Damage Control Laparotomy and Management of the Open Abdomen

Management of the open abdomen has been used for decades by general surgeons. Techniques have evolved over those decades to improve control of infection, fluid loss, and improve the ability to close the abdomen to avoid hernia formation. The authors explore the history, indications, and techniques of open abdomen management in multiple settings. The most important considerations in open abdomen management include the reason for leaving the abdomen open, prevention and mitigation of ongoing organ dysfunction, and eventual plans for abdominal closure.

Refractory gastrocutaneous fistula treated by two-stage surgery: a case report

BACKGROUND

Gastrocutaneous fistulas are a rare complication of enterocutaneous fistulas and can be caused by intestinal injury, infection, and anastomotic leakage. They are typically treated conservatively or endoscopically; however, for large or difficult-to-treat gastrocutaneous fistulas, surgical intervention is required. Herein, we present a case of a huge gastrocutaneous fistula that was successfully treated with a two-stage surgery performed using open abdomen management.

CASE PRESENTATION

A 61-year-old man with a perforated gastric ulcer underwent omental filling as an emergency surgery. Post-operative leakage led the development of a 10-cm gastrocutaneous fistula. He was transferred to our hospital for the treatment of gastrocutaneous fistula. Furthermore, nutritional therapy was administered for dehydration, electrolyte abnormalities, metabolic acidosis, and acute kidney injury due to the high-output nature of the fistula. Moreover, owing to the intraperitoneal severe adhesion and poor nutritional status, two-stage surgery was planned. In the first stage, extensive dissection of the adhesions, distal gastrectomy reconstruction with Roux-en-Y anastomosis, and jejunostomy were performed. Furthermore, open abdomen management was conducted to check for the presence of unexpected complications due to extensive dissection of the adhesion and anastomotic leakage. Subsequently, in the second stage of the surgery, abdominal closure was performed on the 9th day after gastrectomy.

CONCLUSION

Open abdomen management may be effective for huge gastrocutaneous fistulas with extensive adhesions that require surgical intervention.

Open abdominal vacuum pack technique for the management of severe abdominal complications after cytoreductive surgery in ovarian cancer

INTRODUCTION

The aim of this study was to evaluate the indications and management of grade III-IV postoperative complications in patients requiring vacuum-assisted open abdomen after debulking surgery for ovarian carcinomatosis.

METHODS

Retrospective study of prospectively collected data from patients who underwent a cytoreductive surgery by laparotomy for an epithelial ovarian cancer that required postoperative management of an open abdomen. An abdominal vacuum-assisted wound closure (VAWC) was applied in cases of abdominal compartmental syndrome (ACS) or intra-abdominal hypertension, to prevent ACS. The fascia was closed with a suture or a biologic mesh. The primary aim was to achieve primary fascial closure. Secondary outcomes considered included complications of cytoreductive surgery (CRS) and open abdominal wounds (hernia, fistula).

RESULTS

Two percent of patients who underwent CRS required VAWC during the study's patient inclusion period. VAWC indications included: (i) seven cases of gastro-intestinal perforation, (ii) three necrotic enterocolitis, (iii) two intestinal ischemia, (iv) three anastomotic leakages and (v) four intra-abdominal hemorrhages. VAWC was used to treat indications (i) to (iv) (which represented 73.7% of cases), to prevent compartmental syndrome. Primary fascia closure was achieved in 100% of cases, in four cases (21.0%) a biologic mesh was used. Median hospital stay was 65 days (range: 18-153). Four patients died during hospitalization, three of these within 30 days of VAWC completion.

CONCLUSION

VAWC for managing open abdominal wounds is a reliable technique to treat surgical post-CRS complications in advanced ovarian cancer and reduces the early post-operative mortality in cases presenting with severe complications.

Results from the prospective International Register of Open Abdomen (IROA): Cohort study

BACKGROUND

Analyzing the data of the International Register of Open Abdomen (IROA), the feasibility of open abdomen treatment has been demonstrated at every age. This new analysis on the IROA database investigates the risk factors for mortality in elderly patients treated with open abdomen for intra-abdominal infection.

METHODS

Data were derived from the IROA, a prospective observational international cohort study that enrolled patients treated with open abdomen worldwide. A univariate analysis of potential risk factors was performed. Inclusion criteria were patients older than 65 years and treated with open abdomen for intra-abdominal infection. End point was overall mortality, calculated within 30 days after open abdomen management, after 1-month and 1-year follow-up.

RESULTS

A total of 116 patients was analyzed with mean age of 76 ± 7 years. Definitive closure was achieved in 93 patients (93/116, 80.2%) for a mean open abdomen duration of 5.0 ± 5.0 days. Complicated patients were 101 (101/116, 87.1%) for a total of 201 complications. Overall, 62 out of 116 patients (53.4%) died: 23 patients (23/62, 37.1%) during open abdomen management, 29 patients (46.8%) within 30 days after abdominal closure, 9 patients (14.5%) after 1-month follow-up, and 1 patient (1.6%) after 1-year follow-up. Age did not affect mortality (75 ± 6 years in alive patients versus 77 ± 7 years in dead patients, p = 0.773). Definitive abdominal closure was the most important factor to prevent mortality.

CONCLUSIONS

This study confirmed that age alone cannot be considered a determinant for death, even in elderly patients managed with open abdomen for severe intra-abdominal infection.

The successful management for long-term intractable enteroatmospheric fistula: A case report

Introduction

Efficacy of open abdomen management with negative pressure wound therapy for enteroatmospheric fistula has been performed. But, few reports have shown its utility for enteroatmospheric fistula several years after onset.

Presentation of case

A 46 year-old woman underwent total colectomy due to total ulcerative colitis in her twenties. Three years before the onset of enteroatmospheric fistula, she underwent simple total hysterectomy for uterine smooth muscle tumor. Small bowel obstruction occurred early and a small bowel bypass was performed. However, she had sudden abdominal pain and was diagnosed with anastomotic leakage of small bowel bypass. Although antibiotic treatment was initiated, infection was difficult to control, and a midline abdominal incision was performed, followed by the formation of enteroatmospheric fistula. She declined early surgical intervention and started receiving home parenteral nutrition with antibiotic treatment. Although central vein management was continued, catheter infection became frequent. Hence, surgical intervention was planned 30 months after the formation of enteroatmospheric fistula. Two-stage abdominal wall reconstruction using open abdomen management with negative pressure wound therapy was planned. The definitive abdominal wall reconstruction was performed 14 days after the initial operation. Finally, she was discharged without reoperation.

Discussion

Enteroatmospheric fistula has no overlying soft tissue and no real fistula tract. Besides these complications, there were complications of the scarred abdominal wall from intestinal fluid exposure for 30 months.

Conclusion

The strategy using open abdomen management with negative pressure wound therapy for long-term enteroatmospheric fistula will have a good postoperative outcome with the same as early intervention.

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Negative pressure wound therapy is effective in postonset enteroatmospheric fistula.

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It repairs abdominal wall skin damage from 30-month intestinal fluid exposure.

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Open abdominal management was able to control infection in the perioperative period.