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Gómez Garnica DG, Rey Chaves CE, Barco-Castillo C, Gutierrez JA, Falla A. Negative Pressure Wound Therapy After Intestinal Anastomosis: A Risk Factor Analysis for Dehiscence. J Surg Res 2024; 296:223-229. [PMID: 38286101 DOI: 10.1016/j.jss.2024.01.003] [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] [Received: 09/20/2023] [Revised: 12/18/2023] [Accepted: 01/02/2024] [Indexed: 01/31/2024]
Abstract
INTRODUCTION Negative pressure wound therapy (NPWT) is part of the temporary abdominal closure in the treatment of patients with traumatic, inflammatory, or vascular disease. However, the use of NPWT when performing an intestinal anastomosis has been controversial. This study aimed to describe the patients managed with NPWT therapy and identify the risk factors for anastomotic dehiscence when intestinal anastomosis was performed. METHODS A single-center cohort study with prospectively collected databases was performed. Patients who required NPWT therapy from January 2014 to December 2018 were included. Patients were stratified according to the performance of intestinal anastomosis and according to the presence of dehiscence. Bivariate and multivariate analyses were performed for anastomotic dehiscence and mortality. RESULTS A total of 97 patients were included. Median age was 52 y old [interquartile range 24.5-70]. Male patients corresponded to 75.6% (n = 34) of the population. Delayed fascial closure was performed in 80% (n = 36). The risk of anastomotic dehiscence was higher in females (odds ratio (OR) 11.52 [confidence interval (CI) 1.29-97.85], P = 0.030), delayed fascial closure (OR 18.18 [CI 2.02-163.5], P = 0.010) and use of vasopressors (OR 12.04 [CI 1.22-118.47], P = 0.033). NPWT pressures >110 mmHg were evidenced in the dehiscence group with statistically significant value (OR 1.2 [0.99-2.26] p 0.04) CONCLUSIONS: There is still controversy in the use of NPWT when performing intestinal anastomosis. According to our data, the risk of dehiscence is higher in females, delayed fascial closure, use of vasopressors, and NPWT pressures >110 MMHG.
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Affiliation(s)
- David Guillermo Gómez Garnica
- Department of General Surgery, Hospital Militar Central, Bogotá DC, Colombia; Universidad Militar Nueva Granada School of Medicine, Bogotá DC, Colombia; Cirugía General, Profesor Asistente, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Carlos Eduardo Rey Chaves
- Estudiante de Posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Bogotá, Colombia.
| | - Catalina Barco-Castillo
- Universidad Militar Nueva Granada School of Medicine, Bogotá DC, Colombia; Department of Urology, Hospital Militar Central, Bogotá DC, Colombia
| | - Jorge Andrés Gutierrez
- Department of General Surgery, Hospital Militar Central, Bogotá DC, Colombia; Universidad Militar Nueva Granada School of Medicine, Bogotá DC, Colombia; Cirugía General, Profesor Asistente, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Andrés Falla
- Department of General Surgery, Hospital Militar Central, Bogotá DC, Colombia; Universidad Militar Nueva Granada School of Medicine, Bogotá DC, Colombia
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Spencer BL, Lotakis DM, Carducci J, Hoff L, Gingrich D, Gadepalli SK, Speck KE. Outcomes of Prolonged Open Abdomen in Children. J Surg Res 2024; 298:1-6. [PMID: 38518531 DOI: 10.1016/j.jss.2024.02.010] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 01/16/2024] [Accepted: 02/16/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION We sought to better characterize outcomes in pediatric patients requiring open abdomen for instability with ongoing resuscitation, second look surgery, or left in discontinuity or congenital or acquired loss of domain that may lead to prolonged open abdomen (POA) or difficulties in successful abdominal wall closure. METHODS We performed a single-institution retrospective review of patients aged less or equal to 18 years who presented to our institution from 2015 to 2022. We defined POA as requiring three or more surgeries prior to abdominal wall closure. Descriptive statistics were performed using median and interquartile range. RESULTS Median age was 15 years (interquartile range 0-6 years), 46% female, and 69% White. Survival rate was 93% for the entire cohort. The most common indication for open abdomen was second look/discontinuity 22/41 (54%). The most common temporary abdominal wall closure was wound vac (43%). Fifty eight percent patients achieved primary tissue closure, the remaining required mesh. Of the 42 patients, 25 required POA. They had increasing rate of secondary infections at 56% compared to 44% (P = 0.17). The groups were further divided into indications for open abdomen including ongoing resuscitation, second look/discontinuity, and loss of domain with similar outcomes. CONCLUSIONS In the largest series of long-term outcomes in pediatric patients with an open abdomen, we found that a majority of children were able to be primarily closed without mesh despite the number of surgeries required. Further studies require a protocolized approach to improve the long-term outcomes of these patients.
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Affiliation(s)
- Brianna L Spencer
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan.
| | - Dimitra M Lotakis
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | | | - Lauren Hoff
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Devon Gingrich
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Samir K Gadepalli
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - K Elizabeth Speck
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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Proaño-Zamudio JA, Argandykov D, Renne A, Gebran A, Dorken-Gallastegi A, Paranjape CN, Kaafarani HMA, King DR, Velmahos GC, Hwabejire JO. Revisiting abdominal closure in mesenteric ischemia: is there an association with outcome? Eur J Trauma Emerg Surg 2023; 49:2017-2024. [PMID: 36478280 DOI: 10.1007/s00068-022-02199-0] [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] [Received: 09/24/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Current guidelines advocate liberal use of delayed abdominal closure in patients with acute mesenteric ischemia (AMI) undergoing laparotomy. Few studies have systematically examined this practice. The goal of this study was to evaluate the effect of delayed abdominal closure on postoperative morbidity and mortality in patients with AMI. METHODS We performed a retrospective cohort study of the ACS-NSQIP 2013-2017 registry. We included patients with a diagnosis of AMI undergoing emergency laparotomy. Patients were divided into two groups based on the type of abdominal closure: (1) delayed fascial closure (DFC) when no layers of the abdominal wall were closed and (2) immediate fascial closure (IFC) if deep layers or all layers of the abdominal wall were closed. Propensity score matching was performed based on comorbidities, pre-operative, and operative characteristics. Univariable analysis was performed on the matched sample. RESULTS The propensity-matched cohort consisted of 1520 patients equally divided into the DFC and IFC groups. The median (IQR) age was 68 (59-77), and 836 (55.0%) were female. Compared to IFC, the DFC group showed increased in-hospital mortality (38.9% vs. 31.6%, p = 0.002), 30-day mortality (42.4% vs. 36.3%, p = 0.012), and increased risk of respiratory failure (59.5% vs. 31.2%, p < 0.001). CONCLUSIONS The delayed fascial closure technique was associated with increased mortality compared to immediate fascial closure. These findings do not support the blanket incorporation of delayed closure in mesenteric ischemia care or its previously advocated liberal use.
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Affiliation(s)
- Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Angela Renne
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Anthony Gebran
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Ander Dorken-Gallastegi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - David R King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA, 02114, USA.
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Zhao Y, Li R, Liu Y, Song L, Gao Z, Li Z, Peng X, Wang P. An injectable, self-healable, antibacterial, and pro-healing oxidized pullulan polysaccharide/carboxymethyl chitosan hydrogel for early protection of open abdominal wounds. Int J Biol Macromol 2023; 250:126282. [PMID: 37572809 DOI: 10.1016/j.ijbiomac.2023.126282] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 05/30/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/14/2023]
Abstract
Open abdomen (OA) is an effective method for treating critical abdominal conditions such as severe abdominal infections. The temporary abdominal closure (TAC) technique is often used to temporarily restore the physiological environment of the abdominal cavity and maintain the homeostatic balance of the abdominal cavity. However, most of the common TAC materials available today lack bio-responsiveness, tend to abrade the intestinal canal, and lead to delayed tissue healing of the wound. Hydrogels could mimic the extracellular matrix and have shown significant potential in life science fields such as tissue regeneration, wound repair, and controlled drug release. In this study, a composite hydrogel scaffold was constructed by the Schiff base reaction of oxidized pullulan polysaccharide with carboxymethyl chitosan. The hydrogel exhibited excellent self-healing, cellular biocompatibility, and antibacterial and anti-inflammatory abilities, and in experiments it reduced secondary damage caused by friction between tissue and patch, thereby preventing serious complications such as intestinal fistula, promoted M1-M2 polarization of macrophages, reduced the inflammatory response, regulated the inflammatory microenvironment in vivo, promoted angiogenesis and granulation tissue regeneration, and accelerated wound healing. Therefore, our hydrogel provides a new strategy for material-assisted wound protection during OA and has potential clinical applications.
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Affiliation(s)
- Yeying Zhao
- Department of Emergency Medicine, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 266000, PR China
| | - Ruojing Li
- Department of Emergency Medicine, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 266000, PR China
| | - Yangyang Liu
- Department of Emergency Medicine, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 266000, PR China
| | - Lei Song
- Department of Emergency Medicine, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 266000, PR China
| | - Zhao Gao
- Department of Emergency Medicine, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 266000, PR China
| | - Ze Li
- Department of Emergency Medicine, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 266000, PR China; School of Medicine, Nanjing University, Nanjing 210008, PR China.
| | - Xingang Peng
- Department of Emergency Medicine, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 266000, PR China.
| | - Peige Wang
- Department of Emergency Medicine, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao 266000, PR China.
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Rajabaleyan P, Jensen RO, Möller S, Qvist N, Ellebaek MB. Primary anastomosis and suturing combined with vacuum-assisted abdominal closure in patients with secondary peritonitis due to perforation of the small intestine: a retrospective study. BMC Surg 2023; 23:280. [PMID: 37715227 PMCID: PMC10503050 DOI: 10.1186/s12893-023-02179-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 08/31/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Intestinal resection and a proximal stoma is the preferred surgical approach in patients with severe secondary peritonitis due to perforation of the small intestine. However, proximal stomas may result in significant nutritional problems and long-term parenteral nutrition. This study aimed to assess whether primary anastomosis or suturing of small intestine perforation is feasible and safe using the open abdomen principle with vacuum-assisted abdominal closure (VAC). METHODS Between January 2005 and June 2018, we performed a retrospective chart review of 20 patients (> 18 years) with diffuse faecal peritonitis caused by small intestinal perforation and treated with primary anastomosis/suturing and subsequent open abdomen with VAC. RESULTS The median age was 65 years (range: 23-90 years). Twelve patients were female (60%). Simple suturing of the small intestinal perforation was performed in three cases and intestinal resection with primary anastomosis in 17 cases. Four patients (20%) died within 90-days postoperatively. Leakage occurred in five cases (25%), and three patients developed an enteroatmospheric fistula (15%). Thirteen of 16 patients (83%) who survived were discharged without a stoma. The rest had a permanent stoma. CONCLUSIONS Primary suturing or resection with anastomosis and open abdomen with VAC in small intestinal perforation with severe faecal peritonitis is associated with a high rate of leakage and enteroatmospheric fistula formation. TRIAL REGISTRATION The study was approved by the Danish Patient Safety Authority (case number 3-3013-1555/1) and the Danish Data Protection Agency (file number 18/28,404). No funding was received.
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Affiliation(s)
- Pooya Rajabaleyan
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
| | - Rie Overgaard Jensen
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Sören Möller
- OPEN, Open Patient data Explorative Network, Department of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Niels Qvist
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Mark Bremholm Ellebaek
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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6
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Kirkpatrick AW, Coccolini F, Tolonen M, Minor S, Catena F, Gois E, Doig CJ, Hill MD, Ansaloni L, Chiarugi M, Tartaglia D, Ioannidis O, Sugrue M, Colak E, Hameed SM, Lampela H, Agnoletti V, McKee JL, Garraway N, Sartelli M, Ball CG, Parry NG, Voght K, Julien L, Kroeker J, Roberts DJ, Faris P, Tiruta C, Moore EE, Ammons LA, Anestiadou E, Bendinelli C, Bouliaris K, Carroll R, Ceresoli M, Favi F, Gurrado A, Rezende-Neto J, Isik A, Cremonini C, Strambi S, Koukoulis G, Testini M, Trpcic S, Pasculli A, Picariello E, Abu-Zidan F, Adeyeye A, Augustin G, Alconchel F, Altinel Y, Hernandez Amin LA, Aranda-Narváez JM, Baraket O, Biffl WL, Baiocchi GL, Bonavina L, Brisinda G, Cardinali L, Celotti A, Chaouch M, Chiarello M, Costa G, de'Angelis N, De Manzini N, Delibegovic S, Di Saverio S, De Simone B, Dubuisson V, Fransvea P, Garulli G, Giordano A, Gomes C, Hayati F, Huang J, Ibrahim AF, Huei TJ, Jailani RF, Khan M, Luna AP, Malbrain MLNG, Marwah S, McBeth P, Mihailescu A, Morello A, Mulita F, Murzi V, Mohammad AT, Parmar S, Pak A, Wong MPK, Pantalone D, Podda M, Puccioni C, Rasa K, Ren J, Roscio F, Gonzalez-Sanchez A, Sganga G, Scheiterle M, Slavchev M, Smirnov D, Tosi L, Trivedi A, Vega JAG, Waledziak M, Xenaki S, Winter D, Wu X, Zakaria AD, Zakaria Z. The unrestricted global effort to complete the COOL trial. World J Emerg Surg 2023; 18:33. [PMID: 37170123 PMCID: PMC10173926 DOI: 10.1186/s13017-023-00500-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. METHODS The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. DISCUSSION OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. TRIAL REGISTRATION National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).
