HHE Emergency care supplement 2018 - Page 18

interval greater than 60 hours from the time of symptom onset to undertaking initial laparotomy. The presence of two or more risk factors was associated with a 55% RL rate, and three or more factors with an 83% RL rate. RL was associated with a fourfold increase in the rate of hospital death. 41 In such situations, controversies arise regarding managing complex abdominal infection with an open abdomen technique that will allow re-look and also mitigate concerns of intra- abdominal hypertension. While the only randomised controlled trial undertaken under these circumstances showed that the abdomen should be closed if it is safe to do so, attempts at primary closure in all circumstances may be associated with an increased incidence of multi-organ failure, resulting in poor survival. Conversely, the risk of treating abdominal sepsis with an open abdomen include significant disruption of respiratory mechanics, loss of abdominal ‘domain’, exposure to nosocomial pathogens, challenging wound care and even enteroatmospheric fistulation.Various temporary abdominal closure (TAC) techniques have been described, involving gauze and large, impermeable, self-adhesive membrane dressings; mesh (for example, Vicryl™, Dexon™); nonabsorbable mesh (for example, GORE-TEX™, polypropylene), negative pressure wound therapy (NPWT), NPWT with continuous fascial traction, dynamic retention sutures, Wittmann patch™, and Bogota bag. A large systematic review of 74 studies in over 4300 patients (of which 79% had received treatment for peritonitis) showed that NPWT was the most frequent described TAC technique, and the highest weighted fascial closure rate was found in series describing NPWT with continuous mesh or suture mediated fascial traction and dynamic retention sutures. 42 However, it was not possible to show differences in mortality, fistula and fascial closure rates, when comparing NPWT alone and NPWT with fascial traction. 42 Laparoscopic treatment in abdominal sepsis is becoming more commonly used. 22,23 However the most recent NELA report has not shown an increase in its use over a three-year period, which remained at 8%. 24 Therapeutic advantages of laparoscopy are well known in the management of appendicitis, cholecystitis, and perforated gastric and duodenal ulcer. In other situations such as diverticulitis, results from a multicentre randomised trial have not shown laparoscopic lavage to be superior to sigmoid resection for the treatment of purulent perforated diverticulitis. 43 Great care should be taken when laparoscopic treatment is being considered for use in the septic abdomen, and should include assessment of the source of sepsis, the likelihood that adequate source control can be achieved by laparoscopic means, patient physiology and habitus, the risks of injury to other organs in a potentially hostile environment and, not least, the training and expertise of the surgical team. However, as technological advancement extends the potential range of minimally invasive procedures, it seems likely that wider adoption of these approaches will, at least in selected patients, reduce the need for open surgical treatment for abdominal sepsis. References 1 Moynihan BG. The ritual of a surgical operation. Br J Surg 1920;8(29):27–35. 2 Bone RC et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. 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