Open abdomen with negative-pressure wound therapy versus primary fascial closure in abdominal septic shock: a propensity-weighted cohort study

Background. To evaluate whether initial open-abdomen management with negative-pressure wound therapy (OA-NPWT) was associated with 30-day mortality compared with primary fascial closure in patients undergoing urgent surgery for abdominal septic shock, while accounting for confounding by indication. Methods. We conducted a retrospective single-center cohort study of consecutive adults undergoing urgent source-control laparotomy between May 2021 and April 2026. Propensity-score overlap weighting was used to balance pre-decision clinical and operative characteristics. The primary outcome was 30-day mortality. Exploratory analyses assessed factors associated with OA-NPWT selection and treatment-effect heterogeneity. Results. Among 128 patients, 52 (40.6%) received OA-NPWT and 76 (59.4%) underwent primary fascial closure. After overlap weighting, estimated 30-day mortality was 24.8% with OA-NPWT and 23.9% with primary closure (risk difference, 0.9 percentage points; 95% CI, -18.4 to 20.2; RR, 1.04; 95% CI, 0.47–2.29). Sensitivity and time-to-event analyses were concordant. OA-NPWT was associated with longer mechanical ventilation. Its selection was associated mainly with shorter operative duration, second-vasoconstrictor use, and procedure type. No reproducible clinical or baseline-risk subgroup showed a differential mortality effect. Conclusions. Initial OA-NPWT management was not associated with a detectable difference in 30-day mortality after adjustment for confounding by indication, although clinically important benefit or harm could not be excluded. These findings support selective rather than routine open-abdomen use in abdominal septic shock. Clinical trial registration Not applicable. This was a retrospective observational cohort study.