Factors affecting primary fascial closure of the open abdomen in the nontrauma patient

doi:10.1016/j.surg.2012.07.015

Surgery

Volume 152, Issue 4, October 2012, Pages 777-784

Presented at the 69th annual meeting of the Central Surgical Association in Madison, WI, March 1–3, 2012.

https://doi.org/10.1016/j.surg.2012.07.015 Get rights and content

Introduction

Septic wound complications are known to limit the ability of surgeons to perform primary fascial closure after damage control laparotomy (DCL) in patients with trauma. Factors preventing primary fascial closure after DCL in nontrauma patients, however, are unknown. We aim to identify these risk factors.

Methods

Institutional research board approval was obtained to review the medical records of nontrauma patients undergoing DCL between December 2006 and June 2010. Patients who died before an attempt at fascial closure were excluded. Univariate analysis was performed comparing patients with primary fascial closure to partial fascial or planned ventral hernia. Data are presented as median or percentage as appropriate. Statistical significance was considered at P < .05.

Results

One hundred eighty-one patients were identified (53% male), of whom 8 died before an attempt at fascial closure, leaving 173 patients within the study cohort. Primary fascial closure was achieved in 111 patients (64%), with the remaining patients receiving either partial fascial or planned ventral hernia closure. The cumulative rate of primary fascial closure plateaued by day 12 at 62%. Patients who achieved primary fascial closure had a greater incidence of pre-existent coronary artery disease (32% vs 16%) and arrhythmia (27% vs 11%). There was a superior base deficit on admission (−7 vs −9) in the primary closure cohort. There was equivalent mortality (21% vs 25%) and intensive care unit stay (9 days vs 14 days); however, the overall hospital stay (22 vs 42 days) and ventilator days (4 vs 6) in the primary fascial closure group were shortened. Success of primary fascial closure was associated with lower incidence of septic complications (39% vs 59%), enterocutaneous fistulae (4% vs 11%), and intra-abdominal abscess (14% vs 33%), as well as fewer days of open abdomen management (2 vs 6), and number of serial abdominal explorations (2 vs 4) and a lower fluid balance over the first 10 days.

Conclusion

The development of septic complications such as intra-abdominal abscess and enterocutaneous fistulae were associated with inability to primarily close the fascia after DCL. In addition, longer duration of open abdomen management, greater number of serial abdominal explorations, and worse base deficits were negatively associated with primary fascial closure.

Section snippets

Material and methods

Institutional review board approval was obtained to retrospectively analyze patients admitted with an OA from December 2006 to June 2010. Patients were excluded if their OA was a result of trauma, if they were younger than 18 years of age, or if they died before an attempt at fascial closure. Data from patients who underwent a primary fascial closure were compared with those in whom primary fascial closure could not be achieved (ie, planned ventral hernia or partial fascial closure). Cumulative

Results

A total of 181 patients were identified, of which 8 patients died before fascial closure attempt, leaving a total of 173 patients constituting the study cohort (n = 88 male). The mean age was 63 years. The majority of patients underwent OA resulting from general operative procedures (90%) with the remaining after vascular operations (10%). Concern regarding bowel viability and fecal contamination each accounted for approximately one-third of the indications for OA, whereas loss of domain

Discussion

The use of the OA technique has been advocated in many disease processes by acute-care surgeons. Its application allows for serial abdominal examinations and treatments such as ischemic bowel resection, debridement of necrotic/infected material, and hemorrhage control.13, 14 The use of the OA technique improves mortality rates not only in trauma patients but also in critically ill nontrauma populations with intra-abdominal catastrophes. For example, in the setting of abdominal compartment

References (18)

M.L. Cheatham et al.
Long-term impact of abdominal decompression: a prospective comparative analysis
J Am Coll Surg
(2008)
T.E. Rasmussen et al.
Early abdominal closure with mesh reduces multiple organ failure after ruptured abdominal aortic aneurysm repair: guidelines from a 10-year case-control study
J Vasc Surg
(2002)
H.H. Stone et al.
Management of the major coagulopathy with onset during laparotomy
Ann Surg
(1983)
M.F. Rotondo et al.
“Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury
J Trauma
(1993)
N.Y. Patel et al.
Temporary abdominal closure: long-term outcomes
J Trauma
(2011)
J.J. Diaz et al.
The management of the open abdomen in trauma and emergency general surgery: part 1-damage control
J Trauma
(2010)
T.R. Vogel et al.
The open abdomen in trauma: do infectious complications affect primary abdominal closure?
Surg Infect
(2006)
M.L. Cheatham et al.
Long-term physical, mental, and functional consequences of abdominal decompression
J Trauma
(2004)
B.L. Zarzaur et al.
Quality of life after abdominal wall reconstruction following open abdomen
J Trauma
(2011)

There are more references available in the full text version of this article.

