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Management of fistula of ileal conduit in open abdomen by intra-condoit negative pressure system.

Yetişir F, Salman AE, Aygar M, Yaylak F, Aksoy M, Yalçin A.

Int J Surg Case Rep. 2014;5(7):385-8.

INTRODUCTION:

We aimed to present the management of a patient with fistula of ileal conduit in open abdomen by intra-condoid negative pressure in conjunction with VAC Therapy and dynamic wound closure system (ABRA).

PRESENTATION OF CASE:

65-Year old man with bladder cancer underwent radical cystectomy and ileal conduitoperation. Fistula from uretero-ileostomy anastomosis and ileus occurred. The APACHE II score was 23, Mannheim peritoneal index score was 38 and Björck score was 3. The patient was referred to our clinic with ileus, open abdomen andfistula of ileal conduit. Patient was treated with intra-conduid negative pressure, abdominal VAC therapy and ABRA.

DISCUSSION:

Management of urine fistula like EAF in the OA may be extremely challenging. Especially three different treatment modalities of EAF are established in recent literature. They are isolation of the enteric effluent from OA, sealing of EAF with fibrin glue or skin flep and resection of intestine including EAF and re-anastomosis. None of these systems were convenient to our case, since urinary fistula was deeply situated in this patient with generalized peritonitis and ileus.

CONCLUSION:

Application of intra-conduid negative pressure in conjunction with VAC therapy and ABRA is life saving strategies to manage open abdomen with fistula of ileal conduit.


Management of the open abdomen using combination therapy with ABRA and ABThera systems.

Mukhi AN, Minor S

Can J Surg. 2014 Oct;57(5):314-9.

BACKGROUND:

The open abdomen is an increasingly used technique that is applied in a wide variety of clinical situations. The ABThera Open Abdomen Negative Pressure Therapy System is one of the most common and successful temporary closure systems, but it has limited ability to close the fascia in approximately 30% of patients. The abdominal reapproximation anchor system (ABRA) is a dynamic closure system that seems ideal to manage patients who may not achieve primary fascial closure with ABThera alone. We report on the use of the ABRA in conjunction with the ABThera in patients with an open abdomen.

METHODS:

We retrospectively analyzed patients with an open abdomen managed with the ABThera and ABRA between January 2007 and December 2012 at the Halifax Infirmary, QEII Health Science Centre, Halifax, Nova Scotia.

RESULTS:

Sixteen patients had combination therapy using the ABRA and ABThera systems for treatment of the open abdomen. After removing patients who died prior to closure, primary fascial closure was achieved in 12 of 13 patients (92%).

CONCLUSION:

We observed a high rate of primary fascial closure in patients with an open abdomen managed with theABThera system in conjunction with the ABRA. Applying mechanical traction in addition to the ABThera should be considered in patients predicted to be at high risk for failure to achieve primary fascial closure.


Use of dynamic wound closure system in conjunction with
vacuum-assisted closure therapy in delayed closure of open abdomen.

Salman AE, Yetişir F, Aksoy M, Tokaç M, Yildirim MB, Kiliç M.

Hernia. 2014 Feb;18(1):99-104.

AIM:

Definitive abdominal closure may not be possible for several days or weeks after laparotomy in damage-control surgery, abdominal compartment syndrome and intra-abdominal sepsis, until the patient has stabilized. Vacuum-assisted closure (VAC therapy(®), KCI, San Antonio, TX, USA) and abdominal re-approximation anchor system (ABRA, Canica, Almonte, Ontario, Canada) are novel techniques in delayed closure of open abdomen. Our aim is to present the use of these strategies in the management of 7 patients with open abdomen.

METHODS:

Between August 2010 and December 2011, 7 patients with severe peritonitis were stabilized by laparotomy and treated with either ABRA system or ABRA system in conjunction with VAC dressing. VAC dressing applied to 4 patients initially and followed by ABRA. ABRA was applied alone to remaining 3 patients. Demographic data and patient characteristics, timing of VAC dressing and ABRA system were recorded. ICU and hospital stay and development of incisional hernia were also recorded. Stage of open abdomen, width of abdominal defect, extent to damage to fascia, and pressure sores were staged.

RESULTS:

The mean duration with VAC dressing before ABRA application was 18 days. The mean duration of ABRA application was 53 days. The average width of the abdominal defect was 18 cm. The average length of defect was 20.8 cm. Delayed primary abdominal closure was accomplished in 6 patients without further surgery. Incisional hernia with a small abdominal defect developed in 2 patients.

