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  • Bjorck, M.; Kirkpatrick, A. W.; Cheatham, M.; Kaplan, M.; Leppäniemi, Ari; De Waele, J. J. (2016)
    Background: In 2009, a classification system for the open abdomen was introduced. The aim of such a classification is to aid the (1) description of the patient's clinical course; (2) standardization of clinical guidelines for guiding open abdomen management; and (3) facilitation of comparisons between studies and heterogeneous patient populations, thus serving as an aid in clinical research. Methods: As part of the revision of the definitions and clinical guidelines performed by the World Society of the Abdominal Compartment Syndrome, this 2009 classification system was amended following a review of experiences in teaching and research and published as part of updated consensus statements and clinical practice guidelines in 2013. Among 29 articles citing the 2009 classification system, nine were cohort studies. They were reviewed as part of the classification revision process. A total of 542 patients (mean: 60, range: 9-160) had been classified. Two problems with the previous classification system were identified: the definition of enteroatmospheric fistulae, and that an enteroatmospheric fistula was graded less severe than a frozen abdomen. Results: The following amended classification was proposed: Grade 1, without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization), subdivided as follows: 1A, clean; 1B, contaminated; and 1C, with enteric leak. An enteric leak controlled by closure, exteriorization into a stoma, or a permanent enterocutaneous fistula is considered clean. Grade 2, developing fixation, subdivided as follows: 2A, clean; 2B, contaminated; and 2C, with enteric leak. Grade 3, frozen abdomen, subdivided as follows: 3A clean and 3B contaminated. Grade 4, an established enteroatmospheric fistula, is defined as a permanent enteric leak into the open abdomen, associated with granulation tissue. Conclusions: The authors believe that, with these changes, the requirements on a functional and dynamic classification system, useful in both research and training, will be fulfilled. We encourage future investigators to apply the system and report on its merits and constraints.
  • Kirkpatrick, Andrew W.; Coccolini, Federico; Ansaloni, Luca; Roberts, Derek J.; Tolonen, Matti; McKee, Jessica L.; Leppaniemi, Ari; Faris, Peter; Doig, Christopher J.; Catena, Fausto; Fabian, Timothy; Jenne, Craig N.; Chiara, Osvaldo; Kubes, Paul; Manns, Braden; Kluger, Yoram; Fraga, Gustavo P.; Pereira, Bruno M.; Diaz, Jose J.; Sugrue, Michael; Moore, Ernest E.; Ren, Jianan; Ball, Chad G.; Coimbra, Raul; Balogh, Zsolt J.; Abu-Zidan, Fikri M.; Dixon, Elijah; Biffl, Walter; MacLean, Anthony; Ball, Ian; Drover, John; McBeth, Paul B.; Posadas-Calleja, Juan G.; Parry, Neil G.; Di Saverio, Salomone; Ordonez, Carlos A.; Xiao, Jimmy; Sartelli, Massimo (2018)
    Background: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and selfperpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. Principles of treatment include early antibiotic administration and operative source control. A further therapeutic option may be open abdomen (OA) management with active negative peritoneal pressure therapy (ANPPT) to remove inflammatory ascites and ameliorate the systemic damage from SCIAS. Although there is now a biologic rationale for such an intervention as well as non-standardized and erratic clinical utilization, this remains a novel therapy with potential side effects and clinical equipoise. Methods: The Closed Or Open after Laparotomy (COOL) study will constitute a prospective randomized controlled trial that will randomly allocate eligible surgical patients intra-operatively to either formal closure of the fascia or use of the OA with application of an ANPTT dressing. Patients will be eligible if they have free uncontained intra-peritoneal contamination and physiologic derangements exemplified by septic shock OR a Predisposition-Infection-Response-Organ Dysfunction Score >= 3 or a World-Society-of-Emergency-Surgery-Sepsis-Severity-Score >= 8. The primary outcome will be 90-day survival. Secondary outcomes will be logistical, physiologic, safety, bio-mediators, microbiological, quality of life, and health-care costs. Secondary outcomes will include days free of ICU, ventilation, renal replacement therapy, and hospital at 30 days from the index laparotomy. Physiologic secondary outcomes will include changes in intensive care unit illness severity scores after laparotomy. Bio-mediator outcomes for participating centers will involve measurement of interleukin (IL)-6 and IL-10, procalcitonin, activated protein C (APC), high-mobility group box protein-1, complement factors, and mitochondrial DNA. Economic outcomes will comprise standard costing for utilization of health-care resources. Discussion: Although facial closure after SCIAS is considered the current standard of care, many reports are suggesting that OA management may improve outcomes in these patients. This trial will be powered to demonstrate a mortality difference in this highly lethal and morbid condition to ensure critically ill patients are receiving the best care possible and not being harmed by inappropriate therapies based on opinion only.
