.44-1.58], death (RR = 0.87, 95% CI: 0.64-1.20), bleeding (RR = 0.74, 95% CI: 0.45-1.23), and intestinal failure (RR = 1.00, 95% CI: 0.64-1.57) were no more common in patients receiving NPWT, but the rate of delayed primary closure was significantly lower (RR = 0.74, 95% CI: 0.60-0.90, P = 0.002) when NPWT was used. CONCLUSIONS The indications for an open abdomen in the United Kingdom appear to be significantly different to those described in N. America, where its use in the management of trauma predominates. NPWT in patients with an open abdomen is not associated with an increase in mortality or intestinal fistulation. It is, however, associated with a reduced rate of delayed primary closure. Although this may be related to patient selection, NPWT may leave patients with abdominal wall defects that require further treatment.
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Affiliation(s)
- Gordon L Carlson
- National Intestinal Failure Centre, Department of Surgery, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
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Kreis BE, de Mol van Otterloo AJ, Kreis RW. Open abdomen management: a review of its history and a proposed management algorithm. Med Sci Monit 2013; 19:524-33. [PMID: 23823991 PMCID: PMC3706408 DOI: 10.12659/msm.883966] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 05/10/2013] [Indexed: 12/13/2022] Open
Abstract
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.
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Trastulli S, Cirocchi R, Boselli C, Noya G, Guarino S. Planned relaparotomy versus relaparotomy on demand for treatment of secondary peritonitis. Hippokratia 2013. [DOI: 10.1002/14651858.cd010396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Roberto Cirocchi
- University of Perugia; Department of General Surgery; Terni Italy
| | - Carlo Boselli
- University of Perugia; Department of General Surgery; Terni Italy
| | - Giuseppe Noya
- University of Perugia; Department of General Surgery; Terni Italy
| | - Salvatore Guarino
- Royal Free Hospital - UCL Partner; University Department of Surgery; Pond Street London UK NW3 2QG
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Rasilainen SK, Mentula PJ, Leppäniemi AK. Vacuum and mesh-mediated fascial traction for primary closure of the open abdomen in critically ill surgical patients. Br J Surg 2012; 99:1725-32. [PMID: 23034811 DOI: 10.1002/bjs.8914] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2012] [Indexed: 01/26/2023]
Abstract
BACKGROUND Several temporary abdominal closure techniques have been used in the management of open abdomen. Failure to achieve delayed primary fascial closure results in a large ventral hernia. This retrospective analysis evaluated whether the use of vacuum-assisted closure and mesh-mediated fascial traction (VACM) as temporary abdominal closure improved the delayed primary fascial closure rate compared with non-traction methods. METHODS Patients treated with an open abdomen between 2004 and 2010 were analysed. RESULTS Among 50 patients treated with VACM and 54 using non-traction techniques (control group), the delayed primary fascial closure rate was 78 and 44 per cent respectively (P < 0·001); rates among those who survived to abdominal closure were 93 and 59 per cent respectively. Independent predictors of delayed primary fascial closure in multivariable logistic regression analysis were the use of VACM (odds ratio (OR) 4·43, 95 per cent confidence interval 1·64 to 11·99) and diagnosis other than peritonitis, severe acute pancreatitis or ruptured abdominal aortic aneurysm (OR 3·45, 1·07 to 11·04), which represented the main diagnoses. Prophylactic open abdomen was used to inhibit the development of intra-abdominal hypertension more frequently in the VACM group (28 versus 7 per cent; P = 0·008). Twelve per cent of patients in the VACM group developed an enteroatmospheric fistula compared with 19 per cent of control patients. Among survivors, three of 31 treated with VACM and 17 of 36 controls were left with a planned ventral hernia (P = 0·001). CONCLUSION The indication for open abdomen contributed to the probability of delayed primary fascial closure. VACM resulted in a higher fascial closure rate and lower planned hernia rate than methods that did not provide fascial traction.
