GastrointestinalFluid volume overload negatively influences delayed primary facial closure in open abdomen management
Introduction
The open abdomen (OA) is now a common clinical challenge in surgical intensive care units (ICUs). Several clinical conditions and situations are favorably treated with OA. In patients with intra-abdominal infections, abscesses or severe pancreatitis sometimes precludes closure of the abdominal wall after surgery or leads to abdominal compartment syndrome (ACS) with its profound and life-threatening effects on cardiovascular, respiratory, and renal functions [1]. Leaving the abdomen open enables repeated access to the peritoneal cavity and facilitates repeated debridement of nonviable tissue, peritoneal toilet, and effective drainage.
Management of the OA has become an obligatory conundrum for general and trauma surgeons performing damage-control surgery. In view of the OA complications such as damage of organs, fistula, loss of water-electrolyte and protein, abdominal closure should be performed as soon as possible without compromising the patient's physiological condition. Temporary abdominal closure (TAC) is performed with Bogota bags, towel clips, skin only, or any of the various negative pressure dressings [2]. Early fascial closure of the OA seems feasible within 7–8 d in the majority of light trauma victims [3], whereas a longer time may be required in critically ill patients undergoing OA treatment owing to serious abdominal infection. If TAC techniques do not facilitate primary definitive closure of the abdominal wall, skin-only closure or split-thickness skin grafting may be used for covering the bowels and omentum. The major drawback with these techniques is the formation of extensive ventral hernias that have to be dealt with later.
According to the most recent literature, the most promising TAC method is vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). Acosta et al. [4] reported that VAWCM method provided a high fascial closure rate after long-term treatment of OA and demonstrated the safety of this technique, with few complications, in a prospective nonrandomized descriptive trial containing 151 patients. In the retrospective analysis of Rasilainen et al. [5], VAWCM method improved the delayed primary fascial closure rate by 78%, and planned hernia rate is lower than nontraction methods. And in those OA patients who did not achieve primary fascial closure, deep wound infections and intra-abdominal abscesses have been shown to prevent delayed primary fascial closure.
The intensive care management of the OA is important to the surgical success of primary fascial closure. Historically, the surgical community has advocated aggressive and liberal crystalloid infusion to correct hemodynamic and metabolic derangements. However, this can lead to volume overload and increased risks of ACS, pulmonary edema, and acute respiratory distress syndrome. Judicious intravenous fluid resuscitation targeting dynamic hemodynamic parameters (stroke volume variance or pulse pressure differential) versus static parameters (central venous pressure or left atrial pressure) may decrease the incidence of ACS and OA [6]. As far as we know, no clinical trials of fluid overload and primary facial closure have been attempted. We addressed this by analyzing demographic, clinical, and primary facial closure data from an observational, single-center registry of OA patients treated with VAWCM at our institution.
Section snippets
Study design and population
The study was approved by the Institutional Review Board of the Jinling Hospital. Adult OA patients (>18 y) who were treated with VAWCM in our medical and surgical ICUs between January 2006 and November 2011 were retrospectively included. Patients were excluded if they had age <18 y, preexistent abdominal wall hernia before OA treatment, and anticipated OA treatment lasting fewer than 5 d. Data from patients who underwent a primary fascial closure were compared with those in whom primary
Indications for OA treatment
There were 30 men (75.0%) and 10 women (25.0%) with a mean age of 45 ± 10.1 y. The main disease etiologies contributing to the OA were diffuse peritonitis (16, 40%), severe pancreatitis (eight, 20%), severe trauma (12, 30%), and peritoneal cavity hemorrhage (four, 10%). The main indications for OA treatment were: fascial closure not possible (22, 55%), documented intra-abdominal hypertension or ACS (nine, 23%), need for abdominal cavity drainage owing to severe infection (five, 13%), and
Discussion
In our study, the primary fascial closure rate among the 40 patients with OA treatment was 60%. Although the rate was lower than the success rate of fascial closure in the previous studies with VAWCM therapy (76%–78%) [4], [5], the rate of patients with severe intra-abdominal infection plus trauma was higher compared with other studies (90% versus 35%) [9]. Padalino et al. [10] found that the fascial closure rate was only 33%–60% in OA patients with severe abdominal infections. In our study,
Acknowledgment
This work was supported by the National Science Foundation of China (grant 81370514).
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