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LaGrone LN, Stein D, Cribari C, Kaups K, Harris C, Miller AN, Smith B, Dutton R, Bulger E, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. J Trauma Acute Care Surg 2024; 96:510-520. [PMID: 37697470 DOI: 10.1097/ta.0000000000004088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.
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Affiliation(s)
- Lacey N LaGrone
- From the Department of Surgery (D.S.), University of Maryland, Baltimore, Maryland; Department of Surgery (L.N.L., C.C.), UCHealth, Loveland, Colorado; Department of Surgery (K.K), University of California San Francisco Fresno, San Francisco, California; Department of Surgery (C.H.), Tulane University, New Orleans, Louisiana; Orthopedic Surgery (A.N.M.), Washington University in St. Louis, St. Louis, Missouri; Department of Surgery (B.S.), University of Pennsylvania, Philadelphia, Pennsylvania; American Society of Anesthesiologists (R.D.), Anesthesia, Waco, Texas; Department of Surgery (E.B.), University of Washington, Seattle, Washington; and Department of Surgery (L.M.N.), University of Michigan, Ann Arbor, Michigan
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Hatchimonji JS, Bakillah E, Kaufman EJ, Dowzicky PM, Braslow BM, Kalapatapu VR, Reilly PM, Sharoky CE. The open abdomen in mesenteric ischemia: A tool for patients undergoing revascularization. World J Surg 2024; 48:331-340. [PMID: 38686782 DOI: 10.1002/wjs.12056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 05/02/2024]
Abstract
BACKGROUND We examined outcomes in Acute Mesenteric Ischemia (AMI) with the hypothesis that Open Abdomen (OA) is associated with decreased mortality. METHODS We performed a cohort study reviewing NSQIP emergency laparotomy patients, 2016-2020, with a postoperative diagnosis of mesenteric ischemia. OA was defined using flags for patients without fascial closure. Logistic regression was used with outcomes of 30-day mortality and several secondary outcomes. RESULTS Out of 5514 cases, 4624 (83.9%) underwent resection and 387 (7.0%) underwent revascularization. The OA rate was 32.6%. 10.8% of patients who were closed required reoperation. After adjustment for demographics, transfer status, comorbidities, preoperative variables including creatinine, white blood cell count, and anemia, as well as operative time, OA was associated with OR 1.58 for mortality (95% CI [1.38, 1.81], p < 0.001). Among revascularizations, there was no such association (p = 0.528). OA was associated with ventilator support >48 h (OR 4.04, 95% CI [3.55, 4.62], and p < 0.001). CONCLUSION OA in AMI was associated with increased mortality and prolonged ventilation. This is not so in revascularization patients, and 1 in 10 patients who underwent primary closure required reoperation. OA should be considered in specific cases of AMI. LEVEL OF EVIDENCE Retrospective cohort, Level III.
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Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emna Bakillah
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Phillip M Dowzicky
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin M Braslow
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Venkat R Kalapatapu
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine E Sharoky
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Grossman H, Dhanasekara CS, Shrestha K, Marschke B, Morris E, Richmond R, Ko A, Tennakoon L, Campion EM, Wood FC, Brandt M, Ng G, Regner JL, Keith SL, McNutt MK, Kregel H, Gandhi RR, Schroeppel TJ, Margulies DR, Hashim YM, Herrold J, Goetz M, Simpson L, Doan XL, Dissanaike S. Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study. Trauma Surg Acute Care Open 2023; 8:e001178. [PMID: 38020867 PMCID: PMC10668238 DOI: 10.1136/tsaco-2023-001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap. Methods This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R. Results Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves. Conclusion Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity. Level of evidence III.
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Affiliation(s)
- Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Ara Ko
- Department of Surgery, Stanford Medicine, Stanford, California, USA
| | | | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Frank C Wood
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Maggie Brandt
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Grace Ng
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Justin L Regner
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Stacey L Keith
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Michelle K McNutt
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Heather Kregel
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rajesh R Gandhi
- Department of Surgery, JPS Health Network, Fort Worth, Texas, USA
| | | | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yassar M Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Herrold
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Mallory Goetz
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - LeRone Simpson
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Xuan-Lan Doan
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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García A, Sanchez AI, Ferrada P, Wolfe L, Duchesne J, Fraga GP, Benjamin E, Campbell A, Morales C, Pereira BM, Ribeiro M, Quiodettis M, Peck G, Salamea JC, Kruger VF, Ivatury R, Scalea T. Risk factors for the leakage of the repair of duodenal wounds: a secondary analysis of the Panamerican Trauma Society multicenter retrospective review. World J Emerg Surg 2023; 18:28. [PMID: 37016441 PMCID: PMC10074841 DOI: 10.1186/s13017-023-00494-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/19/2023] [Indexed: 04/06/2023] Open
Affiliation(s)
- Alberto García
- Division of Trauma and Acute Care Surgery, Department of Surgery, Department of Intensive Care, Fundación Valle del Lili, Cra 98 No. 18-49, 760032, Cali, Colombia.
- Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cali, Colombia.
