The open abdomen in trauma and non-trauma patients: WSES guidelines
創傷和非創傷患者的開腹：WSES 指南

Abstract  抽象

Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a “planned second-look” laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.
損傷控制復甦可能導致術后腹內高壓或腹筋膜室綜合征。這些情況可能導致惡性、自我延續的迴圈，導致嚴重的生理紊亂和多器官衰竭，除非被腹部（手術或其他）減壓打斷。此外，在某些臨床情況下，由於內臟水腫、無法控制引人注目的感染源或需要重新探索（作為“計劃的二次檢查”剖腹手術）或完成先前啟動的損傷控制程式或腹壁破裂，腹部無法閉合。在沒有其他感知選擇的情況下，創傷和非創傷患者的開腹已被提出可有效預防或治療重傷或危重疾病的患者生理紊亂。然而，它的使用仍然存在爭議，因為它消耗資源並且代表了一種可能產生嚴重不良反應的非解剖學情況。因此，只有在最能從中受益的患者中才考慮使用它。腹筋膜間閉合術應在患者生理上能夠耐受時儘快進行。應採取一切預防措施，以盡量減少併發症。

Background  背景

Damage control management (DCM) of severely injured or physiologically deranged patients is considered by many to consist of damage control resuscitation (DCR) and damage control surgery (DCS). Use of DCM in patients with deranged physiology may trigger intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS) that may aggravate physiologic derangement or multiorgan failure (MOF) in a vicious circle unless interrupted by abdominal decompression (surgical or other) [1, 2]. Further, in other clinical situations, the abdomen cannot be closed due to visceral edema, the inability to completely control the compelling source of infection or to the necessity to re-explore (in a “planned re-look laparotomy”) or to complete DCS procedures or in cases of abdominal wall damage. Although open abdomen (OA) has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness, it must be recognized as a non-anatomic situation that has potential for severe side effects while increasing resource utilization [3].
許多人認為，重傷或生理紊亂患者的損傷控制管理 （DCM） 包括損傷控制復甦 （DCR） 和損傷控制手術 （DCS）。在生理紊亂患者中使用 DCM 可引發腹內高壓（intraabdomal hypertension， IAH）或腹筋膜室綜合征（abdomal comtallment syndrome， ACS），除非腹部減壓（手術或其他）中斷，否則可能會加重生理紊亂或多器官衰竭（multiorgan failure， MOF）[1， 2]。此外，在其他臨床情況下，由於內臟水腫、無法完全控制引人注目的感染源或需要重新探索（在“計劃複看剖腹手術中”）或完成 DCS 手術或腹壁損傷，腹部無法閉合。儘管開腹（open abdomence， OA）已被提出可有效預防或治療重傷或危重患者的生理紊亂，但必須認識到它是一種非解剖學情況，在增加資源利用率的同時可能產生嚴重副作用[3]。

The World Society for Emergency Surgery (WSES) accepted the definitions of IAH, ACS, and related conditions published by the World Society Abdominal Compartment Syndrome in 2013 (WSACS) [2,3,4] (Fig. 1).
世界急診外科學會（WSES）接受了世界腹室綜合征學會（WSACS）於 2013 年發表的 IAH、ACS 和相關疾病的定義[2,3,4]（圖  1）。

Fig. 1  圖1

WSACS grading of intra-abdominal hypertension (IAH) (IAP intra-abdominal pressure, ACS abdominal compartment syndrome) [4]
腹內高壓（intra-abdominal hypertension， IAH）的 WSACS 分級（IAP 腹內壓、ACS 腹腔室綜合征）[4]

OA management consists of intentionally leaving the abdominal fascial edges of the paired rectus abdominus muscles un-approximated (laparostomy) in order to truncate operation, prevent IAH/ACS, and facilitate re-exploration without damaging the abdominal fascia [3]. Temporary abdominal closure (TAC) refers to the method for providing protection to the abdominal viscera during the time the fascia remains open [2, 5]. Patients undergoing OA management are at risk of developing entero-atmospheric fistula (EAF) and a “frozen abdomen,” intra-abdominal abscesses, and lower rates of definitive fascial closure [6, 7]. The risk-benefit ratio must be kept in mind in using OA. It should not be performed liberally. Measures to mitigate complications are necessary. In all patients with an OA, every effort should be exerted to achieve primary fascial closure (i.e., fascia-to-fascia closure of the abdominal wall within the index hospitalization) as soon as the patient can physiologically tolerate it [3].
OA 治療包括有意將成對腹直肌的腹部筋膜邊緣留出近似狀態（腹腔造口術），以截斷手術、預防 IAH/ACS 並促進重新探查，而不損傷腹筋膜[3]。臨時腹部閉合（TAC）是指在筋膜保持開放狀態期間為腹部內臟提供保護的方法[2,5]。 接受 OA 治療的患者有發生腸大氣瘺（entero-atmospheric fistula， EAF）和“腹部冰凍”、腹腔內膿腫的風險，並且根治性筋膜閉合率較低[6,7]。 使用 OA 時必須牢記風險收益比。它不應該被隨意執行。有必要採取措施減輕併發症。對於所有 OA 患者，一旦患者在生理上能夠耐受，就應盡一切努力實現初次筋膜閉合（即指數住院期間腹壁的筋膜-筋膜閉合）[3]。

Purpose and use of this guideline
本指南的目的和用途

The guidelines are evidence-based, with the grades of recommendation, based on the evidence. These guidelines present methods for optimal management of open abdomen in trauma and non-trauma patients. They do not represent a standard of practice. They are suggested plans of care, based on best available evidence and a consensus of experts. They, however, do not exclude other approaches as being within a standard of practice. For example, they should not be used to compel adherence to a given method of medical management, which should be finally determined after taking into account conditions at the relevant medical institution (staff levels, experience, equipment, etc.) and the characteristics of the individual patient. The responsibility for the results, however, rests with the engaging practitioners and not aged therein, and not the consensus group.
該指南以證據為基礎，並根據證據確定推薦等級。這些指南提出了對創傷和非創傷患者進行開腹的最佳管理方法。它們不代表實踐標準。它們是基於最佳現有證據和專家共識的建議護理計劃。然而，它們並不排除其他方法符合實踐標準。例如，不應使用它們來強迫遵守給定的醫療管理方法，該方法應在考慮相關醫療機構的情況（員工級別、經驗、設備等）和個體患者的特徵后最終確定。然而，結果的責任在於參與的從業者，而不是其中的老年人，而不是共識小組。

Methods  方法

A computerized search was performed in MEDLINE, EMBASE, and Scopus by an information scientist/librarian for the time range of January 1980 to August 2017. The terms open abdomen, laparostomy, injuries, trauma, peritonitis, pancreatitis, vascular, ischemia, resuscitation, adult, management, infection, intensive care unit, anastomosis, vasopressors, and follow-up in various combinations with the use of the Boolean operators “AND” and “OR” were used. No search restrictions were imposed. The dates were selected to allow comprehensive published abstracts of clinical trials, consensus conferences, comparative studies, congresses, guidelines, government publications, multicenter studies, systematic reviews, meta-analyses, large case series, original articles, and randomized controlled trials. Case reports and small case series were excluded. We also analyzed the reference lists of relevant narrative review articles identified during the search to identify any studies that may have been missed.
一名資訊科學家/圖書館員在 MEDLINE、EMBASE 和 Scopus 中對 1980 年 1 月至 2017 年 8 月的時間範圍進行了計算機檢索。使用了開放腹部、剖腹造口術、損傷、創傷、腹膜炎、胰腺炎、血管、缺血、復甦、成人、管理、感染、重症監護病房、吻合口、血管加壓藥和隨訪等術語，並使用布爾運算符“AND”和“OR”進行各種組合。沒有施加搜索限制。選擇這些日期是為了允許全面發表臨床試驗摘要、共識會議、比較研究、大會、指南、政府出版物、多中心研究、系統評價、薈萃分析、大型病例系列、原創文章和隨機對照試驗。病例報告和小型病例系列被排除在外。我們還分析了檢索過程中確定的相關敘述性綜述文章的參考文獻清單，以確定可能遺漏的任何研究。

