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Luton OW, Mortimer M, Hopkins L, Robinson DBT, Egeler C, Smart NJ, Harries R. Is there a role for botulinum toxin A in the emergency setting for delayed abdominal wall closure in the management of the open abdomen? A systematic review. Ann R Coll Surg Engl 2023; 105:306-313. [PMID: 35174720 PMCID: PMC10066655 DOI: 10.1308/rcsann.2021.0284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Emergency laparotomy for either trauma or non-trauma indications is common and management is varied. Use of the open abdomen technique allowing for planned re-look is an option; however, performing delayed definitive fascial closure (DFC) following this can be a challenge. The use of botulinum toxin-A (BTX) infiltration into the lateral abdominal wall has been well documented within the elective setting; its use within the emergency setting is undecided. This systematic review assesses the efficacy and safety of BTX injection into the lateral abdominal wall muscles in the emergency setting. The primary outcome is DFC rate. METHODS Systematic review was performed according to the PROSPERO registered protocol (CRD42020205130). Papers were dual screened for eligibility, and included if they met pre-stated criteria where the primary outcome was DFC. Articles reporting fewer than five cases were excluded. Bias was assessed using the Cochrane Risk of Bias and Joanna Brigg's appraisal tools. FINDINGS Fourteen studies were screened for eligibility, twelve full texts were reviewed and two studies were included. Both studies showed evidence of bias due to confounding factors and lack of reporting. Both studies suggested significantly higher rates of DFC than reported in the literature against standard technique (90.7% vs 66%); however, these data are difficult to interpret due to strict study inclusion criteria or lack of a control population. CONCLUSION The use of BTX is deemed safe and its effects in the emergency situation may have great potential. Unfortunately, to date, there is insufficient evidence to facilitate opinion.
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Affiliation(s)
- OW Luton
- Health Education and Improvement Wales, UK
| | | | - L Hopkins
- Health Education and Improvement Wales, UK
| | | | - C Egeler
- Swansea Bay University Health Board, UK
| | - NJ Smart
- Royal Devon and Exeter NHS Foundation Trust, UK
| | - R Harries
- Swansea Bay University Health Board, UK
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Han J, Gangalam V, Wilson P. Advanced squamous cell carcinoma arising in a laparostomy site. Ann R Coll Surg Engl 2021; 104:35-36. [PMID: 34825574 DOI: 10.1308/rcsann.2021.0150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Chronic wounds occur as a result of a disordered healing process. They can be associated with complications such as chronic pain and infection, but also rarely lead to malignant transformation. There have been few cases of squamous cell carcinomas arising in a surgical wound. We present the case of a 67-year-old patient who developed an advanced invasive squamous cell carcinoma seven years post laparostomy for abdominal compartment syndrome. Surgical resection was not possible due to the advanced stage of the malignancy. This case highlights the importance of good wound care, suspecting malignant development in a non-healing chronic surgical wound site, and the importance of using histological analysis to inform surgery when involving a chronic wound.
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Affiliation(s)
- J Han
- Royal Lancaster Infirmary, UK
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Mauriac P, Francois MO, Marichez A, Dubuisson V, Puges M, Stenson K, Ducasse E, Caradu C, Berard X. Adjuncts to the Management of Graft Aorto-Enteric Erosion and Fistula with in situ Reconstruction. Eur J Vasc Endovasc Surg 2021; 62:786-795. [PMID: 34736846 DOI: 10.1016/j.ejvs.2021.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 06/06/2021] [Accepted: 06/12/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The objective of this retrospective single centre study was to determine whether different enteric reconstruction methods and adjuncts confer a benefit after in situ reconstructions (ISRs) of graft aorto-enteric erosion (AEnE) and fistula (AEnF). METHODS Primary endpoints were in hospital mortality and AEnE/F recurrence. Survival was estimated using the Kaplan-Meier method and explanatory factors were searched for using uni- ± multivariable Cox regression analysis. In 2013, a multidisciplinary team meeting was convened and since then the primary operator has always been a senior surgeon. RESULTS Sixty-six patients were treated for AEnE (n = 38) and AEnF (n = 28, 42%) from 2004 to 2020. All patients with AEnF presented with gastrointestinal bleeding (vs. 0 for AEnE; p < .001). Signs of infection were seen in 50 patients (76% [37 for AEnE vs. 13 for AEnF]; p < .001). Referrals for endograft infection increased over time (n = 15, 23%; one before 2013 vs. 14 after; p = .002). Most patients underwent complete graft excision (n = 52, 79%) with increasing suprarenal cross clamping (n = 21, 32%; four before 2013 vs. 17 after; p = .015). Complex visceral reconstructions decreased over time (n = 31, 47%; 17 before 2013 vs. 14 after; p = .055), while "open abdomens" (OAs) increased (one before 2013 vs. 22 after; p < .001), reducing operating time (p = .012). In hospital mortality reached 42% (n = 28). Estimated survival reached 47.6% (95% confidence interval [CI] 35.0 - 59.1) at one year and 45.6% (95% CI 33.0 - 57.3) at three years and was higher for AEnE than for AEnF (log rank p = .029). AEnE/F recurrence was noted in 12 patients (18%). Older age predicted in hospital mortality in multivariable analysis (p = .034). AEnE/F recurrence decreased with the presence of a primary senior surgeon (vs. junior; p = .003) and OA (1 [4.4%] vs. 11 [26%] for primary fascial closure; p = .045) in univariable analysis. CONCLUSION Mortality and recurrence rates remain high after ISR of AEnE/F. Older age predicted in hospital mortality. Primary closure of enteric defects ≤ 2 cm in diameter reduced operating time without increasing the recurrence of AEnF.