  • Coccolini, Federico; Catena, Fausto; Montori, Giulia; Ceresoli, Marco; Manfredi, Roberto; Nita, Gabriela Elisa; Moore, Ernest E.; Biffl, Walter; Ivatury, Rao; Whelan, James; Fraga, Gustavo; Leppaniemi, Ari; Sartelli, Massimo; Di Saverio, Salomone; Ansaloni, Luca (2015)
    Actually the most common indications for Open Abdomen (OA) are trauma, abdominal sepsis, severe acute pancreatitis and more in general all those situations in which an intra-abdominal hypertension condition is present, in order to prevent the development of an abdominal compartment syndrome. The mortality and morbidity rate in patients undergone to OA procedures is still high. At present many studies have been published about the OA management and the progresses in survival rate of critically ill trauma and septic surgical patients. However several issues are still unclear and need more extensive studies. The definitions of indications, applications and methods to close the OA are still matter of debate. To overcome this lack of high level of evidence data about the OA indications, management, definitive closure and follow-up, the World Society of Emergency Surgery (WSES) promoted the International Register of Open Abdomen (IROA). The register will be held on a web platform (Clinical Registers (R)) through a dedicated web site: www. clinicalregisters. org. This will allow to all surgeons and physicians to participate from all around the world only by having a computer and a web connection. The IROA protocol has been approved by the coordinating center Ethical Committee (Papa Giovanni XXIII hospital, Bergamo, Italy).
  • Sartelli, Massimo; Catena, Fausto; Abu-Zidan, Fikri M.; Ansaloni, Luca; Biffl, Walter L.; Boermeester, Marja A.; Ceresoli, Marco; Chiara, Osvaldo; Coccolini, Federico; De Waele, Jan J.; Di Saverio, Salomone; Eckmann, Christian; Fraga, Gustavo P.; Giannella, Maddalena; Girardis, Massimo; Griffiths, Ewen A.; Kashuk, Jeffry; Kirkpatrick, Andrew W.; Khokha, Vladimir; Kluger, Yoram; Labricciosa, Francesco M.; Leppäniemi, Ari; Maier, Ronald V.; May, Addison K.; Malangoni, Mark; Martin-Loeches, Ignacio; Mazuski, John; Montravers, Philippe; Peitzman, Andrew; Pereira, Bruno M.; Reis, Tarcisio; Sakakushev, Boris; Sganga, Gabriele; Soreide, Kjetil; Sugrue, Michael; Ulrych, Jan; Vincent, Jean-Louis; Viale, Pierluigi; Moore, Ernest E. (2017)
    This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.
  • Rasilainen, Suvi Kaarina; Mentula, Panu; Leppäniemi, Ari (2015)
    Introduction: This study was designed to describe the time-course and microbiology of colonization of open abdomen in critically ill surgical patients and to study its association with morbidity, mortality and specific complications of open abdomen. A retrospective cohort analysis was done. Methods: One hundred eleven consecutive patients undergoing vacuum-assisted closure with mesh as temporary abdominal closure method for open abdomen were analyzed. Microbiological samples from the open abdomen were collected. Statistical analyses were performed using Fisher's exact test for categorical variables. Mann-Whitney U test was used when comparing number of temporary abdominal closure changes between colonized and sterile patients. Kaplan-Meier analysis was done to calculate cumulative estimates for colonization. Cox regression analyses were performed to analyze risk factors for colonization. Results: Microbiological samples were obtained from 97 patients. Of these 76 (78 %) were positive. Sixty-one (80 %) patients were colonized with multiple micro-organisms and 27 (36 %) were cultured positive for candida species. The duration of open abdomen treatment adversely affected the colonization rate. Thirty-three (34 %) patients were colonized at the time of laparostomy. After one week of open abdomen treatment 69, and after two weeks 76 patients were colonized with cumulative colonization estimates of 74 % and 89 %, respectively. Primary fascial closure rate was 80 % (61/76) and 86 % (18/21) for the colonized and sterile patients, respectively. The rate of wound complications did not significantly differ between these groups. Conclusions: Microbial colonization of open abdomen is associated with the duration of open abdomen treatment. Wound complications are common after open abdomen, but colonization does not seem to have significant effect on these. The high colonization rate described herein should be taken into account when primarily sterile conditions like acute pancreatitis and aortic aneurysmal rupture are treated with open abdomen.
