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Pepe G, Chiarello MM, Bianchi V, Fico V, Altieri G, Tedesco S, Tropeano G, Molica P, Di Grezia M, Brisinda G. Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy. J Clin Med 2024; 13:1279. [PMID: 38592102 PMCID: PMC10932196 DOI: 10.3390/jcm13051279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients' quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas.
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Affiliation(s)
- Gilda Pepe
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Maria Michela Chiarello
- General Surgery Operative Unit, Department of Surgery, Provincial Health Authority, 87100 Cosenza, Italy;
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Gaia Altieri
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Silvia Tedesco
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Perla Molica
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Marta Di Grezia
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
| | - Giuseppe Brisinda
- Emergency Surgery and Trauma Center, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (G.P.); (V.B.); (V.F.); (G.A.); (S.T.); (G.T.); (P.M.); (M.D.G.)
- Department of Medicine and Surgery, Catholic School of Medicine “Agostino Gemelli”, Largo Francesco Vito 1, 00168 Rome, Italy
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2
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Yamamoto R, Kuramoto S, Shimizu M, Shinozaki H, Miyake T, Sadakari Y, Sekine K, Kaneko Y, Kurosaki R, Koizumi K, Shibusawa T, Sakurai Y, Wakahara S, Sasaki J. Optimal tentative abdominal closure for open abdomen: a multicenter retrospective observational study (OPTITAC study). Int J Surg 2023; 109:4049-4056. [PMID: 37678286 PMCID: PMC10720862 DOI: 10.1097/js9.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/07/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Primary fascia closure is often difficult following an open abdomen (OA). While negative-pressure wound therapy (NPWT) is recommended to enhance successful primary fascia closure, the optimal methods and degree of negative pressure remain unclear. This study aimed to elucidate optimal methods of NPWT as a tentative abdominal closure for OA to achieve primary abdominal fascia closure. MATERIALS AND METHODS A multicenter, retrospective, cohort study of adults who survived OA greater than 48 h was conducted in 12 institutions between 2010 and 2022. The achievement of primary fascia closure and incidence of enteroatmospheric fistula were examined based on methods (homemade, superficial NPWT kit, or open-abdomen kit) or degrees of negative pressure (<50, 50-100, or >100 mmHg). A generalized estimating equation was used to adjust for age, BMI, comorbidities, etiology for laparotomy requiring OA, vital signs, transfusion, severity of critical illness, and institutional characteristics. RESULTS Of the 279 included patients, 252 achieved primary fascia closure. A higher degree of negative pressure (>100 mmHg) was associated with fewer primary fascia closures than less than 50 mmHg [OR, 0.18 (95% CI: 0.50-0.69), P =0.012] and with more frequent enteroatmospheric fistula [OR, 13.83 (95% CI: 2.30-82.93)]. The methods of NPWT were not associated with successful primary fascia closure. However, the use of the open-abdomen kit was related to a lower incidence of enteroatmospheric fistula [OR, 0.02 (95% CI: 0.00-0.50)]. CONCLUSION High negative pressure (>100 mmHg) should be avoided in NPWT during tentative abdominal closure for OA.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo
| | - Shunsuke Kuramoto
- Department of Acute Care Surgery, Shimane University Faculty of Medicine, Shimane
| | - Masayuki Shimizu
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Kanagawa
| | | | - Tasuku Miyake
- Department of Acute Care Surgery, Shimane University Faculty of Medicine, Shimane
| | | | - Kazuhiko Sekine
- Department of Emergency and Critical Care Medicine, Tokyo Saiseikai Central Hospital, Tokyo
| | - Yasushi Kaneko
- Department of Emergency Medicine, Hiratsuka City Hospital, Kanagawa
| | - Ryo Kurosaki
- Department of Surgery, Japanese Red Cross Maebashi Hospital, Gunma
| | - Kiyoshi Koizumi
- Department of Cardiovascular Surgery, Ashikaga Red Cross Hospital, Tochigi
| | - Takayuki Shibusawa
- Department of Emergency and Critical Care Medicine, National Hospital Organization Tokyo Medical Center, Tokyo
| | | | - Sota Wakahara
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo
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3
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Risinger WB, Smith JW. Damage control surgery in emergency general surgery: What you need to know. J Trauma Acute Care Surg 2023; 95:770-779. [PMID: 37439768 DOI: 10.1097/ta.0000000000004112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
ABSTRACT Damage-control surgery (DCS) is a strategy adopted to limit initial operative interventions in the unstable surgical patient, delaying definitive repairs and abdominal wall closure until physiologic parameters have improved. Although this concept of "physiology over anatomy" was initially described in the management of severely injured trauma patients, the approaches of DCS have become common in the management of nontraumatic intra-abdominal emergencies.While the utilization of damage-control methods in emergency general surgery (EGS) is controversial, numerous studies have demonstrated improved outcomes, making DCS an essential technique for all acute care surgeons. Following a brief history of DCS and its indications in the EGS patient, the phases of DCS will be discussed including an in-depth review of preoperative resuscitation, techniques for intra-abdominal source control, temporary abdominal closure, intensive care unit (ICU) management of the open abdomen, and strategies to improve abdominal wall closure.
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Affiliation(s)
- William B Risinger
- From the Department of Surgery, University of Louisville School of Medicine, Louisville, KY
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4
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Rabel T, Bonnot PE, Hadeedi O, Kepenekian V, Bernard L, Friggeri A, Glehen O, Passot G. Negative-Pressure Wound Therapy for Open Abdomen in Surgical Reintervention after Curative Surgery of Peritoneal Malignancy Increases the Risk of Recurrence. Adv Skin Wound Care 2023; 36:1-5. [PMID: 37861668 DOI: 10.1097/asw.0000000000000018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
OBJECTIVE Negative-pressure wound therapy for open abdomen (NPWTOA) helps reduce the risk of abdominal compartment syndrome. However, the risk of recurrence of cancer is unclear when NPWTOA is applied after oncologic resection. The aim of this study was to evaluate the effects of NPWTOA used for major complications on patients treated with cytoreductive surgery for peritoneal malignancy (PM). METHODS All patients who underwent an NPWTOA after potentially curative surgery of PM in a single institution were included. These patients were pair matched 1:3 on the Peritoneal Cancer Index, completeness of cytoreduction using a scoring index, and PM origin with patients who underwent surgical reintervention without NPWTOA after curative surgery of PM. Survival among the two groups was compared using the Kaplan-Meier method. RESULTS Between 2011 and 2017, among 719 curative surgeries for PM, 13 patients underwent an NPWTOA after surgical reintervention. Researchers paired 9 of these patients to 27 others without NPWTOA after surgical reintervention. Median overall survival was 4.8 and 35 months (P = .391), and median disease-free survival was 4.0 and 13.9 months (P = .022) for the NPWTOA and non-NPWTOA groups, respectively. CONCLUSIONS The use of the NPWTOA during surgical reintervention after curative surgery for PM may increase the risk of early recurrence.
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Affiliation(s)
- Thomas Rabel
- In the Department of Visceral and Oncologic Surgery, Hospital Lyon Sud, Hospices Civils de Lyon, France, Thomas Rabel, MD, is Resident; Pierre-Emmanuel Bonnot, MD, is Surgical Fellow; Omar Hadeedi, MSc, is Visiting Surgical Fellow; and Vahan Kepenekian, MD, is Surgeon and Faculty. Lorraine Bernard is Biostastistician, Department of Biostatistics, Hospices Civils de Lyon. Arnaud Friggeri, MD, PhD, is Anesthesiologist and Faculty, Department of Anesthesiology and Intensive Care, Hopital Lyon Sud. Also in the Department of Visceral and Oncologic Surgery, Hospital Lyon Sud, Olivier Glehen, MD, PhD, is Surgeon and Head of the Department and Guillaume Passot, MD, PhD, is Surgeon. The authors have disclosed no financial relationships related to this article. Submitted August 17, 2022; accepted in revised form December 9, 2022
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5
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Rajabaleyan P, Jensen RO, Möller S, Qvist N, Ellebaek MB. Primary anastomosis and suturing combined with vacuum-assisted abdominal closure in patients with secondary peritonitis due to perforation of the small intestine: a retrospective study. BMC Surg 2023; 23:280. [PMID: 37715227 PMCID: PMC10503050 DOI: 10.1186/s12893-023-02179-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 08/31/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Intestinal resection and a proximal stoma is the preferred surgical approach in patients with severe secondary peritonitis due to perforation of the small intestine. However, proximal stomas may result in significant nutritional problems and long-term parenteral nutrition. This study aimed to assess whether primary anastomosis or suturing of small intestine perforation is feasible and safe using the open abdomen principle with vacuum-assisted abdominal closure (VAC). METHODS Between January 2005 and June 2018, we performed a retrospective chart review of 20 patients (> 18 years) with diffuse faecal peritonitis caused by small intestinal perforation and treated with primary anastomosis/suturing and subsequent open abdomen with VAC. RESULTS The median age was 65 years (range: 23-90 years). Twelve patients were female (60%). Simple suturing of the small intestinal perforation was performed in three cases and intestinal resection with primary anastomosis in 17 cases. Four patients (20%) died within 90-days postoperatively. Leakage occurred in five cases (25%), and three patients developed an enteroatmospheric fistula (15%). Thirteen of 16 patients (83%) who survived were discharged without a stoma. The rest had a permanent stoma. CONCLUSIONS Primary suturing or resection with anastomosis and open abdomen with VAC in small intestinal perforation with severe faecal peritonitis is associated with a high rate of leakage and enteroatmospheric fistula formation. TRIAL REGISTRATION The study was approved by the Danish Patient Safety Authority (case number 3-3013-1555/1) and the Danish Data Protection Agency (file number 18/28,404). No funding was received.
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Affiliation(s)
- Pooya Rajabaleyan
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
| | - Rie Overgaard Jensen
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient data Explorative Network, Department of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Niels Qvist
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Mark Bremholm Ellebaek
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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6
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Roberts DJ, Leppäniemi A, Tolonen M, Mentula P, Björck M, Kirkpatrick AW, Sugrue M, Pereira BM, Petersson U, Coccolini F, Latifi R. The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review. BJS Open 2023; 7:zrad084. [PMID: 37882630 PMCID: PMC10601091 DOI: 10.1093/bjsopen/zrad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/28/2023] [Accepted: 07/28/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery. METHODS A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen. RESULTS The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible. CONCLUSION Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ari Leppäniemi
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matti Tolonen
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Andrew W Kirkpatrick
- TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group, Calgary, Alberta, Canada
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael Sugrue
- Department of Surgery Letterkenny, University Hospital Donegal, Donegal, Ireland
| | - Bruno M Pereira
- Department of Surgery, Masters Program in Health Applied Sciences, Vassouras University, Vassouras, Rio de Janeiro, Brazil
- Department of Surgery, Campinas Holy House General Surgery Residency Program Director, Campinas, Sao Paulo, Brazil
| | - Ulf Petersson
- Department of Surgery, Skane University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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7
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Kirkpatrick AW, Coccolini F, Tolonen M, Minor S, Catena F, Gois E, Doig CJ, Hill MD, Ansaloni L, Chiarugi M, Tartaglia D, Ioannidis O, Sugrue M, Colak E, Hameed SM, Lampela H, Agnoletti V, McKee JL, Garraway N, Sartelli M, Ball CG, Parry NG, Voght K, Julien L, Kroeker J, Roberts DJ, Faris P, Tiruta C, Moore EE, Ammons LA, Anestiadou E, Bendinelli C, Bouliaris K, Carroll R, Ceresoli M, Favi F, Gurrado A, Rezende-Neto J, Isik A, Cremonini C, Strambi S, Koukoulis G, Testini M, Trpcic S, Pasculli A, Picariello E, Abu-Zidan F, Adeyeye A, Augustin G, Alconchel F, Altinel Y, Hernandez Amin LA, Aranda-Narváez JM, Baraket O, Biffl WL, Baiocchi GL, Bonavina L, Brisinda G, Cardinali L, Celotti A, Chaouch M, Chiarello M, Costa G, de'Angelis N, De Manzini N, Delibegovic S, Di Saverio S, De Simone B, Dubuisson V, Fransvea P, Garulli G, Giordano A, Gomes C, Hayati F, Huang J, Ibrahim AF, Huei TJ, Jailani RF, Khan M, Luna AP, Malbrain MLNG, Marwah S, McBeth P, Mihailescu A, Morello A, Mulita F, Murzi V, Mohammad AT, Parmar S, Pak A, Wong MPK, Pantalone D, Podda M, Puccioni C, Rasa K, Ren J, Roscio F, Gonzalez-Sanchez A, Sganga G, Scheiterle M, Slavchev M, Smirnov D, Tosi L, Trivedi A, Vega JAG, Waledziak M, Xenaki S, Winter D, Wu X, Zakaria AD, Zakaria Z. The unrestricted global effort to complete the COOL trial. World J Emerg Surg 2023; 18:33. [PMID: 37170123 PMCID: PMC10173926 DOI: 10.1186/s13017-023-00500-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. METHODS The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. DISCUSSION OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. TRIAL REGISTRATION National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).
