The open abdomen in trauma and non-trauma patients

16 Pages·2017·0.83 MB·English

by  Federico Coccolini

Coccolinietal.WorldJournalofEmergencySurgery (2018) 13:7
DOI10.1186/s13017-018-0167-4
REVIEW Open Access
The open abdomen in trauma and
non-trauma patients: WSES guidelines
Federico Coccolini1*, Derek Roberts2, Luca Ansaloni1, Rao Ivatury3, Emiliano Gamberini4, Yoram Kluger5,
Ernest E. Moore6, Raul Coimbra7, Andrew W. Kirkpatrick2, Bruno M. Pereira8, Giulia Montori1, Marco Ceresoli1,
Fikri M. Abu-Zidan9, Massimo Sartelli10, George Velmahos11, Gustavo Pereira Fraga8, Ari Leppaniemi12,
Matti Tolonen12, Joseph Galante13, Tarek Razek14, Ron Maier15, Miklosh Bala16, Boris Sakakushev17,
Vladimir Khokha18, Manu Malbrain19, Vanni Agnoletti4, Andrew Peitzman20, Zaza Demetrashvili21, Michael Sugrue22,
Salomone Di Saverio23, Ingo Martzi24, Kjetil Soreide25,26, Walter Biffl27, Paula Ferrada3, Neil Parry28,
Philippe Montravers29, Rita Maria Melotti30, Francesco Salvetti1, Tino M. Valetti31, Thomas Scalea32,
Osvaldo Chiara33, Stefania Cimbanassi33, Jeffry L. Kashuk34, Martha Larrea35, Juan Alberto Martinez Hernandez36,
Heng-Fu Lin37, Mircea Chirica38, Catherine Arvieux38, Camilla Bing39, Tal Horer40, Belinda De Simone41,
Peter Masiakos42, Viktor Reva43, Nicola DeAngelis44, Kaoru Kike45, Zsolt J. Balogh46, Paola Fugazzola1,
Matteo Tomasoni1, Rifat Latifi47, Noel Naidoo48, Dieter Weber49, Lauri Handolin50, Kenji Inaba51, Andreas Hecker52,
Yuan Kuo-Ching53, Carlos A. Ordoñez54, Sandro Rizoli55, Carlos Augusto Gomes56, Marc De Moya57, Imtiaz Wani58,
Alain Chichom Mefire59, Ken Boffard60, Lena Napolitano61 and Fausto Catena62
Abstract
Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment
syndrome.Theseconditionsmayresultinavicious,self-perpetuatingcycleleadingtoseverephysiologicderangements
andmultiorganfailureunlessinterruptedbyabdominal(surgicalorother)decompression.Further,insomeclinical
situations,theabdomencannotbeclosedduetothevisceraledema,theinabilitytocontrolthecompellingsourceof
infection or the necessity to re-explore (as a “planned second-look” laparotomy) or complete previously initiated
damagecontrolproceduresorincasesofabdominalwalldisruption.Theopenabdomenintraumaandnon-trauma
patientshasbeenproposedtobeeffectiveinpreventingortreatingderangedphysiologyinpatientswithsevereinjuries
orcriticalillnesswhennootherperceivedoptionsexist.Itsuse,however,remainscontroversialasitisresourceconsuming
andrepresentsanon-anatomicsituationwiththepotentialforsevereadverseeffects.Itsuse,therefore,shouldonlybe
consideredinpatientswhowouldmostbenefitfromit.Abdominalfascia-to-fasciaclosureshouldbedoneassoonasthe
patientcanphysiologicallytolerateit.Allprecautionstominimizecomplicationsshouldbeimplemented.
Keywords:Open abdomen, Laparostomy, Non-trauma, Trauma, Peritonitis, Pancreatitis, Vascular emergencies,
Intra-abdominal infection, Fistula, Nutrition, Re-exploration, Reintervention, Closure, Biological, Synthetic, Mesh,
Technique, Timing, Guidelines
*Correspondence:[email protected]
1GeneralEmergencyandTraumaSurgery,BufaliniHospital,VialeGiovanni
Ghirotti,286,47521Cesena,Italy
Fulllistofauthorinformationisavailableattheendofthearticle
©TheAuthor(s).2018OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.0
InternationalLicense(http://creativecommons.org/licenses/by/4.0/),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedyougiveappropriatecredittotheoriginalauthor(s)andthesource,providealinkto
theCreativeCommonslicense,andindicateifchangesweremade.TheCreativeCommonsPublicDomainDedicationwaiver
(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle,unlessotherwisestated.
Coccolinietal.WorldJournalofEmergencySurgery (2018) 13:7 Page2of16
Background using OA. It should not be performed liberally. Measures
Damage control management (DCM) of severely injured to mitigate complications are necessary. In all patients
orphysiologicallyderangedpatientsisconsideredbymany with an OA, every effort should be exerted to achieve
to consist of damage control resuscitation (DCR) and primary fascial closure (i.e., fascia-to-fascia closure of the
damage control surgery (DCS). Use of DCM in patients abdominal wall within the index hospitalization) as soon
with deranged physiology may trigger intra-abdominal asthepatientcanphysiologicallytolerateit[3].
hypertension(IAH)orabdominalcompartmentsyndrome
(ACS) that may aggravate physiologic derangement or Purposeanduseofthisguideline
multiorgan failure (MOF) in a vicious circle unless The guidelines are evidence-based, with the grades of
interrupted by abdominal decompression (surgical or recommendation, based on the evidence. These guide-
other)[1,2].Further,inotherclinicalsituations,theabdo- lines present methods for optimal management of open
men cannot be closed due to visceral edema, the inability abdomen in trauma and non-trauma patients. They do
to completely control the compelling source of infection not represent a standard of practice. They are suggested
or to the necessity to re-explore (in a “planned re-look plans of care, based on best available evidence and a
laparotomy”) or to complete DCS procedures or in cases consensus of experts. They, however, do not exclude
ofabdominalwalldamage.Althoughopenabdomen(OA) other approaches as being within a standard of practice.