For each article, we subsequently applied a level of evidence (LE) using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system [8] (Table 1). The full GRADE process was not used, as this system is difficult to apply when scant evidence exists. A group of experts in the field of OA management, coordinated by a central coordinator, were subsequently convened in order to elicit their evidence-based opinions on certain key clinical questions relating to the OA. Through a Delphi process, the clinical questions were discussed in rounds. The central coordinator assembled the different answers derived from each round. Each version was then revised and improved through iterative evaluation. The final version about which the agreement was reached resulted in the comments and recommendations made in the present guideline. Statements have been summarized in Table 2.
對於每篇文章，我們隨後使用推薦分級、評估、開發和評估（GRADE）系統應用了證據水準（LE）[8]（表 1）。沒有使用完整的 GRADE 流程，因為在證據匱乏的情況下很難應用該系統。隨後召集了由中央協調員協調的 OA 管理領域的專家小組，以就與 OA 相關的某些關鍵臨床問題徵求他們基於證據的意見。通過德爾菲過程，臨床問題進行了輪次討論。中央協調員彙集了每一輪得出的不同答案。然後通過反覆運算評估對每個版本進行修訂和改進。達成協議的最後版本產生了本準則中提出的評論和建議。 表 2 總結了發言。

Table 1 GRADE system to evaluate the level of evidence and recommendation
表 1 GRADE 系統評估證據和推薦水準

Table 2 Summary of statements
表2 發言摘要

Indications  跡象

Trauma patients  創傷患者

Persistent hypotension, acidosis (pH <7.2), hypothermia (temperature < 34°C) and coagulopathy are strong predictors of the need for abbreviated laparotomy and open abdomen in trauma patients (Grade 2A)
持續性低血壓、酸中毒（pH <7.2）、體溫過低（體溫< 34°C）和凝血障礙是創傷患者（2A 級）需要簡短剖腹手術和開腹手術的有力預測因素

Risk factors for abdominal compartment syndrome such as damage control surgery, injuries requiring packing and planned reoperation, extreme visceral or retroperitoneal swelling, obesity, elevated bladder pressure when abdominal closure is attempted, abdominal wall tissue loss and aggressive resuscitation are predictors of the necessity for open abdomen in trauma patients (Grade 2B)
腹筋膜室綜合征的危險因素，如損傷控制手術、需要包裝和計劃再次手術的損傷、極度內臟或腹膜后腫脹、肥胖、嘗試閉腹時膀胱壓升高、腹壁組織損失和積極復甦是創傷患者需要開腹的預測因素（2B 級）

Decompressive laparotomy is indicated in abdominal compartment syndrome if medical treatment has failed after repeated and reliable IAP measurements (Grade 2B)
如果在重複可靠的 IAP 測量後藥物治療失敗（2B 級），則需要進行減壓剖腹手術治療腹筋膜室綜合征

The inability to definitively control the source of contamination or the necessity to evaluate bowel perfusion may be an indicator to leave the abdomen open in post-traumatic bowel injuries (Grade 2B)
無法明確控制污染源或需要評估腸道灌注可能是創傷后腸損傷（2B 級）中腹部開放的指標

Severely injured patients with hemodynamic instability are at higher risk of ACS for several reasons (i.e., aggressive resuscitation, ischemia-reperfusion injury, visceral or retroperitoneal swelling, recurrent bleeding, and intra-peritoneal packing) [9,10,11,12].
血流動力學不穩定的重傷患者發生 ACS 的風險更高，原因有多種原因（即積極復甦、缺血再灌注損傷、內臟或腹膜后腫脹、反覆出血和腹膜內充血）[9,10,11,12]。

In fact, the post-traumatic physiological derangements and the consequent DCM expose patients at risk for increased intra-abdominal pressure. Risk factors associated with ACS requiring an OA after trauma, indicating a higher need for OA, are acidosis with pH ≤ 7.2, lactate levels ≥ 5 mmol/L, base deficit (BD) ≥ − 6 in patients older than 55 years or ≥ − 15 in patients younger than 55 years, core temperature ≤ 34 °C, systolic pressure ≤ 70 mmHg, estimated blood loss ≥ 4 L during the operation and/or transfusion requirement ≥ 10 U of packed red blood cells in the pre- or pre- and intraoperative settings, and severe coagulation derangements (INR/PT > 1.5 times normal, with or without a concomitant PTT > 1.5 times normal) [10, 13,14,15,16,17].
事實上，創傷后生理紊亂和隨之而來的 DCM 使患者面臨腹內壓升高的風險。與創傷后需要 OA 的 ACS 相關的危險因素是酸中毒，pH 值≤ 7.2，乳酸水準 ≥ 5 mmol/L，鹼缺乏 （BD） ≥ - 6 在 55 歲以上的患者中或 ≥ - 15 在 55 歲以下的患者中，核心溫度≤ 34 °C，收縮壓 ≤ 70 mmHg， 術前、術前和術中估計失血量≥4L 和/或輸血需求≥10U 濃縮紅細胞，嚴重凝血障礙（INR/PT > 為正常值的 1.5 倍，伴有或無伴隨 PTT > 為正常值的 1.5 倍）[10,13,14,15,16,17]。

Other recognized risk factors for IAH should be kept into consideration: obesity, pancreatitis, hepatic failure/cirrhosis, positive end-expiratory pressure > 10 cm H₂0, respiratory failure, acute respiratory distress syndrome [18].
應考慮其他公認的 IAH 危險因素：肥胖、胰腺炎、肝功能衰竭/肝硬化、呼氣末正壓> 10 cm H₂0、呼吸衰竭、急性呼吸窘迫綜合征[18]。

All non-surgical treatment should be implemented to prevent or reduce IAH before proceeding to surgical decompression (i.e., nasogastric and colonic decompression, prokinetic agents, adequate patient positioning and avoidance of constrictive dressings, eventual escharotomy and percutaneous decompression, adequate mechanical ventilation, analgesia, sedation and neuromuscular blockade, balanced fluid resuscitation, eventual diuretic therapy and continuous veno-venous hemofiltration/ultrafiltration, and vasoactive medications).
在進行手術減壓之前，應實施所有非手術治療以預防或減少 IAH（即鼻胃和結腸減壓、促動力劑、適當的患者體位和避免收縮敷料、最終焦痂切開術和經皮減壓術、充分的機械通氣、鎮痛、鎮靜和神經肌肉阻滯、平衡液體復甦、最終利尿劑治療和持續靜脈-靜脈血液濾過/超濾和血管活性藥物）。

