Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction.

BACKGROUND: Damage control surgery and temporary open abdomen (OA) have been adopted widely, in both trauma and non-trauma situations. Several techniques for temporary abdominal closure have been developed. The main objective of this study was to evaluate the fascial closure rate in patients after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) for long-term OA treatment, and to describe complications. METHODS: This prospective study included all patients who received VAWCM treatment between 2006 and 2009 at four hospitals. Patients with anticipated OA treatment for fewer than 5 days and those with non-midline incisions were excluded. RESULTS: Among 151 patients treated with an OA, 111 received VAWCM treatment. Median age was 68 years. Median OA treatment time was 14 days. Main disease aetiologies were vascular (45 patients), visceral surgical disease (57) and trauma (9). The fascial closure rate was 76·6 per cent in intention-to-treat analysis and 89 per cent in per-protocol analysis. Eight patients developed an intestinal fistula, of whom seven had intestinal ischaemia. Intestinal fistula was an independent factor associated with failure of fascial closure (odds ratio (OR) 8·55, 95 per cent confidence interval 1·47 to 49·72; P = 0·017). The in-hospital mortality rate was 29·7 per cent. Age (OR 1·21, 1·02 to 1·43; P = 0·027) and failure of fascial closure (OR 44·50, 1·13 to 1748·52; P = 0·043) were independently associated with in-hospital mortality. CONCLUSION: The VAWCM method provided a high fascial closure rate after long-term treatment of OA. Technique-related complications were few. No patient was left with a large planned ventral hernia.

Colonic ischaemia and intra-abdominal hypertension following open repair of ruptured abdominal aortic aneurysm.

BACKGROUND: The aim was to investigate the association between colonic ischaemia and intra-abdominal pressure (IAP) after surgery for ruptured abdominal aortic aneurysm (rAAA). METHODS: Sigmoid colon perfusion was monitored with an intramucosal pH (pHi) tonometer. Patients with a pHi of 7.1 or less were treated for suspected hypovolaemia with intravenous colloids and colonoscopy. IAP was measured every 4 h. Patients with an IAP of 20 mmHg or more had neuromuscular blockade, relaparotomy or both. RESULTS: A total of 52 consecutive patients had open rAAA repair; 30-day mortality was 27 per cent. Eight patients died shortly after surgery. Fifteen were not monitored for practical reasons; mortality in this group was 33 per cent. IAP and pHi were measured throughout the stay in intensive care in the remaining 29 patients. Monitoring led to volume resuscitation in 25 patients, neuromuscular blockade in 16, colonoscopy in 19 and relaparotomy in two. One patient died in this group. Twenty-three of 29 patients had a pHi of 7.1 or less, of whom 15 had a pHi of 6.9 or less. Sixteen had an IAP of 20 mmHg or more, of whom ten also had a pHi below 6.90. Peak IAP values correlated with the simultaneously measured pHi (r = -0.39, P = 0.003). CONCLUSION: Raised IAP is an important mechanism behind colonic hypoperfusion after rAAA repair. Monitoring IAP and timely intervention may improve outcome.

The clinical importance of monitoring intra-abdominal pressure after ruptured abdominal aortic aneurysm repair.

AIM: The aim of this paper was to review the literature on the clinical importance of monitoring intra-abdominal pressure (IAP) after ruptured abdominal aortic aneurysm (rAAA) repair. METHOD: The literature was searched for abdominal compartment syndrome (ACS) or intra-abdominal pressure and aortic aneurysm. Original articles were studied. Personal experiences were reported. RESULTS: The Consensus Documents of the World Society on the Abdominal Compartment Syndrome (wsacs.org), with their definitions and guidelines, constitute an important step forward for the possibilities to study this clinical entity. Few papers were published describing the problem specifically in the patient population operated on for ruptured abdominal aortic aneurysm (rAAA). The incidence was approximately 5% when the patients were not monitored with IAP, and above 10% when IAP was monitored. The incidence seems to be similar irrespective if open or endovascular repair is performed, though comparative prospective studies were not published. Patients with intra-abdominal hypertension (IAH) or ACS have higher mortality and more complications. If IAH is recognized early conservative treatment may be effective to prevent development of ACS. After ACS has developed, surgical decompression is usually required. A proposed algorithm on how to act on different levels of IAH is presented. CONCLUSIONS: IAH/ACS is an important complication after operation on patients with rAAA. Monitoring IAP may be associated with improved outcomes.

Intra-abdominal hypertension and abdominal compartment syndrome following surgery for ruptured abdominal aortic aneurysm.

OBJECTIVES: To investigate the importance of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), based on the December 2004 consensus definition, on outcome after surgery for ruptured abdominal aortic aneurysm (rAAA). METHODS: Twenty-seven patients underwent open surgery for rAAA after the introduction of intra-abdominal pressure (IAP) measurements among patients at risk of IAH. Case-records were reviewed retrospectively. Seventeen patients underwent IAP-monitoring. RESULTS: Of eight patients with IAP <21 mmHg none developed colonic ischaemia or ACS. Of four patients with IAP 21-25 mmHg (IAH grade III), two underwent colonic resection. One patient treated with open abdomen died from cardiac arrhythmia. Five patients had IAP >25 mmHg (IAH grade IV). All developed ACS. Two were not decompressed and both developed pulmonary complications, one died. Two underwent colonic resection and one was treated with open abdomen, all three survived. Of 10 patients not monitored for IAP, one died of cardiac complications, but no patient developed signs of colonic ischaemia or ACS. Mortality at 30 days and 1 year was 3/27 (11%). CONCLUSION: IAH and ACS were common among patients undergoing surgery for rAAA. The ACS consensus definition seems appropriate in this clinical context. Monitoring IAP, and timely decompression of patients with IAH might improve outcome after surgery for rAAA.

Day-to-day variability of transcutaneous oxygen tension in patients with diabetes mellitus and peripheral arterial occlusive disease.

PURPOSE: We evaluated the day-to-day variability of transcutaneous oxygen tension (tcPO2) in patients with diabetes mellitus and peripheral arterial occlusive disease who were at risk for chronic foot ulceration. METHODS: The tcPO2 was measured in the morning once daily for 3 consecutive days in 10 male patients with diabetes mellitus who were hospitalized. The mean age of the patients was 65 +/- 13 years, and they had a mean duration of diabetes mellitus of 33 +/- 6 years. The tcPO2 was measured at a reference point at the chest (I2 dx), the dorsum of the foot, and in the first intermetatarsal space. Measurements of tcPO2 in the first intermetatarsal space were performed before and during inhalation of 100% oxygen. RESULTS: The mean tcPO2 was higher (P <.001) at I2 dx (56 +/- 10 mm Hg) than at the dorsum of the foot (25 +/- 19 mm Hg) and first intermetatarsal space (27 +/- 20 mm Hg). tcPO2 increased (P <.001) during inhalation of 100% oxygen, whereas the increase was severely reduced in three patients with tcPO2 less than 10 mm Hg at baseline. A reasonably good day-to-day variability of tcPO2 was seen; the linear relations between tcPO2 investigated on days 1, 2, and 3 were highly significant (P =.0001) at each measuring site, and no systematic differences were seen between the repeated measurements (analysis of variance; P =.13 to.85). CONCLUSION: The results show an acceptable day-to-day variability of tcPO2, both at baseline and during oxygen inhalation, in patients with diabetes mellitus and peripheral arterial occlusive disease.