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Affiliation(s)
- S K Rasilainen
- Department of Abdominal Surgery, Helsinki University Central Hospital, Finland.
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Scholtes M, Kurmann A, Seiler CA, Candinas D, Beldi G. Intraperitoneal mesh implantation for fascial dehiscence and open abdomen. World J Surg 2012; 36:1557-61. [PMID: 22402974 DOI: 10.1007/s00268-012-1534-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative fascial dehiscence and open abdomen are severe postoperative complications and are associated with surgical site infections, fistula, and hernia formation at long-term follow-up. This study was designed to investigate whether intraperitoneal implantation of a composite prosthetic mesh is feasible and safe. METHODS A total of 114 patients with postoperative fascial dehiscence and open abdomen who had undergone surgery between 2001 and 2009 were analyzed retrospectively. Contaminated (wound class 3) or dirty wounds (wound class 4) were present in all patients. A polypropylene-based composite mesh was implanted intraperitoneally in 51 patients, and in 63 patients the abdominal wall was closed without mesh implantation. The primary endpoint was incidence of incisional hernia, and the incidence of enterocutaneous fistula was a secondary endpoint. RESULTS The incidence of enterocutaneous fistulas after wound closure post-fascial dehiscence (13% vs. 6% without and with mesh, respectively) or post-open abdomen (22% vs. 28% without and with mesh, respectively) was not significantly different. The incidence of incisional hernia was significantly lower with mesh implantation compared with no-mesh implantation in both contaminated (4% vs. 28%; p = 0.025) and dirty abdominal cavities (5% vs. 34%; p = 0.01). CONCLUSIONS Intra-abdominal contamination is not a contraindication for intra-abdominal mesh implantation. The incidence of enterocutaneous fistula is not elevated despite the presence of contamination. The rate of incisional hernias is significantly reduced after intraperitoneal mesh implantation for postoperative fascial dehiscence or open abdomen.
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Affiliation(s)
- Moritz Scholtes
- Department of Visceral Surgery and Medicine, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
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Quyn AJ, Johnston C, Hall D, Chambers A, Arapova N, Ogston S, Amin AI. The open abdomen and temporary abdominal closure systems--historical evolution and systematic review. Colorectal Dis 2012; 14:e429-38. [PMID: 22487141 DOI: 10.1111/j.1463-1318.2012.03045.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- A J Quyn
- Department of General Surgery, Victoria Hospital, Fife NHS Trust, Kirkcaldy, UK.
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Dubose JJ, Lundy JB. Enterocutaneous fistulas in the setting of trauma and critical illness. Clin Colon Rectal Surg 2011; 23:182-9. [PMID: 21886468 DOI: 10.1055/s-0030-1262986] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
One of the most devastating complications to develop in the general surgical patient is an enterocutaneous fistula (ECF). Critically ill patients suffering trauma, thermal injury, infected necrotizing pancreatitis, and other acute intraabdominal pathology are at unique risk for this complication as well. By using decompressive laparotomy for abdominal compartment syndrome and leaving the abdomen open temporarily for other acute processes, survival in some instances may be improved. However, the exposed viscera are at risk for fistulization in the presence of an open abdomen, a newly defined entity termed the enteroatmospheric fistula (EAF). The purpose of this article is to describe the epidemiology of ECF in the setting of trauma and critical illness, nutrition in injured/critically ill patients with ECF, pharmacologic adjuncts to decrease fistula effluent, wound care, surgical management of the EAF/ECF, and techniques for prevention of these dreaded complications in patients with an open abdomen.