CONCLUSION:

Abdominal re-approximation anchor system and VAC dressing can be used separately or in conjunction with each other for closure of delayed open abdomen successfully


Effect of botulinum toxin type A in lateral abdominal wall muscles thickness and length of patients with midline incisional hernia secondary to open abdomen management.

Ibarra-Hurtado TR, Nuño-Guzmán CM, Miranda-Díaz AG, Troyo-Sanromán R, Navarro-Ibarra R, Bravo-Cuéllar L.

Hernia. 2014 Oct;18(5):647-52

PURPOSE:

Abdominal wall hernia secondary to open abdomen management represents a surgical challenge. The herniaworsens due to lateral muscle retraction. Our objective was to evaluate if Botulinum Toxin Type A (BTA) application inlateral abdominal wall muscles modifies its thickness and length.

METHODS:

A clinical trial of male trauma patients with hernia secondary to open abdomen management was performed from January 2009 to July 2011. Thickness and length of lateral abdominal muscles were measured by a basal Computed Tomography and 1 month after BTA application. A dosage of 250 units of BTA was applied at five points at each side between the external and internal oblique muscles under ultrasonographic guidance. Statistical analysis for differences between basal and after BTA application measures was performed by a paired Student’s t test (significance: p < 0.05).

RESULTS:

Seventeen male patients with a mean age of 35 years were included. There were muscle measure modifications in all the patients. Left muscle thickness: mean reduction of 1 ± 0.55 cm (p < 0.001). Right muscle thickness: mean reduction of 1.00 ± 0.49 cm (p < 0.001). Left muscle length: mean increase of 2.44 ± 1.22 cm (p < 0.001). Right muscle length: mean increase of 2.59 ± 1.38 cm (p < 0.001). No complications secondary to BTA or recurrences at mean follow-up of 49 months were observed.

CONCLUSIONS:

BTA application in lateral abdominal muscles decreases its thickness and increases its length inabdominal wall hernia patients secondary to open abdomen management.


Primary closure of the abdominal wall after “open abdomen” situation.

Kääriäinen M1, Kuokkanen H.

Scand J Surg. 2013;102(1):20-4.

“Open abdomen” is a strategy used to avoid or treat abdominal compartment syndrome. It has reduced mortality both in trauma and non-trauma abdominal catastrophes but also has created a challenging clinical problem. Traditionally, open abdomen is closed in two phases; primarily with a free skin graft and later with a flap reconstruction. A modern trend is to close the abdomen within the initial hospitalization. This requires multi-professional co-operation. Temporary abdominal closure methods, e.g. negative pressure wound therapy alone or combined with mesh-mediated traction, have been developed to facilitate direct fascial closure. Components separation technique, mesh reinforcement or bridging of the fascial defect with mesh and perforator saving skin undermining can be utilized in the final closure if needed. These techniques can be combined. Choice of the treatment depends on the condition of the patient and size of the fascia and skin defect, and the state of the abdominal contents. In this paper we review the literature on the closure of an open abdomen and present the policy used in our institution in the open abdomen situations.


Management of the open abdomen using combination therapy with ABRA and ABThera systems.

Mukhi AN1, Minor S1.

Can J Surg. 2014 Oct;57(5):314-9.

BACKGROUND:

The open abdomen is an increasingly used technique that is applied in a wide variety of clinical situations. The ABThera Open Abdomen Negative Pressure Therapy System is one of the most common and successful temporary closure systems, but it has limited ability to close the fascia in approximately 30% of patients. The abdominal reapproximation anchor system (ABRA) is a dynamic closure system that seems ideal to manage patients who may not achieve primary fascial closure with ABThera alone. We report on the use of the ABRA in conjunction with the ABThera in patients with an open abdomen.

METHODS:

We retrospectively analyzed patients with an open abdomen managed with the ABThera and ABRA between January 2007 and December 2012 at the Halifax Infirmary, QEII Health Science Centre, Halifax, Nova Scotia.

RESULTS:

Sixteen patients had combination therapy using the ABRA and ABThera systems for treatment of the open abdomen. After removing patients who died prior to closure, primary fascial closure was achieved in 12 of 13 patients (92%).

CONCLUSION:

We observed a high rate of primary fascial closure in patients with an open abdomen managed with the ABThera system in conjunction with the ABRA. Applying mechanical traction in addition to the ABThera should be considered in patients predicted to be at high risk for failure to achieve primary fascial closure.


Management of the open abdomen with the Abdominal Reapproximation Anchor dynamic fascial closure system

Candace Haddock, M.D., David E. Konkin, M.D., N. Peter Blair, M.D., M.B.C.

