Subscribe to RSS
DOI: 10.1055/s-0042-119303
Prognosefaktoren der offenen Abdominalbehandlung in der Viszeralchirurgie
Prognostic Factors of Open Abdomen Treatment in Visceral SurgeryPublication History
Publication Date:
24 April 2017 (online)
![](https://www.thieme-connect.de/media/zblchir/201703/lookinside/thumbnails/10-1055-s-0042-119303_zbc1268-1.jpg)
Zusammenfassung
Einführung In der Allgemeinchirurgie dient die offene Abdominalbehandlung (OAT) der Behandlung von abdominellem Kompartmentsyndrom (ACS) und Sepsis, häufig nach einer mit Komplikationen verbundenen Primäroperation. Die Ergebnisse bei diesem Kollektiv hängen möglicherweise von noch unbekannten Faktoren ab. In dieser Studie werden unabhängige patientenbezogene Prognosefaktoren nach OAT untersucht.
Methoden Es wurden 38 klinische Parameter und Überlebensdaten zu 165 konsekutiven Patienten der Allgemeinchirurgie nach OAT gemäß einem festgelegten klinischen Algorithmus in eine prospektive Datenbank eingegeben. Bewertet wurden die chirurgische Grunderkrankung, Überlebensprädiktoren und wichtige Aspekte OAT-bezogener Morbidität. Es wurden unabhängige Prädiktoren für Überleben, OAT-bezogene Morbidität und Dauer des Krankenhausaufenthalts identifiziert.
Ergebnisse OAT-Indikationen waren häufig Peritonitis, Blutungen und ACS. Das Durchschnittsalter der Patienten lag bei 60 Jahren und > 80 % gehörten der Kategorie ASA III/IV an; die Nachuntersuchung erfolgte im Durchschnitt nach 23 Monaten. In 19 % der Fälle waren onkologische Eingriffe erfolgt. Die 30-Tage-Mortalität lag bei 11 %, die 1-Jahres-Mortalität bei 34 %. Malignität war ein negativer Prädiktor (OR 4,63; 95 %-KI: 2,00–10,7), während Übergewicht/leichte Adipositas (BMI 25–35) sowie primärer Faszienverschluss, der bei 82 % der Patienten erreicht wurde, die Überlebensrate verbesserte (OR 0,2; 95 %-KI: 0,07–0,55) bzw. (OR 0,19; (95 %-KI: 0,06–0,57). Nach OAT war häufig das Auftreten einer enteroatmosphärischen Fistel (19 %, EAF) und einer ventralen Hernierung bei unmöglichem Faszienverschluss (18 %) zu verzeichnen. Malignität war ein unabhängiger Risikofaktor für EAF (OR 3,47; 95 %-KI: 1,41–8,53). Weder ein vakuumassistierter Wundverschluss noch eine Polyglactin-Netzeinlage wirkten sich auf das Auftreten der EAF aus.
Schlussfolgerung Allgemeinchirurgische Patienten nach OAT unterscheiden sich signifikant von Traumakohorten, und Mortalität sowie Langzeitmorbidität sind hoch. Der Ausgang wird wesentlich von unabhängigen patientenbezogenen Faktoren nach OAT bestimmt. Zur Verbesserung der Ergebnisse nach OAT wird eine individuell angepasste chirurgische Versorgung auf der Grundlage objektiver Nachweise benötigt.
Abstract
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.