Moreover, failure to definitively control the source of infection at the index operation or the necessity to check bowel perfusion during DCM or abdominal wall tissue loss represents indications to OA management in traumatic abdominal injuries [3, 11].
此外，在指數手術中未能明確控制感染源，或在 DCM 或腹壁組織丟失期間需要檢查腸灌注，這些都是外傷性腹部損傷中 OA 治療的指征[3,11]。

Non-trauma patients  非創傷患者

Decompressive laparotomy is indicated in abdominal compartment syndrome if medical treatment has failed after repeated and reliable IAP measurements (Grade 2B)
如果在重複可靠的 IAP 測量後藥物治療失敗（2B 級），則需要進行減壓剖腹手術治療腹筋膜室綜合征

Peritonitis  腹膜炎

ᅟ

The open abdomen is an option for emergency surgery patients with severe peritonitis and severe sepsis/septic shock under the following circumstances: abbreviated laparotomy due to severe physiological derangement, the need for a deferred intestinal anastomosis, a planned second look for intestinal ischemia, persistent source of peritonitis (failure of source control), or extensive visceral oedema with the concern for development of abdominal compartment syndrome (Grade 2C).
在以下情況下，對於患有嚴重腹膜炎和嚴重敗血症/感染性休克的急診手術患者，可以選擇開腹手術：由於嚴重生理紊亂而縮短剖腹手術、需要推遲腸吻合術、計劃再次檢查腸缺血、持續性腹膜炎來源（來源控制失敗）或廣泛內臟水腫並擔心腹筋膜室綜合征的發展（2C 級）。

Some patients suffering from severe peritonitis may experience a disease progression to septic shock with no room for definitive surgical procedures [3, 19]. In these cases, surgical operation should be abbreviated even in advanced age [20]. In hypotensive patients requiring high-dose vasopressors or inotropes infusion intestinal continuity restoration may be deferred [21]. In incomplete source control or in the presence of visceral edema and/or decreased abdominal wall compliance primary complete fascia closure should not be attempted because of the high risk of IAH/ACS [22]. In all these situations, the abdomen may be left open. However, there is no definitive data regarding the use of the OA in the face of severe peritonitis and therefore, caution should be exercised when using OA in these circumstances.
一些重度腹膜炎患者可能會進展為膿毒性休克，而沒有明確的外科手術空間[3,19]。 在這些情況下，即使在高齡也應縮短手術時間[20]。對於需要大劑量血管加壓藥或正性肌力藥輸注的低血壓患者，腸道連續性恢復可能會推遲[21]。如果源控制不完全，或存在內臟水腫和/或腹壁依從性下降，則不應嘗試一發性完全筋膜封堵術，因為 IAH/ACS 的風險較高[22]。在所有這些情況下，腹部都可能保持開放狀態。然而，沒有關於在嚴重腹膜炎中使用 OA 的明確數據，因此，在這些情況下使用 OA 時應謹慎行事。

Vascular emergencies  血管急症

ᅟ

The open abdomen should be considered following management of hemorrhagic vascular catastrophes such as ruptured abdominal aortic aneurysm (Grade 1C)
在治療出血性血管災難（如腹主動脈瘤破裂（1C 級））后，應考慮開腹

The open abdomen should be considered following surgical management of acute mesenteric ischemic insults (Grade 2C).
急性腸系膜缺血性損傷（2C 級）手術治療后應考慮開腹。

Up to 20% of patients experiencing a ruptured AAA repair develop ACS. Mortality is high (30–50%) and is almost doubled in presence of ACS [23, 24]. OA reduces the ACS incidence [25]. No definitive indications to OA exist; the relative indications to OA are massive resuscitation, deranged physiology, fascial tension at closure, use of balloon occlusion of the aorta, and blood loss > 5 L [25,26,27].
高達 20% 的 AAA 修復破裂患者會發展為 ACS。死亡率很高（30-50%），在 ACS 存在的情況下幾乎翻了一番[23,24]。 OA 可降低 ACS 的發生率[25]。不存在 OA 的明確指征;OA 的相對適應證是大量復甦、生理紊亂、閉合時筋膜張力、使用球囊閉塞主動脈和失血> 5L [25,26,27]。

Advanced age is not a contraindication to DCM [20].
高齡不是 DCM 的禁忌證[20]。

ACS can occur even after endovascular repair (EVAR), and the major risk factor appears to be massive resuscitation [23]. Risk of graft infection due to OA management has been demonstrated to be low [28].
即使在血管內修復（endovascular repair， EVAR）后也可能發生 ACS，主要危險因素似乎是大規模復甦[23]。OA 治療導致的移植物感染風險已被證明較低[28]。

The use of OA after perfusion restoration in a patient with acute mesenteric ischemia as in occlusive proximal or distal superior mesenteric artery emboli, watershed necrosis after AAA repairs (open or endovascular), and non-occlusive mesenteric ischemia (e.g., post-arrest or resuscitation from shock/arrest) should be considered in case of deranged physiology and bowel edema and necessity to perform a second look or delayed anastomosis [29,30,31].
對於急性腸系膜缺血患者，如閉塞性近端或遠端腸系膜上動脈栓塞、AAA 修復後分水嶺壞死（開放性或血管內）和非閉塞性腸系膜缺血（如，停搏后或休克/停頓復甦）患者，應考慮在生理機能紊亂和腸水腫以及需要進行二次檢查或延遲吻合的情況下，在灌注恢復后使用 OA [29，30,31]。

Mesenteric venous thrombosis requiring laparotomy does not routinely mandate OA as often as mesenteric ischemia [32]; however, the risk of IAH/ACS imposes attention to IAP.
需要剖腹手術的腸系膜靜脈血栓形成通常不會像腸系膜缺血那樣頻繁地需要 OA[32];然而，IAH/ACS 的風險需要關注 IAP。

Pancreatitis  胰腺炎

ᅟ

In patients with severe acute pancreatitis unresponsive to step-up conservative management surgical decompression and open abdomen open are effective in treating abdominal compartment syndrome (Grade 2C)
對於對加壓保守治療無反應的嚴重急性胰腺炎患者，手術減壓和開腹可有效治療腹筋膜室綜合征（2C 級）

Leaving the abdomen open after surgical necrosectomy for infected pancreatic necrosis is not recommended except in those situations with high risk factors to develop abdominal compartment syndrome (Grade 1C)
不建議在感染性胰腺壞死手術壞死切除術后保持腹部開放，除非那些有發生腹筋膜室綜合征（1C 級）高風險因素的情況

MOF is the factor mainly associated with mortality in acute pancreatitis (AP) especially when infected necrosis [33,34,35,36,37] is present. As in many other conditions, secondary IAH/ACS may aggravate MOF in a vicious circle [38]. IAH/ACS should be prevented and treated as far as it is possible with non-surgical measures. Surgical decompression is the last but effective tool; it should not be delayed in case of ACS [4, 39]. Pancreatic necrosis may become infected after the first week [40]. The presence of organ failure, early bacteremia, and the extent of pancreatic necrosis are factors associated with infection [40]. Surgical necrosectomy should be considered when more conservative management as percutaneous drainage fails [41]. In case of necrosectomy, OA may be considered, but it is not mandatory. It should be considered only if risks for IAH/ACS exist.
MOF 是急性胰腺炎（acute pancreatitis， AP）死亡率的主要因素，尤其是當存在感染性壞死時[33,34,35,36,37]。 與許多其他疾病一樣，繼發性 IAH/ACS 可能會惡性循環加重 MOF[38]。應盡可能通過非手術措施預防和治療 IAH/ACS。手術減壓是最後但有效的工具;在 ACS 的情況下不應延遲[4,39]。 胰腺壞死可能在第 1 周后被感染[40]。器官衰竭、早期菌血症和胰腺壞死程度是與感染相關的因素[40]。當經皮引流失敗時，應考慮手術壞死切除術[41]。在壞死切除術的情況下，可以考慮 OA，但這不是強制性的。只有在存在 IAH/ACS 風險時才應考慮它。