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Affiliation(s)
- Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, EG23T2N 2T9, Canada.
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Samuel Minor
- Departments of Critical Care Medicine and Surgery, Dalhousie University, Halifax, NS, Canada
| | - Fausto Catena
- Department of Surgery, Bufalini Hospital, Cesena, Italy
| | - Emanuel Gois
- Department of Surgery, Londrina State University, and National COOL Coordinator for Brazil, Londrina, Brazil
| | - Christopher J Doig
- Departments of Critical Care Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Luca Ansaloni
- General Surgery I, San Matteo Hospital Pavia, University of Pavia, Pavia, Italy
| | - Massimo Chiarugi
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Dario Tartaglia
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Orestis Ioannidis
- 4th Department of Surgery, Medical School, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", Thessaloniki, Greece
| | | | - Elif Colak
- University of Samsun, Samsun Training and Research Hospital, Samsun, Turkey
| | - S Morad Hameed
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Hanna Lampela
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Espoo, Finland
| | | | - Jessica L McKee
- Global Project Manager, COOL Trial and the TeleMentored Ultrasound Supported Medical Interventions Research Group, Calgary, AB, Canada
| | - Naisan Garraway
- Departments of Surgery and Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Global Alliance for Infections in Surgery, Macerata, Italy
| | - Chad G Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Neil G Parry
- Departments of Surgery and Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Kelly Voght
- Departments of Surgery and Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lisa Julien
- Department of Surgery, NSHA-Queen Elizabeth II Health Sciences Center, Dalhousie University, Halifax, NS, Canada
| | - Jenna Kroeker
- Departments of Surgery and Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery and School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, CO, USA
| | | | - Elissavet Anestiadou
- 4th Department of Surgery, Medical School, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", Thessaloniki, Greece
| | | | - Konstantinos Bouliaris
- General Surgery Department of Koutlimbaneio, Triantafylleio General Hospital of Larissa, Larissa, Thessaly, Greece
| | | | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Francesco Favi
- Chirurgia Generale E d'Urgenza, Ospedale M. Bufalini - Cesena, AUSL Della Romagna, Cesena, Italy
| | - Angela Gurrado
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Joao Rezende-Neto
- Trauma and Acute Care Surgery, General Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Arda Isik
- General Surgery Department, Istanbul Medeniyet University School of Medicine Istanbul, Istanbul, Turkey
| | - Camilla Cremonini
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Silivia Strambi
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Georgios Koukoulis
- General Surgery Department of Koutlimbaneio, Triantafylleio General Hospital of Larissa, Larissa, Thessaly, Greece
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Sandy Trpcic
- Trauma and Acute Care Surgery, General Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Alessandro Pasculli
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Erika Picariello
- General Surgery Unit, Ospedale M. Buffalini Di Cesena, Cesena, Italy
| | - Fikri Abu-Zidan
- College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Ademola Adeyeye
- Division of Surgical Oncology, Afe Babalola University Multisystem Hospital, Ado-Ekiti, Nigeria
| | - Goran Augustin
- University Hospital Centre Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Felipe Alconchel
- Virgen de la Arrixaca University Hospital IMIB-Arrixaca, Ctra. Madrid-Cartagena, S/N, Murcia, Spain
| | - Yuksel Altinel
- Bagcilar Research and Training Hospital, Istanbul, Turkey
| | - Luz Adriana Hernandez Amin
- Nurse Master of Nursing, Professor and Coordinator of the teaching-service relationship, Faculty of Health Sciences, University of Sucre, Sincelejo, Colombia
| | - José Manuel Aranda-Narváez
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital of Málaga, Malaga, Spain
| | | | | | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Luigi Bonavina
- Department of Surgery, University of Milan Medical School, Milan, Italy
| | - Giuseppe Brisinda
- Department of Surgery, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Luca Cardinali
- Department of Surgery, General Hospital Madonna del Soccorso, San Benedetto del Tronto, Italy
| | - Andrea Celotti
- General Surgery Unit, UO Chirurgia Generale - Ospedale Maggiore Di Cremona, Cremona, Italy
| | - Mohamed Chaouch
- Department of Visceral and Digestive Surgery, Monastir University, Monastir, Tunisia
| | - Maria Chiarello
- Department of Surgery, Azienda Sanitaria Provinciale Di Cosenza, Cosenza, Italy
| | - Gianluca Costa
- Fondazione Policlinico Campus Bio-Medico, University Campus Bio-Medico of Rome, Rome, Italy
| | - Nicola de'Angelis
- Colorectal and Digestive Surgery Unit-DIGEST Department, Beaujon University Hospital AP-HP, University Paris Cité, Clichy, France
| | - Nicolo De Manzini
- Department of General Surgery, Cattinara University Hospital, Trieste, Italy
| | - Samir Delibegovic
- Department of Proctology, Clinic for Surgery, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Italy
| | - Belinda De Simone
- Unit of Digestive and Metabolic Minimally Invasive Surgery, Clinique Saint Louis, Poissy, Poissy, Ile de France, France
- Unit of Emergency and General Surgery, Guastalla Hospital, AUSL Reggio Emilia, Guastalla, Italy
| | - Vincent Dubuisson
- Chirurgie Digestive, Service de Chirurgie Vasculaire Et, Générale University Hospital of Bordeaux FR, Bordeaux, France
| | | | | | - Alessio Giordano
- Emergency and General Consultant Surgeon, Nuovo Ospedale "S. Stefano", Azienda ASL Toscana Centro, Prato, Italy
| | - Carlos Gomes
- Surgery Unit, Hospital Universitário Terezinha de Jesus, SUPREMA, Juiz de Fora, Brazil
| | - Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Jinjian Huang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | | | | | | | - Mansoor Khan
- General Surgery, University Hospitals, Sussex, UK
| | | | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
- International Fluid Academy, Lovenjoel, Belgium
| | - Sanjay Marwah
- Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | | | | | - Alessia Morello
- Department of General Surgery, Madonna del Soccorso Hospital - San Benedetto del Tronto, Italy, Italy
| | - Francesk Mulita
- Department of Surgery, General University Hospital of Patras, Rio, Greece
| | - Valentina Murzi
- Department of Surgical Science, Cagliari State University, Cagliari, Italy
| | | | | | - Ajay Pak
- Department of General Surgery, King George's Medical University, Lucknow, UP, India
| | - Michael Pak-Kai Wong
- School of Medical Sciences & Hospital, Universiti Sains Malaysia, Kelantan, Malaysia
| | | | - Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Caterina Puccioni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Kemal Rasa
- Department of General Surgery, Hüseyin Kemal Raşa, Anadolu Medical Center, Kocaeli, Turkey
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Francesco Roscio
- Division of General and Minimally Invasive Surgery, ASST Valle Olona, Busto Arsizio, Italy
| | - Antonio Gonzalez-Sanchez
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital of Málaga, Malaga, Spain
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Maximilian Scheiterle
- Emergency Surgery Unit and Trauma Team, Careggi University Hospital, Florence, Italy
| | | | - Dmitry Smirnov
- Department of Surgery, South Ural State Medical University, Chelyabinsk City, Russia
| | - Lorenzo Tosi
- Department of General Surgery, University of Bologna, Bologna, Italy
| | | | | | | | - Sofia Xenaki
- Department of General Surgery, University Hospital of Heraklion, Crete, Greece
| | | | - Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Andee Dzulkarnean Zakaria
- Department of Surgery, School of Medical Sciences and Hospital USM, Universiti Sains Malaysia, Georgetown, Malaysia
| | - Zaidi Zakaria
- Department of Surgery, School of Medical Sciences and Hospital USM, Universiti Sains Malaysia, Georgetown, Malaysia
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Gebran A, Proaño-Zamudio JA, Argandykov D, Dorken-Gallastegi A, Renne AM, Parks JJ, Kaafarani HMA, Paranjape C, Velmahos GC, Hwabejire JO. Association of Comorbidities and Functional Level With Mortality in Geriatric Bowel Perforation. J Surg Res 2023; 285:90-99. [PMID: 36652773 DOI: 10.1016/j.jss.2022.12.027] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 11/11/2022] [Accepted: 12/25/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Spontaneous bowel perforation is associated with high morbidity and mortality. This entity remains understudied in the geriatric patient. We sought to use a national surgical sample to uncover independent predictors of mortality in elderly patients undergoing emergent operation for perforated bowel. METHODS Using the American College of Surgeons National Surgical Quality Improvement database, years 2007 to 2017, all geriatric patients (age ≥65 y) who underwent emergency surgery and who had a postoperative diagnosis of bowel perforation were included. Univariate and multivariable analyses were used to identify independent predictors of 30-d mortality. RESULTS A total of 8981 patients were included. The median (interquartile range) age was 75 y (69, 82), and 59.0% were female. Twenty-one percent of patients were partially or totally dependent, and 25.2% were admitted from sources other than home. Overall, 30-d mortality rate was 22.1%. Independent predictors of mortality included the following: age 70-79 y (odds ratio [OR]: 1.59, P < 0.001), age ≥80 y (OR: 3.23, P < 0.001), American Society of Anesthesiologists ≥3 (OR: 4.74, P < 0.001), admission from chronic care facility (OR: 1.61, P < 0.001), being partially or totally dependent (OR: 1.50, P < 0.001), chronic steroid use (OR: 1.36, P < 0.001), and preoperative septic shock (OR: 3.74, P < 0.001). Having immediate fascial closure was protective against mortality (immediate fascial closure only, OR: 0.55, P < 0.001; -immediate closure of all surgical site layers, OR: 0.44, P < 0.001). CONCLUSIONS In geriatric patients, functional status and chronic steroid therapy play an important role in determining survival following surgery for bowel perforation. These factors should be considered during preoperative counseling and decision-making.
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Affiliation(s)
- Anthony Gebran
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ander Dorken-Gallastegi
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela M Renne
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Charudutt Paranjape
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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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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Amano K, Okabe M, Yoshida T, Oba J, Yoshida S, Wakasugi M, Usui A, Nakata Y, Okudera H. Hyperdry Human Amniotic Membrane as a Protective Dressing for Open Wounds With Exposed Bowel in Mice. J Surg Res 2023; 283:898-913. [PMID: 36915018 DOI: 10.1016/j.jss.2022.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 07/02/2021] [Revised: 07/28/2022] [Accepted: 09/15/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION An enteroatmospheric fistula forms when the exposed bowel is perforated with chronic enteric fistula formation. Currently, there is no established preventative method for this condition. Hyperdry (HD) amniotic membrane (AM) can promote early granulation tissue formation on the exposed viscera and is suitable for dressing intractable wounds as it possesses anti-inflammatory, antibacterial, and immunomodulatory properties. This study investigated whether HD-AM promotes early formation of blood vessel-containing granulation tissue for enteroatmospheric fistula treatment. METHODS An experimental animal model of an open wound with exposed bowel was developed. A 15 × 20 mm wound was prepared on the abdomen of Institute of Cancer Research mice, and the HD-AM was placed. The mice were assigned to one of the following groups: HD-AM group, in which the stromal layer of the HD-AM was placed in contact with the exposed bowel; HD-AM UD group, in which the epithelial layer of the HD-AM was placed in contact with the exposed bowel; and the HD-AM (-) or control group, in which the HD-AM was not used. RESULTS On postoperative days 7 and 14, granulation tissue thickness significantly increased in the HD-AM and HD-AM UD groups compared with that in the HD-AM (-) group. Macrophages accumulated in the HD-AM epithelium only in the HD-AM group. During HD-AM contact, a subset of invading macrophages switched from M1 to M2 phenotype. CONCLUSIONS HD-AM is a practical wound dressing with its scaffolding function, regulation of TGF β-1 and C-X-C motif chemokine 5 (CXCL-5), and ability to induce M1-to-M2 macrophage conversion.
