Damage Control Surgery in the Era of Globalization of Health Care - Military and International Outcomes: A SystematicReview

INTRODUCTION

Damage Control Surgery (DCS) is a surgical technique used to manage critically ill and injured patients. This study examines the most recent 10-y outcomes related to DCS, with the secondary goal of scrutinizing the outcomes after DCS across surgical theaters.

METHODS

Studies published between 2012 and 2021 that described adult patients undergoing Abdominal DCS after traumatic injury were included. Outcomes were reported as medians-of-means and interquartile range.

RESULTS

Fifty-two studies met inclusion criteria (9932 patients), all 52 were included in the Military versus Civilian comparison which includes 46 Civilian (9244 patients) and 6 Military (688 patients) studies. Forty-three studies were included in the United States (US) and non-US comparison, with 10 non-US (2092 patients), and 33 US (6572 patients) studies. Overall, study quality was low, the majority having a high or unclear risk of bias. Across all studies, the median 24-h mortality was 14% (5.1-21.2) and 30-d mortality was 17.9% (9.4-28.3). Between subgroups, the Military cohort had a 30-d mortality 9-fold lower than the Civilian cohort (2.1% versus 18.9%), and the non-US cohort had more than 3 times the 24-h mortality (23.8% versus 7.5%) and double the 30-d mortality (37.2% versus 14.6%) of the US cohort.

CONCLUSIONS

Striking disparities are seen within current literature as it relates to outcomes after DCS between Military and Civilian and US and non-US populations. Trauma surgeons both within the US and internationally may benefit from looking to their Military counterparts for guidance to better care patients requiring DCS.

Incidence and Management of Duodenal Trauma in a War Setting: Insights From a Military Hospital in Yemen

Background Duodenal injuries are rare but pose significant challenges in war trauma settings because of their complexity and associated complications. This study evaluated the incidence, anatomical distribution, surgical approaches, postoperative complications, and factors influencing the outcomes of duodenal injury management in a conflict setting in Yemen. Methods A retrospective analysis was conducted on 520 exploratory laparotomy cases from June 2019 to December 2023 at a military hospital in Yemen. Twenty-seven patients with confirmed duodenal injuries were included. Data on demographic characteristics, injury characteristics, surgical management, and outcomes were collected and analyzed. Results Among the 520 exploratory laparotomy cases reviewed, 27 (5.2%) patients had confirmed duodenal injuries. The study population was predominantly young males (n = 26, 96.3%) with a mean age of 21.93 ± 4.08 years. Penetrating trauma was the leading cause of injury (n = 26, 95.7%), and the second portion of the duodenum (D2) was the most frequently affected segment (n = 12, 44.4%). Most injuries were classified as the American Association for the Surgery of Trauma (AAST) grade II (n = 26, 96.3%). Surgical management primarily involved exploratory laparotomy (n = 22, 81.5%) and primary repair (n = 18, 66.7%). Postoperative complications occurred in 70.4% (n = 19), with sepsis (n = 10, 52.6%) and chest-related complications (n = 9, 47.4%) being the most common. The short-term success rate was 81.5% (n = 22), while the mortality rate was 11.1% (n = 3). Shrapnel injuries (80% vs. 13%, p = 0.009), higher injury severity scores (27.20 ± 9.34 vs. 19.14 ± 7.80, p = 0.05), and damage control surgery (60.0% vs. 9.1%, p = 0.008) were key factors associated with poorer outcomes. Conclusion Duodenal injuries after war trauma are associated with high rates of complications and mortality. Early diagnosis, appropriate surgical approaches, and vigilant postoperative care are critical for improved outcomes. These findings highlight the importance of tailored management strategies in conflict settings and the need for further research to optimize care protocols in resource-limited environments.

Risk factors for abdominal surgical site infection after exploratory laparotomy among combat casualties

BACKGROUND

Surgical site infections (SSIs) are well-recognized complications after exploratory laparotomy for abdominal trauma; however, little is known about SSI development after exploration for battlefield abdominal trauma. We examined SSI risk factors after exploratory laparotomy among combat casualties.

METHODS

Military personnel with combat injuries sustained in Iraq and Afghanistan (June 2009 to May 2014) who underwent laparotomy and were evacuated to participating US military hospitals were included. Log-binominal regression was used to identify SSI risk factors.

RESULTS

Of 4,304 combat casualties, 341 patients underwent a total of 1,053 laparotomies. Abdominal SSIs were diagnosed in 49 patients (14.4%): 8% with organ space SSI, 4% with deep incisional SSI, and 4% with superficial SSIs (4 patients had multiple SSIs). Patients with SSIs had more colorectal (p < 0.001), small bowel (p = 0.010), duodenum (p = 0.006), pancreas (p = 0.032), and abdominal vascular injuries (p = 0.040), as well as prolonged open abdomen (p = 0.004) and more infections diagnosed before the SSI (or final exploratory laparotomy) versus non-SSI patients (p < 0.001). Sustaining colorectal injuries (risk ratio [RR], 3.20; 95% confidence interval [CI], 1.58-6.45), duodenum injuries (RR, 6.71; 95% CI, 1.73-25.58), and being diagnosed with prior infections (RR, 10.34; 95% CI, 5.05-21.10) were independently associated with any SSI development. For either organ space or deep incisional SSIs, non-intra-abdominal infections, fecal diversion, and duodenum injuries were independently associated, while being injured via an improvised explosive device was associated with reduced likelihood compared with penetrating nonblast (e.g., gunshot wounds) injuries. Non-intra-abdominal infections and hypotension were independently associated with organ space SSIs development alone, while sustaining blast injuries were associated with reduced likelihood.

