CRD summary
The authors' findings suggested that the highest delayed primary fascial closure rates and lowest mortality after temporary abdominal closure may be obtained with the artificial burr and vacuum-assisted closure techniques. The review findings were based on pooling diverse data from disparate potentially biased studies and may not be reliable.
Authors' objectives
To identify the temporary abdominal closure technique of the open abdomen that is associated with the highest delayed primary fascial closure rate.
Searching
MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials were searched from 1966 to December 2007. Search terms were reported. In addition, related articles and references of selected studies were handsearched. The search was not restricted by language but studies were only included if they were published in English, German or Dutch.
Study selection
Studies of five of more patients receiving open abdominal treatment (defined as the inability to close the abdominal fascia after laparotomy), that reported the delayed primary fascial closure rate, were eligible for inclusion. Studies were excluded if they had a non-consecutive inclusion period, used multiple temporary abdominal closure methods in the same population or evaluated subcostal incisions. Other assessed outcomes included in-hospital mortality, fistulae and abscesses.
Included studies evaluated the following types of temporary closure techniques: vacuum-assisted closure; vacuum pack; artificial burr; meshes or sheets; zippers; silo, skin only; loose packing; and dynamic retention sutures. Participants included patients who had undergone trauma, vascular or general surgery or had developed peritonitis or pancreatitis. Some patients had other conditions such as bleeding, abdominal aortic aneurysm and necrotising fasciitis. Where reported, most patients were male, the median age was 40 years (ranging between 29.5 and 75 years) and the mean Injury Severity Score ranged from 20.3 to 30.5. The included studies were published between 1981 and 2007.
Methods used to select studies were not clearly reported but the authors stated that the final inclusion of studies was done after consensus was reached.
Assessment of study quality
Two reviewers independently assessed validity using a modification of criteria proposed by the Dutch Cochrane Collaboration. Discrepancies were resolved by discussion.
Data extraction
In studies that reported subgroups of patients with specific conditions or temporary abdominal closure techniques; each case series was treated separately. Percentages of patients with death, closure or delayed primary fascial closure were extracted for each case series. In-hospital deaths were used to calculate mortality.
Two reviewers independently extracted data onto a standardised form. Authors were contacted if required.
Methods of synthesis
Delayed primary closure rates and 95% confidence intervals were pooled and grouped by temporary abdominal closure technique. Pooled rates of mortality, fistulae and abscesses were also calculated. Percentages were weighted by study variance. Closure rates were also calculated according to the underlying cause.
Results of the review
Fifty-one studies (57 case series) were included (n=3,169 patients). Sample sizes ranged from five to 377 participants.
Study quality: Most studies were retrospective and were subject to bias in the selection of patient and treatment. Little information was provided about the severity of the underlying condition.
Fascial closure (57 case series): The highest weighted pooled delayed fascial closure rates were found with the artificial burr (90%, range 33 to 93%, n=180 patients, four case series), dynamic retention sutures (85%, n=13 patients, one case series) and vacuum-assisted closure (60%, range 33 to 100%, n=251 patients, eight case series).
Mortality (57 case series): The overall weighted mortality rate was 26%. The lowest weighted pooled mortality rates were found with the artificial burr (17%, range 8 to 67%, four case series) and the vacuum-assisted closure (18%, range 7 to 38%, eight case series). The highest weighted pooled mortality rates were found with the silo (41%, three case series), skin only (39%, two case series) and loose packing (39%, one case series).
Fistulae (54 case series) and abscess (53 case series): The lowest fistulae rate was found with the silo (0%, three case series) and the highest with loose packing (28%, one case series). The lowest abscess rate was found with the mesh/sheet (2.1%, 16 case series) and the highest with the zipper (5.8%, seven case series).
Delayed closure rates were also reported according to the underlying cause.
Authors' conclusions
Findings suggested that the highest delayed primary fascial closure rate and lowest mortality after temporary abdominal closure may be obtained with the artificial burr and vacuum-assisted closure techniques.
The review question was clearly stated. Inclusion criteria were defined for intervention, participants and outcomes and some aspects of study design. Several relevant sources were searched. Some attempts were made to minimise language bias but no attempts were made to minimise publication bias. Methods were used to minimise reviewer errors and bias in the assessment of validity and extraction of data, but it was not clear whether similar steps were taken in study selection. Pooled weighted event rates were calculated despite widely varying rates from individual series. In view of the differences between studies and limited information about study methods and severity of underlying condition, together with the potential for bias in patient and treatment selection (as acknowledged by the authors), pooling data may not have been an appropriate method of comparing techniques. For some outcomes, only a few case series with small number of patients provided data. In addition, publication dates ranged from 1981 and 2007 and techniques may have changed over that period. These limitations mean that review findings may not be reliable.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice.
Research: The authors stated that randomised clinical trials are required to determine the optimal method of temporary abdominal closure technique that is associated with the highest delayed primary fascial closure rate. They acknowledge that a randomised clinical trial in this rare condition may be problematic.
Funding
Siemens Netherlands N.V. unrestricted grant; ZonMW, grant number 945-06-901.
Bibliographic details
Boele van Hensbroek P, Wind J, Dijkgraaf M G, Busch O R, Goslings J C. Temporary closure of the open abdomen: a systematic review on delayed primary fascial closure in patients with an open abdomen. World Journal of Surgery 2009; 33(2): 199-207. [PMC free article: PMC3259401] [PubMed: 19089494]
Original Paper URL
http://www.springerlink.com/content/p23w653267092118/fulltext.pdf
Indexing Status
Subject indexing assigned by NLM
MeSH
Abdomen /surgery; Abdominal Injuries /surgery; Compartment Syndromes /surgery; Fascia /surgery; Hernia, Ventral /surgery; Hospital Mortality; Humans; Laparotomy /methods; Vacuum
AccessionNumber
Database entry date
05/08/2009
Record Status
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.
