Laparostomy Management with ABThera™ Case Experience: ABThera™ Open Abdomen Negative Pressure Therapy System in a Grade IV Open Abdomen Secondary to Acute Pancreatitis

1. Dr Ed Fitzgerald MRCS
General Surgery Registrar
Chelsea & Westminster Hospital, London
Laparostomy Management with ABThera™
Case Experience:
ABThera™ Open Abdomen Negative Pressure
Therapy System in a Grade IV Open Abdomen
Secondary to Acute Pancreatitis
Permissions granted by patient

2. Intra-abdominal hypertension (IAH) &
Abdominal Compartment Syndrome (ACS)
Concept of pathologically raised intra-abdominal pressure
Development is attributed to a range of contributory factors:
• Paralytic ileus
• Aggressive fluid resuscitation
• Retroperitoneal inflammation (e.g. pancreatitis)
• Intra-abdominal inflammation (e.g. peritonitis)
• Intra-abdominal fluid including ascites and haemorrhage
Abdominal compartment syndrome defined as:
• Intra-abdominal pressure > 20mmHg
and
• ≥1 new organ dysfunction
Associated with high mortality of up to 25-75% depending on cause.

3. What are we dealing with?

4. Treated by opening the abdomen
Management of the open abdomen remains a significant challenge
Experience of managing the open abdomen generally relates to trauma or
emergency abdominal surgery
Problems:
1. Protection of abdominal viscera
2. Control and removal of exudate and/or infectious material
3. Loss of fascial domain through lateral retraction of the abdominal wall
Needs meticulous, ongoing post-operative management from an
experienced multidisciplinary team.
The ultimate treatment aims once primary cause treated:
• Closure of the laparostomy
• Ideally by early surgical approximation of the fascia
• Or secondary healing by granulation and delayed ventral hernia repair
• As appropriate to the underlying cause and patient condition

5. The problem…
Permissions granted by patient

6. Permission granted by patient
44-year old gentleman with a history of:
• Hypercholesterolaemia
• Excess alcohol consumption
• Gastritis
• Hepatitis
• Hypertension
Presented 3-day history of constant severe epigastric pain and vomiting
Amy 758, CRP 28, WCC 13
Admitted for analgesia and supportive management of pancreatitis.
Case Experience at Chelsea & Westminster

7. D2/3: Increasingly tachycardic and tachypnoeic
Cold peripheries
Guarding across the upper abdomen.
Aggressive fluid resuscitation continued + radiological imaging requested
Patient was stabilised and admitted to the high dependency unit (level 2 care)
Modified Glasgow criteria of 2 (Calcium 1.9 mmol/L, pO2 7kPa).
Ongoing systemic inflammatory response syndrome led to further deterioration
with circulatory and Type-II respiratory failure
Case Experience

8. CT imaging D2
• Extensive inflammation
within the pancreas
• No discrete fluid collection
• Inflammation within the
overlying small bowel wall
• Atelectasis at the lung
bases bilaterally. Small left
pleural effusion noted
• Appearances consistent
with acute pancreatitis
Permissions granted by patient

9. D4/5:
Continued to deteriorate
Increasingly distended abdomen
Increasing intra-abdominal pressure up to 27 mmHg (measured intra-vesically)
Rising ventilatory airway pressures and decreasing saturations
Reduced renal function requiring period of veno-venous haemofiltration
Diagnosis of abdominal compartment syndrome 2º to acute pancreatitis
Case Experience

10. Continued multi-organ impairment
Permissions granted by patient

11. Decompressive laparostomy
• Decompressive laparostomy was
required on day 5
• Large volume of straw coloured
exudate was drained
• Viscera were markedly oedematous
although well perfused
• Following laparostomy an immediate
reduction in ventilatory airway
pressures occurred and improved
oxygenation rapidly followed
Permissions granted by patient

12. Initial laparostomy management

13. The size of the problem…
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15. How did we do it?
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26. The complications…
• Distal pancreatic necrosis requiring necrosectomy
• D15: laparostomy site spontaneously started bleeding. Superfical tear in
descending colon
• D34: faeculant material began to discharge through the abdominal
ABThera™ dressing. Perforation found in the descending colon
• D46: faeculant material discharged again. Devascularised and necrotic
descending colon -> STC with end ileostomy and oversewn rectal stump
• Repeated dehiscence of the rectal stump closure
• Enterocutaneous fistula developed from superficial anterior loop

27. …and the successes
• D86 slow ventilatory weaning was successfully completed
• D120 ABThera™ dressing removed, with further care of the residual
granulating laparostomy wound bed using V.A.C.® therapy
GranuFoam™ dressings
• D126 patient sufficiently stabilised to allow planned discharge to ward
with out-reach team support
• D159 for management of respiratory failure secondary to Acinetobacter
and gram negative Staphylococcus chest sepsis – briefly readmitted to
intensive care

28. Back on the ward after 126-days
Permissions granted by patient

29. Isolation technique
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30. Granufoam dressings from day 120
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31. Clinical outcome = happy ending
• After 203-days in hospital the patient was sufficiently recovered for
transfer to the regional intestinal failure unit (St. Mark's Hospital, Harrow)
• Continued nutritional optimisation
• Radiological and endoscopic mapping of remaining bowel and fistula
• 383-days following admission underwent restoration of gastrointestinal
continuity
• Adhesiolysis, resection of enterocutaneous fistula, hand-sewn ileo-rectal
anatamosis, synthetic mesh repair of anterior abdominal wall defect and
excision of laparostomy scar
• Full recovery with approx 250 cm of remaining small bowel which should
permit normal diet

32. Ideal method of temporary abdominal control should:
• Allow rapid closure
• Easy nursing maintenance
• Removal of exudate and infectious material
• Protection of the abdominal contents
• Allows re-exploration without tissue damage
• Facilitate formal closure where appropriate
Impact of ABThera™

33. Our learning curve with ABThera™
• Understand how to use it yourself first
• Expect that no-one else to know what you are doing
• Involve them all so they learn (especially if trying to change on ICU!)
• Readily available (especially out of hours) and know where it is!
• Be obsessive about protecting exposed bowel
• Don’t over rely on it
• Ask for help (KCI)

34. JE Fitzgerald, S Gupta, S
Masterson, HH Sigurdsson
HH. Laparostomy
management using the
ABThera™ open
abdomen negative
pressure therapy system
in a grade IV open
abdomen secondary to
acute pancreatitis.
Int Wound J. 2013
Apr;10(2):138-44.
DOI: 10.1111/j.1742-
481X.2012.00953.x.
https://www.ncbi.nlm.nih.gov/p

35. Acknowledgements:
• Sarah Masterson BSc Hons, Specialist Nurse, Tissue Viability Service
• Helgi H. Sigurdsson Consultant Vascular and Emergency General Surgeon
• Chelsea & Westminster Hospital NHS Trust staff
• Local KCI Team who regularly visited providing expertise and nurse training
Questions?
Thank you for your attention