Failed Primary Abdominal Closure in the Trauma Patient
Failed Primary Abdominal Closure in the Trauma Patient
During the 3-year study period, 758 patients, of whom 76 (10%) received a damage-control procedure with open abdomen, underwent exploratory laparotomy for trauma at our institution. Sixty-two subjects met all of the inclusion/exclusion criteria, and the success rate for fascial closure at the time of discharge or death was 71.0% (SC 44, FC 18). As would be expected in cohorts undergoing damage control, high severities of injury were seen in the SC and FC groups both overall (Injury Severity Score [ISS] 29 ± 15 and 21 ± 12, respectively) and in the abdomen (PATI 25 ± 14 and 30 ± 20, respectively). Three deaths occurred in the cohort, all of which were in the SC group and believed to be unrelated to the timing and method of fascial closure, for an overall mortality rate of 4.8%. Demographic characteristics are listed in Table 1. Notably, the FC group exhibited a greater degree of physiological distress at presentation than the SC group as reflected by worsened base excess (P = 0.009). FC subjects also experienced a significantly higher rate of penetrating mechanisms of injury (77.8%) than the SC group (47.7%; P = 0.03) and a lower ISS (20.6 ± 12.1 vs 29.0 ± 15.2; P = 0.04).
No differences were seen between groups at 24 hours after injury when examining the amount of crystalloid infused, number of units of packed red cells transfused, or base excess (Table 2). The FC group exhibited significantly longer hospital stays (P < 0.001) and intensive care unit stays (P = 0.006), more days on ventilators (P = 0.04), higher total hospital charges (P < 0.001), higher total number of surgeries (P < 0.001), and more total days with an open abdomen (P < 0.001).
The logistic regression model indicated significant associations between FC and increasing PATI (OR 1.06, 95% CI 1.01–1.11), worsening base excess on arrival to the emergency department (OR 0.79, 95% CI 0.66–0.93), and lower ISS (OR 0.94, 95% CI 0.89–1.00). The area under the curve for the model was 0.81.
In the overall analysis of fascial- versus vacuum-based management of the open abdomen, no differences were found between the technique used and the likelihood of closure (P = 0.08). When a subgroup analysis was conducted on subjects who still had an open abdomen at 48 hours after injury (SC 18, FC 18), again, no significant difference was seen between vacuum- and fascial-based management techniques on closure rates (P = 0.30; Table 3). Of note, all of the patients closed before 48 hours underwent only vacuum-based management.
Results
During the 3-year study period, 758 patients, of whom 76 (10%) received a damage-control procedure with open abdomen, underwent exploratory laparotomy for trauma at our institution. Sixty-two subjects met all of the inclusion/exclusion criteria, and the success rate for fascial closure at the time of discharge or death was 71.0% (SC 44, FC 18). As would be expected in cohorts undergoing damage control, high severities of injury were seen in the SC and FC groups both overall (Injury Severity Score [ISS] 29 ± 15 and 21 ± 12, respectively) and in the abdomen (PATI 25 ± 14 and 30 ± 20, respectively). Three deaths occurred in the cohort, all of which were in the SC group and believed to be unrelated to the timing and method of fascial closure, for an overall mortality rate of 4.8%. Demographic characteristics are listed in Table 1. Notably, the FC group exhibited a greater degree of physiological distress at presentation than the SC group as reflected by worsened base excess (P = 0.009). FC subjects also experienced a significantly higher rate of penetrating mechanisms of injury (77.8%) than the SC group (47.7%; P = 0.03) and a lower ISS (20.6 ± 12.1 vs 29.0 ± 15.2; P = 0.04).
No differences were seen between groups at 24 hours after injury when examining the amount of crystalloid infused, number of units of packed red cells transfused, or base excess (Table 2). The FC group exhibited significantly longer hospital stays (P < 0.001) and intensive care unit stays (P = 0.006), more days on ventilators (P = 0.04), higher total hospital charges (P < 0.001), higher total number of surgeries (P < 0.001), and more total days with an open abdomen (P < 0.001).
The logistic regression model indicated significant associations between FC and increasing PATI (OR 1.06, 95% CI 1.01–1.11), worsening base excess on arrival to the emergency department (OR 0.79, 95% CI 0.66–0.93), and lower ISS (OR 0.94, 95% CI 0.89–1.00). The area under the curve for the model was 0.81.
In the overall analysis of fascial- versus vacuum-based management of the open abdomen, no differences were found between the technique used and the likelihood of closure (P = 0.08). When a subgroup analysis was conducted on subjects who still had an open abdomen at 48 hours after injury (SC 18, FC 18), again, no significant difference was seen between vacuum- and fascial-based management techniques on closure rates (P = 0.30; Table 3). Of note, all of the patients closed before 48 hours underwent only vacuum-based management.
