The open abdomen - still a challenge for the surgeons. Which is the best technique for temporary abdominal closure? A focus on negative pressure wound therapy

Background. The practice of leaving the abdomen open after an emergency laparotomy has gained increasing popularity recently. Negative pressure wound therapy (NPWT) is known as an effective technique in the management of an open abdomen (OA). A new device, the ABThera™ Open Abdomen Negative Pressure Therapy System (KCI USA, San Antonio, TX, USA), was specifically designed to achieve a temporary abdominal closure (TAC) in the management of an OA. This study was aimed at presenting a successful experience of treating a case of abdominal wall necrosis caused by a perforated ascending colon using the ABThera System. Case Presentation. A 66-year-old man was admitted to our hospital with complaints of severe pain in the abdomen. On admission, abdominal contrast-enhanced computed tomography (CT) showed fluid collection, an air pocket in the subcutaneous fat layer of the abdominal wall, and edematous changes in the adipose tissue in the peritoneum and abdominal wall. Based on a diagnosis of peritonitis resulting from a perforated ascending colon, emergency surgery was performed. A right hemicolectomy, ileostomy construction, and debridement of the necrotic tissues were performed. However, necrotizing fasciitis rapidly spread; therefore, more necrotic tissue was debrided in a second operation. The abdominal wall defect was left open, and the ABThera System was used in the management of the OA; this device promoted wound healing. A reduction was observed in the size of the open wound with visible granulation tissue. The defect was finally covered with a mesh split-thickness skin graft and anterolateral thigh flap. Conclusions. In the management of a case of a massive wound with infection, it can be of great benefit to treat the wound with NPWT initially to decrease its size. The ABThera System could facilitate early and safe management of an OA by surgeons.

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

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2014.03.022 ◽

2014 ◽

Vol 218 (6) ◽

pp. 1251-1253 ◽

Cited By ~ 1

Author(s):

Harry J. Henteleff ◽

Neil G. Parry ◽

Clay Cothren Burlew

Keyword(s):

Negative Pressure ◽

Negative Pressure Wound Therapy ◽

Temporary Abdominal Closure ◽

Comparative Efficacy ◽

Wound Therapy ◽

Abdominal Closure

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

Negative Pressure Wound Therapy Journal ◽

10.18487/npwtj.v3i2.19 ◽

2016 ◽

Vol 3 (2) ◽

Author(s):

Martin Hutan ◽

Christian Bartko ◽

Augustin Prochotsky ◽

Jaroslav Sekac ◽

Jan Skultety ◽

...

Keyword(s):

Negative Pressure ◽

Negative Pressure Wound Therapy ◽

Open Abdomen ◽

Fascial Closure ◽

High Morbidity ◽

Temporary Abdominal Closure ◽

Wound Therapy ◽

Mortality And Morbidity ◽

Prospective Assessment ◽

Sequential Closure

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.

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Negative Pressure Wound Therapy for the Treatment of the Open Abdomen and Incidence of Enteral Fistulas: A Retrospective Bicentre Analysis

Gastroenterology Research and Practice ◽

10.1155/2013/730829 ◽

2013 ◽

Vol 2013 ◽

pp. 1-6 ◽

Cited By ~ 20

Author(s):

Sven Richter ◽

Stefan Dold ◽

Johannes P. Doberauer ◽

Peter Mai ◽

Jochen Schuld

Keyword(s):

Risk Factors ◽

Negative Pressure ◽

Negative Pressure Wound Therapy ◽

Open Abdomen ◽

Fistula Formation ◽

Temporary Abdominal Closure ◽

Wound Therapy ◽

Predisposing Factor ◽

Intestinal Fistulas ◽

The Impact

Introduction.The open abdomen (OA) is often associated with complications. It has been hypothesized that negative pressure wound therapy (NPWT) in the treatment of OA may provoke enteral fistulas. Therefore, we analyzed patients with OA and NPWT with special regard to the occurrence of intestinal fistulas.Methods.The present study included all consecutive patients with OA treated with NWPT from April 2010 to August 2011 in two hospitals. Patients’ demographics, indications for OA, risk factors, complications, outcome and incidence of fistulas before, during and after NPWT were recorded.Results.Of 81 patients with OA, 26 had pre-existing fistulas and 55 were free from a fistula at the beginning of NPWT. Nine of the 55 patients developed fistulas during () or after NPWT (). Seventy-five patients received ABThera therapy, 6 patients other temporary abdominal closure devices. Only diverticulitis seemed to be a significant predisposing factor for fistulas. Mortality was slightly lower for patients without fistulas.Conclusion.The present study revealed no correlation between occurrence of fistulas before, during, and after NWPT, with diverticulitis being the only risk factor. Fistula formation during NPWT was comparable to reports from literature. Prospective studies are mandatory to clarify the impact of NPWT on fistula formation.

