The open abdomen: aetiology, classification and current management strategies

Manuka Honey: Feasibility and Safety in Postoperative Neurosurgical Wound Care

OBJECTIVE

To date, no reports have been published on active Leptospermum manuka honey (ALH) feasibility as a postoperative topical wound supplement in neurosurgical patients. The objective of the study is to present the authors' initial experience with using ALH in postoperative neurosurgical patients.

METHODS

A single-surgeon retrospective case series review of cranial and spinal operations between 2018 and 2020 was performed in patients with nonhealing wounds or wounds deemed "at risk" as defined by grade 1 Sandy surgical wound dehiscence grading classification. An ALH gel or ointment was applied to these incisions once a day for 2 to 4 weeks. Patients were followed up in the clinic every 2 weeks until incisions had healed.

RESULTS

Twenty-five postoperative patients (12 cranial, 13 spinal) were identified to be at high risk of operative debridement. All 25 patients were prescribed a topical application of ALH, which was easily adopted without patient-related adverse events. Seven (four cranial, three spinal) patients required operative debridement and treatment with long-term antibiotic therapy.

CONCLUSIONS

In this small case series of neurosurgical patients who were at risk of poor wound healing, the application of medical-grade ALH was well tolerated without patient-reported adverse events. The ALH may have prevented the need for operative debridement in the majority of patients. Further prospective studies are necessary to establish its efficacy in wound healing in the neurosurgical population.

EWMA Document: Negative Pressure Wound Therapy

1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.¹ NPWT has been described as a effective treatment for wounds of many different aetiologies^2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,^4-6 dehisced sternal wounds following cardiac surgery^7,8 and as a valuable agent in complex non-healing wounds.^9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.¹¹ While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.^12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents^15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.

Negative Pressure Wound Therapy with Instillation in the Septic Open Abdomen Utilizing a Modified Negative Pressure Therapy System

BACKGROUND

Various treatment modalities are utilized to treat the open abdomen. The use of negative pressure wound therapy(NPWT)has been a great advancement and has become the preferred modality for temporary abdominal closure technique (TAC). Programmed instillation of the abdominal cavity with saline solution in conjunction with a commercial negative pressure system showed positive results in the management of severe abdominal sepsis in patients that were treated with an open abdomen. Severe abdominal sepsis continues to be an oftendifficult clinical problem for the general surgeon. The use of an open abdomen technique in this setting and the ideal TAC method continue to be debated. The failure to understand the biomechanical features/limitations of negative pressure devices are often contributing factors associated with therapeutic failures reported in the literature.

OBJECTIVES

To describe the underlying principles behind negative pressure wound therapy with instillation in the context of abdominal sepsis, as well as its optimal usage in these conditions.

METHODS

A systematic review and two retrospective cohort studies, both published and unpublished performed by some of the authors were included to provide a basis form comparison between NPWT and NPWT-I outcomes in managing abdominal sepsis.

CONCLUSION

Our findings suggest that this technique appears to reduce morbidity, mortality, and hospital and critical care length of stay. This communication is intended to help inform general surgeons that manage complex abdominal infections on how to optimally apply this technique.

Amended Classification of the Open Abdomen

BACKGROUND

In 2009, a classification system for the open abdomen was introduced. The aim of such a classification is to aid the (1) description of the patient's clinical course; (2) standardization of clinical guidelines for guiding open abdomen management; and (3) facilitation of comparisons between studies and heterogeneous patient populations, thus serving as an aid in clinical research.

METHODS

As part of the revision of the definitions and clinical guidelines performed by the World Society of the Abdominal Compartment Syndrome, this 2009 classification system was amended following a review of experiences in teaching and research and published as part of updated consensus statements and clinical practice guidelines in 2013. Among 29 articles citing the 2009 classification system, nine were cohort studies. They were reviewed as part of the classification revision process. A total of 542 patients (mean: 60, range: 9-160) had been classified. Two problems with the previous classification system were identified: the definition of enteroatmospheric fistulae, and that an enteroatmospheric fistula was graded less severe than a frozen abdomen.

RESULTS

The following amended classification was proposed: Grade 1, without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization), subdivided as follows: 1A, clean; 1B, contaminated; and 1C, with enteric leak. An enteric leak controlled by closure, exteriorization into a stoma, or a permanent enterocutaneous fistula is considered clean. Grade 2, developing fixation, subdivided as follows: 2A, clean; 2B, contaminated; and 2C, with enteric leak. Grade 3, frozen abdomen, subdivided as follows: 3A clean and 3B contaminated. Grade 4, an established enteroatmospheric fistula, is defined as a permanent enteric leak into the open abdomen, associated with granulation tissue.

