Contemporary management of the open abdomen: standards, challenges, and future directions.

During the course of the last 30 years, several authors have contributed their clinical experience to the literature in an effort to describe the various management strategies for the appropriate use of the open abdomen technique. There remains a great degree of heterogeneity in the patient population, and the surgical techniques described. The open abdomen technique has been used in both military and civilian trauma and vascular and general surgery emergencies. Given the lack of consistent practice, the Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Committee convened a study group to establish recommendations for the use of open abdomen techniques in both trauma and nontrauma surgery. This has been a major undertaking and has been divided into two parts. The EAST practice management guidelines for the open abdomen part 1 "Damage Control" have been published.1 During the development of the open abdomen part II "Management of the Open Abdomen," the current literature remains contentious at best, current methods of treatment continue to change rapidly, and patient populations are so heterogeneous that clear recommendations could not be provided. What follows is a thorough review of the current literature for the management of the open abdomen: part 2 "Management of the Open Abdomen" and provides clinical direction regarding the following specific topics. Early and Delayed Abdominal Fascial Closure (DAFC). Management of intestinal fistula in the setting of the open abdomen. Management of the planned ventral hernia. Process A computerized search of the National Library of Medicine Medline database was undertaken using the PubMed Entrez interface. English language citations were identified during the period of 1984 through 2009 using the primary search strategies outlined. Given the complexity of this literature, several strategies were necessary to appropriately capture the breadth of evidence on the topic. The search excluded case reports, reviews, letters/commentary, editorials, and articles focusing only on pediatric participants. The PubMed Related Articles algorithm was also used to identify additional articles similar to the items retrieved by the primary strategy, in addition to hand searching of the reference lists of key articles retrieved by the searches. Of ∼1,300 articles identified by these two techniques, only prospective or retrospective studies examining open abdominal management were selected, consisting of 79 institutional studies evaluating open abdomen management strategies in the adult surgical/critical care population. The articles were reviewed by a group of 16 surgeons who collaborated to produce this clinical review. The chair, vice chair, and three committee members (JJD, WD, MO) reviewed all the articles to categorize them into the three study topics. They were distributed to all members of the study group for critical review. Each committee member was to answer the following three questions of each article reviewed: What is the class of evidence in the article? Are the results of the article valid based on the data presented? What is your conclusion based on the evidence the article provides. Review During the development of this review, a common language for the closure of the open abdomen was developed, which is provided in Table 1. Figure 1 is a proposed flow diagram for the closure of the open abdomen in trauma, emergency general, and vascular surgery.TABLE 1: Definition of Abdominal Closures and Planned Ventral Hernia: Trauma, Emergency General, and Vascular SurgeryFigure 1.: The closure of the open abdomen in trauma, emergency general, and vascular surgery flow diagram.Early Abdominal Fascial Closure Timing Trauma surgeons have gained an immense amount of experience with multiple techniques used to achieve abdominal closure of the open abdomen, but questions still remain. How long can the abdomen remain open? When does the risk of complications begin to increase? Is there a specific technique that is better than the rest for closing the open abdomen? At what point should all attempts at delayed fascial closure be abandoned and a planned ventral hernia performed? Miller et al.,2 in a study of 344 damage control laparotomies demonstrated that early abdominal fascial closure can be achieved in the majority (63%) of damage control cases during the initial re-laparotomy. They showed that DAFC before 8 days was associated with fewer complications: 12% in those closed before 8 days and 52% closed after 8 days. Yet, in a study of trauma patients with an open abdomen, massive visceral edema, and loss of domain, fascial closure could be achieved using the V.A.C. therapy (vacuum-assisted closure, KCI, San Antonio, TX) overtime out to a 4-week period with acceptable complication rates.3 With this degree of variation in timing to closure and the dreaded risk of life threatening complications more data were needed. Delayed Abdominal Fascial Closure Techniques (Nontraumatic/Traumatic Fascial Closure) Multiple studies have shown that DAFC is safe and effective at achieving successful fascial closure in 65% to 100% of patients with an open abdomen.2,4–25 There is evidence that vacuum-assisted closure devices (VACD) facilitate delayed primary fascial closure with high success rates and low morbidity.3–5,7,13,14,16–18,26 The literature describes both commercially available devices (V.A.C. therapy) as well as "home make" noncommercial "vacuum packed–negative pressure dressing" devices as being helpful in achieving DAFC (Table 2).TABLE 2: Delayed Abdominal Fascial ClosureTABLE 2: Delayed Abdominal Fascial Closure (continued)In the setting of intra-abdominal sepsis, the effectiveness of VACD to achieve DAFC has not been as successful as the experience seen in trauma patients.27 Wondberg et al.28 studied 30 patients with intra-abdominal sepsis and an open abdomen. They showed that only 33% of the study group was able to achieve DAFC with the use of the V.A.C. therapy KCI. Failure to achieve DAFC is associated with significant financial cost, increased morbidity including wound infections and the formation of intestinal fistula.29–31 Although, studies have shown that using VACD in conjunction with dynamic serial fascial advancement, can achieve fascial closure with success rates of 86% to 100% in trauma patients.4,7,18,32 The Wittmann Patch (Starsurgical, Burlington, WI), an "artificial burr" Velcro-like device that is sutured to the abdominal fascia, when used to manage an open abdomen has been shown to facilitates DAFC with a success rate >80% in a group of mixed trauma and abdominal sepsis patients.10,23 The Wittmann Patch can be used as a successful tool to provide dynamic tension in a process toward fascial closure.28,29 Similar to the Wittmann Patch, the use of temporary prosthetic mesh (most commonly polytetrafluoroethylene) with serial tightening/pleating has resulted in fascial closure rates from 89% to 100%.14–21 Serial/dynamic suture tightening, a technique involving repeated partial closure of the fascia, has also been used to achieve DAFC at rates between 61% and 90%.6,12,15Table 3 describes the most commonly used abdominal closure surgical techniques and the differences between them.TABLE 3: Definitive Abdominal Fascial Closure of the Open AbdomenThere is one randomized prospective study comparing various techniques for DAFC. Bee et al.33 compared the use of a VACD versus using a temporary polyglactin mesh and showed no difference in the rate of DAFC (31% vs. 26%). However, the success rates of DAFC in this study are significantly lower than other published studies, making the results difficult to interpret. Fascial Bridge Closure It has been previously described, a patient with an open abdomen can undergo multiple re-operations with progressive closure of the fascial defect, with or without the use of a VADC, and have their fascial defect closed.3 In the setting of ongoing intra-abdominal infection or the formation of an enterocutaneous fistula abdominal fascial closure is often not possible.19 Fascial closure may not be possible because of ongoing visceral edema with loss of abdominal domain or from loss of fascia from infection. At this point, a fascial bridge closure of the resulting abdominal fascial defect may be considered. The abdominal viscera will become cocoon in the 14-day period to 21-day period. Attempting re-enter into the abdomen cavity to free the visceral off the abdominal wall to allow for an easier abdominal fascial closure is both difficult and dangerous. The surgeon is limited in the available surgical options: (1) bridge repair of the fascial defect using a mesh to create a bridge closure, (2) performing an acute abdominal wall reconstruction using most commonly a version of component separation, or (3) a planned ventral hernia. Fansler et al.34 reported their experience with the fascial bridge closure of the open abdomen with permanent prosthetic mesh. In a series of combined trauma and abdominal sepsis patients, polypropylene was used as a fascial bridge for early definitive closure. They had significant complications including a 50% enterocutaneous fistula rate, which were noted with the use of polypropylene mesh. Voyles et al.35 reported a similar experience with a high rate of complications and fistula formation. The association of synthetic prosthetic mesh with bacterial colonization is well known. Once colonized or infected, the prosthetic mesh acts as a chronic source of contamination.27,33,36 The use of permanent prosthetic mesh such as polypropylene, polytetrafluoroethylene, and polyester products has been abandoned in these circumstances because of the high rates of complications seen with their use. Biological mesh material has been commercially available for almost 10 years. Biological mesh originates from human donors, bovine, and porcine animals. Biological mesh has been successfully used to bridge the defect as a result of an open abdomen. Human acellular dermal matrix (HADM) (AlloDerm, LifeCell Corp.) has been shown to be successfully used as a fascial bridge after open abdomen in multiple studies.19,37–39 HADM does not seem to form significant adhesions, seems to tolerate bacterial contamination, and does not require removal in the setting of infection.19,37,38,40–42 Also, HADM has been successfully used for tissue coverage and closure of large traumatic wounds in the setting of significant skin and soft tissue loss.32 Once the HADM has developed a good granulated tissue base, a skin graft can be placed. The authors noted that when no soft-tissue coverage is available, keeping the graft moist is critical to the graft's survival. Moist saline dressings or KCI V.A.C. therapy are most often used for this purpose. Bacterial colonization with overgrowth can occur on the grafts. This has been reported in the early postoperative phase and before the graft has had time to revascularize. The use of silver sulfadiazine or sulfamylon-soaked dressings on the graft should decrease bacterial counts until vascular in-growth has occurred and may prevent early graft loss from infection. The long-term success of using HADM as a fascial bridge for hernia repair after an open abdomen technique is unclear. There are a number of studies suggesting that the long-term strength of the HADM decreases overtime. This multifactorial may be attributable to collagen re-modeling, mesh attenuation, or tissue growth resulting in a high rate of hernia formation.43,44 However, HADM bridge ventral hernia repairs have been performed after trauma and many patients have had definitive repairs.16 Singh et al.,38 report on 10 liver transplant patients treated with an open abdomen and closed with an HADM fascial bridge. In short-term follow-up (10 months), there were no cases of herniation noted. Conversely, de Moya et al.,45 demonstrated that patients treated with an HADM bridge repairs and that at 1-year follow-up had evidence of recurrent hernia or significant abdominal wall laxity. The use of HADM as a fascial bridge under the circumstances of the unclosable abdomen after damage control is supported by the available literature. It protects the viscera from fistulization and may provide definitive abdominal wall