The Role of Open Abdomen in Non-Trauma Patient WSE

Coccolini et al.
World Journal of Emergency Surgery (2017) 12:39

DOI 10.1186/s13017-017-0146-1
REVIEW Open Access
The role of open abdomen in non-trauma

patient: WSES Consensus Paper
Federico Coccolini1*, Giulia Montori1, Marco Ceresoli1, Fausto Catena2, Ernest E. Moore3, Rao Ivatury4, Walter Biffl5,
Andrew Peitzman6, Raul Coimbra7, Sandro Rizoli8, Yoram Kluger9, Fikri M. Abu-Zidan10, Massimo Sartelli11,
Marc De Moya12, George Velmahos12, Gustavo Pereira Fraga13, Bruno M. Pereira13, Ari Leppaniemi14,
Marja A. Boermeester15, Andrew W. Kirkpatrick16, Ron Maier17, Miklosh Bala18, Boris Sakakushev19,
Vladimir Khokha20, Manu Malbrain21, Vanni Agnoletti22, Ignacio Martin-Loeches23, Michael Sugrue24,
Salomone Di Saverio25, Ewen Griffiths26, Kjetil Soreide27,28, John E. Mazuski29, Addison K. May30,
Philippe Montravers31, Rita Maria Melotti32, Michele Pisano1, Francesco Salvetti1, Gianmariano Marchesi33,
Tino M. Valetti33, Thomas Scalea34, Osvaldo Chiara35, Jeffry L. Kashuk36 and Luca Ansaloni1
Abstract
The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated
after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with
a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated
with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal
emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing.
Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal
Research Academy united a worldwide group of experts in an international consensus conference to review and
thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery
and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently
requiring future study were identified.
Keywords: Open abdomen, Laparostomy, Non-trauma, Peritonitis, Pancreatitis, Vascular emergencies, Fistula, Nutrition,
Re-exploration, Re-intervention, Closure, Biological, Synthetic, Mesh, Technique, Timing
Background The abdominal compartment is dramatically affected in

The decision by a surgeon to utilize the open abdomen both its contents and the characteristics of the abdom-
(OA) technique is a dramatically non-anatomic situation inal wall. Several factors as systemic inflammatory re-
that dramatically increases resource utilization and has sponse syndrome, increased vascular permeability, and
potential severe side effects. It is, however, often dramat- aggressive crystalloid resuscitation predispose to fluid
ically effective at countering the drastically impaired sequestration leading to peritoneal fluid formation.
physiology of critical illness when no other perceived Patients with severe sepsis and septic shock commonly
options exist. There are both mandatory and relative receive large amounts of resuscitation fluids and may
indications for OA use, which are heavily influenced by develop excessive gut edema and diminished contractil-
the primary pathophysiologic insults and responses to ity and motility. These changes in combination with
intra-abdominal sepsis and inflammation, both inherent sequestration of second and third space fluids and
to the patient and induced through medical treatments. forced closure of an abdominal wall with altered
compliance may result in increased intra-abdominal
* Correspondence: federico.coccolini@gmail.com pressure (IAP) ultimately leading to intra-abdominal
1
General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, hypertension (IAH) or even abdominal compartment
Piazza OMS 1, 24127 Bergamo, Italy syndrome (ACS) [1, 2].
Full list of author information is available at the end of the article
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International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
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Coccolini et al. World Journal of Emergency Surgery (2017) 12:39 Page 2 of 17
The pathophysiologic implications of elevated IAP hernia defects. This discrepancy in risks and benefits,
have been restarted to be studied in deep during the last along with economic considerations [10], was the primary
20 years [2–4]. In 2013, The Abdominal Compartment reason the WSACS suggested not routinely using the OA
Society (WSACS) updated the previously published def- for septic cases versus traumatic cases [5]. Thus, every ef-
inition and guidelines for the management of intra- fort should be exerted to attempt abdominal closure as
abdominal hypertension [5]. Elevated IAP constitutes soon as the patient can physiologically tolerate it.
IAH and was classified into four grades: (1) grade I
IAP 12–15 mmHg, (2) grade II IAP 16–20 mmHg, Methods
(3) grade III IAP 21–25 mmHg, and (4) grade IV IAP The recommendations are formulated and graded accor-
>25 mmHg. Elevated IAP commonly causes marked ding to the modified Grading of Recommendations Assess-
deficits in loco-regional and whole body perfusion ment, Development and Evaluation (GRADE) hierarchy of
that may result in organ failure [5]. An uncontrolled evidence from the GRADE Group, summarized in the
IAH, with an IAP exceeding 20 mmHg and new onset Table 1 [11].
organ failure, is defined as an abdominal compart- The WSES and Abdominal Compartment Society
ment syndrome (ACS) [2, 5]. ACS is a syndrome and together with the Donegal Research Academy united a
not a disease, as such, it can have many causes and it group of subject-matter experts coordinated by a central
can occur in many disease processes, it is an all or coordinator to review and summarize the evidence and
nothing phenomenon, while IAH is a more graded thereafter to express their evidence-based opinion on
continuum. ACS in turn has further effects on intra- important issues concerning OA utilization in non-
abdominal organs, as well as indirect effects on the trauma patients:
other organ(s) and system(s). The ACS is a potentially Which non-trauma patients can benefit from OA
and frequently lethal complication characterized by techniques and for which specific critical conditions
effects on splanchnic, cardiovascular, pulmonary, is indicated (example, peritonitis, vascular emergen-
renal, and central nervous systems [2, 5]. While me- cies, and severe pancreatitis)?
dical therapies should be attempted, the ACS is ra- What is the optimum TAC technique for use in non-
pidly lethal and opening of the abdominal cavity trauma patients?
conducted promptly if medical interventions do not Is there a role for fluid instillation?
quickly alleviate or temporize the situation. If surgery What is the optimum timing of re-exploration before
has been undertaken for the index disease, leaving the definitive closure in non-trauma patients?
abdomen temporarily open is often required to prevent in- What is the optimum timing to definitively close an
ducing ACS in a critically ill pro-inflammatory patient OA in non-trauma patients?
with visceral edema and ongoing resuscitation. Whether What are the optimum adjunctive techniques to defini-
leaving the abdomen open will primarily influence the tively close an OA in non-trauma patients considering
septic response is also intriguing but unproven at the both non-mesh-mediated techniques and mesh-mediated
present time. techniques?
The OA procedure is defined as intentionally leaving What is the optimum treatment to treat frozen abdomen
the fascial edges of the abdomen un-approximated and enteral fistulas?
(laparostomy). The abdominal contents are exposed and What nutritional support is indicated in OA?
thus must be protected with a temporary coverage, A central project coordinator compiled the answers and
which is itself termed a temporary abdominal coverage statements derived from the first round of presentations
(TAC) [2, 6]. The OA technique, when used appropri- and discussions. The statements were discussed during
ately, may be useful in the management of surgical the Consensus Conference held in Dublin (Ireland) in July
patients with compromised general conditions due to 2016. Once an agreement was reached within the experts
any critical illness/injury but most frequently cases of groups, a final round of discussion among a larger group
intra-abdominal sepsis and severe pancreatitis are seen of experts led to the final version of recommenda-
recently [7]. Despite many serious potential complications reflecting the final expert-consensus document
tions, the OA is perceived to be a life-saving interven- (Table 2).
tion in catastrophically injured patients [2]. Compared
to trauma patients, however, patients undergoing OA Open abdomen in peritonitis
management for intra-abdominal non-trauma emergen- The open abdomen is an option for emergency surgery
cies have greater risks subsequent to OA utilization, in- patients with severe peritonitis and septic shock under
cluding entero-atmospheric fistula (EAF) and a “frozen the following circumstances: abbreviated laparotomy due
abdomen”, intra-abdominal abscesses, and lower rates of to the severe physiological derangement, or the need for a
definitive fascial closure [8, 9] with resultant large ventral deferred intestinal anastomosis or a planned second look