CONCLUSIONS

The authors believe that, with these changes, the requirements on a functional and dynamic classification system, useful in both research and training, will be fulfilled. We encourage future investigators to apply the system and report on its merits and constraints.

Comparative study of the microvascular blood flow in the intestinal wall, wound contraction and fluid evacuation during negative pressure wound therapy in laparostomy using the V.A.C. abdominal dressing and the ABThera open abdomen negative pressure therapy system

This study aimed to compare the changes in microvascular blood flow in the small intestinal wall, wound contraction and fluid evacuation, using the established V.A.C. abdominal dressing (VAC dressing) and a new abdominal dressing, the ABThera open abdomen negative pressure therapy system (ABThera dressing), in negative pressure wound therapy (NPWT). Midline incisions were made in 12 pigs that were subjected to treatment with NPWT using the VAC or ABThera dressing. The microvascular blood flow in the intestinal wall was measured before and after the application of topical negative pressures of −50, −75 and −125mmHg using laser Doppler velocimetry. Wound contraction and fluid evacuation were also measured. Baseline blood flow was defined as 100% in all settings. The blood flow was significantly reduced to 64·6±6·7% (P <0·05) after the application of −50mmHg using the VAC dressing, and to 65·3±9·6% (P <0·05) after the application of −50mmHg using the ABThera dressing. The blood flow was significantly reduced to 39·6±6·7% (P <0·05) after the application of −125mmHg using VAC and to 40·5±6·2% (P <0·05) after the application of −125mmHg using ABThera. No significant difference in reduction in blood flow could be observed between the two groups. The ABThera system afforded significantly better fluid evacuation from the wound, better drainage of the abdomen and better wound contraction than the VAC dressing.

Negative-pressure wound therapy for critically ill adults with open abdominal wounds: a systematic review

BACKGROUND

Open abdominal management with negative-pressure wound therapy (NPWT) is increasingly used for critically ill trauma and surgery patients. We sought to determine the comparative efficacy and safety of NPWT versus alternate temporary abdominal closure (TAC) techniques in critically ill adults with open abdominal wounds.

METHODS

We conducted a systematic review of published and unpublished comparative studies. We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, the Cochrane Database, the Center for Reviews and Dissemination, clinical trials registries, and bibliographies of included articles. Two authors independently abstracted data on study design, methodological quality, patient characteristics, and outcomes.

RESULTS

Among 2,715 citations identified, 2 randomized controlled trials and 9 cohort studies (3 prospective/6 retrospective) met inclusion criteria. Methodological quality of included prospective studies was moderate. One randomized controlled trial observed an improved fascial closure rate (relative risk [RR], 2.4; 95% confidence interval [CI], 1.0-5.3) and length of hospital stay after addition of retention sutured sequential fascial closure to the Kinetic Concepts Inc. (KCI) vacuum-assisted closure (VAC). Another reported a trend toward enhanced fascial closure using the KCI VAC versus Barker's vacuum pack (RR, 2.6; 95% CI, 0.95-7.1). A prospective cohort study observed improved mortality (RR, 0.48; 95% CI, 0.25-0.92) and fascial closure (RR, 1.5; 95% CI, 1.1-2.0) for patients who received the ABThera versus Barker's vacuum pack. Another noted a reduced arterial lactate, intra-abdominal pressure, and hospital stay for those fitted with the KCI VAC versus Bogotá bag. Most included retrospective studies exhibited low methodological quality and reported no mortality or fascial closure benefit for NPWT.

CONCLUSION

Limited prospective comparative data suggests that NPWT versus alternate TAC techniques may be linked with improved outcomes. However, the clinical heterogeneity and quality of available studies preclude definitive conclusions regarding the preferential use of NPWT over alternate TAC techniques.

LEVEL OF EVIDENCE

Systematic review, level III.

