Revista do Colégio Brasileiro de Cirurgiões
https://revistadocbc.org.br/article/doi/10.1590/0100-6991e-2026001525
Revista do Colégio Brasileiro de Cirurgiões
Artigo Original

Abdome complexo: proposta de um marco conceitual preliminar, implicações assistenciais e perspectivas contemporâneas

Complex abdomen: proposal of a preliminary conceptual framework, clinical implications, and contemporary perspectives

Bruno Monteiro T Pereira; Pablo Ottolino; Marcelo Augusto Fontenelle Ribeiro Junior

http://dx.doi.org/10.1590/0100-6991e-2026001525 RCBC, vol.53, e2026001525, 2026
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Resumo

Introdução: O abdome aberto é estratégia fundamental no cuidado de pacientes críticos submetidos a cirurgia de controle de danos, com sepse abdominal grave ou em risco de síndrome compartimental abdominal. Esses pacientes frequentemente evoluem com alterações fisiopatológicas multidimensionais - infecção persistente, falência orgânica, perda da integridade da parede abdominal, déficit nutricional e fístulas enteroatmosféricas - cuja gravidade parece emergir da interação dinâmica entre esses fatores, e não da exposição visceral isolada. As classificações vigentes, notadamente a classificação revisada de Björck, descrevem a progressão anatômica do abdome aberto, mas não integram as dimensões fisiológica, infecciosa, nutricional e organizacional do cuidado. O objetivo é propor o termo “abdome complexo” como marco conceitual preliminar e complementar - e não substitutivo - às classificações existentes.

Métodos: Comunicação científica de natureza conceitual, fundamentada em revisão narrativa da literatura (MEDLINE/PubMed, Embase, Cochrane Library, SciELO e LILACS; 2000 a 2025; português, inglês e espanhol), relatada segundo a escala SANRA. A síntese seguiu a best-fit framework synthesis, com o Cumulative Complexity Model como referencial a priori.

Resultados: São propostos cinco domínios constitutivos - instabilidade fisiológica; infecção intra-abdominal não controlada; perda de domínio parietal; fístula enteroatmosférica ou enteral complexa; falência nutricional e intestinal -, os pontos de corte a eles associados, um modificador contextual organizacional registrado separadamente e o critério de comprometimento simultâneo de dois ou mais domínios. Domínios, pontos de corte e critério foram propostos pelos autores a partir da literatura e da experiência clínica, sem consenso formal e sem validação empírica. O construto é apresentado como fenótipo clínico dinâmico, avaliado em momentos definidos, e não como estágio evolutivo obrigatório ou escore prognóstico.

Conclusão: Trata-se de marco preliminar, e não de definição validada. A formalização desse fenótipo pode aprimorar o raciocínio clínico, a comunicação multidisciplinar e a seleção de populações mais homogêneas em pesquisa. Propõe-se agenda de validação em três etapas - consenso Delphi modificado, avaliação de confiabilidade e validade de conteúdo e teste prognóstico prospectivo em registro multicêntrico -, acompanhada de critérios explícitos de refutação.

Palavras-chave

Abdome Aberto; Fístula Intestinal; Cirurgia de Controle de Danos; Infecções Intra-Abdominais; Terminologia como Assunto

Abstract

Introduction: The open abdomen has become a cornerstone in the care of critically ill patients undergoing damage control surgery, with severe abdominal sepsis, or at risk of abdominal compartment syndrome. These patients frequently develop a multidimensional clinical course - persistent infection, organ failure, loss of abdominal wall integrity, nutritional depletion, and entero-atmospheric fistulas - whose severity appears to emerge from the dynamic interaction among these factors rather than from visceral exposure alone. Current classifications, notably Björck’s amended classification, describe the anatomical progression of the open abdomen but do not integrate the physiological, infectious, nutritional, and organizational dimensions of care. The aim is to propose the term “complex abdomen” as a preliminary conceptual framework complementary to - and not a replacement for - existing classifications.

Methods: Conceptual scientific communication grounded in a narrative review of the literature (MEDLINE/PubMed, Embase, Cochrane Library, SciELO, and LILACS; 2000 to 2025; Portuguese, English, and Spanish), reported according to the SANRA scale. The synthesis followed best-fit framework synthesis, with the Cumulative Complexity Model as the a priori framework.