Table 1 “Modified Grading of Recommendations Assessment, Development and Evaluation (GRADE)” hierarchy of evidence from the
American College of Chest Physicians task force by Guyatt and colleagues [11]
Grade of recommendation Clarity of risk/benefit Quality of supporting evidence Implications
1A
Strong Benefits clearly outweigh risk RCTs without important limitations Strong recommendation,
recommendation, and burdens, or vice versa or overwhelming evidence from applies to most patients in
highquality evidence observational studies most circumstances without
reservation
1B
Strong Benefits clearly outweigh risk RCTs with important limitations Strong recommendation,
recommendation, and burdens, or vice versa (inconsistent results, methodological applies to most patients in
moderate-quality flaws, indirect analyses or imprecise most circumstances without
evidence conclusions) or exceptionally strong reservation
evidence from observational studies
1C
Strong Benefits clearly outweigh risk Observational studies or case series Strong recommendation but
recommendation, and burdens, or vice versa subject to change when
lowquality or very higher quality evidence
lowquality evidence becomes available
2A
Weak Benefits closely balanced RCTs without important limitations Weak recommendation, best
recommendation, with risks and burden or overwhelming evidence from action may differ depending
high-quality evidence observational studies on the patient, treatment
circumstances, or social values
2B
Weak Benefits closely balanced RCTs with important limitations Weak recommendation, best
recommendation, with risks and burden (inconsistent results, methodological action may differ depending
moderate-quality flaws, indirect or imprecise) or on the patient, treatment
evidence exceptionally strong evidence from circumstances, or social values
observational studies
2C
Weak Uncertainty in the estimates Observational studies or case series Very weak recommendation;
recommendation, of benefits, risks, and burden; alternative treatments may be
Low-quality or very benefits, risk, and burden may equally reasonable and merit
lowquality evidence be closely balanced consideration
for intestinal ischemia, or persistent source of peritonitis in a single operation or if extensive visceral edema and
(failure of source control), or extensive visceral edema decreased abdominal wall compliance increases the risk
with the concern for development of abdominal compart- of ACS development, primary fascial closure should not
ment syndrome (grade 2C). be attempted and the abdomen should be left open [14].
In severe secondary peritonitis, some patients may ex- The rationale for using the OA is to leave the abdomen
perience a disease progression to severe sepsis and septic open and to treat the infected peritoneal cavity like an
shock experiencing progressive organ dysfunction, “open abscess” with subsequent re-operations involving
hypotension, myocardial depression, and coagulopathy generous irrigations and potentially active TAC techniques
and a staged approach may be required [12]. These are [15] to definitively control the contamination while also
often hemodynamically unstable and unfit for immediate preventing IAH progression to ACS. No definitive data
complex surgical interventions [12]. If the patient is not exist about the management of severe peritonitis with the
in a condition to be undergone to a definitive repair open abdomen. Robledo et al. compared open versus
and/or abdominal wall closure, the intervention should closed abdomen procedures in 40 patients with severe sec-
be abbreviated due to suboptimal local conditions for ondary peritonitis; no significant differences in mortality
healing and global susceptibility to spiraling organ fail- rates were found (55% open vs. 30% closed). The study
ure. For instance, intestinal continuity restoration can be was interrupted at the first interim analysis for high rela-
deferred to a subsequent surgical intervention, which is tive risk and odds ratios for death in the open group (1.83
particularly important in hypotensive patients who are and 2.85, respectively) [16]. However, the TAC technique
receiving inotropes [13]. In facing the impossibility to that was selected as the “intervention” would be relatively
completely obtain a source control of the contamination contraindicated in current OA management. Some other

