Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3–2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2–3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

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Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review

World Journal of Emergency Surgery ◽

10.1186/s13017-021-00352-5 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Derek J. Roberts ◽

◽

Niklas Bobrovitz ◽

David A. Zygun ◽

Andrew W. Kirkpatrick ◽

...

Keyword(s):

Systematic Review ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Trauma Patients ◽

Clinical Scenario ◽

Cross Sectional ◽

Iliac Vessel ◽

Civilian Trauma ◽

Definitive Surgery

Abstract Background Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes). Methods We searched 11 databases (1950–April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions. Results Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications. Conclusions Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

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Modified Opsite® Sandwich for Temporary Abdominal Closure: A Non-Traumatic Experience

Annals of The Royal College of Surgeons of England ◽

10.1308/003588407x155446 ◽

2007 ◽

Vol 89 (1) ◽

pp. 57-61 ◽

Cited By ~ 15

Author(s):

JM Wilde ◽

MA Loudon

Keyword(s):

Critically Ill ◽

Damage Control ◽

Injured Patient ◽

Damage Control Surgery ◽

Traumatic Experience ◽

Fascial Closure ◽

Trauma Patients ◽

Temporary Abdominal Closure ◽

Abdominal Closure ◽

Operative Severity Score

INTRODUCTION Laparostomy techniques have advanced since the advent of damage control surgery for the critically injured patient. Numerous methods of temporary abdominal closure (TAC) are described in the literature with most reports focusing on trauma. We describe a modified technique for TAC and report its use in a series of critically ill non-trauma patients. PATIENTS AND METHODS Eleven patients under the care of one consultant underwent TAC over a 36-month period. A standardised technique was used in all cases and this is described. Severity of illness at the time of the first laparotomy was assessed using the Portsmouth variant of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM). RESULTS Nineteen TACs were performed in 11 patients with a variety of serious surgical conditions. In-hospital mortality was zero despite seven of the patients having an individual P-POSSUM predicted mortality in excess of 50%. The laparostomy dressing proved simple in construction, facilitated nursing care and was well-tolerated in the critical care environment. All patients underwent definitive fascial closure during the index admission. CONCLUSIONS Laparostomy is a useful technique outwith the context of trauma. We have demonstrated the utility of the modified Opsite® sandwich vacuum pack for TAC in a series of critically ill patients with a universally favourable outcome. This small study suggests that selective use of TAC may reduce surgical mortality.

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Evidence for Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients: A Systematic Review

10.21203/rs.3.rs-126134/v1 ◽

2020 ◽

Author(s):

Derek J. Roberts ◽

Niklas Bobrovitz ◽

David A. Zygun ◽

Andrew W. Kirkpatrick ◽

Chad G. Ball ◽

...

Keyword(s):

Systematic Review ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Trauma Patients ◽

Clinical Scenario ◽

Cross Sectional ◽

Iliac Vessel ◽

Civilian Trauma ◽

Definitive Surgery

Abstract Background: Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes).Methods: We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions. Results: Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring >10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications.Conclusions: Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

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Predictive factors of mortality in open abdomen for abdominal sepsis: a retrospective cohort study on 113 patients

Updates in Surgery ◽

10.1007/s13304-021-01012-8 ◽

2021 ◽

Author(s):

Dario Tartaglia ◽

Jacopo Nicolò Marin ◽

Alice Maria Nicoli ◽

Andrea De Palma ◽

Martina Picchi ◽

...

Keyword(s):

