Loftus Tyler J, Jordan Janeen R, Croft Chasen A, Smith R Stephen, Efron Philip A, Moore Frederick A, Mohr Alicia M, Brakenridge Scott C
Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida.
Department of Surgery, Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida.
J Surg Res. 2017 Apr;210:108-114. doi: 10.1016/j.jss.2016.11.013. Epub 2016 Nov 11.
Temporary abdominal closure (TAC) may be performed for cirrhotic patients undergoing emergent laparotomy. The effects of cirrhosis on physiologic parameters, resuscitation requirements, and outcomes following TAC are unknown. We hypothesized that cirrhotic TAC patients would have different resuscitation requirements and worse outcomes than noncirrhotic patients.
We performed a 3-year retrospective cohort analysis of 231 patients managed with TAC following emergent laparotomy for sepsis, trauma, or abdominal compartment syndrome. All patients were initially managed with negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24- to 48-h intervals.
At presentation, cirrhotic patients had higher incidence of acidosis (33% versus 17%) and coagulopathy (87% versus 54%) than noncirrhotic patients. Forty-eight hours after presentation, cirrhotic patients had a persistently higher incidence of coagulopathy (77% versus 44%) despite receiving more fresh frozen plasma (10.8 units versus 4.4 units). Cirrhotic patients had higher NPWT output (4427 mL versus 2375 mL) and developed higher vasopressor infusion rates (57% versus 29%). Cirrhotic patients had fewer intensive care unit-free days (2.3 versus 7.6 days) and higher rates of multiple organ failure (64% versus 34%), in-hospital mortality (67% versus 21%), and long-term mortality (80% versus 34%) than noncirrhotic patients.
Cirrhotic patients managed with TAC are susceptible to early acidosis, persistent coagulopathy, large NPWT fluid losses, prolonged vasopressor requirements, multiple organ failure, and early mortality. Future research should seek to determine whether TAC provides an advantage over primary fascial closure for cirrhotic patients undergoing emergency laparotomy.
对于接受急诊剖腹手术的肝硬化患者，可能需要进行临时腹部关闭术（TAC）。肝硬化对TAC术后生理参数、复苏需求及预后的影响尚不清楚。我们推测，与非肝硬化患者相比，肝硬化TAC患者的复苏需求不同且预后更差。
我们对231例因脓毒症、创伤或腹腔间隔室综合征接受急诊剖腹手术后采用TAC治疗的患者进行了为期3年的回顾性队列分析。所有患者最初均采用负压伤口治疗（NPWT）TAC，计划再次剖腹手术，并每隔24至48小时尝试进行序贯性腹部关闭。
就诊时，肝硬化患者的酸中毒发生率（33%对17%）和凝血病发生率（87%对54%）高于非肝硬化患者。就诊48小时后，尽管接受了更多的新鲜冰冻血浆（10.8单位对4.4单位），肝硬化患者的凝血病发生率仍持续较高（77%对44%）。肝硬化患者的NPWT引流量更高（4427毫升对2375毫升），血管升压药输注率也更高（57%对29%）。与非肝硬化患者相比，肝硬化患者的无重症监护病房天数更少（2.3天对7.6天），多器官功能衰竭发生率更高（64%对34%），住院死亡率更高（67%对21%），长期死亡率更高（80%对34%）。
采用TAC治疗的肝硬化患者易发生早期酸中毒、持续性凝血病、大量NPWT液体丢失、血管升压药需求延长、多器官功能衰竭和早期死亡。未来的研究应致力于确定对于接受急诊剖腹手术的肝硬化患者，TAC是否比一期筋膜缝合具有优势。
