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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1611_Библиотеки_им_академика_М_И_Перельмана.pdf
73
© Springer International Publishing AG, part of Springer Nature 2018
F. Coccolini et al. (eds.), Open Abdomen, Hot Topics in Acute Care Surgery
and Trauma, https://doi.org/10.1007/978-3-319-48072-5_5
H. Bahouth, MD, BSc
Trauma and Emergency Surgery, Division of General Surgery, Rambam Health Care Campus,
Haifa, Israel
Y. Kluger, MD, FACS (
*)
Division of General Surgery, Pancreatic Surgery Center, Rambam Health Care Campus,
Haifa, Israel
e-mail: y_kluger@rambam.health.gov.il
5
Indications for Open Abdomen
in the Non-trauma Setting
Hany Bahouth and Yoram Kluger
5.1 Introduction
The principles of damage control laparotomy (DCL) in the trauma setting are well
described. Although the indications for this technique vary among care providers, it
is agreed that that this approach revolutionized the management of critically injured
patients [1, 2]. Overall, about 10–15% of all laparotomies for trauma are managed
with damage control techniques [3].
It has been suggested that DCL principles could apply to acute surgical non-
trauma conditions. In non-trauma setting, the causes for the physiologic derange-
ments observed are diverse and different from that of the injured. Despite this
deference, the basic pathophysiology that results in acidosis, coagulopathy, and
hypothermia remains the same.
With better understanding of damage control principles, the open abdomen strat-
egy, first described almost 120 years ago by McCosh [4], became a common and
appreciated philosophy practiced enthusiastically by surgeons in non-trauma emer-
gency general surgery [5].
In spite of the adoption of the open abdomen technique in non-trauma emer-
gency surgery, the indications that define its appropriate application are poorly
agreed among surgeons [6–11]. This is due to the lack of well-constructed random-
ized studies exploring the concept in the non-trauma settings as well as deficiency
of common language and classification system of surgical emergencies that may
favor from open abdomen strategies. Additionally, diverse practice patterns
74
described in various published studies and the inclusions of heterogeneous patient
population contribute to the paucity of evidence-based data [6–8, 11]. Several chal-
lenging clinical and surgical circumstances may indeed benefit from the use of DCS
and the open abdomen philosophy in the non-trauma setting.
In their review, looking at the indications for open abdomen in non-trauma
surgery, Atema et al. [12] included 78 series with overall 4358 patients.
Secondary peritonitis was diagnosed in 3461 (79%). The most frequent single
indication for the open abdomen management was a planned relaparotomy
strategy.
There are no definitive physiological or anatomical criteria to aid surgeons to
properly consider and select damage control strategy in non-trauma surgical
patients. Nevertheless some of the indications and physiological-based criteria were
extrapolated from the trauma arena; temperature lower than 35°C, pH less than
7.20, or base deficit exceeding eight and laboratory or clinical evidence of coagu-
lopathy, need for vasopressors, and massive blood transfusions. These values repre-
sent patients failing to compensate for shock state.
Neto et al. [13] proposed three basic considerations for the application of the
open abdomen strategy:
(a) Anatomical (soft tissue loss, impending risk of abdominal compartment
syndrome)
(b) Physiological (pertain to a severe physiologic derangement)
(c) Logistical (necessity for serial surgical interventions)
Success rates of delayed fascial closure are lower in non-trauma patients com-
pared to trauma patients. Several studies identified peritonitis as an independent
predictor of failure of fascial closure [14–16].
Higher fascial closure rates were achieved at the first re-exploration and less
likely during the second or third take back [17].
Shorter period of open abdomen was also associated with higher fascial closure
rates [18–20]. Moreover, a preemptive open abdomen for intra-abdominal hyperten-
sion or for decompression of established ACS is associated with higher fascial clo-
sure rates [21]. The mortality rates of patients submitted for the open abdomen
exceed 30% and are dependent on the causative event leading to the selection of the
open abdomen strategy [22].
