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Mon Sep 17 15:57:54 BST 2007

I think we need to be very careful here. Do we really need to relearn previous lessons? I do believe we have the ability and responsibility to refine our techniques as we have gained more experience--particularly, as it has become clear that ACS is in many ways an iatrogenic problem to begin with. As we begin to address the iatrogenic component, then we may be able to adjust our practice of leaving the abdomen open. In my experience, leaving the abdomen open when it could have been closed has not resulted in any problems. Typically, the abdomen is just closed in 24-48 hours.  We need to remember that previous studies have shown that once ACS occurs, it has significant associated morbidity--and that prophylaxis is important--whether this prophylaxis takes the form of leaving the abdomen open, adjusting how we resuscitate patients or a combination of the two remains to be determined.

Pat 

Patrick J. Offner MD MPH
Chief, Surgical Critical Care
St Anthony Central Hospital

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Errington Thompson
Sent: Sunday, September 16, 2007 10:15 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: ? Open abdomen techniques overused ? (Cross Posted)

1.    Are we all applying damage control, open abdomen  techniques, etc. too

often?  I think the answer to this question is clearly yes but I'm not sure that this is a bad thing.
2.    Are we increasing the number of enteric fistulas, use of expensive 
secondary closure meshes and devices far too often?  I'm not sure.  I think that this relates to my earlier question about the etiology of these fistulas.  I don't understand the physiology. Are the fistulae secondary to ischemia?  Poor technique or other factors?

3.    Is there a need to return to a swinging back of a  pendulum?  Without
answering the above questions, I don't think that we can address this question.

E

Errington C. Thompson, MD, FACS, FCCM
Trauma/Surgical Critical Care
Mission Hospital
Asheville, NC
Author - A Letter to America
www.whereistheoutrage.net

Everyone deserves to make an informed decision
                                - Errington Thompson, MD

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of KMATTOX at aol.com
Sent: Saturday, September 15, 2007 1:18 PM
To: SURGINET at LISTSERV.UTORONTO.CA
Cc: trauma-list at trauma.org
Subject: ? Open abdomen techniques overused ? (Cross Posted)

I find myself being reflective today while between cases while on in-house  
trauma call.    We just finished a take back on a patient with an  open 
abdomen, needing a washout, and assessment for continued  therapy.   We
found what
everyone is reporting, an enteric  fistula.  We all have seen enteric fistulas following trauma for a  long time, and I do not know if the incidence in the

open abdomen cases is any  less or greater than prior to temporary closure methods.  

More than 12 temporary closure options now exist, and each has its champion. 
   We are increasingly training  surgeons who are more comfortable with laparoscopic technology, and when  faced with even a relatively straight forward 
open trauma case, are applying  damage control.   Now my questions.

1.    Are we all applying damage control, open abdomen  techniques, etc. too

often?
2.    Are we increasing the number of enteric fistulas,  use of expensive 
secondary closure meshes and devices far too often?
3.    Is there a need to return to a swinging back of a  pendulum?

K Mattox

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? Open abdomen techniques overused ? (Cross Posted)