Results: Five constitutive domains are proposed - physiological instability; uncontrolled intra-abdominal infection; loss of abdominal wall domain; entero-atmospheric or complex enteric fistula; nutritional and intestinal failure - together with their associated cut-offs, a contextual organizational modifier recorded separately, and the criterion of simultaneous involvement of two or more domains. The domains, the cut-offs, and the criterion were proposed by the authors on the basis of the literature and clinical experience, without formal consensus and without empirical validation. The construct is presented as a dynamic clinical phenotype assessed at defined time points, not as an obligatory evolutionary stage or a prognostic score.

Conclusion: This is a preliminary framework rather than a validated definition. Formalizing this phenotype may improve clinical reasoning, multidisciplinary communication, and the selection of more homogeneous study populations. A three-step validation agenda - modified Delphi consensus, reliability and content validity assessment, and prospective prognostic testing within a multicenter registry - is proposed, together with explicit refutation criteria.

Keywords

Open Abdomen; Intestinal Fistula; Damage Control Surgery; Intraabdominal Infections; Terminology as Topic

Referências

1 Boele van Hensbroek P, Wind J, Dijkgraaf MG, Busch OR, 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. doi: 10.1007/s00268-008-9867-3.

2 Ribeiro MA Jr, Barros EA, Carvalho SM, Nascimento VP, Cruvinel J Neto, Fonseca AZ. Comparative study of abdominal cavity temporary closure techniques for damage control. Rev Col Bras Cir. 2016;43(5):368-373. doi: 10.1590/0100-69912016005015.

3 Roberts DJ, Leppäniemi A, Tolonen M, Mentula P, Björck M, Kirkpatrick AW, et al. The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review. BJS Open. 2023;7(5):zrad084. doi: 10.1093/bjsopen/zrad084.

4 Coccolini F, Roberts D, Ansaloni L, Ivatury R, Gamberini E, Kluger Y, et al. The open abdomen in trauma and non-trauma patients: WSES guidelines. World J Emerg Surg. 2018;13:7. doi: 10.1186/s13017-018-0167-4.

5 Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain ML, De Keulenaer B, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. 2013;39(7):1190-1206. doi: 10.1007/s00134-013-2906-z.

6 Petersson U, Acosta S, Björck M. Vacuum-assisted wound closure and mesh-mediated fascial traction - a novel technique for late closure of the open abdomen. World J Surg. 2007;31(11):2133-2137. doi: 10.1007/s00268-007-9222-0.

7 Lech GE, Neves BH, Oliveira GT, da Silveira CAB, Kasmirski JA, Lima DL, et al. Vacuum-assisted wound closure and mesh-mediated fascial traction for temporary closure in open abdomen: a single-arm meta-analysis. World J Surg. 2024;48(10):2391-2399. doi: 10.1002/wjs.12336.

8 Bruhin A, Ferreira F, Chariker M, Smith J, Runkel N. Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen. Int J Surg. 2014;12(10):1105-1114. doi: 10.1016/j.ijsu.2014.08.396.

9 Di Saverio S, Tarasconi A, Walczak DA, Cirocchi R, Mandrioli M, Birindelli A, et al. Classification, prevention and management of entero-atmospheric fistula: a state-of-the-art review. Langenbecks Arch Surg. 2016;401(1):1-13. doi: 10.1007/s00423-015-1370-3.

10 Wainstein DE, Calvi RJ, Rezzonico F, Deforel ML, Perrone N, Sisco P. Management of enteroatmospheric fistula: a ten-year experience following fifteen years of learning. Surgery. 2023;173(4):1079-1085. doi: 10.1016/j.surg.2022.12.001.

11 Pereira BM. Condutas terapêuticas nas fístulas enteroatmosféricas. PROACI, Ciclo 20, vol 3. Porto Alegre: Secad/Artmed; 2024.

12 Björck M, Bruhin A, Cheatham M, Hinck D, Kaplan M, Manca G, et al. Classification - important step to improve management of patients with an open abdomen. World J Surg. 2009;33(6):1154-1157. doi: 10.1007/s00268-009-9996-3.

13 Björck M, Kirkpatrick AW, Cheatham M, Kaplan M, Leppäniemi A, De Waele JJ. Amended classification of the open abdomen. Scand J Surg. 2016;105(1):5-10. doi: 10.1177/1457496916631853.