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Affiliation(s)
- Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, EG23T2N 2T9, Canada.
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Samuel Minor
- Departments of Critical Care Medicine and Surgery, Dalhousie University, Halifax, NS, Canada
| | - Fausto Catena
- Department of Surgery, Bufalini Hospital, Cesena, Italy
| | - Emanuel Gois
- Department of Surgery, Londrina State University, and National COOL Coordinator for Brazil, Londrina, Brazil
| | - Christopher J Doig
- Departments of Critical Care Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Luca Ansaloni
- General Surgery I, San Matteo Hospital Pavia, University of Pavia, Pavia, Italy
| | - Massimo Chiarugi
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Dario Tartaglia
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Orestis Ioannidis
- 4th Department of Surgery, Medical School, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", Thessaloniki, Greece
| | | | - Elif Colak
- University of Samsun, Samsun Training and Research Hospital, Samsun, Turkey
| | - S Morad Hameed
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Hanna Lampela
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Espoo, Finland
| | | | - Jessica L McKee
- Global Project Manager, COOL Trial and the TeleMentored Ultrasound Supported Medical Interventions Research Group, Calgary, AB, Canada
| | - Naisan Garraway
- Departments of Surgery and Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Global Alliance for Infections in Surgery, Macerata, Italy
| | - Chad G Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Neil G Parry
- Departments of Surgery and Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Kelly Voght
- Departments of Surgery and Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lisa Julien
- Department of Surgery, NSHA-Queen Elizabeth II Health Sciences Center, Dalhousie University, Halifax, NS, Canada
| | - Jenna Kroeker
- Departments of Surgery and Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery and School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, CO, USA
| | | | - Elissavet Anestiadou
- 4th Department of Surgery, Medical School, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", Thessaloniki, Greece
| | | | - Konstantinos Bouliaris
- General Surgery Department of Koutlimbaneio, Triantafylleio General Hospital of Larissa, Larissa, Thessaly, Greece
| | | | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Francesco Favi
- Chirurgia Generale E d'Urgenza, Ospedale M. Bufalini - Cesena, AUSL Della Romagna, Cesena, Italy
| | - Angela Gurrado
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Joao Rezende-Neto
- Trauma and Acute Care Surgery, General Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Arda Isik
- General Surgery Department, Istanbul Medeniyet University School of Medicine Istanbul, Istanbul, Turkey
| | - Camilla Cremonini
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Silivia Strambi
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Georgios Koukoulis
- General Surgery Department of Koutlimbaneio, Triantafylleio General Hospital of Larissa, Larissa, Thessaly, Greece
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Sandy Trpcic
- Trauma and Acute Care Surgery, General Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Alessandro Pasculli
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Erika Picariello
- General Surgery Unit, Ospedale M. Buffalini Di Cesena, Cesena, Italy
| | - Fikri Abu-Zidan
- College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Ademola Adeyeye
- Division of Surgical Oncology, Afe Babalola University Multisystem Hospital, Ado-Ekiti, Nigeria
| | - Goran Augustin
- University Hospital Centre Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Felipe Alconchel
- Virgen de la Arrixaca University Hospital IMIB-Arrixaca, Ctra. Madrid-Cartagena, S/N, Murcia, Spain
| | - Yuksel Altinel
- Bagcilar Research and Training Hospital, Istanbul, Turkey
| | - Luz Adriana Hernandez Amin
- Nurse Master of Nursing, Professor and Coordinator of the teaching-service relationship, Faculty of Health Sciences, University of Sucre, Sincelejo, Colombia
| | - José Manuel Aranda-Narváez
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital of Málaga, Malaga, Spain
| | | | | | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Luigi Bonavina
- Department of Surgery, University of Milan Medical School, Milan, Italy
| | - Giuseppe Brisinda
- Department of Surgery, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Luca Cardinali
- Department of Surgery, General Hospital Madonna del Soccorso, San Benedetto del Tronto, Italy
| | - Andrea Celotti
- General Surgery Unit, UO Chirurgia Generale - Ospedale Maggiore Di Cremona, Cremona, Italy
| | - Mohamed Chaouch
- Department of Visceral and Digestive Surgery, Monastir University, Monastir, Tunisia
| | - Maria Chiarello
- Department of Surgery, Azienda Sanitaria Provinciale Di Cosenza, Cosenza, Italy
| | - Gianluca Costa
- Fondazione Policlinico Campus Bio-Medico, University Campus Bio-Medico of Rome, Rome, Italy
| | - Nicola de'Angelis
- Colorectal and Digestive Surgery Unit-DIGEST Department, Beaujon University Hospital AP-HP, University Paris Cité, Clichy, France
| | - Nicolo De Manzini
- Department of General Surgery, Cattinara University Hospital, Trieste, Italy
| | - Samir Delibegovic
- Department of Proctology, Clinic for Surgery, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Italy
| | - Belinda De Simone
- Unit of Digestive and Metabolic Minimally Invasive Surgery, Clinique Saint Louis, Poissy, Poissy, Ile de France, France
- Unit of Emergency and General Surgery, Guastalla Hospital, AUSL Reggio Emilia, Guastalla, Italy
| | - Vincent Dubuisson
- Chirurgie Digestive, Service de Chirurgie Vasculaire Et, Générale University Hospital of Bordeaux FR, Bordeaux, France
| | | | | | - Alessio Giordano
- Emergency and General Consultant Surgeon, Nuovo Ospedale "S. Stefano", Azienda ASL Toscana Centro, Prato, Italy
| | - Carlos Gomes
- Surgery Unit, Hospital Universitário Terezinha de Jesus, SUPREMA, Juiz de Fora, Brazil
| | - Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Jinjian Huang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | | | | | | | - Mansoor Khan
- General Surgery, University Hospitals, Sussex, UK
| | | | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
- International Fluid Academy, Lovenjoel, Belgium
| | - Sanjay Marwah
- Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | | | | | - Alessia Morello
- Department of General Surgery, Madonna del Soccorso Hospital - San Benedetto del Tronto, Italy, Italy
| | - Francesk Mulita
- Department of Surgery, General University Hospital of Patras, Rio, Greece
| | - Valentina Murzi
- Department of Surgical Science, Cagliari State University, Cagliari, Italy
| | | | | | - Ajay Pak
- Department of General Surgery, King George's Medical University, Lucknow, UP, India
| | - Michael Pak-Kai Wong
- School of Medical Sciences & Hospital, Universiti Sains Malaysia, Kelantan, Malaysia
| | | | - Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Caterina Puccioni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Kemal Rasa
- Department of General Surgery, Hüseyin Kemal Raşa, Anadolu Medical Center, Kocaeli, Turkey
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Francesco Roscio
- Division of General and Minimally Invasive Surgery, ASST Valle Olona, Busto Arsizio, Italy
| | - Antonio Gonzalez-Sanchez
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital of Málaga, Malaga, Spain
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Maximilian Scheiterle
- Emergency Surgery Unit and Trauma Team, Careggi University Hospital, Florence, Italy
| | | | - Dmitry Smirnov
- Department of Surgery, South Ural State Medical University, Chelyabinsk City, Russia
| | - Lorenzo Tosi
- Department of General Surgery, University of Bologna, Bologna, Italy
| | | | | | | | - Sofia Xenaki
- Department of General Surgery, University Hospital of Heraklion, Crete, Greece
| | | | - Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Andee Dzulkarnean Zakaria
- Department of Surgery, School of Medical Sciences and Hospital USM, Universiti Sains Malaysia, Georgetown, Malaysia
| | - Zaidi Zakaria
- Department of Surgery, School of Medical Sciences and Hospital USM, Universiti Sains Malaysia, Georgetown, Malaysia
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8
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Vacuum-assisted laparostomy in severe abdominal trauma and urgent abdominal pathology with compartment syndrome, peritonitis and sepsis: Comparison with other options for multistage surgical treatment (systematic review and meta-analysis). ACTA BIOMEDICA SCIENTIFICA 2023. [DOI: 10.29413/abs.2023-8.1.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Background. The concept of multistage surgical treatment of patients has been established in surgery rather recently and therefore the discussions on the expediency of using a particular surgical technique in a specific situation still continue. Vacuum-assisted laparostomy is being widely implemented into clinical practice for the treatment of abdominal compartment syndrome, severe peritonitis and abdominal trauma, but the indications and advantages of this method are not clearly defined yet.The aim of the study. To conduct a systematic review and meta-analysis on the comparison of the effectiveness of vacuum-assisted laparostomy with various variants of relaparotomy and laparostomy without negative pressure therapy in the treatment of patients with urgent abdominal pathology and abdominal trauma complicated by widespread peritonitis, sepsis or compartment syndrome.Material and methods. A systematic literature search was conducted in accordance with the recommendations of “Preferred Reporting Items for Systematic Reviews and Meta-Analyses”. We carried out the analysis of non-randomized (since January 2007 until August 6, 2022) and randomized (without time limits for the start of the study and until August 6, 2022) studies from the electronic databases eLibrary, PubMed, Cochrane Library, Science Direct, Google Scholar Search, Mendeley.Results. Vacuum-assisted laparostomy causes statistically significant shortening of the time of treatment of patients in the ICU and in hospital and a decrease in postoperative mortality compared to other variants of laparostomy without vacuum assistance.Conclusion. To obtain data of a higher level of evidence and higher grade of recommendations, it is necessary to further conduct systematic reviews and meta-analyses based on randomized clinical studies.
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9
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Sibilla MG, Cremonini C, Portinari M, Carcoforo P, Tartaglia D, Cicuttin E, Musetti S, Strambi S, Sartelli M, Radica MK, Catena F, Chiarugi M, Coccolini F, Salvetti F, Negoi I, Zese M, Occhionorelli S, Shlyapnikov S, Sugrue M, Demetrashvili Z, Dondossola D, Ioannidis O, Novelli G, Frattini C, Nacoti M, Khor D, Inaba K, Demetriades D, Kaussen T, Jusoh AC, Ghannam W, Sakakushev B, Guetta O, Dogjani A, Costa S, Singh S, Damaskos D, Isik A, Yuan KC, Trotta F, Rausei S, Martinez-Perez A, Bellanova G, Fonseca VC, Hernández F, Marinis A, Fernandes W, Quiodettis M, Bala M, Vereczkei A, Curado R, Fraga GP, Pereira BM, Gachabayov M, Chagerben GP, Arellano ML, Ozyazici S, Costa G, Tezcaner T, Porta M, Li Y, Karateke F, Manatakis D, Mariani F, Lora F, Sahderov I, Atanasov B, Zegarra S, Fattori L, Ivatury R, Xiao J, Ben-Ishay O, Zharikov A, Dubuisson V. Patients with an Open Abdomen in Asian, American and European Continents: A Comparative Analysis from the International Register of Open Abdomen (IROA). World J Surg 2023; 47:142-151. [PMID: 36326921 PMCID: PMC9726668 DOI: 10.1007/s00268-022-06733-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND International register of open abdomen (IROA) enrolls patients from several centers in American, European, and Asiatic continent. The aim of our study is to compare the characteristics, management and clinical outcome of adult patients treated with OA in the three continents. MATERIAL AND METHODS A prospective analysis of adult patients enrolled in the international register of open abdomen (IROA). TRIAL REGISTRATION NCT02382770. RESULTS 1183 patients were enrolled from American, European and Asiatic Continent. Median age was 63 years (IQR 49-74) and was higher in the European continent (65 years, p < 0.001); 57% were male. The main indication for OA was peritonitis (50.6%) followed by trauma (15.4%) and vascular emergency (13.5%) with differences among the continents (p < 0.001). Commercial NPWT was preferred in America and Europe (77.4% and 52.3% of cases) while Barker vacuum pack (48.2%) was the preferred temporary abdominal closure technique in Asia (p < 0.001). Definitive abdominal closure was achieved in 82.3% of cases in America (fascial closure in 90.2% of cases) and in 56.4% of cases in Asia (p < 0.001). Prosthesis were mostly used in Europe (17.3%, p < 0.001). The overall entero-atmospheric fistula rate 2.5%. Median open abdomen duration was 4 days (IQR 2-7). The overall intensive care unit and hospital length-of-stay were, respectively, 8 and 11 days (no differences between continents). The overall morbidity and mortality rates for America, Europe, and Asia were, respectively, 75.8%, 75.3%, 91.8% (p = 0.001) and 31.9%, 51.6%, 56.9% (p < 0.001). CONCLUSION There is no uniformity in OA management in the different continents. Heterogeneous adherence to international guidelines application is evident. Different temporary abdominal closure techniques in relation to indications led to different outcomes across the continents. Adherence to guidelines, combined with more consistent data, will ultimately allow to improving knowledge and outcome.