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Affiliation(s)
- Paul Mauriac
- Vascular and General Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Marc-Olivier Francois
- Vascular and General Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Arthur Marichez
- Vascular and General Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Vincent Dubuisson
- Vascular and General Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Mathilde Puges
- Infectious Disease Department, Bordeaux University Hospital, Bordeaux, France
| | | | - Eric Ducasse
- Vascular and General Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Caroline Caradu
- Vascular and General Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Berard
- Vascular and General Surgery Department, Bordeaux University Hospital, Bordeaux, France.
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Husu HL, Leppäniemi AK, Mentula PJ. Who would benefit from open abdomen in severe acute pancreatitis?-a matched case-control study. World J Emerg Surg 2021; 16:32. [PMID: 34112205 PMCID: PMC8194042 DOI: 10.1186/s13017-021-00376-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/26/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Selection of patients for open abdomen (OA) treatment in severe acute pancreatitis (SAP) is challenging. Treatment related morbidity and risk of adverse events are high; however, refractory abdominal compartment syndrome (ACS) is potentially lethal. Factors influencing the decision to initiate OA treatment are clinically important. We aimed to study these factors to help understand what influences the selection of patients for OA treatment in SAP. METHODS A single center study of patients with SAP that underwent OA treatment compared with conservatively treated matched controls. RESULTS Within study period, 47 patients treated with OA were matched in a 1:1 fashion with conservatively treated control patients. Urinary output under 20 ml/h (OR 5.0 95% CI 1.8-13.7) and ACS (OR 4.6 95% CI 1.4-15.2) independently associated with OA treatment. Patients with OA treatment had significantly more often visceral ischemia (34%) than controls (6%), P = 0.002. Mortality among patients with visceral ischemia was 63%. Clinically meaningful parameters predicting developing ischemia were not found. OA treatment associated with higher overall 90-day mortality rate (43% vs 17%, P = 0.012) and increased need for necrosectomy (55% vs 21%, P = 0.001). Delayed primary fascial closure was achieved in 33 (97%) patients that survived past OA treatment. CONCLUSION Decreased urine output and ACS were independently associated with the choice of OA treatment in patients with SAP. Underlying visceral ischemia was strikingly common in patients undergoing OA treatment, but predicting ischemia in these patients seems difficult.
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Affiliation(s)
- Henrik Leonard Husu
- Department of Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 340, FI-00029 HUS, Helsinki, Finland.
| | - Ari Kalevi Leppäniemi
- Department of Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 340, FI-00029 HUS, Helsinki, Finland
| | - Panu Juhani Mentula
- Department of Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, P.O. Box 340, FI-00029 HUS, Helsinki, Finland
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Abstract
Abdominal compartment syndrome (ACS), defined by the presence of increased intra-abdominal pressure>20mmHg in association with failure of at least one organ system, is a common and feared complication that may occur in the early phase of severe acute pancreatitis (AP). This complication can lead to patient death in the very short term. The goal of this review is to provide the surgeon and intensivist with objective information to help them in their decision-making. In the early phase of severe AP, it is essential to monitor intra-vesical pressure (iVP) to allow early diagnosis of intra-abdominal hypertension or ACS. The treatment of ACS is both medical and surgical requiring close collaboration between the surgical and resuscitation teams. Medical treatment includes vascular volume repletion, prokinetic agents, effective curarization and percutaneous drainage of large-volume ascites. If uncontrolled respiratory or cardiac failure develops or if maximum medical treatment fails, most teams favor performing an emergency xipho-pubic decompression laparotomy with laparostomy. This procedure follows the principles of abbreviated laparotomy as described for abdominal trauma.
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Affiliation(s)
- M Siebert
- Department of Surgery, GHI Le Raincy-Montfermeil, 93370 Montfermeil, France; Department of general surgery and emergency surgery, CHU de Grenoble, Grenoble, France.
