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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.
RESUMO
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.