Abstract Front Sheet - spiral.imperial.ac.uk Anderson... · Web viewShort and long term outcomes of...

Short and long term outcomes of laparostomy following intra-abdominal sepsis

O Anderson BSc MBBS MRCS Specialty RegistrarA Putnis MRCS Senior House Officer

R Bhardwaj MD FRCS Specialist RegistrarM Ho-Asjoe* FRCS Consultant Plastic Surgeon

E Carapeti MD FRCS Consultant Colorectal SurgeonAB Williams MS FRCS Consultant Colorectal SurgeonML George MS FRCS Consultant Colorectal Surgeon

Department of Colorectal Surgery, *Department of Plastic Surgery, St. Thomas’ Hospital, London

Corresponding Author: Mr Oliver AndersonClinical Research FellowCentre for Patient Safety and Service QualityDepartment of Surgery and Cancer10th Floor QEQM BuildingSt Mary's HospitalSouth Wharf RoadLondonW2 1NYUKWork phone: 020 3312 6532Work fax: 020 3312 6309Email: [email protected]

This is the pre-refereed version of a published paper:Anderson O, Putnis A, Bhardwaj R, Ho-Asjoe M, Carapeti E, Williams AB, George ML. Short and long term outcome of laparostomy following intra-abdominal sepsis. Colorectal Dis. 2010 Oct 6. doi: 10.1111/j.1463-1318.2010.02441.x. [Epub ahead of print] PMID: 21040361

The definitive version is available at:http://onlinelibrary.wiley.com/doi/10.1111/j.1463-1318.2010.02441.x/abstract?systemMessage=There+will+be+a+release+of+Wiley+Online+Library+scheduled+for+Saturday+27th+November+2010.+Access+to+the+website+will+be+disrupted+as+follows%3A+New+York+0630+EDT+to+0830+EDT%3B+London+1130+GMT+to+1330+GMT%3B+Singapore+1930+SGT+to+2130+SGT

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Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George

Abstract

Aim: This study reports the short and long term outcomes of patients treated with

a laparostomy for intra-abdominal sepsis.

Methods: Twenty-nine sequential patients with intra-abdominal sepsis treated

with a laparostomy over 6 years.

Results: Median age = 51 years, ITU stay = 8 days, post-operative stay = 87

days, follow-up = 2 years. Mean APACHEII score = 18, giving an expected

mortality of 25%, which was insignificantly different to the observed mortality of

33% (p = 0.35). Enterocutaneous fistulas developed in 15% of the 45% of

patients treated with a vacuum dressing. Fourteen percent of patients developed

intra-abdominal collections and half required formal percutaneous drainage. The

total enterocutaneous fistulation rate was 35% (21% ≤ 30 days and 14% > 30

days). Sixteen fascial reconstruction operations were performed. Component

separation (with mesh) was successfully used to treat 5 patients with

enterocutaneous fistulas whilst mesh repair without component separation was

used in 2 patients and associated with recurrent herniation in 1 and recurrent

fistulation in the other. In total, component separation was successful and

uncomplicated in 83% of patients and mesh repair in 25%.

Conclusion: Laparostomy for intra-abdominal sepsis is associated with mortality

rates insignificantly different to those predicted using APACHEII scores. Vacuum

dressings are associated with enterocutaneous fistulation. Laparostomy is

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associated with a significant risk of early and late enterocutaneous fistulation and

commits the patient to a prolonged recovery with potentially complicated fascial

reconstruction. Component separation fascial reconstruction had better outcomes

than mesh repair in patients with and without enterocutaneous fistulas.

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Introduction

A laparostomy is a laparotomy wound which is deliberately left open with the

believed benefits of effective intra-abdominal drainage, relief of intra-abdominal

pressure, direct visualisation of the intra-abdominal contents post-operatively and

less traumatic re-exploration. The indications for laparostomy are gross intra-

abdominal sepsis that requires drainage or further operations, abdominal

compartment syndrome, necrotising pancreatitis and abdominal trauma. Early

complications are increased fluid and electrolyte losses, evisceration, wound

infection, enterocutaneous fistulation and abscess formation. Late complications

are scarring, enterocutaneous fistulae and ventral hernias. (1, 2)

The outcome of laparostomy in terms of fascial closure rate depends on the

indication. (3) Therefore, our study includes patients treated with a laparostomy

for only one indication, intra-abdominal sepsis. Current evidence on laparostomy

for intra-abdominal sepsis consists of only one randomized controlled trial and

several observational studies. (1, 3-18) We consider cases of laparostomy for

intra-abdominal sepsis only, with particular reference to managing the

laparostomy in the immediate post-operative period and longer term, how best to

reconstruct the resulting defect in the fascia.

