Temporary Abdominal Closure Techniques Research Articles

Open abdomen and entero-atmospheric fistulae: An interim analysis from the International Register of Open Abdomen (IROA)

IntroductionNo definitive data describing associations between cases of Open Abdomen (OA) and Entero-atmospheric fistulae (EAF) exist. The World Society of Emergency Surgery (WSES) and the Panamerican Trauma Society (PTS) thus analyzed the International Register of Open Abdomen (IROA) to assess this question. Material and methodsA prospective analysis of adult patients enrolled in the IROA. ResultsAmong 649 adult patients with OA 58 (8.9%) developed EAF. Indications for OA were peritonitis (51.2%) and traumatic-injury (16.8%). The most frequently utilized temporary abdominal closure techniques were Commercial-NPWT (46.8%) and Bogotà-bag (21.9%). Mean OA days were 7.9 ± 18.22. Overall mortality rate was 29.7%, with EAF having no impact on mortality. Multivariate analysis associated cancer (p = 0.018), days of OA (p = 0.003) and time to provision-of-nutrition (p = 0.016) with EAF occurrence. ConclusionEntero-atmospheric fistulas are influenced by the duration of open abdomen treatment and by the nutritional status of the patient. Peritonitis, intestinal anastomosis, negative pressure and oral or enteral nutrition were not risk factors for EAF during OA treatment.

Management of the Open Abdomen.

Management of the abdominal catastrophe requires a multidisciplinary approach. The plastic surgeon is a key member of the surgical team assisting in the creation of a durable, functional anatomic abdominal wall reconstruction. Plastic surgeons must be familiar with the concepts and pathophysiology related to the open abdomen, techniques for temporary abdominal closure, and when such techniques are appropriate to implement. In this article, the authors provide a review of the open abdomen concept, which practicing plastic surgeons and trainees may find helpful if faced with this clinical scenario.

Effects of temporary abdominal closure methods on mortality and morbidity in patients with open abdomen.

Open abdomen (OA) in which the abdomen is closed with temporary abdominal closure methods is the most effective in patients who develop severe abdominal sepsis or abdominal compartment syndrome. Major techniques used are Vacuum-Assisted Closure Method (VACM) and non-vacuum assisted closure method (NVACM). In the present study, the effects of different abdominal closure methods on morbidity and mortality were evaluated. In the study, the temporary abdominal closure methods of the patients with OA during 2013-2016 were studied retrospectively. OA etiopathologies, mortality prediction scores, final abdominal closure periods and methods, hospitalization periods, complications (enteroatmospheric fistula, mesh infection, and incisional hernia), and mortality rates of patients who underwent VACM and NVACM were determined and compared. The present study included 123 patients who underwent VACM (n=65) and NVACM (n=58). There was no difference between the groups in terms of age, gender, and etiopathogenesis (p>0.05). The mean APACHE 4 and Multiple Organ Dysfunction Score (MODS) scores in the VACM/NVACM groups in treatment period were 47/63 and 11/14, respectively (p<0.05). The mean intensive care and hospitalization periods in the VACM/NVACM groups were 11/16 (days) and 22/28 (days), respectively (p<0.05). The collection and abscess development rates in the VACM and NVACM groups were 46.2% and 77.6%, respectively (p<0.05). The rate of enteroatmospheric fistula (EAF) development in the VACM and NVACM groups were 15.4% and 56.9%, respectively (p<0.05). The mean abdominal closure times in the VACM and NVACM groups were 13 and 17 days, respectively (p<0.05). Mortality rate in the VACM and NVACM groups were 18% (n=18) and 55% (n=32), respectively (p<0.05). In patients with OA, the temporary abdominal closure technique VACM has lower complication and mortality rates and shorter hospitalization period than other methods. Therefore, it is an effective and safe method for the treatment of OA.

Bogota Bag in Abdominal Compartment Syndrome at Kathmandu Model Hospital.