- Department of Surgery, Universidad Icesi, Cali, Colombia.
| | - Alvaro I Sanchez
- Division of Thoracic Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Paula Ferrada
- Division of Trauma and Acute Care Surgery, Innova Fairfax Hospital, Falls Church, VA, USA
| | - Luke Wolfe
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Juan Duchesne
- Department of Surgery, Tulane University, LA, New Orleans, USA
| | - Gustavo P Fraga
- Department of Trauma and Acute Care Surgery, University of Campinas, Campinas, Brazil
| | | | - Andre Campbell
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Carlos Morales
- Department of Surgery, Universidad de Antioquia, Medellín, Colombia
| | - Bruno M Pereira
- University of Vassouras, Rio De Janeiro, Brazil
- Santa Casa de Campinas, Campinas, Brazil
| | - Marcelo Ribeiro
- Consultant General and Trauma Surgeon, Chair Division of Trauma, Burns, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Martha Quiodettis
- Division of Trauma and Acute Care Surgery, Hospital Santo Tomas, Panama City, Panama
| | - Gregory Peck
- Department of Surgery, Robert Wood Johnson Place, New Brunswick, NJ, USA
| | - Juan C Salamea
- Department of Surgery, Hospital Vicente Corral Moscoso, Cuenca, Ecuador
| | - Vitor F Kruger
- Department of Trauma and Acute Care Surgery, University of Campinas, Campinas, Brazil
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Thomas Scalea
- Department of Surgery, Shock Trauma Center, University of Maryland, MD, College Park, USA
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Einav S, Leone M, Martin-Loeches I. Sepsis and antibiotics: When should we deploy a parachute? Int J Antimicrob Agents 2023; 61:106732. [PMID: 36690121 DOI: 10.1016/j.ijantimicag.2023.106732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 01/22/2023]
Abstract
In sepsis and septic shock, guidelines recommend administering antimicrobial therapy within the first hour following diagnosis. This recommendation is based on observational studies suggesting that early antimicrobial therapy is associated with improved outcomes. Consequently, front-line physicians are under pressure to quickly decide on the need for antibiotics in patients for whom the diagnosis of sepsis remains uncertain. However, overuse of antibiotics is associated with emergence of multidrug-resistant bacteria, which constitutes a major health issue worldwide. Front-line physicians may be thought to have been responsible for antibiotic overuse in the same patients. This article reports the situation of physicians who are criticised for using unnecessarily antibiotics or those who are criticised for not timeously using antibiotics; it then discusses several options to help the clinician at the bedside.
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Bonanno FG. Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies. J Clin Med 2022; 12:jcm12010260. [PMID: 36615060 PMCID: PMC9821021 DOI: 10.3390/jcm12010260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022] Open
Abstract
Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.
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Affiliation(s)
- Fabrizio G Bonanno
- Department of Surgery, Polokwane Provincial Hospital, Cnr Hospital & Dorp Street, Polokwane 0700, South Africa
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Irtan S, Reignier PL, Durandy A, Hervieux E, Constant I, Lemale J, Soreze Y, Leger PL, Audry G, Rambaud J, Guellec I. Feasibility of open abdomen surgery treatment for near fatal necrotizing enterocolitis in preterm infants. J Pediatr Surg 2022; 57:1336-1341. [PMID: 34696919 DOI: 10.1016/j.jpedsurg.2021.09.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Necrotizing Enterocolitis (NEC) remained a dramatic complication leading to death or neonatal morbidities in preterms. For some, Intra-Abdominal Hypertension (IAH) and Abdominal Compartment Syndrome worsened the multi-organ failure. An open abdomen surgery could be an alternative to conventional surgical treatment to move beyond this stage. OBJECTIVES To retrospectively describe the clinical course, pre- and post-operative features of preterms suffering from severe NEC with IAH treated by open abdomen surgery and referred to our center from October 2007 to September 2019. Our secondary objective is to identify various risk factors for mortality in this population. METHODS Data on neonatal, clinical, biological, pre and post-operative features and outcome were collected. Univariate analyses were performed to compare their pre and post-operative features stratifying on outcome. RESULTS Among 29 included patients, 14 (48%) survived to discharge without short bowel syndrome. Death was associated with an earlier postnatal age at NEC (16.3 ± 9.1 versus 31.3 ± 25.9 days; p = 0.004) and followed a withdrawal of treatment in 60% of cases. Surgery was associated with a significant improvement of respiratory and hemodynamic features (decrease of mean ventilator pressure from 13.1 ± 5.4 to 11.3 ± 4.0 cmH2O, p < 0.001), oxygen requirement (mean FiO2 decreased from 65.0% ± 31.2 to 49.0% ± 24.6, p < 0.001) and inotropic score (from 38.6 ± 70.1 to 29.9 ± 64.3, p < 0.001). In the survival group, pre and post-operative findings exhibited a significant increase of serum lactate concentrations from 2.7 ± 1.6 to 11.0 ± 20.3 mmol/L (p = 0.02) but a similar pH. CONCLUSION Open abdomen surgery could be considered to rescue preterms with near fatal NEC. IAH and Abdominal Compartment Syndrome in these preterms should be investigated through further studies. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sabine Irtan
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Pierre-Louis Reignier
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Amélie Durandy
- Neonatal Intensive Care Unit, CH Poissy Saint-Germain-en-Laye, Poissy, France
| | - Erik Hervieux
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Isabelle Constant
- Department of Anesthesiology and Intensive Care, Sorbonne University, Armand Trousseau University Hospital, GRC 29, APHP.6, Paris, France
| | - Julie Lemale
- Nutrition and Gastroenteterology, Pediatric Department, Sorbonne University, Armand Trousseau University Hospital, APHP.6, France
| | - Yohan Soreze
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France
| | - Pierre-Louis Leger
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France
| | - Georges Audry
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Jérôme Rambaud
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France
| | - Isabelle Guellec
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France.