Methods

The inclusion criteria were those patients treated with laparostomy for intra-

abdominal sepsis. Exclusion criteria were those patients treated with a

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laparostomy for abdominal compartment syndrome, pancreatitis, abdominal

trauma or abdominal wound dehiscence.

Data were collected prospectively on age, sex, pre-laparostomy ASA grade, pre-

laparostomy APACHE II score (19), primary operation, indication for

laparostomy, co-morbidities, length of post-laparostomy Intensive Care Unit stay,

length of total hospital stay, laparostomy wound management, morbidity and

mortality, reconstructive procedures and length of follow up.

Results

Demographics

Laparostomy was used to treat 29 patients over a 6-year period (2003-2009).

The median age was 51 years (range, 20-83). There were 19 male and 10

female patients. The median ASA grade was 3 (range 1-5).

The APACHE II score has been shown to predict in hospital mortality in cases of

intra-abdominal sepsis (20) and has been adopted by the Surgical Sepsis

Society to stratify the condition. (21) The mean APACHE II score (based on 24

patients in this study) was 17.96 giving a predicted mortality of 25%. (19) The

observed mortality in these 24 patients was 33%. A Chi-squared test shows that

the observed and expected mortalities are not significantly different (Table 2).

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The median length of stay in intensive care was 8 days (range 0-73 days). 21

patients survived longer than 30 days and had a median length of post-

laparostomy hospital stay of 87 days (range 44 - 324).

62% of patients were discharged alive. Out patient follow up in these patients

was a median of 2 years (mean 2.6 years, range 9 months - 5.5 years). No

patients were lost to follow up.

Indications

The indication for laparostomy was for intra-abdominal sepsis in all 29 cases,

with 18 of these due to perforation of the gastrointestinal tract, 6 due to intra-

abdominal sepsis with no perforation identifiable, 4 due to irreversible gut

ischaemia and 1 due to a rejected kidney-pancreas transplant.

In all cases, the abdomen was entered via a laparotomy incision. If the

laparostomy was carried out after the primary operation then the original incision

was re-opened. An appropriate procedure was carried out to treat the pathology

encountered, eliminate the source of infection and reduce contamination. At the

end of the procedure a laparostomy was felt to be appropriate to prevent

persistent or recurrent intra-abdominal infection.

Initial wound management

Initially, 97% of patients had a sterile plastic sheet ('Bogata Bag') sewed to the

fascia of the abdominal wall. One patient had a vacuum dressing (VAC). 97%

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were transferred to intensive care post-operatively (one was transferred to HDU).

In 41% of patients a specialised ‘wound manager’ dressing consisting of a plastic

sheet with drainage ports was used if the fluid output from the laparostomy was

difficult to manage with gauze dressings over the laparostomy. In 45% of patients

a vacuum dressing (VAC) was started at a median of 7 days post-operatively

(range 0 - 45 days) some in the manner described by Brock et. al. (9) and some

in the manner described by Subramonia et. al. (22) 15% of patients treated with

VAC developed a fistula while on VAC therapy. One of these had no Bogata bag

and the VAC was applied on day zero. The other had a VAC applied on day 6.

Enterocutanous fistulation occurred on day 14 and 18 respectively. No patients

had a mesh sewn to the fascia on the same occasion as laparostomy creation.

Intra-abdominal collections

14% of patients developed intra-abdominal collections demonstrated on CT scan,

but only 50% of these required drainage over and above drainage that was

already provided by the laparostomy. This was carried out percutaneously.

30-day complications

Early complications within the first 30 days from operation occurred in 83% of

patients (Table 1). Six (21%) of patients developed an early enterocutaneous

fistula. Two of these patients were being treated with a VAC.

