腹腔开放疗法在严重腹腔感染中的应用

严重腹腔感染传统的治疗措施包括感染源控制措施、抗感染药物合理应用.近年发展为液体复苏与脏器功能支持和腹腔开放疗法.综合这些措施可将腹腔感染的总体病死率降低至20％以下.腹部创伤与感染时,腹腔内压升高、腹腔灌注压降低、腹部脏器灌流不足,外科医师主动将腹腔敞开,此即为腹腔开放疗法.腹腔开放可有效降低腹内压,改善腹腔灌注压,有助于感染源的清创与引流,及时发现处理出血和肠瘘等并发症.腹腔开放疗法的主要并发症是肠空气瘘.防治肠空气瘘的主要措施包括各种临时关腹措施以及早期封闭裸露创面.     

腹腔开放治疗肠瘘并严重腹腔感染73例分析

目的 研究腹腔开放治疗肠外瘘并腹腔感染的时机、方法与效果。比较不同暂时关腹技术,研究消化道与腹壁重建的时机与效果。方法 回顾性分析1999年1月至2008年12月南京军区南京总医院73例接受腹腔开放疗法的肠外瘘并严重腹腹腔感染的临床资料。结果 56例（76.7%）行腹腔开放疗法后存活（存活组）,10例（13.7%）死亡,7例（9.6%）放弃治疗（死亡及放弃治疗者统称为死亡及放弃治疗组）。死亡原因主要是腹腔出血（5例）、感染和脏器功能衰竭（5例）。腹腔开放前的APACHE II评分在存活组和死亡及放弃治疗组分别为13.5±4.3和16.0±5.8,腹腔开放后第5天时分别降至9.2±4.5和12.9±5.5;腹腔开放第15天时,存活组APACHEII评分降至8.1±6.2,而死亡及放弃治疗组评分重新升高至腹腔开放前水平（16.3±11.8）。脏器功能障碍评分亦有类似变化。结论 腹腔开放可有效治疗肠外瘘并严重腹腔感染病人。在多脏器功能严重损害前及时行腹腔开放疗法可有效改善肠瘘并严重腹腔感染的疾病严重度。腹腔开放后第15天左右的疾病严重度可提示病人的转归。行腹腔开放的病人可分为暂时关腹、创面植皮和永久重建3个阶段。消化道与腹壁重建可同时进行。     

重症急性胰腺炎及腹腔感染所致腹腔开放病人的营养支持

目的探讨不同营养支持方式在重症急性胰腺炎及腹腔感染所致的腹腔开放(open abdomen, OA)病人中的应用和对病人预后的影响。方法回顾性纳入自2016年1月至2020年12月上海交通大学医学院附属第九人民医院普外科重症监护室所收治的因重症急性胰腺炎和腹腔感染行OA治疗的病人25例。回顾病人病程中的营养支持方式并将病人分为单纯肠内营养组(enteral nutrition, EN, 8例)及EN联合全肠外营养(total parenteral nutrition, EN+TPN,17例),比较两组病人一般临床资料、热卡达标率、胃肠道功能障碍及临床预后的差异。结果两组病人年龄、性别、原发病、合并症、疾病危重度、静息能量消耗、感染指标、肝肾功能、凝血功能等差异均无统计学意义(均P0.05)。热卡达标率比较,EN组早期热卡达标率显著低于EN+TPN组(营养支持第5、7、11天比较,均P0.05),平均达标时间显著长于EN+TPN组(P=0.005)。胃肠道功能障碍比较中,EN+TPN组消化道麻痹发生率显著高于EN组(37.5%比82.4%,P=0.024)。临床预后比较,两组死亡率差异无统计学意义(P0.05),EN组住院总费用显著低于EN+TPN组(P=0.045)。结论 OA病人给予单纯EN的营养支持方式是安全可行的,虽然额外添加TPN能早期达到热卡目标,但并未能让病人获益。     

