Late closure of the open abdomen in emergency abdomino-pelvic surgery: Advanced indications to negative pressure wound therapy?

Background: Damage control surgery(DCS) is a well-established approach in emergency laparotomy when physiologic instability necessitates an abbreviated operation. In severe intraabdominal infections(IAI), open abdomen(OA) with Negative Pressure Wound Therapy(NPWT) has shown significant efficacy to help reducing morbidity and mortality. Early definitive abdominal closure is recommended to minimize complications, though not always achievable. Methods: From 108 cases of DCS and OA with NPWT performed between February 2015 and February 2024, 72 consecutive patients treated for severe IAI were retrospectively reviewed. We comparatively analyzed clinical and perioperative data of patients treated with OA for ≤ 7 days(short OA) or for > 7 days(long OA), focusing on late OA closure(> 7 days). Primary outcome was overall 30-day survival, secondary outcome the primary fascial closure rate. Results: The main indication for OA was abdominal contamination. Fifty-six patients had short OA, 16 long OA. Overall mortality was 23.6%, with APACHE II score the only independent predictor (OR 1.9, 95% CI 1.25-2.92, p = 0.003). Fifty-two patients survived to achieve early closure and 12 late closure, respectively. Overall PFC rate was 92.2% (59 patients), 75% within late closure (p = 0.001). Compared to short OA, in long OA nine patients (56.3%, p < 0.001) experienced intraabdominal complications including enteroatmospheric fistula (EAF-3, 18.8%) and frozen abdomen (7, 43.8%); in 10 patients (87.5%, p < 0.001) NPWT regimen was modified to isolate and divert effluent or clean a contaminated field. Conclusions: Late closure of the OA for IAI may significantly associate with EAF and frozen abdomen. In these challenging scenarios NPWT specific properties may be leveraged to address complex anatomical situations, extensive contamination, or the need for targeted wound-healing responses.