Table 2 Statement Grid

Statements
Open Abdomen indication:
➢ Peritonitis The open abdomen is an option for emergency surgery patients with severe peritonitis and septic
shock under the following circumstances: abbreviated laparotomy due to the severe physiological
derangement, or the need for a deferred intestinal anastomosis or a planned second look for
intestinal ischemia, or persistent source of peritonitis (failure of source control), or extensive visceral
edema with the concern for development of abdominal compartment syndrome (Grade 2C).
➢ Vascular Emergencies The open abdomen should be strongly considered following management of hemorrhagic vascular
catastrophes such as ruptured abdominal aortic aneurysm (Grade 1C)
The open abdomen should be considered following surgical management of acute mesenteric
ischemic insults (Grade 2C).
➢ Pancreatitis In patients with severe acute pancreatitis unresponsive to step-up conservative management surgical
decompression and leaving the abdomen open is effective in treating abdominal compartment
syndrome (Grade 2C)
Leaving the abdomen open after surgical necrosectomy for infected pancreatic necrosis is not
recommended excepted in those situation at high risk of abdominal compartment syndrome (Grade 1C)
Optimal technique for temporary abdominal Negative pressure wound therapy with continuous fascial traction is suggested as the preferred
closure technique for temporary abdominal closure (Grade 1B).
Temporary Abdominal Closure without Negative pressure wound therapy (e.g., mesh alone, Bogota
bag) whenever possible should NOT be applied for the purpose of temporary abdominal closure,
because of low delayed fascial closure rate and being accompanied by a significant intestinal fistula
rate (Grade 1B).
Is there a role for NPWT with Fluid Instillation? There is inadequate evidence to make a recommendation regarding use of negative pressure wound
therapy in combination with fluid instillation in patients with temporary abdominal closure (NOT
GRADED).
Planning re-exploration before definitive - In critically ill non-trauma patients with open abdomen, once any requirements for on-going
closure resuscitation have ameliorated, early re-operation with the intention of closing the abdomen should
be given a high priority (Grade 1C).
- In critically ill patients with open abdomen, re-laparotomy with concern for ongoing ischemia/
contamination reoperation should be conducted no later than 24–48 h after the index operation,
with the duration from the index operation shortening with increasing degrees of patient non-
improvement and hemodynamic instability (Grade 1C).
Best timing to definitively close an open - Fascia should be closed as soon as possible (Grade 1C).
abdomen - Acidosis (pH <7.25), hypothermia (temperature < 34 °C) and coagulopathy (TEG, INR) are not
predictive of the need for maintaining the open abdomen in non-trauma patients (Grade 2A).
- The abdomen should be maintained open in non-trauma patients if the source of contamination
persists, if a condition of haemodynamic instability persists meaning in presence of on-going fluid
resuscitation or vasopressor support necessity, if a deferred intestinal anastomosis is needed, if there
is the necessity for a planned second look for ischemic intestine and lastly if there are concerns
about abdominal compartment syndrome development (Grade 2C).
- Early fascia closure (within 7 days) should be the strategy for management of the open abdomen
once the source control has been reached, the severe sepsis has been controlled meaning that the
patient is haemodynamically stable and the hypoperfusion has been definitively corrected, no
further surgical re-exploration is needed and there are no concerns for abdominal compartment
syndrome (Grade 2C).
Best solution to definitively close an open abdomen
➢ Non-mesh mediated techniques - Primary fascia closure is the ideal solution to restore the abdominal closure (2A).
- Component separation is an effective technique; however, it’s early use is NOT recommended in
fascial temporary closure. It should be considered only for definitive closure or reconstructive
interventions (Grade 2C)
- Planned ventral hernia (skin graft or skin closure only) remains an option for complicated open
abdomen (i.e. in the presence of entero-atmospheric fistula or in cases with a protracted open
abdomen due to underlying diseases) or in those low resource setting where no other facilities are
present (Grade 2C)
➢ Mesh mediated techniques - A fascial bridge using prosthetic mesh (polypropylene, polytetrafluoruroethylene (PTFE) and
polyester products) should NOTt be recommended to achieve definitive fascial closure in patients
with open abdomen and should be placed only in patients without other alternatives (Grade 1B).
- Biologic meshes are reliable for definitive abdominal wall reconstruction in the presence of a large
wall defect, bacterial contamination, comorbidities and difficult wound healing. NPWT can be used
combined with biologic mesh to facilitate granulation and skin closure (Grade 2B).
- Non–cross-linked biologic meshes seem to be preferred in sublay position when the linea alba can
be reconstructed. Non–cross-linked biologic mesh is easily integrated, with reduced fibrotic reaction
and lesser infection and removal rate (Grade 2B).

Table 2 Statement Grid (Continued)

- The long-term outcome of a bridging non–cross-linked biologic mesh is laxity of the abdominal wall
and a high rate of recurrent ventral hernia. In the bridge position (no linea alba closure), cross-linked
biologic meshes maybe associated with less ventral hernia recurrence (Grade 2B).
Best treatment for open abdomen and - Several clinical circumstances may contribute to the development of entero-atmospheric fistula and
entero-atmospheric fistulas few risk factors may predict its development. Awareness of this complication and avoidance of
contributing conditions for its development are mandatory; moreover preemptive measures are
imperative (Grade 1C).
- The management of entero-atmospheric fistula should be personalized according to standard
classification and grading system. Current different classification schemes echo the problematic and
challenging issues related to their management (Grade 1C)
- The caloric intake and protein demands of patients with entero-atmospheric fistula increase; the
Nitrogen balance should be corrected and protein supplemented. Nutrition should be started
immediately upon recognition of entero-atmospheric fistula (Grade 1C)
- Entero-atmospheric fistula effluent isolation is essential for proper wound healing. Separating the
wound into different compartments in order to facilitate the collection of fistula output is of
paramount importance (Grade 2A).
- Many methods for wound care exist; however in the presence of entero-atmospheric fistula in open
abdomen, negative pressure wound therapy makes effluent isolation feasible and wound healing
conceivable (Grade 2A).
Definitive management of entero-atmospheric fistula should be delayed to after the patient has
recovered and the wound completely healed (Grade 1C).
Nutritional support - Open abdomen patients are in a hyper-metabolic condition; an immediate and adequate nutritional
support is mandatory (Grade 1C).
- Open abdomen techniques result in a significant nitrogen loss that must be replaced with a
balanced nutrition regimen (Grade 1C).
- Early enteral nutrition should be started as soon as possible if the gastrointestinal tract allows (Grade 1C).
- Enteral nutrition should be delayed in patients with high output fistula with no possibility to obtain
feeding access distal to the fistula (Grade 2C)
- Oral feeding is not contraindicated; whenever it’s possible it could be started as soon as the patient
is able to eat (Grade 2C).
Patient Mobilization - To date, no recommendations can be made about early mobilization of patients with open abdomen.
cohort studies showed the effectiveness of OA technique In prospective non-randomized studies, the incidence
in treating severe peritonitis. At present, however, no de- of ACS is reduced when prophylactic OA is employed
finitive data from randomized trials exist. [19]. Unfortunately, selection criteria for employing OA
are not well defined; the surgeon might consider
Open abdomen in vascular emergencies inability to close the fascia without tension; use of
The open abdomen should be strongly considered follow- aortic balloon occlusion catheter; and preoperative
ing management of hemorrhagic vascular catastrophes blood loss >5 L [19, 20]. Such criteria should prompt
such as ruptured abdominal aortic aneurysm (grade 1C). the surgeon to consider temporary OA utilization. When
The open abdomen should be considered following sur- the abdomen is closed primarily, postoperative monitoring
gical management of acute mesenteric ischemic insults of IAP is recommended, with vigilance for ACS as
(grade 2C). reflected by elevated airway pressures, reduced cardiac
The ACS has been well described in the setting of output, or oliguria. Concerns for infection of aortic grafts
ruptured abdominal aortic aneurysm (rAAA) [17]. with OA are allayed by existing data, indicating a relatively
Rupture of aortic as well as iliac or visceral aneurysm low rate [21]. Patients are often selected for endovascular
often results in life-threatening hemorrhagic shock. repair (EVAR) of rAAA if they have less hemodynamic
The combination of severe shock and massive resusci- compromise. Although it is less common, ACS still occurs
tation contributes to retroperitoneal, mesenteric, and after EVAR [17]. The major risk factor appears to be
bowel wall edema and production of ascites that can massive resuscitation. These patients should have vigilant
increase abdominal pressure and lead to ACS. Intra- monitoring for elevated IAP and the onset of ACS.
abdominal hypertension occurs in up to 50% of Mesenteric ischemia may result from arterial (throm-
patients following AAA repair, and ACS occurs in 8–20%. botic, embolic, or low perfusion) or venous (venous
Mortality after rAAA is as high as 30–50%; of note, thrombosis) insults. Fundamental principles of manage-
mortality is generally twice as high among patients who ment include making the diagnosis, restoration of intes-
develop ACS compared with those who do not [18]. tinal perfusion, and assessment of bowel viability with
Consequently, prevention of ACS, if possible, would resection as necessary. The bowel ischemia leads to
be of tremendous benefit to the patient. bowel wall and mesenteric edema, as well as ascites

