Assessment of Risk Factors for Enteric Fistula and Intra-Abdominal Sepsis in Patients with Open Abdomen in Trauma: An Original Research

ABSTRACT

Introduction:

In emergency surgeries, open abdomen or laparostomy, especially with perforated viscus, has been used primarily to prevent delayed ventral hernia, burst abdomen, and abdominal compartment syndrome. In the present study, the clinical and resuscitative factors that are linked with open abdomen morbidity are evaluated.

Material and Methods:

A retrospective analysis was done for all the subjects who were admitted at the tertiary care center between May 2020 and May 2022 for the open abdomen surgeries. These patients were examined to see whether they needed more postoperative care than usual, including the need for resuscitative treatments and other critical clinical indicators. Patients were evaluated if they had any complications. The data that were collected were analysed for any variance using analysis of variance considering P <.05 as significant.

Results:

A total of 100 subjects were analysed in this study. Forty nine patients had intra-abdominal sepsis of the 100 cases examined from historical case records and 1 had entero-cutaneous fistulas. These patients did not necessitate additional actions for intensive care unit care, resuscitation, an chest infection, extended hospital stay, or any disabilities compared to those who did not undergo laparotomy during the same period. In this group of patients with open abdomens, the immediate postoperative period was not linked to an increase in resuscitation efforts or a load on clinical staff. Once patients are stabilized, early definitive abdominal closure is advised to prevent problems associated to laparostomies.

Conclusion:

The quantity of initial fluid revival and the coagulation factors at the time of admission are not related to intra-abdominal sepsis and enteric fistula following laparostomy after significant abdominal injuries.

INTRODUCTION

The surgeon community has been aware of laparostomy (intentionally keeping the abdomen open after a laparotomy) since Ogilive’s time.[1] In his article “The Late Complications of Abdominal War-Wounds,” he first suggested this method. Laparostomy techniques have changed throughout the years and the theory of “Damage Control Surgery (DCS)” for trauma patients has had a significant influence.

Open abdomens (OA) are defined as “an abdomen that necessitates a temporary abdominal closure due to the skin and fascia not being closed after laparotomy”.[2] Open abdomen is regarded as a double-edged sword because it is useful in reducing “Abdominal Compartment Syndrome (ACS)” but it has also been linked to serious complications such as “Intra-Abdominal Sepsis (IAS)” and “Entero-Cutaneous Fistula/Entero-Atmospheric Fistula (ECF/EAF)”.[3-5] The contributing reasons to these potentially fatal OA consequences are currently poorly understood. Few retrospective studies that were predominantly done in rich nations were discovered after a thorough review of the literature; in addition, none of them specifically targeted trauma sufferers from developing countries. The present study was to assess the prevalence and determinants of IAS and ECF/EAF in patients with OA while keeping these things in mind.

MATERIAL AND METHOD

A retrospective study was carried out from April 2020-January 2022. The study comprised patients with abdominal injuries who underwent exploratory laparotomy, followed by laparostomy with temporary abdomen closure, either after the onset of compartment syndrome or as part of DCS. Patients with abbreviated injury score more than three scores in other body regions were disqualified because they might have had an impact on the length of intensive care unit (ICU) and hospital stays. Furthermore, patients with exploratory laparotomies outside of the hospital and pregnant women were omitted from present study. People who passed away from hemorrhagic shock during the first 48 hours were as well excluded. All subjects’ clinical, diagnostic variables, and the demographic were noted like coagulation status, Arterial Blood Gas (ABG) tests, and amount of fluid resuscitation during surgery and the first 48 hours were evaluated. Each patient had their ECF/EAF and IAS complications assessed. They were also evaluated for the effect of IAS and EAF/ECF on hospital and ICU stay duration. Subjects were compared based on the factor if they had/not the abdominal problems. Leakage of digestive tract contents is referred to as an enteric fistula. When it communicated with an epithelized exterior aperture, it was known as ECF. EAF was the name given to it when it spontaneously poured into the abdomen. Intra-abdominal sepsis was diagnosed when there was free pus visible in the peritonium, when peritoneal fluid was culture-positive, or when there was a collection in the peritoneal cavity. The data collected for the department record at the tertiary care were used to study the aforementioned factors.