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In total 28% of patients died within 30 days of laparostomy. Seven patients died

of multiple organ failure (MOF) and one died of respiratory failure. No patients

died of laparostomy related complications.

Late complications

In hospital mortality was 38%. 10% of patients died in hospital after 30 days, two

of pneumonia at day 55 and 60 and one of diabetic ketoacidosis at day 89.

The late enterocutaneous fistula rate in patients surviving longer than 30 days

was 14%. The late enterocutaneous fistulas developed between 3-16 months

after laparostomy formation. Two late enterocutanous fistulas developed in

patients who had split thickness skin grafts over open fascial defects (one of

these was definitely due to minor trauma) and one late enterocutaneous fistula

developed in a patient whose wound healed by secondary intention.

Laparostomy related complications

48% of patients suffered complications related to the laparostomy. These were

composed of the 9 patients who developed fistulae, 2 patients who had MRSA

colonisation of their wounds and 4 patients who had intra-abdominal collections

on CT scan. 28% of patients underwent an intervention to treat their laparostomy

related complication. 7 patients underwent fistula repair and 2 patients underwent

drainage of their collections (one patient had both a fistula repair and a collection

drained).

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Reconstruction

16 fascial reconstructive procedures were carried out on 14 patients at a median

of 10 months post laparostomy creation (range 3 months to 3 years). 25% were

mesh repairs and 75% were component separation operations of which 92% also

used mesh. One patient in the mesh group, had fascial edges that could not be

brought together and therefore had an inlay mesh repair instead of an onlay

mesh repair. The only patient who had a component separation operation that

did not use mesh was due to a fistula contaminating the operative field and a

high risk of mesh infection.

Management of enterocutaneous fistulas

Two (33%) early enterocutaneous fistulas were treated successfully

conservatively and later had component separation operations to repair the

fascia. The other four (66%) had operative repair of the enterocutanous fistula at

the same time as a component separation operation. One of these component

separation operations was complicated by an early technical failure and was

redone successfully on day 1 post-op. Of the three late enterocutaneous fistulas,

one was treated with a mesh repair that was complicated by a recurrent hernia,

one was treated with a mesh repair that was complicated by a recurrent fistula

and subsequently treated by enterocutaneous fistula repair without repairing the

fascia, and one was treated with component separation operation.

Follow-up

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Long term follow up found that only one of the four (25%) mesh repairs was

successful, 2 were complicated by recurrent incisional hernias and 1 by recurrent

fistulation. 83% of the 12 component separation operations were successful. One

patient had a technical failure of suturing the mesh and a hernia recurrence on

day 1 and 1 patient had a recurrent incisional hernia.

Discussion

The majority of laparostomies were performed for intra-abdominal sepsis

secondary to confirmed perforation of the gastrointestinal tract. 4 patients in this

study had collections demonstrated on CT scan. Two required formal drainage. If

these patients had been treated with laparotomy, then all of these collections

would have required formal drainage or re-laparotomy. The 30 day mortality

rate was 28%, but no patients died of laparostomy related complications. 48% of

patients suffered complications due to the laparostomy. Other studies report a

laparostomy complication rate of 25%. (23)

The debate of laparotomy versus laparostomy for intra-abdominal sepsis has

been investigated previously. Table 3 shows the results of other studies that

have treated patients with intra-abdominal sepsis with laparostomy and reported

the APACHEII scores and mortality rate combined with the results of this study.

Other studies that reported their results in a manner that did not allow patients

treated for intra-abdominal sepsis from a gastrointestinal origin to be separated

from those treated for other indications (e.g. pancreatitis) were excluded. A Chi-

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squared test shows that the overall observed mortality rate from all the studies is

not significantly less than that predicted by the APACHE II scores. In comparison,

the patients treated with closed techniques in these studies are shown in Table 4

and the Chi-squared test shows that the overall observed mortality is significantly

greater than that predicted by the APACHE II scores. Two of the three studies

that compared open to closed techniques were observational and their control

groups had significantly lower APACHEII scores than their experimental groups

and were therefore not directly comparable to their control groups. (13, 18) The

single high quality randomized controlled trial that had controls that were directly

comparable to their experimental participants found that laparostomy was

associated with a higher mortality rate although the trial was halted before

statistically significant results were obtained. (4) Therefore, it is still unclear if

laparostomy is better than laparotomy in terms of mortality rate.

