Time, Takebacks, and Transfusions: Artificial Intelligence Identifies Factors Predicting Fascial Closure in Damage Control Laparotomy

Abstract Background: Delayed anastomosis is a treatment strategy used in damage control laparotomy (DCL). During temporary abdominal closure (TAC) with DCL, infusion volume, and negative-pressure wound therapy (NPWT) output volume are associated with the success and prognosis of primary fascial closure (PFC). 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/artificial anus construction in the first surgery and patients who underwent intestinal resection in the first surgery followed by delayed anastomosis with no intestinal continuity. The main outcomes were infusion volume, NPWT output volume and complications.Results: One hundred nine patients who underwent emergency surgery were evaluated. Seventy-three patients were managed with TAC using NPWT. In 16 patients with early anastomosis and 21 patients 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 surgical site infection (p=0.315) and 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. Anastomosis and PFC were achieved for all patients whose delayed anastomosis was postponed.Conclusions: The presence or absence of anastomosis during TAC management does not affect NPWT output volume. 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.Trial RegistrationThe retrospective protocol of this study was approved by our institutional review board (MH2018-611).

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Evolution of Fascial Closure Optimization in Damage Control Laparotomy

The American Surgeon ◽

10.1177/000313481608201223 ◽

2016 ◽

Vol 82 (12) ◽

pp. 1178-1182

Author(s):

Margaret H. Lauerman ◽

Joseph J. Dubose ◽

Deborah M. Stein ◽

Samuel M. Galvagno ◽

Matthew J. Bradley ◽

...

Keyword(s):

Confidence Interval ◽

Odds Ratio ◽

Damage Control ◽

Enterocutaneous Fistula ◽

Fascial Closure ◽

Damage Control Laparotomy ◽

Closure Rate ◽

Urban Level ◽

Level I ◽

Primary Fascial Closure

Management of patients undergoing damage control laparotomy (DCL) involves many surgical, medical, and logistical factors. Ideal patient management optimizing fascial closure with regard to timing and closure techniques remains unclear. A retrospective review of patients undergoing DCL from 2000 to 2012 at an urban Level I trauma center was undertaken. Mortality of DCL decreased over the study period from 62.5 to 34.6 per cent, whereas enterocutaneous fistula rate decreased from 12.5 to 3.8 per cent. Delayed primary fascial closure rate improved from 22.2 to 88.2 per cent. Time to closure ( P < 0.001), time to first attempted closure ( P < 0.001), and number of explorations ( P < 0.001) were associated with ability to achieve delayed primary fascial closure. In subgroup analysis, achievement of delayed primary fascial closure was decreased with time to closure after one week (91.7% vs 52.0%, P = 0.002) and time to first attempted closure after two days (86.5% vs 70.0%, P = 0.042). In multivariate analysis, time to closure (odds ratio: 0.13, 95% confidence interval: 0.04–0.39; P < 0.001) and time to first attempted closure (odds ratio: 0.61, 95% confidence interval: 0.37–0.99; P = 0.046) were the only factors associated with achieving delayed primary fascial closure. Timing of attempted closure plays a significant role in attaining delayed primary fascial closure, highlighting the importance of early re-exploration.

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Damage Control Laparotomy Wound Incisions Can Be Closed With Low Rates of Superficial Surgical Site Infections

The American Surgeon ◽

10.1177/00031348211054522 ◽

2021 ◽

pp. 000313482110545

Author(s):

John D. Cull ◽

Kristen A. Spoor ◽

Katherine F. Pellizzeri ◽

Benjamin M. Manning

Keyword(s):

Retrospective Review ◽

Primary Closure ◽

Damage Control ◽

Surgical Site Infections ◽

Fascial Closure ◽

Damage Control Laparotomy ◽

Secondary Intention ◽

Delayed Primary Closure ◽

Laparotomy Wound

Due to high rates of surgical site infections (SSIs) in damage control laparotomies (DCLs), many surgeons leave wounds to heal by secondary intention. We hypothesize that patients after DCL can have their wounds primarily closed with wicks/Penrose drains with low rates of superficial surgical site infections. A retrospective review of a prospectively maintained DCL database was performed for all patients who underwent DCL from January 2016 to June 2018. From January 2016 to June 2018, a total of 171 patients underwent DCL. After exclusions, 107 patients were reviewed to assess for SSI. 57 patients were closed with wicks/Penrose drains, 3 were closed with delayed primary closure, and 47 patients were closed completely at time of fascial closure. There were 4 (3.7%) superficial SSIs, 13 (12.1%) organ space infections, and 14 surgical site occurrences (3 of which required opening the skin). Primary closure of incisions after DCL has low superficial SSI rates.