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Affiliation(s)
- Joseph J Dubose
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Air Force Center for Sustainment of Trauma Readiness Skills, Baltimore, Maryland
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Ellison GW. Complications of Gastrointestinal Surgery in Companion Animals. Vet Clin North Am Small Anim Pract 2011; 41:915-34, vi. [DOI: 10.1016/j.cvsm.2011.05.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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D'Hondt M, Devriendt D, Van Rooy F, Vansteenkiste F, D'Hoore A, Penninckx F, Miserez M. Treatment of small-bowel fistulae in the open abdomen with topical negative-pressure therapy. Am J Surg 2011; 202:e20-4. [PMID: 21601824 DOI: 10.1016/j.amjsurg.2010.06.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 06/30/2010] [Accepted: 06/30/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND An open abdomen (OA) can result from surgical management of trauma, severe peritonitis, abdominal compartment syndrome, and other abdominal emergencies. Enteroatmospheric fistulae (EAF) occur in 25% of patients with an OA and are associated with high mortality. METHODS We report our experience with topical negative pressure (TNP) therapy in the management of EAF in an OA using the VAC (vacuum asisted closure) device (KCI Medical, San Antonio, TX). Nine patients with 17 EAF in an OA were treated with topical TNP therapy from January 2006 to January 2009. Surgery with enterectomy and abdominal closure was planned 6 to 10 weeks later. RESULTS Three EAF closed spontaneously. The median time from the onset of fistulization to elective surgical management was 51 days. No additional fistulae occurred during VAC therapy. One patient with a short bowel died as a result of persistent leakage after surgery. CONCLUSIONS Although previously considered a contraindication to TNP therapy, EAF can be managed successfully with TNP therapy. Surgical closure of EAFs is possible after several weeks.
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Affiliation(s)
- Mathieu D'Hondt
- Department of Digestive Surgery, Groeninge Hospital, Belgium.
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Layton B, Dubose J, Nichols S, Connaughton J, Jones T, Pratt J. Pacifying the open abdomen with concomitant intestinal fistula: a novel approach. Am J Surg 2010; 199:e48-50. [PMID: 20359566 DOI: 10.1016/j.amjsurg.2009.06.028] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Revised: 05/08/2009] [Accepted: 06/04/2009] [Indexed: 02/04/2023]
Abstract
The management of the open abdomen, particularly when complicated by the presence of intestinal fistula, remains a significant challenge of modern trauma care. Although several approaches have been proposed, these varied and complex cases defy the application of a universal approach to local therapy. Ultimately, abdominal closure is desired but is not always possible. Accordingly, surgeons must be well versed in the application of a number of useful approaches that may serve to facilitate control of fistula drainage while permitting management of the surrounding open wound. We contribute a management approach that is simplistic in design, provides for effective fistula control, and permits the subsequent unhindered granulation of the surrounding wound in abdomens not amenable to delayed closure techniques.
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Affiliation(s)
- Brian Layton
- Department of Surgery, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Chichom Mefire A, Tchounzou R, Masso Misse P, Pisoh C, Pagbe JJ, Essomba A, Takongmo S, Malonga EE. [Analysis of operative indications and outcomes in 238 re-operations after abdominal surgery in an economically disadvantaged setting]. ACTA ACUST UNITED AC 2009; 146:387-91. [PMID: 19765706 DOI: 10.1016/j.jchir.2009.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM OF THE STUDY We analyse aspects of re-operative abdominal surgery in an economically disadvantaged environment with respect to indications, operative findings, treatment modalities, and outcomes. PATIENTS AND METHODS Retrospective chart review over a seven-year period of patients requiring re-operative surgery during the same hospitalization or within 30 days of initial surgery. RESULTS During the study period, 7714 laparotomies were performed. Two hundred and seventy-seven (3.6%) required re-operation; of these, 238 charts (86%) were able to be reviewed. The decision for operative re-intervention was made mainly on the basis of clinical findings. Postoperative peritonitis (50.8%), adhesive bowel obstruction (23.9%), and intestinal fistula (10.9%) were the main indications for re-intervention. Complications occurred in 35% and included postoperative infection (n=70, 33%) and abdominal wall dehiscence (n=37, 15.5%). Mortality was 18% and increased significantly when the initial operative procedure was for peritonitis and re-operation was due to septic complications. CONCLUSION In an economically disadvantaged environment, the re-operation rate after an abdominal surgery does not seem to be higher than that seen in series from developed countries, although there may be factors which bias this observation. The mortality rate for cases with postoperative peritonitis is high, but operative re-intervention based on clinical findings is still considered the favored strategy in our environment. Results may improve with better material medical conditions.
