The Open Abdomen for the Management of Critically Ill Patients with Abdominal Sepsis: Safe? Yes! Effective? Perhaps!

Background The use of Open Abdomen (OA) has been increasingly adopted in the last years to manage patients with severe abdominal sepsis. Several techniques for temporary abdominal closure (TAC) during OA, such as Negative Pressure Wound Therapy (NPWT), have been proposed. The aim of this study was to analyze the outcomes of patients with intra-abdominal infections treated with OA. Methods Ninety-six patients treated with OA for severe secondary peritonitis and/or septic shock from January 2010 to March 2018 were included in the study. Patients demographics with the clinical picture and the type of TACs adopted were the independent variables analyzed. Major outcomes were: DFC rate, morbidity, and mortality. Minor outcomes included the number of revisions and length of the period with OA. Results Patients population included 50 males and 46 females (M: F ratio 1.09:1). Mean age was 66.9 years, mean BMI was 26.3 Kg/m2. 89% of patients presented with an ASA score ≥ 3. Mean Mannheim Peritonitis Index (MPI) was 22.7 (SD ± 6.5). With regard to the negative pressure systems, this was used in 82 patients (85%) with the following distribution: Barker’s vacuum-pack in 41 patients (43%); NPWT system in 38 (39%) and NPWT with dynamic fascial tension system in 3 (3%). In 14 patients (15%), a skin-closure technique was adopted. Overall, the post-operative complications rate was 73%. According to Clavien and Dindo Classification, 25 patients (45%) presented a grade ≥ III complication (6 grade IIIa; 5 grade IIIb; 8 grade IVa and 6 grade IVb). Entero-atmospheric fistula was observed in 2 patients, one in the group treated with NPWT system and one in the group with Barker’s vacuum-pack. DFC was reached in 82 out of 83 patients (99%) who survived the initial operation. In 10 patients (12%), a prosthetic mesh was used. Overall mortality rate was 42%. Mortality rate during OA was 14% (13 patients): for these patients, the mean time from the first laparotomy to death was 6 days. The mortality rate after definitive fascial closure was 33% (27 patients) with an interval from DFC to death of 17.2 days. Meanly, the length of OA was 3.1 days and the number of revisions was 1.4. Conclusion OA appears to be a safe method to manage critically ill patients with abdominal sepsis. Negative pressure systems for temporary abdominal closure allow reaching a high rate of DFC with a low number of enteroatmospheric fistulas. However, morbidity and mortality remain severe suggesting that randomized studies are needed to prove the effectiveness of OA in severe abdominal sepsis.