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Sew it Up! A Western Trauma Association Multi-Institutional Study of Enteric Injury Management in the Postinjury Open Abdomen

Burlew, Clay Cothren MD; Moore, Ernest E. MD; Cuschieri, Joseph MD; Jurkovich, Gregory J. MD; Codner, Panna MD; Crowell, Kody BS; Nirula, Ram MD; Haan, James MD; Rowell, Susan E. MD; Kato, Catherine M.; MacNew, Heather MD; Ochsner, M. Gage MD; Harrison, Paul B. MD; Fusco, Cynthia MD; Sauaia, Angela MD, PhD; Kaups, Krista L. MD; the WTA Study Group

Journal of Trauma-Injury Infection & Critical Care: February 2011 - Volume 70 - Issue 2 - pp 273-277
doi: 10.1097/TA.0b013e3182050eb7
Original Article

Background: Use of damage control surgery techniques has reduced mortality in critically injured patients but at the cost of the open abdomen. With the option of delayed definitive management of enteric injuries, the question of intestinal repair/anastomosis or definitive stoma creation has been posed with no clear consensus. The purpose of this study was to determine outcomes on the basis of management of enteric injuries in patients relegated to the postinjury open abdomen.

Methods: Patients requiring an open abdomen after trauma from January 1, 2002 to December 31, 2007 were reviewed. Type of bowel repair was categorized as immediate repair, immediate anastomosis, delayed anastomosis, stoma and a combination. Logistic regression was used to determine independent effect of risk factors on leak development.

Results: During the 6-year study period, 204 patients suffered enteric injuries and were managed with an open abdomen. The majority was men (77%) sustaining blunt trauma (66%) with a mean age of 37.1 years ± 1.2 years and median Injury Severity Score of 27 (interquartile range = 20–41). Injury patterns included 81 (40%) small bowel, 37 (18%) colonic, and 86 (42%) combined injuries. Enteric injuries were managed with immediate repair (58), immediate anastomosis (15), delayed anastomosis (96), stoma (10), and a combination (22); three patients died before definitive repair. Sixty-one patients suffered intra-abdominal complications: 35 (17%) abscesses, 15 (7%) leaks, and 11 (5%) enterocutaneous fistulas. The majority of patients with leaks had a delayed anastomosis; one patient had a right colon repair. Leak rate increased as one progresses toward the left colon (small bowel anastomoses, 3% leak rate; right colon, 3%; transverse colon, 20%; left colon, 45%). There were no differences in emergency department physiology, injury severity, transfusions, crystalloids, or demographic characteristics between patients with and without leak. Leak cases had higher 12-hour heart rate (148 vs. 125, p = 0.02) and higher 12-hour base deficit (13.7 vs. 9.7, p = 0.04), suggesting persistent shock and consequent hypoperfusion were related to leak development. There was a significant trend toward higher incidence of leak with closure day (χ2 for trend, p = 0.01), with closure after day 5 having a four times higher likelihood of developing leak (3% vs. 12%, p = 0.02).

Conclusions: Repair or anastomosis of intestinal injuries should be considered in all patients. However, leak rate increases with fascial closure beyond day 5 and with left-sided colonic anastomoses. Investigating the physiologic basis for intestinal vulnerability of the left colon and in the open abdomen is warranted.

From the Department of Surgery (C.C.B., E.E.M., A.S.), Denver Health Medical Center, University of Colorado, Denver, Colorado; Department of Surgery (J.C., G.J.J.), Harborview Medical Center, University of Washington, Seattle, Washington; Department of Surgery (P.C.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (K.C., R.N.), University of Utah, Salt Lake City, Utah; Department of Surgery (J.H.), Via Christi Regional Medical Center, Wichita, Kansas; Department of Surgery (S.E.R., C.M.K.), Oregon Health & Sciences University, Portland, Oregon; Department of Surgery (H.M., M.G.O.), Memorial Health University Medical Center, Savannah, Georgia; Department of Surgery (P.B.H.), Wesley Medical Center, Wichita, Kansas; Department of Surgery (C.F.), Cooper University Hospital, Camden, New Jersey; and Department of Surgery (K.L.K.), Community Regional Medical Center, University of California, San Francisco (UCSF)-Fresno, San Francisco, California.

Submitted for publication April 22, 2010.

Accepted for publication November 3, 2010.

Presented at the 40th Annual Meeting of the Western Trauma Association, February 28–March 7, 2010, Telluride, Colorado.

Address for reprints: Clay Cothren Burlew, MD, FACS, Department of Surgery, Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204; email: clay.cothren@dhha.org.

© 2011 Lippincott Williams & Wilkins, Inc.