Indications for Use of Damage Control Surgery in Civilian Trauma Patients: A Content Analysis and Expert Appropriateness Rating Study. Ann Surg. 2016;263:1018-1027. [PMID: 26445471 DOI: 10.1097/sla.0000000000001347]

Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review

BACKGROUND

The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures.

METHODS

This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach.

RESULTS

A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2).

CONCLUSION

A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room.

LEVEL OF EVIDENCE

Delphi-Consensus/Systematic Review; Level IV.

Proper hepatic artery transection followed by blunt abdominal trauma: A case report and review of literature

Abdominal vascular injuries, especially in the celiac trunk, are uncommon in blunt trauma, yet their life-threatening nature necessitates rapid surgical interventions to control possible massive bleedings. Damage control surgery principles may aid management. It is crucial to thoroughly assess all trauma patients, even in instances of initial normal physical examinations.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient

ABSTRACT

Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.

The open abdomen in mesenteric ischemia: A tool for patients undergoing revascularization

BACKGROUND

We examined outcomes in Acute Mesenteric Ischemia (AMI) with the hypothesis that Open Abdomen (OA) is associated with decreased mortality.

METHODS

We performed a cohort study reviewing NSQIP emergency laparotomy patients, 2016-2020, with a postoperative diagnosis of mesenteric ischemia. OA was defined using flags for patients without fascial closure. Logistic regression was used with outcomes of 30-day mortality and several secondary outcomes.

RESULTS

Out of 5514 cases, 4624 (83.9%) underwent resection and 387 (7.0%) underwent revascularization. The OA rate was 32.6%. 10.8% of patients who were closed required reoperation. After adjustment for demographics, transfer status, comorbidities, preoperative variables including creatinine, white blood cell count, and anemia, as well as operative time, OA was associated with OR 1.58 for mortality (95% CI [1.38, 1.81], p < 0.001). Among revascularizations, there was no such association (p = 0.528). OA was associated with ventilator support >48 h (OR 4.04, 95% CI [3.55, 4.62], and p < 0.001).

CONCLUSION

OA in AMI was associated with increased mortality and prolonged ventilation. This is not so in revascularization patients, and 1 in 10 patients who underwent primary closure required reoperation. OA should be considered in specific cases of AMI.

LEVEL OF EVIDENCE

Retrospective cohort, Level III.

Ultra-forward surgical support for special operations forces. Conception, development and certification of the French Special Operations Surgical Team (SOST) airborne capability

When special operations forces (SOF) are in action, a surgical team (SOST) is usually ground deployed as close as possible to the combat area, to try and provide surgical support within the golden hour. The French SOST is composed of 6 people: 2 surgeons, 1 scrub nurse, 1 anaesthetist, 1 anesthetic nurse and 1 SOF paramedic. It can be deployed in 45 min under a tent or in a building. However, some tactical situations prevent the ground deployment. A solution is to deploy the SOST in a tactical unprepared aircraft hold, to make it possible to offer DCS, to treat non-compressible exsanguinating trauma, without any ground logistical footprint. This article describes the stages of the design, development and certification process of the airborne SOST capability. The authors report the modifications and adaptations of the equipment and the surgical paradigms which make it possible to solve the constraints linked to the aeronautical and combat environment. Study type/level of evidence Care management Level of Evidence IV.

Patient-Reported Outcomes Following Severe Abdominal Trauma: A Secondary Analysis of the Damage Control Laparotomy Trial

INTRODUCTION

Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL).

METHODS

The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference.

RESULTS

Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 - 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 - 0.52) DEF versus 0.31 (IQR -0.03 - 0.43) DCL, and at six months 0.51 (IQR 0.30 - 0.74) DEF versus 0.50 (IQR 0.28 - 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively.

CONCLUSIONS

Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.

Optimized Treatment of Nosocomial Peritonitis

This comprehensive review aims to provide a practical guide for intensivists, focusing on enhancing patient care associated with nosocomial peritonitis (NP). It explores the epidemiology, diagnosis, and management of NP, a significant contributor to the mortality of surgical patients worldwide. NP is, per definition, a hospital-acquired condition and a consequence of gastrointestinal surgery or a complication of other diseases. NP, one of the most prevalent causes of sepsis in surgical Intensive Care Units (ICUs), is often associated with multi-drug resistant (MDR) bacteria and high mortality rates. Early clinical suspicion and the utilization of various diagnostic tools like biomarkers and imaging are of great importance. Microbiology is often complex, with antimicrobial resistance escalating in many parts of the world. Fungal peritonitis and its risk factors, diagnostic hurdles, and effective management approaches are particularly relevant in patients with NP. Contemporary antimicrobial strategies for treating NP are discussed, including drug resistance challenges and empirical antibiotic regimens. The importance of source control in intra-abdominal infection management, including surgical and non-surgical interventions, is also emphasized. A deeper exploration into the role of open abdomen treatment as a potential option for selected patients is proposed, indicating an area for further investigation. This review underscores the need for more research to advance the best treatment strategies for NP.

