Open abdomen versus primary closure in nontrauma patients: A weighted analysis of a single-center experience

Abstract

INTRODUCTION The open abdomen (OA) technique is nowadays a worldwide strategy both for trauma and emergency general surgery. Despite the attempt at conducting prospective studies, a high level of evidence is far from established. The aim of this study was to investigate if we overused this strategy and if it improved the postoperative course of our patients. METHODS Emergency laparotomies from 2017 and 2023 were reviewed and stratified according to OA and closed abdomen (CA). Differences were balanced by inverse probability weighting, and the 90-day mortality was estimated. Subgroup analysis was carried out for patients with a Mannheim Peritonitis Index (MPI) of >26, bowel obstruction, bowel ischemia (BI) and gastrointestinal perforation. RESULTS Of the 320 patients, 167 were CA and 153 were OA. Groups were different for American Society of Anesthesiologists, comorbidities, transfusion rate, Physiologic and Operative Severity Score for the Study of Mortality and Morbidity score, MPI, Clinical Frailty Scale score, diagnosis, and resection. Two balanced pseudo-populations were created. The 90-day survival rate was 50.8% for CA and 60.8% for OA (hazard ratio [HR], 0.79; confidence interval [CI], 0.40–1.55; p = 0.502). At the Cox regression, the Clinical Frailty Scale score (HR, 1.125; 95% CI, 1.01–1.25; p = 0.033) and BI (HR, 5.531; 95% CI, 2.37–12.89; p < 0.001) were independent risk factors for mortality. Transfusion rate (odds ratio [OR], 3.44; 95% CI, 1.44–8.23; p < 0.006) and length of stay in the intensive care unit (OR, 1.13; 95% CI, 1.07–1.20; p < 0.001) were associated with major complications. Open abdomen did not modify mortality in the case of bowel obstruction, MPI >26, or gastrointestinal perforation. Finally, OA (HR, 0.056; 95% CI, 0.01–0.22; p = 0.001) and large bowel resection (HR, 6.442; 95% CI, 1.28–32.31; p = 0.040) were predictors of longer survival in the subgroup of patients with BI. CONCLUSION Open abdomen was not associated with a higher complication rate or higher mortality but did result in a longer in-hospital stay. The only setting where OA seemed to be advantageous was in the BI population. LEVEL OF EVIDENCE Epidemiological and Prognostic Study; Level III.