Pérdida de proteínas en líquido peritoneal de pacientes críticos con abdomen abierto / Protein loss in peritoneal fluid of critically ill patients with open abdomen

Introducción. Los pacientes con patología abdominal quirúrgica que requieren manejo con abdomen abierto son susceptibles a la pérdida de proteínas desde la cavidad expuesta. El objetivo de este estudio fue caracterizar la pérdida proteica a través de dos tipos de cierre temporal abdominal. Métodos. Se realizó un estudio decohorte prospectivo, con pacientes críticos manejados durante el año 2021 con abdomen abierto mediante dos tipos de cierre temporal: bolsa de Bogotá y ABThera™. Se recolectaron muestras intraoperatorias seriadas de líquido peritoneal (días 1, 3 y 5). Se calcularon frecuencias y promedios, y se compararon con las pruebas de Chi cuadrado y t de Student. Resultados. Se incluyeron 25 pacientes. El promedio de pérdida de proteínas en líquido peritoneal fue mayor con el sistema ABThera™ (44,38 g/L) comparado con la bolsa de Bogotá (25,18 g/L; p=0,0185). Durante el seguimiento se observó la tendencia a la disminución del promedio de proteínas perdidas por ambos sistemas, pero con ABThera™ se perdieron en promedio 15,47 gr/L más de proteínas, independientemente del estado nutricional y del aporte proteico recibido (p=0,042). No hubo diferencias según la etiología que llevó al manejo con abdomen abierto, los procedimientos quirúrgicos realizados o el estado de infección por COVID-19. Conclusiones. El abdomen abierto representa una fuente importante de pérdida de proteínas, que es diferente según el tipo de cierre temporal usado. Estas pérdidas deberían considerarse en los cálculos de soporte nutricional en la unidad de cuidado intensivo.

Introduction. Patients with surgical abdominal pathology requiring management with an open abdomen are susceptible to protein loss from the exposed cavity. The objective of this study was to characterize protein loss through two types of temporary abdominal closure. Methods. A prospective cohort study was carried out with critically ill patients managed during 2021 with an open abdomen using two types of temporary closure: Bogota bag and ABThera™. Serial intraoperative peritoneal fluid samples were collected (days 1, 3, and 5). Frequencies and averages were calculated and compared with the Chi square and Student's t tests. Results. Twenty-five patients were included. The average protein loss in peritoneal fluid was higher with the ABThera™ system (44.38 g/L) compared to the Bogota bag (25.18 g/L; p-value=0.0185). During follow-up, a tendency to decrease the average protein lost by both systems was observed, but with ABThera™ an average of 15.47 gr/L more protein was lost, regardless of the nutritional status and protein intake received (p=0.042). There were no differences based on etiology leading to open abdomen management, surgical procedures performed, or Covid-19 infection status. Conclusions. The open abdomen represents an important source of protein loss, which is different depending on the type of temporary closure used. These losses should be considered in calculations of nutritional support in the intensive care unit.

Managing the Open Abdomen: Selecting an Appropriate Treatment Strategy.

Significance: The laparotomy is a common surgical procedure with a wide range of indications. Ideally, once the goals of surgery were achieved, the incision edges could then be approximated and the abdomen primarily closed. However, in some circumstances, it may be impossible to achieve primary closure, and instead the abdomen is intentionally left open. This review discusses the indications and objectives for the open abdomen (OA), summarizes the most common techniques for temporary abdominal closure, and illustrates treatment algorithms grounded in the current recommendations from specialty experts. Recent Advances: Still a relatively young technique, multiple strategies, and technologies have emerged to manage the OA. So too have the recommendations evolved, based on updated classifications that take wound characteristics into account. Recent studies have also brought greater clarity on recommendations for managing infection and malnutrition to support improved clinical outcomes. Critical Issues: The status of the OA can change rapidly depending on the patient's condition, the wound quality, and many other factors. Thus, there is a significant need for comprehensive treatment strategies that can be adapted to these developing circumstances. Future Directions: Treatment recommendations should be continuously updated as new technologies are introduced and old techniques fall out of use.

Negative Pressure Wound Therapy After Intestinal Anastomosis: A Risk Factor Analysis for Dehiscence.

INTRODUCTION: Negative pressure wound therapy (NPWT) is part of the temporary abdominal closure in the treatment of patients with traumatic, inflammatory, or vascular disease. However, the use of NPWT when performing an intestinal anastomosis has been controversial. This study aimed to describe the patients managed with NPWT therapy and identify the risk factors for anastomotic dehiscence when intestinal anastomosis was performed. METHODS: A single-center cohort study with prospectively collected databases was performed. Patients who required NPWT therapy from January 2014 to December 2018 were included. Patients were stratified according to the performance of intestinal anastomosis and according to the presence of dehiscence. Bivariate and multivariate analyses were performed for anastomotic dehiscence and mortality. RESULTS: A total of 97 patients were included. Median age was 52 y old [interquartile range 24.5-70]. Male patients corresponded to 75.6% (n = 34) of the population. Delayed fascial closure was performed in 80% (n = 36). The risk of anastomotic dehiscence was higher in females (odds ratio (OR) 11.52 [confidence interval (CI) 1.29-97.85], P = 0.030), delayed fascial closure (OR 18.18 [CI 2.02-163.5], P = 0.010) and use of vasopressors (OR 12.04 [CI 1.22-118.47], P = 0.033). NPWT pressures >110 mmHg were evidenced in the dehiscence group with statistically significant value (OR 1.2 [0.99-2.26] p 0.04) CONCLUSIONS: There is still controversy in the use of NPWT when performing intestinal anastomosis. According to our data, the risk of dehiscence is higher in females, delayed fascial closure, use of vasopressors, and NPWT pressures >110 MMHG.

