Cost evaluation of temporary abdominal closure methods in abdominal sepsis patients successfully treated with an open abdomen. Should we take temporary abdominal closure methods at face value? Health economic evaluation

Economic Analysis of AbClo, a Novel Abdominal Fascia Closure Device, for Patients With an Open Abdomen Following Trauma or Acute Abdominal Surgery

BACKGROUND

Open Abdomen (OA) cases represent a significant surgical and resource challenge. AbClo is a novel non-invasive abdominal fascial closure device that engages lateral components of the abdominal wall muscles to support gradual approximation of the fascia and reduce the fascial gap. The study objective was to assess the economic implications of AbClo compared to negative pressure wound therapy (NPWT) alone on OA management.

METHODS

We conducted a cost-minimization analysis using a decision tree comparing the use of the AbClo device to NPWT alone among patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure. The time horizon was limited to the length of the inpatient hospital stay, and costs were considered from the perspective of the US Medicare payer. Clinical effectiveness data for AbClo was obtained from a randomized clinical trial. Cost data was obtained from the published literature. Probabilistic and deterministic sensitivity analyses were performed. The primary outcome was incremental cost.

RESULTS

The mean cumulative costs per patient were $76 582 for those treated with NPWT alone and $70,582 for those in the group treated with the AbClo device. Compared to NPWT alone, AbClo was associated with lower incremental costs of -$6012 (95% CI -$19 449 to +$1996). The probability that AbClo was cost-savings compared to NPWT alone was 94%.

CONCLUSIONS

The use of AbClo is an economically attractive strategy for management of OA in in patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care

BACKGROUND

This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care.

METHODS

Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS^® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS^® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL.

RESULTS

Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process.

CONCLUSIONS

These guidelines are based on best available evidence for an ERAS^® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Abdominal Negative Pressure Wound Therapy Devices for Management of the Open Abdomen: A Technologic Analysis

PURPOSE

The purpose of this technologic analysis was to analyze technologic features of abdominal negative pressure wound therapy (NPWT).

APPROACH

Published literature regarding abdominal negative pressure wound therapy (aNPWT) devices was reviewed. A summary of management approaches for the open abdomen provides a foundation for understanding the benefits of aNPWT. Safety information regarding aNPWT was derived from the Manufacturer and User Facility Device Experience (MAUDE) Database.

CONCLUSIONS

The open abdomen approach with temporary abdominal closure may be employed for patients with a variety of conditions. Specialized abdominal NPWT devices, either singly or in combination with other approaches, may contribute to improved outcomes in this high-risk patient population. Manufacturer recommendations and clinical guidelines should be followed to minimize patient risk.

Manejo del abdomen abierto en el paciente crítico en un centro de nivel III de Popayán

Introducción. El abdomen abierto es un recurso útil para el tratamiento de pacientes con patología abdominal compleja, con potencial de complicaciones. El objetivo de este estudio fue adaptar la guía de World Society of Emergency Surgery (WSES) 2018, en un hospital de nivel III de atención de la ciudad de Popayán, Colombia, y comparar los resultados obtenidos con los previos a su implementación. Métodos. Estudio cuasi-experimental en dos mediciones de pacientes con abdomen abierto y estancia en cuidado crítico, durante los meses de abril a octubre de los años 2018 y 2019, antes y después de la adaptación con el personal asistencial de la guía de práctica clínica WSES 2018. Se utilizó estadística descriptiva, prueba de Chi cuadrado y se empleó el software SPSS V.25. Resultados. Se incluyeron 99 pacientes críticos, con una edad media de 53,2 años, con indicación de abdomen abierto por etiología traumática en el 28,3 %, infecciosa no traumática en el 32,3 % y no traumática ni infecciosa en el 37,4 %. La mortalidad global fue de 25,3 %, de los cuales, un 68 % se debieron a causas ajenas a la patología abdominal. Las complicaciones postoperatorias se presentaron en 10 pacientes con infección de sitio operatorio y 9 pacientes con fístula enterocutánea. El uso del doble Viaflex se implementó en un 63,6 %, logrando un cierre de la pared abdominal en el 79,8 % de los casos (p=0,038). Conclusión. El abdomen abierto requiere de un abordaje multidisciplinar. El uso de doble Viaflex es una herramienta simple y efectiva. La implementación de la guía disminuyó el porcentaje de mortalidad, los días de abdomen abierto y la estancia en cuidados intensivos.