m. k. müller kantonsspital frauenfeld das... · treatment of secondary peritonitis e.g. after...
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Left open Abdomen & 2nd look on demand?
M. K. Müller
Kantonsspital Frauenfeld
Der chirurgische Bauch-eine interdisziplinäre Herausforderung 9. Nov. 2018
Sekundäre Peritonitis nach:
Outline
Left open abdomenClosed
scheduled 2nd look
Closed2nd look on demand
Verschluss nichtmöglich
DefinitiverVerschluss nicht
gewollt
DefinitiverVerschluss mit
Kriterien
Wieso, weshalb, warum?
• Heterogenes Patientengut– Alter
– Geschlecht
– Begleiterkrankungen
– Exogene Noxen (Nikotin, Medikamente)
• Heterogene Ursache der Peritonitis
• Individuelle Entscheidung
Left open abdomen
Left open abdomen
Verschluss nichtmöglich
• ‘Damage control’
• Kontamination
• Lange Operationszeit
• Kompartment
‘Right operation on the right patient
at the right time’
‘Life before Abdominal wall’
Left open abdomen
Left open abdomen
Verschluss nichtmöglich
• ‘Damage control’
• Kontamination
• Lange Operationszeit
• Kompartment
Case male 34 years
• 192 kg, 180 cm, BMI 59.3 kg/m2
• art. Hypertension
• OSAS, Nicotine 15py
Case 2 male 35 years
Lap. Gastric Bypass (100 min), 07.10.2014
a 250 cm, b 100 cm, circular stapler 25 mm
postoperative ICU 24h
until 4. pod good recovery
Case 2 male 35 years
4. pod
Tachycardia, Dyspnoe, CRP 178 mg/l
CT scan
Case 2 male 35 years
12.10.2015
• Resection of incarcerated small bowel, anastomosis 120 cm proximally to ileoceacal valve
• Revision of Entero-Enterostomy
• Revision of Gastro-Enterostomy and Omental patch
• Decompression of remnant stomach
Further course
• Operative lavage14.10. / 16.10. / 20.10. / 21.10. / 23.10. / 28.10. / 29.10. / 31.10. / 02.11. / 06.11.
• Revision of Entero-Enterostomy18.10. / 19.10. / 25.10. / 26.10. / 27.10.
• Rectus muscle flap04.11.
Further course
• Lavage, Vicryl Mesh, Vac08.11.
• Lavage and Vac10.11. / 14.11. / 17.11.
• Skin graft24.11.
• Tracheostomy, Antibiotics , TPN, Hemodialysis, ICU 12.10. until 17.12.
Further course
• Hospital stay 07.10.2014 until 05.01.2015Neurorehabilitation until 09.05.2015
• Outpatient visit 25.02.129 kg, - 57 kg
• Outpatient visit 15.04.120 kg, - 66 kg
• Outpatient visit 16.07.wheelchair and walking sticks
Treatment of secondary peritonitise.g. after bariatric surgery
• Irrigate & drain the abdominal cavity
• Seal the leaks with an endoscopic stent or clips or sutures or all of the above
• Scheduled looks in the OR
• Get ahead of septicaemia
• Don’t bother about the abdominal wall
Open abdomen
Pros
• No compartment
• Better drainage of contamination
Cons
• Fluid loss
• Temperature control
• Abdominal wall retraction
Left open
Technische Möglichkeiten
• Abdominaler Vac
• Sucutaner Vac
• Retraktionssysteme (z.B: Abra System)
• Ventrofil
• Bogota Bag
• Meshes
• etc.
Left open
The highest weighted fascial closure rate was found in series describing NPWT with continuous mesh or suture mediated fascial traction was 73.1 %.
Weighted rates of fistula varied from 5.7 % after NPWT with fascial traction and 17.2 % after mesh inlay .
Although the best results in terms of achieving delayed fascial closure and risk of enteroatmospheric fistula were shown for NPWT with continuous fascial traction, the overall quality of the available evidence was poor, and uniform recommendations cannot be made.
Outline
Left open abdomenClosed
scheduled 2nd look
Closed2nd look on demand
Verschluss nichtmöglich
DefinitiverVerschluss nicht
gewollt
DefinitiverVerschluss mit
Kriterien
Outline
Closedscheduled 2nd look
DefinitiverVerschluss nicht
gewollt
Temporary Closure, 2nd look
Indication
• Contamination
• Critical ischemia
Risk
• Overtreatment
• Damage to the abdominal wall
Outline
Left open abdomenClosed
scheduled 2nd look
Closed2nd look on demand
Verschluss nichtmöglich
DefinitiverVerschluss nicht
gewollt
DefinitiverVerschluss mit
Kriterien
Outline
Closed2nd look on demand
DefinitiverVerschluss mit
Kriterien
Kriterien für die Relaparotomie
Second look on demand
Comparison of On-Demand vs Planned Relaparotomy Strategy in Patients With Severe Peritonitis
A Randomized Trial
Multicenter n=5, Netherlands, 2001-2005
116 on demand vs. 116 planned
10 Endpoint: 12 mth mortality
O van Ruler , JAMA 2007
Inclusion criteria
• Secondary peritonitis requiring emergency laparotomy
– Perforation or infection of visceral organ
– Ischemia due to strangulation
– Postoperative peritoneal infection
• APACHE II Score >10
Randomization
Planned
• Every 36-48h
• The sequence was terminated, when macroscopically clean
On-demand
• Clinical deterioration or lack of improvement with a likely intraabdominal cause
• Multidisciplinary team
Criteria for relaparotomy
On-demand
• Clinical deterioration or lack of improvement with a likely intraabdominal cause
• Multidisciplinary team
>4 points increase in the MOD-Score
MOD-Score unchanged for 48 hours
Abdominal CompartmentBleedingHemodynamic instabilityBurst AbdomenAnastomotic leakAbscess
Multi Organ Dysfunction Score
Marshall JC, Crit Care Med 1995
Key points
• Heterogeneous cohort of patients
• In open abdomen:
– life before abdominal wall
– NPWT current standard
• 2nd look on demand in selected cases
– Reduction in relaparotomies
– Less health care utilization
• Multidisciplinary approach
MKM 08.11.2018
Danke für die Aufmerksamkeit