Chemical components separation with botulinum toxin A: A novel technique to improve primary fascial closure rates of the open abdomen

M. D. Zielinski, N. Goussous, H. J. Schiller, D. Jenkins

Research output: Contribution to journalArticle

34 Citations (Scopus)

Abstract

Introduction Failure to definitively close the open abdomen (OA) after damage control laparotomy leads to considerable morbidity and mortality. We have developed a novel technique, the 'chemical components separation,' which incorporates injection of botulinum toxin A (BTX), a long-term flaccid paralytic, into the lateral abdominal wall musculature. Methods This is a retrospective review of all OA patients (age C18) from December 2009-June 2010 who underwent BTX injection. Under ultrasound guidance, a total of 300 units of BTX were injected into the external oblique, internal oblique and transversus abdominus. Results A total of 18 patients were injected with a median age of 66 years (56 % male). Indications for OA treatment included questionable bowel viability (39 %), shock (33 %), loss of abdominal domain (6 %) and feculent contamination (17 %). Median ASA score was 3 with an APACHE 3 score of 85. Patients underwent a median of 4 serial abdominal explorations. The primary fascial closure rate was 83 % with a partial fascial closure rate of 6 % and planned ventral hernia rate of 11 %. Of the 9 patients injected within 24 h of their initial OA procedure, 89 % achieved primary fascial closure. Mortality was 11 %; death was unrelated to BTX injection. The overall complication rate was 67 %; specific complications rates included fascial dehiscence (11 %), enterocutaneous fistula development (0 %), intra-abdominal abscess (44 %) and deep surgical site infection (33 %). Conclusion The 'chemical components separation' technique described is safe and avoids the extensive dissection necessary for mechanical components separation in critically ill patients with infected/contaminated abdominal domains. While further evaluation is required, the described technique provides potential to improve delayed primary fascial closure rates in the OA setting.

Original languageEnglish (US)
Pages (from-to)101-107
Number of pages7
JournalHernia
Volume17
Issue number1
DOIs
StatePublished - Feb 2013

Fingerprint

Type A Botulinum Toxins
Abdomen
Injections
Ventral Hernia
Abdominal Abscess
Intestinal Fistula
Surgical Wound Infection
Abdominal Muscles
APACHE
Mortality
Abdominal Wall
Critical Illness
Laparotomy
Dissection
Shock
Morbidity

Keywords

  • Components separation
  • Damage control
  • Hernia
  • Laparotomy
  • Open abdomen

ASJC Scopus subject areas

  • Surgery

Cite this

Chemical components separation with botulinum toxin A : A novel technique to improve primary fascial closure rates of the open abdomen. / Zielinski, M. D.; Goussous, N.; Schiller, H. J.; Jenkins, D.

In: Hernia, Vol. 17, No. 1, 02.2013, p. 101-107.