Open or closed abdomen post laparotomy to control severe abdominal sepsis: a survival analysis / Abdome aberto ou fechado pós-laparotomia para controle de sepse de foco intra-abdominal severa: uma análise de sobrevivência

ABSTRACT Introduction: severe abdominal sepsis, accompained by diffuse peritonitis, poses a significant challenge for most surgeons. It often requires repetitive surgical interventions, leading to complications and resulting in high morbidity and mortality rates. The open abdomen technique, facilitated by applying a negative-pressure wound therapy (NPWT), reduces the duration of the initial surgical procedure, minimizes the accumulation of secretions and inflammatory mediators in the abdominal cavity and lowers the risk of abdominal compartment syndrome and its associated complications. Another approach is primary closure of the abdominal aponeurosis, which involves suturing the layers of the abdominal wall. Methods: the objective of this study is to conduct a survival analysis comparing the treatment of severe abdominal sepsis using open abdomen technique versus primary closure after laparotomy in a public hospital in the South of Brazil. We utilized data extracted from electronic medical records to perform both descriptive and survival analysis, employing the Kaplan-Meier curve and a log-rank test. Results: the study sample encompassed 75 laparotomies conducted over a span of 5 years, with 40 cases employing NPWT and 35 cases utilizing primary closure. The overall mortality rate observed was 55%. Notably, survival rates did not exhibit statistical significance when comparing the two methods, even after stratifying the data into separate analysis groups for each technique. Conclusion: recent publications on this subject have reported some favorable outcomes associated with the open abdomen technique underscoring the pressing need for a standardized approach to managing patients with severe, complicated abdominal sepsis.

RESUMO Introdução: a sepse abdominal grave, com peritonite difusa, é um grande desafio para o cirurgião geral, sendo muito frequente as reintervenções cirúrgicas e complicações desta doença, que apresenta morbimortalidade elevada. A proposta do abdome aberto, aplicando-se a terapia por pressão negativa (TPN), reduz o tempo operatório da primeira abordagem cirúrgica, reduz o acúmulo de secreções e mediadores inflamatórios no sítio abdominal, diminui a possibilidade de síndrome compartimental abdominal e suas complicações. A outra técnica é a síntese primária, quando é optado por fechar a parede por completo. Métodos: o objetivo do estudo foi realizar uma análise de sobrevivência comparando os tratamentos de sepse intra-abdominal severa com Abdome Aberto e Fechado após laparotomia em um hospital universitário no sul do Brasil. As variáveis foram obtidas a partir de prontuários eletrônicos de pacientes submetidos à intervenção cirúrgica e realizou-se uma análise descritiva e de sobrevivência usando a curva de Kaplan-Meier e o teste de log-rank. Resultados: a amostra incluiu 75 laparotomias em 5 anos (40 TPN e 35 sínteses primárias), com mortalidade de 55%. A sobrevida entre os métodos de fechamento não demonstrou significância estatística, mesmo após a divisão em um grupo de análise de cada técnica. Conclusão: recentes publicações destacam resultados favoráveis do abdome aberto, enfatizando a necessidade urgente de uma sistematização na assistência de pacientes com sepse abdominal complicada grave.

Outcomes and associated factors of open abdomen after urgent laparotomy at a University Hospital in Southern Brazil: a retrospective study / Desfechos e fatores associados em pacientes submetidos ao abdome aberto após laparotomia de urgência em um Hospital Universitário no sul do Brasil: um estudo retrospectivo

ABSTRACT Introduction: The technique of open abdomen refers to a surgical procedure that intentionally involves leaving an opening in the abdominal wall. This study aimed to evaluate the clinical outcomes, mortality, and morbidity of patients undergoing open abdomen in a public hospital in Brazil and investigate associated risk factors associated with the outcome. Methods: Data from electronic medical records were collected from 2017 to 2022. The variables were used for descriptive analyses, association analysis, and survival analysis using the Kaplan-Meier curve. Results: The sample included 104 patients, with 84 presenting with acute abdomen and 20 with trauma, having highly variable ages and comorbidities. Peritonitis and the need for early reoperation were the most common indication for the procedure, each accounting for 34%, and negative pressure wound therapy was the most commonly used technique. Fistula was the most frequent complication, with the majority forming in the early days after the surgery. The number of interventions and open abdomen time obtained statistical significance in comparison with the outcome. The overall mortality rate was 62,5%. Conclusion: Despite open abdomen being a technique that can have benefits in controlling intraabdominal contamination and preventing abdominal compartment syndrome, its implementation is associated with complications. The mortality and complication rates were high in this sample. The decision to use the technique should be individualized and based on several factors, including the indications and the patient's clinical status.

RESUMO Introdução: A técnica de abdome aberto refere-se a um procedimento cirúrgico que envolve deixar deliberadamente uma abertura na parede abdominal. Este estudo teve como objetivo avaliar o desfecho clínico, mortalidade e morbidade de pacientes submetidos ao abdome aberto em um hospital público do Brasil e investigar fatores de risco associados ao desfecho. Métodos: Dados a partir de prontuários eletrônicos foram coletados de 2017 a 2022. As variáveis foram utilizadas para análises descritivas, análise de associação e de sobrevivência pela curva Kaplan-Meier. Resultados: A amostra correspondeu a 104 pacientes, sendo 84 por abdome agudo e 20 por trauma, com idade e número de comorbidades variados. A peritonite e a necessidade de reabordagem precoce foram as causas mais comuns para a indicação do procedimento, 34% cada, e a terapia de pressão negativa foi a mais utilizada neste estudo, seguindo a técnica de Barker. Fístula é a complicação mais frequente (41%), sendo que a maioria se formou nos primeiros dias após a realização da cirurgia. O número de intervenções e o tempo de abdome aberto obtiveram significância estatística na comparação com o desfecho. A mortalidade geral foi de 62,5%. Conclusão: Apesar de o abdome aberto ser uma técnica que pode trazer benefícios no controle da contaminação intra-abdominal e prevenção de síndrome compartimental abdominal, sua realização está associada a complicações. A taxa de mortalidade e morbidade foram elevadas nesta amostra. A decisão para uso da técnica deve ser individualizada e baseada em vários fatores, incluindo as indicações e o estado clínico do paciente.

