The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper
Sartelli et al. World Journal of Emergency Surgery
The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper
Massimo Sartelli 0 1
Fikri M. Abu-Zidan 1
Luca Ansaloni 1
Miklosh Bala 1
Marcelo A. Beltrán 1
Walter L. Biffl 1
Fausto Catena 1
Osvaldo Chiara 1
Federico Coccolini 1
Raul Coimbra 1
Zaza Demetrashvili 1
Demetrios Demetriades 1
Jose J. Diaz 1
Salomone Di Saverio 1
Gustavo P. Fraga 1
Wagih Ghnnam 1
Ewen A. Griffiths 1
Sanjay Gupta 1
Andreas Hecker 1
Aleksandar Karamarkovic 1
Victor Y. Kong 1
Reinhold Kafka-Ritsch 1
Yoram Kluger 1
Rifat Latifi 1
Ari Leppaniemi 1
Jae Gil Lee 1
Michael McFarlane 1
Sanjay Marwah 1
Frederick A. Moore 1
Carlos A. Ordonez 1
Gerson Alves Pereira 1
Haralds Plaudis 1
Vishal G. Shelat 1
Jan Ulrych 1
Sanoop K. Zachariah 1 4
Martin D. Zielinski 1 2
Maria Paula Garcia 1 3
Ernest E. Moore 1
0 Department of Surgery, Macerata Hospital , Via Santa Lucia 2, 62100 Macerata , Italy
1 Department of First Faculty of Medicine, General University Hospital, Prague Charles University , Prague , Czech Republic
2 Department of Surgery, Mayo Clinic , Rochester, MN , USA
3 Centro de investigaciones clínicas, Fundación Valle del Lili , Cali , Colombia
4 Department of Surgery, MOSC Medical College Kolenchery , Cochin , India
The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.
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Introduction
The open abdomen (OA) procedure is one of the
greatest surgical advances in recent times and may have
enormous application in the daily management of critically
ill surgical patients. The OA may be a useful option for
treating patients with abdominal sepsis. However its
precise role in these patients is still not clear.
On the basis of the source and nature of the microbial
contamination, peritonitis can be classified into primary,
secondary and tertiary [1].
Primary peritonitis is a diffuse bacterial infection
without loss of integrity of the gastrointestinal tract. It is a
rare condition occurring mainly in infancy, early
childhood and in cirrhotic patients.
Secondary peritonitis is the most common form of
peritonitis and results from loss of integrity of the
gastrointestinal tract due to perforation (e.g. perforated duodenal
ulcer) or by direct invasion from infected intra-abdominal
viscera (e.g. gangrenous appendicitis) [2].
Tertiary peritonitis is defined as a severe recurrent or
persistent intra-abdominal infection >48 h after apparently
successful and adequate surgical source control of
secondary peritonitis [3]. Although it is less common, it may
comprise of a severe systemic inflammation response
[4]. Tertiary peritonitis is associated with microbial
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shift towards nosocomial flora including Staphylococci
coagulase-negative, Candida, Enterococci,
Pseudomonas, Enterobacter and other opportunistic bacteria
and fungi [3, 4]. Mortality rate in tertiary peritonitis is
very high, ranging from 30 to 64 % [4].
Abdominal sepsis is the host’s systemic inflammatory
response to bacterial or yeast peritonitis [5].
Sepsis from an abdominal origin is initiated by the
outer membrane component of gram-negative
organisms (e.g., lipopolysaccharide [LPS], lipid A, endotoxin)
or gram-positive organisms (e.g., lipoteichoic acid,
peptidoglycan), as well toxins from anaerobic bacteria [6].
This leads to the release of proinflammatory cytok (...truncated)