Management of the Open Abdomen

A National Study of Clinical Outcome and Safety of Negative Pressure Wound Therapy

Abstract

Objective: 

To determine clinical outcome of open abdomen therapy and assess the influence of negative pressure wound therapy on outcome.

Background: 

Leaving the abdomen open (laparostomy) is an option following laparotomy for severe abdominal sepsis or trauma. Negative pressure wound therapy (NPWT) has become a popular means of managing laparostomy wounds. It may facilitate nursing care and delayed primary wound closure but the evidence to support its use is poor and concern has arisen about the risk of intestinal fistulation from exposed bowel, leading to an increased risk of death.

Methods: 

Prospective observational study of 578 patients treated with an open abdomen in 105 hospitals in the United Kingdom between January 1, 2010, and June 30, 2011. Propensity analysis was used to compare adverse outcomes (fistulation, death, intestinal failure, bleeding requiring intervention) and delayed primary closure rates in patients who did and did not receive NPWT.

Findings: 

The most common indication for an open abdomen (n = 398, 68.9%) was abdominal sepsis. Overall hospital mortality was 28.2%. The majority of patients (n = 355, 61.4%) were treated with NPWT. Intestinal fistulation [relative risk (RR) = 0.83, 95% confidence interval (CI): 0.44–1.58], death (RR = 0.87, 95% CI: 0.64–1.20), bleeding (RR = 0.74, 95% CI: 0.45–1.23), and intestinal failure (RR = 1.00, 95% CI: 0.64–1.57) were no more common in patients receiving NPWT, but the rate of delayed primary closure was significantly lower (RR = 0.74, 95% CI: 0.60–0.90, P = 0.002) when NPWT was used.

Conclusions: 

The indications for an open abdomen in the United Kingdom appear to be significantly different to those described in N. America, where its use in the management of trauma predominates. NPWT in patients with an open abdomen is not associated with an increase in mortality or intestinal fistulation. It is, however, associated with a reduced rate of delayed primary closure. Although this may be related to patient selection, NPWT may leave patients with abdominal wall defects that require further treatment.

In Brief

This prospective observational study of 578 critically ill surgical patients treated with an open abdomen demonstrated that negative pressure wound therapy was not associated with an increased risk of death, intestinal fistulation, or other serious complications, but it was associated with a lower rate of delayed primary closure.