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Affiliation(s)
- Koji Amano
- Department of Emergency Surgery, Sakai City Medical Center, Sakai, Osaka, Japan
| | - Motonori Okabe
- Department of Regenerative Medicine, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Toyama, Japan
| | - Toshiko Yoshida
- Department of Clinical Biomaterial Application, Medical, University of Toyama, Toyama, Japan.
| | - Jiro Oba
- Department of Emergency & Disaster Medicine, Juntendo University School of Medicine/Graduate School of Medicine, Tokyo, Japan
| | - Satoshi Yoshida
- Department of Regenerative Medicine, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Toyama, Japan
| | - Masahiro Wakasugi
- Department of Emergency and Disaster Medicine, University of Toyama, Toyama, Toyama, Japan
| | - Akihiro Usui
- Department of Emergency Surgery, Sakai City Medical Center, Sakai, Osaka, Japan
| | - Yasuki Nakata
- Department of Emergency Surgery, Sakai City Medical Center, Sakai, Osaka, Japan
| | - Hiroshi Okudera
- Department of Emergency and Disaster Medicine, University of Toyama, Toyama, Toyama, Japan
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Li HY, Wang ZX, Wang JC, Zhang XD. Clostridium perfringens gas gangrene caused by closed abdominal injury: A case report and review of the literature. World J Clin Cases 2023; 11:852-858. [PMID: 36818624 PMCID: PMC9928709 DOI: 10.12998/wjcc.v11.i4.852] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/28/2022] [Accepted: 01/09/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Abdominal Clostridium perfringens (C. perfringens) gas gangrene is a rare infection that has been described in the literature as most frequently occurring in postoperative patients with open trauma. Intra-abdominal gas gangrene caused by C. perfringens infection after closed abdominal injury is extremely rare, difficult to diagnose, and progresses rapidly with high mortality risk. Here, we report a case of C. perfringens infection caused by closed abdominal injury.
CASE SUMMARY A 54-year-old male suffered multiple intestinal tears and necrosis after sustaining an injury caused by falling from a high height. These injuries and the subsequent necrosis resulted in intra-abdominal C. perfringens infection. In the first operation, we removed the necrotic intestinal segment, kept the abdomen open and covered the intestine with a Bogota bag. A vacuum sealing drainage system was used to cover the outer layer of the Bogota bag, and the drainage was flushed under negative pressure. The patient was transferred to the intensive care unit for supportive care and empirical antibiotic treatment. The antibiotics were not changed until the results of bacterial culture and drug susceptibility testing were obtained. Two consecutive operations were then performed due to secondary intestinal necrosis. After three definitive operations, the patient successfully survived the perioperative period. Unfortunately, he died of complications related to Guillain-Barre syndrome 75 d after the first surgery. This paper presents this case of intra-abdominal gas gangrene infection and analyzes the diagnosis and treatment based on a review of current literature.
CONCLUSION When the intestines rupture leading to contamination of the abdominal cavity by intestinal contents, C. perfringens bacteria normally present in the intestinal tract may proliferate in large numbers and lead to intra-abdominal infection. Prompt surgical intervention, adequate drainage, appropriate antibiotic therapy, and intensive supportive care comprise the most effective treatment strategy. If the abdominal cavity is heavily contaminated, an open abdominal approach may be a beneficial treatment.
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Affiliation(s)
- He-Yun Li
- Department of Intensive Care Unit, Shaanxi Nuclear Industry 215 Hospital, Xianyang 712000, Shaanxi Province, China
| | - Zhi-Xiang Wang
- Department of General Surgery, Shaanxi Nuclear Industry 215 Hospital, Xianyang 712000, Shaanxi Province, China
| | - Jian-Chun Wang
- Department of Healthcare-associate Infection Management, Shaanxi Nuclear Industry 215 Hospital, Xianyang 712000, Shaanxi Province, China
| | - Xiao-Di Zhang
- Department of General Surgery, Shaanxi Nuclear Industry 215 Hospital, Xianyang 712000, Shaanxi Province, China
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11
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Rodríguez-Silverio JE, García-Núñez LM, Hernández-García EF, Noyola-Villalobos HF, Moreno-Delagado LF. Enteroatmospheric fistulas in open abdomen in trauma associated with abdominal reintervention and VAC therapy. CIR CIR 2023; 91:658-663. [PMID: 37844886 DOI: 10.24875/ciru.22000419] [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] [Received: 08/18/2022] [Accepted: 11/09/2022] [Indexed: 10/18/2023]
Abstract
BACKGROUND Open abdomen is an alternative for the management of trauma patient, and negative pressure therapy of the wound using VAC® device is a genuine sort of treatment. Although the device poses technical advantages, risks are present and a critical complication is the enteroatmospheric fistula formation (EAF). OBJECTIVE To analize the role of negative pressure therapy length and VAC® device number of changes on the EAF formation in trauma patients udergoing open abdomen. METHOD Cut-off points were calculated using receiver operational characteristics curve. Values were compared with Student's t or Mann-Withney U tests, considering statistically significant p < 0.05. RESULTS EAF were present in 39 cases (5.9%). A significant difference in the presence of EAF was present in patients with negative pressure therapy of the wound length ≥ 11.2 days (46.9 vs. 1.3%; relative risk [RR]: 3.67; 95% confidence interval [95% IC]: 2.4-6.68; p = 0.017) and when ≥ 2.6 VAC® device changes were performed (34.6 vs. 0.5%; RR: 6.92; 95% IC: 1.1-4.3; p < 0.001). CONCLUSIONS At our institution, the practice of >3 VAC® device changes and length of therapy > 11 days should be carefully considered leading to reduce the risk of EAF formation.
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Affiliation(s)
- Jesús E Rodríguez-Silverio
- Departamento de Cirugía General, Hospital Central Militar, Secretaría de la Defensa Nacional
- Escuela Militar de Graduados de Sanidad, Universidad del Ejército y Fuerza Aérea. Ciudad de México, México
| | - Luis M García-Núñez
- Departamento de Cirugía General, Hospital Central Militar, Secretaría de la Defensa Nacional
- Escuela Militar de Graduados de Sanidad, Universidad del Ejército y Fuerza Aérea. Ciudad de México, México
| | - Edgar F Hernández-García
- Departamento de Cirugía General, Hospital Central Militar, Secretaría de la Defensa Nacional
- Escuela Militar de Graduados de Sanidad, Universidad del Ejército y Fuerza Aérea. Ciudad de México, México
| | - Héctor F Noyola-Villalobos
- Departamento de Cirugía General, Hospital Central Militar, Secretaría de la Defensa Nacional
- Escuela Militar de Graduados de Sanidad, Universidad del Ejército y Fuerza Aérea. Ciudad de México, México
| | - Luis F Moreno-Delagado
- Departamento de Cirugía General, Hospital Central Militar, Secretaría de la Defensa Nacional
- Escuela Militar de Graduados de Sanidad, Universidad del Ejército y Fuerza Aérea. Ciudad de México, México
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Wang K, Deng YX, Li KW, Wang XY, Yang C, Ding WW. Multiple portions enteral nutrition and chyme reinfusion of a blunt bowel injury patient with hyperbilirubinemia undergoing open abdomen: A case report. Chin J Traumatol 2022:S1008-1275(22)00139-0. [PMID: 36635154 PMCID: PMC10388244 DOI: 10.1016/j.cjtee.2022.12.009] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/21/2022] [Accepted: 10/15/2022] [Indexed: 12/24/2022] Open
Abstract
Blunt bowel injury (BBI) is relatively rare but life-threatening when delayed in surgical repair or anastomosis. Providing enteral nutrition (EN) in BBI patients with open abdomen after damage control surgery is challenging, especially for those with discontinuity of the bowel. Here, we report a 47-year-old male driver who was involved in a motor vehicle collision and developed ascites on post-trauma day 3. Emergency exploratory laparotomy at a local hospital revealed a complete rupture of the jejunum and then primary anastomosis was performed. Postoperatively, the patient was transferred to our trauma center for septic shock and hyperbilirubinemia. Following salvage resuscitation, damage control laparotomy with open abdomen was performed for abdominal sepsis, and a temporary double enterostomy (TDE) was created where the anastomosis was ruptured. Given the TDE and high risk of malnutrition, multiple portions EN were performed, including a proximal portion EN support through a nasogastric tube and a distal portion EN via a jejunal feeding tube. Besides, chyme delivered from the proximal portion of TDE was injected into the distal portion of TDE via a jejunal feeding tube. Hyperbilirubinemia was alleviated with the increase in chyme reinfusion. After 6 months of home EN and chyme reinfusion, the patient finally underwent TDE reversal and abdominal wall reconstruction and was discharged with a regular diet. For BBI patients with postoperative hyperbilirubinemia who underwent open abdomen, the combination of multiple portions EN and chyme reinfusion may be a feasible and safe option.
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Affiliation(s)
- Kai Wang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Yun-Xuan Deng
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Kai-Wei Li
- The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, China
| | - Xin-Yu Wang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Chao Yang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Wei-Wei Ding
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China.
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Suzuki S, Yamamoto R, Hori S, Kitago M, Kitagawa Y, Sasaki J. Incisional wound closure by sequential partial split-thickness skin grafting following failure of primary abdominal fascia closure after open abdomen management: A case report. Int J Surg Case Rep 2022; 101:107802. [PMID: 36446160 DOI: 10.1016/j.ijscr.2022.107802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Open abdomen (OA) is a widely used technique for managing abdominal organ injury, abdominal compartment syndrome, and abdominal sepsis. While various methods have contributed to successful primary closure of the abdominal fascia after OA, some patients still develop enteroatmospheric fistulas that impede abdominal fascia closure. We report a case of successful epithelialization of the incision by sequential partial split-thickness skin grafting (STSG) in a patient who had failure in primary abdominal fascia closure due to enteroatmospheric fistulas after OA for incisional dehiscence and anastomotic leakage. PRESENTATION OF CASE A 73-year-old male patient underwent pancreaticoduodenectomy for duodenal adenocarcinoma. The abdominal incision was then necrosed and dehisced due to anastomotic leakage on postoperative day (POD) 6, and multiple intra-abdominal lavages with OA were performed. On POD 15, the patient developed enteroatmospheric fistulas; thus, primary fascia closure was considered impossible. On PODs 72 and 106, STSG was conducted on the granulation tissue at the incisional wound, and complete epithelialization was achieved on POD 111. DISCUSSION Sequential partial STSG only needed basic surgical skills and standard devices for surgery. CONCLUSION We reported the case with successful epithelialization of the incision by sequential partial STSG, in which primary abdominal fascia closure was failed due to enteroatmospheric fistulas after OA for incisional dehiscence and anastomotic leakage.
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Brown J, Warnock B, Turk E, Hobson MJ, Friedman ML, Gray BW. Open abdomen during extracorporeal membrane oxygenation is a safe and effective treatment for abdominal compartment syndrome. J Pediatr Surg 2022; 57:216-222. [PMID: 34953565 DOI: 10.1016/j.jpedsurg.2021.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/04/2021] [Accepted: 11/17/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND/PURPOSE Decompressive laparotomy and open abdomen for abdominal compartment syndrome have been historically avoided during Extracorporeal Membrane Oxygenation (ECMO) due to seemingly elevated risks of bleeding and infection. Our goal was to evaluate a cohort of pediatric respiratory ECMO patients who underwent decompressive laparotomy with open abdomen at a single institution and to compare these patients to ECMO patients without open abdomen. METHODS We reviewed all pediatric respiratory ECMO (30 days-18 years) patients treated with decompressive laparotomy with open abdomen at Riley Hospital for Children (1/2000-12/2019) and compared these patients to concurrent respiratory ECMO patients with closed abdomen. We excluded patients with surgical cardiac disease. We assessed demographics, ECMO data, and outcomes and defined significance as p = 0.05. RESULTS 6 of 81 ECMO patients were treated with decompressive laparotomy and open abdomen. Open and closed abdomen groups had similar age (p = 0.223) and weight (0.286) at cannulation, but the open abdomen group had a higher reliance on vasoactive medications (Vasoactive Inotropic Score, p = 0.040). Open abdomen group survival was similar to closed abdomen patients (66.7%, vs 62.7%, p = 1). Open abdomen patients had lower incidence of ECMO complications (33.3% vs 83.6%, p = 0.014), but the groups had similar bleeding complications (p = 0.412) and PRBC transfusion volume (p = 0.941). CONCLUSION/IMPACT Pediatric ECMO patients with open abdomen after decompressive laparotomy had similar survival, blood products administered, and complications as those with a closed abdomen. An open abdomen is not a contra-indication to ECMO support in pediatric respiratory patients and should be considered in select patients.
