FAQIn the following pages, you will find answers to questions from residents and surgeons that are were often posed either at the Medical College of Wisconsin or during my lectures in hospitals across the country and abroad. Q: Is there bacterial growth of concern on the artificial bur? A: We have published data addressing this issue using special bacteriological technique like sonication of the device to be able to recover all bacteria [1]. This research was done some years ago when we did not close the abdominal wound with a self adherent plastic drape HYPOPACK on top of the ARTIFICIAL BUR to prevent contamination from outside in the ICU for example. We virtually found the same bacteria on the ARTIFICIAL BUR as the ones recovered from the abdomen and from peritoneal fluid. There were, of course instances of coagulase negative Gram-positive bacteria, mostly Staphylococcus epidermidis. Nevertheless bacteria were cleared quickly and did not cause problems after closure [1]. My partner Dr. Aprahamian has published the elimination of bacteria in 1995 [2]for all patients who received 2 gram of cefotaxime q12h and 500 mg metronidazole q12h hrs as initial antibiotic therapy [2,3]. I will comment on the rationale for this antibiotic combination separately. We have lots of bacteriological data from cultures taken from the two AFB sheets that were obtained simultaneously with peritoneal fluid cultures and peritoneal tissue cultures from the second period when we were covering the AFB with the HBS for protection. The information has been submitted to the FDA because FDA did ask the same question. We never had to remove the AFB because of colonization of the bur with enterococci, staphylococci or pseudomonas. Usually, when there was adequate source control peritoneal fluid became clear quickly and bacteria did survive neither within the abdominal cavity nor on the AFB. Those bacteria are exposed to high antibiotic concentration within the peritoneal fluid into which the bur is submerged. We have investigated the antibiotic concentration in peritoneal fluid. It surpasses the MIC and often the MBC of bacteria multiple times [4] Q: What about multiresistent enterococci on the artificial bur? Although I had both new anti-enterococcal drugs quinupristin/dalfopristin (Synercid) and linezolid (Zyvox) available for some years on compassionate use basis (I was PI on several clinical studies with both antibiotics) I never used them in "STAR" patients. Those multiresistant bacteria may colonize the artificial bur as they colonize any site in susceptible patients. Do you need to treat those multiresistent bacteria that do not produce significant toxins? The answer to this question is still controversial. If you want to treat you could give the new antibiotics and establish a high concentrations in peritoneal fluid surrounding the AFB. I personally think, however, that - if you can close the source of infection - you do not need to treat those multiresistant bacteria with the goal to remove them from the AFB. The bur will be removed anyway and when the infectious source is eliminated and no further bacteria are "leaking" into the peritoneal cavity", it should not take more than 3 days close fascia-to-fascia after diuresing the patient and nearing the fasciae. I personally I remember a 70-year-old man who was transferred to me to close his wide-open abdomen with multiple small bowel fistulae following multiple previous operations. I was able to resect the fistulae, and close the abdomen fascia-to-fascia. What I did not know, when he was transferred, was that he had vancomycin resistant enterococcus fecium in his wound. We did not have any antibiotics at the time to which the bacterium would have been sensitive because Linezolid and Synercid were not yet available. Nevertheless enterococci were eliminated because we were able to take care of the underlying problem and control i.e. to close the source of infection. Q: Does ARTIFICIAL BUR adhere to the bowel and cause fistulae? A: No, I have never had the problem, although I must admit, that in the first years of doing STAR I was concerned about that issue myself and often placed a PVC "bowl bag", cut open, underneath the bur. If you are concerned, you can do that. We never had a problem with adherence or fistula formation resulting from the direct contact of the bowel to the bur. All the fistulae we temporarily saw, originated from an anastomosis or other surgical manipulations. The nice thing about STAR is, that, at the 24 hourly abdominal reentries one can diagnose areas of bowel wall