The gold standard of quick and definitive treatment of Abdominal compartment syndrome (ACS) is surgical decompression by opening the abdomen and leaving it open until intra-abdominal pressure decreases. Temporary abdominal closure techniques are used to postpone definite closure until predisposing factors causing pathologic elevation of intra-abdominal pressure are resolved.This study aim to analyze feasibility of Bogota Bag placement as a way of temporary abdominal closure. Cases admitted in the period of eight years that were diagnosed to have or at risk to develop ACS and managed with 'Bogota Bag', irrespective of primary diagnosis were reviewed retrospectively. Cause of ACS, reasons to place Bogota bag, its complications and final outcome in terms of mortality related or not related with Bogota Bag placement were assessed. Total of ten patients had placement of Bogota Bag in the period of eight years. Laparotomy for bowel perforation with peritonitis was the most common primary condition contributing to ACS. Bogota bag was placed in two cases after emergency decompression as a therapeutic measure whereas others were done as prophylactic measure. There were two mortalities (20%) which were not directly related to abdominal compartment syndrome. Abdomen closure with Bogota Bag for patients with ACS or likely to develop ACS is a feasible technique with minimal procedure related morbidities.

Negative Pressure Wound Therapy versus modified Barker Vacuum Pack as temporary abdominal closure technique for Open Abdomen management: a four-year experience

BackgroundWe reviewed our experience with patients presenting with trauma and peritonitis who underwent an open abdomen (OA) procedure, and compared outcomes between Negative Pressure Wound Therapy (NPWT) and a modified Barker Vacuum Pack (mBVP) technique.MethodsIn this descriptive study, we retrospectively analyzed data regarding all patients who underwent OA for intra-abdominal sepsis or abdominal trauma at our Centre from January 2012 to December 2015. Demographic data, co-morbidities, indications to surgery, intra-operative details and Björck classification grade were considered. Outcomes included were: time to closure in days, fascial closure rates, ICU and hospital stay, in-hospital and overall mortality, and entero-atmospheric fistula rate.ResultsA total of 83 cases were considered. Mean closure time was 6 days versus 6.5 days (p = 0.71) in NPWT and mBVP groups, respectively; the fascial closure rate was 75.4% versus 93.8% (p = 0.10). At multivariate analysis, in-hospital and overall mortality were significantly higher within the mBVP, as compared to NPWT (OR 3.8, 95% CI 1.1 to 13.1, p = 0.02 – OR 4.2, 95% CI 1.2 to 14.1, p = 0.01). Entero-atmospheric fistula rate was 2.6% in the two groups.ConclusionsNPWT as a temporary abdominal closure technique, as compared to mBVP, appears to be associated with better outcomes in terms of mortality.

Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis

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.

Temporary abdominal closure for trauma and intra-abdominal sepsis: Different patients, different outcomes.

Temporary abdominal closure (TAC) after damage control surgery (DCS) for injured patients has been generalized to septic patients. However, direct comparisons between these populations are lacking. We hypothesized that patients with intra-abdominal sepsis would have different resuscitation requirements and lower primary fascial closure rates than trauma patients. We performed a 3-year retrospective cohort analysis of patients managed with TAC for trauma (n = 77) or intra-abdominal sepsis (n = 147). All patients received negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24- to 48-hour intervals. At presentation, trauma patients had higher rates of hypothermia (31% vs. 18%), severe acidosis (27% vs. 14%), and coagulopathy (68% vs. 48%), and septic patients had higher vasopressor infusion rates (46% vs. 27%). Forty-eight hours after presentation, septic patients had persistently higher vasopressor infusion rates (37% vs. 17%), and trauma patients had received more red blood cell transfusions (6.0 U vs. 0.0 U), fresh frozen plasma (5.0 U vs. 0.0 U), and crystalloid (8,290 vs. 7,159 ml). Among patients surviving to discharge, trauma patients had higher primary fascial closure (PFC) rates (90% vs. 76%). For trauma patients, independent predictors of failure to achieve PCF were ≥2.5 L NPWT output at 48 hours, ≥10 L crystalloid administration at 48 hours, and ≥10 U PRBC + FFP at 48 hours. For septic patients, relaparotomy within 48 hours predicted successful PFC; requirement for ≥3 diagnostic/therapeutic laparotomies predicted failure to achieve PFC. Traumatic injury and intra-abdominal sepsis are associated with distinct pathophysiologic insults, resuscitation requirements, and outcomes. Failure to achieve primary fascial closure in trauma patients was attributable to the triad of hypothermia, acidosis, and coagulopathy; failure to achieve fascial closure in septic patients was dependent upon operative course. Indications and optimal techniques for TAC may differ between these populations. Therapeutic study, level IV; prognostic study, level III.