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Affiliation(s)
- Joshua Brown
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brielle Warnock
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eamaan Turk
- Dow Medical College, Karachi, Sindh, Pakistan
| | - Michael J Hobson
- Indiana University School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care, 705 Riley Hospital Drive RI5900, Indianapolis, IN, 46202, USA; Riley Hospital for Children, Section of Pediatric Critical Care, 705 Riley Hospital Drive, Phase 2, Suite 4900, Indianapolis, IN, 46202, USA
| | - Matthew L Friedman
- Indiana University School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care, 705 Riley Hospital Drive RI5900, Indianapolis, IN, 46202, USA; Riley Hospital for Children, Section of Pediatric Critical Care, 705 Riley Hospital Drive, Phase 2, Suite 4900, Indianapolis, IN, 46202, USA
| | - Brian W Gray
- Riley Hospital for Children, Section of Pediatric Surgery, 705 Riley Hospital Drive RI2500, Indianapolis, IN, 46202, USA; Indiana University, School of Medicine, Department of Surgery, 545 Barnhill Dr., Emerson Hall, Indianapolis, IN, 46202, USA.
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Torretta A, Kaludova D, Roy M, Bhattacharya S, Valente R. Simultaneous early surgical repair of post-cholecystectomy major bile duct injury and complex abdominal evisceration: A case report. Int J Surg Case Rep 2022; 94:107110. [PMID: 35658286 PMCID: PMC9093007 DOI: 10.1016/j.ijscr.2022.107110] [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: 02/25/2022] [Revised: 04/16/2022] [Accepted: 04/16/2022] [Indexed: 10/30/2022] Open
Abstract
BACKGROUND Major bile duct injuries (BDIs) are hazardous complications during 0.4%-0.6% of laparoscopic cholecystectomies. Major BDIs usually require surgical repair, ideally either immediately or at least six weeks after the damage. The complexity of our case lies in the coexistence of early BDI followed by 2-week biliary peritonitis with massive midline evisceration which, in combination, has over 40% mortality risk. METHODS & CASE REPORT We describe the case of a 65-year-old male, transferred to our tertiary HPB service on day 14 after common bile duct complete transection during cholecystectomy and postoperative laparotomy. The patient presented with biliary peritonitis along with full wound dehiscence and extensive evisceration. During emergency peritoneal wash-out surgery we deemed immediate BDI repair feasible by primary Roux-en-Y hepaticojejunostomy (HJ), with multi-stage abdominal closure. In the following days we performed progressive abdominal wall closure in multiple sessions under general anesthesia, aided by vacuum-assisted wound closure and intraperitoneal mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh. DISCUSSION & CONCLUSION The simultaneous use of Roux-en-Y HJ and VAWCM has proven safe and effective in the treatment of BDI and 2-week biliary peritonitis with massive midline evisceration.
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Affiliation(s)
- Alfredo Torretta
- Department of General Surgery, "Val Vibrata" Hospital, ASL Teramo, Italy; HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK
| | - Dimana Kaludova
- HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK.
| | - Mayank Roy
- HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK
| | - Satya Bhattacharya
- HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK.
| | - Roberto Valente
- HPB Surgery Service, Barts and the London Centre, Barts Health NHS Trust, London, UK; Department of Surgery and Interventional Science, University College London, UK; Department of Surgery, Ospedale Policlinico San Martino Genova, Italy.
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Travis TE, Prindeze NJ, Shupp JW, Sava JA. Intra-Abdominal Pressure Monitoring During Negative Pressure Wound Therapy in the Open Abdomen. J Surg Res 2022; 278:100-10. [PMID: 35597024 DOI: 10.1016/j.jss.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/11/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Negative pressure wound therapy (NPWT) is commonly used in open abdomen management, where there may be a simultaneous need for prevention of abdominal hypertension, tamponade of hemorrhage, and continuous fascial tension. The regional pressure dynamics of vacuum dressings are poorly understood. METHODS Three duroc swine underwent mid-line laparotomy and application of vacuum open abdomen dressing, with and without sponge packing. Twenty-five catheters were placed throughout the abdomen to capture and record pressures in each quadrant as the vacuum system was ranged between (-75 mmHg to -200 mmHg pressure). Vital signs and ventilator pressures were measured and recorded concomitantly. RESULTS No variations in ventilatory pressures or vital signs were observed with any setting. NPWT changed pressure in seven of seventy-five catheters (9%), five of which were related to abdominal packing. When data were grouped into abdominal wall, perihepatic, perisplenic, and deep abdominal regions, there was no significant change in abdominal pressure when packing was absent. With packing, only the abdominal wall region showed a pressure change, reaching a maximum of 20% of the set vacuum pressure. CONCLUSIONS NPWT does only little to change the intraabdominal pressure, except in superficial locations in packed abdomens and does not appear to cause hemodynamic changes in a porcine open abdomen model. While NPWT may play an important role in fluid scavenging and fascial tensioning, there are likely to be few benefits or drawbacks specifically related to negative abdominal pressure in the deep abdomen.
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Fung S, Ashmawy H, Krieglstein C, Halama T, Schilawa D, Fuckert O, Hees A, Kröpil F, Rehders A, Lehwald-Tywuschik NC, Knoefel WT. Vertical traction device prevents abdominal wall retraction and facilitates early primary fascial closure of septic and non-septic open abdomen. Langenbecks Arch Surg 2022; 407:2075-2083. [PMID: 35147749 PMCID: PMC8832079 DOI: 10.1007/s00423-021-02424-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/23/2021] [Indexed: 12/04/2022]
Abstract
Purpose One of the major challenges in the management of patients with septic and non-septic open abdomen (OA) is to control abdominal wall retraction. The aim of this study was to evaluate the impact of a novel vertical traction device (VTD) on primary fascial closure (PFC) and prevention of fascial retraction. Methods Twenty patients treated with OA were included in this retrospective multicenter study. All patients were initially stabilized with laparostomy and the abdomen temporarily sealed either with a Bogotá bag or a negative pressure wound therapy system (NPWT). Results The mean duration of OA and fascia-to-fascia distance (FTF) prior to the VTD application were 3 days and 15 cm, respectively. At relook laparotomy 48 h after VTD implementation, the mean FTF distance significantly decreased to 10 cm (p = 0.0081). In all cases, PFC was achieved after a mean period of 7 days. Twelve patients received the VTD in combination with a NPWT, whereas in eight patients, the device was combined with an alternative temporary abdominal closure system (TAC). Although not statistically significant, the FTF distance remarkably decreased in both groups at relook laparotomy 48 h following the device implementation. The mean periods of PFC for patients with septic and non-septic OA were comparable (7.5 vs. 7 days). During follow-up, two patients developed an incisional hernia. Conclusion Vertical traction device prevents fascial retraction and facilitates early PFC in OA. In combination with NPWT, rapid fascial closure of large abdominal defects can be achieved.
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Affiliation(s)
- Stephen Fung
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Hany Ashmawy
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Christian Krieglstein
- Department of Surgery, St. Elisabeth Krankenhaus Köln, Werthmannstr. 1, 50935 Cologne, Germany
| | - Thomas Halama
- Department of Surgery, St. Vinzenz-Hospital, Merheimer Str. 221-223, 50733 Cologne, Germany
| | - Dustin Schilawa
- Department of Surgery, St. Rochus Krankenhaus, Glückaufstraße 10, 44575 Castrop-Rauxel, Germany
| | - Oliver Fuckert
- Department of Surgery, Lukas Krankenhaus, Hindenburgstraße 56, 32257 Bünde, Germany
| | - Anita Hees
- Department of Surgery, St.-Marien Krankenhaus, Kampenstraße 51, 57072 Siegen, Germany
| | - Feride Kröpil
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Alexander Rehders
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Nadja C. Lehwald-Tywuschik
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Surgery (A), Heinrich Heine University and University Hospital Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany
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Athas V, Burtt K, Berne J, Lozada J. Delayed traumatic rupture of ovarian endometrioma on re-exploration after blunt abdominal trauma. Trauma Case Rep 2022; 37:100578. [PMID: 34917742 DOI: 10.1016/j.tcr.2021.100578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/24/2022] Open
Abstract
Traumatic rupture of an ovarian endometrioma is extremely rare injury. We describe a case of a 63-year-old female presenting after a motor vehicle crash (MVC) with complex abdominal injuries requiring exploratory laparotomy that was complicated by delayed presentation of an ovarian endometrioma rupture on second look laparotomy. During the repeat exploration of the abdomen, multiple regions of small bowel and the pelvic floor were noted to be covered with a brown-colored material which was concerning for fecal matter from a missed enterotomy. The patient was kept open for an additional 24 h providing time for occult injuries to reveal themselves and for proper mechanical preparation of the rectum to perform rigid sigmoidoscopy, essential to definitively rule out a missed injury in this rare situation.
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Ribeiro-Junior MAF, Costa CTK, de Souza Augusto S, Néder PR, Elia YGB, Rattan R, Di Saverio S; Peritoneal Resuscitation Study Group. The role of direct peritoneal resuscitation in the treatment of hemorrhagic shock after trauma and in emergency acute care surgery: a systematic review. Eur J Trauma Emerg Surg 2021. [PMID: 34773466 DOI: 10.1007/s00068-021-01821-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/25/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Direct peritoneal resuscitation (DPR) has been used to help preserve microcirculation by reversing vasoconstriction and hypoperfusion associated with the pathophysiological process of shock, which can occur despite appropriate intravenous resuscitation. This approach depends on infusing a hyperosmolar solution intraperitoneally via a percutaneous catheter with the tip ending near the pelvis or the root of the mesentery. The abdomen is usually left open with a negative pressure abdominal dressing to continuously evacuate the infused dialysate. Hypertonicity of the solution triggers visceral vasodilation to help maintain blood flow, even during shock, and is also associated with reduced local inflammatory cytokines and other mediators, preservation of endothelial cell function, and mitigation of organ edema and necrosis. It also has a direct effect on liver perfusion and edema, more rapidly corrects electrolyte abnormalities compared to intravenous resuscitation alone, and may requireless intravenous fluid to stabilize blood pressure, all of which shortens the time required to close patients' abdomen. METHODS An online query using the search term "direct peritoneal resuscitation" was carried out in PubMed, MEDLINE and SciELO, limited to publications indexed from January 2014 to June 2020. Of the 20 articles returned, full text was able to be obtained for 19. A manual review of included articles' references was resulted in the addition of 1 article, for a total of 20 included articles. RESULTS The 20 articles were comprised of 15 animal studies, 4 clinical studies,and 1 expert opinion. The benefits include both local and possibly systemic effects on perfusion, hypoxia, acidosis, and inflammation, and are associated with improved outcomes and reduced complications. CONCLUSION DPR shows promise in patients with hemorrhagic shock, septic shock, and other conditions resulting in an open abdomen after damage control laparotomy.
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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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Brillantino A, Lanza M, Antropoli M, Amendola A, Squillante S, Bottino V, Renzi A, Castriconi M. Usefulness of damage control approach in patients with limited acute mesenteric ischemia: a prospective study of 85 patients. Updates Surg 2021; 74:337-342. [PMID: 34686970 DOI: 10.1007/s13304-021-01192-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Received: 11/24/2020] [Accepted: 10/10/2021] [Indexed: 02/03/2023]
Abstract
To evaluate the efficacy of the damage control approach by two-step surgical procedure in not critical patients (without sepsis or septic shock) with peritonitis from limited acute mesenteric ischemia. From April 2013 to April 2020, 85 patients [49 (57.7%) women and 36 (42.3%) men, median age 69.5 (range 38-92)] were enrolled in this study and underwent emergency surgery. After resection of ischemic bowel, basing on the individual decision of the single surgeon, the patients underwent primary end-to-end anastomosis (Group 1) or damage control approach (Group 2) including primary laparotomy with resection of ischemic bowel, temporary abdominal closure and a second-look procedure at 48 h with re-evaluation of bowel vitality. Forty-seven (55.3%) patients underwent one-stage surgical treatment and 38 (44.7%) patients received a two-step procedure. In the latter group, at second exploration, 8 (21%) patients required a further intestinal resection, due to mesenteric ischemia progression. Both anastomosis dehiscence rate and need for ileostomy in Group 1 patients were significantly higher than in Group 2 (23.4% vs 5.3%: p = 0.03 and 19.1% vs 2.6%: p = 0.03; Fisher's exact test). No significative differences in mortality and morbidity rate were found between the two groups. The damage control approach by two-step surgical procedure may represent a valid innovative option in the management of not critical patients with limited acute mesenteric ischemia, achieving a better clinical outcome if compared with surgical treatment by one-step procedure.
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Affiliation(s)
- Antonio Brillantino
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy.
| | - Michele Lanza
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Massimo Antropoli
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Alfonso Amendola
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Simone Squillante
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
| | - Vincenzo Bottino
- Department of Surgery, "Villa Betania" Hospital, Via Argine 604, 80147, Naples, Italy
| | - Adolfo Renzi
- Department of Surgery, "Buonconsiglio Fatebenefratelli" Hospital, Via Alessandro Manzoni 220, 80123, Naples, Italy
| | - Maurizio Castriconi
- Department of Surgery, "A. Cardarelli" Hospital, Via A. Cardarelli 9, 80131, Naples, Italy
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Willms A, Güsgen C, Schwab R, Lefering R, Schaaf S, Lock J, Kollig E, Jänig C, Bieler D. Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®. Langenbecks Arch Surg 2021; 407:805-817. [PMID: 34611749 DOI: 10.1007/s00423-021-02344-0] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma. METHODS Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene. RESULTS The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004). CONCLUSION DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.