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Affiliation(s)
- Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Camilla Cremonini
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Mattia Portinari
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Dario Tartaglia
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Enrico Cicuttin
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Serena Musetti
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Silvia Strambi
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | | | - Margherita Koleva Radica
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Fausto Catena
- Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Massimo Chiarugi
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124 Pisa, Italy
| | - Federico Coccolini
- General Emergency and Trauma Surgery, Pisa University Hospital, Via Paradisia,1, 56124, Pisa, Italy.
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10
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Zarnescu NO, Dumitrascu I, Zarnescu EC, Costea R. Abdominal Compartment Syndrome in Acute Pancreatitis: A Narrative Review. Diagnostics (Basel) 2022; 13:diagnostics13010001. [PMID: 36611293 PMCID: PMC9818265 DOI: 10.3390/diagnostics13010001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/11/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Abdominal compartment syndrome (ACS) represents a severe complication of acute pancreatitis (AP), resulting from an acute and sustained increase in abdominal pressure >20 mmHg, in association with new organ dysfunction. The harmful effect of high intra-abdominal pressure on regional and global perfusion results in significant multiple organ failure and is associated with increased morbidity and mortality. There are several deleterious consequences of elevated intra-abdominal pressure on end-organ function, including respiratory, cardiovascular, gastrointestinal, neurologic, and renal effects. It is estimated that about 15% of patients with severe AP develop intra-abdominal hypertension or ACS, with a mortality rate around 50%. The treatment of abdominal compartment syndrome in acute pancreatitis begins with medical intervention and percutaneous drainage, where possible. Abdominal compartment syndrome unresponsive to conservatory treatment requires immediate surgical decompression, along with vacuum-assisted closure therapy techniques, followed by early abdominal fascia closure.
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Affiliation(s)
- Narcis Octavian Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
- Correspondence: (N.O.Z.); (E.C.Z.); Tel.: +40-723-592-483 (N.O.Z.); +40-748-412-341 (E.C.Z.)
| | - Ioana Dumitrascu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Eugenia Claudia Zarnescu
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
- Correspondence: (N.O.Z.); (E.C.Z.); Tel.: +40-723-592-483 (N.O.Z.); +40-748-412-341 (E.C.Z.)
| | - Radu Costea
- Department of General Surgery, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Second Department of Surgery, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
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11
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Miles G, Quinlan A, Daniel C. Bison Goring Resulting in Abdominal Evisceration and Cervical Fracture: A Case Report. J Trauma Nurs 2022; 29:319-324. [PMID: 36350171 DOI: 10.1097/jtn.0000000000000685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Handling livestock can be dangerous, and livestock-related injuries are increasing. CASE PRESENTATION An 83-year-old man who was gored and thrown by a bison bull during feeding is presented. The traumatic event resulted in two major injuries: an abdominal laceration with intestinal evisceration and cervical fractures after being lifted and forcefully thrown. The patient's hospital course included emergent surgery using the damage control approach resulting in an open abdomen, postoperatively, intensive care unit placement, and physiological management of the lethal diamond (acidosis, coagulopathy, hypothermia, and hypocalcemia). Finally, the patient's injuries required repeated abdominoplasties, colostomy, and surgical cervical stabilization. Despite a complicated hospitalization, the patient returned to his previous lifestyle within 2 months. CONCLUSION The geriatric population, despite multiple comorbidities, is active, and their dynamic lifestyle can result in severe injuries. Positive outcomes for this population are possible. Even if severely injured, the geriatric population has the propensity to rebound and survive with early aggressive management.
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Affiliation(s)
- Gayla Miles
- Texas Health Harris Methodist Hospital, Fort Worth, Texas
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12
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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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13
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Nakamura F, Yui R, Onoe A, Kishimoto M, Sakuramoto K, Muroya T, Kajino K, Ikegawa H, Kuwagata Y. Study of damage control strategy for non-traumatic diseases: a single-center observational study. Eur J Med Res 2022; 27:192. [PMID: 36183102 PMCID: PMC9526978 DOI: 10.1186/s40001-022-00823-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Damage control strategy (DCS) has been introduced not only for trauma but also for acute abdomen, but its indications and usefulness have not been clarified. We examined clinical characteristics of patients who underwent DCS and compared clinical characteristics and results with and without DCS in patients with septic shock. METHODS We targeted a series of endogenous abdominal diseases in Kansai Medical University Hospital from April 2013 to March 2019. Clinical characteristics of 26 patients who underwent DCS were examined. Then, clinical characteristics and results were compared between the DCS group (n = 26) and non-DCS group (n = 31) in 57 patients with septic shock during the same period. RESULTS All 26 patients who underwent DCS had septic shock, low mean arterial pressure (MAP) before the start of surgery, and required high-dose norepinephrine administration intraoperatively. Their discharge mortality rate was 12%. Among the patients with septic shock, the DCS group had a higher SOFA score (P = 0.008) and MAP was lower preoperatively, but it did not increase even with intraoperative administration of large amounts of fluid replacement and vasoconstrictor. There was no significant difference in 28-day mortality and discharge mortality between the two groups. CONCLUSIONS DCS may be useful in patients with severe septic shock.
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Affiliation(s)
- Fumiko Nakamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka, 573-1010, Japan.
| | - Rintaro Yui
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka, 573-1010, Japan
| | - Atsunori Onoe
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka, 573-1010, Japan
| | - Masanobu Kishimoto
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka, 573-1010, Japan
| | - Kazuhito Sakuramoto
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka, 573-1010, Japan
| | - Takashi Muroya
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka, 573-1010, Japan
| | - Kentaro Kajino
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka, 573-1010, Japan
| | - Hitoshi Ikegawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka, 573-1010, Japan
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Shinmachi 2-5-1, Hirakata, Osaka, 573-1010, Japan
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14
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Zhu C, Zeitouni F, Daniel H, Pham T, McReynolds S, Puckett Y, Hamby P, Ronaghan CA. Two surgeons’ collaboration to close an extreme open abdomen with loss of domain utilizing the abdominal dynamic tissue system and porcine urinary bladder matrix. Proc AMIA Symp 2022; 35:876-878. [DOI: 10.1080/08998280.2022.2092709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Christina Zhu
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Ferris Zeitouni
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Hannah Daniel
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Theophilus Pham
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Shirley McReynolds
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Yana Puckett
- Department of Surgery, West Virginia University School of Medicine, Charleston, West Virginia
| | - Philip Hamby
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas
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15
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Rajabaleyan P, Michelsen J, Tange Holst U, Möller S, Toft P, Luxhøi J, Buyukuslu M, Bohm AM, Borly L, Sandblom G, Kobborg M, Aagaard Poulsen K, Schou Løve U, Ovesen S, Grant Sølling C, Mørch Søndergaard B, Lund Lomholt M, Ritz Møller D, Qvist N, Bremholm Ellebæk M. Vacuum-assisted closure versus on-demand relaparotomy in patients with secondary peritonitis-the VACOR trial: protocol for a randomised controlled trial. World J Emerg Surg 2022; 17:25. [PMID: 35619144 PMCID: PMC9137120 DOI: 10.1186/s13017-022-00427-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Secondary peritonitis is a severe condition with a 20–32% reported mortality. The accepted treatment modalities are vacuum-assisted closure (VAC) or primary closure with relaparotomy on-demand (ROD). However, no randomised controlled trial has been completed to compare the two methods potential benefits and disadvantages. Methods This study will be a randomised controlled multicentre trial, including patients aged 18 years or older with purulent or faecal peritonitis confined to at least two of the four abdominal quadrants originating from the small intestine, colon, or rectum. Randomisation will be web-based to either primary closure with ROD or VAC in blocks of 2, 4, and 6. The primary endpoint is peritonitis-related complications within 30 or 90 days and one year after index operation. Secondary outcomes are comprehensive complication index (CCI) and mortality after 30 or 90 days and one year; quality of life assessment by (SF-36) after three and 12 months, the development of incisional hernia after 12 months assessed by clinical examination and CT-scanning and healthcare resource utilisation. With an estimated superiority of 15% in the primary outcome for VAC, 340 patients must be included. Hospitals in Denmark and Europe will be invited to participate. Discussion There is no robust evidence for choosing either open abdomen with VAC treatment or primary closure with relaparotomy on-demand in patients with secondary peritonitis. The present study has the potential to answer this important clinical question. Trial Registration The study protocol has been registered at clinicaltrials.gov (NCT03932461). Protocol version 1.0, 9 January 2022. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00427-x.
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Affiliation(s)
- Pooya Rajabaleyan
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark. .,University of Southern Denmark, Odense, Denmark.
| | - Jens Michelsen
- Research Unit for Anaesthesiology, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Uffe Tange Holst
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient Data Explorative Network, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Palle Toft
- Research Unit for Anaesthesiology, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Jan Luxhøi
- Surgical Department, Hospital of Southwest Jutland, Esbjerg, Denmark
| | - Musa Buyukuslu
- Surgical Department, Hospital of Southwest Jutland, Esbjerg, Denmark
| | | | - Lars Borly
- Surgical Department, Holbæk Hospital, Holbæk, Denmark
| | | | | | - Kristian Aagaard Poulsen
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | | | - Sophie Ovesen
- Surgical Department, Viborg Hospital, Viborg, Denmark
| | | | | | | | | | - Niels Qvist
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
| | - Mark Bremholm Ellebæk
- Research Unit for Surgery, Odense University Hospital, Odense, Denmark.,University of Southern Denmark, Odense, Denmark
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Akbayir O, Ulukent SC, Guraslan H, Seyhan NA, Gunkaya OS, Cingillioglu B, Akturk E, Yuksel IT. Open abdomen technique used in complications of major gynecological oncology surgery. J Obstet Gynaecol Res 2022; 48:1904-1912. [PMID: 35596265 DOI: 10.1111/jog.15296] [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: 08/13/2021] [Revised: 03/27/2022] [Accepted: 05/08/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the open abdomen technique (laparostomy) used in complications of major gynecological oncology surgery. METHODS We analyzed retrospectively the surgical database of all patients who had undergone major open surgery by the same gynecologic oncologist over a 5-year period. All patients who had had open abdomen procedure were identified; demographic data and indications of primary surgery, temporary abdominal closure procedure details, fascia closure and morbidity, mortality rates were evaluated. Intraabdominal infection and intraoperative massive hemorrhage were the major indications for all open abdomen cases. Mannheim Peritonitis Index was used perioperatively to determine open abdomen decision in intraabdominal infections. Vacuum Assisted Abdominal Closure system and Bogota Bag were used for temporary abdominal closure techniques. RESULTS Out of the total 560 patients who had undergone major oncological surgery, 19 patients (3.3%) had open abdomen procedure due to surgical complications. Eleven patients had intraabdominal infection, six patients had hemodynamic instability due to peri and postoperative hemorrhage, two patients had gross fecal contamination during posterior pelvic exenteration surgery. The fascia was closed totally in 15 (78%), partially in 3 (15%) and could not be closed in 1 patient who had died secondary to multiorgan failure. Total morbidity and mortality rates were 26% (5/19) (two intrabdominal abscess, one pulmonary embolism, one skin necrosis, one enteroatmospheric fistula) and 5.2% (1/19) respectively. CONCLUSION Open abdomen is a life-saving procedure when applied with correct indications and timing. Gynecological oncologic surgeries are candidates to serious complications and gynecologic oncologists dealing with such surgery should be as experienced as general surgeons in this regard.
