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Treatments and other prognostic factors in the management of the open abdomen: A systematic review

Cristaudo, Adam T. MS; Jennings, Scott B. MPhil; Hitos, Kerry PhD; Gunnarsson, Ronny MD, PhD; DeCosta, Alan FRACS

Journal of Trauma and Acute Care Surgery: February 2017 - Volume 82 - Issue 2 - p 407–418
doi: 10.1097/TA.0000000000001314
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BACKGROUND The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain with it associated with a high incidence of complications and poor outcomes. The objective of this article is to perform a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify prognostic factors in OA patients in regard to definitive fascial closure (DFC), mortality and intra-abdominal complications.

METHODS An electronic database search was conducted involving Medline, Excerpta Medica, Central Register of Controlled Trials, Cumulative Index to Nursing, and Allied Health Literature and Clinicaltrials.gov. All studies that described prognostic factors in regard to the above outcomes in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest and assessed for methodological quality.

RESULTS Thirty-one studies were included in the final synthesis. Enteral nutrition, organ dysfunction, local and systemic infection, number of reexplorations, worsening Injury Severity Score, and the development of a fistula appeared to significantly delay DFC. Age and Adult Physiology And Chronic Health Evaluation version II score were predictors for in-hospital mortality. Failed DFC, large bowel resection and >5 to 10 L of intravenous fluids in <48 hours were predictors of enteroatmospheric fistula. The source of infection (small bowel as opposed to colon) was a predictor for ventral hernia. Large bowel resection, >5 to 10 and >10 L of intravenous fluids in <48 hours were predictors of intra-abdominal abscess. Fascial closure on (or after) day 5 and having a bowel anastomosis were predictors for anastomotic leak. Overall methodological quality was of a moderate level.

LIMITATIONS Overall methodological quality, high number of retrospective studies, low reporting of prognostic factors and the multitude of factors potentially affecting patient outcome that were not analyzed.

CONCLUSION Careful selection and management of OA patients will avoid prolonged treatment and facilitate early DFC. Future research should focus on the development of a prognostic model.

LEVEL OF EVIDENCE Systematic review, level III.

From the Department of Surgery (A.T.C., K.H.), Westmead Research Centre for Evaluation of Surgical Outcomes, University of Sydney, Westmead Hospital, Westmead, NSW, Australia; Department of Cardiac and Thoracic Surgery (S.B.J.), Flinders Medical Centre, Adelaide, SA, Australia; College of Medicine and Dentristry, James Cook University (R.G), College of Medicine, Cairns Hospital, Cairns, QLD, Australia; and Department of Surgery (A.D.), College of Medicine and Dentristry, James Cook University, College of Medicine, Cairns Hospital, Cairns, QLD, Australia.

Submitted: May 9, 2016, Revised: September 19, 2016, Accepted: September 23, 2016, Published online: November 30, 2016.

List of meetings at which the article was presented:

The 2015 Joint Meetings of the Section of Academic Surgery (SAS), the Surgical Research Society of Australasia (SRS) and the Academy of Surgical Educators (ASE) Forum in Sydney, Australia (Poster Presentation).

The 2016 Royal Australasian College of Surgeons Annual Scientific Congress in May, in Brisbane, Australia (Verbal Presentation).

The 2016 Westmead Association Hospital Week Research Symposium in August, in Sydney, Australia (Poster Presentation).

Address for reprints: Adam T. Cristaudo, MS, Westmead Research Centre for Evaluation of Surgical Outcomes, Department of Surgery, University of Sydney, Westmead Hospital, Westmead, NSW, 2145, Australia. Address: 2 Hubner Drive, Rothwell, QLD, 4022; email: adamcristaudo@bigpond.com.

© 2017 Lippincott Williams & Wilkins, Inc.