Predictive Factors ◽

Open Abdomen ◽

Damage Control ◽

Damage Control Surgery ◽

Abdominal Sepsis ◽

Apache Ii ◽

Fascial Closure ◽

Apache Ii Score ◽

Co Morbidity ◽

Fistula Rate

AbstractOver the past few years, the open abdomen (OA) as a part of Damage Control Surgery (DCS) has been introduced as a surgical strategy with the intent to reduce the mortality of patients with severe abdominal sepsis. Aims of our study were to analyze the OA effects on patients with abdominal sepsis and identify predictive factors of mortality. Patients admitted to our institution with abdominal sepsis requiring OA from 2010 to 2019 were retrospectively analyzed. Primary outcomes were mortality, morbidity and definitive fascial closure (DFC). Comparison between groups was made via univariate and multivariate analyses. On 1474 patients operated for abdominal sepsis, 113 (7.6%) underwent OA. Male gender accounted for 52.2% of cases. Mean age was 68.1 ± 14.3 years. ASA score was > 2 in 87.9%. Mean BMI, APACHE II score and Mannheim Peritonitis Index were 26.4 ± 4.9, 15.3 ± 6.3, and 22.6 ± 7.3, respectively. A negative pressure wound system technique was used in 47% of the cases. Overall, mortality was 43.4%, morbidity 76.6%, and DFC rate was 97.8%. Entero-atmospheric fistula rate was 2.2%. At multivariate analysis, APACHE II score (OR 1.18; 95% CI 1.05–1.32; p = 0.005), Frailty Clinical Scale (OR 4.66; 95% CI 3.19–6.12; p < 0.0001) and ASA grade IV (OR 7.86; 95% CI 2.18–28.27; p = 0.002) were significantly associated with mortality. OA seems to be a safe and reliable treatment for critically ill patients with severe abdominal sepsis. Nonetheless, in these patients, co-morbidity and organ failure remain the major obstacles to a better prognosis.

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Damage control in penetrating duodenal trauma: less is better

Colombia Medica ◽

10.25100/cm.v52i2.4509 ◽

2021 ◽

Vol 52 (2) ◽

pp. e4104509

Author(s):

Carlos Alberto Ordoñez ◽

Michael Parra ◽

Mauricio Millan ◽

Yaset Caicedo ◽

Natalia Padilla ◽

...

Keyword(s):

Surgical Management ◽

Primary Repair ◽

Damage Control ◽

Treatment Algorithm ◽

Surgical Techniques ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Trauma Patients ◽

Severe Injuries ◽

Duodenal Injuries

The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma which are commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and consequential increase in the rates of mortality. The aim of this article is to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery which sticks to the philosophy of “Less is Better”. Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability and/or significant associated injuries then the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

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Epidemiological evaluation of hepatic trauma victims undergoing surgery

Revista do Colégio Brasileiro de Cirurgiões ◽

10.1590/0100-69912016001006 ◽

2016 ◽

Vol 43 (1) ◽

pp. 22-27 ◽

Cited By ~ 5

Author(s):

Mitre Kalil ◽

Isaac Massaud Amim Amaral

Keyword(s):

Blunt Trauma ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Liver Trauma ◽

Metropolitan Region ◽

Trauma Patients ◽

Hepatic Trauma ◽

Female Ratio ◽

Packed Red Blood Cells

Objective : to evaluate the epidemiological variables and diagnostic and therapeutic modalities related to hepatic trauma patients undergoing laparotomy in a public referral hospital in the metropolitan region of Vitória-ES. Methods : we conducted a retrospective study, reviewing charts of trauma patients with liver injuries, whether isolated or in association with other organs, who underwent exploratory laparotomy, from January 2011 to December 2013. Results : We studied 392 patients, 107 of these with liver injury. The male: female ratio was 6.6 : 1 and the mean age was 30.12 years. Penetrating liver trauma occurred in 78.5% of patients, mostly with firearms. Associated injuries occurred in 86% of cases and intra-abdominal injuries were more common in penetrating trauma (p <0.01). The most commonly used operative technique was hepatorrhaphy and damage control surgery was applied in 6.5% of patients. The average amounts of blood products used were 6.07 units of packed red blood cells and 3.01 units of fresh frozen plasma. The incidence of postoperative complications was 29.9%, the most frequent being infectious, including pneumonia, peritonitis and intra-abdominal abscess. The survival rate of patients suffering from blunt trauma was 60%, and penetrating trauma, 87.5% (p <0.05). Conclusion : despite technological advances in diagnosis and treatment, mortality rates in liver trauma remain high, especially in patients suffering from blunt trauma in relation to penetrating one.

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Damage control or definitive repair? A retrospective review of abdominal trauma at a major trauma center in South Africa

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2018-000235 ◽

2019 ◽

Vol 4 (1) ◽

pp. e000235 ◽

Cited By ~ 1

Author(s):

Ross Weale ◽

Victor Kong ◽

Johan Buitendag ◽

Abraham Ras ◽

Joanna Blodgett ◽

...