Damage Control Surgery and Transfer in Emergency General Surgery

Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.

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

ABSTRACT

Damage-control surgery (DCS) is a strategy adopted to limit initial operative interventions in the unstable surgical patient, delaying definitive repairs and abdominal wall closure until physiologic parameters have improved. Although this concept of "physiology over anatomy" was initially described in the management of severely injured trauma patients, the approaches of DCS have become common in the management of nontraumatic intra-abdominal emergencies.While the utilization of damage-control methods in emergency general surgery (EGS) is controversial, numerous studies have demonstrated improved outcomes, making DCS an essential technique for all acute care surgeons. Following a brief history of DCS and its indications in the EGS patient, the phases of DCS will be discussed including an in-depth review of preoperative resuscitation, techniques for intra-abdominal source control, temporary abdominal closure, intensive care unit (ICU) management of the open abdomen, and strategies to improve abdominal wall closure.

Conservative management of multi-trauma induced peritonitis: Experience, outcomes, and indications

BACKGROUND

The concept of mandatory laparotomy in treating traumatic peritonitis has been increasingly questioned recently.

AIM

To summarize and share the experience of conservative treatment of patients with multi-trauma induced peritonitis.

METHODS

A retrospective review was performed on patients with multiple injury induced traumatic peritonitis.

RESULTS

A total of 184 patients with multiple injury induced traumatic peritonitis were reviewed. 46 of them underwent conservative treatment. None of the 46 patients with conservative treatment switched to surgical treatment, and all of them were cured and discharged after successful conservative treatment. No significant abnormal findings were observed at regular follow-up after discharge.

CONCLUSION

Conservative management is safe, effective, feasible, and beneficial in hemodynamically stable patients with traumatic peritonitis if there is no definite evidence of severe abdominal visceral organ injury.

The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review

BACKGROUND

The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery.

METHODS

A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen.

RESULTS

The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible.

CONCLUSION

Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.

Standard practice in the treatment of unstable pelvic ring injuries: an international survey

PURPOSE

Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe.

METHODS

A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents).

RESULTS

The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization).

CONCLUSION

The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences' impact on outcomes needs to be further explored.

National Assessment of Opportunities for Improvement in Preventable Trauma Deaths: A Mixed-Methods Study

Trauma is a significant public health issue worldwide, particularly affecting economically active age groups. Quality management of trauma care at the national level is crucial to improve outcomes of major trauma. In Korea, a biennial nationwide survey on preventable trauma death rate is conducted. Based on the survey results, we analyzed opportunities for improving the trauma treatment process. Expert panels reviewed records of 8282 and 8482 trauma-related deaths in 2017 and 2019, respectively, identifying 258 and 160 cases in each year as preventable deaths. Opportunities for improvement were categorized into prehospital, interhospital, and hospital stages. Hemorrhage was the primary cause of death, followed by sepsis/multiorgan failure and central nervous system injury. Delayed hemostatic procedures and transfusions were common areas for improvement in hospital stage. Interhospital transfers experienced significant delays in arrival time. This study emphasizes the need to enhance trauma care by refining treatment techniques, centralizing patients in specialized facilities, and implementing comprehensive reviews and performance improvements throughout the patient transfer system. The findings offer valuable insights for addressing trauma care improvement from both clinical and systemic perspectives.

How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature

INTRODUCTION

Early patient assessment is relevant for surgical decision making in severely injured patients and early definitive surgery is known to be beneficial in stable patients. The aim of this systematic review is to extract parameters indicative of risk factors for adverse outcome. Moreover, we aim to improve decision making and separate patients who would benefit from early versus staged definitive surgical fixation.

METHODS

Following the PRISMA guidelines, a systematic review of peer-reviewed articles in English or German language published between (2000 and 2022) was performed. The primary outcome was the pathophysiological response to polytrauma including coagulopathy, shock/haemorrhage, hypothermia and soft tissue injury (trauma, brain injury, thoracic and abdominal trauma, and musculoskeletal injury) to determine the treatment strategy associated with the least amount of complications. Articles that had used quantitative parameters to distinguish between stable and unstable patients were summarized. Two authors screened articles and discrepancies were resolved by consensus. Quantitative values for relevant parameters indicative of an unstable polytrauma patient were obtained.

RESULTS

The initial systematic search using MeSH criteria yielded 1550 publications deemed relevant to the following topics (coagulopathy (n = 37), haemorrhage/shock (n = 7), hypothermia (n = 11), soft tissue injury (n = 24)). Thresholds for stable, borderline, unstable and in extremis conditions were defined according to the existing literature as follows: Coagulopathy; International Normalized Ratio (INR) and viscoelastic methods (VEM)/Blood/shock; lactate, systolic blood pressure and haemoglobin, hypothermia; thresholds in degrees Celsius/Soft tissue trauma: traumatic brain injury, thoracic and abdominal trauma and musculoskeletal trauma.

