Novel technique to improve primary fascial closure rates of the open abdomen

Comment to: Chemical components separation with botulinum toxin A: a novel technique to improve primary fascial closure rates of the open abdomen by Zielinski et al.T. R. Ibarra-Hurtado & C. M. Nuño-Guzmán

To the Editor Descarga carta al editor

We read with great interest the article by Dr. Zielinski et al.

[1 ]. The authors presented a retrospective review of their experience with botulinum toxin A (BTA) (Botox ,

Allergan, Inc. Irvine, CA 92612) application into the lateral

abdominal wall musculature of open abdomen (OA)

patients, in order to describe the BTA injection technique

and to determine its effects on the abdominal wall after

OA, which is named by the authors ‘‘chemical components

separation technique.’’ A total of 18 patients were included.

Indications for OA management included bowel viability

(39 %), shock (33 %), feculent contamination (17 %), and

loss of abdominal domain (6 %). A median of 3 serial

abdominal explorations (1–8) after the initial OA management

was required. Temporary abdominal closures with

negative pressure dressings were applied. A primary fascial

closure rate of 83 %, partial fascial closure rate of 6 %, and

planned ventral hernia rate of 11 % are reported. The

authors reported a BTA injection within 24 h of the initial

OA procedure in 50 % of the cases, achieving an 89 %

primary fascial closure rate, and 11 % partial fascial closure

rate of these patients. An overall 67 % complication

rate was found, with fascial dehiscence in 11 %.

The clinical effect of botulinum toxin has been demonstrated

as early as day 3 after intramuscular injection

with a maximum effect at 2 weeks [2 ]. In a prospective

study of twelve patients with abdominal wall hernia secondary

to OA management, the maximal effect of BTA

(Dysport, IPSEN, France) was observed at 3 weeks after

injection. A significant reduction in the transverse hernia

defect diameter was achieved [3 ]. The high overall primary

fascial closure rate in patients with BTA injection within

24 h of the initial OA procedure achieved by Dr. Zielinski

et al. [1 ] is particularly interesting.

We would like to ask Dr. Zielinski et al., at what time

were the remaining patients injected with BTA and the

time at which abdominal closure was performed.

Dr. Zielinski et al. reported 6 injection sites on the

abdominal wall: right/left subcostal; right/left anterior

axillary; right/left lower quadrants. Injection of 16.6 units

of the BTA solution for each of external oblique, internal

oblique, and transverse muscles is performed at each of

the 6 injection sites (50 units per injection site, total of

300 units). Our group reported BTA application at 10

sites: two sites at the middle axillary line between costal

margin and iliac crest level, and three sites between

anterior axillary line and middle clavicular line between

costal margin and iliac crest level, with similar sites on

the opposite side, for a total of 50 units per injection site

dosage [3 ].

A considerable range of 20–75 % of surviving patients

managed with OA will have the abdominal fascia closed

prior to discharge, while the remaining patients may

undergo abdominal wall reconstruction afterward [4 ]. With

no doubt, BTA injection will constitute an important

adjuvant to abdominal wall closure in patients under OA

management, planned ventral hernia or large abdominal

wall hernias.