Keyword(s):

South Africa ◽

Abdominal Trauma ◽

Injury Severity ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Organ Injury ◽

Trauma Patients ◽

Abbreviated Injury Scale ◽

Trauma Service

BackgroundThis study set out to review a large series of trauma laparotomies from a single center and to compare those requiring damage control surgery (DCS) with those who did not, and then to interrogate a number of anatomic and physiologic scoring systems to see which best predicted the need for DCS.MethodsAll patients over the age of 15 years undergoing a laparotomy for trauma during the period from December 2012 to December 2017 were retrieved from the Hybrid Electronic Medical Registry (HEMR) at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, namely the DCS and non-DCS cohort, based on what was recorded in the operative note. These groups were then compared in terms of demographics and spectrum of injury, as well as clinical outcome. The following scores were worked out for each patient: Penetrating Abdominal Trauma Index (PATI), Injury Severity Score, Abbreviated Injury Scale-abdomen, and Abbreviated Injury Scale-chest.ResultsA total of 562 patients were included, and 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. The mechanism was penetrating trauma in 81% of cases (453 of 562). A large proportion of trauma victims were male (503 of 562, 90%), with a mean age of 29.5±10.8. An overall mortality rate of 32% was recorded for DCS versus 4% for non-DCS (p<0.001). In general patients requiring DCS had higher lactate, and were more acidotic, hypotensive, tachycardic, and tachypneic, with a lower base excess and lower bicarbonate, than patients not requiring DCS. The most significant organ injuries associated with DCS were liver and intra-abdominal vascular injury. The only organ injury consistently predictive across all models of the need for DCS was liver injury. Regression analysis showed that only the PATI score is significantly predictive of the need for DCS (p=0.044). A final multiple logistic regression model demonstrated a pH <7.2 to be the most predictive (p=0.001) of the need for DCS.ConclusionDCS is indicated in a subset of severely injured trauma patients. A pH <7.2 is the best indicator of the need for DCS. Anatomic injuries in themselves are not predictive of the need for DCS.Levels of evidenceLevel III.

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Correlation between surgical site infection and obesity after exploratory laparotomy in trauma patients

QJM ◽

10.1093/qjmed/hcab097.012 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Ahmed Abdelaziz ◽

Ahmed Sabry ◽

Mohamed Fayek

Keyword(s):

Surgical Site Infection ◽

Abdominal Trauma ◽

Damage Control ◽

Exploratory Laparotomy ◽

Fascial Closure ◽

Wound Complications ◽

Trauma Patients ◽

Obese Patients ◽

Site Infection ◽

University Hospitals

Abstract Background Obesity has become a major contributor to the global burden of chronic disease and disability. Understanding the effect of obesity on the incidence of wound infections and other wound complications remains incomplete despite considerable attention to both the growing ‘‘epidemic’’ of obesity and the frequent occurrence of surgical site infection (SSI) after surgical procedures. Damage-control laparotomy specifically has been associated with a higher rate of infectious complications and a lower rate of primary fascial closure in obese patients. Aim of the work The aim of the study is to evaluate the correlation between obesity and surgical site infection (SSI) in patients undergoing exploratory laparotomy after abdominal trauma. Patients and methods A retrospective study performed on obese patients of both genders aged between 18 and 60 years old undergoing exploratory laparotomy after abdominal trauma at the surgery departments of Ain Shams University Hospitals, Al-Bank Al-Ahly Hospital, Al-Mataria Hospital and Al-Salam Hospital, Cairo, Egypt for two years (1st of January 2018 to 1st of January 2020). Patients with infected wounds, receiving antibiotic therapy at the time of injury, those with a known immunodeficiency, who died within 48 hours after injury, who had sustained burn injuries, who underwent surgery at another institution before admission to our hospital were excluded. The rate of 30-day SSI post-operatively among obese and non-obese patients were compared. Statistical analysis was also done. Results Out of 782 patients, only 480 of those patients for whom BMI data were available, 360 (75%) were males and 120 (25%) were females. Out of the 480 patients: 168 patients had BMI more than 30; 114 patients (67.8%) had SSI (P < 0.05), 312 patients had BMI less than 30; 61 patients (19.5%) had SSI. All of the included patients were fulfilling the inclusion and the exclusion criteria. On multivariate analysis, obesity was the strongest predictor of SSI (odds ratio = 1.59; 95% confidence interval, 1.32-1.91) after adjustment for sex and age. Obese patients with SSI compared with the non-obese had longer hospital stays (mean, 9.5 vs 8.1 days, respectively; P < .001) and markedly higher rates of hospital readmission (27.1% vs 6.5%, respectively; P < .001). Conclusion Obesity is considered as one of the risk factors in causing surgical site infection. Thus, this study showed the relation of BMI and obesity with surgical site infection in case of exploratory laparotomy after abdominal trauma.