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Elkbuli A, Newsome K, Fanfan D, Sutherland M, Bilski T, Liu H, Ang D. Laparoscopic Versus Laparotomy Surgical Interventions for Trauma Patients with Single Upper Left Quadrant Penetrating Injuries: Analysis of the American College of Surgeons Trauma Quality Improvement Program Dataset. Am Surg 2022; 88:2182-2193. [PMID: 35592893 DOI: 10.1177/00031348221101510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We aim to identify patient cohorts where laparoscopy can be safely utilized with comparable or better outcomes to laparotomy among patients with single penetrating LUQ injuries with a hypothesis that compared to laparotomy, laparoscopy may be associated with equal or improved outcomes of low injury severity patients. METHODS Retrospective review of the ACS-TQP-Participant Use File 2016-2019 dataset. Patients with single LUQ penetrating injuries were included. Primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included: risk-adjusted complication rates, hospital length-of-stay (H-LOS), and ICU-LOS. Descriptive statistics and multivariable regression with reliability adjustments to account for variations in practice were performed. RESULTS Of 4149 patients analyzed, 3571 (86.1%) underwent laparotomy, 489 (11.8%) underwent laparoscopy, and 89 (2.1%) underwent laparoscopy-to-laparotomy conversion. Adjusted mortality rates were not significantly different among all study cohorts (P > .05). Compared to laparoscopy, adjusted odds of complications were 4.3-fold higher for all patients who underwent laparotomy and 4-fold higher for laparoscopy-to-laparotomy (LtL) patients (P < .05). Diaphragmatic injuries were associated with significantly increased odds of undergoing LtL, whereas sustaining a colonic injury, gastric injury, hepatic injury, or requiring PRBC transfusions were associated with significantly increased odds of undergoing laparotomy (P < .05). H-LOS (days) was significantly longer for patients who underwent laparotomy compared to laparoscopy (3.9 ± 4.0 vs. 10.8 ± 13.4, P < .0001). CONCLUSIONS Laparoscopy may be considered a viable alternative to laparotomy for hemodynamically stable adult patients with single penetrating LUQ injuries of low injury burden validating our hypothesis. Laparoscopy may be less safe for patients with associated diaphragmatic, colonic, or hepatic injuries.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Division of Medical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Kevin Newsome
- 5450Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Dino Fanfan
- 5450Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Mason Sutherland
- 2814NSU NOVA Southeastern University, Dr. Kiran.C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Tracy Bilski
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Division of Medical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Huazhi Liu
- Department of Surgery, Division of Trauma and Surgical Critical Care, 23703Ocala Regional Medical Center, Ocala, FL, USA
| | - Darwin Ang
- Department of Surgery, Division of Trauma and Surgical Critical Care, 23703Ocala Regional Medical Center, Ocala, FL, USA
- University of South Florida, Tampa, FL, USA
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Tanahashi Y, Sato H, Kawakami A, Sasaki S, Nishinari Y, Ishida K, Kojika M, Endo S, Inoue Y, Sasaki A. Difference between delayed anastomosis and early anastomosis in damage control laparotomy affecting the infusion volume and NPWT output volume: is infusion restriction necessary in delayed anastomosis? A single-center retrospective analysis. Trauma Surg Acute Care Open 2022; 7:e000860. [PMID: 35340705 PMCID: PMC8905971 DOI: 10.1136/tsaco-2021-000860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 02/19/2022] [Indexed: 11/05/2022] Open
Abstract
Objectives During temporary abdominal closure (TAC) with damage control laparotomy (DCL), infusion volume and negative-pressure wound therapy (NPWT) output volume are associated with the success and prognosis of primary fascial closure. The same may also hold true for anastomosis. The aim of this research is to evaluate whether the difference between early anastomosis and delayed anastomosis in DCL is related to infusion volume and NPWT output volume. Methods This single-center retrospective analysis targeted patients managed with TAC during emergency surgery for trauma or intra-abdominal sepsis between January 2011 and December 2019. It included patients who underwent repair/anastomosis/colostomy in the first surgery and patients who underwent intestinal resection in the first surgery followed by delayed anastomosis with no intestinal continuity. Results Seventy-three patients were managed with TAC using NPWT, including 19 cases of repair, 17 of colostomy, and 37 of anastomosis. In 16 patients (trauma 5, sepsis 11) with early anastomosis and 21 patients (trauma 16, sepsis 5) with delayed anastomosis, there was no difference in the infusion volume (p=0.2318) or NPWT output volume (p=0.7128) 48 hours after surgery. Additionally, there was no difference in the occurrence of suture failure (p=0.8428). During the second-look surgery after 48 hours, the anastomosis was further postponed for 48% of the patients who underwent delayed anastomosis. There was no difference in the infusion volume (p=0.0783) up to the second-look surgery between the patients whose delayed anastomosis was postponed and those who underwent delayed anastomosis, but there was a tendency toward a large NPWT output volume (p=0.024) in the postponed delayed anastomosis group. Conclusion Delayed anastomosis may be managed with the same infusion volume as that used for early anastomosis. There is also the option of postponing anastomosis if the planned delayed anastomosis is complicated. Level of evidence Therapeutic/Care Management, Level IV.