Enteroatmospheric fistulas in open abdomen in trauma associated with abdominal reintervention and VAC therapy.

BACKGROUND: Open abdomen is an alternative for the management of trauma patient, and negative pressure therapy of the wound using VAC® device is a genuine sort of treatment. Although the device poses technical advantages, risks are present and a critical complication is the enteroatmospheric fistula formation (EAF). OBJECTIVE: To analize the role of negative pressure therapy length and VAC® device number of changes on the EAF formation in trauma patients udergoing open abdomen. METHOD: Cut-off points were calculated using receiver operational characteristics curve. Values were compared with Student's t or Mann-Withney U tests, considering statistically significant p < 0.05. RESULTS: EAF were present in 39 cases (5.9%). A significant difference in the presence of EAF was present in patients with negative pressure therapy of the wound length ≥ 11.2 days (46.9 vs. 1.3%; relative risk [RR]: 3.67; 95% confidence interval [95% IC]: 2.4-6.68; p = 0.017) and when ≥ 2.6 VAC® device changes were performed (34.6 vs. 0.5%; RR: 6.92; 95% IC: 1.1-4.3; p < 0.001). CONCLUSIONS: At our institution, the practice of >3 VAC® device changes and length of therapy > 11 days should be carefully considered leading to reduce the risk of EAF formation.

INTRODUCCIÓN: El abdomen abierto es una alternativa para manejar al paciente traumatizado, y una variante para instituirlo es la terapia de presión negativa de la herida con el dispositivo VAC®. Aunque tiene ventajas técnicas, no está exento de riesgos y una complicación crítica es la formación de fístulas enteroatmosféricas (FEA). OBJETIVO: Analizar el papel de la duración de la terapia de presión negativa y del número de cambios del dispositivo VAC® sobre la aparición de FEA en pacientes traumatizados manejados con abdomen abierto. MÉTODO: Se establecieron puntos de corte con curva de características operacionales del receptor. Los valores se compararon con la prueba t de Student o U de Mann-Whitney, considerando p < 0.05 como valor estadísticamente significativo. RESULTADOS: La FEA se presentó en 39 casos (5.9%). Hubo una diferencia significativa en la aparición de FEA en pacientes con duración de la terapia de presión negativa de la herida ≥ 11.2 días (46.9 vs 1.3%; riesgo relativo [RR]: 3.67; intervalo de confianza del 95% [IC95%]: 2.4-6.68; p = 0.017) y cuando se practicaron ≥ 2.6 cambios del dispositivo VAC® (34.6 vs. 0.5%; RR: 6.92; IC95%: 1.1-4.3; p < 0.001). CONCLUSIONES: En nuestra institución, la práctica de más de tres cambios del dispositivo VAC® y el mantenimiento de la terapia por más de 11 días debe ser cuidadosamente considerado para reducir el riesgo de formación de FEA.

Cierre dinámico y toxina botulínica: una alternativa novedosa para el cierre definitivo del abdomen abierto y contenido / Dynamic closure system and botulinum toxin: a novel alternative for definitive closure of open abdomen

RESUMEN Se presenta el caso de un paciente masculino de 54 años que, cursando internación por neumonía- COVID-19, intercurrió con shock séptico por diverticulitis aguda Hinchey IV, por lo que se realizó cirugía de Hartmann. Evolucionó con isquemia colónica, se realizó colectomía total y abdomen abierto y contenido (AAyC). El manejo del AAyC se realizó con sistema de vacío (VAC) durante 7 semanas, resultando un AAyC tipo IIIa (Björck) con un gap de 16 cm. Se decidió iniciar, una vez dadas las condiciones clínicas del paciente, el cierre dinámico (CD) con tracción fascial con malla de polipropileno asociado a inyección de toxina botulínica (TB). Esta estrategia permitió el cierre fascial primario (CFP) de la pared abdominal en la quinta semana de comenzado el tratamiento, evitando de esta manera la morbilidad de un cierre por segunda intención.

ABSTRACT We report the case of a 54-year-old male patient hospitalized for COVID-19 pneumonia who developed septic shock due to acute Hinchey IV diverticulitis and required Hartmann's surgery. The patient evolved with colonic ischemia and underwent total colectomy and open abdomen (OA) with temporary abdominal closure (TAC) that was managed with a vacuum-assisted wound closure (VAWC) system for 7 weeks, resulting in a Björck grade 3A OA with a 16-cm gap. As he had a favorable clinic course, dynamic closure with mesh-mediated fascial traction was decided, associated with botulinum toxin (BT) injection. This strategy allowed primary fascial closure (PFC) of the abdominal wall 5 weeks after treatment was initiated, thus avoiding the complications of healing by secondary intention.