Clinical effectiveness of dermal substitution in burns by topical negative pressure: a multicenter randomized controlled trial

Previous research has shown clinical effectiveness of dermal substitution; however, in burn wounds, only limited effect has been shown. A problem in burn wounds is the reduced take of the autograft, when the substitute and graft are applied in one procedure. Recently, application of topical negative pressure (TNP) was shown to improve graft take. The aim of this study was to investigate if application of a dermal substitute in combination with TNP improves scar quality after burns. In a four-armed multicenter randomized controlled trial, a split-skin graft with or without a dermal substitute and with or without TNP was compared in patients with deep dermal or full-thickness burns requiring skin transplantation. Graft take and rate of wound epithelialization were evaluated. Three and 12 months postoperatively, scar parameters were measured. The results of 86 patients showed that graft take and epithelialization did not reveal significant differences. Significantly fewer wounds in the TNP group showed postoperative contamination, compared to other groups. Highest elasticity was measured in scars treated with the substitute and TNP, which was significantly better compared to scars treated with the substitute alone. Concluding, this randomized controlled trial shows the effectiveness of dermal substitution combined with TNP in burns, based on extensive wound and scar measurements.

Blood flow response in small intestinal loops at different depths during negative pressure wound therapy of the open abdomen

High closure rates of the open abdomen have been reported following negative pressure wound therapy (NPWT). However, the method has occasionally been associated with increased development of intestinal fistulae. We have previously shown that the application of NPWT to the open abdomen causes a decrease in microvascular blood flow in the small intestinal loop and the omentum adjacent to the visceral protective layer of the dressing. In this study we investigate whether the negative pressure affects only small intestinal loops lying directly below the dressing or if it also affects small intestinal loops that are not in direct contact with the dressing. Six pigs underwent midline incision and application of NPWT to the open abdomen. The microvascular blood flow was measured in four intestinal loops at different depths from the visceral protective layer, at two different locations: beneath the dressing and at the anterior abdominal wall, before and after the application of NPWT of -50, -70, -100, -120, -150 and -170 mmHg, using laser Doppler velocimetry. Negative pressures between -50 and -170 mmHg caused a significant decrease in the microvascular blood flow in the intestinal loops in direct contact with the visceral protective layer. A slight, but significant, decrease in blood flow was also seen in the intestinal loops lying beneath these loops. The decrease in microvascular blood flow increased with the amount of negative pressure applied. No difference in blood flow was seen in the intestinal loops lying deeper in the abdominal cavity. A decrease in blood flow was seen in the upper two intestinal loops located apically and anteriorly, but not in the lower two, indicating that this is a local effect and that pressure decreases with distance from the source. A long-term decrease in blood flow in the intestinal wall may induce ischaemia and secondary necrosis in the intestinal wall, which could promote the development of intestinal fistulae. We believe that NPWT of the open abdomen is a very effective treatment, but that it could be improved by gaining more knowledge on the mechanisms involved.

Early enteral nutrition improves outcomes of open abdomen in gastrointestinal fistula patients complicated with severe sepsis

BACKGROUND

Although nutrition therapy is favorably considered as an assistant therapeutic measure in critical illness, little data evaluate its role in gastrointestinal fistula patients with severe sepsis after an open abdomen. The purpose of this study is to evaluate the role of early nutrition therapy in that population.

METHODS

This is a retrospective review of patients who underwent open abdomen management for gastrointestinal fistula and severe sepsis from January 2001 to June 2009. Nutrition therapy, fistula, abdominal closure, and demographics were noted. Succus entericus reinfusion (SER) was performed for high-output volume or multiple fistulae. Patients were divided into two groups based on whether enteral nutrition (EN) was initiated within 14 days after admission. Delivery route of nutrients, mortality, complications, and time to abdominal closure were compared among groups.

RESULTS

Eighty-two patients were included. Fifty-six (68.3%) patients survived to discharge. Forty-one (50%) patients received SER. EN was initiated within 14 days in 36 patients, with a mean initiation time at 8.3 ± 3.4 days; 46 patients did not start any EN within 14 days (29.9 ± 20.9 days). The mean age, BMI, APACHE II score, and fistula characteristics were similar between groups. The abdominal closure was accomplished more rapidly in patients fed within 14 days (142.8 vs 184.5 days, P = .017), with decreased mortality (11.1% vs 47.8%, P < .001).

CONCLUSIONS

Nutrition therapy plays an important role in the management of gastrointestinal fistula with severe sepsis. Early EN could be successfully delivered for that population, with improved mortality risk.