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Current Use of Damage-Control Laparotomy, Closure Rates, and Predictors of Early Fascial Closure at the First Take-Back

Journal of Trauma and Acute Care Surgery ◽

10.1097/ta.0b013e31821b245a ◽

2011 ◽

Vol 70 (6) ◽

pp. 1429-1436 ◽

Cited By ~ 48

Author(s):

Quinton M. Hatch ◽

Lisa M. Osterhout ◽

Asma Ashraf ◽

Jeanette Podbielski ◽

Rosemary A. Kozar ◽

...

Keyword(s):

Damage Control ◽

Fascial Closure ◽

Damage Control Laparotomy ◽

Take Back

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Primary fascial closure after damage control laparotomy: Sepsis vs haemorrhage

Injury ◽

10.1016/j.injury.2013.01.039 ◽

2014 ◽

Vol 45 (1) ◽

pp. 151-155 ◽

Cited By ~ 17

Author(s):

Naeem Goussous ◽

Donald H. Jenkins ◽

Martin D. Zielinski

Keyword(s):

Damage Control ◽

Fascial Closure ◽

Damage Control Laparotomy ◽

Primary Fascial Closure

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Time to first take-back operation predicts successful primary fascial closure in patients undergoing damage control laparotomy

Surgery ◽

10.1016/j.surg.2014.04.019 ◽

2014 ◽

Vol 156 (2) ◽

pp. 431-438 ◽

Cited By ~ 44

Author(s):

Matthew J. Pommerening ◽

Joseph J. DuBose ◽

Martin D. Zielinski ◽

Herb A. Phelan ◽

Thomas M. Scalea ◽

...

Keyword(s):

Damage Control ◽

Fascial Closure ◽

Damage Control Laparotomy ◽

Take Back ◽

Primary Fascial Closure

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A core outcome set for damage control laparotomy via modified Delphi method

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2021-000821 ◽

2022 ◽

Vol 7 (1) ◽

pp. e000821

Author(s):

Saskya Byerly ◽

Jeffry Nahmias ◽

Deborah M Stein ◽

Elliott R Haut ◽

Jason W Smith ◽

...

Keyword(s):

Anastomotic Leak ◽

Delphi Study ◽

Damage Control ◽

Core Outcome Set ◽

Fascial Closure ◽

Consensus Method ◽

Core Outcome ◽

Damage Control Laparotomy ◽

Modified Delphi ◽

Outcome Set

ObjectivesDamage control laparotomy (DCL) remains an important tool in the trauma surgeon’s armamentarium. Inconsistency in reporting standards have hindered careful scrutiny of DCL outcomes. We sought to develop a core outcome set (COS) for DCL clinical studies to facilitate future pooling of data via meta-analysis and Bayesian statistics while minimizing reporting bias.MethodsA modified Delphi study was performed using DCL content experts identified through Eastern Association for the Surgery of Trauma (EAST) ‘landmark’ DCL papers and EAST ad hoc COS task force consensus.ResultsOf 28 content experts identified, 20 (71%) participated in round 1, 20/20 (100%) in round 2, and 19/20 (95%) in round 3. Round 1 identified 36 potential COS. Round 2 achieved consensus on 10 core outcomes: mortality, 30-day mortality, fascial closure, days to fascial closure, abdominal complications, major complications requiring reoperation or unplanned re-exploration following closure, gastrointestinal anastomotic leak, secondary intra-abdominal sepsis (including anastomotic leak), enterocutaneous fistula, and 12-month functional outcome. Despite feedback provided between rounds, round 3 achieved no further consensus.ConclusionsThrough an electronic survey-based consensus method, content experts agreed on a core outcome set for damage control laparotomy, which is recommended for future trials in DCL clinical research. Further work is necessary to delineate specific tools and methods for measuring specific outcomes.Level of evidenceV, criteria

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Postoperative Neuromuscular Blocker Use Is Associated With Higher Primary Fascial Closure Rates After Damage Control Laparotomy

Yearbook of Anesthesiology and Pain Management ◽

10.1016/j.yane.2011.01.017 ◽

2011 ◽

Vol 2011 ◽

pp. 246-247

Author(s):

C.A. Lien

Keyword(s):

Damage Control ◽

Neuromuscular Blocker ◽

Fascial Closure ◽

Damage Control Laparotomy ◽

Primary Fascial Closure

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