hasbeenproposedtobeeffectiveinpreventingortreating For example, they should not be used to compel adher-
deranged physiology in patients with severe injuries or ence to a given method of medical management, which
critical illness, it must be recognized as a non-anatomic should be finally determined after taking into account
situation that has potential for severe side effects while conditions at the relevant medical institution (staff
increasingresourceutilization[3]. levels, experience, equipment, etc.) and the characteristics
The World Society for Emergency Surgery (WSES) oftheindividualpatient.Theresponsibilityfortheresults,
accepted the definitions of IAH, ACS, and related however, rests with the engaging practitioners and not
conditions published by the World Society Abdominal agedtherein,andnottheconsensusgroup.
CompartmentSyndromein2013(WSACS)[2–4](Fig.1).
OA management consists of intentionally leaving the Methods
abdominal fascial edges of the paired rectus abdominus A computerized search was performed in MEDLINE,
muscles un-approximated (laparostomy) in order to EMBASE,andScopusbyaninformationscientist/librarian
truncate operation, prevent IAH/ACS, and facilitate for the time range of January 1980 to August 2017. The
re-exploration without damaging the abdominal fascia [3]. terms open abdomen, laparostomy, injuries, trauma,
Temporary abdominal closure (TAC) refers to the method peritonitis, pancreatitis, vascular, ischemia, resuscitation,
forprovidingprotectiontotheabdominalvisceraduringthe adult, management, infection, intensive care unit, anasto-
timethefasciaremainsopen[2,5].PatientsundergoingOA mosis,vasopressors,andfollow-upinvariouscombinations
management are at risk of developing entero-atmospheric with the use of the Boolean operators “AND” and “OR”
fistula (EAF) and a “frozen abdomen,” intra-abdominal were used. No search restrictions were imposed. The dates
abscesses, and lower rates of definitive fascial closure were selected to allow comprehensive published abstracts
[6, 7]. The risk-benefit ratio must be kept in mind in of clinical trials, consensus conferences, comparative
studies, congresses, guidelines, government publications,
multicenterstudies,systematicreviews,meta-analyses,large
case series, original articles, and randomized controlled
IAH grade IAP [mmHg]
trials.Casereportsandsmallcaseserieswereexcluded.We
alsoanalyzedthereferencelistsofrelevantnarrativereview
Grade I 12 - 15
articles identified during the search to identify any studies
thatmayhavebeenmissed.
Grade II 16 - 20
For each article, we subsequently applied a level of
evidence (LE) using the Grading of Recommendations,
Grade III 21 - 25
Assessment,Development,andEvaluation(GRADE)system
[8](Table1).ThefullGRADEprocesswasnotused,asthis
Grade IV > 25
system is difficult to apply when scant evidence exists. A
group of experts in the field of OA management, coordi-
> 20 with new organ
ACS
natedbyacentralcoordinator,weresubsequentlyconvened
disfunction/failure
in order to elicit their evidence-based opinions on certain
Fig.1WSACSgradingofintra-abdominalhypertension(IAH)(IAP
keyclinicalquestionsrelatingtotheOA.ThroughaDelphi
intra-abdominalpressure,ACSabdominalcompartmentsyndrome)[4]
process, the clinical questions were discussed in rounds.
Coccolinietal.WorldJournalofEmergencySurgery (2018) 13:7 Page3of16
Table1GRADEsystemtoevaluatethelevelofevidenceandrecommendation
Gradeofrecommendation Clarityofrisk/benefit Qualityofsupportingevidence Implications
1A
Strongrecommendation, Benefitsclearlyoutweighrisk RCTswithoutimportantlimitations Strongrecommendation,applies
high-qualityevidence andburdens,orviceversa oroverwhelmingevidencefrom tomostpatientsinmost
observationalstudies circumstanceswithoutreservation
1B
Strongrecommendation, Benefitsclearlyoutweighrisk RCTswithimportantlimitations Strongrecommendation,applies
moderate-qualityevidence andburdens,orviceversa (inconsistentresults,methodological tomostpatientsinmost
flaws,indirectanalyses,orimprecise circumstanceswithoutreservation
conclusions)orexceptionallystrong
evidencefromobservationalstudies
1C
Strongrecommendation, Benefitsclearlyoutweighrisk Observationalstudiesorcaseseries Strongrecommendationbut
low-qualityorvery andburdens,orviceversa subjecttochangewhenhigher
low-qualityevidence qualityevidencebecomesavailable
2A
Weakrecommendation, Benefitscloselybalancedwith RCTswithoutimportantlimitations Weakrecommendation,best
high-qualityevidence risksandburden oroverwhelmingevidencefrom actionmaydifferdependingon
observationalstudies thepatient,treatment
circumstances,orsocialvalues
2B
Weakrecommendation, Benefitscloselybalancedwith RCTswithimportantlimitations Weakrecommendation,best
moderate-qualityevidence risksandburden (inconsistentresults,methodological actionmaydifferdependingon
flaws,indirect,orimprecise)or thepatient,treatment
exceptionallystrongevidence circumstances,orsocialvalues
fromobservationalstudies
2C
Weakrecommendation, Uncertaintyintheestimatesof Observationalstudiesorcaseseries Veryweakrecommendation;
low-qualityorvery benefits,risks,andburden;benefits, alternativetreatmentsmay
low-qualityevidence risk,andburdenmaybe beequallyreasonableand
closelybalanced meritconsideration
The central coordinator assembled the different answers abdominalwalltissue lossand aggressiveresuscitation
derived from each round. Each version was then revised arepredictorsof thenecessityforopenabdomen in
andimprovedthroughiterativeevaluation.Thefinalversion traumapatients(Grade2B)
about which the agreement was reached resulted in the
comments and recommendations made in the present
guideline.StatementshavebeensummarizedinTable2. Decompressivelaparotomy isindicatedinabdominal
compartment syndromeifmedicaltreatmenthas
Indications failed afterrepeated and reliableIAP measurements
Traumapatients (Grade2B)
Persistent hypotension,acidosis(pH<7.2),
hypothermia (temperature<34°C)andcoagulopathy The inability to definitively control the source of
are strong predictorsof theneedforabbreviated contamination or the necessity to evaluate bowel
laparotomy andopenabdomenintraumapatients perfusion may be an indicator to leave the
(Grade2A) abdomen open in post-traumatic bowel injuries
(Grade 2B)
Riskfactorsforabdominalcompartment syndrome Severely injured patients with hemodynamic instability
suchasdamage control surgery,injuriesrequiring areathigherriskofACSforseveralreasons(i.e.,aggressive
packingandplannedreoperation,extreme visceralor resuscitation, ischemia-reperfusion injury, visceral or
retroperitonealswelling, obesity,elevatedbladder retroperitoneal swelling, recurrent bleeding, and intra-
pressurewhenabdominal closure isattempted, peritoneal packing) [9–12].
