Vacuum-assisted fascial closure for patients with abdominal trauma
Patrick A Stone1, Stephen M Hass, Sarah K Flaherty
1Department of Surgery, West Virginia University School of Medicine, Charleston, West Virginia, USA.
Background:
Massive fluid resuscitation often is required for patients with intraabdominal trauma. Subsequently, fascial closure is not always possible in this subset of patients. Under these circumstances, an initial step can be the use of a temporary abdominal closure method. The authors currently use a vacuum-assisted closure to manage the open abdomen for some of their trauma patients. They present their experience over the past 3 years.
Methods:
From January 2000 to December 2002, 48 trauma patients were treated with temporary abdominal closure using a vacuum-assisted dressing. The ultimate management of the abdominal defect, the serum lactate levels measured in the emergency department, and the fluid balance at the last attempt to accomplish fascial closure were reviewed.
Results:
Delayed fascial closure was achieved in 23 (71.9%) of 32 patients who survived to discharge (26 of 48, 54.2%). Of the 32 patients who survived to discharge, 9 (28.1%) required an alternative closure, most often a split-thickness skin graft. Of the 16 patients who died before discharge, 8 died within 24 hours after admission. Whereas 5 of the 16 deaths occurred after delayed abdominal closure, 11 patients died without abdominal closure. Emergency department serum lactate levels above 8 mg/dL show a positive correlation with in-hospital mortality (6 of 16 patients; 38%; p = 0.001) and mortality within 24 hours of admission (6 of 8 patients; 75%; p = 0.003). Admission lactate levels were not associated with the type of closure achieved. However, primary closure was associated with a significant decrease in lactate levels during the first 12 hours. Complications included five abdominal abscesses, two enterocutaneous fistulas, and one split-thickness skin graft failure.
Conclusions:
Patients requiring temporary abdominal closure have a significant in-hospital mortality rate of 33%. Delayed primary closure with vacuum assistance was achieved for 71.9% of the surviving patients. Maintaining a negative or total positive fluid balance of less than 20 L before the last attempted fascial closure improves successful closure rates, as seen in 19 of 22 patients (86.4%). The vacuum-assisted closure technique also enabled successful primary closure for two patients with extreme delay (>8 days). Elevated serum lactate levels are significantly correlated with early and in-hospital mortality. A significant decrease in lactate level during the first 12 hours is associated with achievement of primary closure.