strength. Yet, the long-term results in providing definitive fascial strength are not known. Acute Component Separation One option for closure of the open abdomen is an acute abdominal wall reconstruction using the component separation techniques. Ramirez et al.,46 were the first to describe the component separation technique for reconstruction of large abdominal wall fascial defect without the use of prosthetic mesh. In its basic form, the technique is as follows: (1) the anterior abdominal wall skin flaps are developed and dissected out to the anterior superior iliac spine and the chest wall, (2) the aponeurosis of the external oblique muscle is divided lateral to the semilunar line on to the chest wall to the level of the xiphoid, (3) free up the external oblique, which will allow the rectus myofascial component to be mobilized medially, and (4) the midline is sutured together. The component separation has become the most commonly used surgical technique for closure of large "planned" ventral hernias with a skin graft during the elective reconstructive phase.11,47,48 Its use for acute definitive closure in the setting of an open abdomen has not been well studied. Formal component separation is generally considered an "elective" reconstructive technique. Its use in the acute setting in the face of resolving intra-abdominal sepsis, visceral, and abdominal wall edema as a result of systemic inflammatory response syndrome and ongoing systemic sepsis is not advisable. Once a formal component separation has been performed, it is eliminated as an option for later abdominal wall reconstruction. There are at least three versions of the component separation technique. The original description by Ramirez et al. is described above. Another surgical technique is the "separation of parts" by the Memphis group. There is also a "open book" technique, which in addition to the lateral release of the external oblique, the rectus fascia (either anterior or posterior) is flipped into the midline using the linea alba as the fulcrum to extend the midline. The rectus roll-over technique by itself has been studied in the setting of definitive closure after the open abdomen in both trauma and general surgery patients. The anterior rectus fascia is incised near its lateral border on both sides, medialized, and sewn in the midline. In a series of 29 patients, the technique was used successfully to close defects up to 15 cm.30 In follow-up of 65 months, no recurrent abdominal wall hernias were noted, although mid-abdominal bulging was noted in 50% of patients. Enteroatmospheric Fistula as a Complication of the Open Abdomen During the initial damage control laparotomy, the open abdomen technique is used for rapid re-entry into the abdomen. DAFC can be commonly achieved once all the intra-abdominal injuries have been addressed. In the setting of intra-abdominal sepsis and/or pancreatitis, DAFC is not as successful.49 It is well recognized that the longer the time period to fascial closure, the higher the complication rates especially intestinal fistulas.50,51 In addition, the obese patient is at increased risk of having more complications after damage control laparotomy and longer time period to primary fascial closure.50,52 Trauma patients who required a prolong period of an open abdomen as part of their damage control management have five times the fistula rate verses those patients who were closed during the initial trauma laparotomy. The enteroatmospheric intestinal fistula results in the setting of the open abdomen. The fistula can develop as a result of an anastomotic leak with exposed suture lines, traumatized bowel, and nontraumatized bowel, which has been exposed for a period of time. This is one of the most devastating complications of the open abdomen. The foremost risk factors are the inability to perform primary abdominal facial closure in a timely manner, and deep space infections, and intra-abdominal abscess.19 The use of polypropylene mesh for bridge repair of the open abdomen has been shown to have unacceptably high rates of fistula complications and is no longer recommended for definitive closure in the acute setting of open abdominal management.34 Fistulae arising during early clinical management of open abdomens result in leakage of intraluminal contents over the unprotected surface of bowel. The patient with an enteroatmospheric fistula has extremely complicated critical care, open abdomen, and nutritional management issues. Inadequate fistula management will result in acute protein calorie malnutrition, electrolyte disturbances, and prolonged hospitalization.53 The key components of management of the patient with an enterocutaneous fistula are as follows: (1) sepsis control, (2) nutritional support, and (3) local wound care (Fig. 2). A key to treating entero-atmospheric fistulas is management of the initial inciting events and treatment of resulting complications. Source control and eradication of sepsis are essential. If possible, promote spontaneous closure and diminish the catabolic strain on the tissues.54 In patients with intestinal fistulas with a tract or skin coverage, management of fistula output has been assisted by hormonal agents; however, randomized control trials do not favor octreotide as the standard of care.55 Medical management has decreased the need for operative management of intestinal fistulas. More than 50% of patient with intestinal fistulas will require surgery for the control of sepsis and subsequent surgical repair for failure to close spontaneously.56,57 Nutrition support either enteral or parenteral is considered a critical supportive measure to prevent malnutrition in an already debilitated patient.58 Although, a full discussion of the management of intestinal fistula is beyond the scope of this article, Table 4 provides additional literature.Figure 2.: Intestinal fistula complicating the open abdomen flow diagram.TABLE 4: Enterocutaneous and Entero-atmospheric FistulaLocal wound care can be extremely problematic in the patient with an open abdomen and an entero-cutaneus fistula. In an attempt to mitigate the inflammatory state preventing resolution of the entero-atmospheric fistula, Jamshidi and Schecter59 treated seven patients with direct application of a biological dressing (HADM and/or cadaveric split thickness skin graft). Five of this series of seven closed with only two requiring further operative management. Physiologically similar, the application of skin graft to the granulated wound bed can have good results with as much as 93% graft take at 1 week.60 The use of an innovative negative pressure dressings or the KCI V.A.C. therapy to collect the draining succus entericus to keep the open abdomen clean can be a daily wound management issue. An innovative option for improving wound care is the creation of the "floating stoma." Recent case studies have described techniques for "floating stoma" with or without KCI V.A.C. therapy of the wound bed in attempts to simplify treatment before and after definitive repair.61 The restoration of gastrointestinal continuity at the time of the abdominal wall reconstruction is safe and the preferred treatment for entero-atmospheric fistula.62 Success depends on the achievement of the goals set out in the management phase; the eradication of sepsis, optimizing nutrition status (albumin >3.25 g/dL), and delaying operative repair a minimum of 3 months to 12 months to allow for the development of a "neo-peritoneal cavity."63 An essential management priority is to stage the "elective" gastrointestinal reconstruction when the patient's sepsis has resolved. After the inflammatory process within the abdominal cavity has resolved, the intra-abdominal adhesions will progress through the various stages of inflammation to vascularize and loosen fibrous adhesions resulting in a safer operative procedure.64 Even in the most optimized patient, entero-atmospheric fistulas remain among the most challenging problems, a surgeon will face. Planned Ventral Hernia Fabian et al.65 and other authors are credited with the initial description of the stages of damage control. The goals of damage control are (1) patient survival, (2) reconstruction of the patient's traumatic injuries with the final goal and (3) being abdominal fascial closure.47,62,66,67 As noted above, there are multiple techniques to achieve early or DAFC. When this is not possible, the planned ventral hernia technique is used. Once it has been determined that the abdominal fascia will not come together because of massive visceral edema, loss of domain, and/or loss of abdominal wall tissue, the only option left is a planned ventral hernia or fascial bridge with biological mesh or absorbable mesh.68,69 The initial goal of a planned ventral hernia is to keep the viscera within the abdominal cavity. This is accomplished by using absorbable mesh (Vicryl [Ethicon] or Dexon [Covidien]) to prevent evisceration. This allows time for the viscera to adhere together. This occurs during the course of 2 weeks to 3 weeks. Once the base of the open wound has granulated, a skin graft can be performed to cover the viscera. If the fascial defect is not large, another option is to elevate skin flaps and perform a skin only closure.70 Caution must be exercised when elevating skin flaps in the setting of continued intra-abdominal sepsis, lack of source control, and massive visceral edema; because this setting has a high risk of skin flap infarction and flap loss. In this setting, allowing the wound base to progress to a good granulated base and proceeding to skin graft tissue coverage may be the safest option. Regardless of the technique used, visceral coverage is essential to decrease metabolic burden and prevent the formation of entero-atmospheric fistulae as a result of trauma from exposure or dressing changes. Temporary abdominal closure with silicone sheets or Gortex has also been used to keep the abdominal contents from eviscerating.11,71 This is done until the viscera have adhered together. The prosthetic mesh is removed and the granulation bed is skin grafted. Others have used bilateral bipedal flaps to cover the granulation bed with skin. The goal is to decrease the incidence of intestinal fistula formation.37,72 The of biological mesh has been used in an attempt to do stage repairs of ventral The data to that the majority of patients with biological mesh may develop of the repair resulting in a hernia months to 12 months The of biological mesh in the process has not been The final stage of damage control is an "elective" abdominal wall of the complexity of this the EAST Open Abdomen Committee is in the process of a set of guidelines for abdominal wall reconstruction after the open abdomen. regarding the operative and postoperative management and follow-up will be (Table Planned Ventral control laparotomy in trauma, emergency general, and vascular in the setting of an laparotomy as a result of has become the standard of The open abdomen technique has become an essential component of the The management and closure of the open abdomen has developed into a surgical and remains a challenging to the techniques have been developed to close the open abdomen. The majority of open abdomens can undergo early abdominal fascial closure during the initial re-laparotomy. If three or more laparotomies are DAFC can be achieved in the majority of cases using three surgical techniques Wittmann closure with or without the use of a wound When the midline fascia be two other techniques to are bridge closure with absorbable mesh or acute component The development of the entero-atmospheric fistula is a major clinical complication of the open abdomen. The development of the "floating stoma" and skin graft of the open abdomen in achieving control of contents and wound when DAFC be one may to ventral with the of abdominal wall reconstruction in the The management of the open abdomen remains a heterogeneous of This is to various such as the of the open abdomen emergency general, and vascular and the of intra-abdominal In addition, there are no for the open abdomen. a of was in 2009 to a for the open The is and can be to there is no of the proposed and it has not been studied or However, a standard of the open abdomen is a is to be in to this clinical (Table of the