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Affiliation(s)
- Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Christoph Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany.
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Sebastian Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Johan Lock
- Department of General, Transplantation, Vascular and Paediatric Surgery, University Hospital of Würzburg, VisceralWürzburg, Germany
| | - Erwin Kollig
- Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery, and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany
| | - Christoph Jänig
- Department of Anesthesiology and Intensive Care, German Armed Forces Central Hospital, Koblenz, Germany
| | - Dan Bieler
- Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery, and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany.,Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Medical School, Düsseldorf, Germany
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Akashi Y, Ogawa K, Sasaki K, Kim J, Enomoto T, Hisakura K, Ohara Y, Owada Y, Takahashi K, Shimomura O, Hashimoto S, Sekido M, Oda T. Delayed primary fascia closure of Björck grade 4 open abdomen with enteroatmospheric fistulas after repeated surgery for adhesive small bowel obstruction: a case report. BMC Surg 2021; 21:333. [PMID: 34452624 PMCID: PMC8394647 DOI: 10.1186/s12893-021-01329-6] [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: 03/16/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An open abdomen with frozen adherent bowels is classified as grade 4 in Björck's open abdomen classification, and skin grafting after wound granulation is a typical closure option. We achieved delayed primary fascia closure for a patient who developed open abdomen with enteroatmospheric fistulas due to severe adherent small bowel obstruction. We present here the details of his management. CASE PRESENTATION A 52-year-old man suffered acute abdominal pain during a flight and received an emergency laparotomy due to adhesive small bowel obstruction. Repeated laparotomies were required, and later open abdomen and proximal site jejunostomy were selected. After negative pressure wound therapy, he was transferred to our institution. Two enteroatmospheric fistulas emerged on the exposed intestine, and we diagnosed the condition as a Björck grade 4 open abdomen. After 8 months of wound care and parenteral nutrition, we decided to attempt primary wound closure because the patient required permanent oral restriction and total parenteral nutrition due to short bowel syndrome. A circular incision along the circumference of the exposed bowel allowed us to take a safe approach into the abdominal cavity. We removed the intestinal adhesions completely and resected the bowels, including the fistulas and anastomosed parts. Finally, the abdominal wall defect was reconstructed using the component separation technique, and the patient was discharged without an ostomy. CONCLUSIONS Primary fascia closure for grade 4 open abdomen is hard, but leaving a long interval before radical surgery and applying pertinent wound management may help solve this adverse situation.
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Affiliation(s)
- Yoshimasa Akashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan.
| | - Koichi Ogawa
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Kaoru Sasaki
- Department of Plastic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Jaejeong Kim
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Tsuyoshi Enomoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Katsuji Hisakura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Yusuke Ohara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Yohei Owada
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Kazuhiro Takahashi
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Osamu Shimomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Shinji Hashimoto
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Mitsuru Sekido
- Department of Plastic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Tatsuya Oda
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
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Petersen S, Huber M, Storni F, Puhl G, Deder A, Prause A, Schefold JC, Doll D, Schober P, Luedi MM. Outcome in patients with open abdomen treatment for peritonitis: a multidomain approach outperforms single domain predictions. J Clin Monit Comput 2021. [PMID: 34247307 DOI: 10.1007/s10877-021-00743-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/07/2021] [Indexed: 11/12/2022]
Abstract
Numerous patient-related clinical parameters and treatment-specific variables have been identified as causing or contributing to the severity of peritonitis. We postulated that a combination of clinical and surgical markers and scoring systems would outperform each of these predictors in isolation. To investigate this hypothesis, we developed a multivariable model to examine whether survival outcome can reliably be predicted in peritonitis patients treated with open abdomen. This single-center retrospective analysis used univariable and multivariable logistic regression modeling in combination with repeated random sub-sampling validation to examine the predictive capabilities of domain-specific predictors (i.e., demography, physiology, surgery). We analyzed data of 1,351 consecutive adult patients (55.7% male) who underwent open abdominal surgery in the study period (January 1998 to December 2018). Core variables included demographics, clinical scores, surgical indices and indicators of organ dysfunction, peritonitis index, incision type, fascia closure, wound healing, and fascial dehiscence. Postoperative complications were also added when available. A multidomain peritonitis prediction model (MPPM) was constructed to bridge the mortality predictions from individual domains (demographic, physiological and surgical). The MPPM is based on data of n = 597 patients, features high predictive capabilities (area under the receiver operating curve: 0.87 (0.85 to 0.90, 95% CI)) and is well calibrated. The surgical predictor “skin closure” was found to be the most important predictor of survival in our cohort, closely followed by the two physiological predictors SAPS-II and MPI. Marginal effects plots highlight the effect of individual outcomes on the prediction of survival outcome in patients undergoing staged laparotomies for treatment of peritonitis. Although most single indices exhibited moderate performance, we observed that the predictive performance was markedly increased when an integrative prediction model was applied. Our proposed MPPM integrative prediction model may outperform the predictive power of current models.
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Iacono SA, Krumrei NJ, Niroomand A, Walls DO, Lissauer M, To J, Butts CA. Age Is But a Number: Damage Control Surgery Outcomes in Geriatric Emergency General Surgery. J Surg Res 2021; 267:452-457. [PMID: 34237630 DOI: 10.1016/j.jss.2021.05.051] [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] [Received: 02/15/2021] [Revised: 04/24/2021] [Accepted: 05/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Damage control surgery (DCS) with temporary abdominal closure (TAC) is increasingly utilized in emergency general surgery (EGS). As the population ages, more geriatric patients (GP) are undergoing EGS operations. Concern exists for GP's ability to tolerate DCS. We hypothesize that DCS in GP does not increase morbidity or mortality and has similar rates of primary closure compared to non-geriatric patients (NGP). METHODS A retrospective chart review from 2014-2020 was conducted on all non-trauma EGS patients who underwent DCS with TAC. Demographics, admission lab values, fluid amounts, length of stay (LOS), timing of closure, post-operative complications and mortality were collected. GP were compared to NGP and results were analyzed using Chi square and Wilcox signed rank test. RESULTS Ninety-eight patients (n = 50, <65 y; n = 48, ≥65 y) met inclusion criteria. There was no significant difference in median number of operations (3 versus 2), time to primary closure (2.5 versus 3 d), hospital LOS (19 versus 17.5 d), ICU LOS (11 versus 8 d), rate of primary closure (66% versus 56%), post op ileus (44% versus 48%), abscess (14% versus 10%), need for surgery after closure (32% versus 19%), anastomotic dehiscence (16% versus 6%), or mortality (34% versus 42%). Average time until take back after index procedure did not vary significantly between young and elderly group (45.8 versus 38.5 h; P = 0.89). GP were more likely to have hypertension (83% versus 50%; P ≤ 0.05), atrial fibrillation (25% versus 4%; P ≤ 0.05) and lower median heart rate compared to NGP (90 versus 103; P ≤ 0.05). CONCLUSIONS DCS with TAC in geriatric EGS patients achieves similar outcomes and mortality to younger patients. Indication, not age, should factor into the decision to perform DCS.
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Affiliation(s)
- Stephen A Iacono
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Nicole J Krumrei
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Anna Niroomand
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - David O Walls
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Matthew Lissauer
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jennifer To
- St. Luke's University Health Network, Bethlehem, Pennsylvania
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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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Wang K, Sun SL, Wang XY, Chu CN, Duan ZH, Yang C, Liu BC, Ding WW, Li WQ, Li JS. Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen: a randomized controlled trial. Mil Med Res 2021; 8:36. [PMID: 34099065 DOI: 10.1186/s40779-021-00329-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fluid overload (FO) after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen (OA) patients. Bioelectrical impedance analysis (BIA) is a promising tool for monitoring fluid status and FO. Therefore, we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients. METHODS A pragmatic, prospective, randomized, observer-blind, single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center. A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation (BIA) protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level (HL) measured by BIA or a traditional fluid resuscitation (TRD) in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 days of ICU management. The primary outcome was the 30-day primary fascial closure (PFC) rate. The secondary outcomes included the time to PFC, postoperative 7-day cumulative fluid balance (CFB) and adverse events within 30 days after OA. The Kaplan-Meier method and the log-rank test were utilized for PFC after OA. A generalized linear regression model for the time to PFC and CFB was built. RESULTS A total of 134 patients completed the trial (BIA, n = 66; TRD, n = 68). The BIA patients were significantly more likely to achieve PFC than the TRD patients (83.33% vs. 55.88%, P < 0.001). In the BIA group, the time to PFC occurred earlier than that of the TRD group by an average of 3.66 days (P < 0.001). Additionally, the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml (P < 0.001) and fewer complications. CONCLUSION Among postinjury OA patients in the ICU, the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.
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De Simone B, Davies J, Chouillard E, Di Saverio S, Hoentjen F, Tarasconi A, Sartelli M, Biffl WL, Ansaloni L, Coccolini F, Chiarugi M, De’Angelis N, Moore EE, Kluger Y, Abu-Zidan F, Sakakushev B, Coimbra R, Celentano V, Wani I, Pintar T, Sganga G, Di Carlo I, Tartaglia D, Pikoulis M, Cardi M, De Moya MA, Leppaniemi A, Kirkpatrick A, Agnoletti V, Poggioli G, Carcoforo P, Baiocchi GL, Catena F. WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting. World J Emerg Surg 2021; 16:23. [PMID: 33971899 PMCID: PMC8111988 DOI: 10.1186/s13017-021-00362-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons. METHOD A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019. CONCLUSIONS Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.
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Affiliation(s)
- Belinda De Simone
- Department of Metabolic, Digestive and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, 10 rue du Champ Gaillard, 78303 Poissy, France
| | - Justin Davies
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elie Chouillard
- Department of Metabolic, Digestive and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, 10 rue du Champ Gaillard, 78303 Poissy, France
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy
| | - Frank Hoentjen
- RIMLS - Radboud Institute for Molecular Life Sciences, Radboud University-Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Antonio Tarasconi
- Department of Trauma and Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Walter L. Biffl
- Scripps Memorial Hospital La Jolla, San Diego, California USA
| | - Luca Ansaloni
- Department of Surgery, University Hospital of Pavia, Pavia, Italy
| | - Federico Coccolini
- Department of Emergency and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Massimo Chiarugi
- Department of Emergency and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Nicola De’Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Acquaviva delle Fonti (Bari), Italy
| | - Ernest E. Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital St George, Plovdiv, Bulgaria
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA USA
| | - Valerio Celentano
- Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Hampshire, UK
| | - Imtiaz Wani
- Government Gousia Hospital-Srinagar, Directorate of Health Services-Kashmir, Srinagar, Kashmir India
| | - Tadeja Pintar
- Department of Abdominal Surgery, Umc Ljubljana, Ljubljana, Slovenia
| | - Gabriele Sganga
- Department of Emergency Surgery, “A. Gemelli Hospital”, Catholic University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, General Surgery, Cannizzaro Hospital, Catania, Italy
| | - Dario Tartaglia
- Emergency Surgery Unit & Trauma Center, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - Manos Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National & Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Maurizio Cardi
- Department of Oncological Surgery “P.Valdoni”, Sapienza University, Rome, Italy
| | - Marc A. De Moya
- Trauma/Acute Care Surgery Department, Medical College of Wisconsin/Froedtert Trauma Center, Wauwatosa, Wisconsin USA
| | - Ari Leppaniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Gilberto Poggioli
- Department of Surgical Sciences, Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Paolo Carcoforo
- Department of Surgery, University Hospital of Ferrara, Ferrara, Italy
| | | | - Fausto Catena
- Department of Trauma and Emergency Surgery, Parma University Hospital, Parma, Italy
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Van Orden K, Santos J, Stanfield B, Frost LS, Ruditsky A, Foster A, Brahmbhatt TS, Burke PA, Fernandez-Moure J, Haines K, Agarwal S, Kasotakis G. Bovine versus porcine acellular dermal matrix for abdominal wall herniorrhaphy or bridging. Eur J Trauma Emerg Surg 2021. [PMID: 33712893 DOI: 10.1007/s00068-021-01641-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The management of complicated ventral hernias (CVH), namely ventral hernias in actively or recently infected/contaminated operative fields, and open abdomens in which the native fascia cannot be primarily reapproximated, pose a surgical challenge. Fetal Bovine and Porcine Acellular Dermal Matrix (BADM and PADM) biologic meshes are being increasingly used in these scenarios. A comparison, however, of clinically relevant outcomes between the two is lacking. With this investigation, we aim to review and compare clinically relevant outcomes in patients that underwent abdominal wall herniorrhaphy with either BADM or PADM at a tertiary urban academic institution over a 5-year period. METHODS Patients who had a BADM or PADM implanted during CVH over a 5-year period at a tertiary urban academic hospital were identified. Baseline clinical and hernia characteristics, as well as postoperative outcomes were compared after a retrospective chart review. Phone interviews were also conducted to assess for recurrence, followed by in-person visits as indicated. Cox Proportional Hazard regression was fitted to identify risk factors for recurrence. RESULTS Of the 140 patients who underwent biologic mesh implantation for CVH, 109 were for ventral hernia repair and 31 for open abdomen bridging. Mean age was 52.7 ± 14.2 and males constituted 57.9% of our sample, while 25.1% had undergone > 5 prior abdominal operations. Thirty percent were active smokers, and another 30% required emergency surgery. Only immunosuppression was a risk factor for recurrence [HR 13.3 (1.04-169.2), p = 0.047] on Cox Proportional Hazard regression, while mesh selection had no effect. CONCLUSIONS Both BADM and PADM meshes perform well in CVH, with satisfactory recurrence rates, only slightly higher compared to traditional synthetic mesh repairs.
