|Year : 2016 | Volume
| Issue : 3 | Page : 51-61
Republication: Comparison of open abdomens in nontrauma and trauma patients: A retrospective study
Stanislaw P Stawicki1, James Cipolla2, Corinne Bria3
1 Principal Scientist, OPUS 12 Foundation, King of Prussia, PA, USA
2 Department of Surgery, St. Luke's Hospital and Health Network, Bethlehem, PA, USA
3 University of Cincinnati, Cincinnati, OH, USA
|Date of Submission||13-Mar-2016|
|Date of Acceptance||04-Sep-2016|
|Date of Web Publication||19-Aug-2016|
Stanislaw P Stawicki
Department of Research and Innovation, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, Pennsylvania 18015
Source of Support: None, Conflict of Interest: None
Introduction: Open abdomen (OA) spans an entire spectrum of traumatic and nontraumatic indications. We hypothesize that uniformly managed OA patients have favorable outcomes regardless of the initial traumatic or nontraumatic etiology.
Materials and Methods: This is a retrospective review of OA patients from 2001 to 2006. A comparison was carried out between NTP and trauma OA patients, examining patient demographics, physiologic parameters, resource utilization, and outcome measures.
Results: There were 60 OA patients (35 nontrauma patients [NTPs], 25 trauma patients [TPs]). NTPs were significantly older than TPs (60.9 vs. 38.3 years). The initial mean pH, Simplified Acute Physiology Score II (SAPS), and predicted and observed 28-day mortality were similar for both groups. The initial base deficit was 5.53 in NTP and 10.4 in TP (P = 0.0191). Lactic acid levels were 3.54 in NTP and 5.57 in TP (P = 0.0326). Time to abdominal closure was 18.2 days for TP and 20.7 days for NTP. NTP had longer mean Intensive Care Unit (ICU) stays (11.6 vs. 8.5 days, P= 0.0438). NTP had more abscesses (20.0% vs. 8.00%), fistulae (17.1% vs. 8.00%), and enteric leaks (11.4% vs. 4.00%) than TP. The average number of procedures per patient was 5.81 for NTP and 6.24 for TP (mean 4.34 days between procedures for NTP and 2.38 days for TP).
Conclusions: TP and NTP undergoing OA showed many similarities. Outcomes for OA patients were similar regardless of the initial diagnosis. A trend was observed toward more postoperative complications in the NTP and greater initial physiologic derangement in TP. NTP had longer mean ICU stays. The mortality for both groups was half of that predicted by SAPS II score, likely due to the physiologic benefits of OA.
The following core competencies are addressed in this article: Patient care; Medical knowledge; Practice based learning and improvement; Systems based practice.
Republished with permission from: Stawicki SP, Cipolla J, Bria C. Comparison of open abdomens in nontrauma and trauma patients: A retrospective study. OPUS 12 Scientist. 2007;1(1):1-8.
Keywords: Comparison study, nontrauma patients, open abdomen, trauma patients
|How to cite this article:|
Stawicki SP, Cipolla J, Bria C. Republication: Comparison of open abdomens in nontrauma and trauma patients: A retrospective study. Int J Acad Med 2016;2, Suppl S1:51-61
|How to cite this URL:|
Stawicki SP, Cipolla J, Bria C. Republication: Comparison of open abdomens in nontrauma and trauma patients: A retrospective study. Int J Acad Med [serial online] 2016 [cited 2020 Jan 19];2, Suppl S1:51-61. Available from: http://www.ijam-web.org/text.asp?2016/2/3/51/188729
| Introduction|| |
The concept of open abdomen (OA) has evolved markedly since its inception.,, It now spans an entire spectrum of traumatic and nontraumatic indications.,,, OA is a temporizing measure and is closely related to the damage control (DC) approach, which initially provided trauma surgeons with the ability to break the lethal triad of acidosis, coagulopathy, and hypothermia in critically injured patients. The three components of the lethal triad synergistically lead to a myriad of physiologic derangements and eventually, death.,
The DC/OA approach serves as a bridge to restoring the patient to a more normal physiologic state, with subsequent delayed  abdominal closure. The DC/OA approach can be applied to critically ill nontrauma surgical patients (NTPs) with abdominal sepsis, intra-abdominal and retroperitoneal hemorrhage, severe pancreatitis, and other conditions that produce intra-abdominal hypertension and abdominal compartment syndrome (ACS).,,
The purpose of this study is to compare the utilization and results of DC/OA for TP and NTP at a Level I community-based trauma center. We hypothesize that although the indications and the underlying conditions may differ, the physiology and outcomes of patients undergoing DC/OA are similar. We further postulate that a uniform approach to managing these patients helps attain good outcomes. Although both technical and physiologic aspects of OA management are discussed, the authors will focus on the physiologic aspect of DC surgery.