Analytical statistics

Statistical analysis was performed after data were collected by using the mean and standard deviations for all the intended parameters. The intergroup variations were confirmed using the analysis of variancetests. IBM Corporation’s SPSS was used to conduct the statistical analysis; Version 25.0 of “IBM SPSS Statistics for Windows (IBM Corp., Armonk, New York)”. The chosen level of significance was <0.05.

RESULTS

A total of 100 subjects were finalised. Gender distribution was men: women = 11:1; also was noted that in 68% of the subjects, laparostomy was done as a part of the damage control surgery. In 50 subjects there was observed the 10 had EAF/ECF, while 40 had IAS. Injuries to the colon occurred in five individuals with ECF/EAF, while pancreatic damages occurred in two. Eight of the 40 individuals who had IAS had it because of ECF or EAF. The comparisons were made between those who were impacted with the ECF/EAF and those who were not [Table 1]. The clinical, coagulation, and resuscitative data of the patients in these 2 groups were compared. Similar to this, a comparison of subjects of intra-abdominal sepsis and those without was conducted [Table 2].

Table 1.

Comparison of the subjects for the resuscitation and clinical parameters for the ECF/EAF

Parameters	Without ECF/EAF (n=90)	WithECF/EAF (n=10)	P
Clinical profile:
Age	27	21	0.2
Haemoglobin	11.0	11	0.1
Shock index	1.1	1.04	0.4
Coagulopathy:
aPTT	29.8	31.1	0.5
INR	1.3	1.3	0.06
Platelet count	192	231	0.01
Acidosis:
Base deficit	10.2	8.7	0.4
Lactate	5.0	3.0	0.87
pH	7.18	7.24	0.36
Resuscitation (ED+IO)
FFP (IO)	2	0	0.3
Fluid	4	4	0.1
Plt (IO)	3	0	0.02
RBC (IO)	1	2.4	0.1
Resuscitation (48 h):
Cryo (48 h)	0	0	0.6
FFP (48 h)	0	3	0.7
Fluids (48 h)	6	9.1	0.34
Plt (48 h)	0	1	0.8
RBC (48 h)	1	1	0.8
Resuscitation (till 48 h):
Total FFP	4	4	0.4
Total fluids	11.8	13.8	0.7
Total platelets	4	1	0.8
Total RBC	3	3	0.4

ED, Emergency department; IO, intraoperative.

Table 2.

Comparison of the subjects with and without IAS

Parameters	Without Intra-Abdominal Sepsis (n=60)	With Intra-Abdominal Sepsis (n=40)	P
Clinical profile
Age	29	27	0.1
Haemoglobin	11.3	11.1	0.8
Shock index	1.1	1.17	0.9
Coagulopathy
aPTT	30.2	29.7	0.07
INR	1.36	1.37	0.7
Plt count	201	192	0.5
Acidosis:
Base deficit	9.4	11.3	0.1
Lactate	4.9	4.8	0.8
pH	7.20	7.16	0.4
Resuscitation (ED+IO)
FFP	1	1	0.07
Fluid	4	3	0.3
Plt	3	2	0.051
RBC	1	2	0.15
Resuscitation (48 HOURS)
Cryo	0	0	0.1
FFP	0	3	0.06
Fluids (48 h)	6.1	8	0.7
Plt	0	0	0.10
RBC	1	1	0.07
Resuscitation (till 48 HOURS)
Total FFP	3	3	0.3
Total fluids	10	13.7	0.10
Total platelets	3	3	0.10
Total RBC	3	3	0.10

ED, Emergency department; IO, intraoperative.

A statistically significant correlation discovered was between platelet count and EAF/ECF, but given that platelet counts were more than 100,000 in both groups, this correlation was likely accidental [Table 1]. There was no other correlation between any clinical or resuscitative factors and the emergence of IAS or ECF/EAF [Tables 1 and 2].