Management  管理

Trauma and non-trauma patients
創傷和非創傷患者

ICU management  ICU 管理

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The role of Damage Control Resuscitation in OA management is fundamental and may influence outcome (Grade 2A)
損害控制復甦在 OA 管理中的作用至關重要，可能會影響結果（2A 級）

A multidisciplinary approach is encouraged, especially during the patient’s ICU admission (Grade 2A)
鼓勵採用多學科方法，尤其是在患者入住 ICU（2A 級）期間

Intra-abdominal pressure measurement is essential in critically ill patients at risk for IAH/ACS (Grade 1B)
腹內壓測量對於有 IAH/ACS 風險的危重患者（1B 級）至關重要

Physiologic optimization is one of the determinants of early abdominal closure (Grade 2A)
生理優化是早期腹部閉合的決定因素之一（2A 級）

Inotropes and vasopressors administration should be tailored to patient’s condition and performed surgical interventions (Grade 1A)
正性肌力藥和血管加壓藥的給葯應根據患者的情況進行定製並進行手術干預（1A 級）

Fluid balance should be carefully scrutinized (Grade 2A)
應仔細檢查體液平衡（2A 級）

High attention to body temperature should be given, avoiding hypothermia (Grade 2A)
應高度注意體溫，避免體溫過低（2A 級）

In presence of coagulopathy or high risk of bleeding the negative pressure should be down regulated balancing the therapeutic necessity of negative pressure and the hemorrhage risk (Grade 2B).
在存在凝血障礙或高出血風險的情況下，應下調負壓，平衡負壓的治療必要性和出血風險（2B 級）。

The initial management is fundamental. DCR is part of DCM utilized in treating severely injured and severely physiologically deranged patients. It passes through some cornerstone actions as volume resuscitation, reversal of coagulopathy, correction of acidosis, and all the other pertinent resuscitative measures aiming to restore the normal physiology. The fluid status, nutrition, and respiratory mechanics should also be kept into consideration in managing OA. In fact the possibility of recurrent ACS with its related high mortality is to be posed into consideration [42,43,44].
初始管理是基礎。DCR 是 DCM 的一部分，用於治療重傷和嚴重生理紊亂患者。它通過一些基石作用，如容量復甦、逆轉凝血病、糾正酸中毒以及所有其他旨在恢復正常生理機能的相關復甦措施。在治療 OA 時，還應考慮體液狀態、營養和呼吸力學。事實上，ACS 復發的可能性及其相關的高死亡率也應考慮在內[42,43,44]。

Abdominal pressure should be measured in all patients at risk of developing IAH/ACS; in fact, it has been demonstrated that clinical examination is inaccurate in diagnosing IAH/ACS [45]. As a general principle, it should be measured every 12 h and every 4–6 h once ACS/IAH has been detected or if organ failure happens.
應對所有有發生 IAH/ACS 風險的患者測量腹壓;事實上，臨床檢查在診斷 IAH/ACS 時並不準確[45]。作為一般原則，一旦檢測到 ACS/IAH 或發生器官衰竭，應每 12 小時測量一次，每 4-6 小時測量一次。

Physiology optimization is necessary to allow early abdominal closure. In fact, prolonged OA may delay extubation, increase the risk for EAF and frozen abdomen, and increase complications [46].
生理優化對於早期腹部閉合是必要的。事實上，長期 OA 可能會延遲拔管，增加電弧爐和腹部周炎的風險，並增加併發症[46]。

Multidisciplinary collaboration with all teams managing the patient is required for optimal care of OA patients.
為了對 OA 患者進行最佳護理，需要與所有管理患者的團隊進行多學科合作。

The real extent of heat loss in OA and a temporary abdominal dressing cannot be quantified. It is well known that patient physiology is impaired by hypothermia and its related hypo-perfusion effects such as heart function depression, reduced oxygen delivery, coagulation cascade alteration, and acidosis.
骨關節炎和臨時腹部敷料的熱損失的真實程度無法量化。眾所周知，患者生理機能因體溫過低及其相關的低灌注效應（如心功能抑制、氧氣輸送減少、凝血級聯改變和酸中毒）而受損。

In trauma patients, the “lethal triad” should be rapidly interrupted [47,48,49,50,51,52,53].
在創傷患者中，應迅速中斷“致死性三聯征”[47,48,49,50,51,52,53]。

It is well known that mortality increases in trauma patients with significant core-body temperature drop [54].
眾所周知，核心體溫顯著下降的創傷患者死亡率會增加[54]。

Commercial NPWT systems significantly reduce heat loss but the non-commercial ones still maintain a reduced heat isolation capacity. For this reason, the heat loss control is of paramount importance especially in those settings where non-commercial systems are utilized.
商用 NPWT 系統顯著減少了熱損失，但非商用 NPWT 系統仍保持較低的隔熱能力。因此，熱損失控制至關重要，尤其是在使用非商業系統的環境中。

During ICU stay, it is important to ensure analgesia over hypnosis and consider multimodal analgesia to reduce opioid infusion, trying to keep the patient “awake” but well adapted to mechanical ventilation. Moreover, protective mechanical ventilation strategies should be adopted.
在 ICU 住院期間，重要的是要確保鎮痛而不是催眠，並考慮多模式鎮痛以減少阿片類藥物輸注，盡量讓患者保持“清醒”，但能很好地適應機械通氣。此外，應採用保護性機械通氣策略。

Fluid balance is important as well in OA management and should be carefully scrutinized to avoid over- or under- resuscitation. Careful monitoring and maintenance of adequate urinary output could help in evaluating adequacy of resuscitation effects. Continuous monitoring of cardiac output (CO), targeting at low/normal values, is essential to avoid fluid overload and vasopressor abuse. If increasing vasopressors induce low CO, and fluid responsiveness is transient, consider to target treatments (included inotropes) to the best compromise between MAP, CO, and fluid amount. High-rate maintenance fluid infusions should be avoided. As a counterpart, whenever possible, frequent, small-volume fluid boluses should be preferred. Hypertonic crystalloid and colloid-based resuscitation seem to decrease the risk of iatrogenic, induce resuscitation, and increase IAP [55]. Daily patient weights may help in evaluating fluid retention.
體液平衡在 OA 管理中也很重要，應仔細檢查以避免復甦過度或不足。仔細監測和維持充足的尿量有助於評估復甦效果的充分性。持續監測心輸出量 （CO），以低/正常值為目標，對於避免液體超負荷和血管加壓藥濫用至關重要。如果增加血管加壓藥誘導低 CO，並且液體反應性是短暫的，請考慮靶向治療（包括正性肌力藥），以在 MAP、CO 和液體量之間做出最佳折衷。應避免高速率維持液輸注。作為對應物，應盡可能優先選擇頻繁、小體積的液體推注。高滲晶體和膠體復甦似乎可降低醫源性復甦風險，誘導復甦，並增加 IAP[55]。患者每日體重可能有助於評估體液瀦留。