| Materials and Methods|| |
All patients with OAs at our institution from September 2001 to January 2006 were included. Recorded data included demographics (age and gender), primary diagnoses at the time of the initial DC laparotomy, surgical techniques and types of closure, complications, and 28-day mortality. Many of the definitions used in this study follow the previously published standards and recommendations, according to the World Society of the Abdominal Compartment Syndrome (WSACS), and can be accessed online at http://www.wsacs.org/.
Complications recorded included enterocutaneous fistula, abscess, enteric leak, decubitus ulceration, clostridium difficile colitis, pneumonia (as abstracted from medical record), and deep venous thrombosis (DVT). Physiologic parameters included initial pH, base deficit, lactic acid, and albumin level. Coagulopathy was represented by international normalized ratio (INR) measurements. Outcome measures included 28-day complications and mortality. Predicted mortality for the study group was calculated using the Simplified Acute Physiology Score II (SAPS II) recorded at the time of the index emergency (DC) exploratory laparotomy. A distinction was also made with regards to the index emergency (DC) surgery being the “initial” versus “subsequent” laparotomy. SAPS II was utilized due to its applicability to both traumatic and nontraumatic etiologies.
Resource utilization measurements included hospital length of stay (LOS) starting at the point of initiation of the DC/OA approach to patient death or discharge, Intensive Care Unit (ICU) LOS, time to abdominal closure, type of nutritional supplementation utilized (parenteral and/or enteral), requirement for tracheostomy, abdominal procedures per patient until abdominal closure, average number of days between procedures (between the initial operation and abdominal closure), as well as the number of procedures per patient per LOS (the number of days in hospital divided by the number of procedures per patient). Patients who did not survive beyond the initial 24 h period were excluded from analysis of the following variables: Time to abdominal closure, mean and median LOS, mean ICU LOS, procedures per patient, average days between procedures, procedures per patient per LOS, requirement for tracheostomy, type of nutritional support, and all of the above-listed nonmortality complications.
All patients were managed by a team of five critical care-trained emergency-trauma surgeons according to a modification of previously published treatment algorithm for OA patients [Figure 1]. Initially, all patients had a vacuum-assisted fascial closure (VAFC) applied. Two VAFC techniques employed (based on surgeon preference) included: (a) Polyethylene covered surgical towel with suction drains layered above the towel and covered with an impervious adhesive drape or (b) commercially prepared sponge device (V.A.C., KCI International, San Antonio, Texas, USA). Utilization of vicryl mesh was based on the presence or absence of omental coverage over the underlying bowel. If ample omentum was present and no bowel was exposed, then vicryl mesh was not used. However, if partial coverage of exposed bowel was needed, then vicryl mesh was utilized.
All patients underwent re-exploration within 6–48 h depending on clinical stability and indications for the initial laparotomy. When possible, a tension-free primary fascial closure was performed at that time. Abdominal closure performed within 24 h of the initial surgery was termed early delayed primary closure (DPC). If patients continued to manifest clinical characteristics that obviated abdominal closure (e.g., continued bleeding, bowel or retroperitoneal edema, gross contamination), then VAFC was continued. Primary fascial closure utilizing VAFC more than 24 h after the initial laparotomy was termed DPC with VAFC.
Patients with prolonged VAFC (>7 days) were re-evaluated after definitive operative and physiologic restoration was complete. When possible, DPC with VAFC was performed at that time. If the patient had lost abdominal domain, one of two management options was considered. Patients with gross contamination at any time during the resuscitation were managed as planned ventral hernias (PVHs). These patients had a split-thickness skin graft (STSG) placed over the OA wound when a healthy, clean granulation bed formed [Figure 2]B, I-V, page 7]. An abdominal wall reconstructive procedure would be performed on these patients at a later time.
