Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry)

Abstract

Purpose Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort. Methods We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC. Results In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11,22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002). Conclusion Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma-and non-trauma DCL. Level of evidence 2B.

Damage control surgery in emergency general surgery: What you need to know

“…In a prospective, multicenter study, reducing the interval between the index laparotomy and initial takeback improved PFC rates, with each hour delay reducing the likelihood of success 69 . Likewise, in a retrospective review, returning to the operating room within 24 hours and minimizing the total number of reoperations predicted successful PFC in both trauma and EGS patient populations 62 …”

“…However, in cases of a second look in mesenteric ischemia or IAS, it is reasonable to delay the second exploration to 48 hours 20 . Efforts should be made to perform all definitive repairs during the first relaparotomy, as additional takebacks are associated with increased all-cause infectious complications and a decreased likelihood of abdominal wall closure, the last phase of DCS 62–64 …”

“…20 Efforts should be made to perform all definitive repairs during the first relaparotomy, as additional takebacks are associated with increased all-cause infectious complications and a decreased likelihood of abdominal wall closure, the last phase of DCS. [62][63][64]…”

“…69 Likewise, in a retrospective review, returning to the operating room within 24 hours and minimizing the total number of reoperations predicted successful PFC in both trauma and EGS patient populations. 62 In addition to negative pressure TAC, fascial traction systems offer another surgical option to increase rates of PFC. 49 Although not utilized in the unstable patient during the abbreviated laparotomy, these methods are often required when the OA cannot be closed at the initial relaparotomy.…”

Optimized Treatment of Nosocomial Peritonitis

“…When the selected strategy is not adapted to the patient, the disease, and the expertise of the operator, the clinical management becomes more complex [92]. When source control cannot be definitive, a damage control procedure must be considered [93].…”