production; reperfusion of the bowel can exacerbate occurrence, whereas pancreatic necrosis usually becomes
bowel edema and ascites and thus increase risk of ACS. infected later [34]. Some factors are associated to an in-
For this reason, OA use should be considered following creased risk of infected necrosis: the presence of organ
restoration of perfusion in a patient with acute mesen- failure, early bacteremia, and the extent of pancreatic ne-
teric ischemia. As there are no reliable independent crosis [34]. Surgical necrosectomy is the last resort if more
predictors of ACS in this setting, the surgeon should as- conservative management including percutaneous drain-
sess bowel swelling and the patient’s physiology to make age failure [35]. Patients with persistent organ failure com-
this decision [22, 23]. Another reason to consider tem- plicated with infected pancreatic necrosis face a very high
porary OA following mesenteric ischemia is to facilitate mortality risk [36].
second-look laparotomy to assess bowel viability and
perform bowel anastomosis as needed [24]. Bowel resec-
tion is much less common in the setting of venous Optimal technique for temporary abdominal closure
thrombosis than arterial occlusion, so the patients with Negative pressure wound therapy with continuous fascial
mesenteric venous thrombosis probably do not require traction is suggested as the preferred technique for
OA as often as those with acute arterial occlusion [25]; temporary abdominal closure (grade 1B).
although, IAP should be followed. Temporary abdominal closure without negative pres-
sure wound therapy (e.g., mesh alone, Bogota bag) when-
Open abdomen in pancreatitis ever possible should NOT be applied for the purpose of
In patients with severe acute pancreatitis unresponsive to temporary abdominal closure, because of low delayed
step-up conservative management, surgical decompression fascial closure rate and being accompanied by a signifi-
and leaving the abdomen open is effective in treating ab- cant intestinal fistula rate (grade 1B).
dominal compartment syndrome (grade 2C). There is inadequate evidence to make a recommenda-
Leaving the abdomen open after surgical necrosectomy tion regarding use of negative pressure wound therapy in
for infected pancreatic necrosis is not recommended ex- combination with fluid instillation in patients with
cept in those situations at high risk of abdominal com- temporary abdominal closure (NOT GRADED).
partment syndrome (grade 1C). The perceived indications and subsequent treatment
Acute pancreatitis (AP) is a mild self-limiting disease choices in managing OA differ among surgeons. The
in the majority of cases, even though the 15% of patients existing techniques result in different risk of entero-
with AP progress to severe disease identified by develop- atmospheric fistula (EAF) and the different rate of delayed
ment of persistent organ failure [26]. Multiple organ fail- fascial closure. Overall, 74 relevant studies exist for a total
ure (MOF) is the factor mainly associated to mortality in of 4358 patients: 3461 (79%) with peritonitis. The de-
AP, as a counterpart in absence of organ dysfunction or scribed OA indications are considerably different. Thirty-
if it transient the risk of dying is very low [27–29]. How- eight out of 78 series described negative pressure wound
ever, in those with severe AP, MOF develops generally therapy (NPWT) TAC systems. NPWT with a dynamic
early, with over half of the patients exhibiting organ component (mesh-mediated fascial traction or dynamic
dysfunction’s signs at hospital admission and in any case, sutures) gives the best results in terms of delayed fascial
most part of them develops within the first 4 days after closure, but dynamic sutures result more often in fistula.
admission [28, 30]. More than half of the deaths happen NPWT without a dynamic component (Barker’s VAC or
within the first week from onset of AP and generally within commercial products) for the use of temporary fascial
a week after MOF first symptoms [31]. Principal treatments closure has a moderate delayed fascial closure rate and a
of MOF are support therapies: vasopressors, fluid replace- fistula rate similar to mesh closure without NPWT.
ment, and renal replacement therapy and mechanical venti- Several TAC techniques exist that could be used
lation if indicated. During AP, IAH/ACS may aggravate alone or combined together. Six-eight series reported
MOF, and therefore, constant IAP measurements are cru- about one TAC technique. Ten series described pa-
cial to identify patients with high risk of developing ACS tients managed with combined TAC systems. NPWT
[32]. ACS should be prevented and treated, whenever pos- was used alone in 32 studies [37–68], and in 6 stud-
sible, with non-operative management. Surgical decom- ies, NWPT is combined with fascial traction (mesh or
pression is the last but the most effective tool to decrease sutures) [69–74] and eight series described the use of
the IAP, and it should not be postponed if the patient pre- meshes (non-absorbable and/or absorbable) [75–81].
sents ACS manifestation [5, 33]. Six series reported about the Bogota-bag use [75, 82–86];
In the event of AP, the risk to develop subsequent infec- five, about Zipper [87–91]; and other five, about dynamic
tions (i.e., bacteremia, pneumonia and infection of pancre- retention sutures [92–96]. Two more series described
atic or peripancreatic necrosis) is increased. The first week loose packing [97, 98]. Lastly, the Wittmann patch was
of illness is crucial for the extra-pancreatic infection used in one series [99]. The remnant three series applied