-
Literatur
- 1 de Costa A. Making a virtue of necessity: managing the open abdomen. ANZ J Surg 2006; 76: 356-363
- 2 Burlew CC. The open abdomen: practical implications for the practicing surgeon. Am J Surg 2012; 204: 826-835
- 3 Campbell A, Chang M, Fabian T. et al. Management of the open abdomen: from initial operation to definitive closure. Am Surg 2009; 75 (11) (Suppl.): S1-S22
- 4 Regner JL, Kobayashi L, Coimbra R. Surgical strategies for management of the open abdomen. World J Surg 2012; 36: 497-510
- 5 Diaz jr. JJ, Cullinane DC, Dutton WD. et al. The management of the open abdomen in trauma and emergency general surgery: part 1 – damage control. J Trauma 2010; 68: 1425-1438
- 6 Hirshberg A, Mattox KL. Planned reoperation for severe trauma. Ann Surg 1995; 222: 3-8
- 7 Schein M. Planned reoperations and open management in critical intra-abdominal infections: prospective experience in 52 cases. World J Surg 1991; 15: 537-545
- 8 Quyn AJ, Johnston C, Hall D. et al. The open abdomen and temporary abdominal closure systems–historical evolution and systematic review. Colorectal Dis 2012; 14: e429
- 9 Verdam FJ, Dolmans DE, Loos MJ. et al. Delayed primary closure of the septic open abdomen with a dynamic closure system. World J Surg 2011; 35: 2348-2355
- 10 Bee TK, Croce MA, Magnotti LJ. et al. Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure. J Trauma 2008; 65: 337-342
- 11 Willms A, Güsgen C, Schaaf S. et al. Management of the open abdomen using vacuum-assisted wound closure and mesh-mediated fascial traction. Langenbecks Arch Surg 2015; 400: 91-99
- 12 Batacchi S, Matano S, Nella A. et al. Vacuum-assisted closure device enhances recovery of critically ill patients following emergency surgical procedures. Crit Care 2009; 13: R194
- 13 Cheatham ML, Malbrain ML, Kirkpatrick A. et al. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations. Intensive Care Med 2007; 33: 951-962
- 14 Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978; 12: 85-109
- 15 Korenkov M, Paul A, Sauerland S. et al. Classification and surgical treatment of incisional hernia. Results of an expertsʼ meeting. Langenbecks Arch Surg 2001; 386: 65-73
- 16 Muysoms FE, Miserez M, Berrevoet F. et al. Classification of primary and incisional abdominal wall hernias. Hernia 2009; 13: 407-414
- 17 Dubose JJ, Scalea TM, Holcomb JB. et al. Open abdominal management after damage-control laparotomy for trauma: a prospective observational American Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 2013; 74: 113-120
- 18 Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993; 270: 2957-2963
- 19 Cheatham ML, Safcsak K, Fiscina C. et al. Advanced age may limit the survival benefit of open abdominal decompression. Am Surg 2011; 77: 856-861
- 20 Sauvanet A, Mariette C, Thomas P. et al. Mortality and morbidity after resection for adenocarcinoma of the gastroesophageal junction: predictive factors. J Am Coll Surg 2005; 201: 253-262
- 21 Schroeder RA, Marroquin CE, Bute BP. et al. Predictive indices of morbidity and mortality after liver resection. Ann Surg 2006; 243: 373-379
- 22 [Anonymous] Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Am J Clin Nutr 1998; 68: 899-917
- 23 Davenport DL, Xenos ES, Hosokawa P. et al. The influence of body mass index obesity status on vascular surgery 30-day morbidity and mortality. J Vasc Surg 2009; 49: 140-147
- 24 Sakr Y, Elia C, Mascia L. et al. Being overweight or obese is associated with decreased mortality in critically ill patients: a retrospective analysis of a large regional Italian multicenter cohort. J Crit Care 2012; 27: 714-721
- 25 Hatch QM, Osterhout LM, Podbielski J. et al. Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. J Trauma 2011; 71: 1503-1511
- 26 Miller RS, Morris jr. JA, Diaz jr. JJ. et al. Complications after 344 damage-control open celiotomies. J Trauma 2005; 59: 1365-1371
- 27 Pliakos I, Papavramidis TS, Mihalopoulos N. et al. Vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: a clinical trial. Surgery 2010; 148: 947-953
- 28 Rasilainen SK, Mentula PJ, Leppäniemi AK. Vacuum and mesh-mediated fascial traction for primary closure of the open abdomen in critically ill surgical patients. Br J Surg 2012; 99: 1725-1732
- 29 Falconi M, Pederzoli P. The relevance of gastrointestinal fistulae in clinical practice: a review. Gut 2001; 49 (Suppl. 04) iv2-10
- 30 Majercik S, Kinikini M, White T. Enteratmospheric fistula: from soup to nuts. Nutr Clin Pract 2012; 27: 507-512