Outcomes of damage control laparotomy with open abdomen management in the octogenarian population

Age itself or age-associated comorbidities? A nationwide analysis of outcomes of geriatric trauma

PURPOSE

Geriatric trauma patients present physiological challenges to care providers. A nationwide analysis was performed to evaluate the roles of age alone versus age-associated comorbidities in the morbidity and mortality of elderly patients with blunt abdominal trauma (BAT).

METHODS

Patients with BAT registered in the National Trauma Data Bank from 2013 to 2015 were analyzed using propensity score matching (PSM) to evaluate the mortality rate, complication rate, hospital length of stay (LOS), intensive care unit (ICU) LOS and ventilator days between young (age < 65) and elderly (age ≥ 65) patients. An adjusted multivariate logistic regression (MLR) model was also used to evaluate the effect of age itself and age-associated comorbidities on mortality.

RESULTS

There were 41,880 patients with BAT during the study period. In elderly patients, the injury severity score (ISS) decreased with age, but the mortality rate increased inversely (from 5.0 to 13.5%). Under a similar condition and proportion of age-associated comorbidities after a well-batched PSM analysis, elderly patients had significantly higher mortality rates (8.0% vs. 1.9%, p < 0.001), higher complication rates (35.1% vs. 30.6%, p < 0.001), longer hospital LOS (8.9 vs. 8.1 days, p < 0.001), longer ICU LOS (3.7 vs. 2.7 days, p < 0.001) and more ventilator days (1.1 vs. 0.5 days, p < 0.001) than young patients. Furthermore, the MLR analysis showed that age itself served as an independent factor for mortality (odds ratio: 1.049, 95% CI 1.043-1.055, p < 0.001), but age-associated comorbidity was not.

CONCLUSION

In patients with BAT, age itself appeared to have an independent and deleterious effect on mortality, but age-associated comorbidity did not.

Preoperative physical functional status affects the long-term outcomes of elderly patients with open abdomen

Aim

The mortality rates among elderly patients with open abdomen (OA) are high, and pre-existing comorbidities could affect the outcomes. However, long-term prognosis remains uncertain. We examined long-term outcomes in elderly patients with OA, focusing on physical functional status.

Methods

We undertook a retrospective cohort study between 2007 and 2017 at a single institution. Patients with OA who were aged ≥65 years were categorized into two groups: "good preoperative functional status" group (GFG) and "poor preoperative functional status" group (PFG). The GFG was defined as Eastern Cooperative Oncology Group/World Health Organization performance status (PS) 0-1, whereas PFG was defined as PS 2-4. The primary outcomes were survival and PS 2 years following the initial surgery.

Results

Of the 53 participants, 38 and 15 were assigned to the GFG and PFG, respectively. The PFG (median age, 81 years) was older than the GFG (median age, 75.5 years; P = 0.040). The 2-year survival rate was 39.5% in GFG and 6.7% in PFG, and Kaplan-Meier analysis showed significant difference (P = 0.022). Among all patients, the PS at 2 years was worse than that at discharge (P = 0.007). Preoperative PS was correlated with 2-year survival (P = 0.003), whereas age and pre-existing comorbidities were not.

Conclusion

The long-term outcomes of elderly patients with OA are affected by the preoperative physical functional status. Functional status deteriorates in a time-dependent manner. Therefore, surgery requiring OA must be carefully considered for elderly patients with PS 2 or higher.

Intra-abdominal Hypertension and the Open Abdomen: Nursing Guidelines From the Abdominal Compartment Society

Intra-abdominal hypertension has been identified as an independent risk factor for death in critically ill patients. Known risk factors for intra-abdominal hypertension indicate that intra-abdominal pressures should be measured and monitored. The Abdominal Compartment Society has identified medical and surgical interventions to relieve intra-abdominal hypertension or to manage the open abdomen if abdominal compartment syndrome occurs. The purpose of this article is to describe assessments and interventions for managing intra-abdominal hypertension and open abdomen that are within the scope of practice for direct-care nurses. These guidelines provide direction to critical care nurses caring for these patients.