Temporary abdominal closure techniques in open abdomen: preliminary data of international register of open abdomen (IROA): patient enrollment is still ongoing

The present work represents a letter to the editor on the article of Popivanov et al. “Temporary abdominal closure techniques in open abdomen – a word of caution” published recently in the July issue of IJSM.

Temporary abdominal closure techniques in open abdomen - a word of caution

The present work represent a short commentary of the article of Coccolini et al. “IROA: International Register of Open Abdomen, preliminary results” published recently in the February issue of WJES. We provide for a succinct commentary of their article and make certain useful suggestions.

Prospective Assessment of the Negative Pressure Wound Therapy of the Open Abdomen

Open abdomen (OA) is a surgical approach, that emerged in last 15 years, with its management being complicated, timely and financially demanding, burdened with high morbidity and mortality. In recent years, several publications proved superiority of usage of negative pressure wound therapy (NPWT) over usage of conventional temporary abdominal closure techniques in treatment of open abdomen. Different aspects of treatment of OA with NPWT remain to be assessed and stated.Authors of the paper prospectively assessed group of 48 patients with OA, managed by one surgeon with NPWT between 2006-2014, assessing mortality and morbidity in the group stratified by indication for OA, type of sequential closure of OA, presence and management of concomitant enteroatmospheric fistula (EAF), maximal values of C-reactive protein (CRP) and Procalcitonine (PCT), and initial body mass index (BMI). Mortality of the whole group was 35.41%, rate of fascial closure 45.83% and rate of the wound closure 83.33%. Incidence of the fistula was 37.5%, of these 66.67% were successfully locally managed. Incidence of fascial closure without use of sequential closure was significantly lower as opposed to use of different techniques of sequential closure.Unsuccessful local management of EAF is significant predictor of mortality. All other data were not found to be statistically significant. Identifying specific aspects of treatment of OA by NPWT, significantly improving outcomes, and adhering to these aspects in clinical practice will further ameliorate outcomes.

Role of Coral, Demineralized Calf Fetal Growth Plate, and a Combination of the Two in Healing of Bone Defects in Rabbits

Background: Open abdomen occurs most often after damage-control surgery following trauma. This condition is a temporary abdominal closure of the abdominal cavity which is left open. Objectives: This study aims to describe the experience and management in open abdomen trauma patients at a level 1 trauma center in Thailand. Patients andMethods: A retrospective review was performed of all adult trauma patients who had open abdomen after laparotomy between January 2011 and December 2012. Patients who had open abdomen but did not survive in the operating room were excluded. The data were collected from the trauma registry and medical records. Results: After 157 trauma laparotomies, 35 (22%) were open abdomen cases with an average injury severity score was 35. Ninety-four percent of open abdomens occurred after damage-control surgery. Temporary vacuum-assisted closure was applied in all patients. The fascial closure rate was 40%. In patients who failed to achieve a standard fascial closure, the skin closure technique alone was used. Deep surgical site infection was the most common complication after the abdominal cavities were closed. No enterocutaneous fistulae were reported. Conclusions: Vacuum-assisted abdominal closure is a good technique for temporary abdominal closure. In patients who are unable to achieve fascial closure, skin closure alone is safe.