  • Acosta, Stefan; Seternes, Arne; Venermo, Maarit; Vikatmaa, Leena; Sörelius, Karl; Wanhainen, Anders; Svensson, Mats; Djavani, Khatereh; Björck, Martin (2017)
    Objectives: Open abdomen therapy may be necessary to prevent or treat abdominal compartment syndrome (ACS). The aim of the study was to analyse the primary delayed fascial closure (PDFC) rate and complications after open abdomen therapy with vacuum and mesh mediated fascial traction (VACM) after aortic repair and to compare outcomes between those treated with open abdomen after primary versus secondary operation. Methods: This was a retrospective cohort, multicentre study in Sweden, Finland, and Norway, including consecutive patients treated with open abdomen and VACM after aortic repair at six vascular centres in 2006-2015. The primary endpoint was PDFC rate. Results: Among 191 patients, 155 were men. The median age was 71 years (IQR 66-76). Ruptured abdominal aortic aneurysm (RAAA) occurred in 69.1%. Endovascular/hybrid and open repairs were performed in 49 and 142 patients, respectively. The indications for open abdomen were inability to close the abdomen (62%) at primary operation and ACS (80%) at secondary operation. Duration of open abdomen was 11 days (IQR 7-16) in 157 patients alive at open abdomen termination. The PDFC rate was 91.8%. Open abdomen initiated at primary (N = 103), compared with secondary operation (N = 88), was associated with less severe initial open abdomen status (p = .006), less intestinal ischaemia (p = .002), shorter duration of open abdomen (p = .007), and less renal replacement therapy (RRT, p <.001). In hospital mortality was 39.3%, and after entero-atmospheric fistula (N = 9) was 88.9%. Seven developed graft infection within 6 months, 1 year mortality was 28.6%. Intestinal ischaemia (OR 3.71, 95% CI 1.55-8.91), RRT (OR 3.62, 95% CI 1.72-7.65), and age (OR 1.12, 95% CI 1.06-1.12), were independent factors associated with in hospital mortality, but not open abdomen initiated at primary versus secondary operation. Conclusions: VACM was associated with a high PDFC rate after prolonged open abdomen therapy following aortic repair. Patient outcomes seemed better when open abdomen was initiated at primary, compared with secondary operation but a selection effect is possible. (C) 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
  • Husu, Henrik Leonard; Leppäniemi, Ari Kalevi; Lehtonen, Taru Marika; Puolakkainen, Pauli Antero; Mentula, Panu Juhani (2019)
    Purpose: To study mortality in severe acute pancreatitis (SAP) and to identify risk factors for mortality. Materials and methods: A retrospective 17-years' cohort study of 435 consecutive adult patientswith SAP treated at intensive care unit of a university hospital. Results: Overall, 357 (82.1%) patients survived at 90 days follow-up. Three-hundred six (89.5%) patients under 60 years, 38 (60.3%) patients between 60 and 69 years, and 13 (43.3%) patients over 69 years of age survived at 90 days follow-up. Independent risk factors for death within 90-days were: 60 to 69 years of age (odds ratio [OR] 5.1), >69 years of age (OR 10.4), female sex (OR 2.0), heart disease (OR 2.9), chronic liver failure (OR 12.3), open abdomen treatment (OR 4.4) and sterile necrosectomy within 4 weeks (OR 14.7). The 10-year survival estimate was Conclusions: Although younger patients have excellent short-term survival after SAP, the long-term survival estimate is disappointing mostly due to alcohol abuse. (C) 2019 Elsevier Inc. All rights reserved.