|Figure 2: Images depicting three different methods of abdominal closure in the setting of damage control/open abdomen. (A, I-IV) Wittmann Patch closure, with initially wide open abdominal defect (A-I) gradually narrowed to a much smaller size (A-II and A-III), followed by definitive fascial closure (A-IV); (A, I-V) split thickness skin graft closure with planned ventral hernia, beginning with application of VAC therapy over the wound (B-I and B-II), followed by skin grafting and maturation of the skin graft (“pinch sign,” B-III), with synthetic mesh closure of the resulting planned ventral hernia (b-IV) and definitive skin closure (B-V); (C, I-V) Skin flap closure utilizing bioprosthetic material and lateral releasing skin flap, where exposed bowel and omentum (C-I) are covered with bioprosthetic material (C-II and C-III), followed by creation of a relaxing lateral incision, which subsequently is covered with split thickness skin graft from ipsilateral thigh donor site (C-IV). Final result of the skin flap closure approach (C-V)|
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Patients without gross contamination had a velcro Wittmann Patch (WP) sewn to their fascia. The patch consists of two large sheets of velcro-type material, which are attached to the visible fascial edges with permanent sutures. The bottom (deep) sheet overlying the bowel has a smooth surface that faces abdominal contents and a rough external surface that attaches to the rough adhesive surface of the top sheet. The top (superficial) sheet is never allowed to come in direct contact with the bowel as this could potentially generate an enteric fistula. Consequently, the bottom sheet is left wide enough that it completely underlies the top sheet. The patch is then advanced daily (typically, 1–2 cm at a time) until fascial edges are closed primarily [Figure 2]A, I-IV, page 7]. Both the top and the bottom sheet of the WP are trimmed to an appropriate width during each advancement procedure, maintaining complete coverage of the abdominal contents with the smooth surface of the bottom sheet. After patch advancement, the patient is observed for signs of intra-abdominal hypertension (high peak airway pressures, oliguria, and decreased cardiac output).
Patients who failed WP fascial closure were treated as PVH. These patients underwent either STSG coverage over granulated bowel and/or omental surfaces, or skin flap closure (SFC) over a bioprosthetic fascial repair (Alloderm™, LifeCell Corp., Branchburg, NJ, USA or Permacol™, Tissue Science Laboratories, Covington, GA, USA) and STSG coverage of the resulting lateral abdominal skin relaxing incision [Figure 2]C, I-V, page 7]. In some instances, the WP allowed significant reduction of the fascial defect, thus reducing the size of the ventral hernia and the amount of bioprosthetic material used for closure. Although rectus muscle release procedures were not utilized in this study, they remain a very good and viable option for abdominal wall reconstruction following OA.
Analytical methods included descriptive statistics, Chi-square, and Student's t-test statistics. Statistical significance was set at alpha = 0.05. In addition, an updated OA management algorithm was created to reflect the addition of SFC and rectus muscle release procedures to the previously published algorithm.
| Results|| |
A total of 60 patients underwent OA from 2001 to 2006. Thirty-five of those were nontrauma patients (NTPs) and 25 were trauma patients (TPs). NTPs were significantly older than TPs (60.9 vs. 38.3 years). There were 17 men and 18 women in the NTP group, and 17 men and 8 women in the TP group [Table 1].
|Table 1: Comparison of demographic, physiologic, and outcome parameters in nontrauma patients and trauma patients|
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Looking at whether the DC/OA approach was initiated during the “initial” or “subsequent” operation, significantly higher proportion of NTP required DC/OA management during “subsequent” operation (14/35) than did TP (2/25, P = 0.0073). The most common diagnoses on initial presentation among NTPs were perforated viscus (13/35) and ACS following major abdominal operation (6/35). Among TP, the most common diagnoses were severe splenic (8/25) and liver injury (5/25) alone or in combination [Table 2].
|Table 2: Presenting diagnoses directly leading to utilization of open abdomen in this study. More than one diagnosis per patient may be present|
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TPs demonstrated more severe acute physiologic derangement than NTPs [Table 1], as demonstrated by greater initial base deficit (10.4 vs. 5.53, P = 0.0191) and higher initial lactic acid levels (5.57 vs. 3.54, P = 0.0326). There were no significant differences in initial pH and SAPS II scores. Albumin levels were lower in TP than NTP (1.84 vs. 2.37, P = 0.0382). The INR was elevated regardless of the initial presentation, with a mean value of 1.72 ± 1.08 and no statistically significant difference between TP and NTP.