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Affiliation(s)
- Ozgur Akbayir
- Department of Gynecologic Oncology, Prof. Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Suat C Ulukent
- Department of General Surgery, Gaziosmanpasa Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Hakan Guraslan
- Department of Obstetrics and Gynecology, Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Niyazi A Seyhan
- Department of Gynecologic Oncology, Aydin Adnan Menderes University, Aydin, Turkey
| | - Osman S Gunkaya
- Department of Obstetrics and Gynecology, Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Basak Cingillioglu
- Department of Obstetrics and Gynecology, Prof. Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Erhan Akturk
- Department of Obstetrics and Gynecology, Prof. Dr. Cemil Tascioglu City Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ilkbal T Yuksel
- Department of Gynecologic Oncology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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Cheng Y, Wang K, Gong J, Liu Z, Gong J, Zeng Z, Wang X. Negative pressure wound therapy for managing the open abdomen in non-trauma patients. Cochrane Database Syst Rev 2022; 5:CD013710. [PMID: 35514120 PMCID: PMC9073087 DOI: 10.1002/14651858.cd013710.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Management of the open abdomen is a considerable burden for patients and healthcare professionals. Various temporary abdominal closure techniques have been suggested for managing the open abdomen. In recent years, negative pressure wound therapy (NPWT) has been used in some centres for the treatment of non-trauma patients with an open abdomen; however, its effectiveness is uncertain. OBJECTIVES To assess the effects of negative pressure wound therapy (NPWT) on primary fascial closure for managing the open abdomen in non-trauma patients in any care setting. SEARCH METHODS In October 2021 we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL EBSCO Plus. To identify additional studies, we also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports. There were no restrictions with respect to language, date of publication, or study setting. SELECTION CRITERIA We included all randomised controlled trials (RCTs) that compared NPWT with any other type of temporary abdominal closure (e.g. Bogota bag, Wittmann patch) in non-trauma patients with open abdomen in any care setting. We also included RCTs that compared different types of NPWT systems for managing the open abdomen in non-trauma patients. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection process, risk of bias assessment, data extraction, and GRADE assessment of the certainty of evidence. MAIN RESULTS We included two studies, involving 74 adults with open abdomen associated with various conditions, predominantly severe peritonitis (N = 55). The mean age of the participants was 52.8 years; the mean proportion of women was 39.2%. Both RCTs were carried out in single centres and were at high risk of bias. Negative pressure wound therapy versus Bogota bag We included one study (40 participants) comparing NPWT with Bogota bag. We are uncertain whether NPWT reduces time to primary fascial closure of the abdomen (NPWT: 16.9 days versus Bogota bag: 20.5 days (mean difference (MD) -3.60 days, 95% confidence interval (CI) -8.16 to 0.96); very low-certainty evidence) or adverse events (fistulae formation, NPWT: 10% versus Bogota: 5% (risk ratio (RR) 2.00, 95% CI 0.20 to 20.33); very low-certainty evidence) compared with the Bogota bag. We are also uncertain whether NPWT reduces all-cause mortality (NPWT: 25% versus Bogota bag: 35% (RR 0.71, 95% CI 0.27 to 1.88); very low-certainty evidence) or length of hospital stay compared with the Bogota bag (NPWT mean: 28.5 days versus Bogota bag mean: 27.4 days (MD 1.10 days, 95% CI -13.39 to 15.59); very low-certainty evidence). The study did not report the proportion of participants with successful primary fascial closure of the abdomen, participant health-related quality of life, reoperation rate, wound infection, or pain. Negative pressure wound therapy versus any other type of temporary abdominal closure There were no randomised controlled trials comparing NPWT with any other type of temporary abdominal closure. Comparison of different negative pressure wound therapy devices We included one study (34 participants) comparing different types of NPWT systems (Suprasorb CNP system versus ABThera system). We are uncertain whether the Suprasorb CNP system increases the proportion of participants with successful primary fascial closure of the abdomen compared with the ABThera system (Suprasorb CNP system: 88.2% versus ABThera system: 70.6% (RR 0.80, 95% CI 0.56 to 1.14); very low-certainty evidence). We are also uncertain whether the Suprasorb CNP system reduces adverse events (fistulae formation, Suprasorb CNP system: 0% versus ABThera system: 23.5% (RR 0.11, 95% CI 0.01 to 1.92); very low-certainty evidence), all-cause mortality (Suprasorb CNP system: 5.9% versus ABThera system: 17.6% (RR 0.33, 95% CI 0.04 to 2.89); very low-certainty evidence), or reoperation rate compared with the ABThera system (Suprasorb CNP system: 100% versus ABThera system: 100% (RR 1.00, 95% CI 0.90 to 1.12); very low-certainty evidence). The study did not report the time to primary fascial closure of the abdomen, participant health-related quality of life, length of hospital stay, wound infection, or pain. AUTHORS' CONCLUSIONS Based on the available trial data, we are uncertain whether NPWT has any benefit in primary fascial closure of the abdomen, adverse events (fistulae formation), all-cause mortality, or length of hospital stay compared with the Bogota bag. We are also uncertain whether the Suprasorb CNP system has any benefit in primary fascial closure of the abdomen, adverse events, all-cause mortality, or reoperation rate compared with the ABThera system. Further research evaluating these outcomes as well as participant health-related quality of life, wound infection, and pain outcomes is required. We will update this review when data from the large studies that are currently ongoing are available.
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Affiliation(s)
- Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Ke Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Junhua Gong
- Organ Transplant Center, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zhong Zeng
- Organ Transplant Center, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xiaomei Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Fung S, Ashmawy H, Krieglstein C, Halama T, Schilawa D, Fuckert O, Hees A, Kröpil F, Rehders A, Lehwald-Tywuschik NC, Knoefel WT. Vertical traction device prevents abdominal wall retraction and facilitates early primary fascial closure of septic and non-septic open abdomen. Langenbecks Arch Surg 2022; 407:2075-2083. [PMID: 35147749 PMCID: PMC8832079 DOI: 10.1007/s00423-021-02424-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/23/2021] [Indexed: 12/04/2022]
Abstract
Purpose One of the major challenges in the management of patients with septic and non-septic open abdomen (OA) is to control abdominal wall retraction. The aim of this study was to evaluate the impact of a novel vertical traction device (VTD) on primary fascial closure (PFC) and prevention of fascial retraction. Methods Twenty patients treated with OA were included in this retrospective multicenter study. All patients were initially stabilized with laparostomy and the abdomen temporarily sealed either with a Bogotá bag or a negative pressure wound therapy system (NPWT). Results The mean duration of OA and fascia-to-fascia distance (FTF) prior to the VTD application were 3 days and 15 cm, respectively. At relook laparotomy 48 h after VTD implementation, the mean FTF distance significantly decreased to 10 cm (p = 0.0081). In all cases, PFC was achieved after a mean period of 7 days. Twelve patients received the VTD in combination with a NPWT, whereas in eight patients, the device was combined with an alternative temporary abdominal closure system (TAC). Although not statistically significant, the FTF distance remarkably decreased in both groups at relook laparotomy 48 h following the device implementation. The mean periods of PFC for patients with septic and non-septic OA were comparable (7.5 vs. 7 days). During follow-up, two patients developed an incisional hernia. Conclusion Vertical traction device prevents fascial retraction and facilitates early PFC in OA. In combination with NPWT, rapid fascial closure of large abdominal defects can be achieved.
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Affiliation(s)
- Stephen Fung
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Hany Ashmawy
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Christian Krieglstein
- Department of Surgery, St. Elisabeth Krankenhaus Köln, Werthmannstr. 1, 50935 Cologne, Germany
| | - Thomas Halama
- Department of Surgery, St. Vinzenz-Hospital, Merheimer Str. 221-223, 50733 Cologne, Germany
| | - Dustin Schilawa
- Department of Surgery, St. Rochus Krankenhaus, Glückaufstraße 10, 44575 Castrop-Rauxel, Germany
| | - Oliver Fuckert
- Department of Surgery, Lukas Krankenhaus, Hindenburgstraße 56, 32257 Bünde, Germany
| | - Anita Hees
- Department of Surgery, St.-Marien Krankenhaus, Kampenstraße 51, 57072 Siegen, Germany
| | - Feride Kröpil
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Alexander Rehders
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Nadja C. Lehwald-Tywuschik
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
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Faes S, Hübner M, Girardin T, Demartines N, Hahnloser D. Rate of stoma formation following damage-control surgery for severe intra-abdominal sepsis: a single-centre consecutive case series. BJS Open 2021; 5:6423702. [PMID: 34750614 PMCID: PMC8576255 DOI: 10.1093/bjsopen/zrab106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/27/2021] [Accepted: 09/06/2021] [Indexed: 12/29/2022] Open
Abstract
Background Severe intra-abdominal sepsis (IAS) is associated with high mortality and stoma rates. A two-stage approach with initial damage-control surgery (DCS) and subsequent reconstruction might decrease stoma and mortality rates but requires standardization. Methods A standardized two-stage damage-control algorithm for IAS was implemented in April 2016 and applied systematically. Results Some 203 consecutive patients (median age 70 years, 62 per cent ASA score greater than 3) had DCS for severe IAS. Median operation time was 82 minutes, 60 per cent performed during night-time. Median intraoperative noradrenaline doses were 20 (i.q.r. 26) µg/min and blood gas analysis (ABG) was abnormal (metabolic acidosis) in 90 per cent of patients. The second-stage operation allowed definitive surgery in 76 per cent of patients, 24 per cent had up to four re-DCSs until definitive surgery. The in-hospital mortality rate was 26 per cent. At hospital discharge, 65 per cent of patients were stoma free. Risk factors for in-hospital death were noradrenaline (odds ratio 4.25 (95 per cent c.i. 1.72 to 12.83)), abnormal ABG (pH: odds ratio 2.72 (1.24 to 6.65); lactate: odds ratio 6.77 (3.20 to 15.78)), male gender (odds ratio 2.40 (1.24 to 4.85)), ASA score greater than 3 (odds ratio 5.75 (2.58 to 14.68)), mesenteric ischaemia (odds ratio 3.27 (1.71 to 6.46)) and type of resection (odds ratio 2.95 (1.24 to 8.21)). Risk factors for stoma at discharge were ASA score greater than 3 (odds ratio 2.76 (95 per cent c.i. 1.38 to 5.73)), type of resection (odds ratio 30.91 (6.29 to 559.3)) and longer operation time (odds ratio 2.441 (1.22 to 5.06)). Conclusion Initial DCS followed by secondary reconstruction of bowel continuity for IAS within 48 hours in a tertiary teaching hospital was feasible and safe, following a clear algorithm.
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Affiliation(s)
- Seraina Faes
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Timothée Girardin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
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20
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Smit M, van Meurs M, Zijlstra JG. Intra-abdominal hypertension and abdominal compartment syndrome in critically ill patients: A narrative review of past, present, and future steps. Scand J Surg 2021; 111:14574969211030128. [PMID: 34605332 DOI: 10.1177/14574969211030128] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Intra-abdominal hypertension is frequently present in critically ill patients and is an independent predictor for mortality. In this narrative review, we aim to provide a comprehensive overview of current insights into intra-abdominal pressure monitoring, intra-abdominal hypertension, and abdominal compartment syndrome. The focus of this review is on the pathophysiology, risk factors and outcome of intra-abdominal hypertension and abdominal compartment syndrome, and on therapeutic strategies, such as non-operative management, surgical decompression, and management of the open abdomen. Finally, future steps are discussed, including propositions of what a future guideline should focus on. CONCLUSIONS Pathological intra-abdominal pressure is a continuum ranging from mild intra-abdominal pressure elevation without clinically significant adverse effects to substantial increase in intra-abdominal pressure with serious consequences to all organ systems. Intra-abdominal pressure monitoring should be performed in all patients at risk of intra-abdominal hypertension. Although continuous intra-abdominal pressure monitoring is feasible, this is currently not standard practice. There are a number of effective non-operative medical interventions that may be performed early in the patient's course to reduce intra-abdominal pressure and decrease the need for surgical decompression. Abdominal decompression can be life-saving when abdominal compartment syndrome is refractory to non-operative treatment and should be performed expeditiously. The objectives of open abdomen management are to prevent fistula and to achieve delayed fascial closure at the earliest possible time. There is still a lot to learn and change. The 2013 World Society of Abdominal Compartment Syndrome guidelines should be updated and multicentre studies should evaluate the effect of intra-abdominal hypertension treatment on patient outcome.