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Affiliation(s)
- A Chichom Mefire
- Hôpital régional de Limbé, faculté des sciences de la santé, université de Buéa, BP 25526, Yaoundé, Cameroun.
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Marinis A, Gkiokas G, Anastasopoulos G, Fragulidis G, Theodosopoulos T, Kotsis T, Mastorakos D, Polymeneas G, Voros D. Surgical techniques for the management of enteroatmospheric fistulae. Surg Infect (Larchmt) 2009; 10:47-52. [PMID: 19245361 DOI: 10.1089/sur.2008.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND An intestinal fistula in the "open abdomen" is called "enteroatmospheric" and is a great challenge for the surgeon because of the high mortality and morbidity rates associated with it. This report is a study of the surgical strategy for treating patients with enteroatmospheric fistulae. METHODS During a 3-year period (2005-2007), two males and one female patient with a mean age of 63 years were referred to our surgical department for management of enteroatmospheric fistulae that developed after operations carried out for severe peritonitis, which was a consequence of sigmoid diverticulum rupture in two cases and disruption of an entero-enteric Roux-en-Y anastomosis after total gastrectomy for cancer in one. RESULTS All patients were appropriately supported in a surgical intensive care unit, with administration of total parenteral nutrition and appropriate antibiotics to eliminate secondary infections. Several re-operations were necessary to treat the enteroatmospheric fistulae. Eventually, all patients were discharged after a lengthy hospital stay (45-145 days). CONCLUSIONS The essential principles of our operative strategy are: (1) early intervention; (2) a lateral surgical approach via the circumference of the open abdomen to avoid further damage to the exposed viscera; (3) excision of the involved bowel loop with an end-to-end anastomosis; (4) temporary abdominal closure and coverage of the open abdomen with an absorbable mesh, promoting tissue granulation; (5) skin grafting attempts; and (6) selective use of vacuum-assisted closure.
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Affiliation(s)
- Athanasios Marinis
- Second Department of Surgery, Aretaieion University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen. World J Surg 2009; 33:199-207. [PMID: 19089494 PMCID: PMC3259401 DOI: 10.1007/s00268-008-9867-3] [Citation(s) in RCA: 192] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
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.
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Abstract
Much of the evidence for the use of TNP in the open abdomen comes from data on trauma patients. In view of the potentially severe complications, much greater evidence is needed for its application on patients with abdominal sepsis.
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Affiliation(s)
- S L Trevelyan
- National Intestinal Failure Rehabilitation Centre, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
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Arigon JP, Chapuis O, Sarrazin E, Pons F, Bouix A, Jancovici R. Prise en charge des abdomens ouverts par la thérapie vacuum-assisted closure (VAC®) : évaluation rétrospective de 22 malades. ACTA ACUST UNITED AC 2008; 145:252-61. [DOI: 10.1016/s0021-7697(08)73755-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sharma PK, Rakhorst G, Engels E, van der Mei HC, Busscher HJ, Ploeg RJ. Microbubble-enriched lavage fluid for treatment of experimental peritonitis. Br J Surg 2007; 95:522-9. [DOI: 10.1002/bjs.5991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract
Background
Relaparotomies and closed postoperative peritoneal lavage (CPPL) are performed to treat persistent peritonitis. This experimental animal study compared open abdominal lavage with CPPL, and evaluated the potential of microbubble-enriched lavage fluids to improve the efficiency of CPPL and reduce clinical morbidity, mortality and cost.
Methods
Fluorescent polystyrene spheres were injected intraperitoneally into 22 male Wistar rats to simulate localized peritonitis. After 18 h the rats received open abdominal lavage and CPPL, with and without microbubbles. Microbubbles were obtained by adding ultrasound contrast agents to continuous ambulatory peritoneal dialysis fluid.
