背景:损伤控制性剖腹手术的一部分是使筋膜边缘和皮肤开放,以避免腹腔室综合征并允许进一步探查。这个条件,被称为开放性腹部(OA),虽然有效,与严重并发症有关。我们的目标是制定基于证据的建议来定义OA的适应症,临时腹部闭合技术,肠瘘的管理,和确定的墙壁封闭的方法。
方法:根据PRISMA[系统评价和Meta分析的首选报告项目]方案对1990-2014年的文献进行系统筛选。由专家小组审查了76篇文章,以使用GRADE[建议评估等级,发展,和评估]系统,举行了国际共识会议。
结果:创伤中的OA在损伤控制剖腹手术结束时显示,在内脏肿胀的情况下,再次观察血管损伤或严重污染,在腹壁丢失的情况下,如果腹腔室综合征的治疗失败(GoRB,LoEII)。负压伤口治疗是推荐的临时腹部闭合技术,以排出腹膜液,改善护理,并防止筋膜缩回(GoRB,LoEI).在8天内缺乏OA关闭(GoRC,LoEII),肠损伤,大批量更换,并在肠道上使用聚丙烯网(GoRC,LoEI)是冰冻腹部和瘘管形成的危险因素。负压伤口治疗允许隔离瘘管并保护周围组织免于溢出直到肉芽(GoRC,LoEII)。在6个月至12个月后进行瘘管矫正。必须尽早获得OA的最终闭合(GoRC,LoEI)直接缝合,牵引装置,有或没有网格的组件分离。如果存在细菌污染,生物网格是墙加固的一种选择(GoRC,LoEII)。
结论:OA和负压技术改善了创伤患者的护理,但必须尽早关闭以避免并发症。
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).
CONCLUSIONS: OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.