Luca Ansaloni

International consensus conference on open abdomen in trauma.

BACKGROUND A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. METHODS The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. RESULTS OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). CONCLUSION OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

Intra-abdominal actinomycosis, the great mime: case report and literature review

Background: Actinomycosis is a rare, insidious, infectious disease. Cervicofacial, thoracic and abdominopelvic districts are most commonly involved. Its tendency to involve surrounding structures may mimic a tumor on imaging studies. Early diagnosis, obtained with mini-invasive methods or surgical biopsy, is fundamental to optimize therapeutic approach and to reduce morbidity due to aggressive surgery. Antibiotic therapy is the cornerstone of the treatment of actinomycosis, but the combination with a surgical resection can be necessary in patients who do not respond to medical treatment. Methods: A 66-years old female presented at our attention with an abdominal, retroperitoneal mass found during clinical tests for a vertiginous syndrome. Patient presented with asthenia, anorexia, weight loss, and sacral pain. A retroperitoneal mass, studied with Computed tomography (CT) and Positron emission tomography (PET), was found. No inflammatory signs were found in laboratory tests. Previous core biopsies did not provide the expected results. Cause of that, the patient was prepared for a surgical laparoscopic biopsy and ureteral stenting. After frozen biopsies, histological findings have identified filaments of Actinomyces. No apparent cause of this infection has been identified at first exploration. Results: The patient was treated with antibiotic therapy for three months (Amoxicillin: 1g three times daily). At three months first follow-up, the CT shows the reduction of the retroperitoneal mass and the presence of diverticulosis of the sigma near the mass, in absence of signs of fistulisation. Conclusion: Abdominopelvic actinomycosis should be considered in patients with unusual abdominal mass on abdominal CT or PET. Early diagnosis is necessary to avoid aggressive surgery and its morbidities. Open/laparoscopic surgical biopsy is often necessary to identify the infection. Antibiotic therapy is the standard treatment but surgery can help to optimize medical approach removing necrotic tissue and persistent sinuses.

Laparoscopy and Acute Cholecystitis: The Evidence

The laparoscopic approach for acute cholecystitis has gained wide acceptance over the years. The indications for laparoscopic cholecystectomy in an acute setting are examined and the evidence provided by the literature reviewed. Today, the laparoscopic cholecystectomy can be considered the treatment of choice for acute cholecystitis. Severe (gangrenous, empyematous) cholecystitis and advanced age do not preclude the laparoscopic indication. Surgery should be done as soon as possible rather than delayed after the resolution of the acute phase. Percutaneous cholecystostomy cannot be recommended as part of a routine protocol for treatment of acute calculous cholecystitis. At present, no evidence-based classification allows us to tailor the treatment of every single patient according to the general or local conditions.

Thromboprophylaxis in Patients with Abdominal Sepsis

Venous thromboembolism, pulmonary embolism, and deep venous thrombosis are severe complications of surgical patients. Sepsis is associated with hemostatic changes leading to a subclinical activation of coagulation (hypercoagulability) that may contribute to localized venous thromboembolism. Patients with abdominal sepsis may be at increased risk of venous thromboembolism due to their premorbid conditions; surgical intervention; admitting diagnosis of sepsis, events, and exposures in the intensive care unit such as central venous catheterization and invasive tests and procedures; and drugs that potentiate immobility.

Open Abdomen in Patients with Abdominal Sepsis

The “open abdomen” (OA) may be an interesting option in the management of critically ill surgical patients with ongoing sepsis. However its precise role in these patients is still not clear.

Basic Research in Open Abdomen

The most studied topics in basic research about open abdomen are the immunological modifications caused by negative pressure therapy, the distribution of negative pressure in the abdominal cavity, its effects on bowel surface, and the development of means to protect intestinal anastomosis in these situations.

Trauma in Geriatric Age

The definition of the word “elderly” is not one that has been universally agreed though it is generally accepted that it pertains to a subset of population between 45 and 75 years old [1]. People are living much longer worldwide. Currently, the population over 60 years of age accounts for over 40 million persons in the United States. Over the next 20 years, the population over 65 years of age is projected to double in size, reaching 82.3 million (approximately 22% of the total population) by 2040 [2].

The Role of Computed Tomography in the Acute Presentation of Colorectal Cancer

Patients affected by Colorectal cancer (CRC) can present acutely in a setting of occlusion, perforation, and lower gastrointestinal hemorrhage, which can all be life-threatening conditions. Traditional radiology is not sufficient for a complete clinical assessment. Computer Tomography (CT) is the most accurate diagnostic tool to evaluate the TNM staging, tumor side and potential complications. In stable patients without suspected perforation and with caution in occlusion, also Contrast Tomography Colo(CTC) can be useful.

Biological Prosthesis for Abdominal Wall Reconstruction

No definitive evidences exist on the biological prosthesis in abdominal wall reconstruction after open abdomen; dedicated studies are needed. Biological prosthesis seems to be a valid option for abdominal wall repair minimizing mesh-related complications, especially in contaminated surgical fields. In managing great abdominal wall defects, the positioning of a biological prosthesis as a bridge to close the abdomen seems to be the best and most obvious solution to solve the acute problem. Biological prosthesis seems to be associated with a high rate of hernia recurrence in long-term follow-up.

The Management of the Open Abdomen: The Temporary Closure Systems

NPWT with continuous fascial traction is suggested as the preferred technique for TAC. TAC without NPWT (e.g., mesh alone, Bogota bag) whenever possible should not be applied for the purpose of TAC, because of low delayed fascial closure rate and being accompanied by a significant intestinal fistula rate. Wittman patch could be safety and less expensive alternative.