CONCLUSION

In this systematic literature review, we summarize publications by focusing on different pathways that stimulate pathophysiological cascades and remote organ damage. We propose that these parameters can be used for clinical decision making within the concept of safe definitive surgery (SDS) in the treatment of severely injured patients.

Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies

Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.

The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania

BACKGROUND

Damage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania.

METHODS

We analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for "reopening of recent laparotomy" or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates.

RESULTS

In total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality.

CONCLUSION

There is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.

Pathophysiology in patients with polytrauma

The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.

Severe isolated injuries have a high impact on resource use and mortality: a Dutch nationwide observational study

PURPOSE

The Berlin poly-trauma definition (BPD) has proven to be a valuable way of identifying patients with at least a 20% risk of mortality, by combining anatomical injury characteristics with the presence of physiological risk factors (PRFs). Severe isolated injuries (SII) are excluded from the BPD. This study describes the characteristics, resource use and outcomes of patients with SII according to their injured body region, and compares them with those included in the BPD.

METHODS

Data were extracted from the Dutch National Trauma Registry between 2015 and 2019. SII patients were defined as those with an injury with an Abbreviated Injury Scale (AIS) score ≥ 4 in one body region, with at most minor additional injuries (AIS ≤ 2). We performed an SII subgroup analysis per AIS region of injury. Multivariable linear and logistic regression models were used to calculate odds ratios (ORs) for SII subgroup patient outcomes, and resource needs.

RESULTS

A total of 10.344 SII patients were included; 47.8% were ICU admitted, and the overall mortality was 19.5%. The adjusted risk of death was highest for external (2.5, CI 1.9-3.2) and for head SII (2.0, CI 1.7-2.2). Patients with SII to the abdomen (2.3, CI 1.9-2.8) and thorax (1.8, CI 1.6-2.0) had a significantly higher risk of ICU admission. The highest adjusted risk of disability was recorded for spine injuries (10.3, CI 8.3-12.8). The presence of ≥ 1 PRFs was associated with higher mortality rates compared to their poly-trauma counterparts, displaying rates of at least 15% for thoracic, 17% for spine, 22% for head and 49% for external SII.

CONCLUSION

A severe isolated injury is a high-risk entity and should be recognized and treated as such. The addition of PRFs to the isolated anatomical injury criteria contributes to the identification of patients with SII at risk of worse outcomes.

Single Center Retrospective Review of Post-laparotomy CT Abdomen and Pelvis Findings and Trends

Purpose

To identify common findings visualized on CT following damage control laparotomy, including post-surgical changes and additional injuries, and to determine change in frequency of post-laparotomy CT at our institution over time.

Methods

Single institution, IRB-Exempt, retrospective review of the University of Kentucky trauma registry from 1/2006 to 2/2019 for all trauma patients undergoing exploratory laparotomy initially and subsequently undergoing CT of the abdomen and pelvis within 24 hours. Operative findings from surgical operation notes and findings reported on post-laparotomy CT were recorded, including vascular and solid organ injuries, operative changes, free intraperitoneal fluid/air, and retroperitoneal findings. Next steps in management were also recorded.

Results

In total 1,047 patients underwent exploratory laparotomy initially at our institution between 1/2006-2/2019. Of those, only 96 had a diagnostic CT of the abdomen and pelvis within 24 h after initial surgery, first occurring in 2010. Among these 96, there were 71 blunt and 25 penetrating injuries. Most common injuries recognized during exploratory laparotomy were bowel/mesentery (55), spleen (34), and liver (26). Regarding CT findings, all patients (96/96, 100%) had residual pneumoperitoneum, 84/96 (87.5%) had residual hemoperitoneum, 36/96 (37.5%) noted post-surgical changes or additional injuries to the spleen, 36/96 (37.5%) to the bowel/mesentery, and 32/96 (33.3%) to the liver, and 34/96 (35.4%) were noted to have pelvic fractures. After CT, 31/96 (32.3%) went back to the OR for relook laparotomy and additional surgical intervention and 7/96 (7.3%) went to IR for embolization. Most common procedures during relaparotomy involved the bowel (8) and solid organs (6).

Conclusions

CT examination within 24 h post damage control laparotomy was exceedingly rare at our institution prior to 2012 but has steadily increased. Frequency now averages 20.5% yearly. Damage control laparotomy is an uncommon clinical scenario; however, knowledge of frequent injuries and common post-operative changes will aid in radiologist detection of additional injuries helping shape next step management and provide adequate therapy.

Assessing Factor V Antigen and Degradation Products in Burn and Trauma Patients

INTRODUCTION

Proposed mechanisms of acute traumatic coagulopathy (ATC) include decreased clotting potential due to factor consumption and proteolytic inactivation of factor V (FV) and activated factor V (FVa) by activated protein C (aPC). The role of FV/FVa depletion or inactivation in burn-induced coagulopathy is not well characterized. This study evaluates FV dynamics following burn and nonburn trauma.