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Tartaglia D, Marin JN, Nicoli AM, De Palma A, Picchi M, Musetti S, Cremonini C, Salvadori S, Coccolini F, Chiarugi M. Predictive factors of mortality in open abdomen for abdominal sepsis: a retrospective cohort study on 113 patients. Updates Surg 2021; 73:1975-1982. [PMID: 33683639 PMCID: PMC8500907 DOI: 10.1007/s13304-021-01012-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 10/26/2020] [Accepted: 02/22/2021] [Indexed: 11/26/2022]
Abstract
Over the past few years, the open abdomen (OA) as a part of Damage Control Surgery (DCS) has been introduced as a surgical strategy with the intent to reduce the mortality of patients with severe abdominal sepsis. Aims of our study were to analyze the OA effects on patients with abdominal sepsis and identify predictive factors of mortality. Patients admitted to our institution with abdominal sepsis requiring OA from 2010 to 2019 were retrospectively analyzed. Primary outcomes were mortality, morbidity and definitive fascial closure (DFC). Comparison between groups was made via univariate and multivariate analyses. On 1474 patients operated for abdominal sepsis, 113 (7.6%) underwent OA. Male gender accounted for 52.2% of cases. Mean age was 68.1 ± 14.3 years. ASA score was > 2 in 87.9%. Mean BMI, APACHE II score and Mannheim Peritonitis Index were 26.4 ± 4.9, 15.3 ± 6.3, and 22.6 ± 7.3, respectively. A negative pressure wound system technique was used in 47% of the cases. Overall, mortality was 43.4%, morbidity 76.6%, and DFC rate was 97.8%. Entero-atmospheric fistula rate was 2.2%. At multivariate analysis, APACHE II score (OR 1.18; 95% CI 1.05–1.32; p = 0.005), Frailty Clinical Scale (OR 4.66; 95% CI 3.19–6.12; p < 0.0001) and ASA grade IV (OR 7.86; 95% CI 2.18–28.27; p = 0.002) were significantly associated with mortality. OA seems to be a safe and reliable treatment for critically ill patients with severe abdominal sepsis. Nonetheless, in these patients, co-morbidity and organ failure remain the major obstacles to a better prognosis.
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Affiliation(s)
- Dario Tartaglia
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy.
| | - Jacopo Nicolò Marin
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Alice Maria Nicoli
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Andrea De Palma
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Martina Picchi
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Serena Musetti
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Camilla Cremonini
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Stefano Salvadori
- Consiglio Nazionale delle Ricerche Area della Ricerca di Pisa, Pisa, Toscana, Italy
| | - Federico Coccolini
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
| | - Massimo Chiarugi
- Emergency Surgery Department and Trauma Center, University of Pisa, New Santa Chiara Hospital, Via Paradisa 2, 56124, Pisa, Italy
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Dietz UA, Baur J, Piso RJ, Willms A, Schwab R, Wiegering A. [Laparostoma-Avoidance and treatment of complications]. Chirurg 2021; 92:283-96. [PMID: 33351159 DOI: 10.1007/s00104-020-01322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The open abdomen (OA) is an established concept for treating severe abdominal diseases. The most frequent reasons for placement of an open abdomen are abdominal sepsis (e.g. from intestinal perforation or anastomotic leakage), severe abdominal organ injury and abdominal compartment syndrome. The pathophysiology is much more complex than the surgeon's eye can see in an OA. The temporary closure of the abdominal wall ensures sufficient drainage of infected ascites, protection of the intestinal loops and conditioning of the abdominal wall in order to be able carry out definitive closure of the abdominal wall at the end of the surgical treatment. Negative peritoneal pressure therapy combined with fascia traction (with or without mesh) is well-established in the management of an open abdomen.
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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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Wu XW, Zheng T, Hong ZW, Ren HJ, Wu L, Wang GF, Gu GS, Ren JA. Current progress of source control in the management of intra-abdominal infections. Chin J Traumatol 2020; 23:311-313. [PMID: 32863153 PMCID: PMC7718538 DOI: 10.1016/j.cjtee.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/14/2020] [Accepted: 07/10/2020] [Indexed: 02/04/2023] Open
Abstract
Intra-abdominal infection (IAI) is a deadly condition in which the outcome is associated with urgent diagnosis, assessment and management, including fluid resuscitation, antibiotic administration while obtaining further laboratory results, attaining precise measurements of hemodynamic status, and pursuing source control. This last item makes abdominal sepsis a unique treatment challenge. Delayed or inadequate source control is an independent predictor of poor outcomes and recognizing source control failure is often difficult or impossible. Further complicating issue in the debate is surrounding the timing, adequacy, and procedures of source control. This review evaluated and summarized the current approach and challenges in IAI management, which are the future research directions.
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Affiliation(s)
- Xiu-Wen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China,Lab for Trauma and Surgical Infection, Jinling Hospital, Nanjing, China
| | - Tao Zheng
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China,Lab for Trauma and Surgical Infection, Jinling Hospital, Nanjing, China
| | - Zhi-Wu Hong
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China,Lab for Trauma and Surgical Infection, Jinling Hospital, Nanjing, China
| | - Hua-Jian Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China,Lab for Trauma and Surgical Infection, Jinling Hospital, Nanjing, China
| | - Lei Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China,Lab for Trauma and Surgical Infection, Jinling Hospital, Nanjing, China
| | - Ge-Fei Wang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China,Lab for Trauma and Surgical Infection, Jinling Hospital, Nanjing, China
| | - Guo-Sheng Gu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China,Lab for Trauma and Surgical Infection, Jinling Hospital, Nanjing, China
| | - Jian-An Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China,Lab for Trauma and Surgical Infection, Jinling Hospital, Nanjing, China,Corresponding author.
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Willms AG, Schwab R, von Websky MW, Berrevoet F, Tartaglia D, Sörelius K, Fortelny RH, Björck M, Monchal T, Brennfleck F, Bulian D, Beltzer C, Germer CT, Lock JF. Factors influencing the fascial closure rate after open abdomen treatment: Results from the European Hernia Society (EuraHS) Registry : Surgical technique matters. Hernia 2020; 26:61-73. [PMID: 33219419 PMCID: PMC8881440 DOI: 10.1007/s10029-020-02336-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [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: 08/21/2020] [Accepted: 11/02/2020] [Indexed: 01/09/2023]
Abstract
Purpose Definitive fascial closure is an essential treatment objective after open abdomen treatment and mitigates morbidity and mortality. There is a paucity of evidence on factors that promote or prevent definitive fascial closure. Methods A multi-center multivariable analysis of data from the Open Abdomen Route of the European Hernia Society included all cases between 1 May 2015 and 31 December 2019. Different treatment elements, i.e. the use of a visceral protective layer, negative-pressure wound therapy and dynamic closure techniques, as well as patient characteristics were included in the multivariable analysis. The study was registered in the International Clinical Trials Registry Platform via the German Registry for Clinical Trials (DRK00021719). Results Data were included from 630 patients from eleven surgical departments in six European countries. Indications for OAT were peritonitis (46%), abdominal compartment syndrome (20.5%), burst abdomen (11.3%), abdominal trauma (9%), and other conditions (13.2%). The overall definitive fascial closure rate was 57.5% in the intention-to-treat analysis and 71% in the per-protocol analysis. The multivariable analysis showed a positive correlation of negative-pressure wound therapy (odds ratio: 2.496, p < 0.001) and dynamic closure techniques (odds ratio: 2.687, p < 0.001) with fascial closure and a negative correlation of intra-abdominal contamination (odds ratio: 0.630, p = 0.029) and the number of surgical procedures before OAT (odds ratio: 0.740, p = 0.005) with DFC. Conclusion The clinical course and prognosis of open abdomen treatment can significantly be improved by the use of treatment elements such as negative-pressure wound therapy and dynamic closure techniques, which are associated with definitive fascial closure. Electronic supplementary material The online version of this article (10.1007/s10029-020-02336-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A G Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - R Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - M W von Websky
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital of Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - F Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - D Tartaglia
- Emergency Surgery Unit, Cisanello University Hospital, Via Paradisa 1, 56124, Pisa, Italy
| | - K Sörelius
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - R H Fortelny
- Department of General, Visceral and Oncological Surgery, Wilhelminenspital, 1160, Vienna, Austria.,Medical Faculty, Sigmund Freud University of Vienna, 1020, Vienna, Austria
| | - M Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, SE 751 85, Uppsala, Sweden
| | - T Monchal
- Department of General Surgery, Sainte Anne Military Hospital, 2 Boulevard Sainte-Anne, 83000, Toulon, France
| | - F Brennfleck
- Department of Surgery, Regensburg University Hospital, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - D Bulian
- Department of Abdominal, Tumor, Transplant and Vascular Surgery, Cologne-Merheim Medical Center, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - C Beltzer
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Hospital of Ulm, Oberer Eselsberg, Ulm, Germany
| | - C T Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - J F Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital of Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
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Boolaky KN, Tariq AH, Hardcastle TC. Open abdomen in the trauma ICU patient: who? when? why? and what are the outcome results? Eur J Trauma Emerg Surg 2020; 48:953-961. [PMID: 33205225 DOI: 10.1007/s00068-020-01543-6] [Citation(s) in RCA: 3] [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: 08/01/2020] [Accepted: 10/31/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Temporary abdominal closure is a component of damage control surgery and may decrease mortality rates. The ultimate aim in managing an open abdomen is to achieve definitive fascial closure. The aim of this study is to assess the previously known predictors for failure to achieve definitive fascial closure and identify new predictors in order to achieve a better outcome. METHODS An 11-year retrospective chart review included open abdomen cases at Inkosi Albert Luthuli Hospital Trauma ICU in KZN (Ethics Approval BCA207-09). The evaluated outcomes were definitive fascial closure, open abdomen and mortality. Variables included age, co-morbidities, albumin levels, renal failure, multiple blood transfusions, type of blood products given, entero-atmospheric fistulas, TAC, anastomosis, intra-abdominal abscess, type of nutrition, ACS, number of re-laparotomies, deep site infections (peritonitis), systemic infections (bloodstream), ventilator acquired pneumonia, head injury, and type of fluids given. RESULTS This study reviewed 188 cases, 46.8% (88) arrived from elsewhere with an open abdomen while 53.2% (100) did not; 46.8% suffered blunt trauma, 45.2% suffered gunshots, while 8.0% were stabbed. Ninety deaths (47.9%) occurred during the index admission with 57 (30.3%) within the first 30 days. For both death within 30 days and death as final outcome, the majority were blunt abdominal trauma, 51.1 and 52.6%, respectively. Out of 188 patients, 27.1% had definitive fascial closure and 26.6% remained with an open abdomen. The relevant variables related to failure to achieve fascial closure were hypoalbuminemia (p = 0.002, p = 0.036), anastomotic leak (p < 0.05), VAP (p = 0.007), age (p = 0.002), intra-abdominal abscesses (p = 0.006), ACS (p = 0.005), multiple re-laparotomies (p = 0,028), deep surgical site infection (p < 0.05) and multi-organ failure (p = 0.003). CONCLUSION This study identified the predictors of failed fascial closure and mortality. While not directly modifiable, hypoalbuminaemia, anastomotic leak and sepsis, leading to multiple re-laparotomy, preclude early closure and portend high mortality.
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Affiliation(s)
| | - Ali Hassan Tariq
- General Surgery, Prince Mshiyeni Memorial Hospital, Umlazi, South Africa
| | - Timothy Craig Hardcastle
- Trauma Unit, Inkosi Albert Luthuli Central Hospital, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa. .,IALCH Trauma Service, 800 Vusi Mzimela Rd, Mayville, Durban, 4055, South Africa.