Open abdomen management for severe peritonitis in elderly. Results from the prospective International Register of Open Abdomen (IROA): Cohort study

BACKGROUND

Analyzing the data of the International Register of Open Abdomen (IROA), the feasibility of open abdomen treatment has been demonstrated at every age. This new analysis on the IROA database investigates the risk factors for mortality in elderly patients treated with open abdomen for intra-abdominal infection.

METHODS

Data were derived from the IROA, a prospective observational international cohort study that enrolled patients treated with open abdomen worldwide. A univariate analysis of potential risk factors was performed. Inclusion criteria were patients older than 65 years and treated with open abdomen for intra-abdominal infection. End point was overall mortality, calculated within 30 days after open abdomen management, after 1-month and 1-year follow-up.

RESULTS

A total of 116 patients was analyzed with mean age of 76 ± 7 years. Definitive closure was achieved in 93 patients (93/116, 80.2%) for a mean open abdomen duration of 5.0 ± 5.0 days. Complicated patients were 101 (101/116, 87.1%) for a total of 201 complications. Overall, 62 out of 116 patients (53.4%) died: 23 patients (23/62, 37.1%) during open abdomen management, 29 patients (46.8%) within 30 days after abdominal closure, 9 patients (14.5%) after 1-month follow-up, and 1 patient (1.6%) after 1-year follow-up. Age did not affect mortality (75 ± 6 years in alive patients versus 77 ± 7 years in dead patients, p = 0.773). Definitive abdominal closure was the most important factor to prevent mortality.

CONCLUSIONS

This study confirmed that age alone cannot be considered a determinant for death, even in elderly patients managed with open abdomen for severe intra-abdominal infection.

A Multi-Institutional Analysis of Damage Control Laparotomy in Elderly Trauma Patients: Do Geriatric Trauma Protocols Matter?

BACKGROUND

Trauma centers are receiving increasing numbers of older trauma patients. There is a lack of literature on the outcomes for elderly trauma patients who undergo damage control laparotomy (DCL). We hypothesized that trauma centers with geriatric protocols would have better outcomes in elderly patients after DCL.

METHODS

A retrospective chart review of consecutive adult trauma patients with DCL at 8 level 1 trauma centers was conducted from 2012 to 2018. Patients aged 40 or older were included. Age ≥ 55 years was defined as elderly. Demographics, injury information, clinical outcomes, including mortality, and complications were recorded. Univariate and multivariate analyses were performed.

RESULTS

A total of 379 patients with DCLs were identified with an average age of 54.8 ± 0.4 years with 39.3% (n = 149/379) of patients aged ≥ 55. Geriatric protocols or a consulting geriatric service was present at 37.5% (n = 3/8) of institutions. Age ≥ 55 was a significant risk factor for in-hospital mortality (OR 2, 95% CI 1.0-4.0, P = .04). Institutions without dedicated geriatric trauma protocols/services had higher overall in-hospital mortality on both univariate (57.9% vs 34.3%, P = .02) and multivariate analyses (OR 2.1, 95% CI 1.3-3.4, P < .001).

CONCLUSIONS

Surgical management of older trauma patients remains a challenge. Geriatric protocols or dedicated services were found to be associated with improved outcomes. Future efforts should focus on standardizing the availability of these resources at trauma centers.

Acute Kidney Injury Following Exploratory Laparotomy and Temporary Abdominal Closure

BACKGROUND

Acute kidney injury (AKI) following exploratory laparotomy and temporary abdominal closure (TAC) is poorly understood but clinically significant. We hypothesized that the prevalence of AKI would be highest 96 h following TAC, early hypoxemia would predict AKI, and that AKI would be an independent predictor of mortality.

METHODS

We performed a retrospective analysis of 251 acute care surgery patients managed with TAC by negative pressure wound therapy (NPWT). Kidney Disease: Improving Global Outcomes AKI stages were assessed on admission, initial TAC, and following TAC at 48 h, 96 h, and 7 d. Multivariate regression was performed to identify risk factors for AKI and inpatient mortality.

