开放性腹部的处理：东部创伤外科学会的系统评价、荟萃分析和实践管理指南。
Management of the open abdomen: A systematic review with meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma.
机构信息
From the Tufts Medical Center (E.J.M, N.B.), Division of Trauma and Acute Care Surgery, Department of Surgery, Boston, Massachusetts; Atrium Health Wake Forest Baptist (R.A.) Division of Acute Care Surgery, Department of Surgery, Winston-Salem, North Carolina; Cooper University Hospital (A.G.-S.), Division of Trauma and Acute Care Surgery, Department of Surgery, Camden, New Jersey; NYU Langone Hospital-Long Island (G.A.B.), Division of Trauma and Acute Care Surgery, Department of Surgery, Mineola, New York; Northwestern Memorial Hospital (J.P.), Division of Trauma and Critical Care, Department of Surgery, Chicago, Illinois; University of Texas Southwestern (L.D.), Division of Burn, Trauma, Acute and Critical Care Surgery, Department of Surgery, Dallas, Texas; The George Washington School of Medicine and Health Sciences (S.K.), Center of Trauma and Critical Care, Department of Surgery, Washington, District of Columbia; Duke University Medical Center (G.K.), Division of Trauma and Critical Care Surgery, Department of Surgery, Durham, North Carolina; MetroHealth Medical Center (J.C.), Cleveland, Ohio; and Northwell Health-North Shore University Hospital (E.K.) Division of Acute Care Surgery, Department of Surgery, Great Neck, New York.
出版信息
J Trauma Acute Care Surg. 2022 Sep 1;93(3):e110-e118. doi: 10.1097/TA.0000000000003683. Epub 2022 May 12.
BACKGROUND
Multiple techniques describe the management of the open abdomen (OA) and restoration of abdominal wall integrity after damage-control laparotomy (DCL). It is unclear which operative technique provides the best method of achieving primary myofascial closure at the index hospitalization.
METHODS
A writing group from the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of the current literature regarding OA management strategies in the adult population after DCL. The group sought to understand if fascial traction techniques or techniques to reduce visceral edema improved the outcomes in these patients. The Grading of Recommendations Assessment, Development and Evaluation methodology was utilized, meta-analyses were performed, and an evidence profile was generated.
RESULTS
Nineteen studies met inclusion criteria. Overall, the use of fascial traction techniques was associated with improved primary myofascial closure during the index admission (relative risk, 0.32) and fewer hernias (relative risk, 0.11.) The use of fascial traction techniques did not increase the risk of enterocutaneous fistula formation nor mortality. Techniques to reduce visceral edema may improve the rate of closure; however, these studies were very limited and suffered significant heterogeneity.
CONCLUSION
We conditionally recommend the use of a fascial traction system over routine care when treating a patient with an OA after DCL. This recommendation is based on the benefit of improved primary myofascial closure without worsening mortality or enterocutaneous fistula formation. We are unable to make any recommendations regarding techniques to reduce visceral edema.
LEVEL OF EVIDENCE
Systematic Review and Meta-Analysis; Level IV.
背景
多种技术描述了在损伤控制性剖腹手术后（DCL）处理开放性腹部（OA）和恢复腹壁完整性的方法。目前尚不清楚哪种手术技术在指数住院期间能提供实现原发性筋膜闭合的最佳方法。
方法
东部创伤外科学会的一个写作小组对成人 DCL 后 OA 管理策略的当前文献进行了系统回顾和荟萃分析。该小组试图了解筋膜牵引技术或减少内脏水肿的技术是否能改善这些患者的结局。使用了推荐评估、制定与评估分级方法（Grading of Recommendations Assessment, Development and Evaluation，GRADE），进行了荟萃分析，并生成了证据概况。
结果
19 项研究符合纳入标准。总体而言，使用筋膜牵引技术与指数住院期间原发性筋膜闭合率提高相关（相对风险，0.32），疝的发生率降低（相对风险，0.11）。使用筋膜牵引技术不会增加肠皮瘘形成或死亡率的风险。减少内脏水肿的技术可能会提高闭合率；然而，这些研究非常有限，且存在显著的异质性。
结论
我们有条件推荐在治疗 DCL 后 OA 患者时使用筋膜牵引系统，而不是常规护理。这一建议基于改善原发性筋膜闭合率的益处，而不会增加死亡率或肠皮瘘形成的风险。我们无法就减少内脏水肿的技术提出任何建议。
证据水平
系统回顾和荟萃分析；证据等级 IV。
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