DISCUSSION

One of the most important aspects of critically damaged patients is DCS. Resuscitation can cause visceral edema and increased intra-abdominal pressure in patients with shock and hemorrhagic which can result in ACS. In these situations, keeping the abdomen open avoids this problem. But OA itself has very high risks of complications. In OA subjects following trauma laparotomy, Salim Ali et al.[6] observed ECF/EAF rates as high as 15% and IAS rates of 34% in 2008. In the present study, 40 patients (40%) had IAS while EAF/ECF was seen in 10 of 100 patients (10%). Bradley et al.[7] using the AAST registry reviewed trauma centers in the America. In their analysis of 517 individuals, they observed intra-abdominal problems in 21.4%, which was more than twice as many as what we discovered in the present study (10% in present study).

In present study, risk variables for the emergence of EAF/ECF were evaluated. At the time of admission, there was no evidence linking EAF/ECF to coagulopathy or acidosis. Our results were comparable to those of Bradley et al.[7] investigation and the two studies were effectively compared. Although they did discover a link between the development of EAF and large bowel resection, no conclusive correlation was discovered in the current investigation, maybe as a result of the smaller sample size and the propensity for early diversion in large bowel injuries. Associating resuscitation techniques in subjects with intra-abdominal problems did not discover a connection between problems and fluid resuscitation.

Nevertheless, Bradley et al.[7] investigation indicated that the development of intra-abdominal complications was independently predicted by large volume resuscitation. A retrospective examination of 123 individuals with colonic anastomosis was performed by Schnüriger et al.[8] Large volume resuscitation of more than 10.5 liters in the first three days was discovered to be a reliable indicator of anastomotic leak. In this investigation, we were unable to identify any link between fluid resuscitation and the onset of EAF. Those with sepsis required around 9 liters of crystalloid resuscitation in the first 48 hours, compared to patients without abdominal sepsis who required only 6.2 liters. However, this variance was not determined to be statistically significant.

In addition, ECF/EAF lengthens hospital and ICU stays and is a significant cost affliction. EAF/ECF lengthened hospital stays by 82 days from 16 days and ICU stays by 28 days from 8 days, as per Teixeira et al.[9] In the current research, we discovered that the average hospital stay climbed to 47 days from 13 days and the average ICU stay increased to 40 days from 5 days.

With a death rate of 10.8%, 277 patients underwent an 11-year study by Hollington et al.[10] on fistulas. In a 10-year research, Fischer et al.[11] discovered that patients with ECF had a death rate of 14% and a median ICU stay of 59 days. In the present study, 2 of the 3 EAF/ECF patients who survived had stays of more than 100 days. Seven of 10 patients with these conditions died from their sequelae. The fact that our sample size was so much smaller may be to blame for the stark difference in our results. Before a clear inference can be drawn comparing the two groups, more research will be required on this topic. It does, however, demonstrate that ECF/EAF is a significant financial and clinical burden. It has long been advised to use OA as a therapy for IAS. But OA itself can result in IAS. IAS subjects have a death rate that ranges from 20% to 60%. A study of 344 damage control OA laparotomies on 276 patients was published by Miller et al.[12] Thirty two patients (11.6%) acquired wound infections, while 30 patients (10.9%) developed intra-abdominal abscesses. Fifty two patients (46%) of 113 participants in the research experienced IAS, with a death rate of 65.3% (34/52). This greater prevalence may be attributed to the reason that the present study was only conducted on subjects with open abdomens and excluded individuals who were treated solely by percutaneous interventions or through laparotomies followed by abdominal closure. The present study did contain certain restrictions although. Its primary flaw is the fact that study involved retrospective data collection. A few pieces of information were lacking, preventing the study from including all individuals with OA. Several confounding factors were also impossible for us to account for. In addition, we did not take into account comorbidities like diabetes or immunosuppressive medication, which would have had an impact on how frequently our patients experienced intra-abdominal problems. Furthermore, as it was an observational study, a control group was not an option. In addition, we believe that comparing our observations to those of patients whose abdomens were mostly closed would have improved our ability to forecast the complications and results in these individuals.

CONCLUSION

The quantity of initial fluid revival and the coagulation factors during admission are not related to intra-abdominal sepsis and enteric fistula following laparostomy after significant abdominal injuries. In addition, clinicians should not waver to leave the abdomen open if necessary. After the patient is stable, an effort must be made to close it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.