Understanding STAR and Bur Patch Decompression

Depending on the complexity of the intra-abdominal pathology, there are two strategically different methods to avert the functional impairments caused by abdominal compartment syndrome (ACS) and achieve complete fascial closure of the open abdomen and planned open abdomen:

  1. Bur Patch Decompression, and
  2. Staged Abdominal Repair (STAR)

Both methods take advantage of the flexibility of the artificial bur temporary fascia prosthesis (trade name Bur Patch), STAR however involves significant additional lifesaving advantages as outlined further below.

Benefits of the Bur Patch

  1. Improving renal and hepatic function
  2. Improving pulmonary function
  3. Improving cardiac function
  4. Improving cerebral function
  5. Improving intra-abdominal perfusion
  6. Improving fascial perfusion

Bur Patch Decompression and Reclosure for ACS

Definition

Bur Patch Decompression is one operation consisting of multiple serial abdominal openings, utilizing a fascial expander prosthesis to temporarily close the abdomen and decompress abdominal compartment syndrome (ACS) and re-approximate the fascia until final fascial closure can be accomplished.

When the abdomen is opened to solely treat ACS, serial abdominal openings without formal abdominal exploration is sufficient.  This decompresses the abdomen and allows for eventual fascial re-approximation and closure.  After the initial Bur Patch placement and abdominal decompression performed in the OR,  consecutive fascial approximations can be done in the ICU.  It is very important to seal the wound and the Bur Patch with a negative pressure wound dressing such as the Hypopack or other negative pressure dressings.

The no more -than 24-hours interval mandated for STAR is not required because inspection of abdominal viscera is not essential and bowel loops and viscera need not to be separated.  The parietal peritoneum, however, should be prevented from adhering to the visceral peritoneum to enhance the medial movement of the abdominal wall to the midline to allow for later final fascial closure.  Usually the soft Bur Patch loop sheet is large enough to act as a separator on one side of the incision.  Sometimes it is helpful to insert a plastic sheet on the other side between parietal and visceral peritoneum. A bowel bag (3M Sterile Isolation Bag 1003) that is cut open  can serve such purpose.

Fascial Closure Rates

Of all devices for temporary abdominal closure, the Bur Patch has the highest fascial closure rate  and the lowest mortality published21 (see figure 1 below).

Fig 1: van Hensbroek et al, WSJ 2009:33(2):199-207

STAR to Adress Complex Pathology and ACS

STAR (or multiple formal abdominal entries) in the OR permits the surgeon to treat not only abdominal compartment syndrome but also other severe intraperitoneal pathology such leaks, fistulas, necroses, and enterostomas, occurring with or without sepsis in often-unstable patients. The procedure is used to treat abdominal compartment syndrome (ACS) and other severe intra-peritoneal pathology such leaks, fistulas, necroses, and enterostomas, occurring with or without sepsis in often-unstable patients.

Definition

Staged Abdominal Repair is a definitive surgical strategy for the planned open abdomen, including serial explorations with repairs and débridement for acute catastrophic abdominal conditions.

STAR is one operation consisting of multiple serial abdominal entries planned either before or during the first operation, the index STAR. STAR utilizes a fascial enlargement prosthesis to temporarily close of the abdomen. Abdominal entries are performed every 24-±12 hours until final fascial closure can be accomplished.

STAR includes five management principles:

Additional Benefits /Advantages of STAR

In addition to the benefits of bur patch decompression such as controlling intra-abdominal pressure and reversing pulmonary, renal, CV, hepatic, and intestinal, and other dysfunctions and preventing fascial retraction and closing the abdomen with a dynamic fascial expander prosthesis (Bur Patch) STAR offers strategic, technical and control benefits as outlined below.

Strategic

Technical

Control

Mortality Improvement

Most STAR patients present with an extremely poor prognosis and mortality predictions often exceed the 20-30% range. STAR improves outcome significantly (see figures 1, 2 and 3.)