| | - A Le Fouler
- Department of Surgery, GHI Le Raincy-Montfermeil, 93370 Montfermeil, France
| | - N Sitbon
- Department of Surgery, GHI Le Raincy-Montfermeil, 93370 Montfermeil, France
| | - J Cohen
- Multipurpose intensive care unit, GHI Le Raincy-Montfermeil, 93370 Montfermeil, France
| | - J Abba
- Department of general surgery and emergency surgery, CHU de Grenoble, Grenoble, France
| | - E Poupardin
- Department of Surgery, GHI Le Raincy-Montfermeil, 93370 Montfermeil, France
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Abstract
INTRODUCTION Laparostomy is important in the management of patients with intra-abdominal gastrointestinal catastrophe or trauma. It carries significant risk and is resource intensive, both in terms of nursing and surgically. The main goal is to achieve prompt myofascial closure (MFC) in order to minimise morbidity and mortality. Early MFC was initially defined as within 2-3 weeks but there is growing evidence that this should be measured in days. METHODS Retrospective analysis was undertaken of laparostomy cases between 2016 and 2018 at an acute trust and trauma centre serving a population of 500,000. Indication, duration of open abdomen (OA), number of relook procedures and consultant presence were examined to see whether they affected MFC rates, morbidity and mortality. RESULTS Overall, 76 laparostomies were performed during the 3-year study period. The most common indication was peritonitis (68.4%). As duration of OA and number of relook procedures increased, the chances of MFC fell significantly. After day 1, MFC rates fell by 20% with each subsequent 24 hours. Leaving the abdomen open primarily at index procedure compared with performing laparostomy following a postoperative complication was associated with significantly higher MFC rates (92.6% vs 68.2%, (p=0.006). The mortality rate was 15.8%. CONCLUSIONS If the OA is not closed within five days or by the third relook procedure, then achieving MFC is unlikely. Alternative methods should be employed to close the abdomen rather than continuing to take the patient back to theatre for relook laparotomies while increasing the risk of morbidity and mortality. A proactive strategy to forming primary laparostomy at the index procedure has high closure rates.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Piccoli M, Agresta F, Attinà GM, Amabile D, Marchi D. "Complex abdominal wall" management: evidence-based guidelines of the Italian Consensus Conference. Updates Surg 2018; 71:255-272. [PMID: 30255435 PMCID: PMC6647889 DOI: 10.1007/s13304-018-0577-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 08/03/2018] [Indexed: 11/29/2022]
Abstract
To date, there is no shared consensus on a definition of a complex abdominal wall in elective surgery and in the emergency, on indications, technical details, complications, and follow-up. The purpose of the conference was to lay the foundations for a homogeneous approach to the complex abdominal wall with the primary intent being to attain the following objectives: (1) to develop evidence-based recommendations to define “complex abdominal wall”; (2) indications in emergency and in elective cases; (3) management of “complex abdominal wall”; (4) techniques for temporary abdominal closure. The decompressive laparostomy should be considered in a case of abdominal compartment syndrome in patients with critical conditions or after the failure of a medical treatment or less invasive methods. In the second one, beyond different mechanism, patients with surgical emergency diseases might reach the same pathophysiological end point of trauma patients where a preventive “open abdomen” might be indicated (a temporary abdominal closure: in the case of a non-infected field, the Wittmann patch and the NPWT had the best outcome followed by meshes; in the case of an infected field, NPWT techniques seem to be the preferred). The second priority is to create optimal both general as local conditions for healing: the right antimicrobial management, feeding—preferably by the enteral route—and managing correctly the open abdomen wall. The use of a mesh appears to be—if and when possible—the gold standard. There is a lot of enthusiasm about biological meshes. But the actual evidence supports their use only in contaminated or potentially contaminated fields but above all, to reduce the higher rate of recurrences, the wall anatomy and function should be restored in the midline, with or without component separation technique. On the other site has not to be neglected that the use of monofilament and macroporous non-absorbable meshes, in extraperitoneal position, in the setting of the complex abdomen with contamination, seems to have a cost effective role too. The idea of this consensus conference was mainly to try to bring order in the so copious, but not always so “evident” literature utilizing and exchanging the expertise of different specialists.
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Affiliation(s)
- Micaela Piccoli
- Department of General Surgery, General Surgery Unit, New Sant'Agostino Hospital, Via Pietro Giardini, 1355, 41126, Modena, Italy
| | - Ferdinando Agresta
- Department of General Surgery, ULSS19 Veneto, Piazzale degli Etruschi 9, 45011, Adria, Italy
| | - Grazia Maria Attinà
- Department of General Surgery, General Surgery Unit, S. Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152, Rome, Italy.
| | - Dalia Amabile
- Department of General Surgery, General Surgery 1, Saint Chiara Hospital, Largo Medaglie D'oro, 9, 38122, Trento, Italy
| | - Domenico Marchi
- Department of General Surgery, General Surgery Unit, New Sant'Agostino Hospital, Via Pietro Giardini, 1355, 41126, Modena, Italy
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Logrado A, Constantino J, Pereira J, Casimiro C. Laparostomy during pregnancy: A case report. Int J Surg Case Rep 2018; 51:120-124. [PMID: 30149329 PMCID: PMC6110995 DOI: 10.1016/j.ijscr.2018.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/12/2018] [Accepted: 08/15/2018] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Acute appendicitis is the main indication for surgery during pregnancy. Physiologic changes during pregnancy and fear of using ionising radiation exams are some of the reasons to delayed diagnosis and consequently to higher morbidity and mortality rates for mother and fetus. PRESENTATION OF CASE We present the case of a 38-year-old woman that resorted to the emergency room on the 13th week of pregnancy with abdominal discomfort, nausea and vomiting that lasted for 7 days. She had been in the Obstetric Emergency Department 6 days prior with the same complaints. She had no fever and she was discharged home following normal obstetric ultrasound. On this second visit, after surgical consultation, septic shock with abdominal source was recognised and patient was taken for emergency exploratory laparotomy. Intraoperatively we found generalised purulent peritonitis secondary to perforated acute appendicitis. Appendectomy, thorough abdominal washing and laparostomy were performed. Patient was admitted on the Intensive Care Unit with septic shock, need for vasopressor therapy and dialysis. Four days after the first intervention the abdominal cavity was closed. She was discharged home on the 14th post-operative day and maintained obstetric follow-up for the remaining uncomplicated pregnancy. DISCUSSION In the presented clinical case, diagnostic delay evolves to abdominal sepsis that demanded a damage control approach. Laparostomy constitutes a damage control gesture, limiting abdominal contamination, preventing abdominal compartment syndrome and allowing subsequent surgical revisions. CONCLUSION Acute abdominal approach using laparostomy allowed for a good outcome, maintaining ongoing pregnancy and with incisional hernia as the only observed morbidity.
