“Stretching” Negative Pressure Wound Therapy: Can Dressing Change Interval be Extended in Patients with Open Abdomens?
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When possible, primary fascial closure was performed. If the patient had lost abdominal domain, one of the two management options was entertained. Open wounds exhibiting gross contamination at any time during the resuscitation were managed as planned ventral hernias (PVH).
Patients with PVH had a split-thickness skin graft (STSG) ± vicryl mesh placed over the OA wound. Placement of vicryl mesh was based on the presence or absence of omental coverage over the underlying bowel. If ample omentum was present and no bowel was exposed, vicryl mesh was not used. If coverage of exposed bowel was needed, vicryl mesh was utilized before skin grafting. A STSG was not placed until a healthy, clean granulation bed formed. Abdominal wall reconstruction would be performed on these patients at a later time.
Patients without gross contamination had a Velcro® Wittmann Patch™ (WP; StarSurgical, Burlington, WI) sewn to their fascia.11 The Velcro® patch was advanced daily until the fascial edges could be approximated primarily. After each advancement, the patient was observed for any signs of intra-abdominal hypertension (high peak airway pressures, oliguria, decreased cardiac output). Patients who failed fascial closure using the WP were received either STSG coverage or skin flap closure (SFC) over a bioprosthetic fascial repair (Alloderm™, LifeCell Corp, Branchburg, NJ; or Permacol™, Tissue Science Laboratories, Covington, Ga) plus STSG coverage of the resulting lateral abdominal skin relaxing incision.12 Negative pressure wound therapy dressings placed over skin grafts were left in place for 4 to 5 days.
Statistical analysis. Statistical analysis was performed using SPSS for Windows™ (Chicago, Ill) software. Descriptive statistics utilized included categorical data as well as continuous variables (reported as mean ± standard deviation). Chi-square statistic was used to analyze categorical data. Student’s t-test statistic was utilized in analysis of continuous variables. Statistical significance was set at alpha = 0.05.
Of the 60 patients with open abdomen (OA) managed from 2001 to 2006, 35 were non-trauma patients (NTP) and 25 were trauma patients (TP). Non-trauma patients were significantly older than TP (60.9 ± 15.9 and 38.3 ± 15.0 years, respectively). The NTP group included 17 men and 18 women and the TP group had 17 men and eight women (see Table 1). The most common diagnoses on initial presentation among NTP patients were perforated viscus (13 out of 35) and abdominal compartment syndrome following major abdominal operation (six out of 35). Among the 25 TP patients, the most common diagnoses were severe splenic (eight) and blunt liver injury (five), alone or in combination.
The initial mean SAPS score was not statistically different between the two groups (NTP: 20.6 ± 7.45; TP: 24.1 ± 9.82; P = 0.1395). The predicted mortality, as determined by SAPS scores, was 39.8% and 49.0% for NTP and TP, respectively (P = 0.1626). The observed 28-day mortality was 17.1% and 32.0% for NTP and TP, respectively (P = 0.1177).
Mean time to abdominal closure was 20.7 ± 19.0 and 18.2 ± 13.7 days for NTP and TP, respectively (P = 0.6623). The hospital length of stay (LOS) was not significantly different between TP and NTP, with a trend toward longer LOS for NTP (44.4 ± 31.0 days for NTP versus 31.7 ± 40.1 days for TP, P = 0.1917).