In this chapter, we will review the most common indications for the open abdo-
men technique in the non-trauma setting and their utility and efficacy.
5.1.1 Open Abdomen for Intraperitoneal Sepsis\Peritonitis
The role of the open abdomen in the management of severe secondary peritonitis is
controversial. Based on small retrospective studies in the 1980s and 1990s, enthusi-
astic adoption of the strategy for patients diagnosed with severe peritonitis was
recorded [23, 24].
H. Bahouth and Y. Kluger
75
Physiologic instability, temporary source control, and avoidance of abdominal
compartment syndrome were the cornerstone indications for damage control in the
septic abdomen. Most abdominal sepsis results from pathologies in the hepatobili-
ary tree, pancreatic necrosis/infection, or hollow viscus perforation/necrosis. The
main surgical focus in the septic abdomen should be therefore to obtain source
control by means of peritoneal lavage, debridement of infected/necrotic tissue, and
definitive or temporary measures to control anatomic integrity and to restore opti-
mal function [25].
In severe secondary peritonitis, a staged approach may be compulsory for three
different reasons or any of their combination [26].
First, the inability to control the source of contamination in a single operation;
second, if the surgeon feels the patient will not tolerate a definitive repair and/or
abdominal wall closure due to the severe physiological derangement [27]; and third,
the presence of extensive visceral edema that may increase the risk of ACS develop-
ment, if primary fascial closure is attempted [28].
Aggressive resuscitation needed in the septic patient in preparation for induction
of anesthesia has led to an increased incidence in abdominal compartment syn-
drome. The use of the open abdomen may therefore allow potential prevention of
this complication [29–32]. Two strategies in the management of these difficult
patients have been reported [33, 34]: relaparotomy on demand (when required by
the patient’s clinical condition) and planned relaparotomy, within 24–48 h after the
index operation. Subsequent studies failed to show any significant benefit of one of
these strategies over the other. In a prospective, open, nonrandomized trial, spon-
sored by the Surgical Infection Society, 239 patients with surgical abdominal infec-
tion were treated with either the open abdomen technique or laparotomy on demand.
No significant difference was observed in mortality between the two groups [35]. In
2007, Robledo and colleagues [36] randomized 40 patients with severe secondary
peritonitis to open abdomen group and a laparotomy on-demand group. The mortal-
ity differences did not reach statistical significance. The authors concluded that
closed management of the abdomen could be a more rational approach in the man-
agement of severe peritonitis.
Van Ruler et al. [37] in a randomized controlled trial looked at patients with
secondary peritonitis and compared the differences between on-demand versus
planned relaparotomy. They found no significant difference in mortality and mor-
bidity between the two groups. However, there was a significant reduction in the
number of procedures, shorter hospital stay, and decreased cost of health care in the
on-demand group. It is important to note that in this study, patients who underwent
abdominal packing or stapled off ends of bowel were excluded. It could be argued
that these are the main target patient group for DCL in the first instance.
However, recent experimental and clinical work has suggested that the open
abdomen technique with temporary abdominal wall closure using negative pressure
therapy (NPT) methods is associated with superior outcomes. Amin et al. [38], in a
prospective analysis of 20 patients treated with NPT following laparotomy for
severe peritonitis, reported 100% survival. The study concluded that NPT is safe,
but further research is needed.
5 Indications for Open Abdomen in the Non-trauma Setting
76
Horwood and colleagues [39], in a study of 27 patients who were treated with
open abdomen and NPT, reported significantly improved observed survival com-
pared with expected survival based on P-POSSUM (physiological and operative
severity score for the enumeration of mortality and morbidity) evaluation. The study
concluded that open abdomen approach with immediate NPT is effective in manag-
ing patients with severe peritonitis.
Kubiak and colleagues [40], in an experimental porcine model with intestinal
ischemia/reperfusion and peritoneal fecal contamination, showed that the open
abdomen combined with NPT reduced mortality and organ dysfunction compared
with animals treated with the traditional passive drainage.