The predicted mortality, as determined by SAPS II scores, was 39.8% for NTP and 49.0% for TP (P = 0.1626). The observed 28-day mortality was 17.1% for NTP and 32.0% for TP (P = 0.2232) when all patients in both groups are considered. When patients who died within 24 h of admission were excluded, the mortality was 9.38% for NTP and 22.7% for TP (P = 0.2855). This reflects a trend toward greater mortality in TP as compared to NTP [Table 1]. When stratified by SAPS II score, NTP with scores >20 had significantly higher mortality than those with scores <20 (6/20 or 30% vs. 0/15 or 0%, P = 0.0311). This difference was not observed in TP. Considering both groups (TP and NTP), patients with initial lactate level >4 mmol/L had significantly higher mortality (12/34 or 35.3%) than those with initial lactate levels <4 mmol/L (2/26 or 7.70%, P = 0.0147).
In terms of nutritional support, patients in both groups received enteral nutrition or a combination of parenteral and enteral nutrition. A minority of patients in each group received parenteral nutrition only (18.8% in NTP and 9.10% in TP group), many of whom either did not survive long enough to transition to enteral nutrition or were maintained on long-term parenteral nutrition secondary to the presence of a fistula.
NPTs were more likely to have postoperative complications, as demonstrated by more abscesses (21.9% vs. 9.09%), fistulae (18.8% vs. 9.09%), and enteric leaks (12.5% vs. 4.54%). Pneumonia complicated clinical course in 21.9% of NTP and 18.1% of TP. DVT was very common in both NTP (25.0%) and TP (40.9%) groups despite an aggressive DVT prophylaxis protocol at our institution. Decubitus ulcers complicated the hospital course of 3/32 NTP (9.38%), one of which required a myocutaneous SFC. Overall, both TP and NTP showed a significant predisposition for complications, with at least one of the listed complications in 68.8% of NTP and 54.5% of TP [Figure 3].
|Figure 3: Complications observed in nontrauma patients (nonshaded bars) and trauma patients (shaded bars) in this study. The complications are listed on the x-axis and the percentage of patients with each complication is reflected on the y-axis. The numbers inside each bar indicate the actual number of patients within each group|
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Twenty-three percent of patients died before definitive abdominal closure, with 6 of those patients (10%) dying within the first 24 h. For patients who survived beyond the first 24 h, additional eight patients (14.8%) died before definitive abdominal closure. DPC was attempted whenever possible (22.2%). For patients in whom DPC was not possible, a combination of WP-aided closure (12.9%), STSG (37.0%) or SFC with bioprosthetic material (12.9%) was utilized. Abdominal closure methods are summarized in [Table 3] (page 8). The mean time to definitive abdominal closure was 20.7 days for NTP and 18.2 days for TP. Although our overall patient sample size was small, we found that patients with SFC utilizing bioprosthetic fascial replacement had their OA closed more than 5 days earlier than the remaining patients (14.7 ± 6.70 vs. 20.9 ± 18.3 days, P = 0.3880).
|Table 3: Comparison of abdominal closure methods between non-trauma patients (NTP) and trauma patients (TP)|
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With respect to resource consumption [Table 1], there was no statistical difference in hospital LOS between TP and NTP (44.4 days for NTP vs. 31.7 days for TP, P = 0.1917). However, the mean ICU LOS was significantly greater in the NTP group than in the TP group (11.6 ± 6.11 vs. 8.50 ± 3.97, P = 0.0438). In addition, 50% of NTP and over 45% of TP required tracheostomy during their hospitalization. The average number of procedures per patient was 5.81 ± 5.03 for NTP and 6.24 ± 5.08 for TP (P = 0.7873), with an average of 4.34 days between procedures for NTP and 2.38 days between procedures for TP (P = 0.0479). Examination of the number of procedures per patient per LOS in TP and NTP showed a trend toward a greater “density” of operations in TP, with smaller time intervals between procedures and shorter LOS following definitive abdominal closure.
| Discussion|| |
The OA technique evolved from the classic trauma DC approach as surgeons became more comfortable managing patients requiring delayed abdominal closures. The heart of the initial management of patients with DC/OA is the prevention of the ACS, which was first noted by Sperling and Wagensteen in 1935, and has been recognized by Gross, who developed the so-called chimney techniquefor gastroschisis., The DC/OA approach halts the ACS and the progression of cardiorespiratory and renal dysfunction.,,, The ACS can affect both TPs and NTPs and constitutes an independent risk factor for multiple organ failure.,,,,,,,
Utilization of OA techniques in the setting of intra-abdominal hypertension and ACS has also been described by vascular surgeons back in 1984. Less often, the “pure” OA approach may be called upon when loss of abdominal domain or other technical or disease factors make abdominal closure impossible, even in the absence of the classic DC indications.