腹腔感染的抗生素疗法

本文所指腹腔感染是指腹腔内消化系统各种非特异性感染性疾病及其各种原因引起的继发性腹膜炎,血源性感染如肝脓肿、腰大肌脓肿不在本文讨论之列。本文讨论腹腔感染抗生素治疗过程中几个重要问题。一、致病菌早在70年代．Gorbach等人就在腹腔感染动物模型上证实,腹腔感染的急性脓毒症期（头3天）主要致病菌为大肠杆菌及其他G-需氧杆菌．脓肿形成期（3天后）主要为脆弱类杆菌及其他G-厌氧杆菌。国内陈菊香等人报告40例腹腔感染,82．5％病人获得阳性培养结果,单纯厌氧菌、单纯需氧菌、混合阳性分别占27．3％、33．3％及39．4％,其中G杆…     

腹腔开放疗法研究进展

正腹腔开放疗法(open abdomen technique)是由英国的Ogilvie医生于1940年提出,用于战伤致腹壁毁损的救治。随后将腹腔开放疗法纳入损伤控制外科,用于创伤病人的救治。此外,为治疗腹腔感染、血管瘤破裂及重症急性胰腺炎合并腹腔间室综合征(abdominal compartment syndrome,ACS)常须采用主动的腹腔开放。本文就腹腔开放疗法的适应证、暂时性关腹措施及后期的腹壁重建等做一综述,为开放腹腔的管理及后续治疗提供证据支持。     

暂时性腹腔关闭与常规关腹技术治疗严重腹腔感染的临床对比

目的观察暂时性腹腔关闭(temporary abdominal closure,TAC)与常规关腹技术在严重腹腔感染中的临床效果。方法回顾性分析2010年3月~2014年7月15例严重腹腔感染的临床资料,其中8例采用负压封闭引流关闭系统(vacuum sealing drainage,VSD)行暂时性关腹,7例常规关腹。比较2组术后腹内压变化、创面愈合时间、术后并发症等。结果常规关腹组术后72 h内腹内压逐渐升高,术后6~72 h各监测的时间点均高于暂时性关腹组(P0.01)。暂时性关腹组术后腹内压变化相对平稳(波动在7.7~18.1 mm Hg之间),创面愈合早[(11.3±1.8)d vs.(19.4±6.7)d,t=-3.142,P=0.005],切口感染少[12.5%(1/8)vs.100%(6/6),P=0.005]。结论暂时性腹腔关闭技术在治疗严重腹腔感染中能有效地预防腹内压升高,促进创面愈合,减少术后并发症,疗效确切。     

重症急性胰腺炎的腹腔高压与腹腔开放治疗

Severe acute pancreatitis (SAP) can induce intra-abdominal hypertension, which has an adverse effect on the function of urinary, circulatory, digestive and neurological system, and finally leads to abdominal compartment syndrome (ACS) if patients were not timely treated. This article focuses on the close relationship between SAP and ACS, which included the definition, classification, pathogenesis of ACS and its pathophysiologic effects on other important organs. The different types and indications of surgical interventions of ACS were discussed in detail. For SAP patients complicated with ACS, urgent open abdomen is important to decrease the abdominal pressure and to prevent the incidence of multi-organ dysfunction syndrome. Complications after open abdomen, such as intestine fistula,abdominal sepsis, intestinal dysfunction and abdominal deficit,should be managed prudently.     

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

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.     

腹腔开放所致复杂腹壁缺损的确定性修复

目的探讨联合应用多种腹壁缺损修复技术治疗腹腔开放所致复杂腹壁缺损的效果。 方法收集2013年1月至2018年1月,东南大学医学院附属江阴医院9例因腹腔间室综合征或严重腹腔感染导致腹腔开放进而引起的复杂腹壁缺损行腹壁缺损修复患者的临床资料,分析其治疗方法和临床效果。 结果本组9例患者中,手术时间（4.5±3.2）h,术后住院时间（9.0±4.2）d。术后腹壁缺损完全修复,且腹壁功能恢复良好患者7例;再发腹壁缺损患者2例。 结论联合应用多种腹壁缺损修复技术可以有效修复腹腔开放导致的复杂腹壁缺损,为这一困难临床结局提供了可行的解决途径。     

Staged management of the open abdomen and enteroatmospheric fistulae using split-thickness skin grafts

Background

Management of the open abdomen with polyglactin 910 mesh followed by split-thickness skin grafts allows safe, early closure of abdominal wounds. This technique can be modified to manage enteroatmospheric fistulae. Staged ventral hernia is performed in a less inflamed surgical field.