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Affiliation(s)
- Marije Smit
- Department of Critical Care, University Medical Center Groningen, University of Groningen, BA 49, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan G Zijlstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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21
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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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Cirocchi R, Popivanov G, Konaktchieva M, Chipeva S, Tellan G, Mingoli A, Zago M, Chiarugi M, Binda GA, Kafka R, Anania G, Donini A, Nascimbeni R, Edilbe M, Afshar S. The role of damage control surgery in the treatment of perforated colonic diverticulitis: a systematic review and meta-analysis. Int J Colorectal Dis 2021; 36:867-879. [PMID: 33089382 PMCID: PMC8026449 DOI: 10.1007/s00384-020-03784-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Damage control surgery (DCS) is the classic approach to manage severe trauma and has recently also been considered an appropriate approach to the treatment of critically ill patients with severe intra-abdominal sepsis. The purpose of the present review is to evaluate the outcomes following DCS for Hinchey II-IV complicated acute diverticulitis (CAD). METHODS A comprehensive systematic search was undertaken to identify all randomized clinical trials (RCTs) and observational studies, irrespectively of their size, publication status, and language. Adults who have undergone DCS for CAD Hinchey II, III, or IV were included in this review. DCS is compared with the immediate and definitive surgical treatment in the form of HP, colonic resection, and primary anastomosis (RPA) with or without covering stoma or laparoscopic lavage. We searched the following electronic databases: PubMed MEDLINE, Scopus, and ISI Web of Knowledge. The protocol of this systematic review and meta-analysis was published on Prospero (CRD42020144953). RESULTS Nine studies with 318 patients, undergoing DCS, were included. The presence of septic shock at the presentation in the emergency department was heterogeneous, and the weighted mean rate of septic shock across the studies was shown to be 35.1% [95% CI 8.4 to 78.6%]. The majority of the patients had Hinchey III (68.3%) disease. The remainder had either Hinchey IV (28.9%) or Hinchey II (2.8%). Phase I is similarly described in most of the studies as lavage, limited resection with closed blind colonic ends. In a few studies, resection and anastomosis (9.1%) or suture of the perforation site (0.9%) were performed in phase I of DCS. In those patients who underwent DCS, the most common method of temporary abdominal closure (TAC) was the negative pressure wound therapy (NPWT) (97.8%). The RPA was performed in 62.1% [95% CI 40.8 to 83.3%] and the 22.7% [95% CI 15.1 to 30.3%]: 12.8% during phase I and 87.2% during phase III. A covering ileostomy was performed in 6.9% [95% CI 1.5 to 12.2%]. In patients with RPA, the overall leak was 7.3% [95% CI 4.3 to 10.4%] and the major anastomotic leaks were 4.7% [95% CI 2.0 to 7.4%]; the rate of postoperative mortality was estimated to be 9.2% [95% CI 6.0 to 12.4%]. CONCLUSIONS The present meta-analysis revealed an approximately 62.1% weighted rate of achieving GI continuity with the DCS approach to generalized peritonitis in Hinchey III and IV with major leaks of 4.7% and overall mortality of 9.2%. Despite the promising results, we are aware of the limitations related to the significant heterogeneity of inclusion criteria. Importantly, the low rate of reported septic shock may point toward selection bias. Further studies are needed to evaluate the clinical advantages and cost-effectiveness of the DCS approach.
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Affiliation(s)
- Roberto Cirocchi
- Department of General Surgery, University of Perugia, 06123 Perugia, Italy
| | - Georgi Popivanov
- Department of Surgery, Military Medical Academy, ul. “Sv. Georgi Sofiyski” 3, 1606 Sofia, Bulgaria
| | - Marina Konaktchieva
- Department of Gastroenterology and Hepatology, Military Medical Academy, ul. “Sv. Georgi Sofiyski” 3, 1606 Sofia, Bulgaria
| | - Sonia Chipeva
- Department of Statistics and Econometrics, University of National and World Economy, Sofia, Bulgaria
| | - Guglielmo Tellan
- Department of Emergency and Acceptance, Critical Areas and Trauma, “Umberto I” University Hospital, Sapienza University of Rome, 00161 Rome, Italy
| | - Andrea Mingoli
- Dipartimento di Chirurgia “P. Valdoni”, Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Mauro Zago
- Department of Emergency and Robotic Surgery - A.Manzoni Hospital, Lecco, Italy
| | - Massimo Chiarugi
- Emergency Surgery & Trauma Center, Cisanello University Hospital, 56124 Pisa, Italy
| | | | - Reinhold Kafka
- Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Gabriele Anania
- Department of Medical Science, University of Ferrara, 4121 Ferrara, Italy
| | - Annibale Donini
- Department of General Surgery, University of Perugia, 06123 Perugia, Italy
| | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy
| | - Mohammed Edilbe
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
| | - Sorena Afshar
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
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23
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Schaaf S, Schwab R, Willms A. Quality of Life After Open Abdominal Treatment With Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction. Mil Med 2021; 186:452-457. [PMID: 33499462 DOI: 10.1093/milmed/usaa336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/04/2020] [Accepted: 09/03/2020] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Little is known about the long-term outcome of open abdomen treatment with vacuum-assisted wound closure and mesh-3. Therefore, this study's purpose is to evaluate this with a particular focus on incisional hernia development and quality of life (QoL). MATERIALS AND METHODS Fifty-five patients who underwent vacuum-assisted wound closure and mesh-mediated fascial traction at our institution from 2006 to 2013 were prospectively enrolled in this study. After a median follow-up period of 3.8 years, 34 patients attended a follow-up examination, including the SF-36 QoL questionnaire. RESULTS The fascial closure rate was 74% (intention-to-treat) and 89% (per-protocol). Enteroatmospheric fistulae occurred in 1.8%. In-hospital mortality was 16.4%, and during the follow-up period, it was 27.4%. Incisional hernias developed in 35% of the cases.The SF-36 physical role (54.6 ± 41.0 (0-100), P < 0.01), physical functioning (68.4 ± 29.5 (0-100), P = 0.01), and physical component summary (41.6 ± 13.0 (19-62), P = 0.01) scores for the patient population were significantly lower than normative scores. The mental dimensions of QoL showed no differences.A subgroup analysis revealed that the lower scores for physical role, physical functioning, and physical component summary only existed in the subgroup of incisional hernia patients. In contrast, physical and mental SF-36 scores of patients without incisional hernias did not differ from the normative scores. CONCLUSIONS Vacuum-assisted wound closure and mesh-mediated fascial traction seems to result in low complication rates. However, incisional hernias occur in 35%, which are the leading cause of reduced QoL. Measures to further improve this rate, such as prophylactic meshes, have to be evaluated.
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Affiliation(s)
- Sebastian Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Rhineland-Palatinate, Koblenz, 56072, Germany
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Rhineland-Palatinate, Koblenz, 56072, Germany
| | - Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Rhineland-Palatinate, Koblenz, 56072, Germany
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Ishikawa D, Takehara Y, Takata A, Takamura K, Sato H. Combination of dirty mass volume and APACHE II score predicts mortality in patients with colorectal perforation. World J Emerg Surg 2021; 16:17. [PMID: 33785047 PMCID: PMC8008772 DOI: 10.1186/s13017-021-00359-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/15/2021] [Indexed: 02/08/2023] Open
Abstract
Background “Dirty mass” is a specific computed tomography (CT) finding that is seen frequently in colorectal perforation. The prognostic significance of this finding for mortality is unclear. Methods Fifty-eight consecutive patients with colorectal perforation who underwent emergency surgery were retrospectively reviewed in the study. Dirty mass identified on multi-detector row CT (MDCT) was 3D-reconstructed and its volume was calculated using Ziostation software. Dirty mass volume and other clinical characteristics were compared between survivor (n = 45) and mortality groups (n = 13) to identify predictive factors for mortality. Mann–Whitney U test and Χ2 test were used in univariate analysis and logistic regression analysis was used in multivariate analysis. Results Dirty mass was identified in 36/58 patients (62.1%) and located next to perforated colorectum in all cases. Receiver-operating characteristic (ROC) curve analysis identified the highest peak at 96.3 cm3, with sensitivity of 0.643 and specificity of 0.864. Univariate analysis revealed dirty mass volume, acute disseminated intravascular coagulation (DIC) score, acute physiology and chronic health evaluation II (APACHE II) score, and sequential organ failure assessment (SOFA) score as prognostic markers for mortality (p<0.01). Multivariate analysis revealed dirty mass volume and APACHE II score as independent prognostic indicators for mortality. Mortality was stratified by dividing patients into four groups according to dirty mass volume and APACHE II score. Conclusions The combination of dirty mass volume and APACHE II score could stratify the postoperative mortality risk in patients with colorectal perforation. According to the risk stratification, surgeons might be able to decide the surgical procedures and intensity of postoperative management.
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Affiliation(s)
- Daichi Ishikawa
- Department of Surgery, Yoshinogawa Medical Center, 120 Nishichiejima, Yoshinogawa City, Tokushima, 776-8511, Japan.
| | - Yukako Takehara
- Department of Surgery, Yoshinogawa Medical Center, 120 Nishichiejima, Yoshinogawa City, Tokushima, 776-8511, Japan
| | - Atsushi Takata
- Department of Surgery, Yoshinogawa Medical Center, 120 Nishichiejima, Yoshinogawa City, Tokushima, 776-8511, Japan
| | - Kazuhito Takamura
- Department of Surgery, Yoshinogawa Medical Center, 120 Nishichiejima, Yoshinogawa City, Tokushima, 776-8511, Japan
| | - Hirohiko Sato
- Department of Surgery, Yoshinogawa Medical Center, 120 Nishichiejima, Yoshinogawa City, Tokushima, 776-8511, Japan
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Berrevoet F, Lampaert S, Singh K, Jakipbayeva K, van Cleven S, Vanlander A. Early Initiation of a Standardized Open Abdomen Treatment With Vacuum Assisted Mesh-Mediated Fascial Traction Achieves Best Results. Front Surg 2021; 7:606539. [PMID: 33634162 PMCID: PMC7900519 DOI: 10.3389/fsurg.2020.606539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/10/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Complete fascial closure is an essential treatment objective and can be achieved by the use of different dynamic closure techniques. Both surgical technique and-decision making are essential for optimal patient outcome in terms of fascial closure. The aim of this study was to analyse patients' outcome after the use of mesh-mediated fascial traction (MMFT) associated with negative pressure wound therapy (NPWT) and identify important factors that negatively influenced final fascial closure. Methods: A single center ambispective analysis was performed including all patients treated for an open abdomen in a tertiary referral center from 3/2011 till 2/2020. All patients with a minimum survival >24 h after initiation of treatment were analyzed. The data concerning patient management was collected and entered into the Open Abdomen Route of the European Hernia Society (EHS). Patient basic characteristics considering OA indication, primary fascial closure, as well as important features in surgical technique including time after index procedure to start mesh mediated fascial traction, surgical closure techniques and patients' long-term outcomes were analyzed. Results: Data were obtained from 152 patients who underwent open abdomen therapy (OAT) in a single center study. Indications for OAT as per-protocol analysis were sepsis (33.3%), abdominal compartment syndrome (31.6%), followed by peritonitis (24.2%), abdominal trauma (8.3%) and burst abdomen (2.4%). Overall fascial closure rate was 80% as in the per-protocol analysis. When patients that started OA management with MMFT and NPWT from the initial surgery a significantly better fascial closure rate was achieved compared to patients that started 3 or more days later (p < 0.001). An incisional hernia developed in 35.8% of patients alive with a median follow-up of 49 months (range 6-96 months). Conclusion: Our main findings emphasize the importance of a standardized treatment plan, initiated early on during management of the OA. The use of vacuum assisted closure in combination with MMFT showed high rates of fascial closure. Absence of initial intraperitoneal NPWT as well as delayed start of MMFT were risk factors for non-fascial closure. Initiation of OA with VACM should not be unnecessary delayed.
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Affiliation(s)
- Frederik Berrevoet
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Silvio Lampaert
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Kashika Singh
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Kamilya Jakipbayeva
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Stijn van Cleven
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Aude Vanlander
- Department of General and Hepatopancreaticobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
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Henn J, Lingohr P, Branchi V, Semaan A, von Websky MW, Glowka TR, Kalff JC, Manekeller S, Matthaei H. Open Abdomen Treatment in Acute Pancreatitis. Front Surg 2021; 7:588228. [PMID: 33521045 PMCID: PMC7841327 DOI: 10.3389/fsurg.2020.588228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/07/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Severe acute pancreatitis (SAP) is a heterogeneous and life-threatening disease. While recent guidelines recommend a stepwise approach starting with non-surgical techniques, emergency laparotomy remains inevitable in certain situations. Open abdomen treatment (OAT) may follow, potentially resulting in additional risks for severe morbidity. Causative factors and clinical impact of OAT in SAP are poorly understood and therefore issue of the present study. Materials and Methods: A retrospective analysis of patients admitted to the Department of General, Visceral, Thoracic and Vascular Surgery at University of Bonn suffering from acute pancreatitis (ICD K.85) between 2005 and 2020 was performed. Medical records were screened for demographic, clinical and outcome parameters. Patients who received primary fascial closure (PFC) were compared to those patients requiring OAT. SAP-specific scores were calculated, and data statistically analyzed (P = 0.05). Results: Among 430 patients included, 54 patients (13%) had to undergo emergency laparotomy for SAP. Patients were dominantly male (72%) with a median age of 51 years. Indications for surgery were infected necrosis (40%), suspected bowel perforation (7%), abdominal compartment syndrome (5%), and acute intra-abdominal hemorrhage (3%). While 22 patients (40%) had PFC within initial surgery, 33 patients (60%) required OAT including a median of 12 subsequent operations (SD: 6, range: 1-24). Compared to patients with PFC, patients in the OAT group had significantly fewer biliary SAP (P = 0.031), higher preoperative leukocyte counts (P = 0.017), higher rates of colon resections (P = 0.048), prolonged ICU stays (P = 0.0001), and higher morbidity according to Clavien-Dindo Classification (P = 0.002). Additionally, BISAP score correlated positively with the number of days spent at ICU and morbidity (P = 0.001 and P = 0.000002). Both groups had equal mortality rates. Discussion: Our data suggest that preoperative factors in surgically treated SAP may indicate the need for OAT. The procedure itself appears safe with equal hospitalization days and mortality rates compared to patients with PFC. However, OAT may significantly increase morbidity through longer ICU stays and more bowel resections. Thus, minimally invasive options should be promoted for an uncomplicated and rapid recovery in this severe disease. Emergency laparotomy will remain ultima ratio in SAP while patient selection seems to be crucial for improved clinical outcomes.
