Damage control in penetrating duodenal trauma: less is better

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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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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Lessons learnt from the Pietermaritzburg experience with damage control laparotomy for trauma

Journal of the Royal Army Medical Corps ◽

10.1136/jramc-2018-000950 ◽

2018 ◽

Vol 164 (6) ◽

pp. 428-431

Author(s):

Ross D Weale ◽

V Y Kong ◽

J M Blodgett ◽

J Buitendag ◽

A Ras ◽

...

Keyword(s):

Trauma Registry ◽

Primary Repair ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Physiological Parameters ◽

Modern Concept ◽

Damage Control Laparotomy ◽

Trauma Service ◽

The Mean

IntroductionThe modern concept of damage control surgery (DCS) for trauma was first introduced less than three decades ago. This audit aims to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to distil the pertinent teaching lessons from this experience.MethodsAll patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry of the Pietermaritzburg Metropolitan Trauma Service, South Africa. Physiological parameters and visceral injuries were assessed. Statistical analysis was performed using STATA V.15.0.ResultsA total of 562 patients underwent trauma laparotomy during the period under review. The mechanism was penetrating trauma in 81% of cases (453/562). A great proportion of trauma victims were male (503/562, 90%), with a mean age of 29.5±10.8. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. Out of the 99 who required DCS, there were 32 mortalities (32%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28±0.15) with a raised lactate (5.25 mmol/L±3.71). Our primary repair rates for enteric injuries were surprisingly high.ConclusionJust under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient.

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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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Abdominal and thoracic wall closure: damage control surgery’s cinderella

Colombia Medica ◽

10.25100/cm.v52i2.4777 ◽

2021 ◽

Vol 52 (2) ◽

pp. e4144777

Author(s):

Fernando Rodríguez-Holguín ◽

Adolfo González-Hadad ◽

David Mejia ◽

Cecibel Ceballos ◽

Amber Nicole Himmler ◽

...

Keyword(s):

Damage Control ◽

Surgical Techniques ◽

Damage Control Surgery ◽

Standard Technique ◽

Thoracic Wall ◽

Trauma Patients ◽

Severely Injured ◽

Success Rates ◽

Surgical Closure ◽

Cavity Closure

Damage control surgery principles allow delayed management of traumatic lesions and early metabolic resuscitation by performing abbreviated procedures and prompt resuscitation maneuvers in severely injured trauma patients. However, the initial physiological response to trauma and surgery, along with the hemostatic resuscitation efforts, causes important side effects on intracavitary organs such as tissue edema, increased cavity pressure, and hemodynamic collapse. Consequently, different techniques have been developed over the years for a delayed cavity closure. Nonetheless, the optimal management of abdominal and thoracic surgical closure remains controversial. This article aims to describe the indications and surgical techniques for delayed abdominal or thoracic closure following damage control surgery in severely injured trauma patients, based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. We recommend negative pressure dressing as the gold standard technique for delayed cavity closure, associated with higher wall closure success rates and lower complication and mortality rates.

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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 surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

Colombia Medica ◽

10.25100/cm.v52i2.4425 ◽

2021 ◽

Vol 52 (2) ◽

pp. e4114425

Author(s):

Carlos Alberto Ordoñez ◽

Michael Parra ◽

Yaset Caicedo ◽

Natalia Padilla ◽

Edison Angamarca ◽

...

Keyword(s):

Surgical Management ◽

Large Bowel ◽

Damage Control ◽

Primary Anastomosis ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Bowel Injury ◽

Penetrating Injuries ◽

Hollow Viscus ◽

Injury Repair

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

The American Surgeon ◽

10.1177/000313481608200518 ◽

2016 ◽

Vol 82 (5) ◽

pp. 427-432 ◽

Cited By ~ 3

Author(s):

Jason W. Smith ◽

Nick Nash ◽

Levi Procter ◽

Matthew Benns ◽

Glen A. Franklin ◽

...

Keyword(s):

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Abdominal Sepsis ◽

Fascial Closure ◽

Trauma Patients ◽

Complication Rates ◽

Emergency General Surgery ◽

Risk Of Death ◽

Abdominal Complication

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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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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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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