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He R, Kong V, Ko J, Narayanan A, Wain H, Bruce J, Laing G, Manchev V, Bekker W, Clarke D. A decade long overview of damage control laparotomy for abdominal gunshot wounds. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02563-2. [PMID: 38888788 DOI: 10.1007/s00068-024-02563-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE Over the last three decades, damage control laparotomy (DCL) has become important in the management of abdominal gunshot wounds (GSW). This paper reviews the experience of a single institution over a decade with the use of DCL for GSW of the abdomen. METHODS Longitudinal data (2013-2022) was collected from the Hybrid Electronic Medical Registry database to identify all patients with an abdominal GSW over the study period. The data was stratified based on patients who underwent DCL and those who did not. Descriptive analysis was completed to summarise the raw data. Univariate and multivariate analysis was completed to identify variables associated with undergoing DCL. RESULTS There were 135 patients (32%) who underwent DCL and 290 patients (68%) who did not. Colonic, small bowel, mesenteric, hepatic, pancreatic and intra-abdominal vessel injuries were associated with the need for DCL (P<0.05). In total, 85 of the 135 (63%) patients who underwent DCL required more than one damage control technique. There were 45 (33%) mortalities in the DCL group compared to 16 mortalities (6%) in the non-DCL group (P<0.001). CONCLUSION One third of patients who underwent a laparotomy following a gunshot wound to the abdomen had a DCL. The indications for DCL include both physiological criteria and injury patterns. DCL is associated with significant morbidity and mortality. Efforts need to be directed towards refining the indications for DCL in this group of patients to prevent inappropriate application of this potentially lifesaving technique.
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Affiliation(s)
- Reuben He
- Department of Surgery, The University of Auckland, Auckland, New Zealand.
| | - Victor Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Jonathan Ko
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | | | - Howard Wain
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - John Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Grant Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Vassil Manchev
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Wanda Bekker
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
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Doklestić K, Lončar Z, Coccolini F, Gregorić P, Mićić D, Bukumiric Z, Djurkovic P, Sengul D, Sengul I. “Zooming” in strategies and outcomes for trauma cases with Injury Severity Score (ISS) ≥16: promise or passé? REVISTA DA ASSOCIAÇÃO MÉDICA BRASILEIRA 2022; 68:847-852. [PMID: 35584438 PMCID: PMC9575904 DOI: 10.1590/1806-9282.20220216] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: Rescuing severe trauma cases is extremely demanding. The present study
purposed to analyze the efficiency of trauma management at Emergency Centre,
University Clinical Centre of Serbia, Belgrade, included outcome within 28
days. METHODS: This retrospective study involved 131 intensive care unit trauma cases with
total Injury Severity Score ≥16, in terms of administrating the two
strategies: (i) definitive surgical repair and (ii) damage control
laparotomy. RESULTS: The damage control laparotomy cases revealed statistically higher Injury
Severity Score and APACHE II scores, significant brain dysfunction, and
hemorrhagic shock on arrival (p<0.001). In addition, the damage control
laparotomy had a higher rate of respiratory complications, multiple organ
deficiency syndrome, and surgical wound complications (p=0.017, <0.001,
and 0.004, respectively), with more days on mechanical ventilation
(p=0.003). Overall mortality was 29.8%. Although higher early mortality
within ≤24 h in the damage control laparotomy (p=0.021) had been observed,
no difference between groups (p=0.172) after the 4th day of hospitalization
was detected. CONCLUSIONS: Trauma patients have a high mortality rate in the 1st hours after the
incident. Compelling evidence linking host and pathogen factors, such as
mitochondrial apoptosis pathways, appears to correlate with loss of organ
dysfunction, both cytopathologically and histopathologically. Adequate
selection of patients necessitating damage control laparotomy, allowed by
the World Society of Emergency Surgery, abdominopelvic trauma
classifications, and improvements in resuscitation, may improve the results
of severe trauma treatment.
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Affiliation(s)
- Krstina Doklestić
- University of Belgrade, Serbia; University Clinical Centre of Serbia, Serbia
| | - Zlatibor Lončar
- University of Belgrade, Serbia; University Clinical Centre of Serbia, Serbia
| | | | - Pavle Gregorić
- University of Belgrade, Serbia; University Clinical Centre of Serbia, Serbia
| | - Dusan Mićić
- University of Belgrade, Serbia; University Clinical Centre of Serbia, Serbia
| | - Zoran Bukumiric
- University of Belgrade, Serbia; University of Belgrade, Serbia
| | | | | | - Ilker Sengul
- Giresun University, Turkey; Giresun University, Turkey
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Willms A, Güsgen C, Schwab R, Lefering R, Schaaf S, Lock J, Kollig E, Jänig C, Bieler D. Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®. Langenbecks Arch Surg 2021; 407:805-817. [PMID: 34611749 DOI: 10.1007/s00423-021-02344-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma. METHODS Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene. RESULTS The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004). CONCLUSION DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.
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Affiliation(s)
- Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Christoph Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany.
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Sebastian Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Johan Lock
- Department of General, Transplantation, Vascular and Paediatric Surgery, University Hospital of Würzburg, VisceralWürzburg, Germany
| | - Erwin Kollig
- Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery, and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany
| | - Christoph Jänig
- Department of Anesthesiology and Intensive Care, German Armed Forces Central Hospital, Koblenz, Germany
| | - Dan Bieler
- Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery, and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany.,Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Medical School, Düsseldorf, Germany
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Brillantino A, Andreano M, Lanza M, D'Ambrosio V, Fusco F, Antropoli M, Lucia A, Zito ES, Forner A, Ambrosino F, Monte G, Cricrì AM, Robustelli U, De Masi A, Calce R, Ciardiello G, Renzi A, Castriconi M. Advantages of Damage Control Strategy With Abdominal Negative Pressure and Instillation in Patients With Diffuse Peritonitis From Perforated Diverticular Disease. Surg Innov 2019; 26:656-661. [PMID: 31221028 DOI: 10.1177/1553350619857561] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose. To evaluate the results of Damage Control Strategy (DCS) in the treatment of generalized peritonitis from perforated diverticular disease in patients with preoperative severe systemic diseases. Methods. All the patients with diffuse peritonitis (Hinchey 3 and 4) and the American Society of Anesthesiologists (ASA) score ≥3 were included and underwent DCS consisting of a 2-step procedure. The first was peritoneal lavage, perforated colon-stapled resection, and temporary abdominal closure with negative pressure wound therapy combined with instillation. The second step, 48 hours later, included the possibility of restoring intestinal continuity basing on local and general patients' conditions. Results. Thirty patients (18 [60%] women and 12 [40%] men, median age 68.5 [range = 35-84] years) were included (18 [60%] ASA III, 11 [36.7%] ASA IV, and 1 [0.03%] ASA V). Seven patients (23.3%) showed sepsis and 1 (3.33%) septic shock. At second surgery, 24 patients (80%) received a colorectal anastomosis and 6 patients (20%) underwent a Hartmann's procedure. Median hospital stay was 18 days (range = 12-62). Postoperative morbidity rate was 23.3% (7/30) and included 1 anastomotic leak treated with Hartmann's procedure. Consequently, at discharge from hospital, 23 patients (76.6%) were free of stoma. Primary fascial closure was possible in all patients. Conclusions. DCS with temporary abdominal closure by negative pressure wound therapy combined with instillation in patients with diffuse peritonitis from complicated diverticulitis could represent a feasible surgical option both in hemodynamically stable and no stable patients, showing encouraging results including a low stoma rate and an acceptable morbidity rate.
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