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T. Cornette and F. Berrevoet
Fig. 25.2 Mesh-mediated fascial traction with negative pressure therapy
halves together with a continuous non-absorbable monolament 2/0 suture [40].
After applying traction ventilatory pressures should be checked by the anesthesiologist to exclude signicant rise in intra-abdominal pressure. On top of the mesh a
layer of extra foam is positioned to cover the mesh, and the procedure is then nalized by draping over the sponge, connecting the suction cap and applying negative
pressure (−125mmHg) (Fig.25.3).
25 Open Abdomen as an Effective Therapy for Abdominal Sepsis, Bedside Assistance…
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Fig. 25.3 Step by step application of mesh-mediated traction and intra-abdominal negative pressure therapy
427
Patients should return to the operating room every 3–4 days to change the NPWT
dressing and further increase the tension on the abdominal wall, by trimming the
mesh and re-suturing it at the midline. Ideally, complete fascial closure will be
achieved after 7–14 days. At the time of complete fascial closure, the subcutaneous
tissue might receive further NPWT for several days to decrease wound morbidity [34].
Results andComplications
At the ICU, hypothermia and uid loss are common and need to be addressed all the
time. Heat loss and evaporation occur due to the large abdominal defect. When the
core temperature drops it causes coagulopathy and bleeding problems, which impact
metabolic acidosis, thus this lethal triad must be corrected.
In 2014 worldwide mortality rates in septic patients were as high as 36.5% [41].
The Closed or Open after Source Control Laparotomy for Severe Complicated
Intra-Abdominal Sepsis (COOL trial) is currently including patients in a RCT and
could be a benchmark for assessing its benets [42]. Whenever OA is used for a
septic abdomen, early fascial closure should be obtained as soon as the damage or
source control has been performed according to the guidelines of both the World
Society of Emergency Surgery and the guidelines of the European Hernia Society
early fascial closure, because it results in lower complications ratios and mortality
[9, 23].
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A small retrospective study of 25 patients reported a signicantly lower mortality
incidence after the use of open abdomen management in septic patients (30–35%
mortality rate found in the literature to only 4%) [43]. However, another recent
study by Prete etal., found no clear difference and reported a mortality rate of 32%
in OA patients, in line with the non-OA mortality for sepsis [44]. The international
registry of open abdomen reported a lower mortality of 20% during OA treatment,
but mortality after closure was not included. The Apache II score was the only predictor of in-hospital mortality in their analysis [45].
The reported morbidity rate of surviving patients in these two studies is similar:
58.3% by Inukai etal. and 58.8% by Prete etal. [43, 44]. The study by Inukai etal.
reported surgical site infections (SSI) as the main complication (24%). Fistulae
were less observed when early fascial closure could be obtained and risk factors for
development of complications were age over 70 years old, diabetes mellitus, OA
duration more than 3 days, and initial operative time more than 60min [43].
T. Cornette and F. Berrevoet
Enteroatmospheric Fistula
This is the most feared surgical complication. It can be caused by anastomotic leakage or serosal damage during previous surgery. The bowel itself is more fragile
during OA, due to evaporation and accompanying dried out serosa. Attempts to seal
the stula are usually unsuccessful, and the common approach is to conduct the
contents of the stula to the exterior. Recent literature suggests two new methods to
drain the stula efciently [46, 47]. A Foley catheter and a special donut (covered
vacuum sponge) can be introduced to exclude the stula site from the rest of the
abdomen under NPWT. Another possibility is the off-label use of Flexi-Seal
(Convatec, Reading, UK) to divert the stula to outside the patient.
The data of the international register of open abdomen show for sepsis, trauma,
and IAH/ ACS similar rates of denitive fascial closure rates and stula formation
[45]. In a study by Kritayakirana etal. the mortality rate in abdominal sepsis patients
using OA was practically equal to IAH, respectively (35% and 31%), whereas in
trauma patients it was lower (11%) [48].
Optimizing theOutcome After Open Abdomen Management
As fascial closure should be obtained as quickly as possible to improve outcomes,
several options are recently suggested to increase the primary fascial closure rate.
Specically in abdominal sepsis, severe necrotizing pancreatitis or stiff abdominal
wall due to critical illness and generalized edema, the use of NPWT + MMFT might
still not be enough to achieve primary fascial closure.
25 Open Abdomen as an Effective Therapy for Abdominal Sepsis, Bedside Assistance…
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429
Botulinum Toxin A
Closing complex and open abdomens when fascial retraction has already occurred
is still very challenging. Not all patients can be primarily closed without a mesh
bridging the defect. Botulinum toxin A (BTA) can be injected in all three muscles
of the abdominal wall (external oblique, internal oblique, and transversus abdominis) using ultrasound guidance. BTA acts as a long-term muscle relaxant, allowing
better approximation of the fascia. Doses of 200–300IU per patient, dispersed into
three points on each side of the abdominal wall, or 35–50 IU per injection site
(±11–17IU per muscle layer) seem safe and well-tolerated [49–51]. The optimal
effect is late, 2–3 weeks after injection, yet in a cohort of 18 patients with OA, 89%
underwent primary fascial closure if BTA was administered within 24h before surgery [52]. Nevertheless conicting results have been announced, and the debate
goes on [53, 54]
Fasciotens™
This vertical traction device (Fasciotens, Essen, Germany) might show potential
benet in early closure of the open abdomen [55]. The idea is counteracting the
natural muscle traction and attenuating fascial retraction, while simultaneously
allowing pressure release with the open abdomen. The current devices can only
accommodate one or the other at the same time. The technique consists of sewing a
double layered mesh to each fascial margin when there was a midline or transverse
laparotomy. The mesh is then connected through surgical sutures to a common suspension with adjustable traction force. Such force is implemented in a routine of 5h
high tension interspersed with 1h of tension release. Fasciotens™ must be repositioned every time to its indicated original place, namely the pubis bone and sternum,
avoiding soft tissue pressure. It is crucial to monitor the patient continuously for
pressure wounds caused by the device, as the involved pulling forces are high. This
device is primarily being indicated in patients under mechanical ventilation in the
intensive care unit [56].