The purpose of this study was to compare the utilization and outcomes of the DC/OA approach in NTP and TP at our institution. We also attempt to define the unifying characteristics of the DC/OA approach in both NTP and TP. The authors believe that although this study's findings are not unexpected, the emergency surgery specialist could potentially benefit from better delineation of the differences between TP and NTP in the setting of OA and DC.
The classic triggers for initiation of DC in TP include pH <7.30, temperature <35°C, and coagulopathy (presence of nonmechanical bleeding). In addition to critically ill TPs, general surgery patients with abdominal sepsis, intra-abdominal or retroperitoneal hemorrhage, or severe pancreatitis may also meet the criteria for initiating the DC/OA approach, based on the above physiologic parameters or the presence of documented ACS., In this series, both the TP and NTP groups showed significant acidosis, with mean pH of 7.26 in NTP and mean pH of 7.17 in TP at the time of the initial operation. Although not directly examined in this study, hypothermia was common, and its presence reflected in SAPS II score calculations. Patients in this study also demonstrated coagulopathy, with INR of approximately 1.7 regardless of the initial diagnosis, and no significant difference between TP and NTP.
The classic trauma DC/OA paradigm consists of a three-phase approach, beginning with an abbreviated laparotomy to control hemorrhage and contamination, followed by resuscitation in an ICU setting, and a number of subsequent laparotomies to provide definitive repair of injuries and to further temporize physiologic deficits., A definitive abdominal closure then follows either in an early or a delayed fashion [Figure 1].,
The resuscitation phase serves to optimize hemodynamics, reverse coagulopathy, achieve resuscitation end points, and re-warm the patient. In those patients who survive the resuscitation phase, the second laparotomy provides the opportunity to perform anatomic restorations and a chance to assess the feasibility of definitive abdominal wall closure. In our series, approximately 5% of patients were able to undergo primary fascial closure at this point. If such DPC is not feasible, the third phase of DC begins and continues until successful abdominal closure is achieved. This was the pathway for approximately 70% of patients in this study. Of note, approximately 24% of patients in this series (17.6% NTP and 33.3% TP) died before definitive abdominal closure. In a large study of DC/OA patients, Miller et al. demonstrated a similar percentage (20%) of patients who did not survive to definitive wound closure.
The NTP group contained more patients, had a greater mean age, and was more evenly distributed between men and women than the TP group. This is not surprising as male predominance among TPs is well documented in the literature., The mean age of the TP group is in good agreement with other DC/OA studies in trauma population.
In this study, there were no significant differences in SAPS II scores between the NTP and TP groups at the time of initiation of the DC/OA approach. However, we observed significantly greater initial base deficit and lactic acid levels in the TP group. This may be because base deficit and lactic acid levels can reflect very acute physiologic changes more accurately than SAPS II and is consistent with previous reports of severe base deficits in TPs undergoing DC. At the same time, we noted a significantly lower initial albumin level in the TP group, which most likely is a reflection of fluid resuscitation rather than underlying hypoalbuminemia. In this series, initial serum lactate level >4 mmol/L was associated with significant mortality (35.3%). Previous studies demonstrate that lactate levels above 8 mmol/L positively correlate with in-hospital mortality and mortality within 24 h of admission following abdominal traumatic injury requiring DC.
Despite no statistically significant differences in mortality between the NTP and TP in this study, we noted a trend toward higher overall mortality in TP. Not surprisingly, patients with SAPS >20 had higher mortality than those with SAPS <20. Our observed overall mortality of TP (33.3%) was somewhat higher than that in other series, which may be because some of these series excluded patients who did not survive the initial 24 h period following injury.,,,,, It has been noted that mortality varies depending on the etiology of OA, with pancreatitis associated with the highest observed mortality (43%), followed by gastrointestinal sepsis (36%) and trauma (13–27%).,, Our experience corroborates the previously observed high mortality in patients with OA due to severe pancreatitis.
Similar to our OA experience, Finlay noted a reduction in observed patient mortality based on predicted mortality rates between 49.6% and 64.5%. The lower observed 28-day mortality in our study (17.1% for NTP and 32.0% for TP), as compared to the predicted mortality (39.8% for NTP and 49.0% for TP), may be due to several factors. Although the data in this study are not sufficient to demonstrate clear mortality advantage, one can speculate that perhaps the greatest contributing factor is the utilization of the DC/OA approach and its physiologic benefits in the face of the ACS., Another factor likely responsible for the improved outcomes is the uniform approach to critically ill TP and NTP by a specialized team of trauma and surgical critical care practitioners. Third, goal-directed resuscitation and modern end-organ supportive measures may play a significant role in this setting.
