Emergency General Surgery,  Trauma Surgery

The Spice That Makes Things Hot

Let food be thy medicine and medicine be thy food.

Hippocrates

This time we will start with a different setting…

Your colleagues call you from the OR. They are operating on a 57-year-old man, without past medical or surgical history except for hypertension. He came earlier that day to the Emergency Department complaining of abdominal pain, fever, nausea, and vomiting. At the physical examination, the patient had a non-reducible right groin hernia and pain all over the abdomen with rebound tenderness. At bedside US, they found free fluid in the hernia sac and lower abdominal quadrants with no bowel movements. The blood test showed leukocytosis and elevated CRP. 

In the clinical and sonographic suspicion of a strangulated groin hernia, the patient was sent to the OR for emergent surgical exploration.  After intubation, the patient expressed his septic shock becoming deeply hypotensive, needing a high volume of fluids and vasoactive drugs.

Your colleagues have already made an inguinotomic incision only to find an ischemic tract of the small bowel with an associated perforation… That’s when they called you…

To safely complete the operation you go for a midline laparotomy. Due to the important impairment of most of the ileum and the patient’s hemodynamic instability, you decide to resect only the perforated loop, without performing a primary anastomosis, and to leave the abdomen open for a second look. 

But this is something we already discussed (read more on open abdomen)… So, why are we publishing this post? What’s new? 

As we know, in polytraumatized or unstable/septic patients the peripheral vasoconstriction, especially in the splanchnic area, continues for a while, even after the normalization of vitals. This is due to the persistent arteriolar spasm among the abdominal organs leading to micro-ischemia, the release of proinflammatory cytokines, and activation of systemic inflammation, which further lead to a vicious circle. 

So… What can we do to help the patients?

Thanks to previous studies, it is known that despite normalization of vitals parameters during normal resuscitation protocols, splanchnic vascular bed hypoperfusion persists in more than 80% of patients!

To limit this auto-maintaining circle of vasoconstriction, micro-damages, and cytokines release, some authors started to instill in an open-abdomen setting the fluid usually used for peritoneal dialysis. This procedure is now called Direct Peritoneal Resuscitation. Basically, it is the continuous irrigation of the abdomen through an infusion catheter positioned near the mesentery root. The infusion is associated with an open abdomen so that the suction is always guaranteed by a negative pressure system.

This management should lead to vasodilation in the splanchnic area with a reduction of cellular hypoxia and organ damage. Up to now, the peritoneal dialysis fluid at 2.5% of glucose warmed at 37-38°C has been used. Remember that the fluid must be hypertonic!

According to the major review, the fluid input rate should be around 800 mL in the first hour, then 400 mL/h. However, we use it at slightly lower rates with good results as well. This relatively high rate of fluid infusion means that, if you want to use an open abdomen commercial kit to temporarily close the abdomen, you’ll need to modify the system or use a big canister… Especially if you don’t want to change it every few hours and lead the hospital to bankruptcy…

Remember the dialysis fluid should just pass and flow through the abdomen and not remain inside it; otherwise, the patient would receive peritoneal dialysis! 

These are the highlights from the beautiful review by Weaver JL et al.:

  • Direct peritoneal resuscitation (DPR) instills hypertonic solution into the abdomen in addition to IV resuscitation;
  • DPR causes rapid vasodilation and improves visceral organ blood flow after shock;
  • DPR reduces edema and allows earlier abdominal closure after damage control surgery;
  • DPR reduces serum levels of inflammatory cytokines and other mediators;
  • DPR increases the number of organs procured per door after acute brain death.

We need to say that this is still a new strategy, still lacking strong scientific results(few animal studies were done and few randomized controlled trials) even though very promising. Up to now, in septic or hemorrhagic abdomen, it has demonstrated a reduction of intra-abdominal complications, a faster closure of the abdomen, and an increased percentage of primary fascial closure (i.e. abdomen closed without the use of meshes). Moreover, in patients hospitalized in ICU, it has demonstrated a decrease in the SOFA Score and APACHE II Score after its use. In recent years, few articles have been published with the first randomized studies with good data.

We have to express a positive personal experience when we use this technology, but the importance of this comment is quite low.

Now let’s get back to our poor patient…

You decide to perform a direct peritoneal resuscitation along with the open abdomen, to help the bowel loops to heal faster and to help the patient to recover quickly from his septic state.

Positioning of drainage on the mesentery root
 The open abdomen is fashioned with a Y-connector

The results of the open abdomen with DPR during the first abdominal revision were remarkable. Small bowel vitality improved, avoiding further resection and allowing performing the anastomosis. You even close the midline incision in a continuous fashion during the relook procedure, applying an NPWT on it. 

The bowel during the relook laparotomy

We hope we create some interest in this new technique… Before using it, study the (small) literature and share the decision among the team!!!

Remember that the difficult part is not to fashion the system, but to manage the high fluid output washing the abdominal cavity.

See you next time… 

Namasté!

All pictures are anonymized, and they are courtesy of Dr. Kurihara H.

References

  1. Boffard KD. Manual of Definitive Surgical Trauma Care. 5th Ed. Boca Raton, FL: CRC Press; 2019.
  2. Crafts TD, et al. Direct peritoneal resuscitation improves survival and decreases inflammation after intestinal ischemia and reperfusion injury. J Surg Res 2015;199:428-34.
  3. Weaver JL, et al. Direct Peritoneal Resuscitation: A review. Int J Surg 2016;33:237-41.
  4. Zakaria R, et al. Vasoactive components of dialysis solution. Perit Dial Int 2008;28:283-95.
  5. Smith JW, et al. Direct peritoneal resuscitation accelerates primary abdominal wall closure after damage control surgery. J Am Coll Surg 2010;210: 658-664.
  6. Smith JW, et al. Adjunctive treatment of abdominal catastrophes and sepsis with direct peritoneal resuscitation: indications for use in acute care surgery. J Trauma Acute Care Surg 2014;77:393-8.
  7. Smith JW, et al. Randomized controlled trial evaluating the efficacy of peritoneal resuscitation in the management of trauma patients undergoing damage control surgery. J Am Coll Surg 2017;224:396-404.
  8. Ribeiro-Junior MAF, et al. The role of direct peritoneal resuscitation in the treatment of hemorrhagic shock after trauma and in emergency acute care surgery: a systematic review. Eur J Trauma Emerg Surg 2021; DOI: https://doi.org/10.1007/s00068-021-01821-x.

How to Cite This Post

Marrano E, Bellio G. The Spice That Makes Things Hot. Surgical Pizza. Published on August 20, 2022. Accessed on September 23, 2022. Available at [https://surgicalpizza.org/trauma/the-spice-that-makes-things-hot/].

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