different TAC systems [82, 100, 101]. The delayed fascial survey of Trauma Association of Canada in 2006, and the
closure rate ranged from 3.2 to 100%. majority of responders indicated the best timing included
Twenty-two series were prospective, and ten out of between 24 and 72 h [106, 107]. Pommerening et al. uti-
them described NPWT (608 patients) showing a lized the American Association for the Surgery of Trauma
weighted fascial closure rate of 53.9% and an EAF rate (AAST) Open Abdomen Registry to evaluate time to the
of 9.8%. The four prospective series on NPWT with first re-operation on trauma OA patients as a predictor of
fascial traction (411 patients) showed a weighted fascial primary fascial closure using a hierarchical multivariate lo-
closure rate of 77.8% and an EAF rate of 4.3%. Including gistic regression analysis [108]. Adjusting for other factors,
retrospective studies data per closure type are in line including resuscitation volumes, increasing delay to the
with the aforementioned results. With the highest first re-operation was associated with a decreased
weighted fascial closure rate for NPWT with fascial trac- likelihood of primary fascial closure (PFC), with a 1.1% de-
tion (73.1%) and dynamic retention sutures (73.6%). crease in PFC rates for every hour after 24 h from the
TAC using a mesh or zipper showed the lowest delayed index operation [108]. Further, there was a trend (95% CI
closure rates (34.2 and 34.0% respectively). Nine series 1.0–3.25 OR) of increased complications in patients
were not exhaustive in describing eventual fascial having the first re-operation after 48 h [108].
closure attempts [16, 45, 75, 81, 87, 89, 98, 102, 103]. It should be clearly understood however that
extrapolation of these findings regarding the timing of
Is there a role for NPWT with fluid instillation? re-operation in trauma patients might not be directly
There are no series published on the use of NPWT with applicable to non-trauma patients with OA. It is
instillation in situations of TAC in non-trauma patients becoming apparent that infected and non-infected pa-
or in trauma patients. Recently, a systematic review tients with auto-activation of the immune responses
performed by an expert consensus group has been pub- leading to multi-organ dysfunction syndrome (MODS)
lished underlining the need of more evidence to support and MOF have more fundamental differences than previ-
the fluid instillation and giving no recommendation of ously appreciated [109]. Fundamental evidences from
its use in abdominal wound [104]. basic science are emerging justifying the OA in critically
ill/injured patents in order to manipulate the systemic im-
Planning re-exploration before definitive closure mune response and ameliorate the bio mediator burdens
In critically ill non-trauma patients with open abdomen, of catastrophic illness [110–113]. There are also newly de-
once any requirements for on-going resuscitation have ame- scribed populations of fully mature indwelling peritoneal
liorated, early re-operation with the intention of closing the macrophages that migrate locally within the peritoneal
abdomen should be given a high priority (grade 1C). cavity within an hour of injury [114]. Whether mechanic-
In critically ill patients with open abdomen, re-laparotomy ally removing such cell populations through scheduled
with concern for ongoing ischemia/contamination re- “wash-outs” is beneficial or harmful is a completely un-
operation should be conducted no later than 24–48 h after studied question. Thus, the timing of re-operation is more
the index operation, with the duration from the index complex in non-trauma patients and urgently requires
operation shortening with increasing degrees of patient non- further study. Lastly, in critically ill patients with an OA,
improvement and hemodynamic instability (grade 1C). re-laparotomy with the intention of cleaning or “washing-
A related question for clinicians is when to re-operate out” the abdomen has an unknown priority and should be
(if ever) for the sole purpose of “revise” when there is rec- subjected to future randomized study.
ognition that closing an abdomen will not be possible.
This question may be further conceptually complicated in
an attempt to distinguish indications to re-operate be- Best timing to definitively close an open abdomen
cause the patient is not improving or deteriorating and Fascia should be closed as soon as possible (grade 1C).
there is fear that contamination or ischemia is ongoing Acidosis (pH <7.25), hypothermia (temperature <34 °C),
and those cases of non-improvement or only modest im- and coagulopathy (TEG, INR) are not predictive of the
provement in whom there is operation intention to “wash” need for maintaining the open abdomen in non-trauma
the peritoneal cavity and to “change” the TAC dressing or patients (grade 2A).
device. No RCTs or meta-analyses examining the timing The abdomen should be maintained open in non-
of re-operation in OA patients exist. Guidelines and trauma patients if the source of contamination persists, if
review papers did not generally discuss timing of re- a condition of hemodynamic instability persists meaning
operation [8, 105]. In the position paper of the WSES, it is in the presence of an on-going fluid resuscitation or vaso-
recommended that as a general principle, patients should pressor support necessity, if a deferred intestinal anasto-
be taken back to the operating room at 24–48 h after the mosis is needed, if there is the necessity for a planned
initial surgery [2]. Other expert opinions come from the second look for ischemic intestine, and lastly if there are

concerns about abdominal compartment syndrome devel- a protracted open abdomen due to underlying diseases) or
opment (grade 2C). in those low-resource setting where no other facilities are
Early fascia closure (within 7 days) should be the strat- present (grade 2C).
egy for management of the open abdomen once the source Abdominal component separation is most commonly
control has been reached, the severe sepsis has been con- considered an elective procedure for ventral hernia re-
trolled meaning that the patient is hemodynamically pair [118]. One important technique described for the
stable and the hypoperfusion has been definitively cor- reconstruction of the abdominal wall is the component
rected, no further surgical re-exploration is needed, and separation. The technique of anterior component separ-
there are no concerns for abdominal compartment syn- ation consists in a relaxing incision made in the apo-
drome (grade 2C). neurosis of the external oblique muscle, a separation of
The early definitive abdominal closure is the first goal the external and internal oblique muscle and the incision
to achieve in order to reduce the OA complications rate of the rectus fascia to achieve the advancement of the
[115], (i.e., EAF, fascial retraction with loss of abdominal abdominal wall to cover the defect. This technique has
wall domain, and incisional hernias) [115, 116]. The pri- been well studied and described in elective giant ventral
mary closure rates have a bimodal distribution, with hernia repair, and it provides an effective technique with
early closure depending on postoperative intensive care a recurrence rate of 16% [125, 126] but a very relevant
management and delayed closure depending on the complication rate of 50%. Other surgical techniques that
choice of the TAC technique [117]. Mortality, complica- have been described include the posterior component
tions, and length of stay were compared between early separation: the rectus sheath is opened and the posterior
and delayed fascial closure in a meta-analysis [118]. 3125 rectus fascia and rectus muscle are separated. At the
patients were included and 1942 (62%) successfully lateral margin of the rectus muscle, the aponeurosis of
achieved early fascial closure. Early fascial closure is a the transverse abdominis muscle is incised with the
factor significantly associated with a reduced mortality separation of the internal oblique muscle from the trans-
(12.3 versus 24.8%, RR 0.53, P < 0.0001) and complica- verse abdominis muscle.
tion rate (RR, 0.68, P < 0.0001). Early fascial closure is However, the use of abdominal component separation
commonly performed within 4–7 days of the initial technique was recently described in acute fascia closure
laparostomy [13]. No major technical difficulties are de- after open abdomen in a small case series by Rasilainen et
scribed to obtain primary fascial closure within few days al. [127] with 75% of primary fascia closure. At present,
from the index operation. Patients having abdominal there is not enough evidence to support component
sepsis are less likely to achieve an early fascial closure separation in the acute setting due to the related high
[119] and therefore should have closure attempts per- morbidity and the fact that these techniques can only be
formed as soon as possible after severe abdominal sepsis performed on a patient once, so that if ill timed, future op-
is controlled [120]. tions are not available. Therefore, a valuable alternative
option for closure of the open abdomen remains the
Best solution to definitively close an open abdomen planned ventral hernia: its main goal is to cover abdominal
Often the OA, particularly if prolonged, results in viscera to prevent complications such as EAF. The ab-
fascia retraction and consequently in large abdominal dominal wall defect could be closed only with skin suture
wall defects that require complex abdominal wall re- and or a skin graft put on the underlying granulating tis-
construction. Moreover, the situation is often compli- sue creating a planned laxity. After physiologic recovery
cated by a contaminated field [121] with high risk of and a significant period of scar and adhesion maturation,
infections and wound complications, such as wound the complete restoration of the patient’s abdominal wall
infections, seromas, fistula formation, recurrence of through reconstructive techniques can be undertaken as
the defect, and mortality [122–124]. an elective procedure.
Non-mesh-mediated techniques Mesh-mediated techniques

