Development and validation of a multivariable prediction model in open abdomen patients for entero-atmospheric fistula.

BACKGROUND: Laparostomy or Open Abdomen (OA) has matured into an effective strategy in the management of abdominal catastrophe. Single prognostic factors have been identified in a previous systematic review regarding entero-atmospheric fistula (EAF). Unfortunately, no prognostic multivariable model for EAF exist. The aim was to develop and validate a multivariable prediction model from a retrospective cohort study involving three hospital's databases. METHODS: Fifty-seven variables were evaluated to develop a multivariable model. Univariate and multivariable logistic regression analyses were performed for on a developmental data set from two hospitals. Receiver operator characteristics analysis with area under the curve (AUC) and 95% confidence intervals (CI) were performed on the developmental data set (internal validation) as well as on an additional validation data set from another hospital (external validation). RESULTS: Five-hundred and forty-eight patients managed with an OA. Two variables remained in the multivariable prediction model for EAF. The AUC for EAF on internal validation were 0.74 (95% CI: 0.58-0.86) and 0.79 (95% CI: 0.67-0.92) on external validation. CONCLUSIONS: A multivariable prediction model for EAF was externally validated and an easy-to-use probability nomogram was constructed using the two predictor variables. LEVEL OF EVIDENCE: III; prognostic.

Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis.

Temporary abdominal closure (TAC) techniques are routinely used in the open abdomen. Ideally, they should prevent evisceration, aid in removal of unwanted fluid from the peritoneal cavity, facilitate in achieving safe definitive fascial closure, as well as prevent the development of intra-abdominal complications. TAC techniques used in the open abdomen were compared with negative pressure wound therapy (NPWT) to identify which was superior. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines involving Medline, Excerpta Medica, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Clinicaltrials.gov. All studies describing TAC technique use in the open abdomen were eligible for inclusion. Data were analyzed per TAC technique in the form of a meta-analysis. A total of 225 articles were included in the final analysis. A meta-analysis involving only randomized controlled trials showed that NPWT with continuous fascial closure was superior to NPWT alone for definitive fascial closure [mean difference (MD): 35% ± 23%; P = 0.0044]. A subsequent meta-analysis involving all included studies confirmed its superiority across outcomes for definitive fascial closure (MD: 19% ± 3%; P < 0.0001), perioperative (MD: -4.0% ± 2.4%; P = 0.0013) and in-hospital (MD: -5.0% ± 2.9%; P = 0.0013) mortality, entero-atmospheric fistula (MD: -2.0% ± 1.8%; P = 0.0041), ventral hernia (MD: -4.0% ± 2.4%; P = 0.0010), and intra-abdominal abscess (MD: -3.1% ± 2.1%; P = 0.0044). Therefore, it was concluded that NPWT with continuous fascial traction is superior to NPWT alone.

Treatments and other prognostic factors in the management of the open abdomen: A systematic review.

BACKGROUND: The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain with it associated with a high incidence of complications and poor outcomes. The objective of this article is to perform a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify prognostic factors in OA patients in regard to definitive fascial closure (DFC), mortality and intra-abdominal complications. METHODS: An electronic database search was conducted involving Medline, Excerpta Medica, Central Register of Controlled Trials, Cumulative Index to Nursing, and Allied Health Literature and Clinicaltrials.gov. All studies that described prognostic factors in regard to the above outcomes in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest and assessed for methodological quality. RESULTS: Thirty-one studies were included in the final synthesis. Enteral nutrition, organ dysfunction, local and systemic infection, number of reexplorations, worsening Injury Severity Score, and the development of a fistula appeared to significantly delay DFC. Age and Adult Physiology And Chronic Health Evaluation version II score were predictors for in-hospital mortality. Failed DFC, large bowel resection and >5 to 10 L of intravenous fluids in <48 hours were predictors of enteroatmospheric fistula. The source of infection (small bowel as opposed to colon) was a predictor for ventral hernia. Large bowel resection, >5 to 10 and >10 L of intravenous fluids in <48 hours were predictors of intra-abdominal abscess. Fascial closure on (or after) day 5 and having a bowel anastomosis were predictors for anastomotic leak. Overall methodological quality was of a moderate level. LIMITATIONS: Overall methodological quality, high number of retrospective studies, low reporting of prognostic factors and the multitude of factors potentially affecting patient outcome that were not analyzed. CONCLUSION: Careful selection and management of OA patients will avoid prolonged treatment and facilitate early DFC. Future research should focus on the development of a prognostic model. LEVEL OF EVIDENCE: Systematic review, level III.