Cuidados de enfermería en pacientes con abdomen abierto y fístulas enterocutáneas / Nursing Care of Patients with Open Abdomen and Enterocutaneous Fistulas / Cuidados de enfermagem em pacientes com abdome aberto e fístulas enterocutâneas

Introducción. Una de las principales intervenciones que realiza el profesional de enfermería es el cuidado de las heridas, su finalidad es evitar posibles complicaciones y estimular la cicatrización del tejido lesionado. El objetivo de esta investigación fue determinar las intervenciones de enfermería realizadas en pacientes con abdomen abierto y fístulas enterocutáneas mediante la revisión de literatura. Metodología. Se realizó una revisión narrativa en un lapso de 10 meses. Las bases de datos utilizadas fueron: PubMed, ScienceDirect, ClinicalKey, MEDLINE, SciELO y Ovid. Se realizó revisión de 50 artículos que cumplían con el objetivo de la revisión. Resultados. Se encontraron cuidados de enfermería relacionados con los cuidados básicos y específicos en pacientes con abdomen abierto y en fístulas enterocutáneas. Discusión. Diversos autores coinciden en que el uso de la Bolsa de Bogotá, es una de las intervenciones de enfermería más utilizadas para las heridas de abdomen abierto, la medición intraabdominal, que permite la identificación precoz del Síndrome Compartimental Abdominal, y el mantenimiento del objetivo nutricional en pacientes con fístulas enterocutáneas, permiten una recuperación exitosa. Conclusiones. Se pudo determinar que existen diversos cuidados de enfermería que deben considerarse en el manejo del abdomen abierto y de las fístulas enterocutáneas, todos estos cuidados permiten que el personal de enfermería tenga un soporte científico útil en el momento de brindar un cuidado a los pacientes con estas condiciones de salud. Esto, con el fin de evitar o disminuir los riesgos de deshidratación, desequilibrio hidroelectrolítico, desnutrición, sepsis e incluso la muerte.

Introduction. One of the main interventions carried out by nursing professionals is the care of wounds. Its purpose is to avoid possible complications and stimulate the scarring of the wounded tissue. The objective of this investigation was to determine the nursing interventions carried out in patients with open abdomens and enterocutaneous fistulas via a literature review. Methodology. A narrative review was carried out over 10 months. The databases used were: PubMed, ScienceDirect, ClinicalKey, MEDLINE, SciELO, and Ovid. Fifty articles that met the objective of the review were used. Results. Nursing care related to basic and specific care in patients with open abdomens and enterocutaneous fistulas was found. Discussion. Different authors agree on the use of the Bogotá Bag, is one of the most used nursing interventions for open abdominal wounds, intraabdominal measurement, which allows for early identification of Abdominal Compartment Syndrome, and maintenance of nutritional objectives in patients with enterocutaneous fistulas allow for successful recovery. Conclusions. We could determine that there are different types of nursing care that must be considered in the handling of open abdomen and enterocutaneous fistulas. All these types of care allow for nursing staff to have a useful scientific support when providing care to patients with these health conditions. This is in order to avoid or reduce the risks of dehydration, hydroelectrolytic imbalance, malnutrition, sepsis, and even death.

Introdução. Uma das principais intervenções realizadas pelo profissional de enfermagem é o cuidado de feridas, sua finalidade é evitar possíveis complicações e estimular a cicatrização do tecido lesado. O objetivo desta pesquisa foi determinar as intervenções de enfermagem realizadas em pacientes com abdome aberto e fístulas enterocutâneas por meio de uma revisão de literatura. Metodologia. Foi realizada uma revisão narrativa durante um período de 10 meses. As bases de dados utilizadas foram: PubMed, ScienceDirect, ClinicalKey, MEDLINE, SciELO e Ovid. Foi realizada uma revisão de 50 artigos que atenderam ao objetivo da revisão. Resultados. Foram encontrados cuidados de enfermagem relacionados aos cuidados básicos e específicos em pacientes com abdome aberto e fístulas enterocutâneas. Discussão. Vários autores concordam que o uso da Bolsa de Bogotá, é uma das intervenções de enfermagem mais utilizadas para feridas abertas abdominais; a medida intra-abdominal, que permite a identificação precoce da Síndrome do Compartimento Abdominal; e a manutenção do objetivo nutricional nos pacientes com fístulas enterocutâneas, permitem uma recuperação bem sucedida. Conclusões. Foi possível determinar que existem diversos cuidados de enfermagem que devem ser considerados no manejo de abdome aberto e fístulas enterocutâneas, todos esses cuidados permitem que a equipe de enfermagem tenha um apoio científico útil no momento de prestar cuidados aos pacientes com estas condições de saúde. Isso, a fim de evitar ou reduzir os riscos de desidratação, desequilíbrio hidroeletrolítico, desnutrição, sepse e até mesmo a morte.

Plicatura de la bolsa Bogotá en cierre difícil de la pared abdominal / Bogotá Pouch Plication in Difficult Closure of the Abdominal Wall

Introducción: El cierre con pérdida masiva de tejido de la pared abdominal constituye un reto en la cirugía. Objetivo: Presentar un caso de cierre abdominal difícil donde se utilizó la técnica plicatura de la bolsa Bogotá hasta lograr aproximación de los planos cutáneo, muscular y aponeurótico. Caso clínico: Paciente recibido en emergencias con herida perforo-cortante en fosa lumbar izquierda. En la intervención se encontró hemoperitoneo por lesión esplénica, diafragmática y sección del ángulo esplénico del colon. Se le realizó esplenectomía, pleurostomía izquierda y rafia de lesión colónica. Pasadas cinco horas se reintervino por signos de choque y se encontró hematoma retroperitoneal y sección completa del polo superior del riñón izquierdo. Se le realizó nefrectomía izquierda. Al quinto día del posoperatorio mostró signos peritoneales y la exploración confirmó peritonitis fecaloidea por dehiscencia de sutura de colon. Se lavó cavidad y se le ejecutó colostomía tipo Devine. La pérdida masiva de pared abdominal obligó a emplear una plicatura de la bolsa Bogotá para aproximar ambos colgajos, se obtuvo aproximación paulatina hasta la síntesis de la pared. Conclusiones: El abdomen catastrófico es una condición grave y de difícil tratamiento. La bolsa Bogotá es una alternativa viable para esta condición y modificada con plicaturas paulatinas permite el acercamiento de los dos colgajos cutáneos y garantiza el cierre de la pared abdominal, además de ser una técnica fácil de usar y económica(AU)