METHODS

Burn and trauma patients were prospectively enrolled. Western blotting was performed on admission plasma to quantitate levels of FV antigen and to assess for aPC or other proteolytically derived FV/FVa degradation products. Statistical analysis was performed with Spearman's, Chi-square, Mann-Whitney U test, and logistic regression.

RESULTS

Burn (n = 60) and trauma (n = 136) cohorts showed similar degrees of FV consumption with median FV levels of 76% versus 73% (P = 0.65) of normal, respectively. Percent total body surface area (TBSA) was not correlated with FV, nor were significant differences in median FV levels observed between low and high TBSA groups. The injury severity score (ISS) in trauma patients was inversely correlated with FV (ρ = -0.26; P = 0.01) and ISS ≥ 25 was associated with a lower FV antigen level (64% versus. 93%; P = 0.009). The proportion of samples showing proteolysis-derived FV was greater in trauma than burn patients (42% versus. 16%; P = 0.0006).

CONCLUSIONS

Increasing traumatic injury severity is associated with decreased FV antigen levels, and a greater proportion of trauma patient samples exhibit proteolytically degraded FV fragments. These associations are not present in burns, suggesting that mechanisms underlying FV depletion in burn and nonburn trauma are not identical.

Reinterventions after damage control surgery

Damage control has well-defined steps. However, there are still controversies regarding whom, when, and how re-interventions should be performed. This article summarizes the Trauma and Emergency Surgery Group (CTE) Cali-Colombia recommendations about the specific situations concerning second interventions of patients undergoing damage control surgery. We suggest packing as the preferred bleeding control strategy, followed by unpacking within the next 48-72 hours. In addition, a deferred anastomosis is recommended for correction of intestinal lesions, and patients treated with vascular shunts should be re-intervened within 24 hours for definitive management. Furthermore, abdominal or thoracic wall closure should be attempted within eight days. These strategies aim to decrease complications, morbidity, and mortality.

Variation in use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia

Background

It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy.

Methods

A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy.

Results

Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39–40.27], level-1 verification status (OR = 6.02; 95% CI 2.01–18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20–2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01–1.58) in the last year.

Conclusions

The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-021-00396-7.

Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®

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.

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

Background

Although 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.

Methods

Eligible 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.

Results

Of 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.

Conclusion

The 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 evidence

Level II.

Analysis of Later Stage Morbidity and Mortality after Pancreatic Surgery Because of Abdominal Trauma

Background: Pancreatic trauma surgery is a complicated surgical procedure for severe pancreatic injuries, accompanied by a high incidence of complications and mortality. This study was designed to explore the long-term prognosis of pancreatic surgery because of abdominal trauma. Patients and Methods: The clinical data of 103 patients who were admitted to Jinling Hospital between August 2012 and August 2019 who had pancreatic trauma surgery were analyzed retrospectively. Results: All admissions involved pancreatic trauma surgery performed at an outside hospital network, which later transferred patients to our institution because of post-operative later-stage complications. Eight patients received American Association for the Surgery of Trauma (AAST) grade 1 or 2 pancreatic injuries and 95 received AAST grade 3, 4, or 5 pancreatic injuries. The primary surgical management of pancreatic injuries included drainage of the pancreatic injury (n = 28), repair of the pancreas (n = 35), partial pancreatectomy (n = 15), pancreaticojejunostomy (n = 6), and pancreaticoduodenectomy (n = 19). The most common mechanism of trauma was motor vehicle collision (n = 72), crush injury (n = 26), and stab wound (n = 5). Of 103 patients suffered varying degrees of gastrointestinal fistulae and intra-abdominal infections, there were 66 cases of pancreatic fistulae (64.1%), 49 cases of enteric fistulae (47.6%), 26 cases of colonic fistulae (25.2%), 14 cases of gastric or gastrointestinal anastomotic fistulae (13.6%), and 13 cases of biliary fistulae (12.6%). Ninety-five patients survived and eight patients died after therapy; the mean length of intensive care unit stay was 33 days. The number of patients who underwent emergency pancreaticoduodenectomy (EPD), the incidence of blood transfusion, the number of fistulae per patient, and the duration of mechanical ventilation and bacteremia in the mortality group were substantially higher than in the survival group (p < 0.05 each). The patients who underwent EPD had more grade 5 pancreatic injuries, more blood transfusions, higher peak total bilirubin, greater numbers of fistulae and open abdomen, and longer duration of mechanical ventilation and mortality than other patients (p < 0.05 each). Conclusions: The grade of pancreatic injury was associated with mortality and post-operative complications. The post-operative mortality and occurrence of complications of EPD because of abdominal trauma were significant; use of damage control surgery could potentially reduce the morbidity and mortality related to this procedure.