The effect of negative wound pressure therapy on haemodynamics in a laparostomy wound model

We have recently shown that negative pressure wound therapy (NPWT) induces a decrease in microvascular blood flow in the small intestinal loop close to the dressing. The effect of NPWT is thus thought to be local. In this study, we investigate whether the application of NPWT in laparostomy affects the haemodynamics. Midline incisions were made in six pigs followed by NPWT at -120 mmHg for 20 minutes. The cardiac output, mean systemic arterial pressure, mean pulmonary artery pressu re, central venous pressure, left atrial pressure and superior mesenteric artery blood flow were recorded. The blood flow in a small branch of the superior mesenteric artery was then recorded under NPWT between -50 and -175 mmHg. Cardiac output was not affected by NPWT [P = not significant (n.s.)]. Neither the mean arterial pressure nor the mean pulmonary artery pressure was affected by NPWT (P = n.s.). Negative pressures of -50, -75, -100 and -125 mmHg did not alter the blood flow in the small branch of the superior mesenteric artery (P = n.s.). After application of -150 mmHg, a significant decrease in blood flow was seen (P < 0·01), while the application of -175 mmHg resulted in only a slight decrease in blood flow (P = n.s.). The effect of NPWT in laparotomy seems to be local and to have no influence on central haemodynamics or the blood flow to the superior mesenteric artery.

Pressure transduction and fluid evacuation during conventional negative pressure wound therapy of the open abdomen and NPWT using a protective disc over the intestines

BACKGROUND

Negative pressure wound therapy (NPWT) has gained acceptance among surgeons, for the treatment of open abdomen, since very high closure rates have been reported with this method, compared to other kinds of wound management for the open abdomen. However, the method has occasionally been associated with increased development of fistulae. We have previously shown that NPWT induces ischemia in the underlying small intestines close to the vacuum source, and that a protective disc placed between the intestines and the vacuum source prevents the induction of ischemia. In this study we compare pressure transduction and fluid evacuation of the open abdomen with conventional NPWT and NPWT with a protective disc.

METHODS

Six pigs underwent midline incision and the application of conventional NPWT and NPWT with a protective disc between the intestines and the vacuum source. The pressure transduction was measured centrally beneath the dressing, and at the anterior abdominal wall, before and after the application of topical negative pressures of -50, -70 and -120 mmHg. The drainage of fluid from the abdomen was measured, with and without the protective disc.

RESULTS

Abdominal drainage was significantly better (p < 0. 001) using NPWT with the protective disc at -120 mmHg (439 ± 25 ml vs. 239 ± 31 ml), at -70 mmHg (341 ± 27 ml vs. 166 ± 9 ml) and at -50 mmHg (350 ± 50 ml vs. 151 ± 21 ml) than with conventional NPWT. The pressure transduction was more even at all pressure levels using NPWT with the protective disc than with conventional NPWT.

CONCLUSIONS

The drainage of the open abdomen was significantly more effective when using NWPT with the protective disc than with conventional NWPT. This is believed to be due to the more even and effective pressure transduction in the open abdomen using a protective disc in combination with NPWT.

[Open abdomen 2009. A national survey of open abdomen treatment in Germany]

BACKGROUND

Open abdomen (OA) treatment has been established worldwide. This survey examines the current status of OA treatment in Germany.

MATERIAL AND METHODS

A national survey was conducted between October 2008 and September 2009 by questionnaires sent to 1,219 surgical departments. Data were evaluated descriptively.

RESULTS

The response rate was 38% overall and 69% for university departments. Open abdomen treatment is used by 94% of all respondents. Most commonly used are staged abdominal lavage (87%), a commercial abdominal dressing system (82%), planned ventral hernia (69%), and other intra-abdominal dressings (e.g. vacuum pack 15%, Bogotá bag 5%). Nearly half of the respondents (46%) indicated a modification of their strategy towards vacuum techniques during the last 5 years.

CONCLUSIONS

Open abdomen procedures are widely used in German surgical departments. This survey indicates a shift of treatment strategies towards vacuum techniques but even though predominant, the effectiveness and safety of these techniques must still be confirmed by prospective controlled trials. This survey helps to identify relevant clinical questions and enables focused trial networking.

Microvascular blood flow response in the intestinal wall and the omentum during negative wound pressure therapy of the open abdomen

PURPOSE

Higher closure rates of the open abdomen have been reported with negative pressure wound therapy (NPWT) compared with other wound therapy techniques. However, the method has occasionally been associated with increased development of intestinal fistulae. The present study measures microvascular blood flow in the intestinal wall and the omentum before and during NPWT.