Fig 2: STAR Series I
Fig 3: STAR Series II

Figures 2 & 3: Results of two subsequent studies showing significant (p<0.05) mortality differences between patients operated by means of classical one step surgery (NON-STAR) and multiple subsequent abdominal entries or staged abdominal Repair (STAR). Patients with same risk factors have been grouped using APACHE-II system.

Special Considerations of STAR

Caution

A time interval of more than 24 hours between two STAR entries may traumatize intraabdominal tissue unnecessarily.  During the first 24 hours, only fibrin fills the spaces between tissues.  After 24 hours, tissue begins to adhere progressively and neovascularization has begun. The manual exploration of abdominal viscera after 24 hours requires more force and can cause more damage and bleeding than if performed before 24 hours.  Thus avoid exploration intervals beyond 24 hours at all costs under this scenario.

Quality of Surgery Control

STAR permits better quality control of surgical procedures by allowing daily inspection of the healing process, by encouraging early intervention and by correcting new, ongoing, or previously missed problems in order to avoid difficult to manage complications.

Meticulous surgical technique and attention to detail

Although a celiotomy or single abdominal entry a routine procedure, multiple sequential abdominal entries require even more perfectionism. With STAR, timing, infrastructure and operative manipulations such as resections, excisions, suturing leaks and anastomoses become critically important. Both, meticulous surgical technique and attention to detail are essential for success of STAR. Bowel walls are often thinned from distension and easily perforated, tissue can be very friable secondary to inflammation, and coagulation may be impaired from sepsis, hemorrhage, hypothermia, and therapeutic anticoagulation.

Surgeon commitment

STAR implies daily abdominal re-entries in the operation room, sometimes for more than 2 weeks. Thus, STAR requires a significant time commitment by the surgeon and care team, including total attention, dedication, sacrifice and self-discipline. Repeated trips to the operating room can tax any ICU and OR. To assure the best outcome, daily surgical explorations are necessary. Uninterrupted wound cover suction must be assured, best by surgeon presence, between the OR and the ICU to prevent wound contamination and uncontrolled fluid loss into the ICU bed.

Place for re-intervention: ICU or OR

While ICU explorations may seem quicker and safe, these can uncover intraabdominal problems better addressed in the operating room. When choosing the ICU as the site for opening and closing the abdomen under STAR strategy, it must be understood that this is not simply a dressing change, but potentially a full celiotomy, that may surprise with life threatening surgical situations. Repair without operating room infrastructure may become difficult.

Single Surgeon Task

Best results are achieved when the same surgeon performs or assists all STAR entries. The complex nature of the intra-abdominal pathology is not easily communicated to another surgeon and management errors are more likely with multiple surgeons assuming primary responsibility for one patient. Key to optimal performance and a successful STAR procedure is same surgeon in charge and his presence during al critical events20-21.

Verbiage: Clinical slang

The term Staged Abdominal Repair (STAR) was first coined in 19916.  Depending on the employed closing device, surgeons speak of “Marlex STAR”, “Bur Patch STAR”, “Ethizip STAR” or “Dynamic Retention Suture (DRS-) STAR”. Surgeons also use the term as a verb: “Let’s STAR the patient”.  To avoid confusion, the first abdominal entry is referred as the Index-STAR and subsequent abdominal entries as STAR#1, STAR# 2 etc.

Helping Families Understand STAR

Educating loved ones of a STAR patient is a major challenge requiring careful explanation and daily conferences to update the family about progress and setbacks. This needed level of communication, compassion and commitment must be appreciated before engaging in STAR. Information that may provide a basis for discussion with the family of STAR patient can be found here.

References

1Wittmann DH, Bergstein JM, Aprahamian C. Film: Velcro for temporary abdominal closure. 9th International Congress of Emergency Surgery, Strassbourg , 364. 1989

2Wittmann DH, Bergstein JM, Aprahamian C. Etappenlavage for diffuse peritonitis. Beitr Anäst Intensivemed 1989;30:199-221.

3Aprahamian C, Wittmann DH, Bergstein JM, Quebbeman EJ. VelcroTM, temporary abdominal closure for planned relaparotomy in trauma. Eastern Assoc.for the Surgery of Trauma, Naples 38. 1990.

