Comparison of early surgical alternatives in the management of open abdomen: a randomized controlled study

BACKGROUND: Abdominal compartment syndrome (ACS) is a clinical syndrome characterized by progressive intraabdominal organ dysfunction resulting from an acute increase in intra-abdominal pressure (IAP). In the absence of prompt treatment, ACS can
lead to lethal organ failure. Treatment of ACS is achieved by immediate decompression of the abdominal cavity. As to how and when decompression laparotomy should be performed depends on the clinical condition of the patients. There is limited data regarding outcomes of abdominal closure techiques. The present study aimed to investigate two different temporary closure methods, the vacuum assisted closure (VAC) and Bogota bag techniques, in 40 patients who underwent decompressive laparotomy as part of the management of ACS.
METHODS: The study included 40 patients who developed ACS during follow-up or following trauma and abdominal surgery. As part of the treatment for ACS, these patients underwent decompressive laparotomy at the Cukurova University Medical Faculty, General Surgery Department and followed up in the Intensive Care Unit of the same hospital. VAC and Bogota bag procedures were performed as temporary closure methods for the treatment of ACS. Patients were randomly assigned to each of the two groups according to the temporary closure method performed. Clinical, laboratory, mortality and morbidity results of the patients in both groups were compared.
RESULTS: Demographic features of the patients (age, sex, body mass index, co-morbidities) were similar between the two groups. The most common reason of ACS was gastrointestinal perforation in 12 (30%) patients. Decrease in incision width was significantly faster in the VAC group than in the Bogota group. Primary closure of fascia was considered appropriate in 16.9 days in the VAC group and 20.5 days in the Bogota bag group. The decrease in abdominal pressure was similar between the two groups on days 1, 4 and 7 but appeared to be significantly lower on day 14 in the VAC group. 12 patients (30%) died during the study. Among the deceased patients, 5 (12%) were in the VAC group, whereas, 7 (17.5%) belonged to the Bogota bag group.
CONCLUSION: Based on these results, it is suggested that VAC has advantages when compared to the Bogota bag as a temporary closure method in the management of abdominal compartment syndrome.

Open abdomen yönetiminde erken dönem cerrahi alternatiflerin karþýlaþtýrýlmasý: Randomize ileriye yönelik çalýþma

AMAÇ: Abdominal kompartman sendromu (AKS), sýnýrlý bir anatomik alana sahip karýnda basýncýn akut ve patolojik artýþý ile karakterize olup, tedavi edilmediði takdirde yüksek oranda mortaliteyle sonuçlananan klinik bir durumdur. Karýniçi basýncýn progresif yükselmesi sonucu ortaya çýkan bu sendromun etkileri sistemik olarak ortaya çýkar. Abdominal kompartman sendromunun tedavisi, artmýþ karýniçi basýncýn düþürülmesidir. Dekompresif
laparotomi kararýný vermede en önemli kriter hastanýn klinik tablosudur. Grade 3 ve 4 hastalarda dekompresif laparatomiyi takiben ameliyat sonrasý karýniçi basýncýn tekrar yükselmesini engellemek için karýn kapatýlmaz, açýk abdomen uygulanýr. Bu çalýþmada, dekompresif laparotomi uygulanmýþ evre 3 ve 4 AKS’li hastalara geçici karýn kapatýlmasýnda kullanýlan Vacuum-assisted closure (VAC) ve Bogota bag yöntemlerinin randomize ileriye yönelik deðerlendirilmesi amaçlandý.
GEREÇ VE YÖNTEM: Bu çalýþmaya Þubat 2007 ile Eylül 2010 tarihleri arasýnda Çukurova Üniversitesi Týp Fakültesi Genel Cerrahi Yoðun Bakýmý’na travma, geçirilmiþ cerrahi sonrasý ya da medikal takiplerinin izlemi sýrasýnda AKS geliþmiþ ve tedavilerinin bir parçasý olarak dekompresif laparotomi uygulanmýþ 40 hasta alýndý. Hastalar ardýþýk randomizasyon yöntemi ile VAC ve Bogota bag olmak üzere iki gruba ayrýldý. Geçici karýn kapama yöntemleri olan bu yöntemlerin sonuçlarý gruplar arasýnda randomize ileriye yönelik olarak klinik, laboratuvar, morbidite ve mortalite yönünden karþýlaþtýrýlarak deðerlendirilldi.
BULGULAR: Her iki gruptaki hastalarýn yaþ, cinsiyet, vücut kitle indeksi ve yandaþ hastalýklarý gibi demografik özellikleri arasýnda anlamlý fark yoktu. AKS geliþen hastalarda etiyolojik faktörler arasýnda en sýk neden 12 hastada (%30) görülen gastrointestinal sistem perforasyonu idi. Ýnsizyon boyutu ölçümlerinde VAC grubunda daha anlamlý bir azalma vardý. Hastanýn primer fasya kapatýlmasý için uygun hale gelmesi için geçen zaman VAC grubunda 16.9 gün iken, Bogota bag’li grupta 20.5 gün idi. Karýniçi basýncý düþürme deðerlendirildiðinde; her iki grupta 1., 4. ve 7. günlerde benzer oranlarda düþme saptanýrken, ameliyat sonrasý 14. günde VAC grubunda anlamlý olarak daha fazla düþme saptandý. Mortalite geliþen hasta sayýsý 12 (%30) iken, beþ (%12.5) hasta VAC grubuna, yedi (%17.5) hasta Bogota bag grubuna aitti.
TARTIÞMA: Bulgulara dayanarak geçici karýn kapama yöntemi olarak VAC uygulamasýnýn daha uygun olduðu kanaatindeyiz.