Introduction: Closure with massive loss of abdominal wall tissue is a challenge in surgery. Objective: To report a case of difficult abdominal closure where the Bogotá bag technique was used until the approximation of the cutaneous, muscular and aponeurotic planes was achieved. Clinical case report: This patient was received in the emergency room with a perforating-cutting wound in the left lumbar fossa. In the intervention, hemoperitoneum was found due to splenic and diaphragmatic injury and section of the splenic flexure of the colon. Splenectomy, left pleurostomy and colonic injury raffia were performed. After five hours, the patient was operated again due to signs of shock. We found a retroperitoneal hematoma and a complete section of the upper pole of the left kidney. It was decided to perform left nephrectomy. On the fifth postoperative day, this patient showed peritoneal signs and examination confirmed fecal peritonitis due to dehiscence of the colon suture. Cavity was washed and a Devine-type colostomy was performed. The massive loss of the abdominal wall made it necessary to use a plication of the Bogotá bag to approximate both flaps, a gradual approximation was obtained until the synthesis of the wall. Conclusions: The catastrophic abdomen is a serious condition that is difficult to treat. The Bogotá bag is a viable alternative for this condition and modified with gradual plications, it allows the two skin flaps to approach each other and guarantees the closure of the abdominal wall, in addition to being an easy-to-use and economical technique(AU)

Retroperitonitis apendicular: factores asociados y manejo de una complicación seria / Appendicular retroperitonitis: associated factors and management of a serious complication

Antecedentes: La retroperitonitis es una rara y severa complicación de la apendicitis. Hasta el presente solo unos pocos reportes de casos han sido publicados en la literatura inglesa. Objetivo: El objetivo de este trabajo es analizar una serie consecutiva de 11 casos tratados en nuestra institución. Materiales y Método: Análisis retrospectivo de una base de datos recolectada en forma prospectiva de todos los pacientes admitidos por retroperitonitis de origen apendicular durante el período marzo 2017-septiembre 2020. Se analizarán las variables asociadas con esta complicación y su manejo. Resultados: 11 pacientes de un total de 601 con diagnóstico de apendicitis presentaron una retroperitonitis durante el período analizado (1,83%). El retardo en el diagnóstico fue en promedio de 8 días (rango 3 - 14 días). Todos los pacientes tuvieron un apéndice retrocecal y 81% presentaron un coprolito asociado. 45% fueron manejados inicialmente con abdomen abierto y contenido, y 55% con cierre fascial primario (50% de fracaso). La morbilidad y mortalidad fueron del 81% y 18%, respectivamente Discusión: La localización retrocecal del apéndice, la presencia de un coprolito y la presentación atípica, con demora en el diagnóstico, fueron factores comunes presentes en nuestra experiencia. El manejo con cierre fascial primario fracasó en la mitad de los casos. La morbimortalidad fue elevada. Conclusión: La retroperitonitis es una infrecuente pero severa complicación de la apendicitis, con elevada morbimortalidad.

Background: Retroperitonitis is a rare and life-threatening complication of appendicitis. So far, only a few cases have been described so far in the English literature. Aim: The objetive of this paper is to analyze a consecutive series of 11 patients treated at our institution. Materials and Method: Retrospective analysis of a prospectively collected database of all patients admitted for appendicular retroperitonitis during the period March 2017-September 2020. The variables associated with this complication and its management are analyzed. Results: 11 patients from 601 with a diagnosis of appendicitis presented with retroperitonitis during the study period (1.83%). Mean delay in diagnosis was 8 days (range 3-14 days). The location of the appendix was retrocecal in all cases and 81% had an appendicolith associated. 45% were initially managed with open abdomen. A 50% failure rate occurred after primary fascial closure. Morbidity and mortality rates were 81% and 18%, respectively. Discussion: Retrocecal location of the appendix, the presence of an appendicolith and atypical presentation with delayed diagnosis were common factors present in our experience. Primary fascial closure was associated with a 50% failure rate. Morbidity and mortality were high. Conclusion: Retroperitonitis is a rare but severe complication of appendicitis, with high morbidity and mortality rates.

Terapia de presión negativa para el manejo de abdomen catastrófico secundario a íleo biliar / Negative Pressure Therapy for Managing Catastrophic Abdomen following Gallstone Ileus

Introducción: El abdomen catastrófico o abdomen hostil es una entidad quirúrgica de gran importancia por la pérdida de los distintos espacios entre los órganos de la cavidad abdominal y las estructuras de la cavidad abdominal. Estas alteraciones producen cambios anatómicos grandes por un síndrome adherencial severo. Objetivo: Demostrar la presentación de un abdomen catastrófico posterior a manejo de íleo biliar en un paciente adulto. Caso clínico: Paciente masculino de 43 años que producto de un abdomen agudo obstructivo por íleo biliar evolucionó tórpidamente en otra casa asistencial. Se realizaron 3 intervenciones quirúrgicas, hasta llegar a nuestra casa asistencial donde se le trata de manera multidisciplinaria e integral. Estuvo 120 días hospitalizado y se le realizó 5 intervenciones quirúrgicas para aplicación y recambio de terapia de presión negativa abdominal abierta (ABThera). Durante la última intervención al encontrar una cavidad limpia y sin fugas se realiza gastroentero anastomosis en Y de Roux con una buena evolución clínico-quirúrgica hasta el alta, con seguimiento dos meses posteriores por consulta externa. Conclusiones: El abdomen catastrófico es un reto para el manejo por los cirujanos porque se requiere aparte de un vasto conocimiento también el apoyo de otras especialidades para poder combatir esta entidad(AU)