The open abdomen technique may be used in critically ill patients to manage abdominal injury, reduce the septic complications, and prevent the abdominal compartment syndrome. Many different techniques have been proposed and multiple studies have been conducted, but the best method of temporary abdominal closure has not been determined yet. Recently, new randomized and nonrandomized controlled trials have been published on this topic. We aimed to perform an up-to-date systematic review on the management of open abdomen, including the most recent published randomized and nonrandomized controlled trials, to compare negative pressure wound therapy (NPWT) with no NPWT and define if one technique has better outcomes than the other with regard to primary fascial closure, postoperative 30-day mortality and morbidity, enteroatmospheric fistulae, abdominal abscess, bleeding, and length of stay. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions, an online literature research (until July 1, 2015) was performed on MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Library databases. The MeSH terms and free words used "vacuum assisted closure" "vac;", "open abdomen", "damage control surgery", and "temporary abdominal closure". No language restriction was made. The initial systematic literature search yielded 452 studies. After a careful assessment of the titles and of the full text was obtained, eight articles fulfilled inclusion criteria. We analyzed 1,225 patients, of whom 723 (59%) underwent NPWT and 502 (41%) did not undergo NPWT, and performed four subgroups: VAC versus Bogota bag technique (two studies, 106 participants), VAC versus mesh-foil laparostomy (two studies, 159 participants), VAC versus laparostomy (adhesive impermeable with midline zip) (one study, 106 participants), and NPWT versus no NPWT techniques (three studies, 854 participants) in which it is not possible to perform an analysis of the different types of treatment. Comparing the NPWT group and the group without NPWT, there was no statistically significant difference in fascial closure (63.5% vs 69.5%; odds ratio [OR], 0.74; 95% confidence interval [CI], 0.27-2.06; p = 0.57), postoperative 30-day overall morbidity (p = 0.19), postoperative enteroatmospheric fistulae rate (2.1% vs 5.8%; OR, 0.63; 95% CIs, 0.12-3.15; p = 0.57), in the postoperative bleeding rate (5.7% vs 14.9%; OR, 0.58; 95% CIs, 0.05-6.84; p = 0.87), and postoperative abdominal abscess rate (2.4% vs 5.6%; OR, 0.42; 95% CI, 0.13-1.34; p = 0.14). On the other hand, statistical significance was found between the NPWT group and the group without NPWT in the postoperative mortality rate (28.5% vs 41.4%; OR, 0.46; 95% CI, 0.23-0.91; p = 0.03) and in the length of stay in the intensive care unit (mean difference, -4.53; 95% CI, -5.46 to 3.60; p < 0.00001). The limitations of the present analysis might be related to the lack of randomized controlled trials, so there is a risk of selection bias favoring NPWT. For several outcomes, there were few studies, confidence intervals were wide, and inconsistency was high, suggesting that although there were no statistically significant differences between the groups, there was insufficient evidence to show that the outcomes were similar. We can conclude from the current available data that NPWT seems to be associated with a trend toward better outcomes compared to the use of no NPWT. It does reflect the evidence presented in the current systematic review; however, the data should be interpreted with substantial caution given a number of weaknesses (in particular, the lack of statistical significance and heterogeneity between studies, i.e., small sample size of the included studies, high variability between studies). We highlight the need for randomized controlled trials having homogeneous inclusion criteria to assess the use of NPWT for the management of open abdomen. Systemic review/meta-analysis, level III.