Coccolinietal.WorldJournalofEmergencySurgery (2018) 13:7 Page4of16
Table2Summaryofstatements
Statements
Indications
Traumapatients Persistenthypotension,acidosis(pH<7.2),hypothermia(temperature<34°C)andcoagulopathyarestrong
predictorsoftheneedforabbreviatedlaparotomyandopenabdomenintraumapatients(Grade2A)
Riskfactorsforabdominalcompartmentsyndromesuchasdamagecontrolsurgery,injuriesrequiringpacking
andplannedreoperation,extremevisceralorretroperitonealswelling,obesity,elevatedbladderpressurewhen
abdominalclosureisattempted,abdominalwalltissuelossandaggressiveresuscitationarepredictorsofthe
necessityforopenabdomenintraumapatients(Grade2B)
Decompressivelaparotomyisindicatedinabdominalcompartmentsyndromeifmedicaltreatmenthasfailed
afterrepeatedandreliableIAPmeasurements (Grade2B)
Theinabilitytodefinitivelycontrolthesourceofcontaminationorthenecessitytoevaluatethebowel
perfusionmaybeanindicatortoleavetheabdomenopeninpost-traumaticbowelinjuries(Grade2B)
Non-traumapatients Decompressivelaparotomyisindicatedinabdominalcompartmentsyndromeifmedicaltreatmenthasfailed
afterrepeatedandreliableIAPmeasurements(Grade2B)
➢Peritonitis Theopenabdomenisanoptionforemergencysurgerypatientswithsevereperitonitisandseveresepsis/septic
shockunderthefollowingcircumstances:abbreviatedlaparotomyduetotheseverephysiologicalderangement,
theneedforadeferredintestinalanastomosis,aplannedsecondlookforintestinalischemia,persistentsourceof
peritonitis(failureofsourcecontrol),orextensivevisceraloedemawiththeconcernfordevelopmentofabdominal
compartmentsyndrome(Grade2C).
➢Vascularemergencies Theopenabdomenshouldbeconsideredfollowingmanagementofhemorrhagicvascularcatastrophessuch
asrupturedabdominalaorticaneurysm(Grade1C)
Theopenabdomenshouldbeconsideredfollowingsurgicalmanagementofacutemesentericischemicinsults(Grade2C).
➢Pancreatitis Inpatientswithsevereacutepancreatitisunresponsivetostep-upconservativemanagementsurgicaldecompression
andopenabdomenopenareeffectiveintreatingabdominalcompartmentsyndrome(Grade2C)
Leavingtheabdomenopenaftersurgicalnecrosectomyforinfectedpancreaticnecrosisisnotrecommended
exceptinthosesituationswithhighriskfactorstodevelopabdominalcompartmentsyndrome(Grade1C)
Management
Traumaandnon-traumapatients TheroleofDamageControlResuscitationinOAmanagementisfundamentalandmayinfluenceoutcome(Grade2A)
ICUmanagement Amultidisciplinaryapproachisencouraged,especiallyduringthepatient’sICUadmission(Grade2A)
Intra-abdominalpressuremeasurementisessentialincriticallyillpatientsatriskforIAH/ACS(Grade1B)
Physiologicoptimizationisoneofthedeterminantsofearlyabdominalclosure(Grade2A)
Inotropesandvasopressorsadministrationshouldbetailoredaccordingtopatientconditionandperformed
surgicalinterventions(Grade1A)
Fluidbalanceshouldbecarefullyscrutinized(Grade2A)
Highattentiontobodytemperatureshouldbegiven,avoidinghypothermia(Grade2A)
Inpresenceofcoagulopathyorhighriskofbleedingthenegativepressureshouldbedownregulated
balancingthetherapeuticnecessityofnegativepressureandthehemorrhagerisk(Grade2B).
Techniquefortemporary Negativepressurewoundtherapywithcontinuousfascialtractionshouldbesuggestedasthepreferred
abdominalclosure techniquefortemporaryabdominalclosure(Grade2B).
Temporaryabdominalclosurewithoutnegativepressure(e.g.Bogotabag)canbeappliedinlowresource
settingsacceptingalowerdelayedfascialclosurerateandhigherintestinalfistularate(Grade2A).
NodefinitiverecommendationscanbegivenabouttemporaryabdominalclosurewithNPWTincombination
withfluidinstillationevenifitseemstoimproveresultsintraumapatients(Notgrades).