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Affiliation(s)
- Yohta Tanahashi
- Department of Surgery, Iwate Medical University, School of Medicine, Iwate, Japan
| | - Hisaho Sato
- Department of Critical Care Medicine, Iwate Medical University, School of Medicine, Iwate, Japan
| | - Akiko Kawakami
- Department of Surgery, Iwate Medical University, School of Medicine, Iwate, Japan
| | - Shusaku Sasaki
- Department of Surgery, Iwate Medical University, School of Medicine, Iwate, Japan
| | - Yutaka Nishinari
- Department of Surgery, Iwate Medical University, School of Medicine, Iwate, Japan
| | - Kaoru Ishida
- Department of Surgery, Iwate Medical University, School of Medicine, Iwate, Japan
| | - Masahiro Kojika
- Department of Surgery, Iwate Medical University, School of Medicine, Iwate, Japan.,Department of Critical Care Medicine, Iwate Medical University, School of Medicine, Iwate, Japan
| | - Shigeatsu Endo
- Department of Critical Care Medicine, Iwate Medical University, School of Medicine, Iwate, Japan.,Morioka Yuai Hospital, Iwate, Japan
| | - Yoshihiro Inoue
- Department of Critical Care Medicine, Iwate Medical University, School of Medicine, Iwate, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University, School of Medicine, Iwate, Japan
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Harvin JA, Adams SD, Dodwad SJM, Isbell KD, Pedroza C, Green C, Tyson JE, Taub EA, Meyer DE, Moore LJ, Albarado R, McNutt MK, Kao LS, Wade CE, Holcomb JB. Damage control laparotomy in trauma: a pilot randomized controlled trial. The DCL trial. Trauma Surg Acute Care Open 2021; 6:e000777. [PMID: 34423135 PMCID: PMC8323393 DOI: 10.1136/tsaco-2021-000777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/05/2021] [Indexed: 11/03/2022] Open
Abstract
Background Although widely used in treating severe abdominal trauma, damage control laparotomy (DCL) has not been assessed in any randomized controlled trial. We conducted a pilot trial among patients for whom our surgeons had equipoise and hypothesized that definitive laparotomy (DEF) would reduce major abdominal complications (MAC) or death within 30 days compared with DCL. Methods Eligible patients undergoing emergency laparotomy were randomized during surgery to DCL or DEF from July 2016 to May 2019. The primary outcome was MAC or death within 30 days. Prespecified frequentist and Bayesian analyses were performed. Results Of 489 eligible patients, 39 patients were randomized (DCL 18, DEF 21) and included. Groups were similar in demographics and mechanism of injury. The DEF group had a higher Injury Severity Score (DEF median 34 (IQR 20, 43) vs DCL 29 (IQR 22, 41)) and received more prerandomization blood products (DEF median red blood cells 8 units (IQR 6, 11) vs DCL 6 units (IQR 2, 11)). In unadjusted analyses, the DEF group had more MAC or death within 30 days (1.71, 95% CI 0.81 to 3.63, p=0.159) due to more deaths within 30 days (DEF 33% vs DCL 0%, p=0.010). Adjustment for Injury Severity Score and prerandomization blood products reduced the risk ratio for MAC or death within 30 days to 1.54 (95% CI 0.71 to 3.32, p=0.274). The Bayesian probability that DEF increased MAC or death within 30 days was 85% in unadjusted analyses and 66% in adjusted analyses. Conclusion The findings of our single center pilot trial were inconclusive. Outcomes were not worse with DCL and, in fact, may have been better. A randomized clinical trial of DCL is feasible and a larger, multicenter trial is needed to compare DCL and DEF for patients with severe abdominal trauma. Level of evidence Level II.