Primary fascia closure is the ideal solution to restore the A fascial bridge using prosthetic mesh (polypropylene, poly-
abdominal closure (grade 2A). tetrafluoruroethylene (PTFE) and polyester products) should
Component separation is an effective technique; however, not be recommended to achieve definitive fascial closure in
its early use is NOT recommended in fascial temporary patients with open abdomen and should be placed only in
closure. It should be considered only for definitive closure patients without other alternatives (grade 1B).
or reconstructive interventions (grade 2C). Biologic meshes are reliable for definitive abdominal
Planned ventral hernia (skin graft or skin closure only) wall reconstruction in the presence of a large wall defect,
remains an option for complicated open abdomen (i.e., in bacterial contamination, comorbidities, and difficult
the presence of entero-atmospheric fistula or in cases with wound healing. NPWT can be used combined with

biologic mesh to facilitate granulation and skin closure of events leading to new healthy tissue deposition and
(grade 2B). prosthesis remodeling. The presence of vital tissue there-
Non-cross-linked biologic meshes seem to be preferred in fore allows for perfusion and a native immune response
sublay position when the linea alba can be reconstructed. preventing mesh infection and abscess formations. The
Non-cross-linked biologic mesh is easily integrated, with re- ideal BP will also maintain mechanical characteristics of a
duced fibrotic reaction and lesser infection and removal synthetic mesh with a sufficient mechanical strength to
rate (grade 2B). withstand the physiological and anatomic stresses of the
The long-term outcome of a bridging non-cross-linked human abdominal wall. Such an ideal BP should also tol-
biologic mesh is laxity of the abdominal wall and a high erate adjunctive NPWT to facilitate wound healing,
rate of recurrent ventral hernia. In the bridge position granulation, and skin closure [100, 138].
(no linea alba closure), cross-linked biologic meshes Discordant data have been published about the use of
maybe associated with less ventral hernia recurrence BP to bridge a wide defect of the abdominal wall. The
(grade 2B). evidence is limited with few studies, all non-randomized,
Two meta-analyses exist on BP in abdominal wall de- and with an overall small number of cases. Further
fect. The first, by Sharrock et al. investigated the man- among heterogeneous patients reported, recurrence rates
agement and closure of OA in trauma patients [128]. have ranged between 0 and 100% [139–152]. When used
Among the included studies, the point estimate recur- as a bridge to close the fascia defect, the reported recur-
rence rate of ventral hernia after 1 year of BP position- rence rate in a large retrospective series was >80% [153].
ing was 51%. However, the authors highlighted the Another study by Booth and colleagues compared pri-
small number of included studies and their poor qual- mary fascia closure with mesh reinforcement with the
ity; moreover, as above mentioned, great differences use of the mesh as a bridge and demonstrated a higher
exist between trauma and septic patients and great cau- recurrence rate in the mesh in a bridge position (8 vs.
tion should be addressed in interpretation of this result. 56%, p < 0.001) [154].
A systematic review and meta-analysis by Atema et al. Several studies investigated the best anatomical pos-
[129] investigated the utilization of BP in abdominal ition in terms of BP function, but were not specifically
wall reconstruction. They clearly stated that the poor focused on OA reconstruction. Nonetheless, evidence,
quantity and quality of available data strongly limits including that from randomized trials, suggest that
taking a clear message from the results. Biological material implanting the BP in the sublay position results in a
in infected fields had a recurrence rate of 30% compared lower recurrence and complication rate [155–157].
with 7% of synthetic material, but data were derived from However, it should be stressed that the data included
a single study and does not justify the use of synthetic ma- was not specific for the OA situation and the heterogen-
terials, especially as a bridge position after OA. eity among patients and indications was very high,
The “bridging” technique refers to using some mesh (ei- resulting in a poor level of evidence.
ther prosthetic or biologic) to physically interpose between Two meta-analyses exist on BP in abdominal wall de-
native abdominal wall fascia that either cannot or should fect. The first, by Sharrock et al. investigated the manage-
not be primarily opposed. Thus, such fascial defects can ment and closure of OA in trauma patients [128]. Among
be closed with a mesh in a bridging position. In general, the included studies, the point estimate recurrence rate of
non-absorbable synthetic materials (i.e., polypropylene ventral hernia after 1 year of BP positioning was 51%.
mesh) reinforce any fascial repair through a combination However, the authors highlighted the small number of in-
of mechanical tension and intense inflammatory reaction, cluded studies and their poor quality; moreover, as above
resulting in the entrapment of the mesh into scar tissue. mentioned, great differences exists between trauma and
However, in a bridging position, there is no native tissue septic patients and great caution should be addressed in
to protect viscera from the mesh and thus, the persistent interpretation of this result.
inflammatory response combined with the contaminated A systematic review and meta-analysis by Atema et
field may induce local side effects such as adhesions, ero- al. [129] investigated the utilization of BP in abdom-
sions, and fistula formation [130–135]. International inal wall reconstruction; the poor quantity and quality
guidelines on emergency repair of abdominal wall hernia of available data strongly limits the results. Biological
therefore do not recommend the use of synthetic meshes material in infected fields had a recurrence rate of
in contaminated fields [136]. 30% compared with 7% of synthetic material, but data
Biological prosthesis (BP) has been designed to perform were derived from a single study and does not justify
as permanent surgical prosthesis in the abdominal wall re- the use of synthetic materials, especially as a bridge
pair, minimizing mesh-related complications [137]. The position after OA.
rationale of their usage in OA is based on the premise that In conclusion, no definitive evidence-based conclusions
the implantation of a biologic material triggers a cascade could be obtained currently from the literature. The