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Affiliation(s)
- Jonas Henn
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Philipp Lingohr
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Vittorio Branchi
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Alexander Semaan
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Martin W von Websky
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Tim R Glowka
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Steffen Manekeller
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Hanno Matthaei
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital Bonn, Bonn, Germany
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Clements TW, Tolonen M, Ball CG, Kirkpatrick AW. Secondary Peritonitis and Intra-Abdominal Sepsis: An Increasingly Global Disease in Search of Better Systemic Therapies. Scand J Surg 2021; 110:139-149. [PMID: 33406974 DOI: 10.1177/1457496920984078] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Secondary peritonitis and intra-abdominal sepsis are a global health problem. The life-threatening systemic insult that results from intra-abdominal sepsis has been extensively studied and remains somewhat poorly understood. While local surgical therapy for perforation of the abdominal viscera is an age-old therapy, systemic therapies to control the subsequent systemic inflammatory response are scarce. Advancements in critical care have led to improved outcomes in secondary peritonitis. The understanding of the effect of secondary peritonitis on the human microbiome is an evolving field and has yielded potential therapeutic targets. This review of secondary peritonitis discusses the history, classification, pathophysiology, diagnosis, treatment, and future directions of the management of secondary peritonitis. Ongoing clinical studies in the treatment of secondary peritonitis and the open abdomen are discussed.
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Affiliation(s)
- T W Clements
- Foothills Medical Centre, Department of Critical Care Medicine and Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - M Tolonen
- HUS Helsinki University Hospital, Helsinki, Finland
| | - C G Ball
- Foothills Medical Centre, Department of Critical Care Medicine and Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - A W Kirkpatrick
- Foothills Medical Centre, Department of Critical Care Medicine and Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Canadian Forces Medical Services, University of Calgary, Calgary, AB, Canada
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28
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Schaaf S, Schwab R, Güsgen C, Willms A. Prophylactic Onlay Mesh Implantation During Definitive Fascial Closure After Open Abdomen Therapy (PROMOAT): Absorbable or Non-absorbable? Methodical Description and Results of a Feasibility Study. Front Surg 2020; 7:578565. [PMID: 33385010 PMCID: PMC7769831 DOI: 10.3389/fsurg.2020.578565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/25/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Incisional hernia development after open abdomen therapy (OAT) remains a common complication in the long run. To demonstrate the feasibility, we describe our method of prophylactic onlay mesh implantation with definitive fascial closure after open abdomen therapy (PROMOAT). To display the feasibility of this concept, we evaluated the short-term outcome after absorbable and non-absorbable synthetic mesh implantation as prophylactic onlay. Material and Methods: Ten patients were prospectively enrolled, and prophylactic onlay mesh (long-term absorbable or non-absorbable) was implanted at the definitive fascial closure operation. The cohort was followed up with a special focus on incisional hernia development and complications. Results: OAT duration was 21.0 ± 12.6 days (95% CI: 16.9-25.1). Definitive fascial closure was achieved in all cases. No incisional hernias were present during a follow-up interval of 12.4 ± 10.8 months (range 1-30 months). Two seromas and one infected hematoma occurred. The outcome did not differ between mesh types. Conclusion: The prophylactic onlay mesh implantation of alloplastic, long-term absorbable, or non-absorbable meshes in OAT showed promising results and only a few complications that were of minor concern. Incisional hernias did not occur during follow-up. To validate the feasibility and safety of prophylactic onlay mesh implantation long-term data and large-scaled prospective trials are needed to give recommendations on prophylactic onlay mesh implantation after OAT.
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Affiliation(s)
- Sebastian Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Christoph Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
| | - Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
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29
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Willms AG, Schwab R, von Websky MW, Berrevoet F, Tartaglia D, Sörelius K, Fortelny RH, Björck M, Monchal T, Brennfleck F, Bulian D, Beltzer C, Germer CT, Lock JF. Factors influencing the fascial closure rate after open abdomen treatment: Results from the European Hernia Society (EuraHS) Registry : Surgical technique matters. Hernia 2020; 26:61-73. [PMID: 33219419 PMCID: PMC8881440 DOI: 10.1007/s10029-020-02336-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/02/2020] [Indexed: 01/09/2023]
Abstract
Purpose Definitive fascial closure is an essential treatment objective after open abdomen treatment and mitigates morbidity and mortality. There is a paucity of evidence on factors that promote or prevent definitive fascial closure. Methods A multi-center multivariable analysis of data from the Open Abdomen Route of the European Hernia Society included all cases between 1 May 2015 and 31 December 2019. Different treatment elements, i.e. the use of a visceral protective layer, negative-pressure wound therapy and dynamic closure techniques, as well as patient characteristics were included in the multivariable analysis. The study was registered in the International Clinical Trials Registry Platform via the German Registry for Clinical Trials (DRK00021719). Results Data were included from 630 patients from eleven surgical departments in six European countries. Indications for OAT were peritonitis (46%), abdominal compartment syndrome (20.5%), burst abdomen (11.3%), abdominal trauma (9%), and other conditions (13.2%). The overall definitive fascial closure rate was 57.5% in the intention-to-treat analysis and 71% in the per-protocol analysis. The multivariable analysis showed a positive correlation of negative-pressure wound therapy (odds ratio: 2.496, p < 0.001) and dynamic closure techniques (odds ratio: 2.687, p < 0.001) with fascial closure and a negative correlation of intra-abdominal contamination (odds ratio: 0.630, p = 0.029) and the number of surgical procedures before OAT (odds ratio: 0.740, p = 0.005) with DFC. Conclusion The clinical course and prognosis of open abdomen treatment can significantly be improved by the use of treatment elements such as negative-pressure wound therapy and dynamic closure techniques, which are associated with definitive fascial closure. Electronic supplementary material The online version of this article (10.1007/s10029-020-02336-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A G Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - R Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - M W von Websky
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital of Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - F Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - D Tartaglia
- Emergency Surgery Unit, Cisanello University Hospital, Via Paradisa 1, 56124, Pisa, Italy
| | - K Sörelius
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - R H Fortelny
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, 1160, Vienna, Austria.,Medical Faculty, Sigmund Freud University of Vienna, 1020, Vienna, Austria
| | - M Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, SE 751 85, Uppsala, Sweden
| | - T Monchal
- Department of General Surgery, Sainte Anne Military Hospital, 2 Boulevard Sainte-Anne, 83000, Toulon, France
| | - F Brennfleck
- Department of Surgery, Regensburg University Hospital, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - D Bulian
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - C Beltzer
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Hospital of Ulm, Oberer Eselsberg, Ulm, Germany
| | - C T Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - J F Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
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Schulz SA, Schaefer S, Richards DC, Karagiannidis C, Thomaidis P, Heiss MM, Bulian DR. The Need for Emergency Laparotomy With Open Abdomen Therapy in the Course of ECMO-A Retrospective Analysis of Course and Outcome. Front Surg 2020; 7:63. [PMID: 33102513 PMCID: PMC7498926 DOI: 10.3389/fsurg.2020.00063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/27/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Abdominal compartment syndrome (ACS) can occur in patients placed on extra corporeal membrane oxygenation (ECMO). This implies the necessity of decompressive laparotomy followed by an open abdomen (OA) to prevent complications such as multi-organ-failure or death. Methods: We searched for ECMO patients in our hospital database between July 2015 and April 2020 and selected those with an emergency laparotomy and OA therapy. Of these, we analyzed only patients who were treated with an OA after establishing the ECMO regarding patient-related parameters like sex, age, height, weight, and indications for ECMO as well as outcome parameters like complete fascial closure rate, mortality, length of stay in intensive care unit (ICU), length and kind of OA therapy, number of surgical procedures, dressing changes concerning negative pressure wound therapy (NPWT), and number of surgical revisions. Results: In eight out of 421 patients (1.9%), a laparostoma had to be created during ECMO support. For temporary closure, either NPWT, abdominal packing, or both were used. The median length of OA therapy was 17 days, and the median length of stay in ICU was 42 days in total. The median number of surgical procedures and NPWT dressing changes was seven. In three of the eight patients, a surgical revision was necessary. The total mortality rate was 50%. In 75%, the fascia could be closed. Two patients died before final closure. In all deceased patients, an abdominal packing was necessary during the course of treatment; in the survivors, only once. No enteroatmospheric fistula or abscesses occurred. Conclusions: ACS in patients placed on ECMO is a very rare condition with a considerable mortality rate but high secondary closure rate of the fascia. A necessary abdominal packing due to a severe bleeding seems to be a risk factor with a potentially fatal outcome.
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Affiliation(s)
- Sissy-A Schulz
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne, Germany
| | - Simone Schaefer
- Department of Pneumology and Critical Care Medicine, ARDS and ECMO Centre, Cologne-Merheim Medical Center (CMMC), University of Witten/Herdecke, Cologne, Germany
| | - Dana C Richards
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, ARDS and ECMO Centre, Cologne-Merheim Medical Center (CMMC), University of Witten/Herdecke, Cologne, Germany
| | - Panagiotis Thomaidis
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne, Germany
| | - Markus M Heiss
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne, Germany
| | - Dirk R Bulian
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne, Germany
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Coccolini F, Perrina D, Ceresoli M, Kluger Y, Kirkpatrick A, Sartelli M, Ansaloni L, Catena F. Open abdomen and age; results from IROA (International Register of Open Abdomen). Am J Surg 2020; 220:229-236. [DOI: 10.1016/j.amjsurg.2019.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/03/2019] [Accepted: 11/10/2019] [Indexed: 01/22/2023]
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Zosimas D, Lykoudis PM, Ivanov B, Hepworth C. Laparostomy and temporary abdominal closure outcomes in emergency non-trauma surgery and parameters affecting early definite primary fascial closure. MINERVA CHIR 2020; 75:419-425. [PMID: 32456399 DOI: 10.23736/s0026-4733.20.08320-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The open abdomen or laparostomy is a great advance of surgery based on the concept of damage control surgery. Aim of the study is to review the laparostomy outcomes of non-trauma emergency surgery patients in a district general hospital and identify parameters affecting early definite primary fascial closure. METHODS The records of all non-trauma emergency surgical patients who underwent laparostomy in a three-year period in a single institute were studied retrospectively. Outcomes included length of stay, morbidity, mortality, readmission rates, number of re-look operations, rate of definite primary fascial closure and time to closure. RESULTS Thirty-two patients were included. Morbidity was 84.4% and mortality rates were 21.9% (in-hospital), 18.8% (30-day) and 46.9% (overall). Median length of hospital stay was 22 days. Rate of primary fascial closure was 87.5% and median time to closure was two days. The number of relook operations was the only independent prognostic factor of definite early primary fascial closure, with higher rates of closure in patients with 1-2 relooks. CONCLUSIONS Although the open abdomen has been demonstrated to improve survival, the precise role in abdominal sepsis has not been elucidated. Current consensus does not support use of open abdomen routinely, however in selected situations it becomes unavoidable. Laparostomy is a valid option in non-trauma emergency surgery and can be managed safely in a district hospital. High closure rates can be achieved if one or two re-look operations are performed with an early attempt for closure.