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Affiliation(s)
- John A Harvin
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sasha D Adams
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Shah-Jahan M Dodwad
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Kayla D Isbell
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles Green
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jon E Tyson
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ethan A Taub
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - David E Meyer
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Laura J Moore
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rondel Albarado
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Michelle K McNutt
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Lillian S Kao
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Department of Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Center for Translational Injury Research, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - John B Holcomb
- Center for Injury Science, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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11
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Iacono SA, Krumrei NJ, Niroomand A, Walls DO, Lissauer M, To J, Butts CA. Age Is But a Number: Damage Control Surgery Outcomes in Geriatric Emergency General Surgery. J Surg Res 2021; 267:452-457. [PMID: 34237630 DOI: 10.1016/j.jss.2021.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/24/2021] [Accepted: 05/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Damage control surgery (DCS) with temporary abdominal closure (TAC) is increasingly utilized in emergency general surgery (EGS). As the population ages, more geriatric patients (GP) are undergoing EGS operations. Concern exists for GP's ability to tolerate DCS. We hypothesize that DCS in GP does not increase morbidity or mortality and has similar rates of primary closure compared to non-geriatric patients (NGP). METHODS A retrospective chart review from 2014-2020 was conducted on all non-trauma EGS patients who underwent DCS with TAC. Demographics, admission lab values, fluid amounts, length of stay (LOS), timing of closure, post-operative complications and mortality were collected. GP were compared to NGP and results were analyzed using Chi square and Wilcox signed rank test. RESULTS Ninety-eight patients (n = 50, <65 y; n = 48, ≥65 y) met inclusion criteria. There was no significant difference in median number of operations (3 versus 2), time to primary closure (2.5 versus 3 d), hospital LOS (19 versus 17.5 d), ICU LOS (11 versus 8 d), rate of primary closure (66% versus 56%), post op ileus (44% versus 48%), abscess (14% versus 10%), need for surgery after closure (32% versus 19%), anastomotic dehiscence (16% versus 6%), or mortality (34% versus 42%). Average time until take back after index procedure did not vary significantly between young and elderly group (45.8 versus 38.5 h; P = 0.89). GP were more likely to have hypertension (83% versus 50%; P ≤ 0.05), atrial fibrillation (25% versus 4%; P ≤ 0.05) and lower median heart rate compared to NGP (90 versus 103; P ≤ 0.05). CONCLUSIONS DCS with TAC in geriatric EGS patients achieves similar outcomes and mortality to younger patients. Indication, not age, should factor into the decision to perform DCS.
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Affiliation(s)
- Stephen A Iacono
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Nicole J Krumrei
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Anna Niroomand
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - David O Walls
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Matthew Lissauer
- Division of Acute Care Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jennifer To
- St. Luke's University Health Network, Bethlehem, Pennsylvania
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12
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Milne DM, Rambhajan A, Ramsingh J, Cawich SO, Naraynsingh V. Managing the Open Abdomen in Damage Control Surgery: Should Skin-Only Closure be Abandoned? Cureus 2021; 13:e15489. [PMID: 34268021 PMCID: PMC8261903 DOI: 10.7759/cureus.15489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 11/05/2022] Open
Abstract
During damage control laparotomy, surgery is abbreviated to allow for the correction of physiologic disturbances, with a plan to return to the operating theatre for definitive surgical repair. Re-entry into the abdomen is facilitated by temporary abdominal closure (TAC). Skin-only closure is one of the many techniques described for TAC Numerous sources advise against the use of this technique because of the risk of complications. This case report describes the use of skin-only closure during a damage control laparotomy. We reviewed the literature surrounding the various options for TAC to elucidate the potential role of skin-only closure after damage control laparotomy.
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Affiliation(s)
- David M Milne
- General Surgery, General Hospital Port of Spain, Port of Spain, TTO
| | - Amrit Rambhajan
- General Surgery, General Hospital Port of Spain, Port of Spain, TTO
| | - Jason Ramsingh
- General Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, GBR
| | - Shamir O Cawich
- Surgery, The University of the West Indies, St. Augustine, TTO
| | - Vijay Naraynsingh
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO.,Surgery, Medical Associates Hospital, St. Joseph, TTO
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13
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Ordoñez CA, Parra MW, Caicedo Y, Padilla N, Angamarca E, Serna JJ, Rodríguez-Holguín F, García A, Salcedo A, Pino LF, González-Hadad A, Herrera MA, Quintero L, Hernández F, Franco MJ, Aristizábal G, Toro LE, Guzmán-Rodríguez M, Coccolini F, Ferrada R, Ivatury R. Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent? Colomb Med (Cali) 2021; 52:e4114425. [PMID: 34188327 PMCID: PMC8216049 DOI: 10.25100/cm.v52i2.4425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | | | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Laureano Quintero
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Fabian Hernández
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - María Josefa Franco
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Gonzalo Aristizábal
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Luis Eduardo Toro
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Federico Coccolini
- Pisa University Hospital, Emergency and Trauma Surgery, Department of General, Pisa, Italy
| | - Ricardo Ferrada
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
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14
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Hanna K, Asmar S, Ditillo M, Chehab M, Khurrum M, Bible L, Douglas M, Joseph B. Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma. J Surg Res 2020; 257:69-78. [PMID: 32818786 DOI: 10.1016/j.jss.2020.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/13/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. METHODS The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. RESULTS A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. CONCLUSIONS MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. LEVEL OF EVIDENCE Level III Prognostic.
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Affiliation(s)
- Kamil Hanna
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Samer Asmar
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Michael Ditillo
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Mohamad Chehab
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Muhammad Khurrum
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Letitia Bible
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Molly Douglas
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
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15
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Loftus TJ, Efron PA, Bala TM, Rosenthal MD, Croft CA, Walters MS, Smith RS, Moore FA, Mohr AM, Brakenridge SC. The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy. J Trauma Acute Care Surg 2019; 86:670-8. [PMID: 30562327 DOI: 10.1097/TA.0000000000002170] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. STUDY DESIGN We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n = 60) to recent historic controls (n = 78) who would have met protocol inclusion criteria. The protocol includes low-volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure. RESULTS Baseline characteristics, including age, American Society of Anesthesiologists class, and postoperative lactate levels, were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p = 0.044) and exhibited higher serum osmolarity (303 vs. 293 mOsm/kg, p = 0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p = 0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p = 0.045, number needed to treat = 8.3). Complication rates were similar between groups. CONCLUSIONS Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations, and higher fascial closure rates with no difference in complications. LEVEL OF EVIDENCE Therapeutic study, level IV.
