Open Abdomen Treatment for Septic Patients with Gastrointestinal Fistula: From Fistula Control to Definitive Closure

The use of open abdomen in the management of gastrointestinal fistula complicated with severe intra-abdominal infection is uncommon. This study was designed to evaluate outcomes of our staged approach for the infected open abdomen. Patients who had gastrointestinal fistula and underwent open abdomen treatment were retrospectively reviewed. Various materials such as polypropylene mesh and a modified sandwich package were used to achieve temporary abdominal closure followed by skin grafting when the granulation bed matured. A delayed definitive operation was performed for final abdominal closure without implant of prosthetic mesh. Between 1999 and 2009, 56 (68.3%) of 82 patients survived through this treatment. Among them, 42 patients achieved final abdominal closure. Spontaneous fistula closure occurred in 16 patients with secondary fistula recorded in six patients. Besides, wound complications occurred in 13 patients with two cases for pulmonary infection. Within a 12-month follow-up period after definitive closure, no additional fistula was recorded excluding planned ventral hernia repair. Open abdomen treatment was effective for gastrointestinal fistula complicated by severe intra-abdominal infection. A delayed and deliberate operative strategy aiming at fistula excision and fascial closure, with simultaneous abdominal wall reconstruction, was required for the infected open abdomen.

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Challenges in the Management of the Open Abdomen

ICU Director ◽

10.1177/1944451612469628 ◽

2012 ◽

Vol 4 (1) ◽

pp. 33-39 ◽

Cited By ~ 1

Author(s):

David J. Worhunsky ◽

Gregory Magee ◽

David A. Spain

Keyword(s):

Open Abdomen ◽

Damage Control ◽

Original Description ◽

Fascial Closure ◽

Critically Ill Patient ◽

Temporary Abdominal Closure ◽

Recurrence Rates ◽

Abdominal Closure ◽

Intra Abdominal Infection ◽

Temporary Closure

First described more than 60 years ago, the open abdomen has now become a relatively common entity in surgical ICUs. Although the indications for an open abdomen have evolved since the original description of the damage control laparotomy, the goal remains to provide an unstable or critically ill patient time to correct their physiologic derangements. Temporary abdominal closure is thus used as a bridge to definitive repair and closure. Unfortunately, the open abdomen is associated with significant morbidity and mortality, and recent studies have suggested an overuse of the technique. Once the decision is made to proceed with an open abdomen, multiple options exist for temporary abdominal closure. The hope is to obtain definitive closure shortly thereafter in an attempt to reduce potential complications including intra-abdominal infection or enteroatmospheric fistula. Options for temporary closure range from the Bogotá bag to vacuum-assisted techniques; a combined technique of sequential fascial closure with vacuum assistance has recently been shown to result in 100% fascial approximation. In situations where fascial closure is unattainable, temporary coverage with a skin graft may be employed, followed by late abdominal closure via complex abdominal herniorrhaphy. Even using advanced methods such as component separation or a “pork sandwich” technique, the complication and recurrence rates remain high. A careful understanding of the indications, optimal management, and potential complications of the open abdomen is necessary to limit its overuse and ultimately reduce some of the challenges associated with it.

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Should Negative Pressure Therapy Replace Any Other Temporary Abdominal Closure Device in Open-Abdomen Management of Secondary Peritonitis?

Surgical Technology Online ◽

10.52198/21.sti.38.gs1386 ◽

2021 ◽

Author(s):

Vincenzo Pappalardo ◽

Stefano Rausei ◽

Vincenzo Ardita ◽

Luigi Boni ◽

Gianlorenzo Dionigi

Keyword(s):