In terms of resource utilization, we noted that NTP demonstrated a trend toward greater hospital LOS. Furthermore, NTP had significantly longer ICU LOS than TP (an approximate 3 days difference). NTP underwent relatively fewer operative interventions per patient per LOS (number of days in hospital divided by the number of procedures per patient, where a larger number indicates greater interval between procedures and/or a greater LOS following the definitive abdominal closure). In fact, NTP did have a significantly greater average number of days between subsequent procedures. At the same time, the TP group had a greater number of procedures per patient. Nearly half of all patients in this study required a tracheostomy, with no significant difference between the TP and NTP groups. Others report a number of operations per patient that is similar to that in our study, with anywhere between 2.5 and 5.2 operations per patient, depending on the type of closure utilized.
Although not measured in this study, the significant requirement for continued medical and surgical services among DC/OA patients continues well after hospital discharge. In fact, in one study, 14% of DC/OA patients required at least one readmission to hospital, with diagnoses including small bowel obstruction, ventral hernia, intra-abdominal abscess, and wound infection. Moreover, mean hospital charges resulting from hospitalization for DC/OA vary from $130,000 to over $300,000 and depend on the type and timing of abdominal closure.
In this series, complications were common in both groups of patients. In fact, over 68% of NTP had at least one complication as compared to approximately 54% of TP. While DVT was more frequent in the TP group, all of the other complications studied tended to be more frequent in the NTP group (enterocutaneous fistula, abscess, enteric leak, decubitus ulceration, pneumonia, clostridium difficile colitis). This is despite the higher mean albumin level in NTP, as well as significantly greater base deficit and lactic acid level in TP at the time of the initial DC/OA operation. Multiple factors could be responsible for this phenomenon, including differences in patient age, differences in type and quantity of resuscitative fluids given, amount of physiologic reserve, preoperative level of functioning, presence of chronic health conditions, and presence of malignancy. In other studies, the most common DC/OA complications included enterocutaneous fistulae (8.6–16.9%) and abscess formation (7–17.1%)., Furthermore, while others report enterocutaneous fistula rates similar to ours, the incidence of abscesses among NTP in our series (20%) is higher than previously reported.,, Miller et al. demonstrated that early definitive closure of the DC/OA is associated with significantly lower fistula formation rate (3%) when compared to temporizing abdominal coverage (30%). In addition, they noted that complication rate increased from 25% to 40% when abdominal packs were left in place for more than 4 days. The authors of this study also observed a higher overall rate of enteric leaks (8.3%) than reported by others (2.9%). The high rate of DVT in this study corroborates previous observations that the risk of DVT increases significantly with increasing magnitude of physiologic derangement and injury severity.
Tsuei et al. investigated the management and outcome of the DC/OA approach in patients with gastrointestinal sepsis, pancreatitis, and trauma, demonstrating that DC/OA management could be effectively applied across the different patient populations. Similar to Tsuei et al., we also noted that types of closure and mortality appear to be related to the underlying etiology. Although not statistically significant, we did observe a trend toward higher initial mortality in TP. We also noted different patterns of abdominal closure techniques used between TP and NTP, including more common use of the WP closure in TP, more frequent utilization of vicryl mesh ± STSG technique in NTP, and tendency to use SFC in NTP. Our findings are similar to those of Tsuei et al. that patients with gastrointestinal sepsis were more likely to require STSG ± vicryl mesh closure while TPs were more likely to have primary or assisted fascial closure. In this series, the average time to abdominal closure was similar for TP and NTP (18 vs. 21 days, respectively).
The overall distribution of TP and NTP in this study is consistent with other previously published reports., While our series included five patients (8.3%) with severe pancreatitis as the etiology of the ACS, such low number of patients precludes any meaningful comparisons utilizing pancreatitis patients as a distinct subgroup. Including our series, severe pancreatitis was the least frequent of diagnoses leading to DC/OA, with approximately 6–31% incidence in major published series., Others reported that patients with OA due to pancreatitis had more operations per patient and were more likely to have no formal abdominal closure and highest mortality.
