Massachusetts Chapter of the American College of Surgeons

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Revisiting mesenteric ischemia: is abdominal closure associated with improved outcome?
Jefferson A. Proaņo-Zamudio, MD, Dias Argandykov, MD, Emanuele Lagazzi, MD, Angela Renne, BS, Charudutt N. Paranjape, MD,Stephanie J. Maroney, MD, Haytham M. A. Kaafarani, MD, MPH, David R. King, MD, George C. Velmahos, MD, PhD, John O. Hwabejire, MD, MPH
Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA

Background: Current guidelines advocate liberal use of delayed abdominal closure after laparotomy for acute mesenteric ischemia (AMI). Few studies have examined this practice. Our aim was to evaluate the effect of delayed abdominal closure on postoperative outcomes in patients with AMI.
Methods: We performed a retrospective cohort study of the ACS-NSQIP 2013-2017 registry. We included patients with a diagnosis of AMI undergoing emergency laparotomy. Patients were divided into two groups: 1)Delayed fascial closure (DFC) when no layers of the abdominal wall were closed, and 2)immediate fascial closure (IFC) if deep layers or all layers of the abdominal wall were closed. Propensity score matching was performed based on comorbidities, pre-operative and operative characteristics. Univariable analysis was performed on the matched sample.
Results: The propensity-matched cohort comprised 1,614 patients equally divided into both groups. The median (IQR) age was 68(59-76), and 864(53.5%) were female. Compared to IFC, the DFC group showed increased in-hospital mortality (39.7% vs. 31.5%, p=0.001) and 30-day mortality (43.1% vs. 35.9%, p=0.003) and increased risk of respiratory failure (59.4% vs. 35.3 %, p<0.001), but decreased risk of surgical site infection (Figure).
Conclusion: The delayed fascial closure technique was associated with increased mortality compared to immediate fascial closure. These findings do not support the blanket incorporation of delayed closure in mesenteric ischemia care or its previously advocated liberal use.


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