创伤开放性腹部国际共识会议

International consensus conference on open abdomen in trauma.

作者信息

Chiara Osvaldo, Cimbanassi Stefania, Biffl Walter, Leppaniemi Ari, Henry Sharon, Scalea Thomas M, Catena Fausto, Ansaloni Luca, Chieregato Arturo, de Blasio Elvio, Gambale Giorgio, Gordini Giovanni, Nardi Guiseppe, Paldalino Pietro, Gossetti Francesco, Dionigi Paolo, Noschese Giuseppe, Tugnoli Gregorio, Ribaldi Sergio, Sgardello Sebastian, Magnone Stefano, Rausei Stefano, Mariani Anna, Mengoli Francesca, di Saverio Salomone, Castriconi Maurizio, Coccolini Federico, Negreanu Joseph, Razzi Salvatore, Coniglio Carlo, Morelli Francesco, Buonanno Maurizio, Lippi Monica, Trotta Liliana, Volpi Annalisa, Fattori Luca, Zago Mauro, de Rai Paolo, Sammartano Fabrizio, Manfredi Roberto, Cingolani Emiliano

机构信息

From the Trauma Center (O.C., S.C., S.S., A.M., F.S., M.L., L.T.), Trauma Surgery and Intensive Care, and Wound Healing Service (J.N.), Niguarda Hospital; and General and Emergency Surgery (P.D.R.), Policlinico Hospital, Milano; Emergency Surgery and Intensive Care (F.C., A.V.), Parma Hospital, Parma; General Surgery (L.A., S.M., F.C., R.M.), Papa Giovanni XXIII Hospital; and General Surgery (M.Z.), Policlinico S Pietro Hospital, Ponte San Pietro, Bergamo; Neurosurgical-Orthopedic Anesthesia and Intensive Care (A.C.), Careggi Hospital, Firenze; General and Emergency Surgery and Intensive Care (M.B., E.D.B.), Rummo Hospital, Benvento; Intensive Care (G.G.), Bufalini Hospital, Cesena; Trauma Surgery and Intensive Care (G.T., S.D.S., G.G., F.M., C.C.), Maggiore Hospital, Bologna; Shock e Trauma Service (G.N., E.C.), San Camillo Hospital; and General Surgery (S.R., F.G.), Umberto 1 Hospital, Roma; General Surgery (P.P., L.F.), San Gerardo Hospital, Monza; General Surgery (P.D.), San Matteo Hospital, Pavia; Trauma Surgery (G.N.), and General Surgery (M.C.), Cardarelli Hospital, Napoli; Department of Surgery (S.R.), Insubria University, Varese; and Emergency Surgery (S.R.), Umberto Parini Hospital, Aosta, Italy; Trauma and Acute Care Surgery (W.B.), Denver Health Medical Center, Denver, Colorado; R Adams Cowley Shock Trauma Center (T.M.S., S.H.), Baltimore, Maryland; and Emergency Surgery (A.L.), Department of Surgery, Meilahti Hospital, Helsinki, Finland.

出版信息

J Trauma Acute Care Surg. 2016 Jan;80(1):173-83. doi: 10.1097/TA.0000000000000882.

DOI:10.1097/TA.0000000000000882

PMID:27551925

Abstract

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.

摘要

背景

损伤控制剖腹术的一部分是让筋膜边缘和皮肤敞开，以避免腹腔间隔室综合征并便于进一步探查。这种情况称为开放性腹腔（OA），虽有效果，但会伴发严重并发症。我们的目的是制定基于证据的建议，以明确开放性腹腔的适应证、临时腹壁关闭技术、肠瘘管理以及确定性腹壁关闭方法。

方法

按照PRISMA[系统评价和Meta分析的首选报告项目]方案对1990年至2014年的文献进行系统筛选。一组专家对76篇文章进行评审，使用GRADE[推荐分级评估、制定与评价]系统确定推荐等级（GoR）和证据水平（LoE），并召开了一次国际共识会议。

结果

创伤患者在损伤控制剖腹术结束时、存在内脏肿胀、需要再次探查血管损伤或严重污染、腹壁缺损以及腹腔间隔室综合征内科治疗失败时，适合采用开放性腹腔（推荐等级B，证据水平II）。负压伤口治疗是推荐的临时腹壁关闭技术，可引流腹腔积液、改善护理并防止筋膜回缩（推荐等级B，证据水平I）。8天内未进行开放性腹腔关闭（推荐等级C，证据水平II）、肠损伤、大量补液以及在肠管上使用聚丙烯网片（推荐等级C，证据水平I）是发生冰冻腹腔和形成瘘管的危险因素。负压伤口治疗可隔离瘘管，保护周围组织免受渗漏物污染，直至形成肉芽组织（推荐等级C，证据水平II）。瘘管矫正应在6个月至12个月后进行。开放性腹腔的确定性关闭应尽早完成（推荐等级C，证据水平I），可采用直接缝合、牵引装置、有或无网片的成分分离术。如果存在细菌污染，生物网片可作为加强腹壁的一种选择（推荐等级C，证据水平II）。