Abstract
Etappenlavage is defined as a series of planned multiple operative procedures performed at a 24-hour interval. It includes a commitment to reexplore the patient's abdomen at the initial corrective operation. This is a report of a prospective study of 117 patients treated by etappenlavage for severe advanced suppurative peritonitis in 2 institutions. Etappenlavage was performed in 15% of all patients with operations for peritonitis. In these patients, the abdominal infection had progressed to an advanced stage of severe functional impairment. A total of 669 laparotomies were performed and the abdomen closed temporarily utilizing retention sutures (n=45), a simple zipper (n=26), a slide fastener (n=29), and Velcro® analogue (n=17). An average of 6.1 procedures were necessary to control the infection. In 57% of the patients, additional complications were recognized and repaired after the initial operation. Patients were artificially ventilated for an average of 17 days. The median duration of therapy was 33 (range, 3–183) days. Twenty-eight patients died between days 3 and 71 (median, 9) after initiation of therapy. In 88%, uncomplicated wound healing was observed after wounds were closed definitely. In the last 17 patients, no complications were attributable to the use of 2 adhesive sheets of polyamide plus nylon or perlon for temporary abdominal closure (Velcro®-like artificial burr). APACHE II scoring predicted a median mortality of 47%. The actual mortality was 25%. Overall, the mortality of advanced diffuse peritonitis was reduced from a predicted 34–93% (APACHE II/SIS scoring) to 24%. Velcro® analogue (artificial burr) was the most practical device for temporary abdominal closure.
Résumé
L'etappenlavage est défini comme une série d'interventions répétées à intervalles de 24 heures. Cette technique implique une nouvelle exploration de l'abdomen lors de l'intervention initiale. Dans ce travail, nous rapportons les résultats chez 117 patients étudiés prospectivement traités par l'etappenlavage pour péritonite sévère dans 2 institutions. L'etappenlavage a été effectuée chez 15% des patients ayant une péritonite. Chez ces patients, l'infection abdominale avait évolué et comportait une défaillance fonctionnelle avancée. On a pratiqué 669 laparotomies et la fermeture pariétale provisoire a nécessité des sutures sur bourdonnets (n=45), une fermeture éclair (n=26), un fermoir à glissière (n=29), et des Velcro® équivalent (n=17). En moyenne, on a réopéré ces patients 6.1 fois pour contrôler l'infection. Chez 57% des patients on a mis en évidence des complications supplémentaires qui ont requis une réparation secondaire. La ventilation artificielle était nécessaire environ 17 jours. La durée moyenne du traitement à ventre ouvert a été de 33 (3–183) jours. Vingt-huit patients sont morts entre jour 3 et 71 (médiane, 9 jours) après la première laparotomie. La plaie abdominale a cicatrisé sans problème chez 88% des patients après fermeture définitive. Chez les 17 autres patients, on a utilisé 2 feuillets adhésifs de polyamide mélangé soit à du fil de nylon soit à du perlon, rapprochés avec un Velcro®. La mortalité médiane prévisible avec le score APACHE II était de 47%. La mortalité réelle était de 25%. La mortalité de la péritonite diffuse avancée a été réduite depuis un score combiné (APACHE II/SIS) de 34–93% à 24%. La fermeture temporaire par Velcro® équivalent s'est avérée la plus pratique.
Resumen
Se define el etappenlavage como una serie de procedimientos operatorios múltiples que se realizan cada 24 horas para el tratamiento de la sepsis intraabdominal avanzada. La definición implica el compromiso de reexplorar el abdomen diariamente después de la operación inicial. El presente artículo informa los resultados de un estudio prospectivo sobre 117 pacientes tratados mediante etappenlavage por peritonitis supurativa en 2 instituciones. Se realizó etappenlavage en 15% de todos los pacientes operados por peritonitis, aquellos en quienes la infección abdominal había progresado hasta un estado de severa alteración funcional. En total se realizaron 669 laparotomías y el abdomen fue cerrado temporalmente utilizando suturas de retención (n=45), un zipper simple (n=26), un cierre de lámina plástica (n=29), o una lámina de plástico adhesivo (Velcro® equivalente, n=17). Fue necesario realizar un promedio de 6.1 procedimientos para lograr el control de la infección. En 57% de los casos se reconocieron y corrigieron complicaciones adicionales después de la operación inicial. Los pacientes fueron sometidos a ventilación mecánica por un promedio de 17 días. El promedio de duración del regimen terapéutico fue de 33 (rango, 3–183) días; 28 pacientes murieron entre los 3 y los 71 días (promedio, 9) después del inicio del regimen terapéutico. Cicatrización libre de complicaciones ocurrió en 88% de los casos una vez que las heridas fueron cerradas en forma definitiva. En los últimos 17 pacientes el cierre temporal del abdomen fue efectuado mediante el uso de 2 láminas adhesivas de nylon o perlon (Velcro®); no se hallaron complicaciones que pudieran ser atribuíbles a este método. La aplicación del método APACHE II para establecer el grado de severidad de la enfermedad predijo una tasa de mortalidad promedio de 47%; la tasa real de mortalidad fue de 25%. La tasa global de mortalidad de la peritonitis difusa avanzada fue reducida de una tasa predecible de 34–93% (APACHE II/SIS) a 24%. El Velcro® equivalente probó ser el aditamento mas útil para el cierre temporal de la laparotomía.
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Formerly of Hamburg, Federal Republic of Germany.
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Wittmann, D.H., Aprahamian, C. & Bergstein, J.M. Etappenlavage: Advanced diffuse peritonitis managed by planned multiple laparotomies utilizing zippers, slide fastener, and Velcro® analogue for temporary abdominal closure. World J. Surg. 14, 218–226 (1990). https://doi.org/10.1007/BF01664876
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DOI: https://doi.org/10.1007/BF01664876