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Affiliation(s)
- Dimitrios Zosimas
- Department of General Surgery, Queen's Hospital, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK -
| | - Panagis M Lykoudis
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Bogdan Ivanov
- Department of General Surgery, Queen's Hospital, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK
| | - Clive Hepworth
- Department of General Surgery, Queen's Hospital, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK
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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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Sartelli M, Pagani L, Iannazzo S, Moro ML, Viale P, Pan A, Ansaloni L, Coccolini F, D'Errico MM, Agreiter I, Amadio Nespola G, Barchiesi F, Benigni V, Binazzi R, Cappanera S, Chiodera A, Cola V, Corsi D, Cortese F, Crapis M, Cristini F, D'Arpino A, De Simone B, Di Bella S, Di Marzo F, Donati A, Elisei D, Fantoni M, Ferrari A, Foghetti D, Francisci D, Gattuso G, Giacometti A, Gesuelli GC, Marmorale C, Martini E, Meledandri M, Murri R, Padrini D, Palmieri D, Pauri P, Rebagliati C, Ricchizzi E, Sambri V, Schimizzi AM, Siquini W, Scoccia L, Scoppettuolo G, Sganga G, Storti N, Tavio M, Toccafondi G, Tumietto F, Viaggi B, Vivarelli M, Tranà C, Raso M, Labricciosa FM, Dhingra S, Catena F. A proposal for a comprehensive approach to infections across the surgical pathway. World J Emerg Surg 2020; 15:13. [PMID: 32070390 PMCID: PMC7029591 DOI: 10.1186/s13017-020-00295-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/10/2020] [Indexed: 02/08/2023] Open
Abstract
Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, ASUR Marche, Macerata, Italy.
| | - Leonardo Pagani
- Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
| | | | - Maria Luisa Moro
- Regional Agency for Health and Social Care, Emilia-Romagna Region-ASSR, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Clinics of Infectious Diseases, S. Orsola-Malpighi Hospital, "Alma Mater Studiorum"-University of Bologna, Bologna, Italy
| | - Angelo Pan
- Infectious Diseases, ASST di Cremona, Cremona, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- Emergency Surgery Unit, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - Marcello Mario D'Errico
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Iris Agreiter
- Bone Marrow Transplant Unit, Denis Burkitt, St. James's Hospital, Dublin, Ireland
| | | | - Francesco Barchiesi
- Infectious Diseases Unit, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Valeria Benigni
- Clinical Administration, Senigallia Hospital, ASUR Marche, Senigallia, AN, Italy
| | | | - Stefano Cappanera
- Infectious Diseases Clinic, Department of Medicine, "S. Maria" Hospital, Terni, University of Perugia, Perugia, Italy
| | | | - Valentina Cola
- Department of Hospital Pharmacy, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Daniela Corsi
- Department of Anesthesiology and Intensive Care Unit, Civitanova Marche Hospital, ASUR Marche, Civitanova Marche, MC, Italy
| | - Francesco Cortese
- Emergency Surgery and Trauma Care Unit, San Filippo Neri Hospital, Rome, Italy
| | - Massimo Crapis
- Infectious Diseases Unit, Pordenone Hospital, Pordenone, Friuli-Venezia Giulia, Italy
| | | | - Alessandro D'Arpino
- Hospital Pharmacy Unit, Santa Maria della Misericordia Hospital, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Belinda De Simone
- Operative Unit of General Surgery, Azienda USL IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Stefano Di Bella
- Infectious Diseases Department, Trieste University Hospital, Trieste, Italy
| | | | - Abele Donati
- Department of Anesthesiology and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Daniele Elisei
- Department of Anesthesiology and Intensive Care Unit, Macerata Hospital, ASUR Marche, Macerata, Italy
| | - Massimo Fantoni
- Department of Infectious Diseases, Fondazione Policlinico A. Gemelli IRCCS, Istituto di Clinica delle Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy
| | - Anna Ferrari
- Department of Critical Care Medicine Unit, San Filippo Neri Hospital, Rome, Italy
| | - Domitilla Foghetti
- Department of Surgery, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
| | | | - Gianni Gattuso
- Infectious Diseases Unit, Carlo Poma Hospital, Mantua, Italy
| | - Andrea Giacometti
- Infectious Diseases Clinic, Department of Biological Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | | | - Cristina Marmorale
- Department of Surgery, Marche Polytechnic University of Marche Region, Ancona, Italy
| | - Enrica Martini
- Hospital Hygiene Unit, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | | | - Rita Murri
- Department of Infectious Diseases, Fondazione Policlinico A. Gemelli IRCCS, Istituto di Clinica delle Malattie Infettive, Università Cattolica S. Cuore, Rome, Italy
| | - Daniela Padrini
- Clinical Administration Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
| | | | - Paola Pauri
- Unit of Microbiology and Virology, Senigallia Hospital, Senigallia, AN, Italy
| | | | - Enrico Ricchizzi
- Regional Agency for Health and Social Care, Emilia-Romagna Region-ASSR, Bologna, Italy
| | - Vittorio Sambri
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy.,Unit of Microbiology, The Great Romagna Area Hub Laboratory, Pievesestina, Cesena, Italy
| | | | - Walter Siquini
- Department of Surgery, Macerata Hospital, ASUR Marche, Macerata, Italy
| | - Loredana Scoccia
- Unit of Hospital Pharmacy, Macerata Hospital, ASUR Marche, Macerata, Italy
| | - Giancarlo Scoppettuolo
- Infectious Diseases Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gabriele Sganga
- Division of Emergency Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Marcello Tavio
- Infectious Diseases Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Giulio Toccafondi
- Clinical Risk Management and Patient Safety Center, Tuscany Region, Florence, Italy
| | - Fabio Tumietto
- Department of Medical and Surgical Sciences, Clinics of Infectious Diseases, S. Orsola-Malpighi Hospital, "Alma Mater Studiorum"-University of Bologna, Bologna, Italy
| | - Bruno Viaggi
- Department of Anesthesiology, Neuro Intensive Care Unit, Florence Careggi University Hospital, Florence, Italy
| | - Marco Vivarelli
- Unit of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Cristian Tranà
- Department of Surgery, Macerata Hospital, ASUR Marche, Macerata, Italy
| | | | | | - Sameer Dhingra
- Faculty of Medical Sciences, School of Pharmacy, The University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
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Dynamic closure techniques for treatment of an open abdomen: an update. Hernia 2020; 24:325-331. [PMID: 32020342 DOI: 10.1007/s10029-020-02130-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/27/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain as it is associated with a high incidence of complications and poor outcomes. The objective is to perform a systematic review on dynamic closure techniques for fascial closure during open abdomen management. METHODS An electronic database search was conducted involving 4 different databases (MEDLINE (PubMed), SCOPUS, WEB OF SCIENCE (WOS) and EMBASE). All studies that described dynamic closure techniques in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest. RESULTS Thirteen studies were included in the final synthesis. Overall methodological quality was low with a high number of retrospective observational studies and low number of patients. All included studies are observational cohort studies. No studies reported on the use of either Wittmann patch, dynamic retention sutures or ABRA system. Two studies reported on the ABRA system in combination with Negative Pressure Wound Therapy (NPWT), while 9 reported on mesh-mediated fascial traction (MMFT) combined with NPWT. Other types of fascial traction, either by dynamic suture lines or by a self-made silastic tube system, and NPWT were reported in 2 studies. Overall closure rates are 93.2% for the ABRA system + NPWT versus 72.0% for the mesh-mediated fascial traction + NPWT. CONCLUSION Careful selection and good management of OA patients will avoid prolonged treatment and facilitate early fascial closure. Future research should focus on comparison of different temporary dynamic closure techniques to evolve toward best treatment options, in terms of both fascial closure rates and long-term incisional hernia rates.
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Mitra LG, Saluja V, Dhingra U. Open Abdomen in a Critically Ill Patient. Indian J Crit Care Med 2020; 24:S193-S200. [PMID: 33354041 PMCID: PMC7724942 DOI: 10.5005/jp-journals-10071-23613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
One of the damage control strategies used to avoid or treat abdominal compartment syndrome is “open abdomen (OA),” where the facial edges and the skin is left open, exposing the abdominal viscera. Although it reduces the mortality both in trauma and non-trauma abdominal complications, it does create a significant challenge in an intensive care setting, as it has physiological consequences that need early recognition and prompt treatment both in the intensive care unit and in the operating room. The article aims to review literature on “open abdomen,” describe the challenges in such cases, and proposes a guideline for the intensivist in managing a patient with an OA. How to cite this article: Mitra LG, Saluja V, Dhingra U. Open Abdomen in a Critically Ill Patient. Indian J Crit Care Med 2020;24(Suppl 4):S193–S200.
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Affiliation(s)
- Lalita Gouri Mitra
- Department of Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vandana Saluja
- Department of Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Udit Dhingra
- Department of Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
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Asti E, Bonavina L. Commentary on "The effects of reoperation on surgical outcomes following surgery for major abdominal emergencies: A retrospective cohort study" (Int J Surg 2019;72:235-40). Int J Surg 2019; 73:99-100. [PMID: 31862254 DOI: 10.1016/j.ijsu.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Emanuele Asti
- University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Piazza Malan 1, 20097, San Donato Milanese (Milano), Italy
| | - Luigi Bonavina
- University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Piazza Malan 1, 20097, San Donato Milanese (Milano), Italy.
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Padar M, Reintam Blaser A, Talving P, Lipping E, Starkopf J. Abdominal Compartment Syndrome: Improving Outcomes With A Multidisciplinary Approach - A Narrative Review. J Multidiscip Healthc 2019; 12:1061-1074. [PMID: 31908470 PMCID: PMC6927564 DOI: 10.2147/jmdh.s205608] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 10/24/2019] [Indexed: 12/11/2022] Open
Abstract
Abdominal compartment syndrome (ACS) refers to a severe increase in intra-abdominal pressure associated with single or multiorgan failure. ACS with specific pathophysiological processes and detrimental outcomes may occur in a variety of clinical conditions. Patients with ACS are predominantly managed in critical care settings, however, a wide range of multidisciplinary interventions are frequently required from medical, surgical, radiological and nursing specialties. The medical management, aiming to prevent the progression of intra-abdominal hypertension to ACS, is extensively reviewed. Timing and techniques of surgical decompression techniques, as well as management of open abdomen, are outlined. In summary, the current narrative review provides data on history, definitions, epidemiology and pathophysiology of the syndrome and highlights the importance of multidisciplinary approach in the management of ACS in adults.
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Affiliation(s)
- Martin Padar
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.,Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.,Department of Intensive Care, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Peep Talving
- Department of Surgery, University of Tartu, Tartu, Estonia.,Management Board, North Estonia Medical Centre, Tallinn, Estonia
| | - Edgar Lipping
- Department of Surgery, Division of Acute Care Surgery, North Estonia Medical Centre, Tallinn, Estonia
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.,Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
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39
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Jobin SP, Maitra S, Baidya DK, Subramaniam R, Prasad G, Seenu V. Role of serial lactate measurement to predict 28-day mortality in patients undergoing emergency laparotomy for perforation peritonitis: prospective observational study. J Intensive Care 2019; 7:58. [PMID: 31890220 PMCID: PMC6907168 DOI: 10.1186/s40560-019-0418-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/03/2019] [Indexed: 12/04/2022] Open
Abstract
Background Serial lactate measurement is found to predict mortality in septic shock. Majority of patients with perforation peritonitis for emergency laparotomy are in sepsis and mortality rate is substantial. However, lactate dynamics has not been studied in this patient population. Methods After institutional ethics clearance and informed written consent, 113 patients with suspected or proven perforation peritonitis presenting for emergency laparotomy were recruited in this prospective observational trial. Baseline Mannheim peritonitis index (MPI), SOFA and APACHE II score were calculated. Lactate values were obtained at baseline, immediate and 24-h postoperative period. Primary outcome was 28-day mortality. Results Mortality was 15.04% at 28 days. Age, SOFA, qSOFA, APACHE, preoperative lactate, MPI and site of perforation were significantly different between survivors and non-survivors. Arterial lactate values at preoperative (cut off 2.75 mmol/L), immediate postoperative (cut off 2.8 mmol/L) and 24 h-postoperative period (cut off 2.45 mmol/L) independently predicted mortality at day 28. Combination of MPI and 24-h lactate value was best predictor of mortality with AUC 0.99. Conclusion Preoperative, immediate postoperative and 24-h postoperative lactate value independently predict 28-day mortality in perforation peritonitis patients undergoing emergency laparotomy. Combination of MPI and 24-h lactate value is the most accurate predictor of mortality. Trial registration Clinical Trial Registry of India - CTRI/2018/01/011103
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Affiliation(s)
- S P Jobin
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No 5011, 5th Floor, Teaching Block, New Delhi, 110029 India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No 5011, 5th Floor, Teaching Block, New Delhi, 110029 India
| | - Dalim Kumar Baidya
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No 5011, 5th Floor, Teaching Block, New Delhi, 110029 India
| | - Rajeshwari Subramaniam
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No 5011, 5th Floor, Teaching Block, New Delhi, 110029 India
| | - Ganga Prasad
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No 5011, 5th Floor, Teaching Block, New Delhi, 110029 India
| | - Vathulru Seenu
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Room No 5011, 5th Floor, Teaching Block, New Delhi, 110029 India
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Cicuttin E, Ansaloni L, Ceresoli M, Fugazzola P, Tomasoni M, Sartelli M, Catena F, Coccolini F. Trends in open abdomen management in Italy: a subgroup analysis from the IROA project. Updates Surg 2019; 72:171-177. [PMID: 31621034 DOI: 10.1007/s13304-019-00687-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
Use of open abdomen (OA) progressively acquired increasing importance with the diffusion of the damage control management of critical patients. The purpose of the present study is to identify the state of the art about the use of OA in Italy, focusing on techniques, critical issues and clinical outcomes. A prospective analysis of adult patients enrolled in the IROA, limited to the Italian participating centres was performed. 375 patients were enrolled. Mean age was 64 ± 16 years old, 56% of the patients were male, mean BMI was 26.9 ± 5.2. Main indications for using OA were secondary peritonitis (32.5%), post-operative peritonitis (22.9%) and trauma (11.7%). Main OA techniques used were commercial negative pressure wound therapy (49.6%) and Bogotà bag (27.7%). Definitive closure of the abdomen was reached in 82.4% of patients after 6 ± 7 days of OA. The primary fascia closure rate was 84.7%. Overall mortality was 29.1%. The complication rate was 50.8%, with an enteroatmospheric fistula incidence: 7.5%. A univariate analysis performed on complication type found the duration of OA treatment (p = 0.024) to be statistically significant. Univariate analysis on mortality risk identified as significant age, duration of OA (in days) and pancreatitis as indication; multivariate analysis confirmed age (p < 0.001) and pancreatitis (p = 0.002) as statistically significant. A large variety of behaviours towards the patient requiring OA exists. A strong acceptance of common, recognized and evidence-based guidelines is essential, to obtain more uniformity in patient management and coherence of collected data, thus leading to improvement in outcomes and reduction of costs.