The American Journal of Surgery (2013) 205, 528-533

BACKGROUND:

With the increased use of damage control surgery and open abdomens, there are growing challenges in achieving primary fascial closure. The purpose of this study was to retrospectively review our experience using the Abdominal Reapproximation Anchor (ABRA; Canica Design Inc, Almonte, Ontario, Canada), a dynamic fascial closure system, to gain fascial apposition in complex
abdominal surgical patients.

METHODS:

A retrospective review of patients who underwent placement of the ABRA device to aid in abdominal closure was undertaken. Details including age, sex, the reason for an open abdomen, the number of operations, the time to primary closure, the success rate of primary closure, and complications related to the use of the ABRA were analyzed.

RESULTS:

Between January 2006 and July 2011, 36 patient charts were identified. The average Acute Physiology and Chronic Health Evaluation II score was 21.9 6 6.9. There was a mean of 3.1 6 1.8 laparotomies before ABRA placement for each patient, and the duration of ABRA placement until removal was 10.4 6 6.1 days. Complete fascial apposition was achieved in 83% of the patients
across the entire study and in 91% of the patients in the final 2 years. Component separation was used in 17% of cases. The incisional hernia rate was 13% at 6 months and 11% at 12 months.

CONCLUSION:

Our use of the ABRA system resulted in an 83% fascial apposition rate, which further improved when experience was taken into account. The incisional hernia rate was acceptable in this complicated patient group. This technique is an excellent addition to a surgeon’s armamentarium for complicated abdominal cases that require an open abdomen. Further prospective studies are planned to identify ideal candidates for this technique.


Delayed primary closure of the septic open abdomen with a dynamic closure system.

Verdam FJ1, Dolmans DE, Loos MJ, Raber MH, de Wit RJ, Charbon JA, Vroemen JP.

World J Surg. 2011 Oct;35(10):2348-55.

BACKGROUND:

The major challenge in the management of patients with an infected open abdomen (OA) is to control septic peritonitis and intra-abdominal fluid secretion, and to facilitate repeated abdominal exploration, while preserving the fascia for delayed primary closure. We here present a novel method for closure of the infected OA, based on continuous dynamic tension, in order to achieve re-approximation of the fascial edges of the abdominal wall.

METHODS:

Eighteen cases with severe peritonitis of various origin (e.g., gastrointestinal perforations, anastomotic leakage) were primarily stabilized by laparostomy, sealed with either the vacuum-assisted closure abdominal dressing or the Bogotá bag. After hemodynamic stabilization and control of the sepsis, the Abdominal Re-approximation Anchor System (ABRA; Canica Design, Almonte, Ontario, Canada) was applied. This system approximates the wound margins through dynamic traction exerted by transfascial elastomers. Before ABRA application, 5/18 patients had a grade 2B, 2/18 a grade 3, and 11/18 a grade or 4 status according to the open abdomen classification of Björck.

RESULTS:

In this severely ill population the mean time before ABRA system application was 12 days (range: 2-39 days). Two of 18 patients died of non-ABRA-related causes within three weeks. In 14 of the remaining 16 patients (88%) primary abdominal closure of the midline was accomplished in 15 days (range: 7-30 days). The other two patients needed a component separation technique according to Ramirez to reach closure. However, secondary wound dehiscence occurred in both these patients. Two thirds of patients (12/18) developed pressure sores to the skin and/or dermis, but all healed without further complications. During outpatient clinic follow-up, 4/14 successfully closed patients still developed a midline hernia.

CONCLUSIONS:

Delayed primary closure of OA in septic patients could be achieved in 88% with this new approximation system. However, the risk of hernia development remained. We consider this system a useful tool in the treatment of septic patients with an open abdomen.


Management of open abdominal wounds with dynamic fascial closure system.

Reimer MW1, Yelle JD, Reitsma B, Doumit G, Allen MA, Bell MS.

Can J Surg. 2008 Jun;51(3):209-14.

BACKGROUND:

In damage-control surgery, definitive abdominal closure may not be possible for several days or weeks after laparotomy until the patient has stabilized.

METHODS:

We present 23 patients treated with the Canica ABRA dynamic wound closure system that re-approximated open abdomens with silicone elastomers placed transfascially across the wound. This study aimed to assess the results of using this system and to identify risk factors for unsuccessful closure. The system maintains a medially directed force across the wound. A traditional regimen of wound dressing changes was performed.