4Wittmann DH, Aprahamian C, Bergstein JM. Etappenlavage: advanced diffuse peritonitis managed by planned multiple laparotomies utilizing zippers, slide fastener, and Velcro analogue for temporary abdominal closure. World J Surg 1990;14(2):218-26.

5Aprahamian C, Wittmann DH, Bergstein JM, Quebbeman EJ. Temporary abdominal closure (TAC) for planned relaparotomy (etappenlavage) in trauma. Journal of Trauma 1990;30(6):719-23.

6Wittmann DH, Aprahamian C, Bergstein JM, Bansal N. Staged abdominal repair (STAR) compares favorably to conventional operative therapy for intra-abdominal infection when stratifies by APACHE-II. 22nd Annual Meeting of the Western Trauma Association Feb./March 1992

7Wittmann DH, Aprahamian C, Bergstein JM, Edmiston CE, Frantzides CT, Quebbeman EJ, et al. A burr-like device to facilitate temporary abdominal closure in planned multiple laparotomies. Eur J Surg 1993;159(2):75-9.

8Wittmann DH, Bansal N, Bergstein JM, Wallace JR, Wittmann MM, Aprahamian C. Staged abdominal repair compares favorably with conventional operative therapy for intra-andominal infections when adjusting for prognostic factors with a conventional operative therapy for intra-abdominal infections when adjusting for prognostic factors with a logistic model. Theoretical Surgery 1994;25:273-284.

9Wittmann DH, Schein M, Condon RE. Management of secondary peritonitis. Annals of Surgery 1996;224(1):10-8.

10Wittmann DH. Operative and nonoperative therapy of intraabdominal infections. Infection 1998;26(5):335-41

11Wittmann DH, Bergstein JM, Wallace JR, Aprahamian CA: STAR and STIR Effectively Treat Abdominal Compartment Syndrome and Reduce Mortality of Traumatic and Infectious Abdominal Catastrophes 59th (Boston) and 60th (San Antonio) Annual Meeting of the AAST; 2000; Booklet of Abstracts, Session IV Poster 68

12Wittmann DH. Staged Abdominal Repair: Development and Current Practice of an Advanced Operative Technique for Diffuse Suppurative Peritonitis. Acta Chir Austriaca (European Surgeon); 2000;32(4):171-178

13Taviloglu K. Staged abdominal re-operation for abdominal trauma. Ulus Travma Acil Cerrahi Derg 2003;9(3):149-53.

14Ozguc H, Yilmazlar T, Gurluler E, Ozen Y, Korun N, Zorluoglu A. Staged abdominal repair in the treatment of intra-abdominal infection: analysis of 102 patients. J Gastrointest Surg 2003;7(5):646-51Cipolla J et al. A proposed algorithm for managing the open abdomen. Am Surg 71(2005)202

15Fantus RJ et al. Use of controlled fascial tension and an adhesion preventing barrier to achieve delayed primary fascial closure in patients managed with an open abdomen. Am J Surg 192(2006)243

16Hadeed JG et al. Delayed primary closure in damage control laparotomy: the value of the Wittmann patch. Am Surg 73(2007)10

17Tieu BH et al. The use of the Wittmann Patch facilitates a high rate of fascial closure in severely injured trauma patients and critically ill emergency surgery patients. J Trauma 65(2008) 865

18Weinberg JA et al. Closing the open abdomen: improved success with Wittmann Patch staged abdominal closure. J Trauma 65(2008)345

19Keramati M et al. The Wittmann Patch as a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn. Burns 34(2008)493

20Wittmann, DH. Staged abdominal repair (STAR) For Penetrating Abdominal Trauma. In Lenworth Jacobs (ed.) TECHNICAL OPERATIVE PROCEDURES: HOW I DO IT. Tips from Master Surgeons - ATOM-II, Chapter 1, p. 29-32, 2010

21van Hensbroek PB, Wind J, Dijkgraaf MGW, Busch ORC, Goslings JC Temporary Closure of the Open Abdomen: A Systematic Review on Delayed Primary Fascial Closure in Patients with an Open Abdomen ; World J Surg; 2009;33(2):199-207