METHODS

Six pigs underwent midline incision and application of NPWT to the open abdomen. The microvascular blood flow in the underlying intestinal loop wall and the omentum was recorded before and after the application of NPWT of -50, -70, -100, -120, -150, and -170 mmHg respectively, using laser Doppler velocimetry.

RESULTS

A significant decrease in microvascular blood flow was seen in the intestinal wall during application of all negative pressures levels. The blood flow was 2.7 (±0.2) Perfusion Units (PU) before and 2.0 (±0.2) PU (*p < 0.05) after application of -50 mmHg, and 3.6 (±0.6) PU before and 1.5 (±0.2) PU (**p < 0.01) after application of -170 mmHg.

CONCLUSIONS

In the present study, we show that negative pressures between -50 and -170 mmHg induce a significant decrease in the microvascular blood flow in the intestinal wall. The decrease in blood flow increased with the amount of negative pressure applied. One can only speculate that a longstanding decreased blood flow in the intestinal wall may induce ischemia and secondary necrosis in the intestinal wall, which, theoretically, could promote the development of intestinal fistulae. We believe that NPWT of the open abdomen is a very effective treatment but could probably be improved.

Comparative study of the microvascular blood flow in the intestinal wall during conventional negative pressure wound therapy and negative pressure wound therapy using paraffin gauze over the intestines in laparostomy

Higher closure rates of the open abdomen have been reported with negative pressure wound therapy (NPWT) than with other kinds of wound management. We have recently shown that NPWT decreases the blood flow in the intestinal wall, and that the blood flow could be restored by inserting a protective disc over the intestines. The aim of the present study was to investigate whether layers of Jelonet™ (Smith & Nephew) dressing (paraffin tulle gras dressing made from open weave gauze) over the intestines could protect the intestines from hypoperfusion. Midline incisions were made in ten pigs and were subjected to treatment with NPWT with and without four layers of Jelonet over the intestines. The microvascular blood flow was measured in the intestinal wall before and after the application of topical negative pressures of -50, -70 and -120 mmHg, using laser Doppler velocimetry. Baseline blood flow was defined as 100% in all settings. The blood flow was significantly reduced, to 61 ± 7% (P < 0·001), after the application of -50 mmHg using conventional NPWT, and to 62 ± 7% (P < 0·001) after the application of -50 mmHg with Jelonet dressings between the dressing and the intestines. The blood flow was significantly reduced, to 38 ± 5% (P < 0·001), after the application of -70 mmHg, and to 42 ± 6% (P < 0·001) after the application of -70 mmHg with Jelonet dressings. The blood flow was significantly reduced, to 34 ± 9% (P < 0·001), after the application of -120 mmHg, and to 38 ± 6% (P < 0·001) after the application of -120 mmHg with Jelonet dressings. The use of four layers of Jelonet over the intestines during NPWT did not prevent a decrease in microvascular blood flow in the intestinal wall.

Macroscopic changes during negative pressure wound therapy of the open abdomen using conventional negative pressure wound therapy and NPWT with a protective disc over the intestines

BACKGROUND

Higher closure rates of the open abdomen have been reported with negative pressure wound therapy (NPWT) than with other wound management techniques. However, the method has occasionally been associated with increased development of fistulae. We have previously shown that NPWT induces ischemia in the underlying small intestines close to the vacuum source, and that a protective disc placed between the intestines and the vacuum source prevents the induction of ischemia. In the present study we compare macroscopic changes after 12, 24, and 48 hours, using conventional NPWT and NPWT with a protective disc between the intestines and the vacuum source.

METHODS

Twelve pigs underwent midline incision. Six animals underwent conventional NPWT, while the other six pigs underwent NPWT with a protective disc inserted between the intestines and the vacuum source. Macroscopic changes were photographed and quantified after 12, 24, and 48 hours of NPWT.

RESULTS

The surface of the small intestines was red and mottled as a result of petechial bleeding in the intestinal wall in all cases. After 12, 24 and 48 hours of NPWT, the area of petechial bleeding was significantly larger when using conventional NPWT than when using NPWT with the protective disc (9.7 ± 1.0 cm(2) vs. 1.8 ± 0.2 cm(2), p < 0.001, 12 hours), (14.5 ± 0.9 cm(2) vs. 2.0 ± 0.2 cm(2), 24 hours) (17.0 ± 0.7 cm(2) vs. 2.5 ± 0.2 cm(2) with the disc, p < 0.001, 48 hours)

CONCLUSIONS

The areas of petechial bleeding in the small intestinal wall were significantly larger following conventional NPWT after 12, 24 and 48 hours, than using NPWT with a protective disc between the intestines and the vacuum source. The protective disc protects the intestines, reducing the amount of petechial bleeding.