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Affiliation(s)
- Ana Logrado
- Serviço de Cirurgia Geral do Centro Hospitalar Tondela-Viseu, Avenida Rei D. Duarte, 3504-509, Viseu, Portugal.
| | - Júlio Constantino
- Serviço de Cirurgia Geral do Centro Hospitalar Tondela-Viseu, Avenida Rei D. Duarte, 3504-509, Viseu, Portugal.
| | - Jorge Pereira
- Serviço de Cirurgia Geral do Centro Hospitalar Tondela-Viseu, Avenida Rei D. Duarte, 3504-509, Viseu, Portugal.
| | - Carlos Casimiro
- Serviço de Cirurgia Geral do Centro Hospitalar Tondela-Viseu, Avenida Rei D. Duarte, 3504-509, Viseu, Portugal.
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Bernardes A, Melo C, Ferraz S. Surgical treatment of postoperative laparostomy and pyloroduodenostomy-Case report. Int J Surg Case Rep 2018; 48:131-134. [PMID: 29894924 PMCID: PMC6038102 DOI: 10.1016/j.ijscr.2018.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 05/08/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Postoperative duodenal-cutaneous fistula represents a rare and very complex problem. In most cases operative management becomes necessary, but only after local and systemic stabilization and sepsis control. CASE PRESENTATION A 39-year-old man was admitted for surgical management of laparostomy and pyloro-duodenostomy of the first (DI) and second (DII) duodenal segments with one year of evolution, as a complication of several surgical interventions. The patient had been previously submitted to surgical interventions in another institution for: 1- lower gastrointestinal haemorrhage: treated with total colectomy; 2- upper gastrointestinal haemorrhage: performed a pyloroduodenotomy and pyloroplasty; 3- evisceration: abdominal wall closure; 4- biliary peritonitis due to pyloroplasty dehiscence: submitted to laparotomy with placement of a gastrostomy tube and pyloroduodenostomy tube; 5- intestinal haemorrhage through the pyloroduodenostomy tube: inconclusive exploratory laparotomy plus laparostomy; 6- gastrointestinal haemorrhage and shock: submitted to jejunal segmental resection (haemorrhagic mucous nodule); 7- several complications related to drainage, fistulae and celiostomy. DISCUSSION After initial medical treatment for local and systemic stabilization during four months, the following surgical procedures were performed: antrectomy; duodenectomy of DI and the suprapapillary part of DII; T-L gastrojejunostomy; duodenojejunostomy (DII and DIII) L-L at 40 cm of the gastrojejunal anastomosis; T-L jejunojejunostomy; abdominoplasty with a mesh and fibrin glue application; primary cutaneous closure. A multitubular drain was positioned near the duodeno-jejunal anastomosis and a suction drain was positioned in the subcutaneous space. CONCLUSION The patient was discharged at the 60th postoperative day, asymptomatic and with a weight gain of 10 kg.
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Affiliation(s)
- António Bernardes
- General Surgery, Coimbra Hospital and University Centre, Praceta Prof Mota Pinto, 3000-075, Coimbra, Portugal.
| | - Catarina Melo
- General Surgery, Coimbra Hospital and University Centre, Praceta Prof Mota Pinto, 3000-075, Coimbra, Portugal.
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Coccolini F, Roberts D, Ansaloni L, Ivatury R, Gamberini E, Kluger Y, Moore EE, Coimbra R, Kirkpatrick AW, Pereira BM, Montori G, Ceresoli M, Abu-Zidan FM, Sartelli M, Velmahos G, Fraga GP, Leppaniemi A, Tolonen M, Galante J, Razek T, Maier R, Bala M, Sakakushev B, Khokha V, Malbrain M, Agnoletti V, Peitzman A, Demetrashvili Z, Sugrue M, Di Saverio S, Martzi I, Soreide K, Biffl W, Ferrada P, Parry N, Montravers P, Melotti RM, Salvetti F, Valetti TM, Scalea T, Chiara O, Cimbanassi S, Kashuk JL, Larrea M, Hernandez JAM, Lin HF, Chirica M, Arvieux C, Bing C, Horer T, De Simone B, Masiakos P, Reva V, DeAngelis N, Kike K, Balogh ZJ, Fugazzola P, Tomasoni M, Latifi R, Naidoo N, Weber D, Handolin L, Inaba K, Hecker A, Kuo-Ching Y, Ordoñez CA, Rizoli S, Gomes CA, De Moya M, Wani I, Mefire AC, Boffard K, Napolitano L, Catena F. The open abdomen in trauma and non-trauma patients: WSES guidelines. World J Emerg Surg 2018; 13:7. [PMID: 29434652 PMCID: PMC5797335 DOI: 10.1186/s13017-018-0167-4] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 01/18/2018] [Indexed: 02/08/2023] Open
Abstract
Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a "planned second-look" laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Derek Roberts
- Department of Surgery, Foothills Medical Centre, Calgary, Canada
| | - Luca Ansaloni
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | | | - Bruno M. Pereira
- Faculdade de Ciências Médicas (FCM)–Unicamp Campinas, Campinas, SP Brazil
| | - Giulia Montori
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Marco Ceresoli
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - George Velmahos
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | | | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Matti Tolonen
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Joseph Galante
- Trauma and Acute Care Surgery and Surgical Critical Care Trauma, Department of Surgery, University of California, Davis, USA
| | - Tarek Razek
- General and Emergency Surgery, McGill University Health Centre, Montréal, QC Canada
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Miklosh Bala
- General Surgery Department, Hadassah Medical Centre, Jerusalem, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | | | - Manu Malbrain
- ICU and High Care Burn Unit, Ziekenhius Netwerk Antwerpen, Antwerpen, Belgium
| | | | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Ingo Martzi
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie Universitätsklinikum Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Kjetil Soreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Walter Biffl
- Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI USA
| | | | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON Canada
