Project Title: WESTERN TRAUMA ASSOCIATION MULTI-INSTITUTIONAL
STUDY: OPEN ABDOMENS
Background:
Management of the open abdomen has become an obligatory conundrum for
general and trauma surgeons. Originally, patients requiring an open abdomen were those
trauma patients with adverse intraoperative physiology who underwent abbreviated
laparotomy with damage control techniques (halt hemorrhage and limit gastrointestinal
contamination). The techniques of damage control surgery, such as use of the open
abdomen with delayed definitive repair of injuries, have subsequently been anecdotally
applied to the general/vascular surgery and medical patient populations as well. An
additional etiology of the open abdomen is the abdominal compartment syndrome due to
either intraabdominal injury (primary ACS) or following massive resuscitation
(secondary ACS). Release of intraabdominal hypertension through decompressive
laparotomy has improved patient outcomes, but relegates the patient to an open abdomen,
albeit often temporary.
Although there is reduced mortality in these critically ill patients, the trade-off is
the morbidity of the resultant open abdomen. Although the initial focus on the reduction
in postinjury mortality is appropriate, it is time to refine techniques to minimize
complications and improve outcomes. An important step is to quantify and characterize
the abdominal complications, determine current abdominal closure rates, and elucidate if
these are related to the underlying injury or the open abdomen per se. To date, a variety
of institutions have reported their experience, with a multitude of endpoints, techniques,
and outcomes. Moreover, a search of the current literature does not reveal a collective
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review of all patients requiring open abdomen treatment (regardless of underlying
etiology - trauma, general surgery, medical). We propose a multi-institutional study to
better analyze the specific complications and actual rates of those complications
following treatment of the open abdomen, as well as identification of variables that may
be altered to affect patient outcome.
We would like to retrospectively review all cases requiring open abdomen
treatment from 1/1/03 to 12/31/07 (a 5 year period). Specific questions to be answered
include:
1. Intraabdominal complications:
The actual incidence of such complications as enterocutaneous fistula, abscess
formation, and biloma has yet to be determined in a large study population. Particular
variables that might impact such complications include time to abdominal closure,
technique used to attain closure, underlying injuries including bowel enterotomies, and
associated hypotension. As a mediating factor of this analysis, the use of empiric
antibiotics or antifungals for the open abdomen will be collected in the datasheet. There
are no studies to date that have evaluated current practice trends nor proposed treatment
algorithms. Additionally, underlying patient factors and injury patterns will be analyzed
in relation to intraabdominal abscess rates (hence the need for specific injuries including
grading of injury as well as physiologic variables and fluid requirements).
2. Overall outcomes/abdominal closure rates by etiology:
To date, there has not been a study on the incidence of open abdomen treatment
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nor associated outcomes across all aspects of patient care – medical patients (pancreatitis,
abdominal sepsis), post-injury patients (damage control surgery, abdominal compartment
syndrome), general surgery (ruptured abdominal aortic aneurysm, perforated viscus), or
ObGyn patients (HEELP syndrome, oncologic surgery).
Additionally, multiple techniques have been introduced to obtain fascial closure
for the open abdomen. Vacuum-assisted closure (VAC) has reduced but not eliminated
the use of either split-thickness skin grafts to cover the exposed bowel or mesh
(prosthetic or biologic) approximation of the fascia. The success rate of primary fascial
closure in the majority of studies ranges from 30-67%, with three studies reporting fascial
approximation of 88-100% with VAC-assisted closure. We question the current rate of
fascial closure in modern trauma centers with large patient volumes. How is abdominal
closure currently attained? Is there a difference in closure rates between patient
populations with differing etiologies of the open abdomen? What is the timeframe to
closure?
3. Placement of feeding access and use of enteral nutrition:
The physiologic benefits of enteral nutrition are widely recognized. Multiple
studies have shown decreased septic complications, prevention of gut mucosal atrophy,
preservation of normal flora, and attenuation of the hypermetabolic postinjury response
with total enteral nutrition (TEN); however, the benefit of TEN is most conspicuous
following severe trauma. Although early enteral nutrition is preferred in critically injured
patients, acquiring access may be challenging. In multiply injured patients who develop
the ACS, the postresuscitation visceral edema is often daunting at operative
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decompression. In fact, the observed bowel edema may limit definitive closure of the
patient’s abdominal wall. For this reason there may be hesitancy to both place enteral
access via needle catheter jejunostomy through the edematous bowel wall, and to institute
enteral feeding following either definitive closure or with an open abdomen due to
assumed gut dysfunction. We question current practice techniques of feeding access
placement, institution of enteral feeding, and extent of enteral feeding if the patient’s
abdomen is open.
In summary, patients will be identified using our trauma registry and operative
records. Specific data to be collected are noted on the attached datasheet. After
identification of the patient, data will be collected but the patient’s name, date of injury,
birth date, etc will not be recorded on the data sheet. Any patient over the age of 89 years
will be placed in a grouped category classified as >89 yo. A sample data sheet is
included for clarification. Hence, following the one-time data collection, association to
the original patient file will not be possible.
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Patient Identification/Recruitment: Patients will be identified from operative and trauma
registry databases.
Subject Population: All patients requiring an open abdomen following surgical
intervention from 1/03 to 1/08 – a 5 year period.
Age Range: 0-99 years
Time Period for Data Collection: 1/1/03 to 12/31/07
Special Populations: May be included in this retrospective review but will not be
specifically culled from a database.
References:
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Miller PR, Thompson JT, Faler BJ, et al. Late fascial closure in lieu of ventral
hernia: the next step in open abdomen management. J Trauma 2002:53:843-9.
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Cothren CC, Moore EE, Johnson JL, Ciesla DJ, Moore JB, Burch JM. “100%
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