CONCLUSION

Despite severity of injuries and the battlefield environment, the combat casualty laparotomy SSI rate is relatively low at 14%, with similar risk factors and rates reported following severe civilian trauma.

LEVEL OF EVIDENCE

Epidemiological, level III.

Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties

BACKGROUND

Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties.

METHODS

Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals.

RESULTS

Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively.

CONCLUSIONS

Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high.

[Approach to liver, spleen and pancreatic injuries including damage control surgery of terrorist attacks]

BACKGROUND

Terrorist attacks have outreached to Europe with more and more attacks on civilians. Derived from war surgery experience and from lessons learned from major incidents, it seems mandatory for every surgeon to improve understanding of the special circumstances of trauma following a terrorist attack and its' management.

METHOD

A short literature review is followed by outlining the damage control surgery (DCS) principle for each organ system with practical comments from the perspective of a specialized hepatobiliary (HPB) surgery unit.

CONCLUSION

Every surgeon has to become familiar with the new entities of blast injuries and terrorist attack trauma. This concerns not only the medical treatment but also tailoring surgical treatment with a view to a lack of critical resources under these circumstances. For liver and pancreatic trauma, simple treatment strategies are a key to success.

Treatments and other prognostic factors in the management of the open abdomen: A systematic review

BACKGROUND

The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain with it associated with a high incidence of complications and poor outcomes. The objective of this article is to perform a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify prognostic factors in OA patients in regard to definitive fascial closure (DFC), mortality and intra-abdominal complications.

METHODS

An electronic database search was conducted involving Medline, Excerpta Medica, Central Register of Controlled Trials, Cumulative Index to Nursing, and Allied Health Literature and Clinicaltrials.gov. All studies that described prognostic factors in regard to the above outcomes in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest and assessed for methodological quality.

RESULTS

Thirty-one studies were included in the final synthesis. Enteral nutrition, organ dysfunction, local and systemic infection, number of reexplorations, worsening Injury Severity Score, and the development of a fistula appeared to significantly delay DFC. Age and Adult Physiology And Chronic Health Evaluation version II score were predictors for in-hospital mortality. Failed DFC, large bowel resection and >5 to 10 L of intravenous fluids in <48 hours were predictors of enteroatmospheric fistula. The source of infection (small bowel as opposed to colon) was a predictor for ventral hernia. Large bowel resection, >5 to 10 and >10 L of intravenous fluids in <48 hours were predictors of intra-abdominal abscess. Fascial closure on (or after) day 5 and having a bowel anastomosis were predictors for anastomotic leak. Overall methodological quality was of a moderate level.

LIMITATIONS

Overall methodological quality, high number of retrospective studies, low reporting of prognostic factors and the multitude of factors potentially affecting patient outcome that were not analyzed.

CONCLUSION

Careful selection and management of OA patients will avoid prolonged treatment and facilitate early DFC. Future research should focus on the development of a prognostic model.

LEVEL OF EVIDENCE

Systematic review, level III.

Ratio-driven resuscitation predicts early fascial closure in the combat wounded

BACKGROUND

Operation Iraqi Freedom and Operation Enduring Freedom have seen the highest rates of combat casualties since Vietnam. These casualties often require massive transfusion (MT) and immediate surgical attention to control hemorrhage. Clinical practice guidelines dictate ratio-driven resuscitation (RDR) for patients requiring MT. With the transition from crystalloid to blood product resuscitation, we have seen fewer open abdomens in combat casualties. We sought to determine the effect RDR has on achieving early definitive abdominal fascial closure in combat casualties undergoing exploratory laparotomy.

METHODS

Records of 1,977 combat casualties admitted to a single US military hospital from April 2003 to December 2011 were reviewed. Patients receiving an MT and laparotomy in theater constituted the study cohort. The cohort was divided into RDR, defined as a ratio of 0.8-U to 1.2-U packed red blood cells to 1-U fresh frozen plasma, and No-RDR groups. Age, injury patterns, mechanism of injury, injury severity, blood products, number of laparotomies, and days to fascial closure were collected. Assessed outcomes were number of days (early ≤ 2 days) and number of laparotomies to achieve fascial closure.

RESULTS

The mean age of the study cohort (n = 172) was 24.0 years, and mean Injury Severity Score (ISS) was 24.8. Improvised explosive device blast was the most common mechanism of injury (74.4%). The cohort was divided into RDR patients (n = 73) and no RDR (n = 99). There was no difference in mean age, mean ISS, or rate of nontherapeutic exploratory laparotomies between the groups. RDR patients had a significantly lower abdominal injury rate (34.2% vs. 72.7%, p < 0.01), had fewer laparotomies (2.7 vs. 4.3, p = 0.003), and achieved primary fascial closure faster (2.4 days vs. 7.2 days, p = 0.004). On multivariate analysis, RDR (2.74; 95% confidence interval, 1.44-5.2) was an independent predictor for early fascial closure.

CONCLUSION

Adherence to RDR guidelines resulted in significantly decreased number of abdominal operations and was identified as an independent predictor for early fascial closure. Further investigation is warranted to validate these findings.

LEVEL OF EVIDENCE

Therapeutic study, level III.