Management of Open Abdomen After Trauma Laparotomy: Experience at a Level 1 Trauma Center in Thailand

Background: Open abdomen occurs most often after damage-control surgery following trauma. This condition is a temporary abdominal closure of the abdominal cavity which is left open. Objectives: This study aims to describe the experience and management in open abdomen trauma patients at a level 1 trauma center in Thailand. Patients and Methods: A retrospective review was performed of all adult trauma patients who had open abdomen after laparotomy between January 2011 and December 2012. Patients who had open abdomen but did not survive in the operating room were excluded. The data were collected from the trauma registry and medical records. Results: After 157 trauma laparotomies, 35 (22%) were open abdomen cases with an average injury severity score was 35. Ninety-four percent of open abdomens occurred after damage-control surgery. Temporary vacuum-assisted closure was applied in all patients. The fascial closure rate was 40%. In patients who failed to achieve a standard fascial closure, the skin closure technique alone was used. Deep surgical site infection was the most common complication after the abdominal cavities were closed. No enterocutaneous fistulae were reported. Conclusions: Vacuum-assisted abdominal closure is a good technique for temporary abdominal closure. In patients who are unable to achieve fascial closure, skin closure alone is safe.

Open abdomen in trauma patients: a double-edged sword.

The use of open abdomen (OA) as a technique in the treatment of exsanguinating trauma patients was first described in the mid-19th century. Since the 1980s, OA has become a relatively new and increasingly common strategy to manage massive trauma and abdominal catastrophes. OA has been proven to help reduce the mortality of trauma. Nevertheless, the OA method may be associated with terrible and devastating complications such as enteroatmospheric fistula (EAF). As a result, OA should not be overused, and attention should be given to critical care as well as special management. The temporary abdominal closure (TAC) technique after abbreviated laparotomy was used to improve wound healing and facilitate final fascial closure of OA. Negative pressure therapy (NPT) is the most commonly used TAC method.

A new technique to close open abdomen using negative pressure therapy and elastic gums

‘‘Open abdomen’’ is a routine surgical procedure in patients presenting with abdominal compartment syndrome, polytrauma requiring a second look and abdominal sepsis. In these cases, free access to the abdominal cavity may be necessary to drain fluid collections or to solve postoperative complications [1–3]. Several techniques for temporary abdominal closure have been described in the literature, but we observe a lack of experience as regards definitive closure techniques [4]. Here we present a kit which combines the use of a mesh, negative pressure therapy and elastic gums to attain definitive closure of the open abdomen in patients requiring a previous temporary closure and in whom it is impossible to accomplish primary closure of abdominal fascia, subcutaneous tissue and skin.

Management and treatment options for patients with open abdomen.

Abdominal sepsis and trauma are the main indications for open abdomen. However, there is no robust evidence that open abdomen is better than closed in these cases. When using open abdomen, treatment goals are to control the source of infection, protect the bowel from damage, minimise adhesions between the bowel and abdominal wall, facilitate nursing care and allow permanent closure of the wound by bringing the fascial edges closer. Several temporary abdominal closure techniques exist, but are associated with high mortality and morbidity rates. There is no evidence that any specific temporary abdominal closure technique is better than others; however, negative pressure wound therapy appears to be a popular method of management of open abdomen.

Open abdomen and temporary abdominal closure techniques with negative pressure

Introduction Nowadays, the open abdomen is widely accepted method for а treatment of severe trauma, severe diffuse peritonitis and abdominal compartment syndrome. During the past 30 years numerous techniques for temporary abdominal closure have been described. The aim of the present study is to review the literature and to compare the effectiveness of the techniques with negative pressure – vacuum pack (VP) and Vacuum Assisted Closure (V.A.C., KCI), which have received a vast popularity in the last two decades. Material and methods The literature search was performed in PUBMED for the period 1995-2014 with key words – “open abdomen”, “temporary abdominal closure”, “VP”, “V.A.C.”. For the purpose of the review, only original articles with a clear description of the methodology and results were considered. Results For the period 2002-2014, 17 eligible studies evaluating the outcome in V.A.C. only and were found with overall 1146 patients and 8 studies reporting V.A.C. with dynamic fascial closure with 413 patients. For the same period, 12 studies evaluating effectiveness of VP only with 921 patients and 4 VP with dynamic fascial closure with 218 patients were found. There were only 2 studies directly comparing VP and V.A.C. Conclusions The literature review demonstrates higher rate of primary fascial closure and lower mortality rate in V.A.C. in comparison to VP on the background of similar frequency of EAFs and intraabdominal abscesses. Based on the results and on our own experience the use of dynamic fascial closure in addition to V.A.C. facilitates the primary fascial closure and should be used in all cases with expected duration of the OA over 9 days. Due to the possible complications the wanton use of the open abdomen should be avoided and all efforts for early closure should be made in the course of the treatment.

