Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis

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.

The impact of operative time on the outcomes of necrotizing soft tissue infections: a multicenter cohort study

“…On the other hand, the reduced operative times were indeed associated with a significant shorter ICU and hospital stays, regardless of the presence of sepsis prior to surgery, the estimated TBSA affected and the ASA classification. The concept of reducing length of ICU and hospital stay by reducing operative times has not yet been described for NSTIs, but has been suggested for surgical procedures in trauma and general surgery [ 8 , 22 ]. Procter et al studied general surgical procedures and found that the odds ratio for ICU admission, adjusted for operative and patient risk variables, increased with 0.32 each half-hour of extra operative time and the hospital length of stay increased with 6% with each half hour extra operative time [ 8 ].…”

Indications for the Appropriate Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients

“…In another propensity-matched cohort study, Harvin et al reported that use of DC instead of definitive laparotomy [for intra-abdominal packing (68%), second-look laparotomy (6%), hemodynamic instability (15%), to expedite postoperative care or intervention (8%), abdominal compartment syndrome prophylaxis (1%), contamination (1%), or other/unclear reasons (1%)] was associated with a significantly increased incidence of gastrointestinal (GI) ileus and bleeding, abdominal fascial dehiscence, superficial surgical site infection (SSI), and death [19]. Finally, in a follow-up study by Harvin et al in 2019, injured patients who underwent DC laparotomy across six American, level-1 trauma centers and were judged by majority faculty vote to have been candidates for definitive laparotomy were matched 1:1 with those who underwent definitive trauma laparotomy at these centers using propensity scores [42]. In this study, for those whom surgeons had equipoise Table 2 Highest rated candidate indications for use of damage control surgery in civilian trauma patients.…”

“…We previously hypothesized that variation in use of DC surgery among trauma centers may occur when surgeons are uncertain which operative profile is best across the large number of varying clinical situations encountered regarding use of DC or definitive laparotomy, definitive laparotomy was associated with a significantly higher probability of fewer hospital-free, ventilator-free, and ICU-free days, suggesting that use of definitive laparotomy in this setting may decrease hospital resource utilization [42]. However, the two groups demonstrated a similar probability of major abdominal complications [42]. [3].…”

“…in different clinical situations and the lack of valid data supporting that DC laparotomy improves survival in severely injured patients. The possible overuse of DC laparotomy across these trauma centers is concerning as some recent data suggest that when DC is used instead of definitive laparotomy in patients in whom surgeons have equipoise between the two, use of DC laparotomy is associated with increased resource utilization [42].…”

What's new in critical illness and injury science? Management of the open abdomen: Getting it together!

“…In 872 patients, there was no difference in the incidence of major abdominal complications, but definitive laparotomy was associated with fewer hospital, ICU, and ventilator days. [20] Further study has been done at the University of Texas-Houston aiming to decrease the number of DCLs performed. Audits and feedback after each case led to a decrease in DCL, from 39% in the control group (2011–2013), to 23% in the Q1 group (2013–2015), and subsequently to 17% after the study period.…”