Open abdomen therapy with vacuum-assisted wound closure and mesh-mediated fascial traction

Introduction: Several life-threatening intra-abdominal conditions may be treated with open abdomen (OA) therapy. Potential complications to OA treatment include damage to the exposed bowel resulting in enteric fistulas, and inability to close the abdomen afterwards resulting in large ventral hernias. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) is a novel technique for temporary closure of an OA, intended to increase the chances of subsequent delayed primary fascial closure without increasing the risk of complications. A classification system for the OA has been proposed by the World Society of the Abdominal Compartment Syndrome (WSACS), aimed at improving OA therapy and facilitating clinical research, but has not previously been evaluated. Aims: The aims were to study: - Short-term clinical outcome of OA therapy with VAWCM with regards to fascial closure and factors associated with failure of fascial closure, mortality, morbidity and possible technique-related complications. - One-year clinical outcome of OA therapy with VAWCM with regards to the incidence of incisional- and parastomal hernias, abdominal wall discomfort and frequency of hernia repair operations after one year. - Validity and reliability of the 2013 OA classification system by WSACS and to propose instructions for use with the classification. - Physiological effects of vacuum therapy (VAWC) in an OA with regards to the extent of negative pressure reaching the bowel, the efficacy of the VAWC system in draining fluid from the abdominal cavity and whether paraffin gauzes can be effectively used as pressure isolation when placed between the vacuum source and the bowel. Results/conclusions : - VAWCM provided a high fascial closure rate after long-term OA treatment in mostly elderly, non-trauma patients. Technique-related complications were few and fistula incidence and mortality were similar to other studies. - Incisional hernia incidence one year after OA therapy with VAWCM was high. Most hernias were small and asymptomatic and few required surgical repair during the first year. - The validity and reliability analysis of the OA classification system by WSACS showed that each patient’s most complex OA grade, worsening OA grade without later improvement, as well as development of grade C (enteric leak) or grade 4 (entero-atmospheric fistula) were associated with worse outcome (mortality and failure of fascial closure). Every effort should be made to prevent patients from ascending to a more complex OA grade, to try to repair enteric leaks and to avoid enteroatmospheric fistulas. - Negative pressure reaching the bowel during VAWC therapy was limited, regardless of negative pressure setting. Reduced therapy pressure did not lead to reduced pressure at the bowel surface. The system drained the abdominal cavity completely of fluid. Paraffin gauzes were of limited value as a means of isolation against pressure propagation

Evaluation of the Open Abdomen Classification System: A Validity and Reliability Analysis.

Classification of the open abdomen (OA) status is essential for clinical studies on the subject and may help to improve OA therapy. This is a validity and reliability analysis of the OA classification proposed by the World Society of the Abdominal Compartment Syndrome in 2013

Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Non trauma Surgical Patients

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are commonly encountered in nontrauma surgical patients. Depending on the etiology of the patient's surgical illness (ruptured abdominal aortic aneurysm, acute pancreatitis, burns, etc.), both the incidence and mortality of IAH/ACS may be quite high. Recent advances in both the diagnosis and resuscitation of these surgical patients have resulted in significantly improved survival over that seen in years past. Intra-abdominal pressure measurements should be performed in any surgical patient who demonstrates risk factors for IAH/ACS

Pressure at the Bowel Surface during Topical Negative Pressure Therapy of the Open Abdomen: An Experimental Study in a Porcine Model.

BACKGROUND: Topical negative pressure (TNP) therapy is increasingly used in open abdomen management. It is not known to what extent this pressure propagates through the dressing to the bowel surface, potentially increasing the risk of bowel fistula formation. The present study in a porcine model was designed to evaluate pressure propagation. METHODS: A commercially available TNP therapy system (ABThera/VAC) was applied in six pigs after laparotomy. Pressure sensors were placed in predetermined positions in the dressing and in the abdominal cavity and the pressure was registered at TNP settings of -50, -75, -100, -125, and -150 mmHg. Next, after infusing 200 ml of saline into the abdomen through a catheter, the amount of fluid drained through the system during 10 min of TNP therapy was registered. Finally, pressure was measured above and below eight layers of paraffin gauzes during TNP therapy. RESULTS: Observed pressure within the outer two foams and the foam of the visceral protective layer correlated with preset TNP. The median pressure at the bowel surface was between -2 and -10 mmHg, regardless of preset TNP. Median fluid drainage was 95% of the infused fluid at -75 mmHg and 124% at -150 mmHg. Paraffin gauzes had a limited isolating effect, reducing the pressure by 13% in median. CONCLUSIONS: Negative pressure reaching the bowel surface during TNP therapy with the ABThera system is limited for all TNP levels. Reduced therapy pressure does not lead to reduced pressure at the bowel surface. The system drains the abdominal cavity completely of fluid. Paraffin gauzes are of limited value as a means of pressure isolation