Available evidence suggests reduction in fascia-to-fascia distance.
Conict of Interest All authors declare that they have no conict of interest.
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T. Cornette and F. Berrevoet
Chapter 26
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Acute Mesenteric Ischaemia: Imaging
andIntervention
LucyRoseHowroyd, BenHawthorn, NiravPatel, andLakshmiRatnam
Abbreviations
AF Atrial brillation
AMI Acute mesenteric ischaemia
CMI Chronic mesenteric ischaemia
CT Computed tomography
CTA Computed tomography angiography
DVT Deep vein thrombus
FMD Fibromuscular dysplasia
IMA Inferior mesenteric artery
MAE Mesenteric arterial embolism
MAT Mesenteric arterial thrombus
MRA Magnetic resonance angiography
MRI Magnetic resonance imaging
MVT Mesenteric venous thrombus
NOMI Non-occlusive mesenteric ischaemia
PE Pulmonary embolus
ROMS Retrograde open mesenteric stenting
SMA Superior mesenteric artery
L. R. Howroyd · B. Hawthorn · N. Patel · L. Ratnam (*)
Department of Radiology, St George’s University Hospitals NHS Foundation Trust,
London, UK
e-mail: rose.howroyd@nhs.net; b.hawthorn@nhs.net; nirav.patel@stgeorges.nhs.uk;
lakshmi.ratnam@stgeorges.nhs.uk
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_26
433© The Author(s), under exclusive license to Springer Nature
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L. R. Howroyd et al.
Introduction
Acute Mesenteric Ischaemia (AMI) is a clinical emergency in which there is a sudden and signicant reduction of blood ow to the bowel, leading to ischaemic injury,
risking infarction and intestinal necrosis. Irrespective of the cause of the reduced
intestinal blood ow, without adequate arterial blood supply the bowel will infarct,
with potentially catastrophic consequences, leading to bowel perforation, septic
shock and ultimately death.
Whilst AMI is not common, accounting for approximately 0.09–0.2% of acute
admissions to emergency departments [1], and around 1% of patients with an acute
abdomen [2], it is a highly morbid condition. The prevalence of AMI increases with
age, signicant co-morbidities and a poorer baseline performance status [3–5] AMI
has been cited as the cause of an acute abdomen in up to 10% of patients over 70 [2].
Despite improvement in diagnosis and treatment options in recent decades, the
reported mortality rates can reach up to 50% [4], and it is ranked as the fth most
common cause of death globally in patients presenting with emergency surgical
conditions [6]. Mortality approaches 100% if treatment is delayed by more than
24h [2, 7, 8].
Aetiologies ofIschaemia
In the obstructive cases, there is a blockage in either the artery supplying or vein
draining the affected segment of bowel. Examples include mesenteric arterial embolism (MAE), mesenteric arterial thrombus (MAT) or mesenteric venous thrombosis
(MVT). In the absence of a physical occlusion, it arises instead because of prolonged and severe mesenteric arterial spasm, or as a consequence of diminished
regional blood ow. This entity is called non-occlusive mesenteric ischaemia
(NOMI) and whilst the pathophysiology is poorly understood, it is a well- recognised
complication of severe systemic illness.
Normal Arterial andVenous Anatomy
The coeliac artery arises anteriorly from the abdominal aorta just below the diaphragm at the T12 level. It supplies the stomach and duodenum to the level of the
ampulla of Vater in the second segment. It also supplies the liver, gallbladder, spleen,
pancreas, greater and lesser omentum. Although not directly involved with the
intestine, it can supply some ow by means or arcades and collateral vessels
(Fig.26.1a).
26 Acute Mesenteric Ischaemia: Imaging andIntervention
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435
Fig. 26.1 Mesenteric
arterial anatomy. (a)
Selective digital
subtraction angiogram of
celiac axis. 1. Common
hepatic artery. 2.
Gastroduodenal artery. 3.
Right hepatic artery. 4.
Left hepatic artery. 5.
Splenic artery. 6. Left
gastric artery. (b) Selective
digital subtraction
angiogram of superior
mesenteric artery. 1.
Proximal superior
mesenteric artery. 2.
Middle colic artery. 3.
Right colic artery. 4.
Ileocolic artery. 5. Ileal
branches. 6. Jejunal
branches. (c) Selective
digital subtraction
angiogram of inferior
mesenteric artery. 1.
Proximal inferior
mesenteric artery. 2. Left
colic artery. 3. Sigmoid
arteries. 4. Superior rectal
artery. 5. Marginal artery
of Drummond
a
b
c
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