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Resuscitation and coagulation in the severely injured trauma patient

Philosophical Transactions of the Royal Society B Biological Sciences ◽

10.1098/rstb.2010.0220 ◽

2011 ◽

Vol 366 (1562) ◽

pp. 192-203 ◽

Cited By ~ 39

Author(s):

Mark J. Midwinter ◽

Tom Woolley

Keyword(s):

Trauma Patient ◽

Damage Control ◽

Damage Control Surgery ◽

Physiological Status ◽

Trauma Patients ◽

Severely Injured ◽

Mortality And Morbidity ◽

Tissue Hypoperfusion ◽

Coagulation Status ◽

Haemostatic Resuscitation

Developments in the resuscitation of the severely injured trauma patient in the last decade have been through the increased understanding of the early pathophysiological consequences of injury together with some observations and experiences of recent casualties of conflict. In particular, the recognition of early derangements of haemostasis with hypocoagulopathy being associated with increased mortality and morbidity and the prime importance of tissue hypoperfusion as a central driver to this process in this population of patients has led to new resuscitation strategies. These strategies have focused on haemostatic resuscitation and the development of the ideas of damage control resuscitation and damage control surgery continuum. This in turn has led to a requirement to be able to more closely monitor the physiological status, of major trauma patients, including their coagulation status, and react in an anticipatory fashion.

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DAMAGE CONTROL SURGERY

The Professional Medical Journal ◽

10.29309/tpmj/2009.16.01.2962 ◽

2009 ◽

Vol 16 (01) ◽

pp. 12-16

Author(s):

MUHAMMAD ATEEQ ◽

SHAZIA JAHAN ◽

M. HANIF

Keyword(s):

Teaching Hospital ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Pelvic Trauma ◽

Biliary Fistula ◽

Phase Iii ◽

Severely Injured ◽

Life Threatening ◽

Abdominal Packing

Objective: To analyze the role of damage control in surgery in severely injured and polytrauma patients. D e s i g n:Descriptive study. S e t t i n g : Surgical unit of District Headquarter (teaching) Hospital, Rawalpindi. P e r i o d : January 2000 to December 2007.Patients a n d m e t h o d s : This study included 28 severely injured patients who presented in the accident and emergency department ofDistrict Headquarters (teaching) Hospital, Rawalpindi. These patients were unstable because of life threatening hemorrhage following someblunt or penetrating trauma. After immediate shifting to operation theater, resuscitation and operative intervention was done simultaneously.Different procedures of damage control surgery like abdominal packing for hepatic and pelvic trauma, major vascular ligation for vascularinjuries of neck and extremities were adopted in phase I. In phase II patients were managed in ITC for coagulopathy and hypothermia.Definitive treatment was done in Phase III after 24-72 hours once patients got stable. R e s u l t s : Total 28 patients included in the study. In18 patients abdominal packing for hepatic injury (n=11) and pelvic fractures (n=7) was done. Major vascular ligations in n=11 and temporaryintestinal clamping in n=1 patient. Planned re-exploration after 24-72 hours in n=16 and unplanned re-exploration within 24 hours in n=5patients was done. Complications included ongoing hemorrhage (n=5), coagulopathy (n=2), controlled biliary fistula (n=1), abdominalcompartment syndrome (n=1), cerebral ischemia (n=1) and gangrene of abdominal wall (n=1). Two patients died.

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