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16
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Harvin JA, Sharpe JP, Croce MA, Goodman MD, Pritts TA, Dauer ED, Moran BJ, Rodriguez RD, Zarzaur BL, Kreiner LA, Claridge JA, Holcomb JB. Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis. J Trauma Acute Care Surg 2019; 87:282-8. [PMID: 30939584 DOI: 10.1097/TA.0000000000002285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization. METHODS In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression. RESULTS Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60-1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively. CONCLUSION In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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17
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Harvin JA, Sharpe JP, Croce MA, Goodman MD, Pritts TA, Dauer ED, Moran BJ, Rodriguez RD, Zarzaur BL, Kreiner LA, Claridge JA, Holcomb JB. Better understanding the utilization of damage control laparotomy: A multi-institutional quality improvement project. J Trauma Acute Care Surg 2019; 87:27-34. [PMID: 31260424 DOI: 10.1097/TA.0000000000002288] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multicenter quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists. METHODS In 2016, six US Level I trauma centers performed a yearlong, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. Damage control laparotomy cases were adjudicated based on the majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for 2 years prior (2014 and 2015) was retrospectively collected and used as a control. To account for secular trends of DCL, interrupted time series was used to effectiveness of the QI interventions. RESULTS Eight hundred seventy-two emergent laparotomies were performed: 73% definitive laparotomies, 24% DCLs, and 3% intraoperative deaths. Of the 209 DCLs, 162 (78%) were voted appropriate, and 47 (22%) were voted to have been potentially safe for definitive laparotomy. Rates of DCL ranged from 16% to 34%. Common indications for DCL for which consensus existed were packing (103/115 [90%] appropriate) and hemodynamic instability (33/40 [83%] appropriate). The only common indication for which primary closure at the initial laparotomy could have been safely performed was avoiding a planned second look (16/32 [50%] appropriate). CONCLUSION A single faceted QI intervention failed to decrease the rate of DCL at six US Level I trauma centers. However, opportunities for improvement in safely decreasing the rate of DCL were present. Second look laparotomy appears to lack consensus as an indication for DCL and may represent a target to decrease the rate of DCL after injury. LEVEL OF EVIDENCE Epidemiological study with one negative criterion, level III.
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18
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Roberts DJ, Stelfox HT, Moore LJ, Cotton BA, Holcomb JB, Harvin JA. Accuracy of Published Indications for Predicting Use of Damage Control During Laparotomy for Trauma. J Surg Res 2020; 248:45-55. [PMID: 31863936 DOI: 10.1016/j.jss.2019.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/24/2019] [Accepted: 11/02/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although studies have identified published indications that experts and practicing surgeons agree indicate use of damage control (DC) laparotomy, it is unknown whether these indications predict use of the procedure in practice. MATERIALS AND METHODS We conducted a diagnostic performance study of the accuracy of a set of published appropriateness indications for predicting use of DC laparotomy. We included consecutive adults that underwent emergent laparotomy for trauma (2011-2016) at Memorial Hermann Hospital. RESULTS We included 1141 injured adults. Two published preoperative appropriateness indications [a systolic blood pressure (BP) persistently <90 mmHg or core body temperature <34°C] produced moderate shifts in the pretest probability of conducting DC instead of definitive laparotomy. Five published intraoperative appropriateness indications produced large and often conclusive changes in the pretest probability of conducting DC during emergent laparotomy. These included the finding of a devascularized or completely disrupted pancreas, duodenum, or pancreaticoduodenal complex; an estimated intraoperative blood loss >4 L; administration of >10 U of packed red blood cells (PRBCs); and a systolic BP persistently <90 mmHg or arterial pH persistently <7.2 during operation. Most indications that produced large changes in the pretest probability of conducting DC laparotomy had an incidence of 2% or less. CONCLUSIONS This study suggests that published appropriateness indications accurately predict use of DC laparotomy in practice. Intraoperative variables exert greater influence on the decision to conduct DC laparotomy than preoperative variables, and those indications that produce large shifts in the pretest probability of conducting DC laparotomy are uncommonly encountered.
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19
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Bouzat P, Valdenaire G, Gauss T, Charbit J, Arvieux C, Balandraud P, Bobbia X, David JS, Frandon J, Garrigue D, Long JA, Pottecher J, Prunet B, Simonnet B, Tazarourte K, Trésallet C, Vaux J, Viglino D, Villoing B, Zieleskiewicz L, Gil-Jardiné C, Weiss E. Early management of severe abdominal trauma. Anaesth Crit Care Pain Med 2020; 39:269-77. [PMID: 31843714 DOI: 10.1016/j.accpm.2019.12.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To develop French guidelines on the management of patients with severe abdominal trauma. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU), the French Society of Urology (Société française d'urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded. METHODS The guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a "damage control surgery" strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology. RESULTS The SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question. CONCLUSIONS Substantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma.