Re-explorationbefore Openabdomenre-explorationshouldbeconductednolaterthan24-48hoursaftertheindexandanysubsequent
definitiveclosure operation,withthedurationfromthepreviousoperationshorteningwithincreasingdegreesofpatient
non-improvementandhemodynamicinstability(Grade1C).
Theabdomenshouldbemaintainedopenifrequirementsforon-goingresuscitationand/orthesourceof
contaminationpersists,ifadeferredintestinalanastomosisisneeded,ifthereisthenecessityforaplanned
secondlookforischemicintestineandlastlyifthereareconcernsaboutabdominalcompartmentsyndrome
development(Grade2B).
Nutritionalsupport Openabdomenpatientsareinahyper-metaboliccondition;immediateandadequatenutritionalsupportis
mandatory(Grade1C).
Openabdomentechniquesresultinasignificantnitrogenlossthatmustbereplacedwithabalancednutrition
regimen(Grade1C).
Coccolinietal.WorldJournalofEmergencySurgery (2018) 13:7 Page5of16
Table2Summaryofstatements(Continued)
Statements
Earlyenteralnutritionshouldbestartedassoonaspossibleinpresenceofviableandfunctional
gastrointestinaltract(Grade1C).
Enteralnutritionshouldbedelayedinpatientswithanintestinaltractindiscontinuity(temporarilystapled
stumps),orinsituationsofahighoutputfistulawithnopossibilitytoobtainfeedingaccessdistaltothefistula
orwithsignsofintestinalobstruction(Grade2C)
Oralfeedingisnotcontraindicatedandshouldbeusedwherepossible(Grade2C).
Patientmobilization Todate,norecommendationscanbemadeaboutearlymobilizationofpatientswithopenabdomen(Notgraded).
Definitiveclosure
Traumaandnon-traumapatients Fasciaand/orabdomenshouldbedefinitivelyclosedassoonaspossible(Grade1C).
Openabdomendefinitive Earlyfascialand/orabdominaldefinitiveclosureshouldbethestrategyformanagementoftheopenabdomen
closure onceanyrequirementsforon-goingresuscitationhaveceased,thesourcecontrolhasbeendefinitively
reached,noconcernregardingintestinalviabilitypersist,nofurthersurgicalre-explorationisneededandthere
arenoconcernsforabdominalcompartmentsyndrome(Grade1B).
➢Non-mesh-mediated Primaryfasciaclosureistheidealsolutiontorestoretheabdominalclosure(2A).
techniques
Componentseparationisaneffectivetechnique;howeveritshouldnotbeusedforfascialtemporaryclosure.It
shouldbeconsideredonlyfordefinitiveclosure(Grade2C).
Plannedventralhernia(skingraftorskinclosureonly)remainsanoptionforthecomplicatedopenabdomen
(i.e.inthepresenceofentero-atmosphericfistulaorincaseswithaprotractedopenabdomendueto
underlyingdiseases)orinthosesettingswherenootheralternativesareviable(Grade2C)
➢Mesh-mediated Theuseofsyntheticmesh(polypropylene,polytetrafluoruroethylene(PTFE)andpolyesterproducts)asafascial
techniques bridgeshouldnotberecommendedindefinitiveclosureinterventionsafteropenabdomenandshouldbe
placedonlyinpatientswithoutotheralternatives(Grade1B).
Biologicmeshesarereliablefordefinitiveabdominalwallreconstructioninthepresenceofalargewalldefect,
bacterialcontamination,comorbiditiesanddifficultwoundhealing(Grade2B).
Non–cross-linkedbiologicmeshesseemtobepreferredinsublaypositionwhenthelineaalbacanbe
reconstructed.(Grade2B).
Cross-linkedbiologicmeshesinfascial-bridgeposition(nolineaalbaclosure)maybeassociatedwithless
ventralherniarecurrence(Grade2B).
NPWTcanbeusedincombinationwithbiologicmeshtofacilitategranulationandskinclosure(Grade2B).
Complicationsmanagement
Traumaandnon-traumapatients Preemptivemeasurestoprevententero-atmosphericfistulaandfrozenabdomenareimperative(i.e.early
abdominalwallclosure,bowelcoveragewithplasticsheets,omentumorskin,nodirectapplicationofsynthetic
prosthesisoverbowelloops,nodirectapplicationofNPWTonthevisceraanddeepburyingofintestinal
anastomosesunderbowelloops)(Grade1C).
Entero-atmosphericfistulamanagementshouldbetailoredaccordingtopatientconditions,fistulaoutputand
positionandanatomicalfeatures(Grade1C)
Inthepresenceofentero-atmosphericfistulathecaloricintakeandproteindemandsareincreased;the
nitrogenbalanceshouldbeevaluatedandcorrectedandproteinsupplemented(Grade1C).
Nutritionshouldbereviewedandoptimizeduponrecognitionofentero-atmosphericfistula(Grade1C)
Entero-atmosphericfistulaeffluentisolationisessentialforproperwoundhealing.Separatingthewoundinto
differentcompartmentstofacilitatethecollectionoffistulaoutputisofparamountimportance(Grade2A).
Inthepresenceofentero-atmosphericfistulainopenabdomen,negativepressurewoundtherapymakes
effluentisolationfeasibleandwoundhealingachievable(Grade2A).
Definitivemanagementofentero-atmosphericfistulashouldbedelayedtoafterthepatienthasrecovered
andthewoundcompletelyhealed(Grade1C).