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | - Rita Maria Melotti
- ICU Department, Sant’Orsola-Malpighi University Hospital, Bologna, Italy
| | - Francesco Salvetti
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Tino M. Valetti
- ICU Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Thomas Scalea
- Surgery Department, University of Maryland School of Medicine, Baltimore, MD USA
| | - Osvaldo Chiara
- Emergency and Trauma Surgery Department, Niguarda Hospital, Milano, Italy
| | | | - Jeffry L. Kashuk
- General Surgery Department, Assuta Medical Centers, Tel Aviv, Israel
| | - Martha Larrea
- General Surgery, “General Calixto García”, Habana Medicine University, Havana, Cuba
| | | | - Heng-Fu Lin
- Division of Trauma, Department of Surgery, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, Republic of China
| | - Mircea Chirica
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Camilla Bing
- General and Emergency Surgery Department, Empoli Hospital, Empoli, Italy
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital and Örebro University, Orebro, Sweden
| | | | - Peter Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Nicola DeAngelis
- Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | - Kaoru Kike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Paola Fugazzola
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Matteo Tomasoni
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Rifat Latifi
- General Surgery Department, Westchester Medical Center, Westchester, NY USA
| | - Noel Naidoo
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia & The University of Newcastle, Perth, Australia
| | - Lauri Handolin
- Trauma Unit, Helsinki University Hospital, Helsinki, Finland
| | - Kenji Inaba
- Division of Trauma and Critical Care, LAC+USC Medical Center, University of Southern California, California, Los Angeles USA
| | - Andreas Hecker
- General and Thoracic Surgery, Giessen Hospital, Giessen, Germany
| | - Yuan Kuo-Ching
- Acute Care Surgery and Traumatology, Taipei Medical University Hospital, Taipei City, Taiwan, Republic of China
| | - Carlos A. Ordoñez
- Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Carlos Augusto Gomes
- Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Juiz de Fora, Brazil
| | - Marc De Moya
- Trauma, Acute Care Surgery, Medical College of Wisconsin/Froedtert Trauma Center, Milwaukee, WI USA
| | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Alain Chichom Mefire
- Department of Surgery and Obs/Gyn, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Ken Boffard
- Milpark Hospital Academic Trauma Center, University of the Witwatersrand, Johannesburg, South Africa
| | - Lena Napolitano
- Acute Care Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI USA
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore Hospital, Parma, Italy
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Coccolini F, Montori G, Ceresoli M, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Sartelli M, De Moya M, Velmahos G, Fraga GP, Pereira BM, Leppaniemi A, Boermeester MA, Kirkpatrick AW, Maier R, Bala M, Sakakushev B, Khokha V, Malbrain M, Agnoletti V, Martin-Loeches I, Sugrue M, Di Saverio S, Griffiths E, Soreide K, Mazuski JE, May AK, Montravers P, Melotti RM, Pisano M, Salvetti F, Marchesi G, Valetti TM, Scalea T, Chiara O, Kashuk JL, Ansaloni L. The role of open abdomen in non-trauma patient: WSES Consensus Paper. World J Emerg Surg 2017; 12:39. [PMID: 28814969 PMCID: PMC5557069 DOI: 10.1186/s13017-017-0146-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022] Open
Abstract
The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore hospital, Parma, Italy
| | | | - Rao Ivatury
- Trauma Surgery, Virginia Commonwealth University, Richmond, VA 23284 USA
| | - Walter Biffl
- Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI 96813 USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, 15213 USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, 92103 USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Marc De Moya
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | - George Velmahos
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | | | - Bruno M. Pereira
- Faculdade de Ciências Médicas (FCM) – Unicamp Campinas, São Paulo, Brazil
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | | | | | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, 98104 USA
| | - Miklosh Bala
- General Surgery Department, Hadassah Medical Centre, Jerusalem, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | | | - Manu Malbrain
- ICU and High Care Burn Unit, Ziekenhius Netwerk Antwerpen, Antwerpen, Belgium
| | | | | | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Ewen Griffiths
- Upper Gatrointestinal Surgery, Birmigham Hospital, Birmigham, UK
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University, Saint Louis, MO 63130 USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN 37232 USA
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | | | - Michele Pisano
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Francesco Salvetti
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Tino M. Valetti
- ICU Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Thomas Scalea
- Trauma Surgery department, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Osvaldo Chiara
- Emergency and Trauma Surgery department, Niguarda Hospital, Milan, Italy
| | - Jeffry L. Kashuk
- General Surgery department, Assuta Medical Centers, Tel Aviv, Israel
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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Guilbaud T, Berdah S, Bege T. Component separation in the management of abdominal wall defect after laparostomy: Clinical and anatomical videos (with video). J Visc Surg 2017; 154:301-302. [PMID: 28595856 DOI: 10.1016/j.jviscsurg.2017.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- T Guilbaud
- Service de chirurgie digestive, hôpital Nord, Aix-Marseille University, chemin des Bourrely, 13915 cedex 20 Marseille, France.