Cited by (35)

Increasing Use of Prophylactic Open Abdomen Therapy With Vacuum Assisted Wound Closure and Mesh Mediated Fascial Traction After Repair of Ruptured Abdominal Aortic Aneurysm
2024, European Journal of Vascular and Endovascular Surgery
Open abdomen therapy (OAT) is commonly used to prevent or treat abdominal compartment syndrome (ACS) in patients with ruptured abdominal aortic aneurysms (rAAAs). This study aimed to evaluate the incidence, treatment, and outcomes of OAT after rAAA from 2006 to 2021. Investigating data on resuscitation fluid, weight gain, and cumulative fluid balance could provide a more systematic approach to determining the timing of safe abdominal closure.
This was a single centre observational cohort study. The study included all patients treated for rAAA followed by OAT from October 2006 to December 2021.
Seventy-two of the 244 patients who underwent surgery for rAAA received OAT. The mean age was 72 ± 7.85 years, and most were male (n = 61, 85%). The most frequent comorbidities were cardiac disease (n = 31, 43%) and hypertension (n = 31, 43%). Fifty-two patients (72%) received prophylactic OAT, and 20 received OAT for ACS (28%). There was a 25% mortality rate in the prophylactic OAT group compared with the 50% mortality in those who received OAT for ACS (p = .042). The 58 (81%) patients who survived until closure had a median of 12 (interquartile range [IQR] 9, 16.5) days of OAT and 5 (IQR 4, 7) dressing changes. There was one case of colocutaneous fistula and two cases of graft infection. All 58 patients underwent successful abdominal closure, with 55 (95%) undergoing delayed primary closure. In hospital survival was 85%. Treatment trends over time showed the increased use of prophylactic OAT (p ≤ .001) and fewer ACS cases (p = .03) assessed by Fisher’s exact test. In multivariable regression analysis fluid overload and weight reduction predicted 26% of variability in time to closure.
Prophylactic OAT after rAAA can be performed safely, with a high rate of delayed primary closure even after long term treatment.
Damage Control Surgery and Transfer in Emergency General Surgery
2023, Surgical Clinics of North America
Supine position and nonmodifiable risk factors for ventilator-associated pneumonia in trauma patients
2017, American Journal of Surgery
Citation Excerpt :
In patients with an open abdomen, permanent visceral coverage, preferably with primary fascial closure, is an important goal of care to avoid the dreaded complications of enteric fistula or abdominal sepsis.13,14 Patients with an open abdomen are often ventilator-dependent for longer periods15 and difficult to mobilize, increasing their risk of ICU complications including VAP. Because of this, factors that delay or complicate abdominal closure should be avoided.
We studied trauma-specific conditions precluding semiupright positioning and other nonmodifiable risk factors for their influence on ventilator-associated pneumonia (VAP).
We performed a retrospective study at a Level I trauma center from 2008 to 2012 on ICU patients aged ≥15, who were intubated for more than 2 days. Using backward logistic regression, a composite of 4 factors (open abdomen, acute spinal cord injury, spine fracture, spine surgery) that preclude semiupright positioning (supine composite) and other variables were analyzed.
In total, 77 of 374 (21%) patients had VAP. Abbreviated Injury Score head/neck greater than 2 (odds ratio [OR] 2.79, P = .006), esophageal obturator airway (OR 4.25, P = .015), red cell/plasma transfusion in the first 2 intensive care unit days (OR 2.59, P = .003), and 11 or more ventilator days (OR 17.38, P < .0001) were significant VAP risk factors, whereas supine composite, scene vs emergency department airway intervention, brain injury, and coma were not.
Factors that may temporarily preclude semiupright positioning in intubated trauma patients were not associated with a higher risk for VAP.
Outcomes of primary fascial closure after open abdomen for nontrauma emergency general surgery patients
2015, American Journal of Surgery
Citation Excerpt :
Interestingly, the time to closure, number of washouts, type of closure (running vs interrupted), indication for initial operation, fluid balance, and intervention performed did not affect fascial complication rates. PFC was attempted in 64% of patients, which is within the range of 24% to 74% reported in the literature for nontrauma3,6,12,13 as well as trauma OA patients (59% to 100%).7,14–16 Cothren et al16 have described sequential fascial closure resulting in 100% fascial closure in a series of 100 injured patients managed with damage control techniques.
Emergency general surgery patients are increasingly being managed with an open abdomen (OA). Factors associated with complications after primary fascial closure (PFC) are unknown.
Demographic and operative variables for all emergency general surgery patients managed with OA at an academic medical center were prospectively examined from June to December 2013. Primary outcome was complication requiring reoperation.
Of 58 patients, 37 managed with OA achieved PFC. Of these, 14 needed re-exploration for dehiscence, compartment syndrome, infection, or other. Complications after PFC were not associated with age, type of operative intervention, time to closure, re-explorations, comorbidities, or mortality. Complications correlated with higher body mass index (P = .02), skin closure (P = .04), plasma infusion (P = .01), and less intraoperative bleeding (P = .05). Deep surgical site infection correlated with fascial dehiscence (P = .02).
Reoperation after PFC was more likely in obese and nonhemorrhagic patients. Recognition of these factors and strategies to reduce surgical site infection may improve outcomes.
Time to first take-back operation predicts successful primary fascial closure in patients undergoing damage control laparotomy