Introduction: Catastrophic abdomen or hostile abdomen is a surgical entity of great significance due to the loss of the different spaces between organs and the structures of the abdominal cavity. These alterations produce major anatomical changes due to a severe adhesive syndrome. Objective: To show the presentation of a catastrophic abdomen following gallstone ileus management in an adult patient. Clinical case: A 43-year-old male patient who, as a consequence of an acute obstructive abdomen due to gallstone ileus, had a torpid evolution into another care facility. Three surgical interventions were performed before he arrived at our care facility, where he was treated in a multidisciplinary and comprehensive way. He was hospitalized for 120 days and underwent five surgical interventions for application and replacement of the open abdomen negative pressure therapy (ABThera). During the last intervention, upon finding a clean cavity without leaks, a Roux-en-Y gastroenteric anastomosis was performed, with a good clinical-surgical evolution until discharge and follow-up of two months thereafter in the outpatient clinic. Conclusions: Catastrophic abdomen is a challenge to be managed by surgeons because it requires, apart from vast knowledge, the support of other specialties to combat this entity(AU)

The role of direct peritoneal resuscitation in the treatment of hemorrhagic shock after trauma and in emergency acute care surgery: a systematic review.

PURPOSE: Direct peritoneal resuscitation (DPR) has been used to help preserve microcirculation by reversing vasoconstriction and hypoperfusion associated with the pathophysiological process of shock, which can occur despite appropriate intravenous resuscitation. This approach depends on infusing a hyperosmolar solution intraperitoneally via a percutaneous catheter with the tip ending near the pelvis or the root of the mesentery. The abdomen is usually left open with a negative pressure abdominal dressing to continuously evacuate the infused dialysate. Hypertonicity of the solution triggers visceral vasodilation to help maintain blood flow, even during shock, and is also associated with reduced local inflammatory cytokines and other mediators, preservation of endothelial cell function, and mitigation of organ edema and necrosis. It also has a direct effect on liver perfusion and edema, more rapidly corrects electrolyte abnormalities compared to intravenous resuscitation alone, and may requireless intravenous fluid to stabilize blood pressure, all of which shortens the time required to close patients' abdomen. METHODS: An online query using the search term "direct peritoneal resuscitation" was carried out in PubMed, MEDLINE and SciELO, limited to publications indexed from January 2014 to June 2020. Of the 20 articles returned, full text was able to be obtained for 19. A manual review of included articles' references was resulted in the addition of 1 article, for a total of 20 included articles. RESULTS: The 20 articles were comprised of 15 animal studies, 4 clinical studies,and 1 expert opinion. The benefits include both local and possibly systemic effects on perfusion, hypoxia, acidosis, and inflammation, and are associated with improved outcomes and reduced complications. CONCLUSION: DPR shows promise in patients with hemorrhagic shock, septic shock, and other conditions resulting in an open abdomen after damage control laparotomy.

Abdominal and thoracic wall closure: damage control surgery's cinderella.

Damage control surgery principles allow delayed management of traumatic lesions and early metabolic resuscitation by performing abbreviated procedures and prompt resuscitation maneuvers in severely injured trauma patients. However, the initial physiological response to trauma and surgery, along with the hemostatic resuscitation efforts, causes important side effects on intracavitary organs such as tissue edema, increased cavity pressure, and hemodynamic collapse. Consequently, different techniques have been developed over the years for a delayed cavity closure. Nonetheless, the optimal management of abdominal and thoracic surgical closure remains controversial. This article aims to describe the indications and surgical techniques for delayed abdominal or thoracic closure following damage control surgery in severely injured trauma patients, based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. We recommend negative pressure dressing as the gold standard technique for delayed cavity closure, associated with higher wall closure success rates and lower complication and mortality rates.

Los principios de la cirugía de control de daños consisten en realizar procedimientos abreviados que permiten diferir el manejo de la lesión traumática para lograr una resucitación metabólica temprana en pacientes severamente comprometidos en su fisiología. Sin embargo, la respuesta fisiológica inicial al trauma y a la cirugía, junto con los esfuerzos de resucitación hemostática, pueden generar edema en los órganos abdominales o torácicos, aumento de la presión en la cavidad visceral y repercusiones hemodinámicas. En consecuencia, con el paso de los años se han desarrollado técnicas para el cierre diferido de la cavidad; aunque, existen controversias sobre la técnica más adecuada para el cierre quirúrgico tanto del abdomen, como del tórax. El objetivo de este artículo es presentar las indicaciones y técnicas quirúrgicas para el cierre diferido del abdomen y tórax respecto a la cirugía de control de daños del paciente con trauma severo, a partir de la experiencia del grupo de cirugía de Trauma y Emergencias de Cali, Colombia. Se recomienda el uso de los sistemas de presión negativa como la estrategia ideal para el cierre diferido de la pared abdominal o torácica, que se asocia con una mayor tasa de cierre definitivo, una menor tasa de complicaciones y mejores resultados clínicos.

Manejo del abdomen abierto en el paciente crítico en un centro de nivel III de Popayán / Management of the open abdomen in critically ill patients in a tertiary level hospital in Popayán

Introducción. El abdomen abierto es un recurso útil para el tratamiento de pacientes con patología abdominal compleja, con potencial de complicaciones. El objetivo de este estudio fue adaptar la guía de World Society of Emer-gency Surgery (WSES) 2018, en un hospital de nivel III de atención de la ciudad de Popayán, Colombia, y comparar los resultados obtenidos con los previos a su implementación. Métodos. Estudio cuasi-experimental en dos mediciones de pacientes con abdomen abierto y estancia en cuidado crítico, durante los meses de abril a octubre de los años 2018 y 2019, antes y después de la adaptación con el personal asistencial de la guía de práctica clínica WSES 2018. Se utilizó estadística descriptiva, prueba de Chi cuadrado y se empleó el software SPSS V.25. Resultados. Se incluyeron 99 pacientes críticos, con una edad media de 53,2 años, con indicación de abdomen abierto por etiología traumática en el 28,3 %, infecciosa no traumática en el 32,3 % y no traumática ni infecciosa en el 37,4 %. La mortalidad global fue de 25,3 %, de los cuales, un 68 % se debieron a causas ajenas a la patología abdominal. Las complicaciones postoperatorias se presentaron en 10 pacientes con infección de sitio operatorio y 9 pacientes con fístula enterocutánea. El uso del doble Viaflex se implementó en un 63,6 %, logrando un cierre de la pared abdominal en el 79,8 % de los casos (p=0,038). Conclusión. El abdomen abierto requiere de un abordaje multidisciplinar. El uso de doble Viaflex es una herramienta simple y efectiva. La implementación de la guía disminuyó el porcentaje de mortalidad, los días de abdomen abierto y la estancia en cuidados intensivos.