In fact, the post-traumatic physiological derangements a higher need for OA, are acidosis with pH≤7.2, lactate
and the consequent DCM expose patients at risk for levels ≥5 mmol/L, base deficit (BD)≥−6 in patients
increased intra-abdominal pressure. Risk factors associ- older than 55 years or ≥−15 in patients younger than
ated with ACS requiring an OA after trauma, indicating 55 years, core temperature≤34 °C, systolic pressure ≤
Coccolinietal.WorldJournalofEmergencySurgery (2018) 13:7 Page6of16
70 mmHg, estimated blood loss ≥4 L during the oper- complete fascia closure should notbeattempted because
ation and/or transfusion requirement ≥10 U of packed of the high risk of IAH/ACS [22]. In all these situations,
red blood cells in the pre- or pre- and intraoperative the abdomen may be left open. However, there is no
settings, and severe coagulation derangements (INR/PT definitive data regarding the use of the OA in the face of
>1.5 times normal, with or without a concomitant PTT severeperitonitisandtherefore,cautionshouldbeexercised
>1.5timesnormal)[10,13–17]. whenusingOAinthesecircumstances.
OtherrecognizedriskfactorsforIAHshouldbekeptinto
consideration:obesity,pancreatitis,hepaticfailure/cirrhosis, Vascularemergencies
positive end-expiratory pressure >10 cm H 0, respiratory
2
failure,acuterespiratorydistresssyndrome[18]. Theopen abdomenshouldbe considered following
All non-surgical treatment should be implemented to managementofhemorrhagicvascularcatastrophessuch
prevent or reduce IAH before proceeding to surgical asrupturedabdominalaorticaneurysm(Grade1C)
decompression (i.e., nasogastric and colonic decompres-
sion, prokinetic agents, adequate patient positioning and
Theopen abdomenshouldbe considered following
avoidance of constrictive dressings, eventual escharotomy
surgicalmanagementofacute mesentericischemic
and percutaneous decompression, adequate mechanical
insults(Grade2C).
ventilation, analgesia, sedation and neuromuscular block-
ade, balanced fluid resuscitation, eventual diuretic therapy
Up to 20% of patients experiencing a ruptured AAA
andcontinuous veno-venoushemofiltration/ultrafiltration, repair develop ACS. Mortality is high (30–50%) and is
andvasoactivemedications).
almost doubled in presence of ACS[23, 24]. OA reduces
Moreover, failure to definitively control the source of
the ACS incidence [25]. No definitive indications to
infectionattheindexoperationorthenecessitytocheck
OA exist; the relative indications to OA are massive
bowelperfusionduringDCMorabdominalwalltissueloss
resuscitation, deranged physiology, fascial tension at
represents indications to OA management in traumatic
closure, use of balloon occlusion of the aorta, and
abdominalinjuries[3,11]. blood loss >5 L [25–27].
AdvancedageisnotacontraindicationtoDCM[20].
Non-traumapatients
ACS can occur even after endovascular repair (EVAR),
and the majorrisk factor appears tobe massiveresuscita-
Decompressivelaparotomy isindicatedinabdominal
tion [23]. Risk of graft infection due to OA management
compartmentsyndromeifmedicaltreatmenthasfailed
hasbeendemonstratedtobelow[28].
afterrepeatedandreliableIAPmeasurements(Grade2B)
TheuseofOAafterperfusionrestorationinapatientwith
acutemesentericischemiaasinocclusiveproximalordistal
superior mesenteric artery emboli, watershed necrosis after
Peritonitis
AAA repairs (open or endovascular), and non-occlusive
mesenteric ischemia (e.g., post-arrest or resuscitation from
Theopen abdomenisanoption foremergency surgery
shock/arrest) should be considered in case of deranged
patientswith severe peritonitis and severe sepsis/septic
physiology and bowel edema and necessity to perform a
shockunderthefollowing circumstances:abbreviated second look or delayed anastomosis [29–31].
laparotomy duetosevere physiologicalderangement,
Mesenteric venous thrombosis requiring laparotomy does
theneedforadeferredintestinalanastomosis,aplanned
not routinely mandate OA as often as mesenteric ischemia
secondlookforintestinalischemia,persistentsourceof
[32];however,theriskofIAH/ACSimposesattentiontoIAP.
peritonitis(failureofsourcecontrol),orextensivevisceral
oedemawiththeconcernfordevelopmentofabdominal
Pancreatitis
compartmentsyndrome(Grade2C).
Inpatientswithsevereacutepancreatitisunresponsiveto
Some patients suffering from severe peritonitis may
step-upconservativemanagementsurgicaldecompression
experience a disease progression to septic shock with no
and open abdomen open are effective in treating
room for definitive surgical procedures [3, 19]. In these
abdominal compartment syndrome (Grade 2C)
cases, surgical operation should be abbreviated even in
advanced age [20]. In hypotensive patients requiring
high-dose vasopressors or inotropes infusion intestinal Leaving the abdomenopenafter surgicalnecrosectomy
continuity restoration may be deferred [21]. In incom- for infected pancreaticnecrosisisnotrecommended
plete source control or in the presence of visceral edema exceptinthosesituationswithhighriskfactorsto
and/or decreased abdominal wall compliance primary developabdominalcompartmentsyndrome(Grade1C)
Coccolinietal.WorldJournalofEmergencySurgery (2018) 13:7 Page7of16
MOF is the factor mainly associated with mortality in physiologically deranged patients. It passes through some
acute pancreatitis (AP) especially when infected necrosis cornerstone actions as volume resuscitation, reversal of
[33–37]ispresent.Asinmanyotherconditions,secondary coagulopathy, correction of acidosis, and all the other
IAH/ACSmayaggravateMOFinaviciouscircle[38].IAH/ pertinentresuscitativemeasuresaimingtorestorethenor-
ACSshouldbepreventedandtreatedasfarasitispossible malphysiology.Thefluidstatus,nutrition,andrespiratory
with non-surgical measures. Surgical decompression is the mechanics should also be kept into consideration in
last but effective tool; it should not be delayed in case of managing OA. In fact the possibility of recurrent ACS
ACS[4,39].Pancreaticnecrosismaybecomeinfectedafter with its related high mortality is to be posed into
the first week [40]. The presence of organ failure, early consideration [42–44].
