Abstract
BackgroundSelection 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.MethodsA single center study of patients with SAP that underwent OA treatment compared with conservatively treated matched controls.ResultsWithin 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.ConclusionDecreased 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.
Highlights
Selection of patients for open abdomen (OA) treatment in severe acute pancreatitis (SAP) is challenging
Delayed primary fascial closure can mostly be achieved when utilizing dynamic fascial traction systems combined with negative pressure wound therapy [7, 8]
Due to otherwise insufficient number of control patients, we allowed a violation of the pre-specified matching principles in the following three cases: one OA-treated patient with Sequential Organ Failure Assessment (SOFA) score 19 was matched with a control patient with SOFA score 16, and two patients were matched despite 11 years age difference
Summary
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; refractory abdominal compartment syndrome (ACS) is potentially lethal. We aimed to study these factors to help understand what influences the selection of patients for OA treatment in SAP. Intra-abdominal hypertension (IAH) affects most patients with severe acute pancreatitis (SAP). IAH correlates with significant mortality, and escalation to abdominal compartment syndrome (ACS). As organ failure is characteristical and ACS occurs commonly in SAP, patient selection and correct timing of OA treatment remains clinically challenging. Enlightening what influences the decision to engage OA treatment might help narrow down selection of patients for this morbid treatment. We report and compare the outcomes of these patients
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