Introduction. The open abdomen is a useful resource for the treatment of patients with complex abdominal pathology, with the potential for complications. The aim of this study was to adapt the World Society of Emergency Surgery (WJES) 2018 guidelines, in a tertiary level hospital and compare the results obtained with those prior to its implementation. Methods. Experimental study in two measurements of patients with open abdomen and stay in critical care, during the months of April to October in 2018 and 2019, before and after the adaptation with the healthcare personnel of the WSES 2018 clinical practice guide. Descriptive statistics, Chi square test and SPSS V.25 software were used. Results. Ninety-nine critically ill patients were included, with a mean age of 53.2 years, with an indication of open abdomen due to traumatic etiology in 28.3%, infectious non-traumatic in 32.3%, and non-traumatic or infectious in 37.4 %. Overall mortality was 25.3%, of which 68% were due to causes other than abdominal pathology. Post-operative complications occurred in 10 patients with surgical site infection and 9 patients with enterocutaneous fistula. The use of the double Viaflex was implemented in 63.6%, achieving a closure of the abdominal wall in 79.8% (p=0.038) of the cases.Conclusion. The open abdomen requires a multidisciplinary approach. The use of double Viaflex is a simple and effective tool. The implementation of the guide decreased the percentage of mortality, the days of open abdomen and the stay in intensive care unit.

Terapia asistida con vacío y estoma flotante (floating stoma): una nueva forma de tratar un absceso periostomal / Vacuum assisted therapy and floating stoma: S new way to treat a periostomal abscess

Resumen Introducción: Los estomas flotantes se definen como un estoma que no está fijado a la piel de la pared abdominal, esta técnica se ha descrito en cirugía para fístulas entero-atmosféricas y de control de daños. Caso Clínico: Presentamos un reporte de caso de manejo de absceso paraostomal en paciente con antecedente de laparotomía por abdomen agudo, por lo que se decide uso de terapia de presión negativa asociada a estoma flotante, demostrando su utilidad en este tipo complejo de pacientes.

Introduction: Floating stomata are defined as a stoma that is not attached to the skin of the abdominal wall, this technique is described in surgery for entero-atmospheric fistulas and damage control. Clinical Case: We present a case report of the management of paraostomal abscess in a patient with a history of laparotomy due to acute abdomen, it was decided to use negative pressure therapy associated with a floating stoma, demonstrating its usefulness in this complex type of patient.

Abdominal and thoracic wall closure: damage control surgery's cinderella / El cierre de la pared abdominal y torácica: La cenicienta en la cirugía control de daños

Abstract Damage control surgery principles allow delayed management of traumatic lesions and early metabolic resuscitation by performing abbreviated procedures and prompt resuscitation maneuvers in severely injured trauma patients. However, the initial physiological response to trauma and surgery, along with the hemostatic resuscitation efforts, causes important side effects on intracavitary organs such as tissue edema, increased cavity pressure, and hemodynamic collapse. Consequently, different techniques have been developed over the years for a delayed cavity closure. Nonetheless, the optimal management of abdominal and thoracic surgical closure remains controversial. This article aims to describe the indications and surgical techniques for delayed abdominal or thoracic closure following damage control surgery in severely injured trauma patients, based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. We recommend negative pressure dressing as the gold standard technique for delayed cavity closure, associated with higher wall closure success rates and lower complication and mortality rates.

Abdominal compartment syndrome among surgical patients.

Abdominal compartment syndrome (ACS) develops when organ failure arises secondary to an increase in intraabdominal pressure. The abdominal pressure is determined by multiple factors such as blood pressure, abdominal compliance, and other factors that exert a constant pressure within the abdominal cavity. Several conditions in the critically ill may increase abdominal pressure compromising organ perfusion that may lead to renal and respiratory dysfunction. Among surgical and trauma patients, aggressive fluid resuscitation is the most commonly reported risk factor to develop ACS. Other conditions that have also been identified as risk factors are ascites, hemoperitoneum, bowel distention, and large tumors. All patients with abdominal trauma possess a higher risk of developing intra-abdominal hypertension (IAH). Certain surgical interventions are reported to have a higher risk to develop IAH such as damage control surgery, abdominal aortic aneurysm repair, and liver transplantation among others. Close monitoring of organ function and intra-abdominal pressure (IAP) allows clinicians to diagnose ACS rapidly and intervene with target-specific management to reduce IAP. Surgical decompression followed by temporary abdominal closure should be considered in all patients with signs of organ dysfunction. There is still a great need for more studies to determine the adequate timing for interventions to improve patient outcomes.