| | - S Berdah
- Service de chirurgie digestive, hôpital Nord, Aix-Marseille University, chemin des Bourrely, 13915 cedex 20 Marseille, France
| | - T Bege
- Service de chirurgie digestive, hôpital Nord, Aix-Marseille University, chemin des Bourrely, 13915 cedex 20 Marseille, France
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14
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Willms A, Schaaf S, Schwab R, Richardsen I, Jänig C, Bieler D, Wagner B, Güsgen C. Intensive care and health outcomes of open abdominal treatment: long-term results of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). Langenbecks Arch Surg 2017; 402:481-492. [PMID: 28382564 DOI: 10.1007/s00423-017-1575-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/08/2017] [Indexed: 01/31/2023]
Abstract
PURPOSE The study's purpose is to evaluate the long-term outcome after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) and to identify predictors of quality of life associated with intensive care. METHODS Fifty-five patients who underwent open abdomen management at our institution from 2006 to 2013 were prospectively enrolled in this study. After a median follow-up period of 3.8 years, 27 patients completed the 36-Item Short Form Survey (SF-36) quality of life questionnaire. As this is a report solely focused on quality of life, direct treatment-related outcome measures like mortality, closure rates, and incisional hernia development of this study cohort have been reported previously. RESULTS = 0.50, β = -0.70, p = 0.02). CONCLUSIONS Despite high short-term mortality and morbidity rates for these critically ill patients, open abdomen treatment using VAWCM allows patients to recover to an acceptable long-term quality of life. The complex intensive care score can be used as a surrogate parameter for the global severity of illness and was the only predictor of physical functioning (SF-36).
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Affiliation(s)
- A Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany.
| | - S Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - R Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - I Richardsen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - C Jänig
- Department of Anesthesiology and Intensive Care, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - D Bieler
- Department of Trauma Surgery and Orthopedics, Plastic and Reconstructive Surgery, and Hand Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
| | - B Wagner
- Support Division of the Directorate-General for Strategy and Operations, Federal Ministry of Defense, Berlin, Germany
| | - C Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Koblenz, Germany
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Muñoz Muñoz E, Pardo-Aranda F, García-Olivares E, Pontes De Sousa SP, Forcada P, Veloso E. Omental patch reinforced with polypropylene mesh and split-thickness skin grafting: A new procedure to close the "open abdomen". Int J Surg Case Rep 2016; 25:153-5. [PMID: 27372030 PMCID: PMC4932488 DOI: 10.1016/j.ijscr.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 06/02/2016] [Accepted: 06/02/2016] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The "open abdomen" expression widely used to define a full-thickness defect of the abdominal wall intentionally made in some situations like abdominal compartment syndrome, has been replaced by a newest one called "laparostomy". The definitive closure of an open abdomen with a giant full abdominal thickness defect remains a problem. CASE REPORT We present a 67-year old male with a descompressive laparostomy treated with a greater omentum flap sutured hermetically with interrupted stitches at the edges of the muscle wall, reinforced with large mesh of polypropylene (PP) placed on-lay and sutured to the fascia by two concentric running sutures of polypropylene. A vacuum-assisted closure device was placed on the second postoperative day and it was kept during three weeks. By then the PP mesh was completely integrated so skin grafts were applied to the surface of the granulation tissue. An incisional hernia was easily repaired at three years of follow-up. Eight months after the last surgery the patient is satisfied with the result achieved. DISCUSSION The great omentum has immunological and angiogenic properties that allow a rapid integration of the polypropylene mesh, even in septic environments, facilitating the engraftment of split-thickness skin graft. The reactive fibrosis caused by the PP mesh replaces the fat tissue but the inner surface is preserved, thereby avoiding subsequent adhesion and facilitates surgical access to the abdominal cavity if necessary in the future. CONCLUSION The structure achieved is a strong structure, capable of visceral isolation that can be useful to close some OA.
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Affiliation(s)
- Emilio Muñoz Muñoz
- Gastrointestinal Surgery Department, Hospital Universitario Mutua Terrassa, Barcelona, Spain
| | - Fernando Pardo-Aranda
- Gastrointestinal Surgery Department, Hospital Universitario Mutua Terrassa, Barcelona, Spain.