Brandon et al. reported 338 primary laparotomies that were performed during the
1-year study period, of which 96 patients (28%) were managed with open abdomen
[41]. In-hospital mortality for the open abdomen patient population was 30%. The
most common preoperative indications in the index laparotomy leading to selection
of the open abdomen strategy were perforated viscus and/or the presence of extra
luminal gas on abdominal imaging (20%), mesenteric ischemia (17%), peritonitis
and/or septic abdomen (16%), and gastrointestinal hemorrhage (12%). Damage
control surgery (n = 35, 37%) was the most commonly reported indication for the
decision to proceed with an open abdomen.
In summary, there is reasonable clinical evidence that planned relaparotomy
does not have a survival benefit compared to on-demand laparotomy based on
several studies, including one large meta-analysis. The open abdomen in abdomi-
nal sepsis might be associated with increased mortality and a higher incidence of
enteroatmospheric fistulae compared to relaparotomy on demand [37, 42–48].
On-demand laparotomy is associated with decreased costs and health-care use
[47, 48].
Unfortunately, the studies dealing with this controversy demonstrate substantial
variability, and therefore their conclusions are scrutinized with caution.
Hemodynamics and the need for vasopressors support of the patients submitted
to emergency surgery due to abdominal sepsis should guide the acute care surgeon
to consider damage control and open abdomen techniques.
5.1.2 Abdominal Compartment Syndrome
Intra-abdominal hypertension (IAH) has been recognized as a clinical entity for
nearly 150 years [49, 50]. The term “abdominal compartment syndrome” (ACS)
was coined by Fietsam in 1989.
In 2004, the World Society of the Abdominal Compartment Syndrome (WSACS)
[50] published the guidelines for the definition, diagnosis, and management of IAH
and ACS.
H. Bahouth and Y. Kluger
77
5.2 Definitions
5.2.1 Intra-abdominal Pressure
IAP is the steady-state pressure within the abdominal cavity [50]. In healthy indi-
viduals, IAP range is 0–5 mm Hg and varies inversely with intrathoracic pressure
during normal breathing.
5.2.2 Intra-abdominal Hypertension
IAH is a sustained or repeated pathological elevation of IAP of 12 mm Hg or
greater [50].
WCACS introduced a useful grading system for IAH: Grade I (IAP 12–15 mm
Hg), Grade II (IAP 16–20 mm Hg), Grade III (IAP 21–25 mm Hg), and Grade IV
(IAP > 25 mm Hg). In contrast with IAH, ACS is not graded.
5.2.3 Abdominal Perfusion Pressure
Abdominal perfusion pressure (APP) is a measure of the relative adequacy of
abdominal blood flow. APP is calculated by subtracting the IAP from the mean arte-
rial pressure (MAP): MAP-IAP = APP. The APP in patients with IAH or ACS
should be maintained at 60 mm Hg or higher [50–52].
5.2.4 Abdominal Compartment Syndrome
ACS is a sustained IAP greater than 20 mm Hg (with or without an APP < 60 mm
Hg) associated with new organ dysfunction or failure [50–52].
5.2.5 Etiology of ACS
WSACS categorizes conditions that cause ACS as primary (surgical), secondary
(medical), and recurrent [52].
Primary ACS is most commonly encountered and occurs from a primary intra-
abdominal pathology.
Secondary ACS refers to ACS that results from massive bowel edema from sep-
sis, capillary leak, massive fluid resuscitation, or burns. Recurrent ACS occurs after
resolution of primary or secondary ACS.
5 Indications for Open Abdomen in the Non-trauma Setting
78
5.2.6 Incidence and Prevalence
Malbrain et al. [53] conducted a prevalence study in 13 intensive care units (ICUs)
and assessed 97 patients. The overall prevalence of IAH was 58.8%. Prevalence was
65% in surgical patients and 54.4% in medical patients.