Fig. 1 Open Abdomen classification according to Bjork et al. [168]
available evidence is really weak: most of the cited meta- Many methods for wound care exist; however, in the
analysis included rather poor quality retrospective case presence of entero-atmospheric fistula in an open abdo-
series. There is also great heterogeneity among the indica- men, negative pressure wound therapy makes effluent iso-
tions for mesh implantation, the anatomic positioning of lation feasible and wound healing conceivable (grade 2A).
the mesh, and the type of mesh. This further weakens the Definitive management of entero-atmospheric fistula
quality of the evidences. Thus, well-performed random- should be delayed to after the patient has recovered and
ized trials comparing different type of meshes and the the wound completely healed (grade 1C).
techniques of mesh positioning are urgently required. Enteric fistula is a severe complication following ab-
dominal surgery. The opening of a fistula onto dehisced
wound therefore exposing and communicating the bowel
Best treatment for open abdomen and entero- and its effluent to the atmosphere is defined as EAF.
atmospheric fistulas The incidence of EAF varies from 4.5 to 25% in the
Several clinical circumstances may contribute to the trauma setting [158] and from 5.7 and 17.2% in non-
development of entero-atmospheric fistula and few risk trauma patients [105]. The presence of this complication
factors may predict its development. Awareness of this dramatically increases considerably mortality, length of
complication and avoidance of contributing conditions stays, and costs [159].
for its development are mandatory; moreover, preemptive Many factors may contribute to the development of
measures are imperative (grade 1C). EAF. All linked as a “vicious cycle”: the lack of overlying
The management of entero-atmospheric fistula should soft tissue, with its blood supply, precludes spontaneous
be personalized according to standard classification and healing and the exposed viscera predispose to additional
grading system. Current different classification schemes disruptions in the gastrointestinal tract. EAFs may result
echo the problematic and challenging issues related to from various etiologies: anastomotic dehiscence or dis-
their management (grade 1C). ruption, iatrogenic injury during dissection or inappro-
The caloric intake and protein demands of patients priate handling, and presence of synthetic prosthetic
with entero-atmospheric fistula increase; the nitrogen material (i.e., mesh) and from the prolonged exposure of
balance should be corrected and protein supplemented. bowel [160–163]. ACS and severe IAH may result in re-
Nutrition should be started immediately upon recogni- duced bowel blood supply and therefore contribute to
tion of entero-atmospheric fistula (grade 1C). EAF development [68]. A prospective analysis of 517
Entero-atmospheric fistula effluent isolation is essential trauma emergency laparotomies showed that large bowel
for proper wound healing. Separating the wound into dif- resections, large volume fluid resuscitation (>5 L/24 h),
ferent compartments in order to facilitate the collection of and increased number of re-explorations were signifi-
fistula output is of paramount importance (grade 2A). cantly associated with an increased incidence of EAF

[158]. Preemptive measures could be undertaken in output by diminishing GI secretions [177] while others
order to prevent this complication: early abdominal wall argue their benefit due to this agents’ reduction in
closure, bowel coverage with omentum or skin, and no splanchnic blood flow and reduction in immune
direct application of NPWT on the viscera are some of function [178, 179].
these measures [112, 164, 165]. The main goal in the management of EAF should be
Several classifications and grading systems of EAF the closure of the fistula. Differently from common GI
exist. Schein and Decker proposed in 1991 a grading sys- fistulas, the EAF is not a true fistula since a fistula tract
tem based on the fistula location. Grade IV indicates a does not exist. The lack of surrounding tissues prevents
fistula related to large abdominal wall defects with the spontaneous closure. The goal of the treatment
grades IVa and IVb indicating the site of the fistula in should be focused on trying to isolate the fistula effluent
regards to its location [166]. EAF can be classified based and enhancing the formation of granulation tissues sur-
on the fistula effluent output: low (<200 ml/day), moder- rounding it. Several different techniques were described
ate (200-500 ml/day), and high (>500 ml/day) [167]. and proposed in the literature to control and treat EAF,
Bjork et al. proposed a classification based on the pres- and some attempts to standardize its management exist
ence of adhesions of the bowel in the setup of the open [169, 170]. A patient diagnosed with EAF in the setup of
abdomen as well as the association to the fistula forma- OA should be treated by medical personnel familiar with
tion (Fig. 1), and this was later adapted by WSACS this complication and its consequences.
[168]. Di Saverio et al. proposed a comprehensive classi- Accurate fistula definition and anatomy should be made.
fication based on the combination of different criteria as Sepsis control and management is important. Diversion of
anatomical location, output, exposure, and number of the fistula output in order to maintain clean the peritoneal
fistulas [169]. As a general principle, a single, superficial cavity is mandatory. Fistula effluent should be measured
fistula located in the lower GI tract with a low output in order to facilitate fluid balance and to ensure skin pro-
has a higher probability of spontaneous closure rather tection from its digestive nature on the skin. This will en-
than multiple fistulas deep in the wound with high out- hance and allow better patient care and mobility.
put [169, 170]. According to this principle, the manage- Several different dressing and techniques were de-
ment should be tailored to each clinical situation and scribed for the management of EAF, each one with rela-
individualized accordingly. In conclusion, the presence tively small case series and discordant results with a
of several different classifications represents the true dif- consequent poor level of evidence [162, 170, 180–183].
ficulties in the management of EAF in OA. Level of evi- Proposed treatments vary from primary suture and fibrin
dence is poor and many recommendations are based on glue for small exposed distal fistula to a fistula suspen-
expert opinion suggestions. sion fixating the fistula edges to the skin. Several
EAF is a poorly predictable and, above all, avoidable variants of NPWT with devices for fistula isolation and
complication. When patients develop EAF, an accurate diversion were described with promising outcomes.
and tailored management scheme should be adopted. The several techniques are described in detail else-
Nutrition plays a key role in the management of these where and are not in the scope of the current position
patients and should be always kept in mind as a funda- paper [170]. The described method to manage NPWT in
mental part of the treatment. The open abdomen strat- patients with EAF in the setup of OA should be applied
egy may result in fluid and electrolytes loss resulting in depending on surgeon preference, skills, and expertise
acid-base derangements [8]. The anatomy and the char- and according to hospital facilities and material availabi-
acteristics of the EAF(s) should be defined in order to lity. Generally, negative pressure wound therapy, with
plan the best treatment option [171]. Parenteral nutri- specifically described variants, is the most accepted tech-
tion (TPN) should be started immediately after the pa- nique. EAF isolation and proper wound management
tient resuscitation. Enteral nutrition in OA patients has will enable skin grafting and converting EAF to a more
been well studied demonstrating a reduction in infec- controllable one with ease of applying effluent collection
tious complications preserving the intestinal mucosal bag. The definitive treatment, i.e., closure of the fistula
barrier and its immunological function [172–174]. En- and repairing the abdominal wall defect should be post-
teral nutrition in patients with an EAF is has but may poned at least 6 months and only after the patient and
increase fistula output. Only small series of patients the wound healed completely.
with EAF treated with EN exists; therefore, no strong
evidence can support these treatments and further
studies are needed [175, 176]. The use of octreotide an- Nutritional support
alogs is controversial. No evidence exists about the use Open abdomen patients are in a hyper-metabolic condi-
of somatostatin and octreotide in managing of EAF. tion; an immediate and adequate nutritional support is
Few studies suggest that octreotide may reduce fistula mandatory (grade 1C).