Results
Open abdominal lavage was 3·5 times more effective in particle removal than CPPL, owing to better fluid dynamics. The introduction of air–liquid interfaces in the form of microbubbles made CPPL up to 2·4 times more effective than lavage without bubbles. Best detachment results were obtained when microbubbles with a flexible surfactant shell and longer blood elimination half-life were used.
Conclusion
Open abdominal and CPPL lavage techniques are not efficient beyond a certain duration and volume as they do not cause bacterial detachment from the peritoneal membrane. Using surface tension forces from microbubbles significantly enhanced polystyrene particle detachment. These findings may have great consequences for the treatment of patients with peritonitis.
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Affiliation(s)
- P K Sharma
- Department of Biomedical Engineering, University Medical Centre Groningen and University of Groningen, Groningen, The Netherlands
| | - G Rakhorst
- Department of Biomedical Engineering, University Medical Centre Groningen and University of Groningen, Groningen, The Netherlands
| | - E Engels
- Department of Biomedical Engineering, University Medical Centre Groningen and University of Groningen, Groningen, The Netherlands
| | - H C van der Mei
- Department of Biomedical Engineering, University Medical Centre Groningen and University of Groningen, Groningen, The Netherlands
| | - H J Busscher
- Department of Biomedical Engineering, University Medical Centre Groningen and University of Groningen, Groningen, The Netherlands
| | - R J Ploeg
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
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Keramati M, Srivastava A, Sakabu S, Rumbolo P, Smock M, Pollack J, Troop B. The Wittmann Patch s a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn. Burns 2007; 34:493-7. [PMID: 17949916 DOI: 10.1016/j.burns.2007.06.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2006] [Accepted: 06/24/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Abdominal compartment syndrome is frequently the result of aggressive fluid resuscitation after burn. Management of the open abdomen following decompressive celiotomy is a major problem. METHODS From 2004 to mid-2005, six patients required decompressive celiotomy after developing abdominal compartment syndrome as a result of burn. A Wittmann Patch as used to close the abdominal wound. Patients were re-explored when clinical parameters improved and the abdomen was closed, with long-term follow-up for the abdominal wound. RESULTS Of the six patients, five had thermal injury and one had electrical injury. The mean total body surface area affected for thermal burn was 78% and for electrical burn was 37%. Diagnosis of abdominal compartment syndrome was based on elevated bladder pressure and organ dysfunction. The patients were treated with decompressive celiotomy and Wittmann Patch closure. Survivors subsequently underwent primary abdominal closure, with no evidence of ventral hernia at long-term follow-up. CONCLUSION In burn cases with abdominal compartment syndrome, a Wittmann Patch ay prove a helpful method of temporary abdominal closure, followed by primary closure with no complications.
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Affiliation(s)
- Magid Keramati
- Department of Surgery, St. Louis University Hospital, St. Louis, MO, USA
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Abstract
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.
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Affiliation(s)
- P Oetting
- Klinik für Chirurgie und Chirurgische Onkologie, Universitätsmedizin Berlin, Charité Campus Buch, Robert-Rössle-Klinik im Helios-Klinikum Berlin, Lindenberger Weg 80, Berlin
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Abstract
Severe secondary peritonitis carries significant mortality, despite advancements in critical care support and other therapies. Surgical management requires a multidisciplinary approach to guide the timing and the number of interventions necessary to eradicate the septic foci and create optimal healing with the fewest complications. Research is needed regarding the best surgical strategy for very severe cases. The use of deferred primary anastomosis seems safe in patients presenting with hemodynamic instability and hypoperfusion. These patients have a high risk of anastomotic failure and fistula formation. Allowing for aggressive resuscitation and judicious assessment of the progression of local inflammation are safe strategies to achieve the highest success and minimize serious and protracted complications in patients who survive the initial septic insult.
