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					VAC Abdominal Dressing – a retrospective
study in the treatment of the open
abdomen following secondary peritonitis
and abdominal compartment syndrom




      Thomas Wild, MD
       Antwerp 2007
          Current treatment of Open
                          Abdomen
   No standard conventional
    treatment
   Based on surgeon’s preference
   To date no large studies
    comparing outcome
                              Methods
   5 surgical departments in Austria
   Retrospective analysis 2001-2006
   Patients with secondary peritonitis
   Treatment with (decided by treating
    physician)
     Open packing (OP)

     Classic VAC (CV)

     VAC Abdominal dressing (AD)
Traditional Methods
Classic V.A.C.
 Abdominal Dressing
Outcome parameters
             Outcome parameters
   APACHE II score
   Duration of open abdomen
   LOS in ICU
   Nursing requirements
   Mortality
                         Patient demographics
                     OP (SD)        CV (SD)       AD (SD)    p-value*

Patient
                          62             102        75
  number (n)
Mean Age                 60.3            62.8       61.8
                                                             p=0.62
  (years)                (15.0)          (13.9)    (15.0)
                         26.5           26.2       29.1
Mean BMI                                                     p=0.13
                          (7.6)         (5.6)      (8.5)
Mean Weight              79.6            76.3       82.9
                                                           p=0.21
  (kg)                   (23.0)          (19.2)     (26.4)
Mean Apache              18.9           16.8        19.3
                                                             p<0.002
  II                      (8.1)         (8.0)        (9.4)

* Kruskal-Wallis test, SD = standard deviation
                                  Primary operation
Reason              Small Large
          Stomach               Pancreas Trauma Absces Ascites Ileus   Acute
                    bowel bowel
Therapy

OP          5         8    20      3       1      2      1       2      20


CV          11       11    35      8       0      4      0       5      28


AD          7        15    20      4       0      2      0       4      23


Total       23       34    75     15       1      8      1      11      71
                                    Therapy at different
                                              hospitals
          3,5

           3

          2,5
therapy




           2

          1,5

           1

          0,5

           0
                Hospital I   Hospital II   Hospital III   Hospital IV   Hospital V
                                            Age distribution
      100

      90

      80
                                                        68,0
      70
                                                                      72,5
      60                   68,0
age




                                          60,0
      50      57,5
      40
      30

      20

      10

       0
            Hospital I   Hospital II   Hospital III   Hospital IV   Hospital V
                                                   APACHE II


            50          p=0.13*

                      p<0.001*           p=0.08*


            40
APACHE II




            30


            20


            10


            0
                 AD                 CV              OP
                                  therapy
                                                              APACHE II score

                                         25

               30                                                                       26

                                                                                   26
                25                                      17
                              22 18,5                                         26
                                                                         15
                20
                                                 14,5             16,5
                                            17
Median APACHE II 15
                                                             14
                 10

                     5                                                                             AD

                     0                                                                        CV
                                                                                                    Therapy
                         Hospital I                                                      OP
                                      Hospital II
                                                    Hospital III
                                                                    Hospital IV
                                                       Mortality

                100%
                             p<0.001*
                90%          p<0.001*
                                                  ns
                80%    76%

                70%

                60%
    mortality




                50%
                                         37%           36%
                40%

                30%

                20%

                10%

                 0%
                       OP                 CV            AD
                                        therapy



OP vs CV :p<0.001* ; OP vs AD : p<0.001* ; CV vs AD : ns*
                                   Hospital I

            100%

            90%
                        p=0,0012
            80%
            70%
            60%
mortality




            50%

            40%

            30%
            20%

            10%
             0%
                   OP                      CV      AD
                                         therapy
Mortality differences
  between hospitals
                                                       Days in ICU

                 40              37,6               36,4
                 35
                                             30
Days (mean)




                 30
                 25                                         OP
                 20                                         CV
                 15                                         AD
                 10
                   5
                   0
                                         ICU stay
              p= 0.25, Kruskal-Wallis test
                        ICU stay different between
                                          hospitals

              120
                         113
              100

               80
                               62
                                    47                             68
Median dICU    60
                                                                        30
                40                              22,5
                                           36               10
                                                     15,5                        17
                20
                                    26,5
                                                                             9             AD
                    0                           15          24,5
                                                                                       CV
                                                                                            Therapy
                        Hospital
                                 Hospital                                             OP
                           I              Hospital
                                    II             Hospital
                                            III             Hospital
                                                     IV
                                                               V
                    Days to abdominal
                               closure

       45
                     P=ns
       40
       35
       30
Days




                                     OP
       25
                                     CV
       20
                                     AD
       15   41.4     21.9    33.3
       10   ±91.4    ±17.5   ±40.4

        5
        0
                Abdominal Closure
                                                    Treatment Pathway
      Time                                            Acute Abdomen                                    Monitoring

                                                   Infection and/or increased                       IAP >25mmHg, CT,
                                                                                                    Defense Necrosis, Fibrin,
                                                   intra-abdominal pressure                         Granulation tissue CRP,
    Emergency                                                                                       Leukocytes, Fibrinogen
     2nd or 3rd                                                                                     Clotting
   postoperative
        day                                          Lavage & Debridement

                                                    Closure not          Closure
                                                    possible             possible


                                VAC application and                   Immediate abdominal           IAP < 15 mmHg
                                                                                                    Necrosis, Fibrin,
                                 dynamic sutures                            closure                 Granulation tissue,
                                                                                                    CRP, Leukocytes,
                                     Closure not                                                    Fibrinogen, Clotting
                                     possible


every 2nd -3rd day             VAC-dressing change, Lavage, Dynamic sutures                         Necrosis, Fibrin,
                                                                                                    Granulation tissue
 (Mo-Wed-Fri.)
                                                                                                    CRP, Leukocytes,
                       Closure not                                      Closure                     Fibrinogen
                       possible                                         possible                    Exudate amount



                                                                                                    IAP < 15 mmHg
                                                                  Abdominal wall closure            Nutrition–Albumin,
                                                                                                    Protein, Pre-albumin,
                                                                                                    Transferrin,
                                                                                                    Kidney function,
                                                                       80% Granulation tissue,      Creatinin, BUN
                     Wound bed preparation and/or                                                   CRP (<5), Leukocytes
  from 4th Day                                                         no Infection, less than 50
                     secondary wound closure                           ml Exudate in 48 hours       (<12.000), Fibrinogen
                                                                                                    Exudate amount 100-
                                                                                                    200 ml/day clear liquid
                    Perspective

Prospective Study is started now

  Please sign in the regestry!

thomas.wild@meduniwien.ac.at

				
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posted:9/15/2012
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