Methods

A retrospective review was performed of 59 consecutive patients who underwent abdominal skin grafting for open abdominal wounds from 2001 to 2011.

Results

The median length of follow-up was 215 days. Thirty-one percent of patients presented with preexisting enteroatmospheric fistulae, and 41% required polyglactin 910 mesh placement before skin grafting. Partial or complete skin graft failure occurred in 7 patients. Four patients required repeat skin grafting. All patients ultimately achieved abdominal wound closure, and none developed de novo fistulae.

Conclusions

With proper technique, skin grafting of the open abdomen with a planned ventral hernia repair is a safe and effective alternative to delayed primary closure.     

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

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.     

The sentinel placement of an open abdomen negative pressure unit

The open abdomen is a common condition after a trauma necessitating celiotomy with the inability to close the fascia either due to damage control surgery or abdominal compartment syndrome. Traditionally the open abdomen has been approached with the use of the open abdomen temporary abdominal closure (Barker Vacuum Pack Dressing). More recently there has been the addition of the ABThera™ open abdomen negative pressure unit introduced by KCI. Our case report is based on the first patient to have placement of the ABThera™ device.     

Outcomes of primary fascial closure after open abdomen for nontrauma emergency general surgery patients

Background

Emergency general surgery patients are increasingly being managed with an open abdomen (OA). Factors associated with complications after primary fascial closure (PFC) are unknown.

Methods

Demographic and operative variables for all emergency general surgery patients managed with OA at an academic medical center were prospectively examined from June to December 2013. Primary outcome was complication requiring reoperation.

Results

Of 58 patients, 37 managed with OA achieved PFC. Of these, 14 needed re-exploration for dehiscence, compartment syndrome, infection, or other. Complications after PFC were not associated with age, type of operative intervention, time to closure, re-explorations, comorbidities, or mortality. Complications correlated with higher body mass index (P = .02), skin closure (P = .04), plasma infusion (P = .01), and less intraoperative bleeding (P = .05). Deep surgical site infection correlated with fascial dehiscence (P = .02).

Conclusions

Reoperation after PFC was more likely in obese and nonhemorrhagic patients. Recognition of these factors and strategies to reduce surgical site infection may improve outcomes.     

Treatment of the open abdomen with topical negative pressure therapy: a retrospective study of 46 cases

The open abdomen is an ongoing challenge for professionals engaged in its treatment. The change in the integrity of the abdominal wall, the loss of fluids, heat and proteins and contamination of the wound are the main problems. The objective of this article is to describe our experience using the abdominal dressing vacuum‐assisted closure therapy in treatment of the open abdomen. Since December 2006, all patients requiring treatment with the open abdomen technique have been treated with the abdominal dressing system and vacuum‐assisted closure therapy (VAC^® KCI, San Antonio, USA). The results obtained with this technique in non traumatic patients are analysed herein. The abdominal dressing system was used on 46 patients in the period between January 2006 and December 2009, with a mean 63 years old (29–80), with a gender distribution of 33 men (72%) and 13 women (28%). Closure of the abdominal wall was possible in 24 patients, 5 of which were primary in the recent postoperative phase, 5 had primary suture of the fascia and application of the supra‐aponeurotic prosthesis and 14 had closure of the abdominal wall with a composite polytetrafluoroethylene (PTFE) and polypropylene mesh. Second intention closure took place in the remaining 22 patients (48%), as their conditions did not allow primary closure. The mean treatment time with abdominal dressing was 26 days (6–92) with an average of eight changes per patient. The abdominal dressing topical negative pressure system is a useful option for consideration in the event of needing to leaves the abdomen open. It stabilises the abdominal wall and quantifies and collects exudate from the wound, protects the intra‐abdominal viscera and keeps the fascia intact and the cutaneous plane for subsequent closure of the wall.