A middle aged man presented with a week long history of severe abdominal pain and distension. CT scans confirmed free air, fluid and probable large bowel perforation. Laparotomy revealed multiple large bowel perforations and four quadrant peritonitis. He had an extensive washout, a colectomy and a laparostomy with negative pressure dressing applied. He returned to theatre at 24 hrs for further washout, and at 48hrs for stoma formation. He had several further relook laparotomies, and abdominal wall closure was achieved on day 10. During this time he had been treated for septic shock and acute kidney injury and had been commenced on parenteral nutrition. His recovery was further complicated by healthcare associated infections but he left hospital nearly a month later.

How is an open abdomen managed after severe abdominal sepsis?

Prad Shanmugasundaram

Managing a patient with an open abdomen on the intensive care unit presents a complex challenge requiring a multidisciplinary approach to the critical decision-making steps. The open abdomen predisposes the patient to complex ventral hernias and the development of intestinal fistulas and so is not a decision to be arrived at lightly.

One of the earliest critical decisions required is whether or not to close the abdomen. This is often a surgical decision taken intra-operatively, but may be helped by measuring intra-abdominal pressure (IAP) after fascial closure, and involvement of an intensivist pre- or intraoperatively. An elevated IAP (>12mmHg) immediately after fascial closure was used a trigger for a laparostomy in a trial that demonstrated low overall mortality and high rate of delayed primary closure (1). An intensivist may also be in a better position to weigh the multisystemic effects of the abdominal injury and the likely postoperative course on intensive care.

Indications for laparostomy formation include: after damage control surgery in major haemorrhage; prevention or treatment of intra-abdominal hypertension; and after laparotomy for severe abdominal sepsis. The need for further subsequent laparotomies must be factored in to the decision making at an early stage also. If further procedures are mandated (as in the case report above, where blind-ending bowel was left and further washouts were required), then temporary abdominal wall closure may be indicated. However, where there is no definite indication for planned re-laparotomy there is evidence that ‘on-demand’ laparotomy may be a more cost-effective strategy with fewer re-laparotomies, shorter intensive care and hospital stay, and reduced health-care costs in an ‘on-demand’ versus planned laparotomy strategies in patients with severe secondary peritonitis (2).

Use of open abdomen techniques after secondary peritonitis is controversial. A large systematic review of patients with an open abdomen (n=4303 from 106 papers) noted that patients with an open abdomen secondary to peritonitis had a worse outcome with higher mortality, increased complications and a lower delayed primary closure rate compared to trauma patients (3). However, this may just reflect the pathophysiological processes ongoing in this patient group.

There are commonly held to be three stages in the management of the open abdomen: an initial timely laparotomy, temporary abdominal closure (TAC) techniques, and definitive abdominal closure (4). There are several options available for TAC and the technique chosen can affect outcome. There is strong evidence that passive dressings for TAC are of no benefit, and may indeed be deleterious with a higher incidence of enteroatmospheric fistulae, compared to primary closure and re-look laparotomy on demand (5).

Techniques such as the Bogota bag have largely been abandoned in favour of negative pressure therapy (NPT) techniques, which have been demonstrated to be more effective in controlling intra-abdominal pressure (1). These techniques allow active drainage of potentially infected peritoneal fluid, and modern devices allow even distribution of negative pressure across a relatively wide area which promotes effective fluid removal, reduces bowel oedema and promotes approximation of the abdominal wall wound (6).

NICE produced interventional procedures guidance on negative pressure wound therapy for the open abdomen in 2009. This is currently being revised, but VAC therapy was more effective than mesh, packing, zipper and Bogota Bag at achieving delayed primary closure. Mortality rates were lower at 22% for VAC therapy than the other techniques. Fistulas occurred at a rate of around 7-8%, and abscesses at around 4-8% (7). A NICE national audit conducted has recently finished collecting data on current management of the open abdomen in the UK. This is expected to report in early 2014.

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Lessons learnt:

Emergency laparotomies in this country are under considerable scrutiny at present with the recent publication of the first report of the National Emergency Laparotomy Audit which showed a wide variation in practice across the UK (8). Use of the open abdomen is increasingly used in cases of severe abdominal sepsis, with surgical consultants and trainees becoming increasingly experienced at applying negative pressure therapy techniques, and critical care nursing and medical staff becoming increasingly experienced at caring for them. Further work is required to identify those patients who would benefit most from laparostomy, and the optimal method and duration of temporary abdominal closure.

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References:

1. Batacchi S, Matano S, Nella A, Zagli G, Bonizzoli M, Pasquini A, Anichini V, Tucci V, Manca G, Ban K, Valeri A, Peris A: Vacuum-assisted closure device enhances recovery of critically ill patients following emergency surgical procedures. Crit Care 2010, 13:R194
2. van Ruler O, Mahler CW, Boer KR, Reuland EA, Gooszen HG, Opmeer BC, de Graaf PW, Lamme B, Gerhards MF, Steller EP, van Till JW, de Borgie CJ, Gouma DJ, Reitsma JB, Boermeester MA; Dutch Peritonitis Study Group. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA. 2007 Aug 22;298(8):865-72
3. Quyn AJ, Johnston C, Hall D et al. The open abdomen and temporary abdominal closure systems – historical evolution and systematic review. Colorectal Disease 2012 14: e429–38
4. Yuan Y, Ren J, Yulong H. Current status of the open abdomen treatment for intra-abdominal infection. Gastroenterol Res Pract 2013: 532013. Epub Oct 2013
5. Robledo FA, Luque-de-Leon E, Suarez R, Sanchez P, de-la-Fuente M, Vargas A, Mier J. Open versus closed management of the abdomen in the surgical treatment of severe secondary peritonitis: a randomized clinical trial. Surg Infect 2007;8:63–72.
6. Demetriades D. Total management of the open abdomen. Int Wound J 2012; 9 (Suppl. 1):17-24
7. Negative pressure wound therapy for the open abdomen. NICE interventional procedures guidance 322 (2009). This guidance is currently under review and is expected to be updated in 2013. Available from http://www.nice.org.uk/guidance/IPG322
8. Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ on behalf of the UK Emergency Laparotomy Network. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. BJA 2012; 109:368-375