Throughout our experience with DC/OA, we noted several techniques useful in expediting abdominal closure and in reducing the size of the resultant fascial defect. In one scenario, the WP can be utilized to minimize the size of the fascial defect and thus to reduce the amount of bioprosthetic material utilized before definitive closure of the defect and coverage with a skin flap, even if primary fascial closure itself is not feasible. In another scenario, gradual closure of the inferior and superior abdominal fasciae and skin allows for significant reduction of the fascial and skin defects and facilitates DPC or allow significant reduction in the use of bioprosthetic material and subsequent reduction in skin flap mobilization requirement.
Of interest, although not statistically significant, we found that among patients who survived to have their abdomens closed, those with SFC utilizing bioprosthetic fascial replacement had their OA closed over 5 days earlier than patients undergoing other types of abdominal closure (14.7 vs. 20.9 days). As our experience with the SFC grows, we expect this difference to become more significant, especially in terms of resource consumption. Other avenues of bioprosthetic material application in DC/OA patients include the possibility of alternative coverage of enteric fistulae.
This study demonstrates the physiologic similarity between the critically ill TP and NTP with DC/OA and supports the theory that outcomes for DC/OA patients can be better than predicted across a broad spectrum of traumatic and nontraumatic diagnoses. We speculate that this may be due to a uniform approach to these patients utilizing a dedicated team of trauma, emergency, and critical care surgeons.
Limitations of this study include its retrospective nature and lack of detail regarding patient resuscitation techniques (volumes, resuscitation solutions used, blood transfusions, etc.). The relatively small patient sample size limits the statistical power of observations in this study. The authors also recognize the shortcomings of utilizing the SAPS II score in the setting of this study, especially when applied to TP population.
The authors of this study did not perform rectus muscle release procedures, which constitute a viable option for closing OA defects. However, rectus muscle release procedure was included as an option in our proposed algorithm for abdominal closure [Figure 1]. While outcome-based study comparing the different abdominal wall reconstructive techniques would significantly add to the current manuscript, such information is not available. In addition, we recognize that the lack of long-term wound complication information (incisional hernias, mesh infections, etc.) represents a significant limitation of this study. Finally, it is difficult to assess how the gradual change and modifications in abdominal closure modalities over the study period affected patient outcomes.
| Conclusions|| |
TPs and NTPs undergoing DC/OA approach were similar in overall outcomes. A trend was observed toward more postoperative complications in the NTP and greater magnitude of initial physiologic derangement in TP. The actual mortality for both groups was half of that predicted by SAPS II score, at least in part due to the beneficial physiologic effects of the DC/OA approach. Both TP and NTP groups demonstrated higher mortality with initial SAPS >20 and lactic acid level >4 mmol/L. Even though the hospital LOS was not statistically different between the two groups, a trend toward longer LOS was noted in NTP. In addition, NTP had significantly longer ICU LOS. While the two groups differed in terms of types of abdominal closure utilized and the average number of days between subsequent procedures, they were similar in terms of the number of procedures per patient and tracheostomy requirement.
Justifications for re-publishing this scholarly content include: (a) The phasing out of the original publication after a formal merger of OPUS 12 Scientist with the International Journal of Academic Medicine and (b) Wider dissemination of the research outcome(s) and the associated scientific knowledge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Asensio JA, Petrone P, Roldán G, Kuncir E, Ramicone E, Chan L. Has evolution in awareness of guidelines for institution of damage control improved outcome in the management of the posttraumatic open abdomen? Arch Surg 2004;139:209-14.
Burch JM, Denton JR, Noble RD. Physiologic rationale for abbreviated laparotomy. Surg Clin North Am 1997;77:779-82.
Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am 1997;77:761-77.
Cipolla J, Stawicki SP, Hoff WS, McQuay N, Hoey BA, Wainwright G, et al.
A proposed algorithm for managing the open abdomen. Am Surg 2005;71:202-7.
Finlay IG, Edwards TJ, Lambert AW. Damage control laparotomy. Br J Surg 2004;91:83-5.
Johnson JW, Gracias VH, Schwab CW, Reilly PM, Kauder DR, Shapiro MB, et al.
Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma 2001;51:261-9.
Tsuei BJ, Skinner JC, Bernard AC, Kearney PA, Boulanger BR. The open peritoneal cavity: Etiology correlates with the likelihood of fascial closure. Am Surg 2004;70:652-6.
Schecter WP, Ivatury RR, Rotondo MF, Hirshberg A. Open abdomen after trauma and abdominal sepsis: A strategy for management. J Am Coll Surg 2006;203:390-6.