bacteremia, and the extent of pancreatic necrosis are fac- Abdominalpressureshouldbemeasuredinallpatients
tors associated with infection [40]. Surgical necrosectomy at risk of developing IAH/ACS; in fact, it has been
should be considered when more conservative manage- demonstrated that clinical examination is inaccurate in
mentaspercutaneousdrainagefails[41].Incaseofnecro- diagnosing IAH/ACS [45]. As a general principle, it
sectomy, OA may be considered, but it is not mandatory. should be measured every 12 h and every 4–6 h once
ItshouldbeconsideredonlyifrisksforIAH/ACSexist. ACS/IAHhasbeen detected oriforganfailure happens.
Physiology optimization is necessary to allow early
Management abdominal closure. In fact, prolonged OA may delay
Traumaandnon-traumapatients extubation,increasetheriskforEAFandfrozenabdomen,
andincreasecomplications[46].
ICUmanagement Multidisciplinary collaboration with all teams managing
thepatientisrequiredforoptimalcareofOApatients.
TheroleofDamageControlResuscitation inOA The real extent of heat loss in OA and a temporary
managementisfundamentaland may influence abdominal dressingcannotbequantified.Itiswellknown
outcome(Grade2A) thatpatientphysiologyisimpairedbyhypothermiaandits
related hypo-perfusion effects such as heart function
depression, reduced oxygen delivery, coagulation cascade
Amultidisciplinaryapproachisencouraged,especially alteration,andacidosis.
during thepatient’sICUadmission(Grade2A) In trauma patients, the “lethal triad” should be rapidly
interrupted[47–53].
It is well known that mortality increases in trauma
Intra-abdominal pressuremeasurementisessentialin
patientswithsignificantcore-bodytemperaturedrop[54].
critically illpatientsatriskforIAH/ACS(Grade1B)
Commercial NPWT systems significantly reduce heat
loss but the non-commercial ones still maintain a reduced
Physiologicoptimization isoneofthedeterminantsof heatisolationcapacity.Forthisreason,theheatlosscontrol
early abdominal closure (Grade2A) is of paramount importance especially in those settings
wherenon-commercialsystemsareutilized.
During ICU stay, it is important to ensure analgesia
Inotropesandvasopressorsadministrationshouldbe
overhypnosisandconsidermultimodalanalgesiatoreduce
tailoredtopatient’scondition andperformed surgical
opioidinfusion,tryingtokeepthepatient“awake”butwell
interventions(Grade1A)
adapted to mechanical ventilation. Moreover, protective
mechanicalventilationstrategiesshouldbeadopted.
Fluidbalanceshouldbecarefullyscrutinized(Grade2A) Fluid balance is important as well in OA management
and should be carefully scrutinized to avoid over- or
under-resuscitation.Carefulmonitoringandmaintenance
Highattention tobodytemperature shouldbegiven,
of adequate urinary output could help in evaluating ad-
avoidinghypothermia(Grade2A)
equacy of resuscitation effects. Continuous monitoring
of cardiac output (CO), targeting at low/normal values,
Inpresence ofcoagulopathyorhighriskof bleeding the is essential to avoid fluid overload and vasopressor
negativepressure shouldbedown regulatedbalancing abuse. If increasing vasopressors induce low CO, and
thetherapeuticnecessityofnegativepressure andthe fluid responsiveness is transient, consider to target
hemorrhagerisk(Grade2B). treatments (included inotropes) to the best compromise
betweenMAP,CO,andfluidamount.High-ratemainten-
The initial management is fundamental. DCR is part ance fluid infusions should be avoided. As a counterpart,
of DCM utilized in treating severely injured and severely whenever possible, frequent, small-volume fluid boluses
Coccolinietal.WorldJournalofEmergencySurgery (2018) 13:7 Page8of16
should be preferred. Hypertonic crystalloid and colloid- closure and mortality rate. The results favored the non-
basedresuscitationseemtodecreasetheriskofiatrogenic, negativepressuresystemsintraumaandnegativepressure
induce resuscitation, and increase IAP [55]. Daily patient temporaryclosureinsevereperitonitispatients[46].Also,
weightsmayhelpinevaluatingfluidretention. recentcontradictorydatafromasingle-centerRCTshowed
Inotrope infusion should be balanced keeping in mind that NPWTand fluid instillation seemed to improve out-
thepatients’condition,theperformedsurgicalprocedures, comes in trauma patients in terms of early and primary
and the necessity to prevent further complications due to closure[64].
theiroveruse[56,57]. Another important issue in OA management is the
Volumetric-based monitoring technologies can be very necessity to balance the antimicrobial therapy in relation
useful in hemodynamic evaluation during DCR phases in to positive culturesofintra-abdominalfluids.Twooptions
critically ill patients. In fact, the elevated intra-abdominal are generally followed without any strong literature
andintra-thoracicpressurecanimpairtherealvalueofthe evidence: treating all the cultured organisms (with high
measurements obtained with traditional pressure-based proportions of staphylococci, candida, and MDR Gram-
parameters such as pulmonary artery occlusion pressure negative bacilli including Pseudomonas) or a “wait and
and central venous pressure [58–60]. The alteration of see” strategy. WSES suggests to follow guidelines for
these parameters can potentially lead to wrong decisions intra-abdominal infections [65].
as regards the correct fluid status and as a consequence
the necessary amount of fluid to be administered. This
balance is essential also to optimize the surgical success Re-exploration beforedefinitive closure
of primary fascial closure [12, 61, 62].
