The Need for Emergency Laparotomy With Open Abdomen Therapy in the Course of ECMO—A Retrospective Analysis of Course and Outcome

Abstract

Background: Abdominal compartment syndrome (ACS) can occur in patients placed on extra corporeal membrane oxygenation (ECMO). This implies the necessity of decompressive laparotomy followed by an open abdomen (OA) to prevent complications such as multi-organ-failure or death. Methods: We searched for ECMO patients in our hospital database between July 2015 and April 2020 and selected those with an emergency laparotomy and OA therapy. Of these, we analyzed only patients who were treated with an OA after establishing the ECMO regarding patient-related parameters like sex, age, height, weight, and indications for ECMO as well as outcome parameters like complete fascial closure rate, mortality, length of stay in intensive care unit (ICU), length and kind of OA therapy, number of surgical procedures, dressing changes concerning negative pressure wound therapy (NPWT), and number of surgical revisions. Results: In eight out of 421 patients (1.9%), a laparostoma had to be created during ECMO support. For temporary closure, either NPWT, abdominal packing, or both were used. The median length of OA therapy was 17 days, and the median length of stay in ICU was 42 days in total. The median number of surgical procedures and NPWT dressing changes was seven. In three of the eight patients, a surgical revision was necessary. The total mortality rate was 50%. In 75%, the fascia could be closed. Two patients died before final closure. In all deceased patients, an abdominal packing was necessary during the course of treatment; in the survivors, only once. No enteroatmospheric fistula or abscesses occurred. Conclusions: ACS in patients placed on ECMO is a very rare condition with a considerable mortality rate but high secondary closure rate of the fascia. A necessary abdominal packing due to a severe bleeding seems to be a risk factor with a potentially fatal outcome.

Open abdomen during extracorporeal membrane oxygenation is a safe and effective treatment for abdominal compartment syndrome

“…The overall incidence of ECMO complications was lower in the open abdomen group. Schulz and colleagues recently reported similar findings to ours in an adult cohort of ECMO patients requiring decompressive laparotomy for abdominal compartment syndrome [4]. They reported a slightly lower survival rate and a considerably longer median LOS, but the methods and findings were otherwise quite similar, providing encouraging corroboration from an adult population to our findings in a pediatric one.…”

“…They reported a slightly lower survival rate and a considerably longer median LOS, but the methods and findings were otherwise quite similar, providing encouraging corroboration from an adult population to our findings in a pediatric one. Interestingly, they described age as a risk factor for mortality in populations with this treatment, as did Glowka in a similar adult study, providing one possible explanation for our higher survival rate [4,7]. The pediatric series published in 2013 by Rollins described a similar treatment course in the same age group as ours [3].…”

“…This recommended treatment algorithm stands in contrast to the method described by Schultz and Glowka in adults and by Rollins in children, all of whom performed decompressive laparotomy after ECMO initiation. We believe that our method of opening the abdomen before initiating ECMO support is superior and may lead to better outcomes, particularly compared to Rollins' pediatric series, none of whom survived to discharge [3,4,6].…”

“…There are documented examples of these complications [2,3], but they are scant in the literature and do not conclusively demonstrate that these risks outweigh the potentially life-saving benefit of ECMO support. In adults, the use of laparotomy with open abdomen in ECMO patients was recently described by Schulz and colleagues [4]. This singlecenter retrospective study reported that laparotomy with open abdomen was a necessary treatment in adult ECMO patients with abdominal compartment syndrome but had an associated mortality of 50% in their 8-patient cohort [4].…”

“…In adults, the use of laparotomy with open abdomen in ECMO patients was recently described by Schulz and colleagues [4]. This singlecenter retrospective study reported that laparotomy with open abdomen was a necessary treatment in adult ECMO patients with abdominal compartment syndrome but had an associated mortality of 50% in their 8-patient cohort [4].…”