M. K. Müller Kantonsspital Frauenfeld das... · Treatment of secondary peritonitis e.g. after...

Left open Abdomen & 2nd look on demand?

M. K. Müller

Kantonsspital Frauenfeld

Der chirurgische Bauch-eine interdisziplinäre Herausforderung 9. Nov. 2018

Sekundäre Peritonitis nach:

Outline

Left open abdomenClosed

scheduled 2nd look

Closed2nd look on demand

Verschluss nichtmöglich

DefinitiverVerschluss nicht

gewollt

DefinitiverVerschluss mit

Kriterien

Wieso, weshalb, warum?

• Heterogenes Patientengut– Alter

– Geschlecht

– Begleiterkrankungen

– Exogene Noxen (Nikotin, Medikamente)

• Heterogene Ursache der Peritonitis

• Individuelle Entscheidung

Left open abdomen

Left open abdomen

Verschluss nichtmöglich

• ‘Damage control’

• Kontamination

• Lange Operationszeit

• Kompartment

‘Right operation on the right patient

at the right time’

‘Life before Abdominal wall’

Left open abdomen

Left open abdomen

Verschluss nichtmöglich

• ‘Damage control’

• Kontamination

• Lange Operationszeit

• Kompartment

Case male 34 years

• 192 kg, 180 cm, BMI 59.3 kg/m2

• art. Hypertension

• OSAS, Nicotine 15py

Case 2 male 35 years

Lap. Gastric Bypass (100 min), 07.10.2014

a 250 cm, b 100 cm, circular stapler 25 mm

postoperative ICU 24h

until 4. pod good recovery

Case 2 male 35 years

4. pod

Tachycardia, Dyspnoe, CRP 178 mg/l

CT scan

Case 2 male 35 years

12.10.2015

• Resection of incarcerated small bowel, anastomosis 120 cm proximally to ileoceacal valve

• Revision of Entero-Enterostomy

• Revision of Gastro-Enterostomy and Omental patch

• Decompression of remnant stomach

Further course

• Operative lavage14.10. / 16.10. / 20.10. / 21.10. / 23.10. / 28.10. / 29.10. / 31.10. / 02.11. / 06.11.

• Revision of Entero-Enterostomy18.10. / 19.10. / 25.10. / 26.10. / 27.10.

• Rectus muscle flap04.11.

Further course

• Lavage, Vicryl Mesh, Vac08.11.

• Lavage and Vac10.11. / 14.11. / 17.11.

• Skin graft24.11.

• Tracheostomy, Antibiotics , TPN, Hemodialysis, ICU 12.10. until 17.12.

Further course

• Hospital stay 07.10.2014 until 05.01.2015Neurorehabilitation until 09.05.2015

• Outpatient visit 25.02.129 kg, - 57 kg

• Outpatient visit 15.04.120 kg, - 66 kg

• Outpatient visit 16.07.wheelchair and walking sticks

Treatment of secondary peritonitise.g. after bariatric surgery

• Irrigate & drain the abdominal cavity

• Seal the leaks with an endoscopic stent or clips or sutures or all of the above

• Scheduled looks in the OR

• Get ahead of septicaemia

• Don’t bother about the abdominal wall

Open abdomen

Pros

• No compartment

• Better drainage of contamination

Cons

• Fluid loss

• Temperature control

• Abdominal wall retraction

Left open

Technische Möglichkeiten

• Abdominaler Vac

• Sucutaner Vac

• Retraktionssysteme (z.B: Abra System)

• Ventrofil

• Bogota Bag

• Meshes

• etc.

Left open

The highest weighted fascial closure rate was found in series describing NPWT with continuous mesh or suture mediated fascial traction was 73.1 %.

Weighted rates of fistula varied from 5.7 % after NPWT with fascial traction and 17.2 % after mesh inlay .

Although the best results in terms of achieving delayed fascial closure and risk of enteroatmospheric fistula were shown for NPWT with continuous fascial traction, the overall quality of the available evidence was poor, and uniform recommendations cannot be made.

Outline

Left open abdomenClosed

scheduled 2nd look

Closed2nd look on demand

Verschluss nichtmöglich

DefinitiverVerschluss nicht

gewollt

DefinitiverVerschluss mit

Kriterien

Outline

Closedscheduled 2nd look

DefinitiverVerschluss nicht

gewollt

Temporary Closure, 2nd look

Indication

• Contamination

• Critical ischemia

Risk

• Overtreatment

• Damage to the abdominal wall

Outline

Left open abdomenClosed

scheduled 2nd look

Closed2nd look on demand

Verschluss nichtmöglich

DefinitiverVerschluss nicht

gewollt

DefinitiverVerschluss mit

Kriterien

Outline

Closed2nd look on demand

DefinitiverVerschluss mit

Kriterien

Kriterien für die Relaparotomie

Second look on demand

Comparison of On-Demand vs Planned Relaparotomy Strategy in Patients With Severe Peritonitis

A Randomized Trial

Multicenter n=5, Netherlands, 2001-2005

116 on demand vs. 116 planned

10 Endpoint: 12 mth mortality

O van Ruler , JAMA 2007

Inclusion criteria

• Secondary peritonitis requiring emergency laparotomy

– Perforation or infection of visceral organ

– Ischemia due to strangulation

– Postoperative peritoneal infection

• APACHE II Score >10

Randomization

Planned

• Every 36-48h

• The sequence was terminated, when macroscopically clean

On-demand

• Clinical deterioration or lack of improvement with a likely intraabdominal cause

• Multidisciplinary team

Criteria for relaparotomy

On-demand

• Clinical deterioration or lack of improvement with a likely intraabdominal cause

• Multidisciplinary team

>4 points increase in the MOD-Score

MOD-Score unchanged for 48 hours

Abdominal CompartmentBleedingHemodynamic instabilityBurst AbdomenAnastomotic leakAbscess

Multi Organ Dysfunction Score

Marshall JC, Crit Care Med 1995

Key points

• Heterogeneous cohort of patients

• In open abdomen:

– life before abdominal wall

– NPWT current standard

• 2nd look on demand in selected cases

– Reduction in relaparotomies

– Less health care utilization

• Multidisciplinary approach

MKM 08.11.2018

Danke für die Aufmerksamkeit