RESULTS:

The dynamic closure system remained in place an average of 48 days and was applied an average of 18 days after the beginning of treatment for the openabdominal wound. Delayed primary fascial closure was achieved in 14 of 23 patients (61%) without further surgery. Six patients (26%) healed with ventral hernias but with a smaller abdominal defect. Two patients (9%) developed enterocutaneous fistulae through the wound that required further surgery. An overall reduction in wound area of 95% was achieved.

CONCLUSION:

This dynamic wound closure technique permitted the delayed primary closure of open abdomens in 61% of cases when treatment was instituted an average of 18 days after initial laparotomy


Classification – important step to improve management of patients with an open abdomen.

Björck M1, Bruhin A, Cheatham M, Hinck D, Kaplan M, Manca G, Wild T, Windsor A.

World J Surg. 2009 Jun;33(6):1154-7.

This short report is a distillation of the proceedings from a consensus group meeting in January 2009. It outlines a proposed classification system for patients with an open abdomen (OA). The classification allows (1) a description of the patient’s clinical course; (2) standardized clinical guidelines for improving OA management; and (3) improved reporting of OA status, which will facilitate comparisons between studies and heterogeneous patient populations. The following grading is suggested: grade 1A, clean OA without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization); grade 1B, contaminated OA without adherence/fixity; grade 2A, clean OA developing adherence/fixity; grade 2B, contaminated OA developing adherence/fixity; grade 3, OA complicated by fistula formation; grade 4, frozen OA with adherent/fixed bowel, unable to close surgically, with or without fistula. We propose that this classification system will facilitate communication, clarify OA management, and potentially improve patient care.


One hundred percent fascial approximation with sequential abdominal closure of the open abdomen.

Cothren CC1, Moore EE, Johnson JL, Moore JB, Burch JM.

Am J Surg. 2006 Aug;192(2):238-42.

BACKGROUND:

Damage-control surgery and the recognition of the abdominal compartment syndrome have improved patient outcomes but at the cost of an open abdomen. Multiple techniques have been introduced to obtain fascial closure for the open abdomen to minimize morbidity and cost of care. We performed a modification of the vacuum-assisted closure (VAC) technique that provided constant fascial tension, hypothesizing this would result in a higher rate of primary fascial closure.

METHODS:

After initial temporary closure of the abdomen after post-injury damage control or decompressive laparotomy for abdominal compartment syndrome, we began the sequential closure technique. The technique begins by covering the bowel with the multiple white sponges overlapped like patchwork, and the fascia is placed under moderate tension over the white sponges with #1-PDS sutures. Large black VAC sponges are placed on top of the white sponges and affixed with an occlusive dressing and standard suction tubing is placed. Patients are returned to the operating room for sequential fascial closure and replacement of the sponge sandwich every 2 days, with a resulting decrease in the fascial defect.

RESULTS:

Fourteen patients underwent sequential abdominal closure during the study period: 9 owing to damage control surgery and 5 owing to secondary abdominal compartment syndrome. Average time to closure was 7.5 +/- 1.0 days (range 4-16) and average number of laparotomies to closure was 4.6 +/- 0.5 (range 3-8). All patients attained primary fascial closure.

CONCLUSION:

We propose a modification of the previously described vacuum-assisted closure technique that achieves 100% fascial approximation in our limited experience. Further application and refinement of this technique may eliminate the need for delayed complex and costly reconstructive abdominal wall procedures for the open abdomen.


Closure of massive abdominal wall defects: a case report using the abdominal reapproximation anchor (ABRA) system.

Urbaniak RM1, Khuthaila DK, Khalil AJ, Hammond DC.

Ann Plast Surg. 2006 Nov;57(5):573-7.

Closure of massive abdominal wounds can be a challenging surgical problem. Presented here is a novel technique for reconstitution of the abdominal wall after severe internal injuries complicated by sepsis required a prolonged period of open abdominal dressing changes. By using an innovative and effective progressive tension band system, the fascial edges could be reapproximated over time allowing primary wound closure. This system is recommended as an effective instrument to accomplish closure of these difficult wounds.


Prospective evaluation of vacuum assisted fascial closure after open abdomen : planned ventral hernia rate is substantially reduced.

Miller PR1, Meredith JW, Johnson JC, Chang MC.

Ann Surg. 2004 May;239(5):608-14; discussion 614-6.

OBJECTIVE:

The goal of this report is to examine the success of vacuum-assisted fascial closure (VAFC) under a carefully applied protocol in abdominal closure after open abdomen.