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Yeung E, Kaster M, Scheese D, Mathews T, Prezkop G, Golden D, Granet J, Behm R. Closing Contaminated Fascial Defects With Synthetic Mesh and a Vacuum-Assisted Closure Device. J Surg Res 2021; 259:313-9. [PMID: 33127065 DOI: 10.1016/j.jss.2020.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/26/2020] [Accepted: 09/22/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The use of synthetic mesh is considered too high risk, and therefore, not an option when closing a contaminated abdominal fascial defect. This study evaluated the clinical outcomes when using synthetic mesh combined with vacuum-assisted closure (VAC) dressing to close these facial defects. MATERIALS AND METHODS From 2010 to 2016, a retrospective review was performed, including 34 patients in a single rural trauma center who underwent a damage control laparotomy in the presence of a contaminated or infected field. Definitive abdominal closure with a bridging polypropylene mesh along with the application of a VAC dressing was done in all cases. Data collection included baseline demographics, operative indication, postoperative complications, mortality and length of follow up. RESULTS Median age of the patients was 67 y (IQR 40-87 y), with 22 (65%) being male at the time of operation. The median duration of clinical follow-up was 15.15 mo. The observed complications included three fistulas, two hernias, nine draining sinus tracts, and three mesh explanations with an overall complication rate of 41.1%. Although the absolute observed fistula rate was 8.8% (3 cases), the adjusted mesh-related fistulas formation rate after chart review was 0.0%. No mortalities were attributed directly to mesh-related complication. CONCLUSIONS This study found no mesh-related fistulas when using a synthetic mesh along with a VAC dressing for abdominal closure in a contaminated field. These results may provide a platform for further study regarding the safety of this technique.
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Flores-Álvarez E, De la Torre-González JC, Rivera-Barragán V, De la Cruz-Álvarez LD. Sequential closure of the abdominal wall for the management of open abdomen. A new surgical technique. CIR CIR 2020; 88:624-629. [PMID: 33064717 DOI: 10.24875/ciru.20000760] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The open abdomen is a surgical technique used in the treatment of patients with abdominal sepsis, abdominal trauma and abdominal hypertension syndrome. Objective The aim was to demonstrate the effectiveness of a new surgical technique designed for the management and closure of the abdominal wall in patients with open abdomen. Method Study of all patients treated with open abdomen in our Hospital over a five-year period. Results It were included 24 patients, 18 men and 6 women. The average age was 41.5 ± 15.9 years. Operative diagnosis was abdominal compartment syndrome in 7 (29%) cases, abdominal sepsis in 9 (38%), and abdominal trauma in 8 (33%). The median of APACHE II score was 8 points (range: 5-21) while the assessment of SIRS score had a median of 2 points (range: 1-4). The median of surgical procedures performed in operating room was two per patient. The median of fascial surgical closures performed in the patient bed was four. A successful closure of the abdominal wall was performed in 21 of 22 live patients (95%). Conclusions The sequential closure of the abdominal wall is an effective technique that offers an alternative to the management of the open abdomen.
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Affiliation(s)
- Efrén Flores-Álvarez
- Departamento de Enseñanza e Investigación y Servicio de Cirugía General, Centenario Hospital Miguel Hidalgo, Aguascalientes, México
| | - J Cruz De la Torre-González
- Departamento de Enseñanza e Investigación y Servicio de Cirugía General, Centenario Hospital Miguel Hidalgo, Aguascalientes, México
| | - Virgilio Rivera-Barragán
- Departamento de Enseñanza e Investigación y Servicio de Cirugía General, Centenario Hospital Miguel Hidalgo, Aguascalientes, México
| | - Luis D De la Cruz-Álvarez
- Departamento de Enseñanza e Investigación y Servicio de Cirugía General, Centenario Hospital Miguel Hidalgo, Aguascalientes, México
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Betancourt AS, Milagros GC, Sibaja P, Fernandez L, Norwood S. 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. Ann Med Surg (Lond) 2020; 56:11-16. [PMID: 32566220 PMCID: PMC7296327 DOI: 10.1016/j.amsu.2020.06.007] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 12/03/2022] Open
Abstract
Background Many commercial and artisanal devices are utilized for temporary abdominal closure in patients being managed with an open abdomen for abdominal sepsis. The costs of materials required to treat patients with an open abdomen varies drastically. In Costa Rica, due to the lack of accurate information relating to the actual cost to manage a patient entails that the method with the least expensive materials is usually selected. Study design A single-center retrospective review of 46 patients diagnosed with abdominal sepsis and successfully treated with an open abdomen and one of the three temporary abdominal closure methods during the year 2018 in a tertiary hospital was evaluated using a gross-cost pricing model developed by the authors. The three temporary abdominal closure methods were a locally manufactured Bogota Bag, and commercial abdominal negative pressure therapy dressing and negative pressure therapy with 0.9% saline solution instillation. The per-unit-costs were hospital day and intensive care day, number of surgical procedures per patient, cost negative pressure therapy kits. Results Statistically significant cost reduction was observed in the cohort treated with negative pressure therapy with instillation as compared to the other temporary abdominal closure methods. The reduction of hospital length of stay, as well as fewer number of surgeries were the main contributing factors in diminishing costs. On average, the costs to treat a patient utilizing negative pressure therapy with instillation was nearly 50% lower than using the other two temporary abdominal closure methods. Conclusions The costs relating to managing abdominal sepsis in the septic open abdomen vary greatly according to the temporary abdominal closure utilized. If the hospital length of stay, intensive care unit length of stay and number of surgeries required are the main parameters used in determining costs, the use of negative pressure therapy with 0.9% saline solution instillation reduces costs by nearly 50% in comparison to conventional negative pressure wound therapy and Bogota Bag. In this instance, the more expensive method at first glance, obtained a considerable cost reduction when compared to therapies that utilize less expensive materials. The costs of materials required to treat patients with an OA varies drastically. In Costa Rica, due to the lack of accurate information relating to the actual cost to manage a patient entails that the method with the least expensive materials is usually selected. Statistically significant cost reduction was observed in the cohort treated with negative pressure therapy with instillation as compared to the other TAC methods. On average, the costs to treat a patient utilizing negative pressure therapy with instillation was up to 50% lower than using the other two TAC methods.
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Affiliation(s)
- Alfredo Sanchez Betancourt
- Centro de Investigación Clínica de Oriente, Universidad Estatal a Distancia, Sabanilla, Escazú, San Jose, Costa Rica
- Corresponding author.
| | - Gonzalez Cole Milagros
- Centro de Investigación Clínica de Oriente, Universidad Estatal a Distancia, Sabanilla, Escazú, San Jose, Costa Rica
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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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Di Bella A, Bruscino A, Alemanno G, Bergamini C, Prosperi P. Open abdomen management for massive intestinal infarction due to acute splanchnic venous thrombosis in a patient with protein S deficiency. A case report. Int J Surg Case Rep 2020; 72:122-6. [PMID: 32534415 DOI: 10.1016/j.ijscr.2020.05.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/22/2020] [Accepted: 05/23/2020] [Indexed: 11/21/2022] Open
Abstract
Portomesenteric venous thrombosis is rare and can lead to serious consequences. Open abdomen is a successful strategy in case of resections for bowel ischemia. Thrombosis at an ucommon site should be investigated for prothrombotic states. Long-term anticoagulation is recommended in lifelong trombophilic states.
Introduction Acute mesenteric ischemia (AMI) refers to the sudden onset of intestinal hypoperfusion that can also result from splanchnic venous occlusion. The portomesenteric venous system (PMVS) is an unusual site of thrombosis in patients with protein S deficiency and its obstruction is a rare cause of AMI. Aim of this report is to illustrate a successful strategy in a case of massive small bowel infarction managed with an open abdomen (OA) approach. Case presentation A 64 year-old woman presented to the emergency department with acute abdominal pain, rectal bleeding, diarrhea and vomiting. Contrast-enhanced computed tomography (CECT) showed small bowel ischemia and the complete occlusion of all the PMVS branches. Surgery was performed with an OA approach and anticoagulation was immediately begun. Further workup revealed isolated protein S deficiency and history of atrophic gastritis. Thromboprophylaxis with warfarin was started on discharge and no recurrence of thrombotic events was recorded during the one-year follow-up. Discussion PMVS thrombosis related to protein S deficiency is a rare condition that can rapidly lead to an acute abdomen. CECT is the gold standard, because it detects splanchnic thrombosis and its possible complications, like bowel ischemia. In case of surgery, a planned second-look operation is the best strategy to assess bowel viability and possible ischemic progression. Conclusions OA management plays a fundamental role in case of resection for bowel ischemia. Patients with thrombosis at an uncommon site should be further investigated for prothrombotic states.
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Poillucci G, Podda M, Russo G, Perri SG, Ipri D, Manetti G, Lolli MG, De Angelis R. Open abdomen closure methods for severe abdominal sepsis: a retrospective cohort study. Eur J Trauma Emerg Surg 2020; 47:1819-1825. [PMID: 32377924 DOI: 10.1007/s00068-020-01379-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 04/24/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE The open abdomen (OA) procedure as part of damage control surgery represents a significant surgical advance in severe intra-abdominal infections. Major techniques used for OA are negative pressure wound therapy (NPWT) and non-NPWT. The aim of this retrospective study is to evaluate the effects of different abdominal closure methods and their outcomes in patients presenting with abdominal sepsis treated with OA. MATERIALS AND METHODS We retrospectively analyzed clinical outcomes of patients affected by severe intra-abdominal sepsis treated with OA. Demographic features, mortality prediction score, abdominal closure methods, length of hospital stay, complications and mortality rates of patients were determined and compared. RESULTS This study included 106 patients, of whom 77 underwent OA with NPWT and 29 with non-NPWT. OA duration was longer in NPWT patients (p = 0.007). In-hospital mortality rates in NPWT and in non-NPWT patients were 40.3% and 51.7%, respectively (p = 0.126), with an overall 30-day mortality rate of 18.2% and 51.7%, respectively (p = 0.0002). After emergency colorectal surgery, patients who underwent OA with NPWT had a lower rate of colostomy (p = 0.025). CONCLUSIONS NPWT is the best temporary abdominal closure technique to decrease mortality and colostomy rates in patients managed with OA for severe intra-abdominal infections.
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Affiliation(s)
- Gaetano Poillucci
- Department of General and Specialized Surgery "Paride Stefanini", Policlinico Universitario Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Mauro Podda
- Department of General, Emergency and Minimally Invasive Surgery, Policlinico Universitario "D. Casula", University of Cagliari, Monserrato, Italy
| | - Giulia Russo
- Department of General Surgery, San Camillo De Lellis Hospital, Rieti, Italy
| | | | - Domenico Ipri
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Gabriele Manetti
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Maria Giulia Lolli
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Renato De Angelis
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
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Poortmans N, Berrevoet F. Dynamic closure techniques for treatment of an open abdomen: an update. Hernia 2020; 24:325-31. [PMID: 32020342 DOI: 10.1007/s10029-020-02130-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/27/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain as it is associated with a high incidence of complications and poor outcomes. The objective is to perform a systematic review on dynamic closure techniques for fascial closure during open abdomen management. METHODS An electronic database search was conducted involving 4 different databases (MEDLINE (PubMed), SCOPUS, WEB OF SCIENCE (WOS) and EMBASE). All studies that described dynamic closure techniques in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest. RESULTS Thirteen studies were included in the final synthesis. Overall methodological quality was low with a high number of retrospective observational studies and low number of patients. All included studies are observational cohort studies. No studies reported on the use of either Wittmann patch, dynamic retention sutures or ABRA system. Two studies reported on the ABRA system in combination with Negative Pressure Wound Therapy (NPWT), while 9 reported on mesh-mediated fascial traction (MMFT) combined with NPWT. Other types of fascial traction, either by dynamic suture lines or by a self-made silastic tube system, and NPWT were reported in 2 studies. Overall closure rates are 93.2% for the ABRA system + NPWT versus 72.0% for the mesh-mediated fascial traction + NPWT. CONCLUSION Careful selection and good management of OA patients will avoid prolonged treatment and facilitate early fascial closure. Future research should focus on comparison of different temporary dynamic closure techniques to evolve toward best treatment options, in terms of both fascial closure rates and long-term incisional hernia rates.