14 Slater NJ, Montgomery A, Berrevoet F, Carbonell AM, Chang A, Franklin M, et al. Criteria for definition of a complex abdominal wall hernia. Hernia. 2014;18(1):7-17. doi: 10.1007/s10029-013-1168-6.

15 Parker SG, Halligan S, Liang MK, Muysoms FE, Adrales GL, Boutall A, et al. Definitions for loss of domain: an international Delphi consensus of expert surgeons. World J Surg. 2020;44(4):1070-1078. doi: 10.1007/s00268-019-05317-z.

16 Pereira BM, Duchesne J, Concon-Filho A, Leppäniemi A. Entero-atmospheric fistula migration: a new management alternative for complex septic open abdomen. Anaesthesiol Intensive Ther. 2020;52(1):56-62. doi: 10.5114/ait.2020.92748.

17 Coccolini F, Ceresoli M, Kluger Y, Kirkpatrick A, Montori G, Salvetti F, et al. Open abdomen and entero-atmospheric fistulae: an interim analysis from the International Register of Open Abdomen (IROA). Injury. 2019;50(1):160-166. doi: 10.1016/j.injury.2018.09.040.

18 Baethge C, Goldbeck-Wood S, Mertens S. SANRA - a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4:5. doi: 10.1186/s41073-019-0064-8.

19 Carroll C, Booth A, Leaviss J, Rick J. "Best fit" framework synthesis: refining the method. BMC Med Res Methodol. 2013;13:37. doi: 10.1186/1471-2288-13-37.

20 Shippee ND, Shah ND, May CR, Mair FS, Montori VM. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol. 2012;65(10):1041-1051. doi: 10.1016/j.jclinepi.2012.05.005.

21 Plsek PE, Greenhalgh T. Complexity science: the challenge of complexity in health care. BMJ. 2001;323(7313):625-628. doi: 10.1136/bmj.323.7313.625.

22 Tuffin R. Implications of complexity theory for clinical practice and healthcare organization. BJA Educ. 2016;16(10):349-352. doi: 10.1093/bjaed/mkw013.

23 Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi: 10.1001/jama.2016.0287.

24 Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22(7):707-710. doi: 10.1007/BF01709751.

25 Sartelli M, Coccolini F, Kluger Y, Agastra E, Abu-Zidan FM, Abbas AES, et al. WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections. World J Emerg Surg. 2021;16(1):49. doi: 10.1186/s13017-021-00387-8.

26 Tanaka EY, Yoo JH, Rodrigues AJ Jr, Utiyama EM, Birolini D, Rasslan S. A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain. Hernia. 2010;14(1):63-69. doi: 10.1007/s10029-009-0560-8.

27 Pironi L, Arends J, Baxter J, Bozzetti F, Peláez RB, Cuerda C, et al. ESPEN endorsed recommendations. Definition and classification of intestinal failure in adults. Clin Nutr. 2015;34(2):171-180. doi: 10.1016/j.clnu.2014.08.017.

28 Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79. doi: 10.1016/j.clnu.2018.08.037.

29 Cederholm T, Jensen GL, Correia MITD, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM criteria for the diagnosis of malnutrition - a consensus report from the global clinical nutrition community. Clin Nutr. 2019;38(1):1-9. doi: 10.1016/j.clnu.2018.08.002.

30 Serfin J, Dai C, Harris JR, Smith N. Damage control laparotomy and management of the open abdomen. Surg Clin North Am. 2024;104(2):355-366. doi: 10.1016/j.suc.2023.09.008.

31 Huang J, Ren H, Jiang Y, Wu X, Ren J. Technique advances in entero-atmospheric fistula isolation after open abdomen: a review and outlook. Front Surg. 2021;7:559443. doi: 10.3389/fsurg.2020.559443.

32 Gross DJ, Smith MC, Zangbar-Sabegh B, Chao K, Chang E, Boudourakis L, et al. Challenge of uncontrolled enteroatmospheric fistulas. Trauma Surg Acute Care Open. 2019;4(1):e000381. doi: 10.1136/tsaco-2019-000381.

33 Kim JJ, Franczyk M, Gottlieb LJ, Song DH. Cost-effective alternative for negative-pressure wound therapy. Plast Reconstr Surg Glob Open. 2017;5(2):e1211. doi: 10.1097/GOX.0000000000001211.

34 Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401-409. doi: 10.1016/j.jclinepi.2013.12.002.
 

 

Submetido em:
14/08/2025

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20/08/2026

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