RESULTS

Fifty-seven percent of all patients developed AKI within 7 days of laparotomy (stage 1: 14%, 2: 21%, 3: 22%). The prevalence of AKI peaked 48 h following TAC, and stage correlated with inpatient mortality (stage 0: 7%, 1: 13%, 2: 19%, 3: 37%, P < 0.001). Overall mortality was 14%. Factors predictive of stage 2 or 3 AKI at 48 h included age >65 years (OR 2.6 [95% CI 1.4-4.9]), NPWT output >30 mL/h from first TAC to 48 h (2.0 [1.1-3.9]), and three parameters at initial laparotomy: mean arterial pressure <60 mm Hg (2.9 [1.0-8.5]), temperature <36°C (2.1 [1.1-3.8]), and anion gap >21 mEq/L (1.9 [1.0-3.7]). AKI was an independent predictor of inpatient mortality (5.5 [2.5-11.8]).

CONCLUSIONS

AKI is common following TAC, reaches greatest prevalence 48 h after initial laparotomy, and is associated with increased mortality. NPWT fluid loss is a risk factor for AKI that is unique to TAC patients.

Caring for critically injured children: An analysis of 56 pediatric damage control laparotomies

BACKGROUND

Injury is the leading cause of death in children under 18 years. Damage control principles have been extensively studied in adults but remain relatively unstudied in children. Our primary study objective was to evaluate the use of damage control laparotomy (DCL) in critically injured children.

METHODS

An American College of Surgeons-verified Level 1 trauma center review (1996-2013) of pediatric trauma laparotomies was undertaken. Exclusion criteria included: age older than 18 years, laparotomy for abdominal compartment syndrome or delayed longer than 2 hours after admission. Demographics, mechanism, resuscitation variables, injuries, need for DCL, and outcomes were evaluated. Independent t test, Mann-Whitney U test, Fisher's exact test, and single-factor analysis of variance assessed statistical significance. Study endpoints were hospital survival and DCL complications.

RESULTS

Of 371 children who underwent trauma laparotomy, the median age (IQR; LQ-UQ) age was 16 (5; 11-17) years. Most (73%) were male injured by blunt mechanism (65%). Fifty-six (15%) children (Injury Severity Score [ISS], 33 (25; 17-42), pediatric trauma score 5 (6; 2-8), penetrating abdominal trauma index score [PATI] 29 (32; 12-44)) underwent DCL after major solid organ (63%), vascular (36%), thoracic (38%) and pelvic (36%) injury. DCL patients were older (16.5 (4; 14-18) vs. 16 (7; 10-17)) and were more severely injured (ISS, 33 [25; 17-42] vs. 16 [16; 9-25]), requiring greater intraoperative packed red blood cell transfusion (8 [13; 3.5-16.5] vs. 1 (0; [0-1] units) than definitive laparotomy counterparts. Nonsurvivors arrived in severe physiologic compromise (base deficit, 17 [17; 8-25] vs. 7 [4; 4-8]), requiring more frequent preoperative blood product transfusion (67% vs. 10%) after comparable injury (ISS survivors, 36 [23; 18-41] vs. nonsurvivors 26 (7; 25-32), p = 0.8880). Fifty-five percent of DCL patients survived (length of stay, 26 [21; 18-39] days) requiring 3 (2; 2-4) laparotomies during 4 (6; 2-8) days until closure (fascial, 90%; vicryl/split thickness skin grafting, 10%). DCL complications (surgical site infection, 18%; dehiscence, 2%; enterocutaneous fistula, 2%) were analyzed. When stratified by age (<15 years vs. 15-18 years) and period (1996-2006 vs. 2007-2013), no differences were found in injury severity or DCL outcomes (p > 0.05). After controlling for DCL, age, and gender, multivariate analysis indicated only ISS (odds ratio, 1.10 [95% confidence interval, 1.01 - 1.19], p = 0.0218) and arrival systolic blood pressure (odds ratio, 0.96 [95% confidence interval, 0.93-0.99], p = 0.0254) predicted mortality after severe injury.