2014, Surgery (United States)
Citation Excerpt :
Given that fluids follow the path of least resistance, an open abdominal cavity may, in fact, facilitate increased bowel edema and distention of abdominal contents, which might otherwise not occur in a closed abdominal cavity.19 In the initial publication from the AAST Open Abdomen database, Dubose et al7 noted that the number of re-explorations was highly correlated with failure to achieve primary fascial closure, and this was seconded by Bradley et al20 in their examination of the risk factors for development of enterocutaneous fistulae.21 In the nontrauma population, Zielinski's group noted increased primary fascial closure with fewer days of OA management as well as fewer reexplorations.18
Failure to achieve primary fascial closure (PFC) after damage control laparotomy is costly and carries great morbidity. We hypothesized that time from the initial laparotomy to the first take-back operation would be predictive of successful PFC.
Trauma patients managed with open abdominal techniques after damage control laparotomy were prospectively followed at 14 Level 1 trauma centers during a 2-year period. Time to the first take-back was evaluated as a predictor of PFC using hierarchical multivariate logistic regression analysis.
A total of 499 patients underwent damage control laparotomy and were included in this analysis. PFC was achieved in 327 (65.5%) patients. Median time to the first take-back operation was 36 hours (interquartile range 24–48). After we adjusted for patient demographics, resuscitation volumes, and operative characteristics, increasing time to the first take-back was associated with a decreased likelihood of PFC. Specifically, each hour delay in return to the operating room (24 hours after initial laparotomy) was associated with a 1.1% decrease in the odds of PFC (odds ratio 0.989; 95% confidence interval 0.978–0.999; P = .045). In addition, there was a trend towards increased intra-abdominal complications in patients returning after 48 hours (odds ratio 1.80; 95% confidence interval 1.00–3.25; P = .05).
Data from this prospective, multicenter study demonstrate that delays in returning to the operating room after damage control laparotomy are associated with reductions in PFC. These findings suggest that emphasis should be placed on returning to the operating room within 24 hours after the initial laparotomy if possible (and no later than 48 hours).
Fluid volume overload negatively influences delayed primary facial closure in open abdomen management
2014, Journal of Surgical Research
Citation Excerpt :
Selewski et al. [21] compared weight-based methods versus the fluid balance method for calculating fluid overload, suggesting weight-based definitions of fluid overload are more useful and practical, as used at the bedside in our study. Recently, Goussous et al. [22] tried to identify factors preventing primary fascial closure after damage control laparotomy in nontrauma patients. They found that success of primary fascial closure was associated with a lower fluid balance over the first 10 d. However, it must be pointed that in our study, the rate of patients with severe intra-abdominal infection plus trauma was high (90%).
The open abdomen (OA) is associated with significant morbidity and mortality, and its management poses a formidable challenge. Inability to achieve primary closure of the abdominal wall is one of the most severe complications of this technique. Factors influencing primary fascial closure, however, are unknown. This study aims to explore the influence of fluid volume overload on the application of vacuum-assisted and mesh-mediated fascial traction (VAWCM) in OA treatment.
A review of patients undergoing OA management using VAWCM technique from January 2006 to November 2011 was performed. Patients with aged <18 y OA treatment for fewer than 5 d and abdominal wall hernia before OA treatment were excluded.
Average age was 45 ± 10.1 y and average OA treatment time was 31 ± 6.8 d. The complete fascial closure rate was 60%. The overall mean bodyweight-based fluid overload was 7.2 kg (range: −8.0 to +21.6 kg), representing a mean percent weight gain of 11.5% (range: −9.5% to +27%). Patients with fluid-related weight gain ≥10% had a lower primary facial closure rate than those with <10% (39% versus 77%). And primary facial closure rate seems to further decrease with fluid-related weight gain ≥20%, suggesting a dose-response effect of progressive fluid accumulation.
The VAWCM method provided a high primary fascial closure rate after long-term treatment of OA. Fluid volume overload negatively influences delayed primary facial closure. Judicious intravenous fluid resuscitation should be advocated in the therapy of critically ill patients.

View all citing articles on Scopus

View full text

Central Surgical AssociationFactors affecting primary fascial closure of the open abdomen in the nontrauma patient

Introduction

Methods

Results

Conclusion

Section snippets

Material and methods

Results

Discussion

J Am Coll Surg

J Vasc Surg

Management of the major coagulopathy with onset during laparotomy

Ann Surg

“Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury

J Trauma

Temporary abdominal closure: long-term outcomes

J Trauma

The management of the open abdomen in trauma and emergency general surgery: part 1-damage control

J Trauma

The open abdomen in trauma: do infectious complications affect primary abdominal closure?

Surg Infect

Long-term physical, mental, and functional consequences of abdominal decompression

J Trauma

Quality of life after abdominal wall reconstruction following open abdomen

J Trauma

Central Surgical Association
Factors affecting primary fascial closure of the open abdomen in the nontrauma patient