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Rajasurya V, Surani S. Abdominal compartment syndrome: Often overlooked conditions in medical intensive care units. World J Gastroenterol 2020; 26:266-278. [PMID: 31988588 PMCID: PMC6969886 DOI: 10.3748/wjg.v26.i3.266] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/17/2019] [Accepted: 01/01/2020] [Indexed: 02/06/2023] Open
Abstract
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome are well recognized entities among surgical patients. Nevertheless, a number of prospective and retrospective observational studies have shown that IAH is prevalent in about half of the critically ill patients in the medical intensive care units (ICU) and has been widely recognized as an independent risk factor for mortality. It is alarming to note that many members of the critical care team in medical ICU are not aware of the consequences of untreated IAH and the delay in making the diagnosis leads to increased morbidity and mortality. Frequently it is underdiagnosed and undertreated in this patient population. Elevated intra-abdominal pressure decreases the blood flow to the kidneys and other abdominal viscera and also results in reduced cardiac output and difficulties in ventilating the patient because of increased intrathoracic pressure. When intraabdominal hypertension is not promptly recognized and treated, it leads to abdominal compartment syndrome, multiorgan dysfunction syndrome and death. Large volume fluid resuscitation is very common in medical ICU patients presenting with sepsis, shock and other inflammatory conditions like pancreatitis and it is one of the major risk factors for the development of intra-abdominal hypertension. This article presents an overview of the epidemiology, definitions, risk factors, pathophysiology and management of IAH and abdominal compartment syndrome in critically ill medical ICU patients.
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Affiliation(s)
- Venkat Rajasurya
- Department of Pulmonary and Critical Care, Novant Health System, Winston-Salem, NC 27103, United States
| | - Salim Surani
- Department of Pulmonary Critical Care and Sleep Medicine, Texas A&M Health Science Center, Bryan, TX 77807, United States
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Mitra LG, Saluja V, Dhingra U. Open Abdomen in a Critically Ill Patient. Indian J Crit Care Med 2020; 24:S193-S200. [PMID: 33354041 PMCID: PMC7724942 DOI: 10.5005/jp-journals-10071-23613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
One of the damage control strategies used to avoid or treat abdominal compartment syndrome is “open abdomen (OA),” where the facial edges and the skin is left open, exposing the abdominal viscera. Although it reduces the mortality both in trauma and non-trauma abdominal complications, it does create a significant challenge in an intensive care setting, as it has physiological consequences that need early recognition and prompt treatment both in the intensive care unit and in the operating room. The article aims to review literature on “open abdomen,” describe the challenges in such cases, and proposes a guideline for the intensivist in managing a patient with an OA. How to cite this article: Mitra LG, Saluja V, Dhingra U. Open Abdomen in a Critically Ill Patient. Indian J Crit Care Med 2020;24(Suppl 4):S193–S200.
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Affiliation(s)
- Lalita Gouri Mitra
- Department of Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vandana Saluja
- Department of Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Udit Dhingra
- Department of Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
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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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Karhof S, Haverkort M, Simmermacher R, Hietbrink F, Leenen L, van Wessem K. Underlying disease determines the risk of an open abdomen treatment, final closure, however, is determined by the surgical abdominal history. Eur J Trauma Emerg Surg 2019; 47:113-120. [PMID: 31451863 PMCID: PMC7851030 DOI: 10.1007/s00068-019-01205-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 04/29/2019] [Accepted: 08/10/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Temporary abdominal closure is frequently used in several situations such as abbreviated surgery in damage control situations or when closing is impossible due to organ distention or increased abdominal pressure. The ultimate goal is to eventually close the fascia; however, little is known about factors predicting abdominal closure. The purpose of this study was to identify characteristics associated with the need for open abdomen as well as indicating the possibility of delayed fascial closure after a period of open abdominal treatment. METHODS A retrospective review of all patients that underwent midline laparotomy between January 2008 and December 2012 was performed. Both factors predicting open abdominal treatment and possibility to close the fascia afterwards were identified and analyzed by univariate and multivariate analyses. RESULTS 775 laparotomies in 525 patients (60% male) were included. 109 patients (21%) had an open abdomen with a mortality rate of 27%. Male gender and acidosis were associated with open abdominal treatment. In 54%, the open abdomen could be closed by delayed fascial closure. The number of laparotomies both before and during temporary abdominal treatment was associated with failure of closure. CONCLUSION In this study, male sex and physiological derangement, reflected by acidosis, were independent predictors of open abdominal treatment. Furthermore, the success of delayed fascial closure depends on number of abdominal surgical procedures. Moreover, based on our experiences, we suggest to change modalities early on, to prevent multiple fruitless attempts to close the abdomen.
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Affiliation(s)
- Steffi Karhof
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Mark Haverkort
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rogier Simmermacher
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Luke Leenen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Karlijn van Wessem
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Aguilar-Frasco J, Moctezuma-Velázquez P, Rodríguez-Quintero JH, Pastor-Sifuentes FU, Garcia-Ramos ES, Clemente-Gutierrez U, Morales-Maza J, Santes O, Hernández-Acevedo JD, Contreras-Jimenez E, Y Terán SM. Myths and realities in the management of the open abdomen with negative pressure systems. A case report and literature review. Int J Surg Case Rep 2019; 61:174-179. [PMID: 31376738 PMCID: PMC6677784 DOI: 10.1016/j.ijscr.2019.07.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 06/03/2019] [Revised: 07/03/2019] [Accepted: 07/17/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The open abdomen is a useful resource for treating patients with abdominal hypertension and abdominal compartment syndrome. Currently, early closure assisted with negative pressure devices is considered standard of treatment, and its use has demonstrated favorable outcomes and a decreased rate of complications. PRESENTATION OF A CASE We present a case of a 32-year-old male patient with diagnosis of non-seminomatous germinal testicular tumor (Stage IIIB (T3-N3-M1), which was summited to surgery, as a complication he presented massive bleeding, that culminated in acute compartment syndrome. With the aforementioned findings the patient re entered the operating room and was managed with open abdomen combined with a medial retraction technique of the abdominal fascia. Currently, the patient has not presented recurrence or late complications after a year. DISCUSSION The use of negative pressure techniques for open abdomen management began to be generalized in 1995. Subsequently, this technique evolved to V.A.C therapy (Vacuum-assisted closure therapy). Currently, these negative pressure techniques have become the most used method for the temporary closure and management of open abdomen. Controversies continue to limit its widespread use and effectiveness. CONCLUSION Adequate application of negative pressure therapy in combination with techniques of medial retraction of the abdominal fascia, have proved to be useful in management for patients with open abdomen.
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Affiliation(s)
- J Aguilar-Frasco
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico.
| | - P Moctezuma-Velázquez
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - J H Rodríguez-Quintero
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - F U Pastor-Sifuentes
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - E Sanchez Garcia-Ramos
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - U Clemente-Gutierrez
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - J Morales-Maza
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - O Santes
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - J D Hernández-Acevedo
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - E Contreras-Jimenez
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - S Mier Y Terán
- General surgery department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
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Eickhoff R, Guschlbauer M, Maul AC, Klink CD, Neumann UP, Engel M, Hellmich M, Sterner-Kock A, Krieglstein CF. A new device to prevent fascial retraction in the open abdomen - proof of concept in vivo. BMC Surg 2019; 19:82. [PMID: 31286901 PMCID: PMC6615246 DOI: 10.1186/s12893-019-0543-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 09/07/2018] [Accepted: 06/24/2019] [Indexed: 12/11/2022] Open
Abstract
Background An open abdomen is often necessary for survival of patients after peritonitis, compartment syndrome, or in damage control surgery. However, abdominal wall retraction relieves delays and complicates abdominal wall closure. The principle of the newly fascia preserving device (FPD) is the application of anteriorly directed traction on both fascial edges over an external support through a longitudinal beam to relieve increased abdominal pressure and prevent fascial retraction. Methods Twelve pigs were randomly divided into two groups. Both groups underwent midline laparotomy under general anesthesia. Group one was treated with the new device, group two served as controls. The tension for closing the abdominal fascia was measured immediately after laparotomy as well as at 24 and 48 h. Vital parameters and ventilation pressure were recorded. Post mortem, all fascial tissues were histologically examined. Results All pigs demonstrated increases in abdominal circumference. In both groups, forces for closing the abdomen increased over the observation period. Concerning the central closing force after 24 h we saw a significant lower force in the FPD group (14.4 ± 3 N) vs. control group (21.6 ± 5.7 N, p < 0.001). By testing the main effects using an ANOVA analysis we found a significant group related effect concerning closing force and abdominal circumference of the FDP-group vs. control group (p < 0.001; p < 0.001). The placement of the device on chest and pelvis did not influence vital parameters and ventilation pressure. Histologic exam detected no tissue damage. Conclusions This trial shows the feasibility to prevent fascial retraction during the open abdomen by using the new device. Thus, it is expected that an earlier closure of the abdominal wall will be possible, and a higher rate of primary closure will be attained.
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Affiliation(s)
- Roman Eickhoff
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Maria Guschlbauer
- Center for Experimental Medicine, University of Cologne, Robert-Koch-Str. 10 Building No. 51A, 50931, Cologne, Germany.,Decentral Animal Facility, University Hospital of Cologne, Gleueler Str. 24, 50931, Cologne, Germany
| | - Alexandra C Maul
- Center for Experimental Medicine, University of Cologne, Robert-Koch-Str. 10 Building No. 51A, 50931, Cologne, Germany
| | - Christian D Klink
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ulf P Neumann
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Michael Engel
- Department of Surgery, Marienhospital Brühl GmbH, Mühlenstraße, 21-25 50321, Brühl, Germany
| | - Martin Hellmich
- IMSB, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Anja Sterner-Kock
- Center for Experimental Medicine, University of Cologne, Robert-Koch-Str. 10 Building No. 51A, 50931, Cologne, Germany
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Leppäniemi A, Tolonen M, Tarasconi A, Segovia-Lohse H, Gamberini E, Kirkpatrick AW, Ball CG, Parry N, Sartelli M, Wolbrink D, van Goor H, Baiocchi G, Ansaloni L, Biffl W, Coccolini F, Di Saverio S, Kluger Y, Moore E, Catena F. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg 2019; 14:27. [PMID: 31210778 PMCID: PMC6567462 DOI: 10.1186/s13017-019-0247-0] [Citation(s) in RCA: 295] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/27/2019] [Indexed: 02/08/2023] Open
Abstract
Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.
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Affiliation(s)
- Ari Leppäniemi
- Abdominal Center, Helsinki University Hospital Meilahti, Haartmaninkatu 4, FI-00029 Helsinki,, Finland
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital Meilahti, Haartmaninkatu 4, FI-00029 Helsinki,, Finland
| | - Antonio Tarasconi
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | | | - Emiliano Gamberini
- Anesthesia and Intensive Care Medicine, Maurizio Bufalini Hospital, Cesena, Italy
| | | | - Chad G. Ball
- Foothills Medical Centre & the University of Calgary, Calgary, AB Canada
| | - Neil Parry
- London Health Sciences Centre, London, ON Canada
| | | | - Daan Wolbrink
- Radboud University Nijmegen, Nijmegen, The Netherlands
| | | | - Gianluca Baiocchi
- Surgical Clinic, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | - Walter Biffl
- Trauma and Acute Care Surgery, Scripps memorial Hospital, La Jolla, CA USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini hospital, Cesena, Italy
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest Moore
- Trauma Surgery, Denver Health Medical Center, Denver, CO USA
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
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50
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Xu ZY, Ren HJ, Huang JJ, Li ZA, Ren JA. Application of a 3D-printed ”fistula stent” in plugging enteroatmospheric fistula with open abdomen: A case report. World J Gastroenterol 2019; 25:1775-1782. [PMID: 31011261 PMCID: PMC6465945 DOI: 10.3748/wjg.v25.i14.1775] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/14/2019] [Accepted: 03/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Open abdomen (OA) has been generally accepted for its magnificent superiority and effectiveness in patients with severe trauma, severe intra-abdominal infection, and abdominal compartment syndrome. In the meantime, OA calls for a mass of nursing and the subsequent enteroatomospheric fistula (EAF), which is one of the most common complications of OA therapy, remains a thorny challenge.
CASE SUMMARY Our team applied thermoplastic polyurethane as a befitting material for producing a 3D-printed “fistula stent” in the management of an EAF patient, who was initially admitted to local hospital because of abdominal pain and distension and diagnosed with bowel obstruction. After a series of operations and OA therapy, the patient developed an EAF.
CONCLUSION Application of this novel “fistula stent” resulted in a drastic reduction in the amount of lost enteric effluent and greatly accelerated rehabilitation processes.
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Affiliation(s)
- Zi-Yan Xu
- Research Institute of General Surgery, Jinling Hospital, Nanjing 210002, Jiangsu Province, China
- School of Medicine, Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Hua-Jian Ren
- Research Institute of General Surgery, Jinling Hospital, Nanjing 210002, Jiangsu Province, China
| | - Jin-Jian Huang
- Research Institute of General Surgery, Jinling Hospital, Nanjing 210002, Jiangsu Province, China
| | - Zong-An Li
- NARI School of Electrical and Automation Engineering, Nanjing Normal University, Nanjing 210042, Jiangsu Province, China
| | - Jian-An Ren
- Research Institute of General Surgery, Jinling Hospital, Nanjing 210002, Jiangsu Province, China
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