Oncology case of the week:

Transcription

1 Oncology case of the week: The Abdomen That Won t Close Anton Sharapov, R4 July 14, 2004

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3 Case 56 yof in ER resident on call asked to assess stoma looks infected has been on antibiotics not settling

4 PMH Rectal Ca, LAR, 1999 Recurrence 2 years later CT scar, PET met into sacrum difficult intraoperative course invasion into sacrum Hartman s resection

5 HPI Has had firm skin ridge at stoma 1/12 Has been well till one week ago Redness => draining sinus been scoped and bx 3/52 ago suspicious area 3 cm deep to skin reported as scar what next?

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7 Exam Indurated erythematous skin 11-5 o clock muco-cutaneous separation at 3 and 9 purulent drainage no fever what next?

8 Scope suspicious area at the skin level bx necrosis, scar, focus of adeno Ca new primary vs recurrence?

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10 Natural Hx people with CRC 70 resectable with curative intent 45 cured 25 recur 6 local only - 2 live 4 liver or lung - 2 live 15 multiple mets, die

11 30 advanced disease 5 die with unresectable local disease 25 attempt at resection 9 liver mets only, 2 live 16 die with dissiminated disease

12 Local recurrence for colon Ca - most within 2 years for rectal Ca- 80% within 3 years

13 Back to case What procedure if any is indicated?

14 Case Consent for completion colectomy, abdominal wall resection and iliostomy is obtained En bloc resection survival reduced from 49% to 17% if tumor planes are violated

15 Intraoperative Stoma with surrounding 3 cm abdominal wall is excised purulent pockets of cellulitis drained colectomy ->iliostomy rectal stump left in place.

16 Closure Upon completion of resection need 5 by 10 cm fascia to perform tension-free closure options?

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18 Abdomen that won t close

19 Trauma setting Oncological setting Pediatric setting avoid forced closure of abdomen 1913, recoginion of effect on kidney function 1980 s, Kron, abdominal compartment syn postponement of definitive closure of the abdomen

20 Broad causes Extrinsic Pneumatic Antishock Garments reduction of the large hernia with tight closure retroperitoneal bleed pancreatitis abscess

21 Intraperitoneal cause Gastric dilatation intestitinal obstruction ileus Mesenteric venous obstruction Bleed pneumoperitoneum packing

22 Typical Situations Technically impossible damage control abbreviated laparotomy unstable, cold, coagulopathic, acidotic abdominal compartment prophylaxis suboptimal splanchnic perfusion Need detensive/decompressive laparatomy second look required

23 What are the options?

24 Leave Belly Open Oldest technique Mikulicz technique Faure modification, 1928 sac with gauze, gauze removed, belly closed Makosha added catheters for abx lavage

25 Open Leaving bowel open leads to intestinal fistula formation prolonged hospitalization increased risk of ventral hernia creative closure solutions

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27 IDEA: Staged abdominal repair STAR Planned temporary closure TAC definitive apo to apo closure

28 Variation on the theme Skin vs aponeurotic recruitment for TAC Number of TACs prior to definitive AAC Schedule of TAC(s) prior to definitive AAC Material used +/- lavage if gross contamination Static vs dynamic approach to closure

29 Temporary Abdominal Closure - TAC Creative Static approach - mainstream utilizes skin as fixation point attempt to preserve fascia for later closure temporizing closure -> definitive closure Prolonged gap between TAC and daac Dynamic approach constant tension applied to fascia flaps continuous closure of the fascia defect Closure within a week

30 Materials available Endogenous (skin/fascia/flaps) prosthesis allograft

31 Endogenous mobilize fascia lateral relaxing incisions fascia edge inversion Towel clip, skin only 2 cm from edge, 2 cm apart, cover with tape suture skin running mortician closure

32 Dr.Oswaldo Borray, Bogota

33 Prosthesis plastic silo to skin, not fascia polyvinyl plastic silo urology 3 l irrigation bag

34 Prosthesis cont d Mesh non-absorbable absorbable

35 Non absorbable mesh Not an ideal option high incidence of wound sepsis enterocutaneous fistulae rates of 30-40% quoted in trauma setting composite mesh tissue impervious biomaterial reduces incidence of adhesions-fistulazations 24% with goretex in trauma setting Do not lower incidence of ventricular hernias!

36 Absorbable mesh polyglyctin (vicryl), polyglycotic (Dexon) 4 stages according to Cameron: cover midgut remove (!( mesh in 2-3 weeks when granulation tissue formed underneath split thickness graft definitive closure in 6-12 months

37 Problematic Even absorbable mesh causes fistulae fistula in 15%, eventration in 37% on one trauma series Need inert-tissue impervious interface Gore-tex patch (eptfe) Polyethylene foil Silicone sheets High hernia rate

38 Throw in the towel blue towel closure, VAC JP to LCS stays closed up to 7 days, then definitive closure or allow granulation

39 Allograft Human Acellular Dermis seeding human dermal foreskin fibroblast cells on a 3D bioresorbable polymer scaffold Primary closures have been attempted

40 Definitive closure Within 10 days ideally Usually delayed by 4-6/12 Aponeurosis to aponeurosis closure myocutaneous flaps Separation of parts closure

41 Component/parts separation technique

42 Separation of parts Abdominal wound STSG followed by separtion of parts closure 6/12 later

43 Abdominal wound dehiscence STSG -> separation of parts

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45 Dynamic closure- A STAR Technique of SERIAL TAC operations Accelerated STAR Planned Performed h apart Controlled tension exerted on aponeurosis Requires suturing to aponeurosis, not skin

46 Dynamic closure Gradual approximation of aponeurosis Closure within a week Decreased inflamatory edema Appear to decrease mortality

47 Dynamic techniques Staged abdominal repairs Kwan s trampoline/abdominal palisade Zippers slide fastener Velcro devices appear to be most useful

48 The Suture Tension Adjustment Reel originally introduced to assist in closure of calf fasciotomy defects applies constant and progressive tension to wound edges.

49 Complications Evisceration Intraabdominal abscess Fistula (bili, bowel, pancreatic) Intestinal obstruction Liver necrosis

50 Back to the case Vicryl mesh fascia closure Skin closure will see what happens

51 Final comments No randomized trials Dynamic STAR offers the best chance to close at first hospitalization TAC should use tissue impervious material to cover abdomen No contact between mesh, bowel, apo edge Separation of parts is worthwhile to consider Consider high volume lavage if gross intraabdominal contamination

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53 References Atweh N.A., Lye K.D., Kavic S., et al. Closure of large abdominal wounds with an adjustable suture-tension device. J Am Coll Surg 2002;195: Losanoff J.E., Richman B.W., Jones J.W.. Temporary abdominal coverage and reclosure of the open abdomen: frequently asked questions. J Am Coll Surg 2002;195: Rink A.D., Goldschmidt D., Dietrich J., et al. Negative side-effects of retention sutures for abdominal wound closure. A prospective randomized study. Eur J Surg 2000;166: Hodgson N.C., Malthaner R.A., Ostbye T.. The search for an ideal method of abdominal fascial closurea meta-analysis. Ann Surg 2000;231: de Vries Reilingh T.S., van Goor H., Rosman C., et al. Components separation technique for the repair of large abdominal wall hernias. J Am Coll Surg 2003;196:32-7. John L. Cameron. Current Surgical Therapy, 8th edition