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Wei S, Green C, Kao LS, Padilla-Jones BB, Truong VTT, Wade CE, Harvin JA. Accurate risk stratification for development of organ/space surgical site infections after emergent trauma laparotomy. J Trauma Acute Care Surg 2019; 86:226-231. [PMID: 30531329 PMCID: PMC7004798 DOI: 10.1097/ta.0000000000002143] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Organ/space surgical site infection (OS-SSI) develops frequently after trauma laparotomies and is associated with significant morbidity. No valid model exists to accurately risk-stratify the probability of OS-SSI development after emergent laparotomy. Risk stratification for OS-SSI in these patients could guide promising, but unproven, interventions for OS-SSI prevention, such as more frequent dosing of intraoperative antibiotics or direct peritoneal resuscitation. We hypothesize that in trauma patients who undergo emergent laparotomy, probability of OS-SSI can be accurately estimated using patient data available during the index operation. METHODS Retrospective review was performed on a prospectively maintained database of emergent trauma laparotomies from 2011 to 2016. Patient demographics and risk factors for OS-SSI were collected. We performed Bayesian multilevel logistic regression to develop the model based on a 70% training sample. Evaluation of model fit using area under the curve was performed on a 30% test sample. The Bayesian approach allowed the model to address clustering of patients within physician while implementing regularization to improve predictive performance on test data. RESULTS One hundred seventy-two (15%) of 1,171 patients who underwent laparotomy developed OS-SSI. Variables thought to affect development of surgical site infections and were available to the surgeon near the conclusion of the trauma laparotomy were included in the model. Two variables that contributed most to OS-SSIs were damage-control laparotomy and colon resection. The area under the curve of the predictive model validated on the test sample was 0.78 (95% confidence interval, 0.71-0.85). CONCLUSION Using a combination of factors available to surgeons before the end of an emergent laparotomy, the probability of OS-SSI could be accurately estimated using this retrospective cohort. A Web-based calculator is under design to allow the real-time estimation of probability of OS-SSI intraoperatively. Prospective validation of its generalizability to other trauma cohorts and of its utility at the point of care is required. LEVEL OF EVIDENCE Prognostic study, level IV.
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Affiliation(s)
- Shuyan Wei
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Surgical Trials and Evidence-based Practice
| | - Charles Green
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Clinical Research and Evidence-based Medicine
| | - Lillian S Kao
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Surgical Trials and Evidence-based Practice
| | - Brandy B Padilla-Jones
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Van TT Truong
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Center for Clinical Research and Evidence-based Medicine
| | - Charles E Wade
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - John A Harvin
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
- Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
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Richman A, Burlew CC. Lessons from Trauma Care: Abdominal Compartment Syndrome and Damage Control Laparotomy in the Patient with Gastrointestinal Disease. J Gastrointest Surg 2019; 23:417-424. [PMID: 30276590 DOI: 10.1007/s11605-018-3988-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/20/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Aaron Richman
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA
| | - Clay Cothren Burlew
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA.
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Harvin JA, Green CE, Pedroza C, Tyson JE, Moore LJ, Wade CE, Holcomb JB, Kao LS. Using Machine Learning to Identify Change in Surgical Decision Making in Current Use of Damage Control Laparotomy. J Am Coll Surg 2019; 228:255-264. [PMID: 30639299 DOI: 10.1016/j.jamcollsurg.2018.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/26/2018] [Accepted: 12/27/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND In an earlier study, we reported the successful reduction in the use of damage control laparotomy (DCL); however, no change in the relative frequencies of specific indications was observed. In this study, we aimed to use machine learning to help identify the changes in surgical decision making that occurred. STUDY DESIGN Adult patients undergoing emergent trauma laparotomy were included: pre-quality improvement (QI): January 1, 2011 to October 31, 2013 and post-QI: November 1, 2013 to June 30, 2016. Using 72 variables before or during emergent laparotomy, random forest algorithms predicting DCL before and after a QI intervention were created. The main end point of the algorithms was the strength of individual factor significance in predicting the use of DCL, calculated by determining the mean decrease in accuracy (MDA) in the model if that variable was removed. RESULTS In the pre-QI group, 24 of 72 factors significantly predicted DCL, the strongest being bowel resection (mean MDA 16) and operating room RBC transfusions (mean MDA 15). The remaining variables were spread along the continuum of care from injury to emergent laparotomy end. In the post-QI group, 12 of 72 factors significantly predicted DCL, the strongest being last operating room lactate (mean MDA 12) and operating room RBC transfusions (mean MDA 14). In addition to having 12 fewer significant factors predictive of DCL, the predictive factors in the post-QI group were mainly intraoperative factors. CONCLUSIONS A machine learning analysis provided novel insights into the changes in decision making achieved by a successful QI intervention and should be considered an adjunct to understanding successful pre- and post-intervention QI studies. The analysis suggested a shift toward using mostly intraoperative factors to determine the use of DCL.
