Open abdomen in acute mesenteric ischemia

Adopting damage control surgery in acute mesenteric ischemia

The increasing use of revascularization of the mesenteric arterial circulation in acute mesenteric ischemia has created an increased demand for second or third look laparotomies for assessing bowel viability and definitive reconstructions of the bowel [1]. In patients who develop peritonitis, a damage control strategy is sensible [2]. The frequency of patients with acute mesenteric ischemia in series reporting damage control laparotomy in non-trauma patients varies between 13% [3] and 41% [4] (Table 1 [3–7]), which means that acute mesenteric ischemia is a common indication to leave the abdomen open. The survival rate was reported to be 62% in 16 actively treated patients in one series [2]. In a retrospective study of patients with peritonitis secondary to acute superior mesenteric artery (SMA) occlusion comparing open abdomen (OA) and primary fascial closure, non-OA patients more often required bowel resection at second look. Moreover, patients with primary fascial closure had higher rates of intra-abdominal sepsis, intra-abdominal hypertension, acute renal failure, short-bowel syndrome and mortality compared to OA patients [8].
In the recently developed “European Society of Vascular Surgery Guidelines on the management of diseases of the mesenteric arteries and veins”, damage control surgery and second look laparotomy are recommended when bowel infarction has developed in patients undergoing intestinal revascularization [9]. This strategy is less well studied in non-occlusive mesenteric ischemia and mesenteric venous gangrene [10], but liberal use of second look laparotomy seems to be a rational approach in these entities of acute mesenteric ischemia as well.

Treatment of acute superior mesenteric artery occlusion

Optimal treatment may include both open and endovascular surgery, and patients are best treated in a vascular centre with a hybrid operating room, if available within a reasonable distance [11]. Evaluation of preoperative clinical status and computed tomography (CT) angiography are often enough to determine whether the patient has peritonitis or not, and whether the occlusion is embolic or thrombotic [12]. In the case of peritonitis, laparotomy is indicated to evaluate the extent and severity of intestinal ischemia by inspection of color of the intestines, dilatation and peristaltic motion of the bowel, palpable pulsations in the mesenteric arcade arteries, and bleeding from cut surfaces. Arterial revascularization, open, hybrid or endovascular, is done preferably before any bowel surgery [9]. There is rarely any indication for revascularization of both the SMA and the celiac trunk; SMA revascularization seems to be more important and durable. In an acute thrombotic occlusion, retrograde open mesenteric stenting [13] may be a very useful hybrid approach where the SMA is exposed at laparotomy followed by retrograde recanalization of the thrombotic and atherosclerotic occlusion of the SMA and stenting in retrograde or antegrade manner. All initial emergency vascular procedures and all necessary damage control visceral surgery (Figure 1) should be performed during the same operation. Close collaboration between vascular and gastrointestinal surgeons is necessary to improve outcomes.

Temporary abdominal closure in acute mesenteric ischemia

It should be remembered that intestinal ische­mia may be extensive even if it is not evident by inspection during laparotomy, since ischemia starts from the mucosa side, propagating towards the serosa side later (Figures 1A and B). Even a low grade of intra-abdominal hypertension may become fatal when a large portion of the intestinal tract is ische­mic [14]. In this situation it is important to optimize the perfusion of the remaining bowel, which often requires open abdomen treatment [1]. In the event of ischemic bowel perforation at laparotomy, the affected intestinal segment is rapidly resected, followed by mesenteric revascularization, leaving the reconstruction of the intestinal tract until second look laparotomy after 18-36 hours. The optimal temporary abdominal closure (TAC) method in patients with acute mesenteric ischemia is not clear. While temporary skin only closure may be a sufficient option in some patients, full open abdomen to optimize visceral circulation may be necessary in others.

Open abdomen therapy with negative pressure wound therapy on ischemic bowel

Negative pressure wound therapy (NPWT) has become standard therapy in patients with OA for the management of abdominal vascular emergencies [15]. There is, however, an ongoing discussion among surgeons whether the use of NPWT during OA may cause bowel damage, enteric leak and entero-atmospheric fistula [16–18]. Intuitively, patients with ischemic bowel should be considered to be at a greater risk of bowel injury during NPWT than patients with non-ischemic bowel. In case series without a control group, intestinal ischemia requiring bowel resection with anastomosis [19] and long-term NPWT in open abdomen due to secondary peritonitis [20] were factors reported to be associated with the development of entero-atmospheric fistulae and high mortality. It should be very clear, though, that OA therapy in itself, inevitably carries an inherent risk of bowel injury and intestinal fistula formation, with the bowel exposed to an unnatural environment and manipulated during dressing changes. Clinical data do not support a causal relationship between NPWT and intestinal fistula development [21–25]. In addition, an experimental study has shown that the actual negative pressure reaching the surface of the bowel during NPWT is only a few mm Hg, and it seems unlikely that this would cause pressure damage to the bowel wall [26]. However, a similar experimental setup in the presence of various degrees of small bowel ischemia is warranted to clarify whether NPWT has the potential to cause clinical and/or histological bowel injury.
In two recent systematic reviews with meta-analyses [27, 28] on OA and TAC techniques, NPWT with continuous fascial traction was associated with a higher delayed fascial closure rate and lower entero-atmospheric fistula formation rate compared to NPWT alone. This emphasizes the importance of having an effective method to close the abdomen as quickly as possible to reduce the risk of complications associated with OA therapy.

Delayed bowel anastomosis or stoma

Intestinal recovery may appear to occur very quickly after revascularization, but the surgeon can only inspect the intestines from the serosa side. Healing of any bowel anastomosis is considered to be better when the bowel anastomosis is performed delayed at second look compared to immediately at first explorative laparotomy. At the first or second look, bowel resection is performed quickly with staplers without reconstruction (Figure 1C). At the following laparotomy, bowel anastomosis or stoma is created. In one center, the practice was to routinely create a temporary stoma followed by administration of parenteral nutrition until the surgical recovery phase was over [29]. In patients undergoing extensive bowel resections, proximal resection of the jejunum, or multiple resections, bowel anastomosis after effective intestinal revascularization (Figure 1E) may be beneficial in avoiding high output stoma, short bowel syndrome and increased mortality associated with intestinal failure [30].

Acknowledgements

1. Financial support and sponsorship: none.
2. Conflict of interest: none.

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