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Научни трудове на Съюза на учените в България - Пловдив. Серия Г. Медицина, фармация и дентална медицина т. ХХ. ISSN 1311-9427 (Print), ISSN 2534-9392 (On-line). 2017. Scientific works of the Union of Scientists in Bulgaria-Plovdiv, series G. Medicine, Pharmacy and Dental medicine, Vol. ХХ. ISSN 1311-9427 (Print), ISSN 2534-9392 (On-line). 2017.
РИСКОВИ ФАКТОРИ ЗА УСЛОЖНЕНИЯ И СМЪРТНОСТ ПРИ ОСТРИЯ ГНОЕН ПЕРИТОНИТ ЛЕКУВАН ПО МЕТОДА НА „ОТВОРЕНИЯ КОРЕМ" Б. Сакакушев, Б. Атанасов Медицински Университет/ УМБАЛ „Св. Георги" Първа Клиника по
Хирургия
MORBIDITY & MORTALITY RISK FACTORS IN OPEN ABDOMEN STRATEGY FOR COMPLICATED INTRA-ABDOMINAL INFECTIONS
B. Sakakushev, B. Atanasov Medical University/University Hospital"St.George"Plovdiv-General
Surgery Department
ABSTRACT
The Open Abdomen/OA/ management is a complex and challenging situation that requires a multidisciplinary approach. The mortality rates in patients underwent to OA are high, usually over 30 % depending on the patient condition and the causative event. Intra-abdominal operations/manipulations aimed to control sepsis in abbreviated relaparotomy include general intra-abdominal procedures - aspiration, lavage, necrectomy and specific ones - suture, resection, anastomosis and stoma. We present a retrospective analysis of 91 cases of severe IAI treated with open abdomen strategy in our ward from 2004 till 2016, emphasizing on two basic operative technics, practiced by different surgical teams - simple lavage versus complete repeated small bowel adhesiolysis/CRSBA/ in every planned re-laparotomy until abdominal wall closure. In every following intervention we revise the whole abdominal cavity performing CRSBA from fresh, up to 48 hours dated adhesions, inspecting sutures, anastomoses, revealing inter-intestinal abscesses. In absence of remaining pus and necrotic focus in the abdominal cavity and subsiding abdominal wall infection we restore the abdominal wall aiming at primary fascia closure using total monofilament sutures and reinforcing nylon situational sutures. In CRSBA and simple lavage groups the rate of inter-intestinal abscess were 7 versus 6, visceral lesions - 6 versus 9, anastomosis dehiscence - 6 versus 8, fascia suture take down - 8 versus 11, fistula formation - 7 versus 15, "frozen abdomen" - 5 versus 36 and lethality - 9 versus 17 respectively. The most serious complications which mainly led to a total mortal outcome of 26 patient were acute necrotizing pancreatitis, fistula formation/n 22/ and "frozen abdomen"/n 41/. CRSBS in every planned re-laparotomy until abdomen closure results in less early and late complications and lethality compared to simple lavage. Our results show benefits of two fold less fistula formation as well as "frozen abdomen" in CRSBS compared to simple lavage.
Key Words: Open Abdomen/OA/, Temporary Abdominal Closure/TAC/, Complete Repeated Small Bowel Adhesiolysis/CRSBA/, Abdominal Compartment Syndrome/ACS/
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INTRODUCTION:
Current indications for Open Abdomen treatment are Severe Sepsis /Septic Shock/ and prevention of ACS, where we can distinguish anatomical physiological and logistical issues/1/. The control of sepsis on index and subsequent operations is the main objective in necrotizing pancreatitis and severe secondary pancreatitis/2/.The type and term of relaparotomy either "planned" or "on demand" must be done early, most appropriately until the 48th hour to achieve lowest mortality/3/.There is no consensus for the optimal type of temporary abdominal closure/TAC/ technique, although some benefits of constant negative pressure devices recently are supposed to reduce peritoneal and systemic inflammation and decrease complication rates/2,4/. Intra-abdominal operations/manipulations aimed to control sepsis in abbreviated re-laparotomy include general intra-abdominal procedures - aspiration, lavage, necrectomy and specific ones - suture, resection, anastomosis, stoma/3/. The best mode of restitution of the abdominal wall is progressive closure and complete adoption of the fascia defect by primary closure if possible till the 8th day of index operation/5,6/.The most serious local complication of OA - entero-atmospheric fistula often requires surgical treatment, depending on site and size of thhe fistula and surgeon's experience/7/.
In the current literature we did not find sufficient information on morbidity and mortality risk factors in OA strategy, therefore we were motivated to analyze our experience in this respect.
PATIENTS AND METHODS:
A retrospective analysis of 91 cases of severe IAI treated with open abdomen strategy in our clinic from 2004 till 2016 has been performed, emphasizing on two basic operative technics practiced by different surgical teams - simple lavage versus complete repeated small bowel adhesiolysis/ CRSBA/ in every planned re-laparotomy until abdominal wall closure. The rate and type of the substantial early/intraoperative/ complications like bowel paresis, inter-intestinal abscess, visceral lesions, suture or anastomosis take down were compared in both strategies as well as late ones like fistula formation and frozen abdomen.