Research output: Contribution to journalArticle

Zielinski, M. D. ; Goussous, N. ; Schiller, H. J. ; Jenkins, D. / Chemical components separation with botulinum toxin A : A novel technique to improve primary fascial closure rates of the open abdomen. In: Hernia. 2013 ; Vol. 17, No. 1. pp. 101-107.
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abstract = "Introduction Failure to definitively close the open abdomen (OA) after damage control laparotomy leads to considerable morbidity and mortality. We have developed a novel technique, the 'chemical components separation,' which incorporates injection of botulinum toxin A (BTX), a long-term flaccid paralytic, into the lateral abdominal wall musculature. Methods This is a retrospective review of all OA patients (age C18) from December 2009-June 2010 who underwent BTX injection. Under ultrasound guidance, a total of 300 units of BTX were injected into the external oblique, internal oblique and transversus abdominus. Results A total of 18 patients were injected with a median age of 66 years (56 {\%} male). Indications for OA treatment included questionable bowel viability (39 {\%}), shock (33 {\%}), loss of abdominal domain (6 {\%}) and feculent contamination (17 {\%}). Median ASA score was 3 with an APACHE 3 score of 85. Patients underwent a median of 4 serial abdominal explorations. The primary fascial closure rate was 83 {\%} with a partial fascial closure rate of 6 {\%} and planned ventral hernia rate of 11 {\%}. Of the 9 patients injected within 24 h of their initial OA procedure, 89 {\%} achieved primary fascial closure. Mortality was 11 {\%}; death was unrelated to BTX injection. The overall complication rate was 67 {\%}; specific complications rates included fascial dehiscence (11 {\%}), enterocutaneous fistula development (0 {\%}), intra-abdominal abscess (44 {\%}) and deep surgical site infection (33 {\%}). Conclusion The 'chemical components separation' technique described is safe and avoids the extensive dissection necessary for mechanical components separation in critically ill patients with infected/contaminated abdominal domains. While further evaluation is required, the described technique provides potential to improve delayed primary fascial closure rates in the OA setting.",
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N2 - Introduction Failure to definitively close the open abdomen (OA) after damage control laparotomy leads to considerable morbidity and mortality. We have developed a novel technique, the 'chemical components separation,' which incorporates injection of botulinum toxin A (BTX), a long-term flaccid paralytic, into the lateral abdominal wall musculature. Methods This is a retrospective review of all OA patients (age C18) from December 2009-June 2010 who underwent BTX injection. Under ultrasound guidance, a total of 300 units of BTX were injected into the external oblique, internal oblique and transversus abdominus. Results A total of 18 patients were injected with a median age of 66 years (56 % male). Indications for OA treatment included questionable bowel viability (39 %), shock (33 %), loss of abdominal domain (6 %) and feculent contamination (17 %). Median ASA score was 3 with an APACHE 3 score of 85. Patients underwent a median of 4 serial abdominal explorations. The primary fascial closure rate was 83 % with a partial fascial closure rate of 6 % and planned ventral hernia rate of 11 %. Of the 9 patients injected within 24 h of their initial OA procedure, 89 % achieved primary fascial closure. Mortality was 11 %; death was unrelated to BTX injection. The overall complication rate was 67 %; specific complications rates included fascial dehiscence (11 %), enterocutaneous fistula development (0 %), intra-abdominal abscess (44 %) and deep surgical site infection (33 %). Conclusion The 'chemical components separation' technique described is safe and avoids the extensive dissection necessary for mechanical components separation in critically ill patients with infected/contaminated abdominal domains. While further evaluation is required, the described technique provides potential to improve delayed primary fascial closure rates in the OA setting.

AB - Introduction Failure to definitively close the open abdomen (OA) after damage control laparotomy leads to considerable morbidity and mortality. We have developed a novel technique, the 'chemical components separation,' which incorporates injection of botulinum toxin A (BTX), a long-term flaccid paralytic, into the lateral abdominal wall musculature. Methods This is a retrospective review of all OA patients (age C18) from December 2009-June 2010 who underwent BTX injection. Under ultrasound guidance, a total of 300 units of BTX were injected into the external oblique, internal oblique and transversus abdominus. Results A total of 18 patients were injected with a median age of 66 years (56 % male). Indications for OA treatment included questionable bowel viability (39 %), shock (33 %), loss of abdominal domain (6 %) and feculent contamination (17 %). Median ASA score was 3 with an APACHE 3 score of 85. Patients underwent a median of 4 serial abdominal explorations. The primary fascial closure rate was 83 % with a partial fascial closure rate of 6 % and planned ventral hernia rate of 11 %. Of the 9 patients injected within 24 h of their initial OA procedure, 89 % achieved primary fascial closure. Mortality was 11 %; death was unrelated to BTX injection. The overall complication rate was 67 %; specific complications rates included fascial dehiscence (11 %), enterocutaneous fistula development (0 %), intra-abdominal abscess (44 %) and deep surgical site infection (33 %). Conclusion The 'chemical components separation' technique described is safe and avoids the extensive dissection necessary for mechanical components separation in critically ill patients with infected/contaminated abdominal domains. While further evaluation is required, the described technique provides potential to improve delayed primary fascial closure rates in the OA setting.

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