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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
Page 1/24
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
Page 2/24
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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.
Page 3/24
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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
Page 4/24
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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).
Page 5/24
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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%
Page 6/24
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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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Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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).
Page 8/24
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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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Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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-
Page 10/24
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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
Page 11/24
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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.
Page 12/24
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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)
Page 13/24
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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
Day 9Anastomotic leak
Glycine bag only
MOF N/A 3 3 No None Died of MOF at day 3.
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
MOF N/A 8 8 No None Died of MOF at day 8.
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
Alive and fascia closed
at 3 years8 33 M ? 1 Hartman's for
perforated diverticular disease
Day 0Intra-abdominal
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
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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
Day 14Intra-abdominal
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
Day 14Anastomotic leak
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
Day 0Intra-abdominal
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)
Alive and fascia closed
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
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
Haemodialysis patient
Fascia not closed.
19 39 M 8 2 Laparoscopic Right hemicolectomy large
caecal polyp
Day 10Anastomotic leak
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
Day 0Intra-abdominal
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
Day 0Intra-abdominal
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
Day 0Intra-abdominal
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
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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
Alive and fascia closed
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+
11 52 No Repair of fistula/Component
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
Day 9Anastomotic leak
VACDay 6
Fistula Day 18
0 91 No Repair of fistula/Component
separation with mesh (Strattice)
10 months Revised 1 day later
due to technical failure - mesh gave
way - reinforced with Proceed mesh
Alive and fascia closed
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
Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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)
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Short and long term outcomes of laparostomy following intra-abdominal sepsisAnderson, Putnis, Bhardwaj, Ho-Asjoe, Carapeti, Williams, George
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