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Affiliation(s)
- John A Harvin
- Department of Surgery, University of Texas McGovern Medical School, Houston, TX; Center for Translational Injury Research, University of Texas McGovern Medical School, Houston, TX.
| | - Charles E Green
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, TX; Center for Clinical Research and Evidence Based Medicine, University of Texas McGovern Medical School, Houston, TX
| | - Claudia Pedroza
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, TX; Center for Clinical Research and Evidence Based Medicine, University of Texas McGovern Medical School, Houston, TX
| | - Jon E Tyson
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, TX; Center for Clinical Research and Evidence Based Medicine, University of Texas McGovern Medical School, Houston, TX
| | - Laura J Moore
- Department of Surgery, University of Texas McGovern Medical School, Houston, TX; Center for Translational Injury Research, University of Texas McGovern Medical School, Houston, TX
| | - Charles E Wade
- Department of Surgery, University of Texas McGovern Medical School, Houston, TX; Center for Translational Injury Research, University of Texas McGovern Medical School, Houston, TX
| | - John B Holcomb
- Department of Surgery, University of Texas McGovern Medical School, Houston, TX; Center for Translational Injury Research, University of Texas McGovern Medical School, Houston, TX
| | - Lillian S Kao
- Department of Surgery, University of Texas McGovern Medical School, Houston, TX; Center for Clinical Research and Evidence Based Medicine, University of Texas McGovern Medical School, Houston, TX
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Hu P, Uhlich R, Gleason F, Kerby J, Bosarge P. Impact of initial temporary abdominal closure in damage control surgery: a retrospective analysis. World J Emerg Surg 2018; 13:43. [PMID: 30237824 PMCID: PMC6139137 DOI: 10.1186/s13017-018-0204-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/03/2018] [Indexed: 02/05/2023] Open
Abstract
Background Damage control surgery has revolutionized trauma surgery. Use of damage control surgery allows for resuscitation and reversal of coagulopathy at the risk of loss of abdominal domain and intra-abdominal complications. Temporary abdominal closure is possible with multiple techniques, the choice of which may affect ability to achieve primary fascial closure and further complication. Methods A retrospective analysis of all trauma patients requiring damage control laparotomy upon admission to an ACS-verified level one trauma center from 2011 to 2016 was performed. Demographic and clinical data including ability and time to attain primary fascial closure, as well as complication rates, were recorded. The primary outcome measure was ability to achieve primary fascial closure during initial hospitalization. Results Two hundred and thirty-nine patients met criteria for inclusion. Primary skin closure (57.7%), ABThera™ VAC system (ABT) (15.1%), Bogota bag (BB) (25.1%), or a modified Barker's vacuum-packing (BVP) (2.1%) were used in the initial laparotomy. Patients receiving skin-only closure had significantly higher rates of primary fascial closure and lower hospital mortality, but also significantly lower mean lactate, base deficit, and requirement for massive transfusion. Between ABT or BB, use of ABT was associated with increased rates of fascial closure. Multivariate regression revealed primary skin closure to be significantly associated with primary fascial closure while BB was associated with failure to achieve fascial closure. Conclusions Primary skin closure is a viable option in the initial management of the open abdomen, although these patients demonstrated less injury burden in our study. Use of vacuum-assisted dressings continues to be the preferred method for temporary abdominal closure in damage control surgery for trauma.
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Affiliation(s)
- Parker Hu
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 701 19th Street South, 112 Lyons-Harrison Research Building, Birmingham, AL 35294 USA
| | - Rindi Uhlich
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Frank Gleason
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Jeffrey Kerby
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Patrick Bosarge
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
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Mashbari H, Hemdi M, Chow KL, Doherty JC, Merlotti GJ, Salzman SL, Singares ES. A Randomized Controlled Trial on Intra-Abdominal Irrigation during Emergency Trauma Laparotomy; Time for Yet Another Paradigm Shift. Bull Emerg Trauma 2018; 6:100-107. [PMID: 29719839 PMCID: PMC5928265 DOI: 10.29252/beat-060203] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/17/2018] [Accepted: 01/20/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To determine the optimal volume of abdominal irrigation that will prevent surgical site infections (both deep and superficial), eviscerations and fistula formations; and improve 30-day mortality in trauma patients. METHODS We conducted a three-arm parallel clinical superiority randomized controlled trial comparing different volumes of effluent (5, 10 and 20 liters) used in trauma patients (both blunt and penetrating) age 14 and above undergoing an emergency laparotomy between April 2002 and July 2004 in a busy urban Level 1 trauma center. RESULTS After randomization, a total of 204 patients were analyzed. All patient groups were comparable with respect to age, gender distribution, admission injury severity score, and mechanism of injury, estimated blood loss and degree of contamination. The mortality rate overall was 1.96% (4/204).No differences were noted with respect to contamination, wound infection, fistula formation, and evisceration. The twenty liter group (Group III) showed a trend toward an increased incidence of deep surgical site infections when compared to the five liter (Group I) (p=0.051) and ten liter (Group II) (p=0.057) groups. This did not however reach statistical significance. CONCLUSION The old surgical adage "the solution to pollution is dilution" is not applicable to trauma patients. Our results suggest that using more irrigation, even when large amounts of contamination have occurred, does not reduce post-operative complications or affect mortality; and it may predispose patients to increased incidence of abscess formation. (Trial registration number: ISRCTN66454589).
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Affiliation(s)
| | - Mohannad Hemdi
- University of Illinois, College of Medicine, Chicago, USA
| | - Kevin L. Chow
- University of Illinois, College of Medicine, Chicago, USA
| | | | | | | | - Eduardo Smith Singares
- University of Illinois, College of Medicine, Chicago, USA
- Advocate Christ Medical Center, USA
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