Up to the present, the optimal time to close an open abdomen remains controversial. This study was designed to evaluate whether early fascial abdominal closure had advantages over delayed approach for open abdomen populations. Medline, Embase, and Cochrane Library were searched until April 2013. Search terms included “open abdomen,” “abdominal compartment syndrome,” “laparostomy,” “celiotomy,” “abdominal closure,” “primary,” “delayed,” “permanent,” “fascial closure,” and “definitive closure.” Open abdomen was defined as “fail to close abdominal fascia after a laparotomy.” Mortality, complications, and length of stay were compared between early and delayed fascial closure. In total, 3125 patients were included for final analysis, and 1942 (62%) patients successfully achieved early fascial closure. Vacuum assisted fascial closure had no impact on pooled fascial closure rate. Compared with delayed abdominal closure, early fascial closure significantly reduced mortality (12.3% versus 24.8%, RR, 0.53, P < 0.0001) and complication incidence (RR, 0.68, P < 0.0001). The mean interval from open abdomen to definitive closure ranged from 2.2 to 14.6 days in early fascial closure groups, but from 32.5 to 300 days in delayed closure groups. This study confirmed clinical advantages of early fascial closure over delayed approach in treatment of patients with open abdomen.

Few descriptions of temporary abdominal closure for planned relaparotomy have been reported in burned patients. The purpose of this study is to describe our experience and outcomes in the management of burned patients with an open abdomen. The authors performed a retrospective review of all admissions to our burn center from March 2003 to June 2008, identifying patients treated by laparotomy with temporary abdominal closure. The authors collected data on patient demographics, indication for laparotomy, methods of temporary and definitive abdominal closure, and outcomes. Of 2,104 patients admitted, 38 underwent a laparotomy with temporary abdominal closure. Their median TBSA was 55%, and the incidence of inhalation injury was 58%. Abdominal compartment syndrome was the most common indication for laparotomy (82%) followed by abdominal trauma (16%). The in-hospital mortality associated with an open abdomen was 68%. Temporary abdominal closure was performed most commonly using negative pressure wound therapy (90%). Fascial closure was performed in 21 patients but was associated with a 38% rate of failure requiring reexploration. Of 12 survivors, fascial closure was achieved in seven patients and five were managed with a planned ventral hernia. Burned patients who necessitate an open abdomen management strategy have a high morbidity and mortality. Fascial closure was associated with a high rate of failure but was successful in a select group of patients. Definitive abdominal closure with a planned ventral hernia was associated with no increased mortality and remains an option when "tension-free" fascial closure cannot be achieved.