Our early enterocutaneous fistula rate was 21%, which in keeping with other

studies' reported rates of 0-29%. (15-17) The late enterocutaneous fistula rate

was 14%, which is also in keeping with other studies' reported rates of 0-16%. (3,

5, 15, 16)

15% of patients developed an enterocutaneous fistula while being treated with a

VAC, which is in keeping with other studies' reported rates of 11-36%. (9, 22, 24)

We did not find that VAC therapy removed the requirement for later fascial

reconstruction in any of our patients. (22) Patients in our study were unable to

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undergo early fascial closure due to oedematous bowel or physiological

instability.

Mesh has a lower rate of recurrent herniation when compared to primary suture

repair of ventral hernias in uncontaminated fields. (25) Fansler et. al. 1995

reports the results of using polypropylene mesh after laparostomy as a 50%

fistulation rate with split skin graft used over polypropylene mesh and a 40%

fistulation rate with secondary intention alone over a polypropylene mesh, but a

0% fistulation rate with a full thickness skin graft over a polypropylene mesh. (26)

Component separation was first described by Ramirez et. al. (27) Component

separation covers the abdominal wall defect with a layer of skin thicker than a full

thickness skin graft with or without mesh beneath. It has been shown to be the

best of the autologous tissue repair techniques of large abdominal wall hernias in

a systematic review (28) and out performs mesh repair in terms of successful

repair of giant abdominal wall defects (47% vs. 39%) (28, 29) Component

separation also has been shown to have good results when used on patients with

fistulas and contaminated surgical fields with a re-fistulation rate of 12-27% and a

re-herniation rate of 8-22%. (30, 31) In contrast, mesh repair of abdominal wall

hernias in the presence of a contaminated surgical field is more likely to cause a

fistula at a rate of 3.5% and has a re-herniation rate of 43%. (32) These reports

are consistent with our results that showed component separation to be more

successful at treating enterocutaneous fistulas and hernias than mesh repair.

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The median time of initial fascial reconstructive surgery was 10 months after

laparostomy, which is in line with recommendations (33) and fascial closure was

achieved in 52% of cases. Other studies have shown a fascial closure rate of 0-

46% in cohorts of patients surviving intra-abdominal sepsis treated with

laparostomy. (1, 3, 7, 8, 12)

In conclusion, laparostomy outcomes for intra-abdominal sepsis reported in this

study are similar to those previously reported. The high early mortality rate is due

to the severity of the underlying sepsis and is not significantly different from the

expected mortality rate predicted from the APACHE II scores. Laparostomy has a

significant enterocutaneous fistulation rate and causes significant long-term post-

operative morbidity. Laparostomy should be used judiciously for intra-abdominal

sepsis. The best technique to achieve fascial closure is component separation.

(10, 23, 34)

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Num

ber

Age Sex

AP

AC

HE

II S

core

AS

A PrimaryProcedure

Laparostomy Indication

Wound management

Ear

ly M

orbi

dity

(<30

day

s)

Late

Mor

bidi

ty

Inte

nsiv

e C

are

Uni

t (d

ays)

Leng

th o

f Sta

y (d

ays)

Ski

n gr

afts

Fascial Reconstruction Outcome

1 72 F 21 2 Extended right hemi-colectomy for

synchronous caecal and transverse

cancer

Day 6Anastomotic leak

Glycine bag only

MOF N/A 3 3 No None Died of MOF at day 3.

Fascia not closed.

2 74 M 17 2 Left hemicolectomy for sigmoid cancer


Glycine bag only


Fascia not closed.

3 39 M 34 5 Sub-total colectomy, ileostomy and

mucus fistula for ischaemic colitis

secondary to septic embolus

Day 2Ischaemic rectum

Glycine bag only


Fascia not closed.

4 71 M 19 5 Cystectomy and ileal conduit for bladder

cancer

Day 7Peritonitis, no

perforation identified

Wound manager

MOF N/A 17 17 No None Died of MOF at day 17. Fascia not

closed.5 20 F ? 1 Repair of colonic

serosal tear due to blunt trauma.