CONCLUSION

DCL is a proven, lifesaving surgical technique in adults. This report is the first to analyze the use of DCL in children with critical abdominal injuries. With similar survival and morbidity rates as critically injured adults, DCL merits careful consideration in children with critical abdominal injuries.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Treatments and other prognostic factors in the management of the open abdomen: A systematic review

BACKGROUND

The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain with it associated with a high incidence of complications and poor outcomes. The objective of this article is to perform a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify prognostic factors in OA patients in regard to definitive fascial closure (DFC), mortality and intra-abdominal complications.

METHODS

An electronic database search was conducted involving Medline, Excerpta Medica, Central Register of Controlled Trials, Cumulative Index to Nursing, and Allied Health Literature and Clinicaltrials.gov. All studies that described prognostic factors in regard to the above outcomes in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest and assessed for methodological quality.

RESULTS

Thirty-one studies were included in the final synthesis. Enteral nutrition, organ dysfunction, local and systemic infection, number of reexplorations, worsening Injury Severity Score, and the development of a fistula appeared to significantly delay DFC. Age and Adult Physiology And Chronic Health Evaluation version II score were predictors for in-hospital mortality. Failed DFC, large bowel resection and >5 to 10 L of intravenous fluids in <48 hours were predictors of enteroatmospheric fistula. The source of infection (small bowel as opposed to colon) was a predictor for ventral hernia. Large bowel resection, >5 to 10 and >10 L of intravenous fluids in <48 hours were predictors of intra-abdominal abscess. Fascial closure on (or after) day 5 and having a bowel anastomosis were predictors for anastomotic leak. Overall methodological quality was of a moderate level.

LIMITATIONS

Overall methodological quality, high number of retrospective studies, low reporting of prognostic factors and the multitude of factors potentially affecting patient outcome that were not analyzed.

CONCLUSION

Careful selection and management of OA patients will avoid prolonged treatment and facilitate early DFC. Future research should focus on the development of a prognostic model.

LEVEL OF EVIDENCE

Systematic review, level III.

Complications and Mortality Associated with Temporary Abdominal Closure Techniques: A Systematic Review and Meta-Analysis

Temporary abdominal closure (TAC) techniques are routinely used in the open abdomen. Ideally, they should prevent evisceration, aid in removal of unwanted fluid from the peritoneal cavity, facilitate in achieving safe definitive fascial closure, as well as prevent the development of intra-abdominal complications. TAC techniques used in the open abdomen were compared with negative pressure wound therapy (NPWT) to identify which was superior. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines involving Medline, Excerpta Medica, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and Clinicaltrials.gov. All studies describing TAC technique use in the open abdomen were eligible for inclusion. Data were analyzed per TAC technique in the form of a meta-analysis. A total of 225 articles were included in the final analysis. A meta-analysis involving only randomized controlled trials showed that NPWT with continuous fascial closure was superior to NPWT alone for definitive fascial closure [mean difference (MD): 35% ± 23%; P = 0.0044]. A subsequent meta-analysis involving all included studies confirmed its superiority across outcomes for definitive fascial closure (MD: 19% ± 3%; P < 0.0001), perioperative (MD: -4.0% ± 2.4%; P = 0.0013) and in-hospital (MD: -5.0% ± 2.9%; P = 0.0013) mortality, entero-atmospheric fistula (MD: 22.0% ± 1.8%; P = 0.0041), ventral hernia (MD: -4.0% ± 2.4%; P = 0.0010), and intra-abdominal abscess (MD: -3.1% ± 2.1%; P = 0.0044). Therefore, it was concluded that NPWT with continuous fascial traction is superior to NPWT alone.

Nontrauma open abdomens: A prospective observational study

BACKGROUND

Damage-control surgery with open abdomen (OA) is described for trauma, but little exists regarding use in the emergency general surgery. This study aimed to better define the following: demographics, indications for surgery and OA, fascial and surgical site complications, and in-hospital/long-term mortality. We hypothesize that older patients will have increased mortality, patients will have protracted stays, they will require specialized postdischarge care, and the indications for OA will be varied.