Vidal et al. (14:6) studied the incidence of IAP in 83 critically ill patients in a
single ICU. A total of 31% of the patients had IAH at the time of admission to the
unit, and the condition developed in another 33% after admission. ACS developed
in ten patients (12%), and eight of the ten (80%) died. Brandon et al. had a total of
338 primary laparotomies that were performed during the 1-year study period, of
which 96 patients (28%) were managed with an OA/ 6% due to ACS [8].
Reintam et al. [54] enrolled 257 patients receiving mechanical ventilation to
identify the differences in incidence, course, and outcome of primary and secondary
IAH and to determine if IAH is an independent risk factor for death. ICU mortality
was 37.9% for patients with IAH and 19.1% for patients without IAH (P = 0.001).
The authors [55] concluded that development of IAH is an independent risk factor
for death.
5.2.7 Management and Treatment
Sedation, analgesia, and neuromuscular blockade can be used to decrease
IAP. Drainage of any significant ascites may reduce the IAP.
Abdominal decompression via decompressive laparotomy is the standard treat-
ment of refractory IAH and ACS. A transverse bilateral subcostal incision may be
elected or the subcutaneous linea alba fasciotomy (SLAF) technique, described by
Leppäniemi et al. [56].
The goals of decompressive laparotomy (DL) include decrease of increased IAP
to stop organ dysfunction, to allow the continued expansion of abdominal viscera
and to provide temporary abdominal coverage. With decompression, there is an
immediate decrease in IAP; however, the pressure may not decrease to normal lev-
els. An immediate recovery for some organs can be noticed. Despite the positive
hemodynamic consequences of DL, a 6-year study from England showed that there
was no significant difference in pre- and postoperative organ dysfunction score after
DL [57].
However, Raeburn et al. found that the development of ACS in cases in which the
fascia was closed, the skin only was approximated, or a Bogota bag was used was
equivalent [58].
5.3 Summary
ACS is a life-threatening condition. High index of suspicion for proper diagnosis
before the onset of organ failure and prompt treatment once the diagnosis is made
will result in favorable outcome. The classic syndrome of cardiopulmonary and
H. Bahouth and Y. Kluger
79
splanchnic abnormalities represents advanced stage, and surgical decompression
should not be delayed until this stage is reached [59–62].
5.3.1 Acute Severe Pancreatitis
Sever acute pancreatitis (SAP) is defined by the presence of persistent organ failure
for >48 h. SAP develops in 15–20% of the patients [63–65].
The incidence of intra-abdominal hypertension (IAH) in patients with severe
acute pancreatitis (SAP) is approximately 60–80%. Chen et al. [66] and Al-Bahrani
et al. [67] reported an incidence of approximately 60%, using the current definitions
of IAH according to the (WSACS) [68]. When the current WSACS definition was
used, the reported incidence of abdominal compartment syndrome (ACS) in these
patients was 27%. Dambrauskas et al. reported IAH in 58% and ACS in 19% of
patients with severe acute pancreatitis [69].
There is growing evidence in the literature that development of abdominal com-
partment syndrome (ACS) in patients with severe acute pancreatitis (SAP) has a
strong impact on the course of disease [69–72]. The mortality rate in patients devel-
oping ACS remains high, 50–75% despite several interventional options. The mor-
tality was 11% in patients without this complication [73]. IAH in severe acute
pancreatitis is reported to be an early phenomenon. A very recent prospective study
from Scotland evaluating 218 patients with AP estimated that 14% had IAH on
admission and another 3% developed IAH during hospitalization [74]. Up to 70%
of patients have been reported to have IAH on admission to the ICU. The duration
of IAH is more important than the absolute increase in IAP [52]. The etiologies for
the development of IAH during SAP are several: visceral edema, ascites, acute peri-
pancreatic fluid collection, paralytic ileus, duodenal obstruction causing gastric
dilatation, and aggressive fluid resuscitation. The abdominal wall may also be
edematous with decreased compliance, which in synergy with increased intra-
abdominal volume leads to IAH.