Day 8Colonic leak

Wound manager

Fistula None 56 117 No Component separation with mesh at 1 year

Alive and fascia closed

at 4 years6 51 M 4 3 Exploratory

laparotomy and wash out - no

perforation found

Day 0Intra-abdominal

sepsis

VACDay 23

None None 4 121 YesDay 81

None Died of cancer at 15

months. Fascia not

closed.7 68 F ? 3 TAH + BSO for

benign diseaseDay 10

Small bowel perforation

VACDay 17

Stroke None 17 98 YesDay 98

Component separation with

mesh at 98 days


at 3 years8 33 M ? 1 Hartman's for

perforated diverticular disease


sepsis

Glycine bag only

None Fistula 4 136 No Repair of fistula/Vipro Mesh

day 94. Gortex Mesh repair

at 2 years.

Alive with recurrent incisional

hernia at 5 years.

9 43 F 5 1 TAH + BSO for stage 4 ovarian

Day 14Perforated rectum

VACDay 2

MRSA None 3 44 No None Died of cancer at 15

Page 9/24


cancer months. Fascia not

closed. 10 52 M 14 3 Small bowel

resection and ileostomy formation

for small bowel perforation. Crohn's

disease.

Day 8Peritonitis, no

perforation identified

Wound manager

MRSA None 56 156 No None Alive fascia not closed at

5 years

11 64 M 12 3 Hartman's for ischaemic sigmoid

perforation


sepsis

VACDay 43

None Fistula 5 217 Yes Day 275

Repair of fistula/Gortex Mesh day 183. Removed

due to infection. Fistula after day

275. Fistula repair.

Fistula closed but fascia not

closed.Died at 4

years

12 59 F 15 2 Right hemicolectomy for small bowel

obstruction at day 7 post Laparoscopic cholecystectomy


VACDay 3

MOF None 7 324 No None Died at 1 year. Fascia not closed

13 22 M ? 2 Right hemicolectomy for penetrating

abdominal trauma


sepsis

? None None ? 150 Yes Component separation with mesh at 3 years

Alive and fascia closed at 5.5 years

14 38 F 12 3 Kidney and pancreas transplant

Day 29Pancreatic graft

failure

VAC Day 6

None Fistula 8 71 Yes Repair of fistula/Component

separation at 7 months (no mesh

due to fistula)


at 2 years

15 73 M 25 4 Endovascular AAA repair

Day 6Ischaemic large

bowel

Glycine bag only

MOFCollection

treated conservatively

None 73 83 YesDay 68

None Died of pneumonia at

2 months. Fascia not

closed.16 36 M 19 3 Kidney and

pancreas transplantDay 20

Duodenal leak and pancreatic

abscess

VAC Day 45

(+ wound manager)

Primary haemorrhage

None 1 71 Yes At

6/12

Component separation with

mesh at 3 years. Incisional hernia.

Alive with incisional

hernia at 4 years.

17 83 F 14 3 Hartmann's for diverticular perforation

Day 62nd look

laparotomy withIntra-operative

bowel perforation

Wound manager

Pneumonia None 25 55 No None Died of pneumonia at

day 55. Fascia not

closed.18 34 M 16 ? Reversal of

Hartmann's and formation of ileostomy.

Day 90Peritontits, no

perforation found

Glycine bag only

Collection treated

conservatively

None 10 89 No None Died of diabetic

ketoacidosis day 89.

Page 10/24


Haemodialysis patient

Fascia not closed.

19 39 M 8 2 Laparoscopic Right hemicolectomy large

caecal polyp


Wound manager

Fistula None 31 74 No Component separation with

mesh at 12 months

Alive fascia closed at 18

months.20 75 M 44 5 Open AAA repair Day 19

Subtotal colectomy for

ischaemic colon

VACDay 7

(+ wound manager)

MOF N/A 30 30 No None Died of MOF day 30.

Fascia not closed.

21 61 M 45 3 Right hemicolectomy for ischaemic

caecum secondary to pseudo-obstruction


sepsis

VAC Day 7

(+ wound manager)

Respiratory failure (COPD)

N/A 22 22 No None Died of respiratory failure day 22. Fascia not closed.