Openabdomenre-explorationshouldbeconductedno
laterthan24-48hoursaftertheindexandanysubsequent
Techniquefortemporaryabdominalclosure
operation,withthedurationfromthepreviousoperation
shortening with increasing degrees of patient non--
Negativepressurewound therapywith continuous improvement and hemodynamic instability (Grade
fascialtractionshouldbe suggested asthepreferred 1C).
techniquefortemporaryabdominalclosure(Grade2B).
The abdomenshouldbemaintainedopen if
Temporaryabdominalclosurewithoutnegativepressure requirementsforon-goingresuscitationand/orthe
(e.g.Bogotabag)canbeappliedinlowresourcesettings sourceofcontaminationpersists,ifadeferredintestinal
acceptingalowerdelayedfascialclosurerateandhigher anastomosisisneeded,ifthereisthenecessityfora
intestinalfistularate(Grade2A). plannedsecondlookforischemicintestineandlastlyif
thereareconcernsaboutabdominalcompartment
No definitive recommendationscanbe givenabout syndromedevelopment(Grade2B).
temporaryabdominalclosure with NPWTin
combination with fluidinstillation evenif it seemsto Indications to re-explore an OA may vary between
improve resultsintraumapatients(Notgraded). traumaandnon-traumapatients.Ingeneral,thepatient’s
non-improvement possibly is due to an intra-abdominal
Several strategies to maintain the OA have been de- reason. No definitive data regarding the timing of re-
scribed.Theyresultindifferentdelayedfascialclosurerate operation in OA patients exist [6, 66]. It is generally
andEAFrisk.Ingeneral,negativepressureassociatedtoa recommended that OA patients should be re-explored
dynamic component (mesh-mediated fascial traction or 24–72 h after the initial or any subsequent surgical
dynamicsutures)allowstoreach the best resultsin terms intervention [2, 67, 68]. Some data regarding trauma
ofdelayedfascialclosure,butdynamicsuturesresultmore patients showed that the time of re-exploration reduces
often in fistula [3]. Negative pressure without a dynamic the primary fascial closure rate of 1.1% for each hour
component (Barker’s VAC or commercial products) after the first 24 h after the index operation [69]. More-
results in a moderate delayed fascial closure rate and a over,increasedcomplicationratewasobservedinpatients
fistula rate similar to mesh closure without negative havingthefirstre-operationafter48h[3,69].
pressure [3]. In non-trauma patients, the indication to re-explore
Recent data from the International Register of Open theabdominalcavityarelessdefiniteandusually are due
Abdomen (IROA study) showed that different techniques to the necessity to continue DCM, to the impossibility
ofOAresultedindifferentresultsaccordingtothetreated to definitively control the source of infection or to the
disease [63] (trauma and severe peritonitis) and if treated necessitytore-assesthebowelvascularizationorlastly,to
with or without negative pressure in terms of abdominal concernsregardingthepossibilityofACS[2,3,20,70].
Coccolinietal.WorldJournalofEmergencySurgery (2018) 13:7 Page9of16
Even though there is some evidence that OA may be Patientmobilization
justified in severely injured or physiologically deranged
patientswiththeaimtomanipulatethesystemicimmune No recommendationscanbemade about early
response and ameliorate the bio mediator burden, no mobilizationofpatientswithopen abdomen(Not
definitive statement can be made [3, 71–75]. graded).
Nutritionalsupport No definite evidence exists regarding the optimal
timing for mobilization of patients with OA [84]. Pro-
Open abdomenpatientsareinahyper-metabolic longed bed rest is associated with a significant increase
condition;immediateandadequatenutritionalsupport in morbidity. Mobilization occurring within the first
ismandatory(Grade1C). 2-5daysofICU admission is defined “early” [85] anditis
associatedwithpositiveeffectsonoutcomes[86–90].
OA patients with NPWT may be “early” mobilized
Open abdomentechniquesresultina significant
by active or passive transfer thanks to the provisional
nitrogenlossthat mustbe replaced with abalanced
abdominalwallfunctionsuppliedbyNPWTsystems[3].
nutrition regimen (Grade1C).
Earlyenteralnutritionshouldbe started assoon as
Definitiveclosure
possibleinthepresenceof viable andfunctional Openabdomendefinitiveclosure
gastrointestinaltract(Grade1C).
Fasciaand/orabdomen shouldbedefinitively closed
Enteralnutrition shouldbe delayed inpatientswith
assoon aspossible(Grade1C).
anintestinal tractindiscontinuity (temporarilyclosed
loops),or insituationsofahigh output fistulawith no
possibilitytoobtain feedingaccessdistaltothefistula
Earlyfascialand/orabdominaldefinitiveclosure
orwith signsof intestinalobstruction (Grade2C)
shouldbe the strategyformanagementoftheopen
abdomen once any requirements for on-going
resuscitation have ceased, the source control has
Oralfeeding isnotcontraindicated and shouldbeused
been definitively reached, no concern regarding
wherepossible(Grade2C).
intestinal viability persist, no further surgical re-ex-
ploration is needed and there are no concerns for
Malnutrition is a risk factor for poor outcomes [76].
abdominal compartment syndrome (Grade 1B).
Critically ill patients with OA are in a hyper-catabolic
state with an estimated nitrogen loss of almost 2 g/L of
Thepriorityinordertoreducemortality,complications,
abdominal fluid output. Abdominal fluid evacuation is
and length of stay linked to the OA should be the early
to be measured in order to adjust nutritional integra-
definitive abdominal closure [10, 91, 92]. Major factors
tions [77].In case ofEAF,nitrogenloss greatly increases.
influencing early definitive closure are postoperative ICU
Parenteralnutrition should be started as soonas possible.
management and the TAC technique [93]. Early fascial
OncetheresuscitationisalmostcompleteandtheGItract
closureiscommonlydefinedasoccurringwithin4–7days
isviable,enteralnutrition(EN)shouldbestarted.Relative
from the index operation [21]. In contrast to trauma
contraindication to EN is a viable bowel shorter than
patients, those affected by abdominal sepsis usually
75cm[78].
experience a lower rate of early fascial closure [94] even
Polymeric formula supplying a daily intake of 20- to
though continuous fascial traction seems to increase
30-kcal/kg non-protein calories with 1.5- to 2.5-g/kg
this rate [95]. Fascial closure should be attempted as
proteins is usually sufficient to maintain a positive
soon as the source of infection is controlled [96].
nitrogen balance.