In index laparotomy we applied the following procedures and techniques: o wash out exudate and pus o inspect the peritoneal cavity
o perform if needed necrectomy/excision/, resection of necrotic visceral part or organ/
ectomy/, suture of lesions, anastomosis or stoma o lavage of the abdominal cavity.
The laparotomy wound is left open completely or partially for compartment syndrome prevention, drainage and enhancing the relaparotomy. TAC over omentum or small bowell is maintained with polyamide antibacterial mesh, which is fixed with 8-12 fascial sutures/Fig No 1 &2/. The mesh we use is strong enough, elastic, tiny perforated to prevent bowel damage, allows observation of underlying organs, drainage and is very cheap. Fig No 1 Polyamide mesh for TAC Fig No 2 Fixed mesh
For temporary wound closure over the mesh we use hydrogel dressing and wound edges dressing with Acticoat/Fig No 3 & 4/.
Fig No 3 Hydrogel dressing Fig No 4 Acticoat wound edge dressing
In every following intervention we revise the whole abdominal cavity performing total small bowel adhesiolysis from fresh, up to 48 hours dated adhesions, inspecting sutures, anastomoses, revealing interintestinal abscesses. Excessive small bowel dilatation/ileus-peritonitis/ we deal with proximal/oral/ digital small bowel emptying via nasogastric tube.
Thus we discover and correct pathological findings, enhancing restoration of gastro-intestinal passage, avoiding complications like frozen abdomen, fistulae and fascial retraction. Throughout the step by step lavage for mechanical and antiseptic abdominal toilet in stercoral peritonitis we use hibiscrub solution and physiological serum, followed by diluted iodine solution. In absence of remaining pus and necrotic focus in the abdominal cavity and subsiding abdominal wall infection we restore the abdominal wall aiming at primary fascial closure using total monofilament sutures and reinforcing nylon situational sutures.
RESULTS
The outcome of 91 patients in whom a total of 435 operations have been performed is presented/ Table No 1/. The number of patients and the procedures performed were almost similar - 43 patients with CRSBA with 203 operations and 48 ones with simple lavage and 232 procedures performed respectively.
Table No 1 Patients, procedures and complications
Patients/Procedures Complication type CRSBA Patient n 43 Procedures n 203 Simple Lavage Patient n 48 Procedures n 232 Total Patient n 91 Procedures n 435
Inter-intestinal abscess 7 6 13
Visceral lesions 6 9 15
Anastomosis 6 8 14
dehiscence
Fascia suture take 8 11 19
down
Fistula 7 15 22
Frozen Abdomen 5 36 41
Lethality 9 17 26
In CRSBA and simple lavage groups the rate of inter-intestinal abscess were 7 versus 6, visceral lesions - 6 versus 9, anastomosis dehiscence - 6 versus 8, fascia suture take down - 8 versus 11, fistula formation - 7 versus 15, "frozen abdomen" - 5 versus 36 and lethality - 9 versus 17 respectively. The most serious complications which mainly led to a total mortal outcome of 26 patient were acute necrotizing pancreatitis, fistula formation/n 22/ and "frozen abdomen"/n 41/.
DISCUSSION
The most common indications for OA are trauma, abdominal sepsis, severe acute pancreatitis and all situations in which an abdominal compartment syndrome is present/8, 9/. The mortality rates in patients underwent to OA are high, usually over 30 % depending on the patient cohort and on OA causative event/10/. The OA management is a complex and challenging situation that requires a multidisciplinary approach. In fact only by a close cooperation between surgeons and the Intensive Care Unit team would be possible to obtain good results in terms of survival improvement and morbidity reduction/11/. Management of the abdominal contents incorporates several basic techniques and considerations: appropriate temporary covering, enteric injury repair in most patients, placement of an anastomosis in an area of the abdomen with minimal manipulation without exposure to the atmosphere, acquiring enteral access for initiation of enteral nutrition, and ultimate abdominal closure/12/. Planned re-laparotomy shortens postoperative bowel paresis, fastens restoration of bowel function. It faster liquidates residual infection and decreases number of re-laparotomies, leading to early primary fascial abdominal wall closure. Planned re-laparotomy also reduces or avoids formation of late complications like istula formation and"Frozen Abdomen". When there is an indication for continued OAM after 24-72 hours, the focus should be on maintaining abdominal wall integrity by using one of the described techniques. In 5-9 days it usually becomes clear whether early primary closure will be successful or not. If not, the residual fascial defect probably has to be closed with mesh (biological or prosthetic), split skin grafts, component parts separation techniques, or a combination of these/13/. The case report of the use of "Coliseum technique" which creates constant traction to all dissected abdominal wall layers, isolates the adhered "frozen abdomen," and offers a wide operating field in convenience of the surgeon is recent technique option/14/.
Our complications rate and outcomes demonstrate the benefit of CRSBA compared to simple lavage. While inter-intestinal abscess, visceral lesions, anastomosis dehiscence and suture take down had the same rate in both groups, fistula formation and especially "frozen abdomen" were twice and seven times less oftener in CRSBA group respectively. Lethality was almost two fold in simple lavage group.
CONCLUSION
CRSBS in every planned re-laparotomy until abdomen closure results in less early and late complications and lethality compared to simple lavage. Our results show benefits of two fold less fistula formation as well as "frozen abdomen" in CRSBS compared to simple lavage.
A prospective RCT will give more evidence of real advantages of CRSBS compared to simple lavage.
Reference
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