| | - Esteban García-Olivares
- Gastrointestinal Surgery Department, Hospital Universitario Mutua Terrassa, Barcelona, Spain
| | | | - Pilar Forcada
- Pathologist Department, Hospital Universitario Mutua Terrassa, Barcelona, Spain
| | - Enrique Veloso
- Gastrointestinal Surgery Department, Hospital Universitario Mutua Terrassa, Barcelona, Spain
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Bobkiewicz A, Walczak D, Smoliński S, Kasprzyk T, Studniarek A, Borejsza-Wysocki M, Ratajczak A, Marciniak R, Drews M, Banasiewicz T. Management of enteroatmospheric fistula with negative pressure wound therapy in open abdomen treatment: a multicentre observational study. Int Wound J 2016; 14:255-264. [PMID: 27000995 DOI: 10.1111/iwj.12597] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/11/2016] [Accepted: 02/24/2016] [Indexed: 12/11/2022] Open
Abstract
The management of enteroatmospheric fistula (EAF) in open abdomen (OA) therapy is challenging and associated with a high mortality rate. The introduction of negative pressure wound therapy (NPWT) in open abdomen management significantly improved the healing process and increased spontaneous fistula closure. Retrospectively, we analysed 16 patients with a total of 31 enteroatmospheric fistulas in open abdomen management who were treated using NPWT in four referral centres between 2004 and 2014. EAFs were diagnosed based on clinical examination and confirmed with imaging studies and classified into low (<200 ml/day), moderate (200-500 ml/day) and high (>500 ml/day) output fistulas. The study group consisted of five women and 11 men with the mean age of 52·6 years [standard deviation (SD) 11·9]. Since open abdomen management was implemented, the mean number of re-surgeries was 3·7 (SD 2·2). There were 24 EAFs located in the small bowel, while four were located in the colon. In three patients, EAF occurred at the anastomotic site. Thirteen fistulas were classified as low output (41·9%), two as moderate (6·5%) and 16 as high output fistulas (51·6%). The overall closure rate was 61·3%, with a mean time of 46·7 days (SD 43·4). In the remaining patients in whom fistula closure was not achieved (n = 12), a protruding mucosa was present. Analysing the cycle of negative pressure therapy, we surprisingly found that the spontaneous closure rate was 70% (7 of 10 EAFs) using intermittent setting of negative pressure, whereas in the group of patients treated with continuous pressure, 57% of EAFs closed spontaneously (12 of 21 EAFs). The mean number of NPWT dressing was 9 (SD 3·3; range 4-16). In two patients, we observed new fistulas that appeared during NPWT. Three patients died during therapy as a result of multi-organ failure. NPWT is a safe and efficient method characterised by a high spontaneous closure rate. However, in patients with mucosal protrusion of the EAFs, spontaneous closure appears to be impossible to achieve.
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Affiliation(s)
- Adam Bobkiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Dominik Walczak
- Department of General Surgery, John Paul II Memorial Hospital, Belchatow, Poland
| | - Szymon Smoliński
- Department of Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Kasprzyk
- Department of General, Vascular and Oncologic Surgery, Regional Specialistic Hospital, Słupsk, Poland
| | - Adam Studniarek
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Maciej Borejsza-Wysocki
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrzej Ratajczak
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Ryszard Marciniak
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Michal Drews
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Tomasz Banasiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Poznan, Poland
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Abstract
Surgery for acute pancreatitis has undergone significant changes over the last 3 decades. A better understanding of the pathophysiology has contributed to this, but the greatest driver for change has been the rise of less invasive interventions in the fields of laparoscopy, endoscopy and radiology. Surgery has a very limited role in the diagnosis of acute pancreatitis. The most common indication for intervention in acute pancreatitis is for the treatment of complications and most notably the treatment of infected walled off necrosis. Here, the step-up approach has become established, with prior drainage (either endoscopic or percutaneous) followed by delay for maturing of the wall and then debridement by endoscopic or minimally invasive surgical methods. Open surgery is only indicated when this approach fails. Other indications for surgery in acute pancreatitis are for the treatment of acute compartment syndrome, non-occlusive intestinal ischaemia and necrosis, enterocutaneous fistulae, vascular complications and pseudocyst. Surgery also has a role in the prevention of recurrent acute pancreatitis by cholecystectomy. Despite the more restricted role, surgeons have an important contribution to make in the multidisciplinary care of patients with complicated acute pancreatitis.
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Montori G, Coccolini F, Manfredi R, Ceresoli M, Campanati L, Magnone S, Pisano M, Poiasina E, Nita G, Catena F, Ansaloni L. One year experience of swine dermal non-crosslinked collagen prostheses for abdominal wall repairs in elective and emergency surgery. World J Emerg Surg 2015; 10:28. [PMID: 26136817 PMCID: PMC4487506 DOI: 10.1186/s13017-015-0023-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/22/2015] [Indexed: 02/08/2023] Open
Abstract
Introduction The approach to the abdominal wall surgical repair is dramatically changed in the last years. This study evaluates our institutional outcomes about the usage of biological meshes for abdominal wall repair in different setting: in elective surgery, in emergency surgery and in abdominal wall repair following open abdomen (OA) procedure. Methods A database was prospectively conducted (January–December 2014) and data were reviewed for patients who underwent to an abdominal wall reconstruction with swine dermal non-cross linked collagens prostheses either in elective or emergency setting, and following OA/laparostomy procedure. Demographic data, co-morbidities, indications for surgery, intra-operative details, post-operative complications and outcome (peri-operative, 3, 6, 9-months) were analyzed. Results A total of 30 cases were reported: 9 in elective surgery (Group 1), 4 in emergency surgery (Group 2) and 17 with abdominal wall closure following OA management (Group 3). Two meshes were removed: 1 in the Group 1 and 1 in the Group 3. During follow-up only one patient in the Group 3 had a recurrence of the incisional hernia. Mortality rate was 11.1 % at 3 months in Group 1, 0 % in the Group 2, and 29.4 % in peri-operative period in the Group 3. Conclusions The use of non-cross linked biological meshes can be safe and versatile in different situations from elective to emergency surgery, and also for the reconstruction of the abdominal wall after OA procedure, with an acceptable recurrence and mortality rate.
