This paper reports a new analysis on the IROA database, investigating the risk factors of mortality for open abdomen treatment in elderly patients (>65 years) with severe peritonitis. IROA is a prospective observational international cohort study that enrolled patients treated with open abdomen worldwide. Univariate analysis of potential mortality risk factors was performed in 116 patients.

The main findings were that age and ASA score did not affect mortality in this group of patients; and definitive abdominal closure was the most important factor to prevent mortality.

Data were recorded on a web platform (Clinical Registers®) through a dedicated website (www.clinicalregisters.org). It was recorded by participants throughout the world. This may be the source of flaw. Some studied factors were dependant on observer expertise, experience, and judgement; e.g. intraoperative procedure, temporary abdominal closure technique, duration of open abdomen, and ICU length of stay. These are also affected by local practice guidelines. Thus not only the patients were not homogeneous as pointed by authors, but the management was not either.

However, I agree that any one single center or even centers affiliated to one university may not have enough number of homogeneous open abdominal patients over 65 years; who are managed by even near identical guidelines.

Definitive abdominal closure was reported as the most important factor to prevent mortality, based on the finding that 100% of alive patients had definitive abdominal closure vs. 62.9% of patients who died, p<0.001. Definitive abdominal closure is not a therapeutic intervention included in open abdomen treatment. It follows successful open abdomen treatment. If treatment of open abdomen is prosperous then the surgeon can close the abdomen. It is indicated when intra-abdominal infection is completely eradicated. In fact, premature abdominal closure can lead to recurrent infection, abdominal compartment syndrome, and abdominal wall dehiscence. Definitive abdominal closure can be done for cured open abdomen patients who are not at the risk of mortality any more. Thus, definitive abdominal closure, per se, cannot be considered a factor that prevents mortality. But, it can be considered an index of successful open abdomen treatment and a cured patient.

I have no conflict of interest herein.