Several challenging clinical situations in patients with peritonitis can result in an open abdomen (OA) and subsequent temporary abdominal closure (TAC). Indications and treatment choices differ among surgeons. The risk of fistula development and the possibility to achieve delayed fascial closure differ between techniques. The aim of this study was to review the literature on the OA and TAC in peritonitis patients, to analyze indications and to assess delayed fascial closure, enteroatmospheric fistula and mortality rate, overall and per TAC technique. Electronic databases were searched for studies describing the OA in patients of whom 50% or more had peritonitis of a non-traumatic origin. The search identified 74 studies describing 78 patient series, comprising 4,358 patients of which 3,461 (79%) had peritonitis. The overall quality of the included studies was low and the indications for open abdominal management differed considerably. Negative pressure wound therapy (NPWT) was the most frequent described TAC technique (38 of 78 series). The highest weighted fascial closure rate was found in series describing NPWT with continuous mesh or suture mediated fascial traction (6 series, 463 patients: 73.1%, 95% confidence interval 63.3-81.0%) and dynamic retention sutures (5 series, 77 patients: 73.6%, 51.1-88.1%). Weighted rates of fistula varied from 5.7% after NPWT with fascial traction (2.2-14.1%), 14.6% (12.1-17.6%) for NPWT only, and 17.2% after mesh inlay (17.2-29.5%). Although the best results in terms of achieving delayed fascial closure and risk of enteroatmospheric fistula were shown for NPWT with continuous fascial traction, the overall quality of the available evidence was poor, and uniform recommendations cannot be made.

Open abdomen (OA) is a useful option for treatment strategy in many acute abdominal catastrophes. A number of temporary abdominal closure (TAC) methods are used with limited number of comparative studies. The present study was done to examine risk factors for failed delayed primary fascial closure (DPFC) and risk factors for mortality in patients treated with OA. This study was a multicenter retrospective analysis of the hospital records of all consecutive patients treated with OA during the years 2009 to 2016 at five tertiary referral hospitals and three secondary referral centers in Finland. Six hundred seventy-six patients treated with OA were included in the study. Vacuum-assisted closure with continuous mesh-mediated fascial traction (VACM) was the most popular TAC method used (N = 398, 59%) followed by VAC (N = 128, 19%), Bogota bag (N = 128, 19%), and self-designed methods (N = 22, 3%). In multivariate analysis, enteroatmospheric fistula and the number of needed TAC changes increased the risk for failed DPFC (odds ratio [OR], 8.9; 95% confidence interval [CI], 6.2-12.8; p < 0.001 and OR, 1.1; 95% CI, 1.0-1.3; p < 0.001, respectively). Instead, VACM and ruptured abdominal aortic aneurysm as cause for OA both decreased the risk for failed DPFC (OR, 0.1; 95% CI, 0.0-0.3; p < 0.001 and OR, 0.2; 95% CI, 0.1-0.7; p = 0.012). The overall mortality rate was 30%. In multivariate analysis for mortality, multiorgan dysfunction (OR, 2.4; 95% CI, 1.6-3.6; p < 0.001), and increasing age (OR, 4.5; 95% CI, 2.0-9.7; p < 0.001) predicted increased mortality. Institutional large annual patient volume (OR, 0.4; 95% CI, 0.3-0.6; p < 0.001) and ileus and postoperative peritonitis in comparison to severe acute pancreatitis associated with decreased mortality (OR, 0.2; 95% CI, 0.1-0.4; p < 0.001; OR, 0.5; 95% CI, 0.3-0.8; p = 0.009). Kaplan-Meier analysis showed increased survival in patients treated with VACM in comparison with other TAC methods (LogRank p = 0.019). We report superior role for VACM methodology in terms of successful primary fascial closure and increased survival in patients with OA. Therapeutic/care management, level IV.

Temporary abdominal closure (TAC) techniques are routinely used in the open abdomen. Ideally, they should prevent evisceration, aid in removal of unwanted fluid from the peritoneal cavity, facilitate in achieving safe definitive fascial closure, as well as prevent the development of intra-abdominal complications. TAC techniques used in the open abdomen were compared with negative pressure wound therapy (NPWT) to identify which was superior. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines involving Medline, Excerpta Medica, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Clinicaltrials.gov. All studies describing TAC technique use in the open abdomen were eligible for inclusion. Data were analyzed per TAC technique in the form of a meta-analysis. A total of 225 articles were included in the final analysis. A meta-analysis involving only randomized controlled trials showed that NPWT with continuous fascial closure was superior to NPWT alone for definitive fascial closure [mean difference (MD): 35% ± 23%; P = 0.0044]. A subsequent meta-analysis involving all included studies confirmed its superiority across outcomes for definitive fascial closure (MD: 19% ± 3%; P &lt; 0.0001), perioperative (MD: -4.0% ± 2.4%; P = 0.0013) and in-hospital (MD: -5.0% ± 2.9%; P = 0.0013) mortality, entero-atmospheric fistula (MD: 22.0% ± 1.8%; P = 0.0041), ventral hernia (MD: -4.0% ± 2.4%; P = 0.0010), and intra-abdominal abscess (MD: -3.1% ± 2.1%; P = 0.0044). Therefore, it was concluded that NPWT with continuous fascial traction is superior to NPWT alone.

