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

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

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

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.

A case of burn evisceration with full-thickness injury to abdominal wall, bowel, bladder, and three extremities

Background Severe electrical burns are a rare cause of admission to major burn centers. Incidence of electrical injury causing full-thickness injury to viscera is an increasingly scarce, but severe presentation requiring rapid intervention. We report one of few cases of a patient with full-thickness electrical injury to the abdominal wall, bowel, and bladder. Case report The patient, a 22-year-old male, was transferred to our institution from his local hospital after sustaining a suspected electrical burn. On arrival the patient was noted to have severe burn injuries to the lower abdominal wall with evisceration of multiple loops of burned small bowel as well as burns to the groin, left upper, and bilateral lower extremities. In the trauma bay, primary and secondary surveys were completed, and the patient was taken for CT imaging and then emergently to the operating room. On exploration, the patient had massive full-thickness burns to the lower abdominal wall, five full-thickness burns to small bowel, and intraperitoneal bladder rupture secondary to full-thickness burn. The patient underwent damage-control laparotomy including enterectomies, debridement of bladder coagulative necrosis, and layered closure of bladder injury followed by temporary abdominal closure with vacuum dressing. The patient also underwent right leg escharotomy and partial right foot fasciotomies. The patient was subsequently transferred to the nearest burn center for continued resuscitation and comprehensive burn care. Conclusion Severe electrical burns can be associated with devastating visceral injuries in rare cases. Though uncommon, these injuries are associated with very high mortality rates. The authors assert that rapid evaluation and initial stabilization following ATLS guidelines, damage-control laparotomy, and goal-directed resuscitation in concert with transfer to a major burn center are essential in effecting a successful outcome in these challenging cases.

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

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).

Damage control laparotomy in trauma: a pilot randomized controlled trial. The DCL trial

BackgroundAlthough 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.MethodsEligible 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.ResultsOf 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.ConclusionThe 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 evidenceLevel II.