Vacuum-assisted closure of laparostomy wounds: a critical review of the literature

Vacuum-assisted closure (VAC) reduces the burden for carers of laparostomy wounds but evidence from randomised trials is lacking. This review analyses the evidence for the VAC abdominal wound management system (KCI, San Antonio, TX) in the open abdomen. Three prospective studies provide level III evidence that VAC allows delayed primary fascial closure in the majority of these wounds up to 21 days after occurrence, but not where duration of VAC was less than 9 days or if vacuum pack techniques were used in place of VAC. Fistulae occurred in a minority of wounds complicated by multi-organ failure or sepsis and could not be attributed to VAC itself. Two retrospective analyses suggested VAC may reduce re-operation rate and length of stay in complex wounds. Whilst randomised controlled trials remain the gold standard of evidence for effectiveness of health care interventions, contemporaneous level III evidence supports the hypothesis that VAC increases the rate of primary fascial closure. Whilst enterocutaneous fistula formation is reported in the most complex of these wounds, there is no more evidence that these are consequential to as opposed to coincident with VAC use.

Seatbelt syndrome associated with an isolated rectal injury: case report

Seatbelt syndrome is defined as a seatbelt sign associated with a lumbar spine fracture and a bowel perforation. An isolated rectal perforation due to seatbelt syndrome is extremely rare. There is only one case reported in the Danish literature and non in the English literature. A 48-year old front seat restrained passenger was involved in a head-on collision. He had lower abdominal pain and back pain. Seatbelt mark was seen across the lower abdomen. Initial trauma CT scan was normal except for a burst fracture of L5 vertebra which was operated on by internal fixation on the same day. The patient continued to have abdominal pain. A repeated abdominal CT scan on the third day has shown free intraperitoneal air. Laparotomy has revealed a perforation of the proximal part of the rectum below the recto sigmoid junction. Hartmann's procedure was performed. The abdomen was left open. Gradual closure of the abdominal fascia over a period of two weeks was performed. Postoperatively, the patient had temporary urinary retention due to quada equina injury which resolved 10 months after surgery. The presence of a seatbelt sign and a lumbar fracture should raise the possibility of a bowel injury.

Classification--important step to improve management of patients with an open abdomen

This short report is a distillation of the proceedings from a consensus group meeting in January 2009. It outlines a proposed classification system for patients with an open abdomen (OA). The classification allows (1) a description of the patient's clinical course; (2) standardized clinical guidelines for improving OA management; and (3) improved reporting of OA status, which will facilitate comparisons between studies and heterogeneous patient populations. The following grading is suggested: grade 1A, clean OA without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization); grade 1B, contaminated OA without adherence/fixity; grade 2A, clean OA developing adherence/fixity; grade 2B, contaminated OA developing adherence/fixity; grade 3, OA complicated by fistula formation; grade 4, frozen OA with adherent/fixed bowel, unable to close surgically, with or without fistula. We propose that this classification system will facilitate communication, clarify OA management, and potentially improve patient care.

Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds

Over the past two decades, topical negative pressure (TNP) wound therapy has gained wide acceptance as a genuine strategy in the treatment algorithm for a wide variety of acute and chronic wounds. Although extensive experimental and clinical evidence exists to support its use and despite the recent emergence of randomised control trials, its role and indications have yet to be fully determined. This article provides a qualitative overview of the published literature appertaining to the use of TNP therapy in the management of acute wounds by an international panel of experts using standard methods of appraisal. Particular focus is applied to the use of TNP for the open abdomen, sternal wounds, lower limb trauma, burns and tissue coverage with grafts and dermal substitutes. We provide evidence-based recommendations for indications and techniques in TNP wound therapy and, where studies are insufficient, consensus on best practice.