Management of the open abdomen is a considerable burden for patients and healthcare professionals. Various temporary abdominal closure techniques have been suggested for managing the open abdomen. In recent years, negative pressure wound therapy (NPWT) has been used in some centres for the treatment of non-trauma patients with an open abdomen; however, its effectiveness is uncertain. To assess the effects of negative pressure wound therapy (NPWT) on primary fascial closure for managing the open abdomen in non-trauma patients in any care setting. In October 2021 we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL EBSCO Plus. To identify additional studies, we also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports. There were no restrictions with respect to language, date of publication, or study setting. We included all randomised controlled trials (RCTs) that compared NPWT with any other type of temporary abdominal closure (e.g. Bogota bag, Wittmann patch) in non-trauma patients with open abdomen in any care setting. We also included RCTs that compared different types of NPWT systems for managing the open abdomen in non-trauma patients. Two review authors independently performed the study selection process, risk of bias assessment, data extraction, and GRADE assessment of the certainty of evidence. We included two studies, involving 74 adults with open abdomen associated with various conditions, predominantly severe peritonitis (N = 55). The mean age of the participants was 52.8 years; the mean proportion of women was 39.2%. Both RCTs were carried out in single centres and were at high risk of bias. Negative pressure wound therapy versus Bogota bag We included one study (40 participants) comparing NPWT with Bogota bag. We are uncertain whether NPWT reduces time to primary fascial closure of the abdomen (NPWT: 16.9 days versus Bogota bag: 20.5 days (mean difference (MD) -3.60 days, 95% confidence interval (CI) -8.16 to 0.96); very low-certainty evidence) or adverse events (fistulae formation, NPWT: 10% versus Bogota: 5% (risk ratio (RR) 2.00, 95% CI 0.20 to 20.33); very low-certainty evidence) compared with the Bogota bag. We are also uncertain whether NPWT reduces all-cause mortality (NPWT: 25% versus Bogota bag: 35% (RR 0.71, 95% CI 0.27 to 1.88); very low-certainty evidence) or length of hospital stay compared with the Bogota bag (NPWT mean: 28.5 days versus Bogota bag mean: 27.4 days (MD 1.10 days, 95% CI -13.39 to 15.59); very low-certainty evidence). The study did not report the proportion of participants with successful primary fascial closure of the abdomen, participant health-related quality of life, reoperation rate, wound infection, or pain. Negative pressure wound therapy versus any other type of temporary abdominal closure There were no randomised controlled trials comparing NPWT with any other type of temporary abdominal closure. Comparison of different negative pressure wound therapy devices We included one study (34 participants) comparing different types of NPWT systems (Suprasorb CNP system versus ABThera system). We are uncertain whether the Suprasorb CNP system increases the proportion of participants with successful primary fascial closure of the abdomen compared with the ABThera system (Suprasorb CNP system: 88.2% versus ABThera system: 70.6% (RR 0.80, 95% CI 0.56 to 1.14); very low-certainty evidence). We are also uncertain whether the Suprasorb CNP system reduces adverse events (fistulae formation, Suprasorb CNP system: 0% versus ABThera system: 23.5% (RR 0.11, 95% CI 0.01 to 1.92); very low-certainty evidence), all-cause mortality (Suprasorb CNP system: 5.9% versus ABThera system: 17.6% (RR 0.33, 95% CI 0.04 to 2.89); very low-certainty evidence), or reoperation rate compared with the ABThera system (Suprasorb CNP system: 100% versus ABThera system: 100% (RR 1.00, 95% CI 0.90 to 1.12); very low-certainty evidence). The study did not report the time to primary fascial closure of the abdomen, participant health-related quality of life, length of hospital stay, wound infection, or pain. Based on the available trial data, we are uncertain whether NPWT has any benefit in primary fascial closure of the abdomen, adverse events (fistulae formation), all-cause mortality, or length of hospital stay compared with the Bogota bag. We are also uncertain whether the Suprasorb CNP system has any benefit in primary fascial closure of the abdomen, adverse events, all-cause mortality, or reoperation rate compared with the ABThera system. Further research evaluating these outcomes as well as participant health-related quality of life, wound infection, and pain outcomes is required. We will update this review when data from the large studies that are currently ongoing are available.

Enteroatmospheric fistulae in open abdomen: Management and outcome – Single center experience