Inotrope infusion should be balanced keeping in mind the patients’ condition, the performed surgical procedures, and the necessity to prevent further complications due to their overuse [56, 57].
正性肌力藥輸注應平衡，同時考慮到患者的病情、所進行的外科手術以及防止過度使用導致進一步併發症的必要性[56,57]。

Volumetric-based monitoring technologies can be very useful in hemodynamic evaluation during DCR phases in critically ill patients. In fact, the elevated intra-abdominal and intra-thoracic pressure can impair the real value of the measurements obtained with traditional pressure-based parameters such as pulmonary artery occlusion pressure and central venous pressure [58,59,60]. The alteration of these parameters can potentially lead to wrong decisions as regards the correct fluid status and as a consequence the necessary amount of fluid to be administered. This balance is essential also to optimize the surgical success of primary fascial closure [12, 61, 62].
基於體積的監測技術在危重患者 DCR 階段的血流動力學評估中非常有用。事實上，腹內壓和胸腔內壓升高會損害使用傳統基於壓力的參數（如肺動脈閉塞壓和中心靜脈壓）獲得的測量值的實際值[58,59,60]。 這些參數的改變可能會導致對正確的液體狀態做出錯誤的決定，從而導致需要施用的液體量。這種平衡對於優化初次筋膜閉合術的手術成功率也至關重要[12,61,62]。

Technique for temporary abdominal closure
臨時腹部閉合技術

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Negative pressure wound therapy with continuous fascial traction should be suggested as the preferred technique for temporary abdominal closure (Grade 2B).
應建議將持續筋膜牽引的負壓傷口治療作為臨時腹部閉合術（2B 級）的首選技術。

Temporary abdominal closure without negative pressure (e.g. Bogota bag) can be applied in low resource settings accepting a lower delayed fascial closure rate and higher intestinal fistula rate (Grade 2A).
無負壓的臨時腹部閉合術（例如 波哥大袋）可以應用於資源匱乏的環境，接受較低的延遲筋膜閉合率和較高的腸瘺率（2A 級）。

No definitive recommendations can be given about temporary abdominal closure with NPWT in combination with fluid instillation even if it seems to improve results in trauma patients (Not graded).
無法給出關於 NPWT 聯合輸液的臨時腹部閉合的明確建議，即使它似乎可以改善創傷患者的結果（未分級）。

Several strategies to maintain the OA have been described. They result in different delayed fascial closure rate and EAF risk. In general, negative pressure associated to a dynamic component (mesh-mediated fascial traction or dynamic sutures) allows to reach the best results in terms of delayed fascial closure, but dynamic sutures result more often in fistula [3]. Negative pressure without a dynamic component (Barker’s VAC or commercial products) results in a moderate delayed fascial closure rate and a fistula rate similar to mesh closure without negative pressure [3].
已經描述了維持開放獲取的幾種策略。它們導致不同的延遲筋膜閉合率和電弧爐風險。一般來說，與動態成分（網片介導的筋膜牽引或動態縫合）相關的負壓可以在延遲筋膜閉合方面達到最佳效果，但動態縫合更常見於瘺管[3]。無動態成分的負壓（Barker's VAC 或商業產品）會導致中度延遲筋膜閉合率和與無負壓網片閉合相似的瘺管率[3]。

Recent data from the International Register of Open Abdomen (IROA study) showed that different techniques of OA resulted in different results according to the treated disease [63] (trauma and severe peritonitis) and if treated with or without negative pressure in terms of abdominal closure and mortality rate. The results favored the non-negative pressure systems in trauma and negative pressure temporary closure in severe peritonitis patients [46]. Also, recent contradictory data from a single-center RCT showed that NPWT and fluid instillation seemed to improve outcomes in trauma patients in terms of early and primary closure [64].
國際開腹登記冊（IROA 研究）的最新數據表明，根據治療的疾病[63]（外傷和嚴重腹膜炎）以及是否在腹閉合和死亡率方面，不同的 OA 技術會導致不同的結果。結果有利於非負壓系統用於創傷和負壓暫時閉合重症腹膜炎患者[46]。此外，最近一項單中心 RCT 的相互矛盾的數據顯示，NPWT 和輸液似乎能改善創傷患者早期和初次閉合的結局[64]。

Another important issue in OA management is the necessity to balance the antimicrobial therapy in relation to positive cultures of intra-abdominal fluids. Two options are generally followed without any strong literature evidence: treating all the cultured organisms (with high proportions of staphylococci, candida, and MDR Gram-negative bacilli including Pseudomonas) or a “wait and see” strategy. WSES suggests to follow guidelines for intra-abdominal infections [65].
OA 管理的另一個重要問題是必須平衡與腹腔內液陽性培養相關的抗菌治療。在沒有任何強有力的文獻證據的情況下，通常遵循兩種選擇：治療所有培養的微生物（葡萄球菌、念珠菌和耐多藥革蘭氏陰性桿菌（包括假單胞菌 ）比例很高）或“觀望”策略。WSES 建議遵循腹腔內感染指南[65]。

Re-exploration before definitive closure
最終關閉前的重新探索

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Open abdomen re-exploration should be conducted no later than 24-48 hours after the index and any subsequent operation, with the duration from the previous operation shortening with increasing degrees of patient non-improvement and hemodynamic instability (Grade 1C).
開腹重新探查應在指數和任何後續手術后 24-48 小時內進行，隨著患者不改善和血流動力學不穩定程度的增加，上次手術的持續時間會縮短（1C 級）。

The abdomen should be maintained open if requirements for on-going resuscitation and/or the source of contamination persists, if a deferred intestinal anastomosis is needed, if there is the necessity for a planned second look for ischemic intestine and lastly if there are concerns about abdominal compartment syndrome development (Grade 2B).
如果需要持續復甦和/或污染源仍然存在，如果需要延遲腸吻合術，如果有必要計劃對缺血性腸道進行第二次檢查，最後，如果擔心腹筋膜室綜合征的發展（2B 級），則應保持腹部開放。

Indications to re-explore an OA may vary between trauma and non-trauma patients. In general, the patient’s non-improvement possibly is due to an intra-abdominal reason. No definitive data regarding the timing of re-operation in OA patients exist [6, 66]. It is generally recommended that OA patients should be re-explored 24–72 h after the initial or any subsequent surgical intervention [2, 67, 68]. Some data regarding trauma patients showed that the time of re-exploration reduces the primary fascial closure rate of 1.1% for each hour after the first 24 h after the index operation [69]. Moreover, increased complication rate was observed in patients having the first re-operation after 48 h [3, 69].
重新探索 OA 的指徵可能因創傷患者和非創傷患者而異。一般來說，患者的不好轉可能是由於腹腔內原因。目前尚無關於 OA 患者再次手術時間的明確數據[6,66]。 一般建議 OA 患者在初始手術或後續手術干預后 24-72 小時重新探索[2,67,68]。 一些關於創傷患者的數據顯示，重新探查的時間使指數手術后前 24 小時每小時的原發性筋膜閉合率降低 1.1%[69]。此外，在 48 小時後首次再次手術的患者中觀察到併發症發生率增加 [3， 69]。