Negative Pressure ◽

Open Abdomen ◽

Secondary Peritonitis ◽

Fascial Closure ◽

Temporary Abdominal Closure ◽

Negative Pressure Therapy ◽

Pressure Therapy ◽

Advantages And Disadvantages ◽

Abdominal Closure ◽

Primary Fascial Closure

AIM: To clarify the advantages of negative pressure therapy (NPT) compared to other methods of temporary abdominal closure (TAC) in the management of secondary peritonitis. METHODS: We retraced the history of known methods of TAC, and analyzed their advantages and disadvantages. We evaluated as the NPT mechanisms, both from the macroscopic that bio-molecular point of view, well suits to manage this difficult condition. RESULTS: The ideal TAC technique should be quick to apply, easy to change, protect and contain the abdominal viscera, decrease bowel edema, prevent loss of domain and abdominal compartment syndrome, limit contamination, allow egress of peritoneal fluid (and its estimation) and not result in adhesions. It should also be cost-effective, minimize the number of dressing changes and the number of surgical revisions, and ensure a high rate of early closure with a low rate of complications (especially entero-atmospheric fistula). For NPT, the reported fistula rate is 7%, primary fascial closure ranges from 33 to 100% (average 60%) and the mortality rate is about 20%. With the use of NPT as TAC, it may be possible to extend the window of time to achieve primary fascial closure (for up to 20-40 days). CONCLUSION: NPT has several potential advantages in open-abdomen (OA) management of secondary peritonitis and may make it possible to achieve all the goals suggested above for an ideal TAC system. Only trained staff should use NPT, following the manufacturer’s instructions when commercial products are used. Even if there was a significant evolution in OA management, we believe that further research into the role of NPT for secondary peritonitis is necessary.

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Application of pie-crusting technique to facilitate closure of open abdomen after decompressive laparotomy

BMJ Case Reports ◽

10.1136/bcr-2021-244219 ◽

2021 ◽

Vol 14 (8) ◽

pp. e244219

Author(s):

Thomas J Martin ◽

Tareq Kheirbek

Keyword(s):

Abdominal Wall ◽

Primary Closure ◽

Open Abdomen ◽

Abdominal Wall Reconstruction ◽

Skin Grafting ◽

Temporary Abdominal Closure ◽

Pressure Therapy ◽

Abdominal Closure ◽

Decompressive Laparotomy ◽

Split Thickness Skin Grafting

We present the case of a 23-year-old man who developed abdominal compartment syndrome secondary to severe pancreatitis and required decompressive laparotomy and pancreatic necrosectomy. Despite application of a temporary abdominal closure system (ABThera Open Abdomen Negative Pressure Therapy), extensive retroperitoneal oedema and inflammation continued to contribute to loss of domain and prevented primary closure of the skin and fascia. The usual course of action would have involved reapplication of ABThera system until primary closure could be achieved or sufficient granulation tissue permitted split-thickness skin grafting. Though a safe option for abdominal closure, application of a skin graft would delay return to baseline functional status and require eventual graft excision with abdominal wall reconstruction for this active labourer. Thus, we achieved primary closure of the skin through the novel application of abdominal wall ‘pie-crusting’, or tension-releasing multiple skin incisions, technique.

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Current Status of the Open Abdomen Treatment for Intra-Abdominal Infection

Gastroenterology Research and Practice ◽

10.1155/2013/532013 ◽

2013 ◽

Vol 2013 ◽

pp. 1-7 ◽

Cited By ~ 9

Author(s):

Yujie Yuan ◽

Jianan Ren ◽

Yulong He

Keyword(s):

Open Abdomen ◽

Damage Control ◽

Fluid Management ◽

Damage Control Surgery ◽

Skin Grafting ◽

Current Status ◽

Fascial Closure ◽

Surgical Interventions ◽

Abdominal Infection ◽

Intra Abdominal Infection

The open abdomen has become an important approach for critically ill patients who require emergent abdominal surgical interventions. This treatment, originating from the concept of damage control surgery, was first applied in severe traumatic patients. The ultimate goal is to achieve formal abdominal fascial closure by several attempts and adjuvant therapies (fluid management, nutritional support, skin grafting, etc.). Up to the present, open abdomen therapy becomes matured and is multistage-approached in the management of patients with severe trauma. However, its application in patients with intra-abdominal infection still presents great challenges due to critical complications and poor clinical outcomes. This review focuses on the specific use of the open abdomen in such populations and detailedly introduces current concerns and advanced progress about this therapy.

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Open abdomen treatment with negative pressure wound therapy at department for abdominal surgery, UCC Maribor: Our experiences and results

Acta chirurgica iugoslavica ◽

10.2298/aci1601121k ◽

2016 ◽

Vol 63 (1) ◽

pp. 121-123

Author(s):

Bojan Krebs

Keyword(s):