Enteroatmospheric fistula（EAF）は，open abdomen management（OAM）に伴う致死的合併症の一つで，開腹術創部に直接開口する消化管瘻を指す。43歳の男性が交通事故に伴う多発外傷で長期のOAMを余儀なくされた。早期閉腹のためfascial traction法を用いて腹壁の退縮を予防し，第20病日，component separation法を試みたが閉腹困難であり，第30病日に小腸のEAFを発症した。EAF管理に際しては，ストーマ化による瘻孔排液の分離に難渋し漏れが頻発したが，陰圧閉鎖療法を併用した物理的な瘻孔圧迫や腸管縫合による閉鎖が腸内容物の排液量制御に有用であった。但し，完全な閉鎖は困難で時間を要するため，栄養吸収に問題がなければ早期の植皮術・ストーマ管理が入院期間の短縮に有用と考えた。 Enteroatmospheric fistula (EAF), the digestive tract fistula opening directly to the laparotomy wound is one lethal complication associated with open abdomen management. A 43–year–old man who sustained severe multiple abdominal trauma due to a traffic accident required long–term open abdomen management. In order to perform early fascial closure, the fascial traction method was used in combination with negative pressure wound therapy (NPWT) to prevent fascial retraction. On the 20th hospital day, the component separation method was tried for fascial closure, but was unsuccessful. On the 30th hospital day, EAF in the small intestine was confirmed. In EAF management, being unable to drain intestinal fluid from the fistula caused frequent leakage, which resulted in adjacent skin erosion. Physical compression to the fistula on top of NPWT and simple intestinal closure decreased the amount of fistula output. The complete closure of chronic EAF is extremely difficult and time–consuming. Therefore, if the patient’s nutritional absorption is normal, the early stoma management with a split thickness skin graft should be considered to reduce the length of hospital stay. Enteroatmospheric fistula（EAF）は，開腹術創部に直接開口する消化管瘻を指し，open abdomen management（OAM）に時折発症する重篤な合併症である。死亡率は42%と報告 1されており，治療に難渋することも多い。今回，我々は多発外傷に合併したEAFの1例を経験したため，症例から得られた管理の要点と工夫を報告する。 患 者：43歳の男性 既往歴：特記事項なし 現病歴：大型バイク走行中に，乗用車と衝突し約10m飛ばされた（来院90分前）。救急隊接触時（来院82分前），呼吸数40/min，SpO2 94%（室内気），血圧151/65mmHg，心拍数128/min，意識レベルGlasgow coma scale（GCS）14（E4V4M6），瞳孔径右3.0mm，左2.0mmでありドクターヘリが要請された。右胸郭礫音および呼吸音減弱所見から右血気胸が疑われ，フライトスタッフにより現場で右胸腔ドレナージ，末梢輸液路確保が行われた（来院約40分前）。飛行中，呼吸数34/min，血圧86/65mmHg，心拍数124/minとショック状態になり，当院救急外来搬入となった。 初療経過：来院時，呼吸数34/min，SpO2 99%（リザーバーマスク10L/min），血圧75/–mmHg，心拍数127/min，意識レベルGCS 12（E4V3M5）で，身長180cm，体重91kg，body mass index 28.1kg/m2の肥満体型であった。Primary surveyにて骨盤X線検査上65mmの恥骨結合離開を認め，約1,000mLの初期輸液にも反応が悪かったため，不安定型骨盤骨折に伴うnon–responderと判断し，経口気管挿管および輸血による蘇生を開始した。搬入15分後に，止血術として骨盤後腹膜パッキングを施行し，SAM Pelvic Sling II（Seaberg, Oregon, USA）にて骨盤固定を追加した。来院時の血液検査では，fibrinogen 174.0mg/dL，D–dimer 30.86µg/mL，PT–INR 1.00，血小板238,000/µL，pH 7.30，lactate 5.0mmol/Lであった。循環動態の回復を確認後，全身CTを施行した（来院40分後）。骨盤骨折に伴い両側内腸骨動脈分枝から血管外漏出像を認めたため，血管造影室へ移動し（来院65分後），引き続き両側内腸骨動脈塞栓術を行った。その際，施行した上腸間膜動脈造影にて回腸枝に血管外漏出像を認め，腹部超音波検査にて液体貯留の増加が確認されたため，大動脈遮断バルーンを横隔膜上に留置し，引き続き緊急開腹術を施行した（来院110分後）。腹腔内には約2,000mLの出血を認め，回腸腸間膜が広範に断裂し，活動性出血を認めた。損傷部の腸間膜動静脈を結紮止血し，回腸部分切除術を施行した。全身CTで，脳内出血（右側脳室部），肺挫傷（右上下葉背側，左下葉背側），全身多発骨折（右第1～9肋骨，両側橈尺骨，右脛骨，右鎖骨，右肩甲骨）などの合併損傷を認めた（ISS 57，RTS 5.148，TRISS Ps 26%）。全身状態から手術時間の短縮と縫合不全の危険を考慮しダメージコントロール手術の方針とした。小腸吻合は行わず，陰圧閉鎖療法（negative pressure wound therapy: NPWT）による一時的閉腹法（OAM）とし，骨盤創外固定術を追加した（来院245分後）。この時点で，fibrinogen 212.0mg/dL，D–dimer 11.37µg/mL，PT–INR 1.01，血小板74,000/µL，pH 7.26，lactate 4.8mmol/Lであった。搬入後約6時間における総輸液量は，晶質液5,000mL，濃厚赤血球20単位，新鮮凍結血漿24単位，血小板10単位（集中治療室入室後）であった。 入院後経過（Fig. 1）：集中治療室入室時（来院310分後），血圧132/78mmHg，心拍数121/min，体温38.1℃，bilevel positive airway pressureモードでPaCO2 33.9mmHg，PaO2 108.0mmHg，P/F 270，pH 7.34，lactate 1.8mmol/Lと比較的安定していた。膀胱内圧は当初36mmHgと高値であったが，腹部コンパートメント症候群の症状はなく，尿量も150mL/hrと良好であり，後腹膜パッキングによる上昇と判断した。その後，膀胱内圧は20mmHg前後まで改善していった。手術に伴い抗菌薬は第1病日よりCEZ 1g×4/日（～第7病日）を使用した。第4病日，second look 手術にて小腸吻合術を施行したが，後腹膜血腫および腸管浮腫により閉腹困難な状態であったためNPWTとしてV.A.C.（KCI Medical, San Antonio, USA）を用いた管理を開始した。第6病日，筋膜の退縮を防止する目的でPROLENE mesh（Johnson & Johnson, New Jersey, USA）によるfascial traction法 2 , 1を追加し，連日meshを折り込み，腹壁の近接化を図った。第7病日，術創部感染を疑い，抗菌薬をTAZ/PIPC 4.5g×3/日に変更し，第14病日にABPC/SBT 3g×4/日（～第27病日）へde–escalationした。第20病日，component separation法 2による腹壁再建を試みたが閉腹は困難であり，planned ventral hernia（PVH）の方針へ変更した。しかし第30病日，小腸にEAFを発症した。Fistula V.A.C. 法 3 , 3，baby bottle nipple V.A.C. 法 4 , 4などを試みたが瘻孔排液の分離は困難であった（Fig. 2a, b）。第49病日より経腸栄養を，第72病日より常食の摂取を開始したが，漏れのため，多い日で1日4回の創部処置を要し創傷治癒は遅延した（Fig. 3a）。第79病日，腹腔内膿瘍に対してST 1,440mg×2/日（～第97病日）を使用した。第120病日ごろより，凸型に形成した手術手洗い用滅菌スポンジ（DISPOMEDIC® SCRUB：C.V. MEDICA®, Sarral, Spain）を瘻孔部から腸管内に挿入し外圧迫を併用したNPWTに変更したところ（Fig. 2c, d），1日1回程度の創処置で対応が可能となり，自由に経口摂取を行うことで栄養状態は著明に改善した（Fig. 1, 3b）。第163病日，小腸縫合術を施行したが完全な閉鎖は困難で（Fig. 3c），第208病日，腹壁の皮膚・皮下脂肪層で縫合部を覆う形で再縫合を行った（Fig. 3d）。その後も完全な小腸瘻の閉鎖には至らなかったものの排液量の減少が得られ，第240病日退院となった。 Clinical course. The patient developed EAF on Day 30, and he was discharged from the hospital on Day 240. It was important for nutritional management to use intestinal nutrition at the earliest possible date and was essential for both the patient’s recovery and wound healing. V.A.C.: vacuum–assisted closure, NPWT: negative pressure wound therapy, STSG: split thickness skin graft, EAF: enteroatmospheric fistula, CRP: C reactive protein, ALB: albumin, comp: compression with sponge Serial wound managements during the clinical course. a: Fistula V.A.C. method on Day 54. b: Baby bottle nipple V.A.C. method on Day 90. c: Compression in the fistula with sponge on Day 124. d: The sponge formed in T shape. The change in wound appearance. a: Abdominal wound on Day 54. EAF was found on the right side edge of the wound (white arrow). b: Abdominal wound on Day 163. Remarkable granulation is seen while the EAF remains same in size. c: Status post split thickness skin graft on the granulating tissue on Day 190. d: Approximation of the abdominal wall on Day 208. Hwabejireら 5は，死亡率と直結する腹部コンパートメント症候群の発症リスクは総蘇生液量96mL/kgで上昇し始め，1,302mL/kgで著明に上昇すると報告しているが，本症例では117mL/kgであった。また，massive transfusion protocolに準じて来院直後から濃厚赤血球：新鮮凍結血漿：血小板の比率を1：1.2：0.5で投与を行い，fibrinogenに関しては 200mg/dL前後を維持できており，希釈性凝固障害の防止もできたと考える。本症例では，全身状態および後腹膜血腫・パッキングによる腹腔内圧上昇から，OAMは不可避の状態であったが，以上より蘇生液量は適正であったと判断する。 EAFの管理に関しては，瘻孔排液の適確な分離による腹腔内や瘻孔周囲への流出防止，露出腸管の肉芽・上皮化形成促進が目標となる 6。過去の報告例 6を参考に様々な創処置を試したが，瘻孔周囲は露出腸管と肉芽組織であるため平坦ではなく，ストーマ面板の密着は困難であり 7，腸液の漏れが頻発した。瘻孔排液を受け止めるのではなく，出にくくするという発想で手洗い用スポンジを用いた物理的圧迫の方が漏れは少ない結果であった。また，V.A.C. の裏面に溜まった腸内容物は露出臓器と常に接触しており，創周囲の皮膚は糜爛を繰り返し 6，創傷治癒を遅延させた。我々はこのような状況下での分層植皮術は生着が見込めないと考えていたが，Cheesboroughら 8は，EAF例においても約2週間での早期分層植皮術の有効例を報告している。確かにストーマ管理においては腹壁と面板の密着のため，瘻孔部周囲における上皮化手段が必須であり，早期の分層植皮術は検討の余地がある。瘻孔閉鎖に関しては，瘻孔管がなく血管の発達した組織が周囲にないため自然閉鎖はない 6。ごく小さな瘻孔の場合，中間層皮膚移植片などで覆いNPWTを併用することで閉鎖が期待できる 9。本症例は，近位・瘻孔が大きい・排液量が中等量以上に該当し，縫合や被覆材での閉鎖は困難と報告 6されているが，現状でのストーマ管理では，著明な排液量による栄養状態・水分バランスの悪化が懸念された。瘻孔閉鎖の強い希望もあり，全身管理により栄養状態が改善し，開腹創部が安定化するのを待って小腸縫合に踏み切った。縫合部の緊張軽減のために減張縫合を加えたものの再発を認めたため，腹壁皮膚で縫合部を寄せて覆った結果，完全な閉鎖は困難であったが，排液量の減量に有効であった。 EAFでは，NPWTを併用した物理的な瘻孔圧迫や腸管縫合による閉鎖は排液量制御に有用となり得るが，完全な閉鎖は困難で時間を要する。栄養吸収に問題がなければ早期の植皮術・ストーマ管理が発症後の入院期間短縮に有用と考察した。 なお本論文の要旨は，第30回日本外傷学会において報告した。 本報告において，利益相反はない。