EN starting within the first 24–48 h improves wound
healing and fascial closure rate, decreases catabolism,
reduces pneumonia and fistula rate, preserves GI tract Solutionstodefinitivelycloseanopenabdomen
integrity, and finally reduces complications, length of In case of prolonged OA, fascia retraction and large ab-
hospital stay, and costs [79–81]. Compared to prolonged dominal wall defects requiring complex abdominal wall
total parenteral nutrition, early EN decreases septic reconstruction may occur. In contaminated fields, the
complications especially in abdominal trauma and trau- complication risk in abdominal wall definitive closure is
maticbrain injuries[3,79,82,83]. increased[92,97–99].
Coccolinietal.WorldJournalofEmergencySurgery (2018) 13:7 Page10of16
Techniques used to definitively close the abdomen are defect,bacterialcontamination, comorbiditiesand
principallydividedinto non-meshandmeshmediated. difficultwoundhealing(Grade2B).
Non-mesh-mediatedclosure techniques Non–cross-linkedbiologicmeshesseemtobe preferred
insublaypositionwhenthelineaalbacanbe
Primaryfasciaclosure istheidealsolutiontorestore reconstructed.(Grade2B).
the abdominalclosure (2A).
Cross-linkedbiologicmeshesinfascial-bridge position
Component separation isaneffectivetechnique; (nolineaalbaclosure)maybeassociatedwithlessventral
however it shouldnotbeused for fascialtemporary herniarecurrence(Grade2B).
closure.It shouldbeconsidered onlyfordefinitive
closure(Grade2C).
NPWTcanbeused incombination with biologicmesh
tofacilitategranulationand skinclosure (Grade2B).
Plannedventralhernia(skin graftor skinclosure only)
remainsanoptionforthecomplicatedopenabdomen
Several data exist regarding the abdominal wall
(i.e. inthepresenceofentero-atmosphericfistulaor in
closure after OA [104, 105]. Non-absorbable synthetic
caseswith aprotractedopenabdomen duetounder-
materials (i.e., polypropylene mesh) in a bridging pos-
lyingdiseases)or inthosesettingswherenootheralter-
ition (i.e., no linea alba closure), where no native tissue
nativesare viable(Grade2C)
protect viscera, may induce several local side effects
(adhesions, erosions, and fistula formation) [106–111].
Abdominal component separation should be consid-
Synthetic meshes in contaminated fields are not rec-
ered an elective procedure for ventral hernia repair
ommended by guidelines in emergency abdominal wall
[100]. In fact, it should not be used during the OA man-
reconstruction [112].
agement but reserved to the definitive closure interven-
Biological prostheses (BP) were designed to perform as
tions. At a delayed time point, very good results
permanent surgical prosthesis in abdominal wall repair,
reaching up to 75% of fascial closure rate have been re-
minimizingmesh-relatedcomplications.Non-cross-linked
ported [101]. The separation of components can be
biologicmeshiseasilyintegrated,withreducedfibroticre-
approached anteriorly or posteriorly [102, 103].
actionandlesserinfectionandremovalrate[113].
Planned ventral hernia represents a valid alternative to
BP can be used as a bridge for large abdominal wall de-
cover abdominal viscera and to prevent EAF. In fact, in fects [114–127]; however, the long-term outcome of a
cases of persistent contamination, several comorbidities
bridgingnon-cross-linkedBPislaxityoftheabdominalwall
or in severely ill patients, with or without sufficient skin
andahighrateofrecurrentventralhernia[113].Asacon-
tocover the abdominalwall defect,delayingthe eventual
sequence, non-cross-linked BP should be used in a sublay
synthetic prosthetic reconstruction may be a safer op-
position(i.e.,withlineaalbaclosure)andcross-linkedones
tion. The decision either to close the skin or to perform shouldbepreferredwhenthefascialbridgeisneeded[128–
vascularized flaps, pedicled flaps in small-/mid-sized de-
130]. BP could also tolerate adjunctive NPWT to facilitate
fects, or free flaps such as tensor fasciae latae for exten- woundhealing,granulation,andskinclosure[131–133].
sive thoraco-abdominal defects is usually taken,
considering the wound conditions, the dimension of the
Complicationmanagement
skindefect,andthe center facilities[13].
Preemptivemeasurestoprevententero-atmospheric
Mesh-mediated closuretechniques
fistulaand frozen abdomen areimperative(i.e. early
abdominal wall closure, bowel coverage with plastic
Theuseof syntheticmesh(polypropylene,
sheets, omentum or skin, no direct application of
polytetrafluoruroethylene (PTFE) and polyester
synthetic prosthesis over bowel loops, no direct
products)asafascialbridge shouldnotbe
application of NPWT on the viscera and deep
recommended indefinitive closureinterventionsafter
burying of intestinal anastomoses under bowel
open abdomenand shouldbe placed only inpatients
loops) (Grade 1C).
withoutotheralternatives(Grade1B).
Entero-atmosphericfistulamanagement shouldbe
Biologicmeshesarereliablefordefinitive abdominal tailored according topatientcondition,fistulaoutput
wallreconstruction inthepresence ofalarge wall and position and anatomical features (Grade1C).