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Advantages of Damage Control Strategy With Abdominal Negative Pressure and Instillation in Patients With Diffuse Peritonitis From Perforated Diverticular Disease

Surgical Innovation ◽

10.1177/1553350619857561 ◽

2019 ◽

Vol 26 (6) ◽

pp. 656-661 ◽

Cited By ~ 5

Author(s):

Antonio Brillantino ◽

Mauro Andreano ◽

Michele Lanza ◽

Vito D’Ambrosio ◽

Ferdinando Fusco ◽

...

Keyword(s):

Diverticular Disease ◽

Control Strategy ◽

Negative Pressure ◽

Negative Pressure Wound Therapy ◽

Damage Control ◽

Morbidity Rate ◽

Diffuse Peritonitis ◽

Temporary Abdominal Closure ◽

Wound Therapy ◽

Abdominal Closure

Purpose. To evaluate the results of Damage Control Strategy (DCS) in the treatment of generalized peritonitis from perforated diverticular disease in patients with preoperative severe systemic diseases. Methods. All the patients with diffuse peritonitis (Hinchey 3 and 4) and the American Society of Anesthesiologists (ASA) score ≥3 were included and underwent DCS consisting of a 2-step procedure. The first was peritoneal lavage, perforated colon-stapled resection, and temporary abdominal closure with negative pressure wound therapy combined with instillation. The second step, 48 hours later, included the possibility of restoring intestinal continuity basing on local and general patients’ conditions. Results. Thirty patients (18 [60%] women and 12 [40%] men, median age 68.5 [range = 35-84] years) were included (18 [60%] ASA III, 11 [36.7%] ASA IV, and 1 [0.03%] ASA V). Seven patients (23.3%) showed sepsis and 1 (3.33%) septic shock. At second surgery, 24 patients (80%) received a colorectal anastomosis and 6 patients (20%) underwent a Hartmann’s procedure. Median hospital stay was 18 days (range = 12-62). Postoperative morbidity rate was 23.3% (7/30) and included 1 anastomotic leak treated with Hartmann’s procedure. Consequently, at discharge from hospital, 23 patients (76.6%) were free of stoma. Primary fascial closure was possible in all patients. Conclusions. DCS with temporary abdominal closure by negative pressure wound therapy combined with instillation in patients with diffuse peritonitis from complicated diverticulitis could represent a feasible surgical option both in hemodynamically stable and no stable patients, showing encouraging results including a low stoma rate and an acceptable morbidity rate.

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The Use Of Negative Pressure Wound Therapy (NPWT) In The Management Of Enteroatmospheric Fistula – Case Report And Literature Review

Polish Journal of Surgery ◽

10.1515/pjs-2015-0098 ◽

2015 ◽

Vol 87 (10) ◽

Cited By ~ 3

Author(s):

Rajmund Jaguścik ◽

Dominik A. Walczak ◽

Joanna Porzeżyńska ◽

Piotr W. Trzeciak

Keyword(s):

Negative Pressure ◽

Metabolic Disorders ◽

Multidisciplinary Approach ◽

Negative Pressure Wound Therapy ◽

Open Abdomen ◽

Oral Intake ◽

Surgical Team ◽

Wound Therapy ◽

Necrotic Pancreatitis ◽

Enteroatmospheric Fistula

AbstractAn enteric fistula that occurs in an open abdomen is called an enteroatmospheric fistula (EAF) and is the most challenging complication for a surgical team to deal with. The treatment of EAF requires a multidisciplinary approach. First of all, sepsis has to be managed. Any fluid, electrolyte and metabolic disorders need to be corrected. Oral intake must be stopped and total parenteral nutrition introduced. The control and drainage of the effluent from the fistula is a separate issue. Since there are no fixed algorithms for the treatment of EAF, surgeons need to develop their own, often highly unconventional solutions.We present the case of a 24-year-old man who developed enteroatmospheric fistula after laparotomy and relaparotomy due to acute necrotic pancreatitis. Both the laparostomy and the fistula were successfully managed using modified negative pressure wound therapy. The literature regarding this issue was also reviewed.

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