Long Term Outcome After Open Abdomen Treatment: Function and Quality of Life

Abstract

Background: Open abdomen treatment (OAT) is widely accepted to manage severe abdominal conditions such as peritonitis and abdominal compartment syndrome but can be associated with high morbidity and mortality. The main risks in OAT are (1) entero-atmospheric fistula (EAF), (2) failure of primary fascial closure, and (3) incisional hernias. In this study, we assessed the long-term functional outcome after OAT to understand which factors impacted most on quality of life (QoL)/daily living activities and the natural course after OAT.Materials and Methods: After a retrospective analysis of 165 consecutive OAT patients over a period of 10 years (2002–2012) with over 65 clinical parameters that had been performed at our center (1), we initiated a prospective structured follow-up approach. All survivors were invited for a clinical follow-up. Forty complete datasets including clinical and social follow-up with SF-36 scores were available for full analysis.Results: The patients were dominantly male (75%) with a median age of 52 years. Primary fascial closure (PC) was achieved in 9/40 (23%), while in 77% a planned ventral hernia (PVH) approach was followed. A total of 3/4 of the PVH patients underwent a secondary-stage abdominal wall reconstruction (SSR), but 2/3 of these reconstructed patients developed recurrent hernias. Fifty-five percent of the patients with PC developed an incisional hernia, while 20% of all patients developed significant scarring (Vancouver Scar Score >8). Scar pain was described by 15% of the patients as “moderate” [Visual Analog Scale (VAS) 4–6] and by 10% as “severe” (VAS > 7). While hernia presence, PC or PVH, and scarring showed no impact on QoL, male sex and especially EAF formation significantly reduced QoL.Discussion: Despite many advantages, OAT was associated with relevant mortality and morbidity, especially in the early era before the implementation of a structured concept at our center. Follow-up revealed that hernia incidence after OAT and secondary reconstruction were high and that 25% of patients qualifying for a secondary reconstruction either did not want surgery or were unfit. Sex and EAF formation impacted significantly on QoL, which was lower than in the general population. With regard to hernia incidence, new strategies such as prophylactic mesh implantation upon fascial closure should be discussed analogous to other major abdominal procedures.

Outcome of Laparostomy as a Treatment Measure for Abdominal Compartment Syndrome: A Retrospective Study

“…14 Another 9.09% developed a small bowel fistula. 10 A clear advantage noted in our study is how only 2.7% of the entire population had a fistula. It was also found to be significantly smaller in number than its occurrence in other techniques.…”

“…Fifty-five percent of the patients with primary closure techniques developed an incisional hernia in a study conducted in Bonn, Germany. 10 Similarly, a study on the complications of using Bogota bags showed that 65.45% of the cases needed skin grafting or healing by the formation of granulation tissue, leading to the development of hernias in the future. 11 The overall incidence of incisional hernia after laparotomy was 9.9%.…”

Management of the patient with the open abdomen

“…Long-term complications in survivors of an open abdomen approach include large incisional hernias, which often require repair [51 ▪▪ ]. The ideal timing and method of repair remain controversial.…”

Don't fear the (small) bite: A narrative review of the rationale and misconceptions surrounding closure of abdominal wall incisions

“…The connection between healing of the laparotomy wound and development of the above complications has thus been well established over the years. A variety of factors influencing the healing process have been identified with the intention to develop strategies to reduce post laparotomy complications: These factors can be grouped in three main categories, (a) patient related, (b) surgeon or surgical technique related and (c) material related ( 1 , 2 , 7 , 10 – 15 ) ( Table 1 ).…”