In emergency surgery, managing abdominal sepsis and critically ill patients with imminent abdominal compartment syndrome (ACS) using an open abdomen (OA) approach has become standard practice for damage control. To prevent significant complications associated with OA therapy, such as abdominal infections, entero-atmospheric fistula (EAF), and abdominal wall hernia formation, early definitive fascial closure (DFC) is crucial. This study aims to assess the feasibility of a novel device designed to facilitate early fascial closure in patients with an open abdomen. Between 2019 and 2020, nine patients undergoing open abdomen management were enrolled in this study. All patients were treated using vertical mesh-mediated fascial traction combined with a novel vertical traction device (VTD). Data from these cases were collected and retrospectively analyzed. In this study, all patients were treated with OA due to impending ACS. Three patients died before achieving DFC, while the remaining six patients successfully underwent DFC. The mean number of surgical procedures after OA was 3 ± 1, and the mean time to DFC was 9 ± 3 days. The use of the VTD in combination with negative pressure wound therapy (NPWT) resulted in a 76% reduction in fascia-to-fascia distance until DFC was achieved. The application of the VTD did not affect ventilation parameters or the Simplified Acute Physiology Score II (SAPS II), but intra-abdominal pressure (IAP) was reduced from 31 ± 8 mmHg prior to OA to 8.5 ± 2 mmHg after applying the device. The primary complication associated with the device was skin irritation, with three patients developing skin blisters as the most severe manifestation. Overall, the novel VTD appears to be a safe and feasible option for managing OA cases. It may reduce complications associated with OA by promoting early definitive fascial closure.

Aims Encapsulating peritoneal sclerosis (EPS) is a rare phenomenon characterised by encasement and obstruction of the bowel by thickened peritoneum. In our centre, EPS laparotomies are typically managed with open abdomen (OA) and planned relook at 24-48 hours. The aim of the study was to compare ABTHERATM open abdomen negative pressure wound therapy (NPWT) with packing (betadine-soaked gauze) as temporary abdominal closure (TAC) techniques in OA management. Methods We performed retrospective analysis of a contemporaneously maintained database of all patients who underwent surgery for EPS between 2010-2020. A variety of variables were included with the primary endpoint being time to definitive fascial closure. Patient demographics, surgical complications, subsequent method of closure (including mesh usage) and outcomes were recorded. Results 99/122 patients underwent open abdomen management. 43/99 were managed with NPWT and 56/99 were managed with packing. The NPWT group had significantly higher fascial closure rates without need for subsequent bridged (mesh) closure when compared to the packed abdomen [62.8% vs 12.5%, (p &amp;lt; 0.001, c2 test)]. In the NPWT group, there were also fewer failed closures [4.7% vs 19.6%, (p = 0.03, c2 test)] along with shorter time to definitive closure and reduced theatre episodes. No incidence of intestinal fistulation was associated with NPWT. Conclusion This study provides definitive guidance as to the benefit of ABTHERATM open abdomen NPWT for fascial closure following open abdominal management. ABTHERATM open abdomen NPWT provides significant advantages over traditional methods of TAC and may provide benefit in OA management in other patient groups (sepsis and trauma) as well.

BackgroundAn 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 presentationA 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.ConclusionsPrimary 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.

Management and closure of the open abdomen after damage control laparotomy for trauma. A systematic review and meta-analysis

Primary fascia closure is often difficult following an open abdomen (OA). While negative-pressure wound therapy (NPWT) is recommended to enhance successful primary fascia closure, the optimal methods and degree of negative pressure remain unclear. This study aimed to elucidate optimal methods of NPWT as a tentative abdominal closure for OA to achieve primary abdominal fascia closure. A multicenter, retrospective, cohort study of adults who survived OA greater than 48h was conducted in 12 institutions between 2010 and 2022. The achievement of primary fascia closure and incidence of enteroatmospheric fistula were examined based on methods (homemade, superficial NPWT kit, or open-abdomen kit) or degrees of negative pressure (<50, 50-100, or >100mmHg). A generalized estimating equation was used to adjust for age, BMI, comorbidities, etiology for laparotomy requiring OA, vital signs, transfusion, severity of critical illness, and institutional characteristics. Of the 279 included patients, 252 achieved primary fascia closure. A higher degree of negative pressure (>100mmHg) was associated with fewer primary fascia closures than less than 50mmHg [OR, 0.18 (95% CI: 0.50-0.69), P =0.012] and with more frequent enteroatmospheric fistula [OR, 13.83 (95% CI: 2.30-82.93)]. The methods of NPWT were not associated with successful primary fascia closure. However, the use of the open-abdomen kit was related to a lower incidence of enteroatmospheric fistula [OR, 0.02 (95% CI: 0.00-0.50)]. High negative pressure (>100mmHg) should be avoided in NPWT during tentative abdominal closure for OA.