Open abdomen techniques result in a significant nitro- Patient mobilization

gen loss that must be replaced with a balanced nutrition To date, no recommendations can be made about early
regimen (grade 1C). mobilization of patients with open abdomen.
Early enteral nutrition should be started as soon as Patients with an open abdomen generally should not be
possible if the gastrointestinal tract allows (grade 1C). mobilized out of bed until their abdomens are definitively
Enteral nutrition should be delayed in patients with closed, for risk of evisceration [190]. This statement was
high output fistula with no possibility to obtain feeding extrapolated from trauma literature [191]. However, pro-
access distal to the fistula (grade 2C). longed bed rest is associated with significant increase in
Oral feeding is not contraindicated; whenever its complication rate. More recent attention has been focused
possible, it could be started as soon as the patient is on intensive care unit (ICU)-acquired weakness and the
able to eat (grade 2C). long-term adverse functional sequelae for ICU survivors,
The hyper-catabolic state of critically ill patients is asso- particularly in the physical domain and this has led to an
ciated with muscle proteolysis, acute protein malnutrition, increased interest in early mobilization in the ICU as a
immune function impairment, and subclinical develop- potential means of prevention [192–196]. The optimal
ment of MOF. Several studies clearly demonstrated mal- timing for initiation of mobilization of patients with OA
nutrition as a fundamental risk factor associated to poor has yet to be defined. Early mobilization is currently
outcomes during hospital stay [184]. Furthermore, in a defined as occurring within the first 2 to 5 days of ICU
critically ill patient, OA leads to significant nitrogen loss admission [197].
estimated to be 2 g per liter of abdominal fluid output. Patients with open abdomen managed with NPWT
This issue requires adequate consideration and an ad- however, may be mobilized by active or passive transfer.
justed integration [185]. For this reason, the measurement Further research must occur to provide the rationale to
of the abdominal fluid loss is mandatory [185]. This loss early mobilization prior to definitive abdominal closure.
in nitrogen and protein is ulterior greatly increased in the
presence of EAF. A particular attention must be given to Conclusions
this critical aspect because patients with OA are the sick- Management of the open abdomen remains a very
est, most inflamed, and subsequently most hyper- controversial domain, in which many techniques are still
metabolic among surgical patients. During the OA patient debated. Many important issues remain to be addressed
management, once the resuscitation is almost completed through carefully designed and rigorously conducted stud-
and the GI tract allows it, EN should be started as soon as ies. Until better data is available, the use of the OA should
possible. Thus, it will bring beneficial effects for the be carefully tailored to each single patient taking care to
patient as faster fascia closure and lower pneumonia and not overuse this effective tool. Every effort should be
fistula rate [173, 186, 187]. If malnutrition occurs, mucosal exerted to attempt abdominal closure as soon as the patient
atrophy and malabsorption are among the earliest conse- can physiologically tolerate it. Finally, all the precautions
quences. Gut-associated lymphoid tissue seems to be di- should be considered to minimize the complication rate.
minished, and as a consequence, it can increase the risk
for disseminated infection due to bacterial translocation Abbreviations
through the intestinal wall [188]. EN helps in maintaining AAST: American Association for the Surgery of Trauma; ACS: Abdominal
gut mucosal barrier in good shape and function; as a con- compartment syndrome; AP: Acute pancreatitis; BP: Biological prosthesis;
EAF: Entero-atmospheric fistula; EN: Enteral nutrition; EVAR: Endovascular
sequence, it has been demonstrated to enhance immunity repair; GRADE: Grading of Recommendations Assessment, Development and
and IgA secretion, to prevent muscle atrophy, and lastly Evaluation; IAH: Intra-abdominal hypertension; IAP: Intra-abdominal pressure;
to decreases systemic inflammation and oxidative injury INR: International Normalized Ratio; MODS: Multi-organ dysfunction
syndrome; MOF: Multiple organ failure; NPWT: Negative pressure wound
[188, 189]. Early EN within the first 24–48 h is demon- therapy; OA: Open abdomen procedure; PTFE: Polytetrafluoruroethylene;
strated to improve wound healing, decrease catabolism, rAAA: Ruptured abdominal aortic aneurysm; RCT: Randomized controlled
preserve GI tract integrity, and finally, it reduces compli- trial; TAC: Temporal abdominal closure; TEG: Thromboelastography;
TPN: Parenteral nutrition; WSACS: The Abdominal Compartment Syndrome;
cations, length of hospital stay, and costs. Compared to WSES: World Society of Emergency Surgery
TPN early EN decreases septic complications especially in
abdominal trauma and traumatic brain injuries. A retro- Acknowledgements
spective, single-institution study comparing DCS interven- Special thanks to Ms. Franca Boschini (Bibliographer, Medical Library, Papa
tions with open abdomen performed to treat ACS, 43 Giovanni XXIII Hospital, Bergamo, Italy) for the precious bibliographical work.
patients underwent early (<4 days) and 35 late (>4 days)

Funding
EN. Early EN significantly increased primary closure (74% None.
vs. 49%), reduced the fistula rate (9% vs. 26%) with no
difference in infections and but with a significant reduc- Availability of data and materials
tions in hospitalization costs [186]. Not applicable

Authors’ contributions Sant’Orsola-Malpighi University Hospital, Bologna, Italy. 33ICU Department,

FCo, GMo, MC, FCa, EEM, RI, WB, AP, RC, SR, YK, FMA-Z, MSa, MDM, GV, GPF, Papa Giovanni XXIII Hospital, Bergamo, Italy. 34Trauma Surgery department,
BMP, AL, MAB, AK, RM, MB, BS, VK, MM, VA, MIL, MSu, SDS, EG, KS, JEM, AKM, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
35
PM, RMM, MP, FS, GMa, TMV, TS, OC, JLK, and LA did the manuscript conception Emergency and Trauma Surgery department, Niguarda Hospital, Milan, Italy.
36
and draft, critically revised the manuscript, and contributed with important General Surgery department, Assuta Medical Centers, Tel Aviv, Israel.
scientific knowledge giving the final approval. All authors read and approved
the final manuscript. Received: 22 February 2017 Accepted: 25 July 2017
Ethics approval and consent to participate

Not applicable
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The Role of Open Abdomen in Non-Trauma Patient WSE

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Coccolini et al.

World Journal of Emergency Surgery (2017) 12:39

REVIEW Open Access

The role of open abdomen in non-trauma

Background The abdominal compartment is dramatically affected in

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Table 2 Statement Grid

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Non-mesh-mediated techniques Mesh-mediated techniques

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Fig. 1 Open Abdomen classification according to Bjork et al. [168]

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Open abdomen techniques result in a significant nitro- Patient mobilization

patients underwent early (<4 days) and 35 late (>4 days)

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Authors’ contributions Sant’Orsola-Malpighi University Hospital, Bologna, Italy. 33ICU Department,

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