Treatment of severe intra-abdominal sepsis and/or necrotic foci by an 'open-abdomen' approach. Zipper and zipper-mesh techniques
J. L. Garcia-Sabrido, J. M. Tallado, N. V. Christou, J. R. Polo and E. Valdecantos
Servicio Cirurgia General III, Hospital Provincial Madrid, Spain.
Undrained necrotic tissue or septic foci contribute to continued
"activation" of host processes that in turn lead to multiple organ failure
and death. We hypothesized that if wide-open drainage of the abdominal
cavity is provided, thus not allowing intra-abdominal collections to form,
mortality in these patients can be reduced. Since 1982 we have treated 49
patients with necrotic pancreatitis and related infections and 15 patients
with severe intra-abdominal sepsis from intestinal perforations. The
surgical treatment was based on the provision for daily laparotomies in the
intensive care unit with the patient under epidural anesthesia by using an
"open-abdomen" technique (zipper alone or a zipper-mesh combination). The
APACHE II score and the functional classification were used to derive
expected mortalities. The patients with intraabdominal sepsis had a mean
APACHE II score of 25 and an expected mortality of 45%, vs the 26.5%
mortality that we observed. The lowest mortality in the necrotic
pancreatitis group was associated with noninfected pancreatic necrosis (6%)
and single abscess (9%) vs 22% mortality rate in the patients with infected
pancreatic necrosis. The mean expected mortality in this group was 47%, vs
the observed 22%. We attributed this result to the daily abdominal
explorations that achieved a complete excision of infected or necrotic
tissue.