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Affiliation(s)
- Carlos A. Ordoñez
- Universidad del Valle, Fundación Clínica Valle del Lili, Autopista Simón Bolívar, Carrera 98 No. 18-49, Cali, Colombia
| | - Juan Carlos Puyana
- Division of Trauma and General Surgery, University of Pittsburgh Medical Center Presbyterian, Suite F-1265, 200 Lothrop Street, Pittsburgh, P A 15213, USA
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Abstract
BACKGROUND The open abdomen, or laparostomy, is becoming increasingly used in the management of critically ill surgical patients. METHODS The published work on laparostomy is reviewed, in the light of personal experience, with particular attention to the history and pathophysiology associated with laparostomy. RESULTS AND CONCLUSION The combination of an inert plastic sheet in contact with the viscera, and the application of subatmospheric pressure on the wound, is an effective combination to maximize the prospects of delayed primary wound closure while minimizing the chance of fistula and ventral hernia.
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Affiliation(s)
- Alan de Costa
- Department of Surgery, Cairns Base Hospital, Cairns Private Hospital, Mount Druitt Hospital Sydney, New South Wales, Australia
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Aydin C, Aytekin FO, Tekin K, Kabay B, Yenisey C, Kocbil G, Ozden A. Effect of Temporary Abdominal Closure on Colonic Anastomosis and Postoperative Adhesions in Experimental Secondary Peritonitis. World J Surg 2006; 30:612-9. [PMID: 16479336 DOI: 10.1007/s00268-005-0511-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The effect of relaparotomies and temporary abdominal closure on colonic anastomoses and postoperative adhesions is under debate. METHODS In the experiments reported here, colonic anastomosis was constructed 24 hours after cecal ligation and puncture in rats that were divided into three groups of eight animals each. The abdomen was closed primarily in groups I and II, and a Bogota bag was used for abdominal closure in group III. At 24 hours following anastomosis, relaparotomy was performed only in group II and III rats, and the abdomen was closed directly in group II; after removal of the Bogota bag in group III animals, the abdomen was closed directly. On the fifth day of anastomotic construction, bursting pressures and tissue hydroxyproline content of the anastomoses, along with peritoneal adhesions, were assessed and compared. RESULTS Mean anastomotic bursting pressures and hydroxyproline contents did not differ among the groups. Median adhesion scores were significantly higher in group III than the other two groups. CONCLUSIONS Relaparotomy and the type of temporary closure have no negative effect on anastomotic healing in rats with peritonitis. Temporary abdominal closure with a Bogota bag caused a significantly high rate of adhesions.
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Affiliation(s)
- Cagatay Aydin
- Department of Surgery, Pamukkale University, School of Medicine, Kinikli, Denizli, 20070 Turkey.
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Lamme B, Mahler CW, van Till JWO, van Ruler O, Gouma DJ, Boermeester MA. [Relaparotomy in secondary peritonitis Planned relaparotomy or relaparotomy on demand?]. Chirurg 2005; 76:856-67. [PMID: 16133555 DOI: 10.1007/s00104-005-1086-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Secondary peritonitis is associated with serious morbidity and a persistent high mortality in recent decades, this despite improvement in antibiotic, intensive care and surgical treatment. The available literature regarding the surgical treatment of secondary peritonitis was searched through Pubmed (1966- January 2005) as well as a hand search of references of retrieved articles. Definitions, pathophysiology and classification of secondary peritonitis are discussed, as well as the scientific rationale for the surgical treatment in secondary peritonitis. The historical development and the scientific foundation of present-day relaparotomy strategies in secondary peritonitis are evaluated, with an emphasis on two frequently applied surgical treatment strategies: planned relaparotomy and relaparotomy on demand. Criteria for relaparotomy after the initial laparotomy and potential areas for further research to reduce both morbidity and mortality are discussed. Furthermore, the care of patients with secondary peritonitis is evolving from a surgical entity to a more multidisciplinary challenge uniting surgeons, intensivists, radiologists and microbiologists. Research needs to be expanded into novel fields to further decrease morbidity and mortality.
