title: Chemical components separation with botulinum toxin A: a novel technique to improve primary fascial closure rates of the open abdomen.
abstract: BACKGROUND
  Failure to definitively close the open abdomen (OA) after damage control laparotomy leads to considerable morbidity and mortality. We have developed a novel technique, the "chemical components separation," which incorporates injection of botulinum toxin A (BTX), a long-term flaccid paralytic, into the lateral abdominal wall musculature.
  
  
  METHODS
  This is a retrospective review of all OA patients (age ≥18) from December 2009-June 2010 who underwent BTX injection. Under ultrasound guidance, a total of 300 units of BTX were injected into the external oblique, internal oblique and transversus abdominus.
  
  
  RESULTS
  A total of 18 patients were injected with a median age of 66 years (56 % male). Indications for OA treatment included questionable bowel viability (39 %), shock (33 %), loss of abdominal domain (6 %) and feculent contamination (17 %). Median ASA score was 3 with an APACHE 3 score of 85. Patients underwent a median of 4 serial abdominal explorations. The primary fascial closure rate was 83 % with a partial fascial closure rate of 6 % and planned ventral hernia rate of 11 %. Of the 9 patients injected within 24 h of their initial OA procedure, 89 % achieved primary fascial closure. Mortality was 11 %; death was unrelated to BTX injection. The overall complication rate was 67 %; specific complications rates included fascial dehiscence (11 %), enterocutaneous fistula development (0 %), intra-abdominal abscess (44 %) and deep surgical site infection (33 %).
  
  
  CONCLUSIONS
  The "chemical components separation" technique described is safe and avoids the extensive dissection necessary for mechanical components separation in critically ill patients with infected/contaminated abdominal domains. While further evaluation is required, the described technique provides potential to improve delayed primary fascial closure rates in the OA setting.
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN, USA. zielinski.martin@mayo.edu
authors.forename: M D
authors.initials: MD
authors.lastname: Zielinski
authors.forename: N
authors.initials: N
authors.lastname: Goussous
authors.forename: H J
authors.initials: HJ
authors.lastname: Schiller
authors.forename: D
authors.initials: D
authors.lastname: Jenkins
mesh_terms: D000005:Abdomen / Q000601:surgery; D018784:Abdominal Abscess / Q000209:etiology; D058107:Abdominal Wound Closure Techniques / Q000009:adverse effects; D000368:Aged; D019274:Botulinum Toxins, Type A / Q000008:administration & dosage*; D017577:Cutaneous Fistula / Q000209:etiology*; D005205:Fascia; D005260:Female; D006801:Humans; D007273:Injections, Intramuscular; D007412:Intestinal Fistula / Q000209:etiology*; D008297:Male; D009465:Neuromuscular Agents / Q000008:administration & dosage*; D012086:Reoperation; D012189:Retrospective Studies; D013529:Surgical Wound Dehiscence / Q000209:etiology; D013530:Surgical Wound Infection / Q000209:etiology*
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A