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Affiliation(s)
- Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521, Cesena, Italy.,Dipartimento Scienze Clinico Chirurgiche, Diagnostiche e Pediatriche, Università degli Studi di Pavia, Pavia, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521, Cesena, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Paola Fugazzola
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521, Cesena, Italy
| | - Matteo Tomasoni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521, Cesena, Italy
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521, Cesena, Italy.
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Ceresoli M, Salvetti F, Kluger Y, Braga M, Viganò J, Fugazzola P, Sartelli M, Ansaloni L, Catena F, Coccolini F. Open Abdomen in Obese Patients: Pay Attention! New Evidences from IROA, the International Register of Open Abdomen. World J Surg 2019; 44:53-62. [PMID: 31602518 DOI: 10.1007/s00268-019-05209-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Open abdomen is the cornerstone of damage control strategies in acute care and trauma surgery. The role of BMI has not been well investigated. The aim of the study was to assess the role of BMI in determining outcomes after open abdomen. METHODS This is an analysis of patients recorded into the International Register of Open Abdomen; patients were classified in two groups according to BMI using a cutoff of 30 kg/m2. The primary outcome was in-hospital mortality; secondary outcomes were primary fascia closure rate, length of treatment, complication rate, entero-atmospheric fistula rate and length of ICU stay. RESULTS A total of 591 patients were enrolled from 57 centers, and obese patients were 127 (21.5%). There was no difference in mortality between the two groups; complications developed during the open treatment were higher in obese patients (63.8% vs. 53.4%, p = 0.038) while post-closure complications rate was similar. Obese patients had a significantly longer duration of the open treatment (9.1 ± 11.5 days vs. 6.3 ± 7.5 days; p = 0,002) and lower primary fascia closure rate (75.5% vs. 89.5%; p < 0,001). No differences in fistula rate were found. There was a linear correlation between the duration of open abdomen and the BMI (Pearson's linear correlation coefficient = 0,201; p < 0,001). CONCLUSIONS Open abdomen in obese patients seems to be safe as in non-obese patients with similar mortality; however, in obese patients the length of open abdomen is significantly higher with higher complication rate, longer ICU length of stay and lower primary fascia closure rate. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, Identifier: NCT02382770.
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Affiliation(s)
- Marco Ceresoli
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy. .,General and Emergency Surgery Department, ASST Monza, Via Pergolesi 33, 20900, Monza, Italy.
| | - Francesco Salvetti
- General and Emergency Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy.,Internal Medicine and Medical Therapy Department, School of Medicine and Surgery, University of Pavia, Pavia, Italy
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Marco Braga
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy.,General and Emergency Surgery Department, ASST Monza, Via Pergolesi 33, 20900, Monza, Italy
| | - Jacopo Viganò
- Internal Medicine and Medical Therapy Department, School of Medicine and Surgery, University of Pavia, Pavia, Italy.,General Surgery I, Surgery Department, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Paola Fugazzola
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
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Abstract
Damage-control surgery (abdominopelvic packing followed by a period of medical stabilization in the intensive care unit) is a life-saving intervention usually reserved for critically injured patients who may not survive an attempt to achieve hemostasis and complete repair of the damage in the operating room. Most obstetricians have little or no experience in this area, although the use of damage-control surgery in selected cases may be life-saving. This approach should be considered when arterial bleeding has been controlled and persistent bleeding is deemed to be secondary to coagulopathy that is refractory to blood product replacement, particularly in the presence of hypothermia, acidosis, and vasopressor requirement. A prototypical (albeit hypothetical) case is described here in which damage-control surgery is indicated.
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Leppäniemi A, Tolonen M, Tarasconi A, Segovia-Lohse H, Gamberini E, Kirkpatrick AW, Ball CG, Parry N, Sartelli M, Wolbrink D, van Goor H, Baiocchi G, Ansaloni L, Biffl W, Coccolini F, Di Saverio S, Kluger Y, Moore E, Catena F. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg 2019; 14:27. [PMID: 31210778 PMCID: PMC6567462 DOI: 10.1186/s13017-019-0247-0] [Citation(s) in RCA: 316] [Impact Index Per Article: 63.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/27/2019] [Indexed: 02/08/2023] Open
Abstract
Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.
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Affiliation(s)
- Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital Meilahti, Haartmaninkatu 4, FI-00029 Helsinki,, Finland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital Meilahti, Haartmaninkatu 4, FI-00029 Helsinki,, Finland
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | | | - Emiliano Gamberini
- Anesthesia and Intensive Care Medicine, Maurizio Bufalini Hospital, Cesena, Italy
| | | | - Chad G. Ball
- Foothills Medical Centre & the University of Calgary, Calgary, AB Canada
| | - Neil Parry
- London Health Sciences Centre, London, ON Canada
| | | | - Daan Wolbrink
- Radboud University Nijmegen, Nijmegen, The Netherlands
| | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps memorial Hospital, La Jolla, CA USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest Moore
- Trauma Surgery, Denver Health Medical Center, Denver, CO USA
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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Schmoch T, Al-Saeedi M, Hecker A, Richter DC, Brenner T, Hackert T, Weigand MA. Evidenzbasierte, interdisziplinäre Behandlung der abdominellen Sepsis. Chirurg 2019; 90:363-378. [DOI: 10.1007/s00104-019-0795-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Outcomes of open abdomen versus primary closure following emergent laparotomy for suspected secondary peritonitis: A propensity-matched analysis. J Trauma Acute Care Surg 2019; 87:623-629. [DOI: 10.1097/ta.0000000000002345] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hypertonic saline resuscitation after emergent laparotomy and temporary abdominal closure. J Trauma Acute Care Surg 2019; 84:350-357. [PMID: 29140948 DOI: 10.1097/ta.0000000000001730] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Our objective was to establish the safety of 3% hypertonic saline (HTS) resuscitation for trauma and acute care surgery patients undergoing emergent laparotomy and temporary abdominal closure (TAC) with the hypothesis that HTS administration would be associated with hyperosmolar hypercholoremic acidosis, lower resuscitation volumes, and higher fascial closure rates, without adversely affecting renal function. METHODS We performed a retrospective cohort analysis of 189 trauma and acute care surgery patients who underwent emergent laparotomy and TAC, comparing patients with normal baseline renal function who received 3% HTS at 30 mL/h (n = 36) to patients with standard resuscitation (n = 153) by baseline characteristics, resuscitation parameters, and outcomes including primary fascial closure and Kidney Disease: Improving Global Outcomes stages of acute kidney injury. RESULTS The HTS and standard resuscitation groups had similar baseline illness severity and organ dysfunction, though HTS patients had lower serum creatinine at initial laparotomy (1.2 mg/dL vs. 1.4 mg/dL; p = 0.078). Forty-eight hours after TAC, HTS patients had significantly higher serum sodium (145.8 mEq/L vs. 142.2 mEq/L, p < 0.001), chloride (111.8 mEq/L vs. 106.6 mEq/L, p < 0.001), and osmolarity (305.8 mOsm/kg vs. 299.4 mOsm/kg; p = 0.006), and significantly lower arterial pH (7.34 vs. 7.38; p = 0.011). The HTS patients had lower intravenous fluid (IVF) volumes within 48 hours of TAC (8.5 L vs. 11.8 L; p = 0.004). Serum creatinine, urine output, and kidney injury were similar between groups. Fascial closure was achieved for 92% of all HTS patients and 77% of all standard resuscitation patients (p = 0.063). Considering all 189 patients, higher IVF resuscitation volumes within 48 hours of TAC were associated with decreased odds of fascial closure (odds ratio, 0.90; 95% confidence interval, 0.83-0.97; p = 0.003). CONCLUSION Hypertonic saline resuscitation was associated with the development of a hypernatremic, hyperchloremic, hyperosmolar acidosis, and lower total IVF resuscitation volumes, without adversely affecting renal function. These findings may not be generalizable to patients with baseline renal dysfunction and susceptibility to hyperchloremic acidosis-induced kidney injury. LEVEL OF EVIDENCE Prognostic study, level II.
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Käser SA, Brosi P, Clavien PA, Vonlanthen R. Blurring the boundary between open abdomen treatment and ventral hernia repair. Langenbecks Arch Surg 2019; 404:489-494. [PMID: 30729317 DOI: 10.1007/s00423-019-01757-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 01/23/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Therapeutic approaches for septic open abdomen treatment remain a major challenge with many uncertainties. The most convincing method is vacuum-assisted wound closure with mesh-mediated fascia traction with a protective plastic sheet placed on the viscera. As this plastic sheet and the mesh must be removed before final fascial closure, such a technique only allows temporary abdominal closure. This retrospective study analyzes the results of a modification of this technique allowing final abdominal closure using an anti-adhesive permeable polyvinylidene fluoride (PVDF) mesh. METHODS The outcome of all consecutive patients with septic open abdomen treatment at one academic surgical department from January 2013 to June 2015 was retrospectively analyzed. RESULTS Retrospectively, 57 severely ill consecutive patients with septic open abdomen treatment with a 30-day mortality of 26% and a 2-year mortality of 51% were included in the study. In 26 patients, no mesh was implanted; in 31 patients, mesh implantation was done at median third-look laparotomy, median 5 days postoperative. Re-laparotomies after mesh implantation (median n = 2) revealed anastomotic leakage in 16% but no new bowel fistula. In 40% of those patients who had mesh implantation, fascia closure was not achieved and the mesh was left in place in a bridging position avoiding planned ventral hernia. CONCLUSION The application of an anti-adhesive PVDF mesh for fascia traction in vacuum-assisted wound closure of septic open abdomen is novel, versatile, and seems to be safe. It offers the highly relevant possibility for provisional and final abdominal closure.
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Affiliation(s)
- Samuel A Käser
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland.
| | - P Brosi
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland
| | - P A Clavien
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland
| | - R Vonlanthen
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland
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Richman A, Burlew CC. Lessons from Trauma Care: Abdominal Compartment Syndrome and Damage Control Laparotomy in the Patient with Gastrointestinal Disease. J Gastrointest Surg 2019; 23:417-424. [PMID: 30276590 DOI: 10.1007/s11605-018-3988-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/20/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Aaron Richman
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA
| | - Clay Cothren Burlew
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA.
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Hecker A, Reichert M, Reuß CJ, Schmoch T, Riedel JG, Schneck E, Padberg W, Weigand MA, Hecker M. Intra-abdominal sepsis: new definitions and current clinical standards. Langenbecks Arch Surg 2019; 404:257-271. [DOI: 10.1007/s00423-019-01752-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/08/2019] [Indexed: 12/22/2022]
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Maurice Lalisang T, Mazni Y, Jeo W, Marbun VG. Factor influencing outcome of source control in the management of complicated intra-abdominal infection in Cipto Mangunkusumo University Hospital. FORMOSAN JOURNAL OF SURGERY 2019. [DOI: 10.4103/fjs.fjs_122_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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