  • Coccolini, Federico; Roberts, Derek; Ansaloni, Luca; Ivatury, Rao; Gamberini, Emiliano; Kluger, Yoram; Moore, Ernest E.; Coimbra, Raul; Kirkpatrick, Andrew W.; Pereira, Bruno M.; Montori, Giulia; Ceresoli, Marco; Abu-Zidan, Fikri M.; Sartelli, Massimo; Velmahos, George; Fraga, Gustavo Pereira; Leppaniemi, Ari; Tolonen, Matti; Galante, Joseph; Razek, Tarek; Maier, Ron; Bala, Miklosh; Sakakushev, Boris; Khokha, Vladimir; Malbrain, Manu; Agnoletti, Vanni; Peitzman, Andrew; Demetrashvili, Zaza; Sugrue, Michael; Saverio, Salomone Di; Martzi, Ingo; Soreide, Kjetil; Biffl, Walter; Ferrada, Paula; Parry, Neil; Montravers, Philippe; Melotti, Rita Maria; Salvetti, Francesco; Valetti, Tino M.; Scalea, Thomas; Chiara, Osvaldo; Cimbanassi, Stefania; Kashuk, Jeffry L.; Larrea, Martha; Hernandez, Juan Alberto Martinez; Lin, Heng-Fu; Chirica, Mircea; Arvieux, Catherine; Bing, Camilla; Horer, Tal; Simone, Belinda De; Masiakos, Peter; Reva, Viktor; DeAngelis, Nicola; Kike, Kaoru; Balogh, Zsolt J.; Fugazzola, Paola; Tomasoni, Matteo; Latifi, Rifat; Naidoo, Noel; Weber, Dieter; Handolin, Lauri; Inaba, Kenji; Hecker, Andreas; Kuo-Ching, Yuan; Ordoñez, Carlos A.; Rizoli, Sandro; Gomes, Carlos Augusto; Moya, Marc De; Wani, Imtiaz; Mefire, Alain Chichom; Boffard, Ken; Napolitano, Lena; Catena, Fausto (2018)
    Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a "planned second-look" laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.
  • Coccolini, Federico; Biffl, Walter; Catena, Fausto; Ceresoli, Marco; Chiara, Osvaldo; Cimbanassi, Stefania; Fattori, Luca; Leppaniemi, Ari; Manfredi, Roberto; Montori, Giulia; Pesenti, Giovanni; Sugrue, Michael; Ansaloni, Luca (2015)
    The indications for Open Abdomen (OA) are generally all those situations in which is ongoing the development an intra-abdominal hypertension condition (IAH), in order to prevent the development of abdominal compartmental syndrome (ACS). In fact all those involved in care of a critically ill patient should in the first instance think how to prevent IAH and ACS. In case of ACS goal directed therapy to achieve early opening and early closure is the key: paradigm of closure shifts to combination of therapies including negative pressure wound therapy and dynamic closure, in order to reduce complications and avoid incisional hernia. There have been huge studies and progress in survival of critically ill trauma and septic surgical patients: this in part has been through the great work of pioneers, scientific societies and their guidelines; however future studies and continued innovation are needed to better understand optimal treatment strategies and to define more clearly the indications, because OA by itself is still a morbid procedure.
  • Coccolini, Federico; Montori, Giulia; Ceresoli, Marco; Catena, Fausto; Moore, Ernest E.; Ivatury, Rao; Biffl, Walter; Peitzman, Andrew; Coimbra, Raul; Rizoli, Sandro; Kluger, Yoram; Abu-Zidan, Fikri M.; Sartelli, Massimo; De Moya, Marc; Velmahos, George; Fraga, Gustavo Pereira; Pereira, Bruno M.; Leppaniemi, Ari; Boermeester, Marja A.; Kirkpatrick, Andrew W.; Maier, Ron; Bala, Miklosh; Sakakushev, Boris; Khokha, Vladimir; Malbrain, Manu; Agnoletti, Vanni; Martin-Loeches, Ignacio; Sugrue, Michael; Di Saverio, Salomone; Griffiths, Ewen; Soreide, Kjetil; Mazuski, John E.; May, Addison K.; Montravers, Philippe; Melotti, Rita Maria; Pisano, Michele; Salvetti, Francesco; Marchesi, Gianmariano; Valetti, Tino M.; Scalea, Thomas; Chiara, Osvaldo; Kashuk, Jeffry L.; Ansaloni, Luca (2017)
    The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.