Abdominal Surgery ◽

Negative Pressure ◽

Open Abdomen ◽

Abdominal Cavity ◽

Fascial Closure ◽

Temporary Abdominal Closure ◽

Pressure System ◽

Abdominal Closure ◽

Primary Surgery ◽

Better Than

Introduction: With the development of modern surgery we often come to situation where, after the procedure, closing of abdomen is not feasable. There are many techniques of temporary abdominal closure but best results today are achieved with negative pressure system. Despite widespread use, there is still a lot of confusion regarding the indications, the application of the technique and complications. Objective: The aim of our study was to explain the system with negative pressure and show our experience and results in the treatment of patients with it. Methods: We retrospectively analyzed the data of all patients from 2011 to 2014 which were treated with negative pressure. We were interested in following data: the date of the primary surgery, diagnosis, date and indication for use of the system with negative pressure, the number of system changes, type of final closure of the abdominal cavity and the date of discharge or death. Results: Between 2011 and 2014 we treated 52 patients, 32 men and 20 women with a system with negative pressure. The average age of the patients was 67 years (25 - 85 years). 25 patients were operated on electively and due to complications we used the system for negative pressure. In 27 patients we used negative pressure system after the primary emergency procedure. Mortality was 50 %. Conclusion: The treatment of the open abdomen with negative pressure is an essential part of modern abdominal surgery. Survival after treatment with negative pressure is better than with other techniques of temporary abdominal closure. Man must take in consideration problems with fascial closure and big postoperative hernias wich demand further operations.

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

The American Surgeon ◽

10.1177/000313481708300220 ◽

2017 ◽

Vol 83 (2) ◽

pp. 191-216 ◽

Cited By ~ 13

Author(s):

Adam Cristaudo ◽

Scott Jennings ◽

Ronny Gunnarsson ◽

Alan Decosta

Keyword(s):

Systematic Review ◽

Open Abdomen ◽

Meta Analysis ◽

Final Analysis ◽

Fascial Closure ◽

Controlled Trials ◽

Cochrane Central Register ◽

Temporary Abdominal Closure ◽

Abdominal Closure ◽

Central Register

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 < 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.

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Open abdomen treatment for complicated intra-abdominal infection patients with gastrointestinal fistula can reduce the mortality

Medicine ◽

10.1097/md.0000000000019692 ◽

2020 ◽

Vol 99 (16) ◽

pp. e19692

Author(s):

Xuzhao Li ◽

Jiangpeng Wei ◽

Ying Zhang ◽

Weizhong Wang ◽

Guosheng Wu ◽

...

Keyword(s):

Open Abdomen ◽

Gastrointestinal Fistula ◽

Abdominal Infection ◽

Intra Abdominal Infection

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Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen

The American Journal of Surgery ◽

10.1016/j.amjsurg.2004.03.007 ◽

2004 ◽

Vol 188 (3) ◽

pp. 301-306 ◽

Cited By ~ 99

Author(s):

Thomas R. Howdieshell ◽

Charles D. Proctor ◽

Erez Sternberg ◽

Jorge I. Cué ◽

J.Sheppard Mondy ◽

...

Keyword(s):

Abdominal Wall ◽

Open Abdomen ◽

Abdominal Wall Reconstruction ◽

Temporary Abdominal Closure ◽

Abdominal Closure

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Management of the Open Abdomen

Seminars in Plastic Surgery ◽

10.1055/s-0038-1666802 ◽

2018 ◽

Vol 32 (03) ◽

pp. 127-132

Author(s):

Alexander Mericli

Keyword(s):

Abdominal Wall ◽

Multidisciplinary Approach ◽

Open Abdomen ◽

Abdominal Wall Reconstruction ◽

Plastic Surgeon ◽

Temporary Abdominal Closure ◽

Clinical Scenario ◽

Surgical Team ◽

Abdominal Closure ◽

The Creation

AbstractManagement 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.

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Overview on Temporary Abdominal Closure Techniques: A Review

Journal of Pharmaceutical Research International ◽

10.9734/jpri/2021/v33i57a33970 ◽

2021 ◽

pp. 68-74

Author(s):

Hashem Bark Awadh Abood ◽

Sadeel Fahad Daghistani ◽

Nouf Hashem Koshak ◽

Yazid Ali Alghamdi ◽

Sahad sami Ghamri ◽

...

Keyword(s):

Open Abdomen ◽

Fascial Closure ◽

Temporary Abdominal Closure ◽

Advantages And Disadvantages ◽

Abdominal Closure ◽

Abdominal Hypertension ◽

Fluid Regulation ◽

Abdominal Compartment ◽

Emergency Abdominal Surgery ◽

The Ideal

Open abdomen (OA) is becoming more common, primarily to prevent intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) following emergency abdominal surgery. The purpose of temporary abdominal closure (TAC) techniques is no longer just abdomen coverage; fluid regulation and early fascial closure are now important considerations. TAC techniques for leaving the abdomen open are numerous. The ideal one should be simple to apply and remove, allow for quick access to a surgical second opinion, drain secretions, ease primary closure with acceptable morbidity and mortality, allow for easy nursing, and, finally, be readily available and inexpensive. Over the years, several TAC methods have been proposed. In this review, we overview different techniques for temporary abdominal closure and its advantages and disadvantages.

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