Systematic review and meta-analysis of the open abdomen and temporary abdominal closure techniques in non-trauma patients.

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.

Systematic review and evidence based recommendations for the use of Negative Pressure Wound Therapy in the open abdomen

Introduction: Negative Pressure Wound Therapy (NPWT) is widely used in the management of the open abdomen despite uncertainty regarding several aspects of usage. An expert panel was convened to develop evidence-based recommendations describing the use of NPWT in the open abdomen. Methods: A systematic review was carried out to investigate the efficacy of a range of Temporary Abdominal Closure methods including variants of NPWT. Evidence-based recommendations were developed by an International Expert Panel and graded according to the quality of supporting evidence. Results: Pooled results, in non-septic patients showed a 72% fascial closure rate following use of commercial NPWT kits in the open abdomen. This increased to 82% by the addition of a ‘dynamic’ closure method. Slightly lower rates were showed with use of Wittmann Patch (68%) and home-made NPWT (vac-pack) (58%). Patients with septic complications achieved a lower rate of fascial closure than non-septic patients but NPWT with dynamic closure remained the best option to achieve fascial closure. Mortality rates were consistent and seemed to be related to the underlying medical condition rather than being influenced by the choice of dressing, Treatment goals for open abdomen were defined prior to developing eleven specific evidence-based recommendations suitable for different stages and grades of open abdomen. Discussion and conclusion: The most efficient temporary abdominal closure techniques are NPWT kits with or without a dynamic closure procedure. Evidence-based recommendations will help to tailor its use in a complex treatment pathway for the individual patient.

What Is the Comparative Efficacy of Negative-Pressure Wound Therapy vs Alternate Temporary Abdominal Closure Techniques in Open Abdominal Wounds?

What Is the Comparative Efficacy of Negative-Pressure Wound Therapy vs Alternate Temporary Abdominal Closure Techniques in Open Abdominal Wounds?

The modified sandwich-vacuum package for fascial closure of the open abdomen in septic patients with gastrointestinal fistula

Numerous temporary abdominal closure (TAC) techniques have been described in treatment of the open abdomen. However, data confirming their role in the management of gastrointestinal fistula complicated with abdominal sepsis are limited. This retrospective study evaluated whether a modified sandwich-vacuum package (MSVP) improved fascial closure rate compared with the polypropylene mesh (PPM)-mediated method. Patients, who experienced gastrointestinal fistula and underwent open abdomen management, were included and divided into MSVP and PPM groups according to the TAC method they received. Mortality, fascial closure rate, postoperative complications, and other outcomes were compared between the two groups. Between 2000 and 2010, 36 patients were treated with MSVP, with 36 cases for PPM. The overall mortality after a TAC procedure was 22.2% and 44.4%, respectively (p = 0.079). Compared with PPM technique, the fascial closure rate under MSVP method was markedly increased (63.9% vs. 33.3%, p = 0.018). Moreover, time to definitive closure (p = 0.003), length of stay in hospital (p = 0.042), and hospital charges (p = 0.001) were significantly decreased. Postoperative fistula was recorded in five patients, with one case from the PPM group developing enteroatmospheric fistula. None of the complications had statistical difference. Early enteral nutrition (EEN) was successfully applied in 36 patients, with 19 cases from the MSVP group. The application of MSVP (odds ratio, 4.889; 95% confidence interval, 1.518-15.746) and EEN (odds ratio, 5.691; 95% confidence interval, 1.662-19.474) were independent predictors of successful fascial closure. The use of MSVP after open abdomen was feasible in septic patients with gastrointestinal fistula. MSVP, together with EEN therapy, should be recommended for such populations.