In non-trauma patients, the indication to re-explore the abdominal cavity are less definite and usually are due to the necessity to continue DCM, to the impossibility to definitively control the source of infection or to the necessity to re-asses the bowel vascularization or lastly, to concerns regarding the possibility of ACS [2, 3, 20, 70].
在非創傷患者中，重新探查腹腔的指徵不太明確，通常是由於需要繼續 DCM，無法明確控制感染源或需要重新評估腸血管化，或者最後是擔心 ACS 的可能性[2,3,20,70]。

Even though there is some evidence that OA may be justified in severely injured or physiologically deranged patients with the aim to manipulate the systemic immune response and ameliorate the bio mediator burden, no definitive statement can be made [3, 71,72,73,74,75].
儘管有一些證據表明，OA 可能適用於重傷或生理紊亂患者，目的是縱全身免疫應答並減輕生物介質負擔，但尚無明確的說法[3,71,72,73,74,75]。

Nutritional support  營養支援

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Open abdomen patients are in a hyper-metabolic condition; immediate and adequate nutritional support is mandatory (Grade 1C).
開腹患者處於代謝亢進狀態;立即和充足的營養支援是強制性的（1C 級）。

Open abdomen techniques result in a significant nitrogen loss that must be replaced with a balanced nutrition regimen (Grade 1C).
開腹技術會導致大量氮流失，必須用均衡的營養方案（1C 級）代替。

Early enteral nutrition should be started as soon as possible in the presence of viable and functional gastrointestinal tract (Grade 1C).
在存在存活且功能齊全的胃腸道（1C 級）的情況下，應儘快開始早期腸內營養。

Enteral nutrition should be delayed in patients with an intestinal tract in discontinuity (temporarily closed loops ), or in situations of a high output fistula with no possibility to obtain feeding access distal to the fistula or with signs of intestinal obstruction (Grade 2C)
對於腸道不連續（暫時閉環）的患者，或高輸出量瘺管無法獲得瘺管遠端的進食通道或有腸梗阻跡象（2C 級）的患者，應延遲腸內營養

Oral feeding is not contraindicated and should be used where possible (Grade 2C).
經口餵養不是禁忌症，應盡可能使用（2C 級）。

Malnutrition is a risk factor for poor outcomes [76]. Critically ill patients with OA are in a hyper-catabolic state with an estimated nitrogen loss of almost 2 g/L of abdominal fluid output. Abdominal fluid evacuation is to be measured in order to adjust nutritional integrations [77]. In case of EAF, nitrogen loss greatly increases. Parenteral nutrition should be started as soon as possible. Once the resuscitation is almost complete and the GI tract is viable, enteral nutrition (EN) should be started. Relative contraindication to EN is a viable bowel shorter than 75 cm [78].
營養不良是不良結局的危險因素[76]。危重的 OA 患者處於高分解代謝狀態，估計腹腔液體輸出量的氮損失接近 2 g/L。測量腹腔液體排出量以調整營養整合[77]。在電弧爐的情況下，氮損失大大增加。應儘快開始腸外營養。一旦復甦幾乎完成並且胃腸道有活力，就應該開始腸內營養 （EN）。EN 的相對禁忌證是活腸短於 75cm [78]。

Polymeric formula supplying a daily intake of 20- to 30-kcal/kg non-protein calories with 1.5- to 2.5-g/kg proteins is usually sufficient to maintain a positive nitrogen balance.
聚合物配方每天提供 20 至 30 大卡/公斤非蛋白質熱量和 1.5 至 2.5 克/公斤蛋白質，通常足以維持正氮平衡。

EN starting within the first 24–48 h improves wound healing and fascial closure rate, decreases catabolism, reduces pneumonia and fistula rate, preserves GI tract integrity, and finally reduces complications, length of hospital stay, and costs [79,80,81]. Compared to prolonged total parenteral nutrition, early EN decreases septic complications especially in abdominal trauma and traumatic brain injuries [3, 79, 82, 83].
在最初 24-48 小時內開始的 EN 可改善傷口癒合和筋膜閉合率，減少分解代謝，降低肺炎和瘺管發生率，保持胃腸道完整性，最終減少併發症、住院時間和費用[79,80,81]。 與長期全腸外營養相比，早期 EN 可減少膿毒性併發症，尤其是在腹部創傷和創傷性腦損傷中[3,79,82,83]。

Patient mobilization  患者動員

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No recommendations can be made about early mobilization of patients with open abdomen (Not graded).
無法就開腹患者的早期活動提出建議（未分級）。

No definite evidence exists regarding the optimal timing for mobilization of patients with OA [84]. Prolonged bed rest is associated with a significant increase in morbidity. Mobilization occurring within the first 2-5 days of ICU admission is defined “early” [85] and it is associated with positive effects on outcomes [86,87,88,89,90].
關於 OA 患者活動的最佳時機，尚無明確證據[84]。長時間臥床與發病率顯著增加有關。入住 ICU 后 2-5 日內進行的活動被定義為“早期”[85]，其對結局的積極影響相關[86,87,88,89,90]。

OA patients with NPWT may be “early” mobilized by active or passive transfer thanks to the provisional abdominal wall function supplied by NPWT systems [3].
由於 NPWT 系統提供的臨時腹壁功能，NPWT 的 OA 患者可以通過主動或被動轉移“早期”活動[3]。

Definitive closure  最終關閉

Open abdomen definitive closure
開腹最終閉合

Fascia and/or abdomen should be definitively closed as soon as possible (Grade 1C).
筋膜和/或腹部應儘快徹底閉合（1C 級）。

Early fascial and/or abdominal definitive closure should be the strategy for management of the open abdomen once any requirements for on-going resuscitation have ceased, the source control has been definitively reached, no concern regarding intestinal viability persist, no further surgical re-exploration is needed and there are no concerns for abdominal compartment syndrome (Grade 1B).
一旦停止了持續復甦的任何要求，明確達到源頭控制，對腸道活力的擔憂持續存在，不需要進一步的手術重新探查，並且沒有對腹筋膜室綜合征（1B 級）的擔憂，早期筋膜和/或腹部根治性閉合應該是開放腹部的管理策略。

The priority in order to reduce mortality, complications, and length of stay linked to the OA should be the early definitive abdominal closure [10, 91, 92]. Major factors influencing early definitive closure are postoperative ICU management and the TAC technique [93]. Early fascial closure is commonly defined as occurring within 4–7 days from the index operation [21]. In contrast to trauma patients, those affected by abdominal sepsis usually experience a lower rate of early fascial closure [94] even though continuous fascial traction seems to increase this rate [95]. Fascial closure should be attempted as soon as the source of infection is controlled [96].
為了降低與 OA 相關的死亡率、併發症和住院時間，應優先考慮早期明確的腹部封堵術[10,91,92]。 影響早期最終關閉的主要因素是術后 ICU 管理和 TAC 技術[93]。早期筋膜閉合通常定義為在指數手術后 4-7 日內發生[21]。與創傷患者相比，腹部膿毒症患者的早期筋膜閉合率通常較低[94]，儘管持續的筋膜牽引似乎會增加這一率[95]。一旦感染源得到控制，應立即嘗試筋膜閉合術[96]。

