Long Term Outcome After Open Abdomen Treatment: Function and Quality of Life.

Background: Open abdomen treatment (OAT) is widely accepted to manage severe abdominal conditions such as peritonitis and abdominal compartment syndrome but can be associated with high morbidity and mortality. The main risks in OAT are (1) entero-atmospheric fistula (EAF), (2) failure of primary fascial closure, and (3) incisional hernias. In this study, we assessed the long-term functional outcome after OAT to understand which factors impacted most on quality of life (QoL)/daily living activities and the natural course after OAT. Materials and Methods: After a retrospective analysis of 165 consecutive OAT patients over a period of 10 years (2002-2012) with over 65 clinical parameters that had been performed at our center (1), we initiated a prospective structured follow-up approach. All survivors were invited for a clinical follow-up. Forty complete datasets including clinical and social follow-up with SF-36 scores were available for full analysis. Results: The patients were dominantly male (75%) with a median age of 52 years. Primary fascial closure (PC) was achieved in 9/40 (23%), while in 77% a planned ventral hernia (PVH) approach was followed. A total of 3/4 of the PVH patients underwent a secondary-stage abdominal wall reconstruction (SSR), but 2/3 of these reconstructed patients developed recurrent hernias. Fifty-five percent of the patients with PC developed an incisional hernia, while 20% of all patients developed significant scarring (Vancouver Scar Score >8). Scar pain was described by 15% of the patients as "moderate" [Visual Analog Scale (VAS) 4-6] and by 10% as "severe" (VAS > 7). While hernia presence, PC or PVH, and scarring showed no impact on QoL, male sex and especially EAF formation significantly reduced QoL. Discussion: Despite many advantages, OAT was associated with relevant mortality and morbidity, especially in the early era before the implementation of a structured concept at our center. Follow-up revealed that hernia incidence after OAT and secondary reconstruction were high and that 25% of patients qualifying for a secondary reconstruction either did not want surgery or were unfit. Sex and EAF formation impacted significantly on QoL, which was lower than in the general population. With regard to hernia incidence, new strategies such as prophylactic mesh implantation upon fascial closure should be discussed analogous to other major abdominal procedures.

[Prognostic Factors of Open Abdomen Treatment in Visceral Surgery]. / Prognosefaktoren der offenen Abdominalbehandlung in der Viszeralchirurgie.

Introduction In general surgery, open abdomen treatment (OAT) is used to treat abdominal compartment syndrome (ACS) and sepsis, often after a primary surgical procedure associated with complications. The results achieved in this patient population may depend on factors that are yet unknown. This study evaluates independent patient-related prognostic factors after OAT. Methods 38 clinical parameters and survival data of 165 consecutive general surgery patients after OAT were entered into a prospective database according to a defined algorithm in order to analyse the underlying surgical pathology, predictors of survival and important aspects of OAT-related morbidity. Independent predictors of survival, OAT-related morbidity and duration of hospital stay were identified. Results Common indications for OAT were peritonitis, haemorrhage and ACS. Median age was 60 years and > 80 % of patients were ASA III/IV; median follow-up was 23 months. Oncologic surgery was performed in 19 % of cases. 30-day and 1-year mortality was 11 % and 34 %, respectively. Malignancy was a negative predictor (OR: 4.63, 95 % CI: 2.00-10.7) while mild obesity (BMI 25-35) and primary fascial closure, which was achieved in 82 % of patients, improved survival (OR: 0.2, 95 % CI: 0.07-0.55; OR: 0.19, 95 % CI: 0.06-0.57). Enteroatmospheric fistula (EAF) and giant hernia with impossible fascial closure were frequent after OAT (19 and 18 %), and malignancy was an independent risk factor for EAF (OR 3.47, CI [95 %]: 1.41-8.53). Vacuum-assisted wound closure or polyglactin mesh interposition did not affect EAF incidence. Conclusions General surgery patients after OAT differ significantly from trauma patients, and mortality as well as long-term morbidity is high. Outcome is greatly determined by independent patient-related factors after OAT. A tailored surgical approach based on objective evidence is needed to further improve the results after OAT.