Damage control surgery in lung trauma

Damage control techniques applied to the management of thoracic injuries have evolved over the last 15 years. Despite the limited number of publications, information is sufficient to scatter some fears and establish management principles. The severity of the anatomical injury justifies the procedure of damage control in only few selected cases. In most cases, the magnitude of the physiological derangement and the presence of other sources of bleeding within the thoracic cavity or in other body compartments constitutes the indication for the abbreviated procedure. The classification of lung injuries as peripheral, transfixing, and central or multiple, provides a guideline for the transient bleeding control and for the definitive management of the injury: pneumorraphy, wedge resection, tractotomy or anatomical resection, respectively.

Identification of specific patterns such as the need for resuscitative thoracotomy, or aortic occlusion, the existence of massive hemothorax, a central lung injury, a tracheobronchial injury, a major vascular injury, multiple bleeding sites as well as the recognition of hypothermia, acidosis or coagulopathy, constitute the indication for a damage control thoracotomy. In these cases, the surgeon executes an abbreviated procedure with packing of the bleeding surfaces, primary management with packing of some selected peripheral or transfixing lung injuries, and the postponement of lung resection, clamping of the pulmonary hilum in the most selective way possible. The abbreviation of the thoracotomy closure is achieved by suturing the skin over the wound packed, or by installing a vacuum system. The management of the patient in the intensive care unit will allow identification of those who require urgent reintervention and the correction of the physiological derangement in the remaining patients for their scheduled reintervention and definitive management.

Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review

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.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

French civilian surgical expertise still inadequately prepared for mass casualties 3 years after major terror attacks in Paris (2015) and Nice (2016)

BACKGROUND

Three years after the terror attacks in Paris and Nice, this study aims to determine the level of interest, the technical skills and level of surgical activity in exsanguinating trauma care for a nonselected population of practicing French surgeons.

METHODS

A questionnaire was sent between July and December 2017 to French students and practicing surgeons, using the French Surgical Colleges' mailing lists. Items analyzed included education, training, interest and clinical activity in trauma care and damage-control surgery (DCS).

RESULTS

622 questionnaires were analyzed and was composed of 318 (51%) certificated surgeons, of whom 56% worked in university teaching hospitals and 47% in Level I trauma centers (TC1); 44% were digestive surgeons and 7% were military surgeons. The mean score of 'interest in trauma care' was 8/10. Factors associated with a higher score were being a resident doctor (p = 0.01), a digestive surgeon (p = 0.0013), in the military (p = 1,71 × 10) and working in TC1 (p = 0.034). The mean "DCS techniques knowledge" score was 6.2/10 and factors significantly associated with a higher score were being a digestive surgeon (respectively, p = 0.0007 and p = 0.001) and in the military (respectively p = 1.74 × 10 and p = 3.94 × 10). Reported clinical activity in trauma and DCS were low. Additional continuing surgical education courses in trauma were completed by 23% of surgeons.

CONCLUSION

French surgeons surveyed showed considerable interest in trauma care and treatment. Despite this, and regardless of surgical speciality, their theoretical and practical knowledge of necessary DCS skills remain inadequate.

LEVEL OF EVIDENCE

Level III, Study Type Survey.

Indications and interventions of damage control orthopedic surgeries: an expert opinion survey

OBJECTIVES

The objectives of this study were to gather an expert opinion survey and to evaluate the suitability of summarized indications and interventions for DCO.

BACKGROUND

The indications to perform temporary surgery in musculoskeletal injuries may vary during the hospitalization and have not been defined. We performed a literature review and an expert opinion survey about the indications for damage control orthopaedics (DCO).

METHODS

Part I: A literature review was performed on the basis of the PubMed library search. Publications were screened for damage control interventions in the following anatomic regions: "Spine", "Pelvis", "Extremities" and "Soft Tissues". A standardized questionnaire was developed including a list of damage control interventions and associated indications. Part II: Development of the expert opinion survey: experienced trauma and orthopaedic surgeons participated in the consensus process.

RESULTS

Part I: A total of 646 references were obtained on the basis of the MeSH terms search. 74 manuscripts were included. Part II: Twelve experts in the field of polytrauma management met at three consensus meetings. We identified 12 interventions and 79 indications for DCO. In spinal trauma, percutaneous interventions were determined beneficial. Traction was considered harmful. For isolated injuries, a new terminology should be used: "MusculoSkeletal Temporary Surgery".

CONCLUSION

This review demonstrates a detailed description of the management consensus for abbreviated musculoskeletal surgeries. It was consented that early fixation is crucial for all major fractures, and certain indications for DCO were dropped. Authors propose a distinct terminology to separate local (MuST surgery) versus systemic (polytrauma: DCO) scenarios.