SUMMARY BACKGROUND DATA:

With the development of damage control techniques and the understanding of abdominal compartment syndrome, the open abdomen has become commonplace in trauma patients. If the abdomen is not closed in the early postoperative period, the combination of adhesions and fascial retraction frequently make primary fascial closure impossible and creation of a planned ventral hernia is required. We have previously reported our experience with the development of a technique for VAFC that allowed for closure of the fascia in many such patients long after initial operation. During this previous study, during which the technique was being developed, VAFC was successful in 69% of patients in whom it was applied, and 22 patients were successfully closed at > or = 9 days after initial surgery (range, 9 to 49 days). A protocol for the use of VAFC in patients with open abdomen was developed on the basis of these data and has been employed since October 2001. The outcome of this protocol’s use is examined.

METHODS:

This is a prospective evaluation of all trauma patients admitted to Wake Forest University Baptist Medical Center over a 19-month period who required management with an open abdomen. VAFC employs suction applied to a large polyurethane sponge under an occlusive dressing in the wound and allows for constant medial traction of the abdominal fascia. It is attempted in all patients in whom the rectus muscles and fascia are intact. Studied variables include fascial closure rate, time to closure, incidence of wound dehiscence, and hernia development after closure.

RESULTS:

From November 1, 2001, through May 31, 2003, 212 laparotomies were performed in injured patients; 53 (25%) of these patients required open abdomenmanagement. Mean injury severity score for the group was 34, with an average abdominal abbreviated injury score of 2.9. Forty-five (78%) survived until abdominal closure. Vacuum dressings were used in all 45 but VAFC was not attempted in 2 patients (1 due to development of enterocutaneous fistula, 1 because a rectus flap was used for another wound). Closure rate in those undergoing VAFC was 88% (38), with mean time to closure being 9.5 days. This is significantly higher than the 69% rate of fascial closure during the time in which the technique was developed (P = 0.03). Twenty-one patients (48%) were closed at > or =9 days (range, 9 to 21 days). Two patients (4.6%) developed wound dehiscence and underwent successful reclosure. One patient (2.3%) developed a ventral hernia on follow-up, which has since been repaired

CONCLUSIONS:

The use of VAFC under a carefully defined protocol has resulted in significantly higher fascial closure rates, obviating the need for subsequent hernia repair in most patients. The utility of this technique is not limited to the early postoperative period, but it can be successful as much as 3 to 4 weeks after initial operation.


Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen.

Howdieshell TR1, Proctor CD, Sternberg E, Cué JI, Mondy JS, Hawkins ML.

Am J Surg. 2004 Sep;188(3):301-6

BACKGROUND:

Inability to close the abdominal wall after laparotomy for trauma may occur as a result of visceral edema, retroperitoneal hematoma, use of packing, and traumatic loss of tissue. Often life-saving, decompressive laparotomy and temporary abdominal closure require later restoration of anatomic continuity of the abdominal wall.

METHODS:

The trauma registry, open abdomen database, and patient medical records at a level 1 university-based trauma center were reviewed from January 1988 to December 2001.

RESULTS:

During the study period, more than 15,000 trauma patients were admitted, with 88 patients (0.6%) requiring temporary abdominal closure (TAC). Patients ages ranged from 12 to 75 years with a mean injury severity score (ISS) of 28 (range 5 to 54). Forty-five patients (51%) suffered penetrating injuries, and 43 (49%) were victims of blunt trauma. Indications for TAC included visceral edema in 61 patients (70%), abdominal compartment syndrome in 10 patients (11%), traumatic tissue loss in 9 patients (10%), and wound sepsis and fascial necrosis in 8 patients (9%). Fifty-six patients (64%) underwent TAC at admission laparotomy, whereas 32 patients (36%) required TAC at reexploration. Seventy-one patients (81%) survived and 17 (19%) died. Of the survivors, 24 patients (34%) underwent same-admission direct fascial closure, and 47 patients (66%) required visceral skin grafting and readmission closure. Reconstructive procedures in the patients requiring skin graft excision included direct fascial repair (20 patients, 44%), components separation closure with or without subfascial tissue expansion (18 patients, 40%), pedicled or free-tissue flaps (4 patients, 8%), and mesh repair (4 patients, 8%). One patient refused closure. The mean follow-up was 48 months (range 6 to 144), with an overall recurrence rate of 15% (range 10% to 50%), highest in the mesh repair group.

CONCLUSIONS:

Silicone sheeting TAC provides a safe and reliable temporary abdominal closure allowing for later definitive reconstruction. Direct fascial repair or components separation closure with or without tissue expansion can be utilized in the majority of patients for definitive reconstruction with low recurrence rate.