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Affiliation(s)
- B Lamme
- Chirurgische Klinik, Academic Medical Center, Amsterdam, Niederlande
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de Hingh IHJT, van Goor H, de Man BM, Lomme RMLM, Bleichrodt RP, Hendriks T. No detrimental effects of repeated laparotomies on early healing of experimental intestinal anastomoses. Int J Colorectal Dis 2005; 20:534-41. [PMID: 15809838 DOI: 10.1007/s00384-004-0731-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2004] [Indexed: 02/04/2023]
Abstract
BACKGROUND Little is known about the impact of repeated laparotomies on intestinal anastomotic healing. While experimental data are completely lacking, the sparse data available from clinical studies report high anastomotic failure rates, suggesting a negative effect in this respect. Since the unequivocal determination of such an effect may have important consequences for choosing the optimal treatment strategy for patients suffering from intra-abdominal infection, an experimental study has been performed in an established rodent model. METHODS Intestinal anastomoses were constructed in healthy Wistar rats (ileal and colonic anastomoses) or 24 h after peritonitis was induced by caecal ligation and puncture (colonic anastomosis only). Rats were then scheduled to undergo no, one (after 24 h) or two relaparotomies (after 24 and 48 h). Anastomotic strength was assessed 3 and 5 days after anastomotic construction. On the third post-operative day anastomotic hydroxyproline levels, matrix metalloproteinase activity and myeloperoxidase activity were measured. RESULTS No negative impact of repeated laparotomies was measured on any of the parameters measured. Under non-infectious conditions even an improvement in breaking strength (+48%, p=0.017) but not bursting pressure was found after two relaparotomies, but only in the ileum on the third post-operative day. CONCLUSIONS In this experimental setting, early anastomotic healing is not adversely affected by repeated laparotomies.
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Affiliation(s)
- I H J T de Hingh
- Department of Surgery, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Teubner A, Anderson ID, Scott NA, Carlson GL. Intra-abdominal hypertension and the abdominal compartment syndrome (Br J Surg 2004; 91: 1102-1110). Br J Surg 2004; 91:1527. [PMID: 15499645 DOI: 10.1002/bjs.4850] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses can be sent electronically via the BJS website (www.bjs.co.uk) or by post. All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Letters submitted by post should be typed on A4-sized paper in double spacing and should be accompanied by a disk.
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Teubner A, Morrison K, Ravishankar HR, Anderson ID, Scott NA, Carlson GL. Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula. Br J Surg 2004; 91:625-31. [PMID: 15122616 DOI: 10.1002/bjs.4520] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Use of total parenteral nutrition (TPN) in patients with acute intestinal failure due to enteric fistulation might be avoided if a simpler means of nutritional support was available. The aim of this study was to determine whether feeding via an intestinal fistula (fistuloclysis) would obviate the need for TPN.
Methods
Fistuloclysis was attempted in 12 patients with jejunocutaneous or ileocutaneous fistulas with mucocutaneous continuity. Feeding was achieved by inserting a gastrostomy feeding tube into the intestine distal to the fistula. Infusion of enteral feed was increased in a stepwise manner, without reinfusion of chyme, until predicted nutritional requirements could be met by a combination of fistuloclysis and regular diet, following which TPN was withdrawn. Energy requirements and nutritional status were assessed before starting fistuloclysis and at the time of reconstructive surgery.
Results
Fistuloclysis replaced TPN entirely in 11 of 12 patients. Nutritional status was maintained for a median of 155 (range 19–422) days until reconstructive surgery could be safely undertaken in nine patients. Two patients who did not undergo surgery remained nutritionally stable over at least 9 months. TPN had to be recommenced in one patient. There were no complications associated with fistuloclysis.
Conclusion
Fistuloclysis appears to provide effective nutritional support in selected patients with enterocutaneous fistula.
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Affiliation(s)
- A Teubner
- Intestinal Failure Unit, Department of Surgery, Hope Hospital, Salford, UK
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