Multidetector CT Findings in the Abdomen and Pelvis after Damage Control Surgery for Acute Traumatic Injuries

After experiencing blunt or penetrating trauma, patients in unstable condition who are more likely to die of uncorrected shock than of incomplete injury repairs undergo emergency limited exploratory laparotomy, which is also known as damage control surgery (DCS). This surgery is part of a series of resuscitation steps, with the goal of stabilizing the patient's condition, with rapid surgical control of hemorrhage followed by supportive measures in the intensive care unit before definitive repair of injuries. These patients often are imaged with multidetector CT within 24-48 hours of the initial surgery. Knowledge of this treatment plan is critical to CT interpretation, because there are anatomic derangements and foreign bodies that would not be present in patients undergoing surgery for other reasons. Patients may have injuries beyond the surgical field that are only identified at imaging, which can alter the care plan. Abnormalities related to the resuscitation period such as the CT hypoperfusion complex and ongoing hemorrhage can be recognized at CT. Familiarity with these imaging and clinical findings is important, because they can be seen not only in trauma patients after DCS but also in other patients in the critical care setting. The interpretation of imaging studies can be helped by an understanding of the diagnostic challenges of grading organ injuries with surgical materials in place and the awareness of potential artifacts on images in these patients. Online supplemental material is available for this article. ^©RSNA, 2019 See discussion on this article by LeBedis .

Outcomes after pneumonectomy versus limited lung resection in adults with traumatic lung injury

Pneumonectomy after traumatic lung injury (TLI) is associated with shock, increased pulmonary vascular resistance, and eventual right ventricular failure. Historically, trauma pneumonectomy (TP) mortality rates ranged between 53 and 100%. It is unclear if contemporary mortality rates have improved. Therefore, we evaluated outcomes associated with TP and limited lung resections (LLR) (i.e., lobectomy and segmentectomy) and aimed to identify predictors of mortality, hypothesizing that TP is associated with greater mortality versus LLR. We queried the Trauma Quality Improvement Program (2010–2016) and performed a multivariable logistic regression to determine the independent predictors of mortality in TLI patients undergoing TP versus LLR. TLI occurred in 287,276 patients. Of these, 889 required lung resection with 758 (85.3%) undergoing LLR and 131 (14.7%) undergoing TP. Patients undergoing TP had a higher median injury severity score (26.0 vs. 24.5, p = 0.03) but no difference in initial median systolic blood pressure (109 vs. 107 mmHg, p = 0.92) compared to LLR. Mortality was significantly higher for TP compared to LLR (64.9% vs 27.2%, p < 0.001). The strongest independent predictor for mortality was undergoing TP versus LLR (OR 4.89, CI 3.18–7.54, p < 0.001). TP continues to be associated with a higher mortality compared to LLR. Furthermore, TP is independently associated with a fivefold increased risk of mortality compared to LLR. Future investigations should focus on identifying parameters or treatment modalities that improve survivability after TP. We recommend that surgeons reserve TP as a last-resort management given the continued high morbidity and mortality associated with this procedure.

Anal function and quality of life analysis after laparoscopic modified Parks for ultra-low rectal cancer patients

Background

To assess postoperative anal function and quality of life of ultra-low rectal cancer patients treated by laparoscopic modified Parks surgery.

Methods

From February 2017 to March 2019, 114 patients with ultra-low rectal cancer above T2 were treated respectively with ultra-low anterior resection (Dixon), modified coloanal anastomosis (modified Parks), and Miles according to the preoperative stage and anastomotic position. The postoperative anal function and Fecal Incontinence Quality of Life Scale (FIQL) of each patient were collected and synthetically analyzed.

Results

Compared with the Dixon group, the postoperative anal function and FIQL in the Parks group were poor at the early stage. However, from 6 to 12 months after surgery, the scores of anal function and FIQL in the Parks group were similar to those in the Dixon group (P > 0.05). Compared with the Miles group, the FIQL of the two groups were similar in the early postoperative stage. However, with the passage of time, from 3 to 9 months after surgery, the four domains of FIQL in the Parks group were higher than those in the Miles group successively (P < 0.05).

Conclusions

Laparoscopic modified Parks is a safe, effective, and economical anus-preserving surgery. Although its early anal function and FIQL were poor, it could gradually recover to the similar level as Dixon. Moreover, it can save the anus and obtain a better postoperative quality of life for some patients who previously could only undergo Miles.

Better understanding the utilization of damage control laparotomy: A multi-institutional quality improvement project

BACKGROUND

Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multicenter quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists.

METHODS

In 2016, six US Level I trauma centers performed a yearlong, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. Damage control laparotomy cases were adjudicated based on the majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for 2 years prior (2014 and 2015) was retrospectively collected and used as a control. To account for secular trends of DCL, interrupted time series was used to effectiveness of the QI interventions.

RESULTS

Eight hundred seventy-two emergent laparotomies were performed: 73% definitive laparotomies, 24% DCLs, and 3% intraoperative deaths. Of the 209 DCLs, 162 (78%) were voted appropriate, and 47 (22%) were voted to have been potentially safe for definitive laparotomy. Rates of DCL ranged from 16% to 34%. Common indications for DCL for which consensus existed were packing (103/115 [90%] appropriate) and hemodynamic instability (33/40 [83%] appropriate). The only common indication for which primary closure at the initial laparotomy could have been safely performed was avoiding a planned second look (16/32 [50%] appropriate).