Solutions to definitively close an open abdomen
徹底關閉開放腹部的解決方案

In case of prolonged OA, fascia retraction and large abdominal wall defects requiring complex abdominal wall reconstruction may occur. In contaminated fields, the complication risk in abdominal wall definitive closure is increased [92, 97,98,99].
在長期骨關節炎的情況下，可能會出現筋膜回縮和需要複雜腹壁重建的大腹壁缺損。在受污染的田地中，腹壁根治性閉合的併發症風險增加[92,97,98,99]。

Techniques used to definitively close the abdomen are principally divided into non-mesh and mesh mediated.
用於明確閉合腹部的技術主要分為非網狀和網狀介導。

Non-mesh-mediated closure techniques
非網片介導的閉合技術

ᅟ

Primary fascia closure is the ideal solution to restore the abdominal closure (2A).
初級筋膜閉合術是恢復腹部閉合術 （2A） 的理想解決方案。

Component separation is an effective technique; however it should not be used for fascial temporary closure. It should be considered only for definitive closure (Grade 2C).
組分分離是一種有效的技術;但是，它不應用於筋膜臨時閉合。它應該只考慮用於最終關閉（2C 級）。

Planned ventral hernia (skin graft or skin closure only) remains an option for the complicated open abdomen (i.e. in the presence of entero-atmospheric fistula or in cases with a protracted open abdomen due to underlying diseases) or in those settings where no other alternatives are viable (Grade 2C)
計劃性腹疝（僅皮膚移植或皮膚閉合）仍然是複雜開腹症（即存在腸大氣瘺或由於基礎疾病導致開腹延長的情況下）或沒有其他替代方案可行的環境（2C 級）的一種選擇

Abdominal component separation should be considered an elective procedure for ventral hernia repair [100]. In fact, it should not be used during the OA management but reserved to the definitive closure interventions. At a delayed time point, very good results reaching up to 75% of fascial closure rate have been reported [101]. The separation of components can be approached anteriorly or posteriorly [102, 103].
腹疝修補術應選擇性手術[100]。事實上，它不應該在 OA 管理期間使用，而應該保留給最終的關閉干預措施。在延遲的時間點，已經報導了非常好的結果，達到筋膜閉合率的 75%[101]。組分的分離可以從前或後進行[102,103]。

Planned ventral hernia represents a valid alternative to cover abdominal viscera and to prevent EAF. In fact, in cases of persistent contamination, several comorbidities or in severely ill patients, with or without sufficient skin to cover the abdominal wall defect, delaying the eventual synthetic prosthetic reconstruction may be a safer option. The decision either to close the skin or to perform vascularized flaps, pedicled flaps in small-/mid-sized defects, or free flaps such as tensor fasciae latae for extensive thoraco-abdominal defects is usually taken, considering the wound conditions, the dimension of the skin defect, and the center facilities [13].
計劃性腹疝是覆蓋腹部內臟和預防 EAF 的有效替代方案。事實上，在持續污染、多種合併症或重症患者的情況下，無論是否有足夠的皮膚覆蓋腹壁缺損，延遲最終的合成假體重建可能是一個更安全的選擇。通常會考慮傷口狀況、皮膚缺損的尺寸和中心設施，決定閉合皮膚或進行血管化皮瓣、中小缺損的帶蒂皮瓣或遊離皮瓣（如闊筋膜張肌）治療廣泛的胸腹部缺損[13]。

Mesh-mediated closure techniques
網狀介導的閉合技術

ᅟ

The use of synthetic mesh (polypropylene, polytetrafluoruroethylene (PTFE) and polyester products) as a fascial bridge should not be recommended in definitive closure interventions after open abdomen and should be placed only in patients without other alternatives (Grade 1B).
在開腹后的最終閉合干預中，不應推薦使用合成網（聚丙烯、聚四氟尿乙烯 （PTFE） 和聚酯產品）作為筋膜橋，而應僅用於沒有其他替代品的患者（1B 級）。

Biologic meshes are reliable for definitive abdominal wall reconstruction in the presence of a large wall defect, bacterial contamination, comorbidities and difficult wound healing (Grade 2B).
在存在大壁缺損、細菌污染、合併症和傷口癒合困難（2B 級）的情況下，生物網對於最終腹壁重建是可靠的。

Non–cross-linked biologic meshes seem to be preferred in sublay position when the linea alba can be reconstructed. (Grade 2B).
當白線可以重建時，非交聯生物網格似乎是子層位置的首選。（2B 級）。

Cross-linked biologic meshes in fascial-bridge position (no linea alba closure) maybe associated with less ventral hernia recurrence (Grade 2B).
筋橋位置的交聯生物網片（無白線閉合）可能與較少的腹疝復發（2B 級）相關。

NPWT can be used in combination with biologic mesh to facilitate granulation and skin closure (Grade 2B).
NPWT 可與生物網結合使用，以促進肉芽形成和皮膚閉合（2B 級）。

Several data exist regarding the abdominal wall closure after OA [104, 105]. Non-absorbable synthetic materials (i.e., polypropylene mesh) in a bridging position (i.e., no linea alba closure), where no native tissue protect viscera, may induce several local side effects (adhesions, erosions, and fistula formation) [106,107,108,109,110,111]. Synthetic meshes in contaminated fields are not recommended by guidelines in emergency abdominal wall reconstruction [112].
關於 OA 后腹壁閉合的數項數據[104,105]。 不可吸收的合成材料（即聚丙烯網）處於橋接位置（即無白線閉合），沒有天然組織保護內臟，可能會引起幾種局部副作用（粘連、糜爛和瘺管形成）[106,107,108,109,110,111]。 緊急腹壁重建指南不建議在受污染的田地中使用合成網[112]。

Biological prostheses (BP) were designed to perform as permanent surgical prosthesis in abdominal wall repair, minimizing mesh-related complications. Non-cross-linked biologic mesh is easily integrated, with reduced fibrotic reaction and lesser infection and removal rate [113].
生物假體 （BP） 旨在作為腹壁修復中的永久性手術假體，最大限度地減少與網片相關的併發症。非交聯生物網易於整合，減少纖維化反應，感染和去除率更低[113]。

BP can be used as a bridge for large abdominal wall defects [114,115,116,117,118,119,120,121,122,123,124,125,126,127]; however, the long-term outcome of a bridging non-cross-linked BP is laxity of the abdominal wall and a high rate of recurrent ventral hernia [113]. As a consequence, non-cross-linked BP should be used in a sublay position (i.e., with linea alba closure) and cross-linked ones should be preferred when the fascial bridge is needed [128,129,130]. BP could also tolerate adjunctive NPWT to facilitate wound healing, granulation, and skin closure [131,132,133].
BP 可作為大腹壁缺損的橋接[114,115,116,117,118,119,120,121,122,123,124,125,126,127]; 然而，橋接性非交聯血壓的長期結局是腹壁鬆弛和復發性腹疝發生率高[113]。因此，非交聯 BP 應用於潛層位置（即白線閉合），當需要筋膜橋時，應首選交聯 BP[128,129,130]。BP 還可以耐受輔助 NPWT 以促進傷口癒合、肉芽形成和皮膚閉合[131,132,133]。