The effects of smoking in pregnancy on factors influencing fetal growth

To access Publisher full text version of this article. Please click on the hyperlink in Additional Links fieldAIM: To evaluate the influence of maternal smoking during pregnancy on factors influencing fetal growth. METHODS: Thirty newborns of smoking mothers were prospectively compared with 60 newborns of non-smoking mothers. Pre-albumin, albumin, triglycerides, glucose, insulin, insulin-like growth factor I, IGF binding protein 3, pH, lactic acid, erythropoietin and hemoglobin concentrations were measured in umbilical cord blood. RESULTS: Infants of smoking mothers had a significantly lower birth weight (3418 +/- 533 vs. 3863 +/- 503 g; p < 0.001), length (50.5 +/- 2,6 vs. 52.3 +/- 1.9 cm; p < 0.001) and head circumference (34.6 +/- 1.8 vs. 35.8 +/- 1.1 cm; p < 0.001) than controls. They also had significantly lower insulin (3.2 (2.0-4.9) vs. 5.8 (4.6-7.1) mU/L; p = 0.008), insulin-like growth factor I (54.4 +/- 32.5 vs. 93.8 +/- 54.5 microg/L; p = 0.001) and IGF binding protein 3 (1664 +/- 432 vs. 1943 +/- 421 microg/L; p = 0.01) concentrations, than controls. Infants of smoking mothers also had significantly higher hemoglobin (167 +/- 14 vs. 157 +/- 13 g/L; p = 0.002) and erythropoietin (42.3 (25.1-72.4) vs. 26.3 (21.9-30.9) U/L; p = 0.03) than controls, but not pH or lactate concentrations. There was no significant difference in pre-albumin, albumin, triglycerides and glucose concentrations. CONCLUSIONS: Smoking during pregnancy causes symmetrical fetal growth impairment, possibly due to decreased oxygen transport to the fetus and decreased concentrations of fetal insulin, insulin-like growth factor I and IGF binding protein 3

One-Year Follow-up After Open Abdomen Therapy With Vacuum-Assisted Wound Closure and Mesh-Mediated Fascial Traction.

BACKGROUND: Open abdomen (OA) therapy frequently results in a giant planned ventral hernia. Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) enables delayed primary fascial closure in most patients, even after prolonged OA treatment. Our aim was to study the incidence of hernia and abdominal wall discomfort 1 year after abdominal closure. METHODS: A prospective multicenter cohort study of 111 patients undergoing OA/VAWCM was performed during 2006-2009. Surviving patients underwent clinical examination, computed tomography (CT), and chart review at 1 year. Incisional and parastomal hernias and abdominal wall symptoms were noted. RESULTS: The median age for the 70 surviving patients was 68 years, 77 % of whom were male. Indications for OA were visceral pathology (n = 40), vascular pathology (n = 22), or trauma (n = 8). Median length of OA therapy was 14 days. Among 64 survivors who had delayed primary fascial closure, 23 (36 %) had a clinically detectable hernia and another 19 (30 %) had hernias that were detected on CT (n = 18) or at laparotomy (n = 1). Symptomatic hernias were found in 14 (22 %), 7 of them underwent repair. The median hernia widths in symptomatic and asymptomatic patients were 7.3 and 4.8 cm, respectively (p = 0.031) with median areas of 81.0 and 42.9 cm(2), respectively (p = 0.025). Of 31 patients with a stoma, 18 (58 %) had a parastomal hernia. Parastomal hernia (odds ratio 8.9; 95 % confidence interval 1.2-68.8) was the only independent factor associated with an incisional hernia. CONCLUSIONS: Incisional hernia incidence 1 year after OA therapy with VAWCM was high. Most hernias were small and asymptomatic, unlike the giant planned ventral hernias of the past

Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction.