Factores asociados a sepsis abdominal en pacientes con laparotomía por trauma abdominal penetrante / Factors associated with abdominal sepsis in patients with laparotomy due to penetrating abdominal trauma

Introducción. Los pacientes que sufren algún tipo de trauma tienen una presentación clínica muy variable, por lo que se han diseñado pautas diagnósticas y terapéuticas con el fin de disminuir el número de laparotomías innecesarias. Las herramientas actuales para la predicción de infección intraabdominal, permiten intervenciones tempranas en los pacientes con alto riesgo y un mejor seguimiento clínico posoperatorio. El objetivo de este trabajo fue realizar un estudio de los factores asociados al desarrollo de las infecciones intraabdominales o sepsis abdominal posterior a laparotomía por trauma penetrante. Métodos. Estudio descriptivo de una cohorte de pacientes atendidos por trauma abdominal penetrante en el Hospital Universitario de Santander, Bucaramanga, Colombia, entre enero de 2016 y diciembre de 2018. El análisis de datos se realizó en el software Stata®, versión 14 (StataCorp. LP, College Station, TX, USA). Resultados. Se incluyeron 174 pacientes con edad media de 32 años, el 10,9 % (n=19) de los pacientes presentaron sepsis abdominal, de este grupo el 94,7 % (n=18) requirieron reintervención quirúrgica (p < 0,0001). La mortalidad general del grupo fue de 5,1 % (n=9), sin diferencia significativa entre los pacientes con o sin sepsis abdominal. Discusión. Dentro de los diferentes desenlaces asociados a laparotomía por trauma, se describe la sepsis abdominal como una de las complicaciones que genera morbilidad significativa, con aumento en la estancia hospitalaria, necesidad de reintervención, aumento en los costos de atención y disminución en la calidad de vida, factores en concordancia con los hallazgos del presente estudio

Introduction. Patients who suffer some type of trauma have a highly variable presentation, which is why diagnostic and therapeutic guidelines have been designed in order to reduce the number of unnecessary laparotomies. Current tools for the prediction of intra-abdominal infections allow early interventions in high-risk patients and a better postoperative clinical follow-up. The objective of this article was to study the factors associated with the development of intra-abdominal infections or abdominal sepsis after laparotomy due to penetrating trauma. Methods. Descriptive study of a cohort of patients treated for penetrating abdominal trauma at the Santander University Hospital, Bucaramanga, Colombia, between January 2016 and December 2018. Data analysis was performed using Stata® software, version 14 (Stata corp. LP, College Station, TX, USA). Results. A total of 174 patients with a mean age of 32 years were included, 10.9% (n=19) of the patients presented abdominal sepsis, of this group 94.7% (n=18) had a surgical reintervention (p < 0.0001). The overall mortality of the group was 5.1% (n=9) with no significant difference between patients with or without abdominal sepsis. Discussion. Among the different outcomes associated with laparotomy due to trauma, abdominal sepsis is described as one of the complications that generates significant morbidity, with an increase in hospital stay, the need for reoperation, an increase in care costs and a decrease in quality of life, factors in agreement with the findings of the present study

Abdomen abierto y cierre temprano de la pared abdominal / Open abdomen and early closure of the abdominal wall

El abdomen abierto es una opción terapéutica en pacientes críticamente enfermos. Se utiliza cuando el cierre de la cavidad abdominal no puede o no debe ser realizado. No obstante, su utilidad como parte de una estrategia tradicionalmente aceptada ha disminuido, en la medida en que se han incrementado las secuelas en la pared abdominal, en especial la hernia ventral. Los procedimientos requeridos para la reconstrucción anatómica y funcional de la pared abdominal, como parte del tratamiento de una hernia ventral, revisten una alta complejidad y constituyen un nuevo escenario quirúrgico. Igualmente, conllevan incertidumbre respecto a su naturaleza y posibles complicaciones, además de que condicionan mayores gastos al sistema de salud. Para evitar los problemas del cierre tardío de la pared abdominal, se han desarrollado alternativas para superar el abordaje tradicional de "tratar y esperar", hacia "tratar y reconstruir" tempranamente. El objetivo de la presente revisión es realizar una descripción de los principales avances en el tratamiento del abdomen abierto y el papel del cierre temprano de la pared abdominal, haciendo énfasis en la importancia de un cambio conceptual en el mismo

The open abdomen is a therapeutic option in critically ill patients. It is used when the closure of the abdominal cavity cannot or should not be performed. However, its usefulness as part of a traditionally accepted strategy has diminished, as sequelae in the abdominal wall, especially ventral hernia, have increased. The procedures required for the anatomical and functional reconstruction of the abdominal wall, as part of the treatment of a ventral hernia, are highly complex and constitute a new surgical scenario. Likewise, they lead to uncertainty regarding their nature and possible complications, in addition to conditioning higher expenses for the health system. To avoid the problems of delayed closure of the abdominal wall, alternatives have been developed to overcome the traditional "try and wait" approach to "treat and reconstruct" early. The objective of this review is to describe the main advances in the treatment of the open abdomen and the role of early closure of the abdominal wall, emphasizing the importance of a conceptual change in it

Successful management of the open abdomen with hydrocolloid dressing in a resource-constrained setting.

PURPOSE: To evaluate and detail the management of a difficult, long-term, open abdomen in a resource constraint setting with the use of Hydrocolloid dressing. METHOD: An observational retrospective study was conducted at a single level-1 trauma center. Over a 5-year period, all the open abdomen patients were evaluated and the cohorts who were treated with Hydrocolloid dressings were described in detail from their admission to their discharge. RESULTS: During this period, there were 147 open abdomens. 7.5% (11) patients required long-term open abdomen management, in which Hydrocolloid dressing was utilized. Of this group, there were no entero/colonic-atmospheric fistulas, and there was either de-novo complete skin coverage, successful skin graft placement, or definitive abdominal wall repair in all the patients. De-novo complete skin coverage took an average of 7.4 months. All the patients were discharged home after an average of 107 days hospitalized. CONCLUSION: Despite not being an optimal management of an open abdomen, there are always a small group of these patients who lose abdominal domain, are critically ill or injured, and have prolonged hospitalization with an open abdomen. In this cohort, and especially in resource constraint settings, Hydrocolloid dressing is a cost-efficient, simple, and effective method to treat the 'long-term' open abdomens.