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Affiliation(s)
- Giulia Montori
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Federico Coccolini
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Roberto Manfredi
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Marco Ceresoli
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Luca Campanati
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Magnone
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Michele Pisano
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Elia Poiasina
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Gabriela Nita
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Fausto Catena
- General surgery department, Ospedale Maggiore, Parma, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
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Rasilainen SK, Juhani MP, Kalevi LA. Microbial colonization of open abdomen in critically ill surgical patients. World J Emerg Surg 2015; 10:25. [PMID: 26136816 PMCID: PMC4487573 DOI: 10.1186/s13017-015-0018-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 06/19/2015] [Indexed: 01/16/2023] Open
Abstract
Introduction This study was designed to describe the time-course and microbiology of colonization of open abdomen in critically ill surgical patients and to study its association with morbidity, mortality and specific complications of open abdomen. A retrospective cohort analysis was done. Methods One hundred eleven consecutive patients undergoing vacuum-assisted closure with mesh as temporary abdominal closure method for open abdomen were analyzed. Microbiological samples from the open abdomen were collected. Statistical analyses were performed using Fisher’s exact test for categorical variables. Mann-Whitney U test was used when comparing number of temporary abdominal closure changes between colonized and sterile patients. Kaplan-Meier analysis was done to calculate cumulative estimates for colonization. Cox regression analyses were performed to analyze risk factors for colonization. Results Microbiological samples were obtained from 97 patients. Of these 76 (78 %) were positive. Sixty-one (80 %) patients were colonized with multiple micro-organisms and 27 (36 %) were cultured positive for candida species. The duration of open abdomen treatment adversely affected the colonization rate. Thirty-three (34 %) patients were colonized at the time of laparostomy. After one week of open abdomen treatment 69, and after two weeks 76 patients were colonized with cumulative colonization estimates of 74 % and 89 %, respectively. Primary fascial closure rate was 80 % (61/76) and 86 % (18/21) for the colonized and sterile patients, respectively. The rate of wound complications did not significantly differ between these groups. Conclusions Microbial colonization of open abdomen is associated with the duration of open abdomen treatment. Wound complications are common after open abdomen, but colonization does not seem to have significant effect on these. The high colonization rate described herein should be taken into account when primarily sterile conditions like acute pancreatitis and aortic aneurysmal rupture are treated with open abdomen.
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Affiliation(s)
| | - Mentula Panu Juhani
- Department of Abdominal Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Leppäniemi Ari Kalevi
- Department of Abdominal Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Mousavie SH, Mirzaei R, Mahjoubi B, Azizi R. Successful management of multiple small bowel perforations due to polyarteritis nodosa. J Res Med Sci 2014; 19:276-8. [PMID: 24949038 PMCID: PMC4061652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 05/26/2013] [Accepted: 07/15/2013] [Indexed: 10/26/2022]
Abstract
Classic Polyarteritis nodosa (PAN)) is a medium-sized vessel vasculitis that usually occurs in middle-aged men. One of the dramatic manifestations of PAN that requires surgical intervention is multiple small bowel perforations. Many studies have reported a high rate of mortality in PAN due to acute abdominal complications. We report here the case of multiple small bowel perforations in a 22-year-old man, who presented with an acute abdomen, and eventually, PAN was diagnosed. In our case, PAN led to multiple small bowel perforations and diffuse patchy necrosis. All perforations were primarily repaired and corticosteroids were prescribed. Using corticosteroid in patients with abdominal sepsis is injurious; however, laparostomy is the method we suggest, to achieve the purpose, including prevention of a short bowel and infection control. Our patient was discharged, well, after 48 days of hospitalization and referred to a rheumatologist.
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Affiliation(s)
- Seyed Hamzeh Mousavie
- Department of General Surgery, Division of Colon and Rectal Surgery, Hazrat-e-Rasoul Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Rezvan Mirzaei
- Associated Professor of Colorectal Surgery, Division of Colon and Rectal Surgery, Hazrat-e-Rasoul Hospital, Iran University of Medical Sciences, Tehran, Iran,Address for correspondence: Dr. Rezvan Mirzaei, Hazrat-e-Rasoul Hospital, Iran University of Medical Sciences, Tehran, Iran. E-mail:
| | - Bahar Mahjoubi
- Associated Professor of Colorectal Surgery, Division of Colon and Rectal Surgery, Hazrat-e-Rasoul Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Rasoul Azizi
- Associated Professor of Colorectal Surgery, Division of Colon and Rectal Surgery, Hazrat-e-Rasoul Hospital, Iran University of Medical Sciences, Tehran, Iran
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Abstract
The need for surgical decompression for abdominal compartment syndrome is becoming more frequent in patients with severe acute pancreatitis, especially in association with massive fluid resuscitation at the early stages of the disease. Decompression can be achieved with either a full-thickness laparostomy that can be performed through a vertical midline or transverse subcostal incision, or by performing a subcutaneous linea alba fasciotomy. Following a fullthickness laparostomy the open abdomen can be best managed with some form of negative abdominal pressure dressing. During dressing changes every 2-3 days, every attempt should be made to gradually close the fascial incision starting from edges, but avoiding recurrent abdominal compartment syndrome. Gradual closure is more likely to succeed in association with a negative fluid balance. Peripancreatic exploration or necrosectomy is seldom required at the initial laparostomy, unless performed for late onset abdominal compartment syndrome associated with infected peripancreatic necrosis. Primary fascial closure should always be attempted. If impossible and there is no need for subsequent abdominal re-exploration, the open wound should be covered with split-thickness skin grafting directly over the bowel loops. After a maturation period of 9-12 months definitive repair of the abdominal wall defect is performed utilizing the components separation technique, mesh repair, or a pedicular or microvascular tensor facia lata flap. Knowledge of the available decompression and reconstruction options is essential for individualized management of patients with severe acute pancreatitis and abdominal compartment syndrome. More research and comparative studies are needed to determine the most successful methods to be used.
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