ischemia early, before the actually perforate and before these ischemic , mostly para-anastomotic spots become the origin of a fistula. Another cause of fistulae may be a retained foreign body. STAR reduces the risk of retained foreign body and necrotic tissue, because you may irrigate the entire abdominal cavity during the daily abdominal re-explorations and inspect completely all pouches and corners within the abdomen. If you have a pancreatic fistula, it is a good idea to place a large size drain when you are finished debriding necrotic tissue around the pancreas as good granulation tissue is replacing the open peripancreatic wounds. Those Drains go from the leaking pancreas outwards and may best leave the abdomen retrocolically through the left flank. No need to mention that extreme care should be taken not to injure the descending colon. These are the only circumstances where I left a drain in the abdomen during and after STAR. Q: What is the hernia rate following Staged Abdominal Repair (STAR) using ARTIFICIAL BUR closure (ABC)? A: About 10% of the patients developed hernia in our hands. Often these were patients that came with pararectal incisions or with abdominal wall infections leading to necrosis of the fascial edges, were on corticosteroids and immunosuppressive following transplantation or had other abdominal wall problems. We submitted the data to FDA and think that it is an acceptable rate of hernia formation. In all STAR patients I was able to close the abdomen fascia to fascia at the last abdominal entry. I was able to repair all post-STAR hernias within a year without using a mesh when a dehiscence and/or hernia developed. Q: Can you always close the fascia even after more than 10 abdominal re-entries? A: The number of abdominal entries had no influence on our ability to close the abdomen fascia-to fascia at the last STAR entry. It it easier, however, to try to achieve closure early, when all source control issues are solved, peritoneal fluid is clear and there are no further areas of concern and all bowel injuries including anastomoses heal well. At this stage you want to eliminate any excess fluid and pull the fascia progressively closer together with help of the bur. Q: Do you form colostomies, when you are not sure that an anastomosis will heal all right? A: A colostomy represents bacterial source that will contaminate the wound not matter how careful you try to keep it out of the wounds. When you have a colostomy cannot easily apply the Hypobaric( Steridrape or so) air tight to create hypobaric pressure in the wound. And there is no need to form a colostomy, unless there is no functional rectum left. Colostomies are formed to avoid spilling of intestinal content into the abdominal cavity in case a leak develops. They were a great idea at the time. With STAR however, you can inspect you anastomosis every day and take care of perianastomotic areas of ischemia or necrosis early. Nothing will be hidden. The case becomes truly surgical because you leave nothing to chance. All the additional risks including a mortality of 2% to 4% associated with the later takedown of colostomies are avoided and the patient will be thankfull no to have to live with feces coming constantly through the abdominal wall. When patients were referred to me with a colostomy already in place have actually taken down all hose colostomies as soon as the patients recovered from sepsis and became stable, mostly at the 3rd STAR entry. I suture my anastomoses with a 4-0 running PDS or Maxon suture taking all layer. If there is a lot of inflammatory bowel edema you must take this into consideration when sewing you anastomosis. The beauty of STAR is, that it allows you to watch you anastomosis healing and catch early loose sutures as the inflammatory edema disappears. [1] Wittmann DH, Aprahamian C, Bergstein JM, Edmiston CE, Frantzides CT, Quebbeman EJ, Condon RE. A burr-like device to facilitate temporary abdominal closure in planned multiple laparotomies. European J Surgery 159(1993)75-79 [2] Aprahamian CA, Schein, Wittmann DH: Cefotaxime and metronidazole in the treatment of intraabdominal infection. Diag Micro Infect 22(1995)183-188 [3] Wittmann DH., Operative and Nonoperative therapy of Intra-abdominal Infections. Infection 26(1998)335-351 [4] Wittmann DH, Bergstein JM, Frantzides C. Calculated Empiric Antibiotic Treatment of Acute Surgical Infections. Infection 19S(1991)345-350 [5] Wittmann DH, Schassan H-H. The Distribution of Beta-lactam Antibiotics in Serum Bone Tissue Fluid and Peritoneal Fluid. Rev Inf Dis 4S(1982)610-616 |