METHODS

A prospective observational study of emergency general surgery OA patients from June 2013 to June 2014 was performed. Demographics, clinical/operative variables, comorbidities, indications for procedure and OA, wound/fascial complications, and disposition were collected. Patients were stratified into age groups (≤ 60, 61-79, and ≥ 80 years). Six-month and 1-year mortality was determined by query of the Social Security Death Index.

RESULTS

A total of 338 laparotomies were performed, of which 96 (28%) were managed with an OA. Median age was 61 years (interquartile range [IQR], 0-68 years), and 51% were male. The median Charlson Comorbidity Index was 2 (IQR, 1.5-5.1), and the median hospital stay was 25 days (IQR, 15-50 days). The most common indications for operation were perforated viscus/free air (20%), mesenteric ischemia (17%), peritonitis (16%), and gastrointestinal hemorrhage (12%). The most common indication for OA was damage control (37%). In the 63 patients with fascial closure, there were 9 (14%) wound infections and 6 (10%) fascial dehiscences. A total of 30% of the patients died in the hospital, and an additional six patients died 6 months after discharge. Patients in the oldest age stratum were more likely to die at 6 months than those in the lower strata.

CONCLUSION

Older patients were more likely to die by 6 months, the median hospital stay was 3 weeks, and there were multiple indications for OA management. With a 6-month mortality of 36% and 70% of survivors requiring postdischarge care, this population represents a critically ill population meriting additional study.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Botulinum toxin A-induced paralysis of the lateral abdominal wall after damage-control laparotomy: A multi-institutional, prospective, randomized, placebo-controlled pilot study

BACKGROUND

Damage-control laparotomy (DCL) is a lifesaving operation used in critically ill patients; however, interval primary fascial closure remains a challenge. We hypothesized that flaccid paralysis of the lateral abdominal wall musculature induced by botulinum toxin A (BTX) would improve rates of primary fascial closure, decrease duration of hospital stay, and enhance pain control.

METHODS

Consenting adults who had undergone a DCL at two institutions were prospectively randomized to receive ultrasound-guided injections of their external oblique, internal oblique, and transversus abdominus muscles with either BTX (150 mL, 2 U/mL) or placebo (150-mL 0.9% NaCl). Patients were excluded if they had a body mass index of greater than 50, remained unstable or coagulopathic, were home O2 dependent, or had an existing neuromuscular disorder. Outcomes were assessed in a double-blinded manner. Univariate and Kaplan-Meier estimates of cumulative probability of abdominal closure were performed.

RESULTS

We randomized 46 patients (24 BTX, 22 placebo). There were no significant differences in demographics, comorbidities, and physiologic status. Injections were performed on average 1.8 ± 2.8 days (range, 0-14 days) after DCL. The 10-day cumulative probability of primary fascial closure was similar between groups: 96% for BTX (95% confidence interval [CI], 72-99%) and 93% for placebo (95% CI, 61-99%) (HR, 1.0; 95% CI, 0.5-1.8). No difference between BTX and placebo groups was observed for hospital length of stay (37 days vs. 26 days, p = 0.30) or intensive care unit length of stay (17 days vs. 11 days, p = 0.27). There was no difference in median morphine equivalents following DCL. The overall complication rate was similar (63% vs. 68%, p = 0.69), with two deaths in the placebo group and none in the BTX group. No BTX or injection procedure complications were observed.

CONCLUSION

The use of BTX after DCL was safe but did not seem to affect primary fascial closure, hospital length of stay, or pain modulation after DCL. Given higher-than-expected rates of primary fascial closure, Type II error may have occurred.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Age and mortality after injury: is the association linear?

INTRODUCTION

Multiple studies have demonstrated a linear association between advancing age and mortality after injury. An inflection point, or an age at which outcomes begin to differ, has not been previously described. We hypothesized that the relationship between age and mortality after injury is non-linear and an inflection point exists.

METHODS

We performed a retrospective cohort analysis at our urban level I center from 2007 through 2009. All patients aged 65 years and older with the admission diagnosis of injury were included. Non-parametric logistic regression was used to identify the functional form between mortality and age. Multivariate logistic regression was utilized to explore the association between age and mortality. Age 65 years was used as the reference. Significance was defined as p < 0.05.