22 75 M 23 3 Radical cystprostatectomy, sigmoid colectomy,

ileal conduit and end colostomy for

bladder cancer

Day 64 Small bowel

obstruction with ileal conduit

perforation and gastric perforation - repair of benign

gastric ulcer, small bowel

resection with ileostomy, completion colectomy,

revision of ileal conduit.

Wound manager

MOF N/A 1 20 No None Died of metastatic

bladder cancer and MOF at day 20. Fascia not closed.

23 50 M 24 5 Exploratory laparotomy and wash out - no

perforation found


sepsis

Wound manager

MOF None 12 12 No None Died of ischaemic gut

at day 12. Fascia not

closed.24 51 F 14 3 Right hemicolectomy

for ischaemic secondary to

vascular insufficiency

Day 6Ischaemic small

bowel perforation

Wound manager

Fistula Hypo-Mg2+

15 85 No Repair of fistula/Component

separation with mesh at 10 months

Alive and fascia closed at 15 months

25 27 M 31 4 Small bowel resection for

gunshot injury

Day 11Large bowel perforation

VACDay ?

None None 7 79 No Mesh repair at 1 year

Alive and fascia closed at 4 years.

26 37 F 7 1 Extended right hemicolectomy for Crohn's disease


sepsis

VAC Day 26

Pelvic collection requiring

None 6 66 Yes Component separation with

mesh at 9 months

Alive and fascia closed at 13 months.

Page 11/24


transgluteal drain

27 73 M ? ? Ileocolic resection for Chron's disease

Day ?Anastomotic leak

? Fistula None ? ? No Repair of fistula/Component

separation with mesh at 2 years


at 2 years

28 43 F 4 3 Right hemicolectomy for Crohn's disease

Day ?Anastomotic leak

VACDay 0

Changed to wound

manager on day 19

FistulaDay 14

Peri-splenic

collection requiring

drain Day 41

Hypo-Mg2+


separation with mesh (Strattice) and

reversal of ileostomy at 7

months

Alive and fascia closed at 9 months

29 52 M 4 2 Anterior resection for CRC


VACDay 6

Fistula Day 18


separation with mesh (Strattice)

10 months Revised 1 day later

due to technical failure - mesh gave

way - reinforced with Proceed mesh


at 1 year

NOTES:MOF = Multiple Organ FailureVAC = vacuum dressingFistula = entero-cutaneous fistulaThe days in the laparostomy column are the days since the primary procedureThe days in the other columns are days since the laparostomy formation

Page 12/24


Table 2Chi-squared test of <30-day mortality

Observed Expected Alive 16 18Dead 8 6Data from 24 patients with APACHEII scores in this study. Mean APACHEII score = 17.96, predicted mortality 25%. Chi squared equals 0.0889 with 1 degree of freedom. The two-tailed P value equals 0.3458 (no significant difference)

Table 3Patients treated with laparostomy for intra-abdominal sepsis

Study n Average APACHEII Score

Observed Mortality (%)

Expected Mortality (%)

Bailey 2000 (5) 7 22.7 28.6 40Walsh 1988 (6) 25 16.6 32 25Garcia 1988 (7)

15 25 26.5 55

Ivatury 1989 (8)

14 15 64 25

Wittmann 1990 (11)

117 ? 25 47

Robledo 2007 (4)

20 24 55 40

Wittmann 1994 (13)

95 15.9 24.2 25

Cuesta 1991 (15)

7 30 28 75

Hakkiluoto 1992 (16)

12 22.25 42 40

Hedderich 1986 (17)

7 16 29 25

Grunau 1996 (18)

13 17.6 77 25

This study 24 17.96 33.3 25

Chi-Squared test = 3.112 1df p=0.0777 (no significant difference)

Table 4Patients treated with laparotomy for intra-abdominal sepsis

Study n AverageAPACHEIIScore

Observed Mortality (%)

Expected Mortality (%)

Robledo 2007 (4) 20 22 30 40Wittmann 1994 (13) 260 10.5 21.8 15Grunau 1996 (18) 35 11.8 23 15

Chi-squared = 8.315 1df p=0.0039 (significant)

Page 13/24


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