BACKGROUND:: Damage control surgery and temporary open abdomen (OA) have been adopted widely, in both trauma and non-trauma situations. Several techniques for temporary abdominal closure have been developed. The main objective of this study was to evaluate the fascial closure rate in patients after vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) for long-term OA treatment, and to describe complications. METHODS:: This prospective study included all patients who received VAWCM treatment between 2006 and 2009 at four hospitals. Patients with anticipated OA treatment for fewer than 5 days and those with non-midline incisions were excluded. RESULTS:: Among 151 patients treated with an OA, 111 received VAWCM treatment. Median age was 68 years. Median OA treatment time was 14 days. Main disease aetiologies were vascular (45 patients), visceral surgical disease (57) and trauma (9). The fascial closure rate was 76·6 per cent in intention-to-treat analysis and 89 per cent in per-protocol analysis. Eight patients developed an intestinal fistula, of whom seven had intestinal ischaemia. Intestinal fistula was an independent factor associated with failure of fascial closure (odds ratio (OR) 8·55, 95 per cent confidence interval 1·47 to 49·72; P = 0·017). The in-hospital mortality rate was 29·7 per cent. Age (OR 1·21, 1·02 to 1·43; P = 0·027) and failure of fascial closure (OR 44·50, 1·13 to 1748·52; P = 0·043) were independently associated with in-hospital mortality. CONCLUSION:: The VAWCM method provided a high fascial closure rate after long-term treatment of OA. Technique-related complications were few. No patient was left with a large planned ventral hernia. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd

Does metabolomic profile differ with regard to birth weight?

To access publisher's full text version of this article click on the hyperlink belowBackground: Macrosomia and child obesity are growing health-care issues worldwide. The purpose of the study was to evaluate how extremely high or low birth weight affects metabolic markers evaluated in newborn screening. Methods: The study was register-based and included full-term singletons born in Iceland from 2009 to 2012 with newborn screening samples taken 72-96 h after birth. Three groups based on birth weight were compared: low birth weight (<2500 g), appropriate-for-gestational age, and extreme macrosomia (≥5000 g). The comparison was adjusted for possible confounding factors. Results: Compared to appropriate-for-gestational age neonates, both low birth weight and extreme macrosomia were associated with higher levels of glutamic acid. The amino acids alanine and threonine were increased in low birth weight neonates. Free carnitine and some medium- and long-chain acylcarnitines were higher in low birth weight infants. Hydroxybutyrylcarnitine was lower in low birth weight infants, but higher in extremely macrosomic neonates. Acetylcarnitine was higher in low birth weight and extremely macrosomic neonates. Succinylcarnitine was lower and hexadecenoylcarnitine higher in macrosomic newborns. Conclusion: Low birth weight and extremely macrosomic neonates show distinctive differences in their metabolomic profile compared to appropriate-for-gestational age newborns. The differences are not explained by gestational age. Impact: The key message of this article is that both low birth weight and extremely macrosomic newborns show dissimilar metabolomic profiles compared to appropriate-for-gestational age neonates.The article contributes to knowledge on what affects evaluation of results in newborn screening.The impact of this article is to provide information on metabolism at both ends of the birth weight range after accounting for confounding factors including gestational age.University of Iceland Doctoral Grants Fun

Mode of delivery was associated with transient changes in the metabolomic profile of neonates.

To access publisher's full text version of this article click on the hyperlink belowAims: To estimate potential differences in neonatal metabolomic profiles at birth and at the time of newborn screening by delivery mode. Methods: A prospective study at Women's Clinic at Landspitali-The National University Hospital of Iceland. Women having normal vaginal birth or elective caesarean section from November 2013 to April 2014 were offered participation. Blood samples from mothers before birth and umbilical cord at birth were collected and amino acids and acylcarnitines measured by tandem mass spectrometry. Results from the Newborn screening programme in Iceland were collected. Amino acids and acylcarnitines from different samples were compared by delivery mode. Results: Eighty three normal vaginal births and 32 elective caesarean sections were included. Mean differences at birth were higher for numerous amino acids, and some acylcarnitines in neonates born vaginally compared to elective caesarean section. Maternal blood samples and newborn screening results showed small differences that lost significance after correction for multiple testing. Many amino acids and some acylcarnitines were numerically higher in cord blood compared to maternal. Many amino acids and most acylcarnitines were numerically higher in newborn screening results compared to cord blood. Conclusion: We observed transient yet distinct differences in metabolomic profiles between neonates by delivery mode. Keywords: acylcarnitines; amino acids; delivery mode; metabolomic profile; newborn screening.University of Iceland Research Fun