New Surgical Technique Proved Dangerous to Patients

American Family Physician,  Nov 1, 1999  by Anne D. Walling

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For many conditions, vertical abdominal incisions provide the best operative access, but up to 3 percent of these wounds subsequently undergo dehiscence. Dehiscence and other incisional complications are major causes of morbidity and, occasionally, mortality following abdominal surgery. The continuous double-loop closure (CDLC) technique was developed to resist dehiscence even under conditions of high intra-abdominal pressure and to enhance healing by ensuring that wound edges remain approximated. Niggebrugge and colleagues evaluated this new technique by comparing it with the continuous running suture (CRS), a closure technique commonly used in abdominal surgery.

A randomized trial was conducted with all patients over 15 years of age who were undergoing abdominal surgery at a Dutch hospital between 1994 and 1997. The only exclusions were patients who had undergone laparotomy within three months of the index surgery. Patients were stratified by the risk of infection, as this is a major factor in dehiscence, then randomly assigned to either the CDLC or the CRS technique at the time of closure during surgery. The outcomes measured included fascial disruption, wound infection, pulmonary complications, wound pain and use of analgesic medications, postoperative gastric or bowel stasis, length of hospital stay and any other recorded morbidity related to surgery.

The 204 patients receiving the CRS technique were comparable in all important variables to the 186 patients treated with the CDLC technique. The only exception was that a higher percentage of the CDLC patients were emergency laparotomy cases (33 percent compared with 23 percent). The rates of wound infection and dehiscence were higher in CDLC patients (9.1 percent versus 6.4 percent and 3.8 percent versus 2.0 percent, respectively), but these differences were not statistically significant. The rate of pulmonary complications was notably higher in CDLC patients (17.2 percent compared with 5.4 percent). The death rate within 30 days of surgery was also greater in CDLC patients for elective and emergency surgeries. The CDLC patients reported less pain at days 2, 4 and 6 postoperatively, but by the eighth day, pain scores between the groups were comparable. The two groups did not differ in length of hospital stay. Because an interim analysis of data showed the important difference in pulmonary complications and mortality, the study was ended prematurely.

The authors conclude that the CDLC technique did not offer increased protection against wound dehiscence but increased the risk of postoperative pulmonary complications and death. They speculate that the increased morbidity and mortality associated with this technique are related to decreased compliance of the abdominal wall and increased intra-abdominal pressure. They cannot recommend use of the CDLC technique.

Niggebrugge AH, et al. Influence of abdominal-wound closure technique on complications after surgery: a randomised study. Lancet May 8, 1999;353:1563-7.

editor's note: Although a relatively small proportion of family physicians performs laparotomies, most are involved in the postoperative care of patients. Alerting surgical colleagues to this study may avoid complications for patients. The study also reminds us to look beyond the belly in post-laparotomy care. A tight surgical wound may cause significant thoracic compromise. In many patients, the balance between establishing optimal conditions for sound wound healing and avoiding compression of abdominal contents is much more precarious than is generally realized.- a.d.w.

Exclusion Criteria for Outpatient Treatment of Acute DVT
General
Hospital admission for reasons other than DVT*
Pregnancy*
Allergy to heparin
Potential high complication risk
Related to recurrent clotting or bleeding
Adults [GREATER THAN]75 years old
History of heparin-induced thrombocytopenia
High risk of noncompliance or inaccessibility for follow-up
Related to bleeding
Hemoglobin [LESS THAN]7 g per dL at time of diagnosis of DVT
Active bleeding/high risk of hemorrhage
   Active bleeding including guaiac-positive stool
   History of stroke in past six weeks
   Noncutaneous surgery in past two weeks
   Platelet count [LESS THAN]75,000 per mm3 (75 3 109 per L)
   Hemodialysis dependency*
   Any other medical conditions with high incidence of hemorrhage
Signs or symptoms of PE or of limited cardiopulmonary reserve
Confirmed or suspected (without confirmatory test) symptomatic PE
Presenting symptom of dyspnea or nonmusculoskeletal chest pain
Abnormal vital signs
   Respiratory rate [GREATER THAN]20 or [LESS THAN]8 breaths per
minute[section]
   Heart rate [GREATER THAN]100 or [LESS THAN]60 beats per minute||
   Temperature [GREATER THAN]38.3[degree sign]C (100.9[degree sign]F)
   Systolic blood pressure [LESS THAN]100 mm Hg
Pao2 less than normal for age
Paco2 [GREATER THAN]45 or [LESS THAN]35 mm Hg
Evidence of ischemia or new arrhythmia on ECG
DVT = deep venous thrombosis; PE = pulmonary embolism; Pao2 = partial
pressure of arterial oxygen; Paco2 = partial pressure of arterial carbon
dioxide; ECG = electrocardiogram.
*-Relative and not absolute exclusion criterion.
Age [GREATER THAN]75 but [LESS THAN]80 years.
Inaccessible because home is [GREATER THAN]50 miles from hospital.
[section]-Vital signs abnormal only because of respiratory rate within 25
percent
of guidelines.
||-Vital signs abnormal only because of heart rate within 10 percent of
guidelines.
Reprinted with permission from Yusen RD, Haraden BM, Gage BF, Woodward RS,
Rubin BG, Botney MD. Criteria for outpatient management of proximal lower
extremity deep venous thrombosis. Chest April 1999;115:975.

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