Abdominal compartment syndrome

Compartment syndrome is a pathophysiological term, comprising a variety of tissues and organ alterations, due to a higher than normal pressure in an anatomically detached space (compartment). In the human body, areas denoted as compartments include the orbital globe, the sub and epidural space, the abdomen, pleura, pericardium, and others. Compartment syndrome was described initially in limbs. Abdominal compartment syndrome is defined as an intra-abdominal pressure above 20 mmHg with evidence of organ failure. Abdominal compartment syndrome develops when the intra-abdominal pressure rapidly reaches certain pathological values, within several hours (intra-abdominal hypertension is observed), and lasts for 6 or more hours. The key to recognizing abdominal compartment syndrome is the demonstration of elevated intra-abdominal pressure which is performed most often via the urinary bladder, and it is considered to be the "gold standard." Multiorgan failure includes damage to the cardiac, pulmonary, renal, neurological, gastrointestinal, abdominal wall, and ophthalmic systems. The gut is the most sensitive to intra-abdominal hypertension, and it develops evidence of end-organ damage before alterations are observed in other systems. The surgical decompression of the abdomen remains the treatment of choice of abdominal compartment syndrome; this usually improves the organ changes, and is followed by one of the temporary abdominal closure techniques in order to prevent secondary intra-abdominal hypertension.

Use of porcine dermal collagen graft and topical negative pressure on infected open abdominal wounds

This article reports on two cases in which porcine dermal collagen grafts were used successfully alongside topical negative pressure therapy in order to close open abdominal wounds in which severe infection was present.

Spill Your Guts! Perceptions of Trauma Association of Canada Member Surgeons Regarding the Open Abdomen and the Abdominal Compartment Syndrome

BACKGROUND

To survey surgeon opinion regarding the management of the open abdomen (OA) and abdominal compartment syndrome (ACS) to assess current practice and direct future prospective clinical studies.

METHODS

Opinions of self-designated trauma, general, pediatric, and vascular surgeons belonging to the Trauma Association of Canada (TAC), were surveyed through a mixed-mode (mail and Web based) questionnaire.

RESULTS

Among 102 eligible candidates, 86 (84%) responded; 83% did regular trauma call, 45% regular critical care call being a separate call 79% of the time; 79% worked in centers serving >500,000 people; the median year of practice entry was 1997. There was no standard definition of what constituted an "open abdomen", preferred time for re-operation, or preferred method for alternate fascial closure, although 90% reported having not closing the fascia after a trauma laparotomy. Being "physically unable" was reported as an indication twice as often as objective measures of airway or bladder pressures. The decision to proceed with OA was reported as rarely or never being made preoperatively by 78% of respondents. None reported an institutional policy regarding OA. Eighty-four percent reported (re)opening an abdomen for primary ACS, 46% for secondary ACS, 28% for tertiary ACS. Self-assessed familiarity for the ACS was 6/7 on a Likert scale. Physical examination was reported as a diagnostic criterion for ACS by 66%, and used to screen by 21% of respondents.

CONCLUSIONS

There is no consensus regarding definition, functional indications, or management of an open abdomen in the perceptions of Canadian trauma providers despite a high self reported level of familiarity with the abdominal compartment syndrome. This is an area of practice with potential and requirements for further multi-center study.

Using Urgotul dressing for the management of epidermolysis bullosa skin lesions

OBJECTIVE

To evaluate the acceptability, tolerance and efficacy of Urgotul wound dressing in the management of epidermolysis bullosa (EB) skin lesions.

METHOD

This was an open-label uncontrolled clinical trial involving 20 patients (I I adults and nine children) with EB simplex or dystrophic EB. Patients were selected from the register of EB patients at the investigating centre and included if they presented with at least one skin lesion requiring management with a non-adherent wound dressing. Lesions were treated with the study dressing for a maximum of four weeks. All dressing changes, wound parameters, pain and effect on quality of life were recorded.

RESULTS

All patients completed the trial. Nineteen out of 20 wounds healed within 8.7 +/- 8.5 days. Overall, 11 patients (55%) considered that their quality of life had improved following use of the dressing, which was also reported to be pain free and 'very easy' or 'easy' to remove at most dressing changes. Nineteen out of 20 patients stated that they would use the study dressing to manage their lesions in future.

CONCLUSION

This study confirmed the very good acceptability and efficacy of Urgotul in the treatment of skin lesions in patients with EB.

Complex wound or complex patient? Strategies for treatment

There is no simple definition of what constitutes a complex wound, but in practice the term tends to refer wounds with one or more complicating factors, e.g. exudate, infection, comorbidity, polypharmacy. Management of complex wounds is based on the same principles as non-complex wounds, i.e. holistic assessment and addressing the issues identified. This article presents three case studies in which these principles are applied.