RESULTS

A total of 1,107 patients were included in the analysis. One-third required intensive care unit (ICU) admission and 48 % had traumatic brain injury. 229 patients (20.6 %) were 84 years of age or older. The overall mortality was 7.2 %. Our model indicates that mortality is a quadratic function of age. After controlling for confounders, age is associated with mortality with a regression coefficient of 1.08 for the linear term (p = 0.02) and a regression coefficient of -0.006 for the quadratic term (p = 0.03). The model identified 84.4 years of age as the inflection point at which mortality rates begin to decline.

CONCLUSIONS

The risk of death after injury varies linearly with age until 84 years. After 84 years of age, the mortality rates decline. These findings may reflect the varying severity of comorbidities and differences in baseline functional status in elderly trauma patients. Specifically, a proportion of our injured patient population less than 84 years old may be more frail, contributing to increased mortality after trauma, whereas a larger proportion of our injured patients over 84 years old, by virtue of reaching this advanced age, may, in fact, be less frail, contributing to less risk of death.

Abdominal damage control surgery and reconstruction: world society of emergency surgery position paper

Damage control laparotomy was first described by Dr. Harlan Stone in 1983 when he suggested that patients with severe trauma should have their primary procedures abbreviated when coagulopathy was encountered. He recommended temporizing patients with abdominal packing and temporary closure to allow restoration of normal physiology prior to returning to the operating room for definitive repair. The term damage control in the trauma setting was coined by Rotondo et al., in 1993. Studies in subsequent years have validated this technique by demonstrating decreased mortality and immediate post-operative complications. The indications for damage control laparotomy have evolved to encompass abdominal compartment syndrome, abdominal sepsis, vascular and acute care surgery cases. The perioperative critical care provided to these patients, including sedation, paralysis, nutrition, and fluid management strategies may improve closure rates and recovery. In the rare cases of inability to primarily close the abdomen, there are a number of reconstructive strategies that may be used in the acute and chronic phases of abdominal closure.

The damage control sequence in the elderly: Strategy, complexities, and outcomes

Traditional management in cases of exsanguinating abdominal trauma led to poor outcomes in critically injured patients. Because prolonged operations were not well tolerated due to the severe physiologic derangements, an abbreviated laparotomy began to be used. Patients were then resuscitated in the intensive care unit and brought back to the operating room once their physiology had been normalised. This approach has been termed the damage control sequence. Elderly trauma patients are susceptible to significant injury that may mandate a damage control sequence. For myriad reasons, including pre-existing medical conditions, decreased physiologic reserve, and the emergent nature of their injuries, the application of this management approach in the elderly is fraught with challenges. The purpose of this review is to enumerate the damage control sequence, describe the complexities of its use in the elderly, and discuss associated outcomes in this challenging patient population.

Outcomes after Massive Transfusion in Nontrauma Patients in the Era of Damage Control Resuscitation

There are little data regarding the use of massive transfusion protocols (MTP) outside of the trauma setting. This study compares the use of an MTP between trauma and non-trauma (NT) patients. Data were collected for trauma and NT patients from the prospectively maintained MTP database at a Level I trauma center over a 4-year period. Massive transfusion was defined as $ 10 units packed red blood cells (PRBCs) in a 24-hour period. Of 439 MTP activations, 37 (8%) were NT patients (64% male; mean age = 51 years, initial base deficit = -10.8). Activations were for gastrointestinal bleeding (n = 18), bleeding during surgery (n = 13), obstetrical complications (n = 5), and ruptured aortic aneurysm (n = 1). Over-activation of MTP (< 10 units PRBCs/24 hours) was higher in NT than trauma patients (19/37, 51% vs 118/284, 29%, P < 0.01). For massive transfusion patients, 24-hour mortality was higher in NT compared with trauma patients (10/17, 59% vs 100/284, 35%, P = 0.05), but there was no difference in 30-day mortality (10/17, 59% vs 144/284, 51%, P = 0.51). With over-activation in 51% of NT patients, MTP usage outside of trauma is inefficient. Outcomes in NT patients were worse than trauma patients, which may be related to the underlying disease processes.