World Society of the Abdominal Compartment Syndrome. Available from: http://www.wsacs.org/
. [Last accessed on 2007 Jan 24].
Reiter A, Mauritz W, Jordan B, Lang T, Pölzl A, Pelinka L, et al.
Improving risk adjustment in critically ill trauma patients: The TRISS-SAPS score. J Trauma 2004;57:375-80.
Guy JS, Miller R, Morris JA Jr., Diaz J, May A. Early one-stage closure in patients with abdominal compartment syndrome: Fascial replacement with human acellular dermis and bipedicle flaps. Am Surg 2003;69:1025-8.
Sperling L, Wagensteen OH. Intraenteric pressure in experimental and clinical obstruction. Proc Soc Exp Biol Med 1935;32:1183-5.
Hamill J. Damage control surgery in children. Injury 2004;35:708-12.
Dolores-Velásquez R, Sauri-lc LF, Sánchez-Lozada R. Efficacy of decompression treatment of abdominal compartment syndrome. Gac Med Mex 2003;139:459-63.
Ivatury RR, Diebel L, Porter JM, Simon RJ. Intra-abdominal hypertension and the abdominal compartment syndrome. Surg Clin North Am 1997;77:783-800.
Rutherford EJ, Skeete DA, Brasel KJ. Management of the patient with an open abdomen: Techniques in temporary and definitive closure. Curr Probl Surg 2004;41:815-76.
Chao A, Chao A, Yen YS, Huang CH. Abdominal compartment syndrome secondary to ovarian mucinous cystadenoma. Obstet Gynecol 2004;104(5 Pt 2):1180-2.
Etzion Y, Barski L, Almog Y. Malignant ascites presenting as abdominal compartment syndrome. Am J Emerg Med 2004;22:430-1.
Loftus IM, Thompson MM. The abdominal compartment syndrome following aortic surgery. Eur J Vasc Endovasc Surg 2003;25:97-109.
McNelis J, Marini CP, Simms HH. Abdominal compartment syndrome: Clinical manifestations and predictive factors. Curr Opin Crit Care 2003;9:133-6.
Papavassiliou V, Anderton M, Loftus IM, Turner DA, Naylor AR, London NJ, et al.
The physiological effects of elevated intra-abdominal pressure following aneurysm repair. Eur J Vasc Endovasc Surg 2003;26:293-8.
Reis R, Labas P, Vician M, Ziak M. The abdominal compartment syndrome. Bratisl Lek Listy 2003;104:32-5.
Rezende-Neto JB, Moore EE, Masuno T, Moore PK, Johnson JL, Sheppard FR, et al.
The abdominal compartment syndrome as a second insult during systemic neutrophil priming provokes multiple organ injury. Shock 2003;20:303-8.
Schein M, Wittmann DH, Aprahamian CC, Condon RE. The abdominal compartment syndrome: The physiological and clinical consequences of elevated intra-abdominal pressure. J Am Coll Surg 1995;180:745-53.
Kron IL, Harman PK, Nolan SP. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg 1984;199:28-30.
Miller RS, Morris JA Jr., Diaz JJ Jr., Herring MB, May AK. Complications after 344 damage-control open celiotomies. J Trauma 2005;59:1365-71.
Nicholas JM, Rix EP, Easley KA, Feliciano DV, Cava RA, Ingram WL, et al.
Changing patterns in the management of penetrating abdominal trauma: The more things change, the more they stay the same. J Trauma 2003;55:1095-108.
Stone PA, Hass SM, Flaherty SK, DeLuca JA, Lucente FC, Kusminsky RE. Vacuum-assisted fascial closure for patients with abdominal trauma. J Trauma 2004;57:1082-6.
Biffl WL, Moore EE, Burch JM, Offner PJ, Franciose RJ, Johnson JL. Secondary abdominal compartment syndrome is a highly lethal event. Am J Surg 2001;182:645-8.
Stawicki SP, Grossman MD, Cipolla J, Hoff WS, Hoey BA, Wainwright G, et al.
Deep venous thrombosis and pulmonary embolism in trauma patients: An overstatement of the problem? Am Surg 2005;71:387-91.
Stawicki SP, Brooks A, Bilski T, Scaff D, Gupta R, Schwab CW, et al.
The concept of damage control: Extending the paradigm to emergency general surgery. Injury 2008;39:93-101.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]