CONCLUSION

A single faceted QI intervention failed to decrease the rate of DCL at six US Level I trauma centers. However, opportunities for improvement in safely decreasing the rate of DCL were present. Second look laparotomy appears to lack consensus as an indication for DCL and may represent a target to decrease the rate of DCL after injury.

LEVEL OF EVIDENCE

Epidemiological study with one negative criterion, level III.

Early Identification of Trauma-induced Coagulopathy: Development and Validation of a Multivariable Risk Prediction Model

OBJECTIVE

The aim of this study was to develop and validate a risk prediction tool for trauma-induced coagulopathy (TIC), to support early therapeutic decision-making.

BACKGROUND

TIC exacerbates hemorrhage and is associated with higher morbidity and mortality. Early and aggressive treatment of TIC improves outcome. However, injured patients that develop TIC can be difficult to identify, which may compromise effective treatment.

METHODS

A Bayesian Network (BN) prediction model was developed using domain knowledge of the causal mechanisms of TIC, and trained using data from 600 patients recruited into the Activation of Coagulation and Inflammation in Trauma (ACIT) study. Performance (discrimination, calibration, and accuracy) was tested using 10-fold cross-validation and externally validated on data from new patients recruited at 3 trauma centers.

RESULTS

Rates of TIC in the derivation and validation cohorts were 11.8% and 11.0%, respectively. Patients who developed TIC were significantly more likely to die (54.0% vs 5.5%, P < 0.0001), require a massive blood transfusion (43.5% vs 1.1%, P < 0.0001), or require damage control surgery (55.8% vs 3.4%, P < 0.0001), than those with normal coagulation. In the development dataset, the 14-predictor BN accurately predicted this high-risk patient group: area under the receiver operating characteristic curve (AUROC) 0.93, calibration slope (CS) 0.96, brier score (BS) 0.06, and brier skill score (BSS) 0.40. The model maintained excellent performance in the validation population: AUROC 0.95, CS 1.22, BS 0.05, and BSS 0.46.

CONCLUSIONS

A BN (http://www.traumamodels.com) can accurately predict the risk of TIC in an individual patient from standard admission clinical variables. This information may support early, accurate, and efficient activation of hemostatic resuscitation protocols.

Accuracy of Published Indications for Predicting Use of Damage Control During Laparotomy for Trauma

BACKGROUND

Although studies have identified published indications that experts and practicing surgeons agree indicate use of damage control (DC) laparotomy, it is unknown whether these indications predict use of the procedure in practice.

MATERIALS AND METHODS

We conducted a diagnostic performance study of the accuracy of a set of published appropriateness indications for predicting use of DC laparotomy. We included consecutive adults that underwent emergent laparotomy for trauma (2011-2016) at Memorial Hermann Hospital.

RESULTS

We included 1141 injured adults. Two published preoperative appropriateness indications [a systolic blood pressure (BP) persistently <90 mmHg or core body temperature <34°C] produced moderate shifts in the pretest probability of conducting DC instead of definitive laparotomy. Five published intraoperative appropriateness indications produced large and often conclusive changes in the pretest probability of conducting DC during emergent laparotomy. These included the finding of a devascularized or completely disrupted pancreas, duodenum, or pancreaticoduodenal complex; an estimated intraoperative blood loss >4 L; administration of >10 U of packed red blood cells (PRBCs); and a systolic BP persistently <90 mmHg or arterial pH persistently <7.2 during operation. Most indications that produced large changes in the pretest probability of conducting DC laparotomy had an incidence of 2% or less.

CONCLUSIONS

This study suggests that published appropriateness indications accurately predict use of DC laparotomy in practice. Intraoperative variables exert greater influence on the decision to conduct DC laparotomy than preoperative variables, and those indications that produce large shifts in the pretest probability of conducting DC laparotomy are uncommonly encountered.

Early management of severe abdominal trauma

OBJECTIVE

To develop French guidelines on the management of patients with severe abdominal trauma.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU), the French Society of Urology (Société française d'urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded.

METHODS

The guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a "damage control surgery" strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology.

RESULTS

The SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question.

CONCLUSIONS

Substantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma.

[Hypovolemic and hemorrhagic shock]

The term "shock" refers to a life-threatening circulatory failure caused by an imbalance between the supply and demand of cellular oxygen. Hypovolemic shock is characterized by a reduction of intravascular volume and a subsequent reduction in preload. The body compensates the loss of volume by increasing the stroke volume, heart frequency, oxygen extraction rate, and later by an increased concentration of 2,3-diphosphoglycerate with a rightward shift of the oxygen dissociation curve. Hypovolemic hemorrhagic shock impairs the macrocirculation and microcirculation and therefore affects many organ systems (e.g. kidneys, endocrine system and endothelium). For further identification of a state of shock caused by bleeding, vital functions, coagulation tests and hematopoietic procedures are implemented. Every hospital should be in possession of a specific protocol for massive transfusions. The differentiated systemic treatment of bleeding consists of maintenance of an adequate homeostasis and the administration of blood products and coagulation factors.

Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020

OBJECTIVES

Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient.

METHODS

I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome.

INCLUSION CRITERIA

adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure).

RESULTS

I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation.

CONCLUSIONS

Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.

Challenges and potential solutions to the evaluation, monitoring, and regulation of surgical innovations

Background

As it may be argued that many surgical interventions provide obvious patient benefits, formal, staged assessment of the efficacy and safety of surgical procedures has historically been and remains uncommon. The majority of innovative surgical procedures have therefore often been developed based on anatomical and pathophysiological principles in an attempt to better manage clinical problems.

Main Body

In this manuscript, we sought to review and contrast the models for pharmaceutical and surgical innovation in North America, including their stages of development and methods of evaluation, monitoring, and regulation. We also aimed to review the present structure of academic surgery, the role of methodological experts and funding in conducting surgical research, and the current system of regulation of innovative surgical procedures. Finally, we highlight the influence that evidence and surgical history, education, training, and culture have on elective and emergency surgical decision-making. The above discussion is used to support the argument that the model used for assessment of innovative pharmaceuticals cannot be applied to that for evaluating surgical innovations. It is also used to support our position that although the evaluation and monitoring of innovative surgical procedures requires a rigorous, fit-for-purpose, and formal system of assessment to protect patient safety and prevent unexpected adverse health outcomes, it will only succeed if it is supported and championed by surgical practice leaders and respects surgical history, education, training, and culture.

Conclusion

We conclude the above debate by providing a recommended approach to the evaluation, monitoring, and regulation of surgical innovations, which we hope may be used as a guide for all stakeholders involved in interpreting and/or conducting future surgical research.

Damage control or definitive repair? A retrospective review of abdominal trauma at a major trauma center in South Africa

Background

This 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.

Methods

All 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.

Results

A 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.

Conclusion

DCS 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 evidence

Level III.

Using Machine Learning to Identify Change in Surgical Decision Making in Current Use of Damage Control Laparotomy

BACKGROUND

In an earlier study, we reported the successful reduction in the use of damage control laparotomy (DCL); however, no change in the relative frequencies of specific indications was observed. In this study, we aimed to use machine learning to help identify the changes in surgical decision making that occurred.

STUDY DESIGN

Adult patients undergoing emergent trauma laparotomy were included: pre-quality improvement (QI): January 1, 2011 to October 31, 2013 and post-QI: November 1, 2013 to June 30, 2016. Using 72 variables before or during emergent laparotomy, random forest algorithms predicting DCL before and after a QI intervention were created. The main end point of the algorithms was the strength of individual factor significance in predicting the use of DCL, calculated by determining the mean decrease in accuracy (MDA) in the model if that variable was removed.

RESULTS

In the pre-QI group, 24 of 72 factors significantly predicted DCL, the strongest being bowel resection (mean MDA 16) and operating room RBC transfusions (mean MDA 15). The remaining variables were spread along the continuum of care from injury to emergent laparotomy end. In the post-QI group, 12 of 72 factors significantly predicted DCL, the strongest being last operating room lactate (mean MDA 12) and operating room RBC transfusions (mean MDA 14). In addition to having 12 fewer significant factors predictive of DCL, the predictive factors in the post-QI group were mainly intraoperative factors.

CONCLUSIONS

A machine learning analysis provided novel insights into the changes in decision making achieved by a successful QI intervention and should be considered an adjunct to understanding successful pre- and post-intervention QI studies. The analysis suggested a shift toward using mostly intraoperative factors to determine the use of DCL.

Damage control surgery: current state and future directions

PURPOSE OF REVIEW

Damage control surgery (DCS) represents a staged surgical approach to the treatment of critically injured trauma patients. Originally described in the context of hepatic trauma and postinjury-induced coagulopathy, the indications for DCS have expanded to the management of extra abdominal trauma and to the management of nontraumatic acute abdominal emergencies. Despite being an accepted treatment algorithm, DCS is based on a limited evidence with current concerns of the variability in practice indications, rates and adverse outcomes in poorly selected patient cohorts.

RECENT FINDINGS

Recent efforts have attempted to synthesize evidence-based indication to guide clinical practice. Significant progress in trauma-based resuscitation techniques has led to improved outcomes in injured patients and a reduction in the requirement of DCS techniques.

SUMMARY

DCS remains an important treatment strategy in the management of specific patient cohorts. Continued developments in early trauma care will likely result in a further decline in the required use of DCS in severely injured patients.

The open abdomen in trauma and non-trauma patients: WSES guidelines

Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a "planned second-look" laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.