5.3.2 Management of IAH & ACS in Patients with Severe Acute
Pancreatitis
The management approach to LAH & ACS is nonoperative or operative [24].
Initial and immediate steps should be nonoperative. The head of the patient’s bed
should be raised not more than 30 degrees, neuromuscular blockage should be
administrated [75], and relief of pain and anxiety with proper medication should be
initiated promptly [52]. Enteral decompression with nasogastric is helpful in man-
aging ileus and gastric dilation frequently encountered in SAP [76]. Prokinetic
agents such as erythromycin and metoclopramide may help in avoiding paralytic
ileus [77]. Administration of loop diuretics to enhance fluid removal may be of ben-
efit if patients’ hemodynamic allow its administration. Removal of fluid by extracor-
poreal techniques is more effective and may have an immediate effect [78].
5 Indications for Open Abdomen in the Non-trauma Setting
80
It remains unclear whether this has any influence on IAH [7, 79].
Percutaneous drainage catheter (PCD) may relieve ACS in patients with intra-
abdominal ascites, collections, or abscesses [80]. It is unclear if this procedure can
achieve sufficient decompression and relief of the ACS.
The efficacy of the nonoperative management of ACS is not well known. In a
study including 74 patients with SAP, 20 patients developed ACS during the first
7 days of admission [72]. Seven patients responded to nonoperative therapy, but the
remaining 13 patients had progressive deterioration of organ dysfunction and
received interventional decompressive procedure.
5.3.3 Indications for Surgical Intervention
The indications for surgical decompression in ACS associated with severe acute
pancreatitis are not clear, and the IAP is not the only parameter for this decision
[81–83].
It is will accepted that when nonsurgical interventions fail to relieve IAH in the
presence of fulminate ACS, especially in the setting of persistent organ dysfunction,
surgical decompression is justified [84].
The effects of abdominal decompression on organ functions were summarized in
a collective review of 250 patients who underwent midline laparotomy [83, 85].
Decompression had a positive effect on hemodynamic, respiratory, and renal func-
tion parameters. Boone et al. [83] reported statistically significant improvements in
several physiologic parameters. However, despite initial improvement almost in all
patients, mortality rate of 50% was recorded. In another retrospective study, the
mortality after various techniques of decompression was 46% [83].
5.3.4 Summary
IAH and ACS are common complications in acute severe pancreatitis. Early moni-
toring, diagnosis, and management improve outcome. Different surgical techniques
exist but currently there are no randomized trials comparing the outcomes of the
different surgical approaches.
5.3.5 Acute Mesenteric Ischemia
Acute mesenteric ischemia (AMI) is a challenging clinical and surgical pathology
with high morbidity and mortality rates. Despite the improvements in diagnostic
studies and management options, the mortality from AMI ranges between 60 and
90% [86] especially in elderly patients.
Acute arterial occlusion is the most common cause of mesenteric ischemia and
results from embolic occlusion in 40–50% and thrombotic occlusion in 20–35% of
the patients [87].
H. Bahouth and Y. Kluger
81
Due to its insidious onset and the lack of a typical clinical presentation, AMI is
usually diagnosed when peritonitis becomes evident. Since bowel resection is a
common treatment for AMI, to assess the final bowel viability accurately, a second-
look laparotomy remains gold standard. This policy includes a routine re- exploration
of the abdomen 24–48 h after the index operation carried out in an effort to preserve
as much bowel as possible. At the index operation, only frank necrotic bowel is
resected. However, the exact indication for second-look laparotomy is still
controversial.
Some surgeons select aggressive approach with a scheduled second-look proce-
dure in any patient who undergoes bowel resection and primary anastomosis [88,
89], whereas others suggest a more selective approach [90, 91]. Sachs et al. reported
that second-look laparotomy benefits only 18–20% of patients operated for
AMI. Other researchers found that fewer than half the patients underwent a second-
look operation and more than 40% benefited from the procedure that resulted appro-
priate treatment. In mesenteric venous thrombosis, the thrombotic process extends
well beyond what appears to be the compromised bowel. Therefore, a second-look
exploration is often the only way to establish the full extent of nonviable bowel.