Complication management  併發症處理

Preemptive measures to prevent entero-atmospheric fistula and frozen abdomen are imperative (i.e. early abdominal wall closure, bowel coverage with plastic sheets, omentum or skin, no direct application of synthetic prosthesis over bowel loops, no direct application of NPWT on the viscera and deep burying of intestinal anastomoses under bowel loops) (Grade 1C).
預防腸大氣瘺和腹部冰凍的先發制人措施勢在必行（即早期腹壁閉合、用塑膠布、網膜或皮膚覆蓋腸道、不直接在腸袢上應用合成假體、不直接在內臟上應用 NPWT 以及將腸吻合口深埋在腸袢下）（1C 級）。

Entero-atmospheric fistula management should be tailored according to patient condition, fistula output and position and anatomical features (Grade 1C).
腸大氣瘺管治療應根據患者情況、瘺管輸出量和位置以及解剖特徵（1C 級）進行定製。

In the presence of entero-atmospheric fistula the caloric intake and protein demands are increased; the nitrogen balance should be evaluated and corrected and protein supplemented (Grade 1C).
在存在腸大氣瘺的情況下，熱量攝入和蛋白質需求增加;應評估和糾正氮平衡並補充蛋白質（1C 級）。

Nutrition should be reviewed and optimized upon recognition of entero-atmospheric fistula (Grade 1C).
在發現腸大氣瘺（1C 級）后，應審查和優化營養。

Entero-atmospheric fistula effluent isolation is essential for proper wound healing. Separating the wound into different compartments to facilitate the collection of fistula output is of paramount importance (Grade 2A).
腸大氣瘺管流出物隔離對於傷口的正常癒合至關重要。將傷口分成不同的隔室以方便收集瘺管輸出量至關重要（2A 級）。

In the presence of entero-atmospheric fistula in open abdomen, negative pressure wound therapy makes effluent isolation feasible and wound healing achievable (Grade 2A).
在開放腹部存在腸大氣瘺的情況下，負壓傷口治療使流出物隔離可行，傷口癒合可行（2A 級）。

Definitive management of entero-atmospheric fistula should be delayed to after the patient has recovered and the wound completely healed (Grade 1C).
腸大氣瘺的根治性治療應推遲到患者康復和傷口完全癒合后（1C 級）。

Risk factors for frozen abdomen and EAF in OA are delayed abdominal closure, non-protection of bowel loops during OA, presence of bowel injury and repairs or anastomosis, colon resection during DCS, the large fluid resuscitation volume (> 5 L/24 h), the presence of intra-abdominal sepsis/abscess, and the use of polypropylene mesh directly over the bowel [66, 134,135,136,137,138,139]. All risk factors often linked as a “vicious cycle” may contribute to the development of frozen abdomen and EAF. Complications increase mortality, length of stays, and costs [140]. Some preemptive measures to prevent this complication are early abdominal wall closure, bowel coverage with plastic sheets, omentum or skin, no direct application of synthetic prosthesis on bowel, no direct application of NPWT on the viscera, and intestinal anastomosis deep buring under bowel loops [73, 141, 142]. EAF can be classified based on the output: low (< 200 mL/day), moderate (200–500 mL/day), and high (> 500 mL/day) [143]; usually, the greater the output, the higher the difficulty in managing the EAF [144, 145]. In EAF management, the definition of characteristics and anatomical features are extremely important in planning the best treatment [146]. The intra-abdominal situation can be classified according to the WSACS classification (Fig. 2) [147]. Nutrition plays a pivotal role in EAF management. While early EN improves outcomes [81, 148,149,150,151], it may increase EAF output even if it seems not to impair final outcomes [152, 153]. Spontaneous closure of an EAF is quite impossible; for this reason, the treatment should try to isolate the fistula effluent to allow granulation tissue formation around [3]. Many different effective techniques have been described with no definitive results [138, 144, 145, 154,155,156,157]. NPWT in all its variants is effective and the most accepted technique [3]. It often allows EAF isolation, adequate wound management, re-epithelization, and eventual subsequent skin graft with the final conversion of the EAF into a sort of enterostomy. EAF definitive treatment (i.e., fistula closure and abdominal wall reconstruction) should be postponed at least of 6 months and only after the patient and the wound healed completely [3].
OA 中腹部冰周和 EAF 的危險因素包括腹部閉合延遲、OA 期間腸袢無保護、存在腸損傷和修復或吻合、DCS 期間結腸切除術、液體復甦量大（> 5 L/24 h）、存在腹腔內膿毒症/膿腫以及直接在腸道上使用聚丙烯網[66， 134,135,136,137,138,139]。 所有通常與「惡性循環」相關的風險因素都可能導致腹部周布和電弧爐的發展。併發症會增加死亡率、住院時間和費用[140]。預防這種併發症的一些先發制人的措施包括早期腹壁閉合、用塑膠片、大網膜或皮膚覆蓋腸道、不直接在腸道上應用合成假體、不在內臟上直接應用 NPWT，以及腸吻合口在腸袢下深埋[73,141,142]。 電弧爐可根據輸出量分為：低（< 200 mL/天）、中度（200–500 mL/天）和高（> 500 mL/天）[143];通常，產量越大，電弧爐的管理難度就越大[144,145]。 在電弧爐治療中，特徵和解剖特徵的定義對於規劃最佳治療極為重要[146]。腹腔內情況可根據 WSACS 分類進行分類（圖 2）[147]。營養在電弧爐管理中起著舉足輕重的作用。雖然早期 EN 可改善結局[81,148,149,150,151]，但即使它似乎不會影響最終結局，它也可能增加電弧爐產量[152,153]。 電弧爐的自發關閉是完全不可能的;因此，治療應嘗試分離瘺管流出物，以允許在周圍形成肉芽組織[3]。已經描述了許多不同的有效技術，但沒有明確的結果[138,144,145,154,155,156,157]。NPWT 的所有變體都是有效的，也是最被接受的技術[3]。它通常允許 EAF 隔離、充分的傷口管理、再上皮化以及最終隨後的皮膚移植，最終將 EAF 轉化為一種腸造口術。電弧內避孕藥根治性治療（即瘺管閉合術和腹壁重建術）應至少推遲 6 個月，且僅在患者和傷口完全癒合后[3]。

Fig. 2  圖2

Open Abdomen classification according to Björck et al. [147]
根據 Björck 等[147]的開腹分類

Conclusions  結論

Open abdomen in trauma and non-trauma patients is dramatically effective in facing the deranged physiology of severe injuries or critical illness when no other perceived options exist. Its use remains very controversial and is a matter of great debate, as it is a non-anatomic situation with potential severe side effects and increased resource utilization. Moreover, the lack of definitive data demands carefully tailoring its use to each single patient, taking care to not overuse it. Abdominal closure attempt should be done as soon as the patient can physiologically tolerate it. All possible precautions should be implemented to minimize complications. Results improve proportionate to the clinicians’ team’s experience with the intricacies of open abdomen management.
在沒有其他感知選擇的情況下，創傷和非創傷患者的開腹在面對嚴重傷害或危重疾病的錯亂生理機能方面非常有效。它的使用仍然非常有爭議，並且是一個很大爭論的問題，因為它是一種非解剖學情況，具有潛在的嚴重副作用和資源利用率的增加。此外，由於缺乏明確的數據，需要根據每位患者仔細調整其使用，注意不要過度使用。一旦患者在生理上可以耐受，就應儘快嘗試進行腹部閉合。應採取所有可能的預防措施，以盡量減少併發症。結果的改善與臨床醫生團隊對開腹治療複雜性的經驗成正比。