In a nonrandomized case–control study [92], patients undergoing planned relap-
arotomy were matched with patients who underwent relaparotomy on demand.
There was no significant difference in mortality between the groups, but multiple
organ failure and septic complications were more common in the patients who
underwent planned relaparotomy.
Second-look laparotomy may be avoided if the experienced surgeon identifies
clear margins of demarcation between well-vascularized and necrotic bowel in a
hemodynamically stable patient.
5.4 Summary
The main problem in defining the role of the second-look operation for AMI is the
lack of prospective studies comparing the outcomes of second-look operations with
a control. Until large prospective studies are available, the indications for a second-
look operation should be evaluated with caution and be based on surgeon experi-
ence and based on the surgical findings as well as patient hemodynamics.
5.4.1 Open Abdomen for Ruptured Abdominal Aortic Aneurysm
The vascular surgeon Irving Kron was the first to describe ACS following ruptured
abdominal aortic aneurysm (RAAA) repair [93].
ACS develops in these patients due to aggressive resuscitation after major bleed-
ing. Survival may be improved if the hypoperfusion of the abdominal organs result-
ing from IAH/ACS be reversed in time [94–96].
Routine measurement of IAP will demonstrate that IAP > 20 mm Hg occurs in
50% of all patients after open repair of a RAAA, and 20% will go on to develop
5 Indications for Open Abdomen in the Non-trauma Setting
82
ACS [96–98]. In conclusion, IAH/ACS is a common problem after RAAA repair, in
particular in the unstable patient requiring massive transfusions, irrespective of
which method of repair is used.
Damage control principles [2, 96–98] in emergency surgery, as well as the
modern blood resuscitation strategies [99], the development of massive transfu-
sion protocols, and permissive hypotension management, are recent advances in
the management of the bleeding vascular patient that may decrease the risk of
IAH/ACS.
Mell et al. [99] showed that patients who received less than one unit of plasma
for every two units of red blood cells during RAAA repair had a four times higher
mortality rate than those receiving more plasma resuscitation highlighting the
importance of a massive transfusion protocol.
With the introduction of endovascular aneurysm repair (EVAR) [100, 101] by
Volodos in 1986, and the application of this technology on patients with ruptured
abdominal aortic aneurysm (AAA), first described by Ohki and Veith [102], the
management of RAAA repair has changed.
Wanhainen et al., in a multicenter prospective cohort study in four Swedish hos-
pitals assessing the risk of requiring open abdomen treatment in patients with
RAAA, found 0.4% (2/455) risk for open abdomen treatment after EVAR and 0.9%
(3/303) after open repair. This risk deference between the two groups may originate
from a selection bias. Selection of more circulatory stable patients for EVAR results,
however, in a lower incidence of IAH/ACS [103].
Whether to leave all patients with open abdomen as routine after open repair of
a RAAA, or if it is better to close those patients who do not have a very tense abdo-
men, and follow them closely in the postoperative period, is still a controversial
issue. The strategy of leaving many patients with open abdomen was first reported
from the Mayo Clinic. They reported having left 19% open after AAA repair
(43/223) [104]. A similar experience was reported from Zürich [96].
This controversy should be solved and addressed by randomized control trials.
Based on the current knowledge, the updated consensus document favors primary
closure and close IAP monitoring unless the abdomen is tense and difficult to close,
which is the case in approximately 5–10% of patients.
5.5 Summary
Open abdomen and damage control philosophy are ill defined and studied in the
acute non-trauma surgical setting. Although many surgeons practice this approach
in diverse abdominal pathologies, no common denominator can be outlined in the
reported cohort. Only well-conducted studies based on internationally agreed
nomenclature will address the issue of who will be the patient that will benefit from
the open abdomen and damage control strategy.
H. Bahouth and Y. Kluger