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Open abdominal management after damage-control laparotomy for trauma: A prospective observational American Association for the Surgery of Trauma multicenter study

DuBose, Joseph J. MD; Scalea, Thomas M. MD; Holcomb, John B. MD; Shrestha, Binod MD; Okoye, Obi MD; Inaba, Kenji MD; Bee, Tiffany K. MD; Fabian, Timothy C. MD; Whelan, James MD; Ivatury, Rao R. MDAAST Open Abdomen Study Group

Journal of Trauma and Acute Care Surgery: January 2013 - Volume 74 - Issue 1 - p 113–122
doi: 10.1097/TA.0b013e31827891ce
AAST 2012 PLENARY PAPERS
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BACKGROUND We conducted a prospective observational multi-institutional study to examine the natural history of the open abdomen (OA) after trauma and identify risk factors for failure to achieve definitive primary fascial closure (DPC) after OA use in trauma.

METHODS Adults requiring OA for trauma were enrolled during a 2-year period. Demographics, presentation, and management variables were used to compare primary fascial closure and non–primary fascial closure patients, with logistic regression used to identify independent risk factors for failure to achieve primary fascial closure.

RESULTS A total of 572 patients from 14 American College of Surgeons–verified Level I trauma centers were enrolled. The majority were male (79%), mean (SD) age 39 (17) years. Injury Severity Score (ISS) was 15 or greater in 85% of patients and 84% had an abdominal Abbreviated Injury Scale (AIS) score of 3 or greater. Overall mortality was 23%. Initial primary fascial closure with unaltered native fascia was achieved in 379 patients (66%). Patients surviving at least 48 hours were grouped into those achieving DPC and those who did not achieve DPC after OA use. After logistic regression, independent risk factors for failure to achieve DPC included the number of reexplorations required (adjusted odds ratio [AOR], 1.3; 95% confidence interval (CI), 1.2–1.6; p < 0.001) the development of intra-abdominal abscess/sepsis (AOR, 2.4; 95% CI, 1.2–4.8; p = 0.011) bloodstream infection (AOR, 2.6; 95% CI, 1.2–5.7; p = 0.017), acute renal failure (AOR, 2.3; 95% CI, 1.2–5.7; p = 0.007), enteric fistula (AOR, 6.4; 95% CI, 1.2–32.8; p = 0.010) and ISS of greater than 15 (AOR, 2.5; 95% CI, 1.1–5.9; p = 0.037).

CONCLUSION Our study identifies independent risk factors associated with failure to achieve primary fascial closure during initial hospitalization after OA use for trauma. Additional study is required to validate appropriate algorithms that optimize the opportunity to achieve primary fascial closure and outcomes in this population.

LEVEL OF EVIDENCE Prognostic study, level III.

From the R Adams Cowley Shock Trauma Center (J.J.D., T.M.S.), University of Maryland Medical Center, Baltimore, Maryland; University of Texas Houston Medical Center (J.B.H., B.S.), Houston, Texas; Los Angeles County + University of Southern California Hospital (O.O., K.I.), Los Angeles, California; University of Tennessee Health Science Center (T.K.B., T.C.F.), Memphis, Tennessee; and Virginia Commonwealth University (J.W., R.R.I.), Richmond, Virginia.

Submitted: September 5, 2012, Revised: September 25, 2012, Accepted: September 26, 2012.

This study was presented at the 71st annual meeting of the American Association for the Surgery of Trauma, September 12–15, 2012, in Kauai, Hawaii.

The opinions contained herein are those of the authors and do not reflect any official position of the United States Air Force or the Department of Defense.

The AAST Open Abdomen Study Group members are the following: Binod Shrestha, MD, and John Holcomb, MD, from the University of Texas Houston Medical Center; Kenji Inaba, MD, Obi Okoye, MD, and Agathoklis Konstantinidis, MD, from the Los Angeles County + University of Southern California Hospital; Tom Scalea, MD, Jay Menaker, MD, and Joe DuBose, MD, from the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center; James F. Whelan, MD, Rao Ivatury, MD, and Stephanie R. Goldberg, MD, from the Virginia Commonwealth University; Martin D. Zielinski, MD, and Donald Jenkins, MD, from the Mayo Clinic Trauma Centers; Stephen Rowe, MD, Darrell Alley, MD, John Berne, MD, and LaDonna Allen, RN, from the East Texas Medical Center; Paola G. Pieri, MD, and Starre Haney, RN, MS, from the Maricopa Integrated Health System; Jeffrey A. Claridge, MD, and Katherine Kelly, MD, from the MetroHealth Medical Center; Tiffany Bee, MD, and Timothy Fabian, MD, from the University of Tennessee Health Science Center; Raul Coimbra, MD, PhD, and Jay Doucet, MD, from the University of California San Diego School of Medicine; Ben Coopwood, MD, David Keith, MD, and Carlos Brown, MD, from the University of Texas Southwestern–Austin, University Medical Center Brackenridge; James M. Haan, MD, and Jeanette Ward, BA, from the Via Christi Hospital, St. Francis Campus; Stuart M. Leon, MD, Evert Erriksson, MD, and Debbie Couillard, RN, BSN, from The Medical University of Southern Carolina; and Marc A. de Moya, MD, and Gwendolyn M. van der Wilden, MSc, from the Massachusetts General Hospital.

Address for reprints: LT COL Joe DuBose, MD, USAF MC, Air Force CSTARS–Baltimore, University of Maryland Medical System/R Adams Cowley Shock Trauma, 22South Greene St, T5R46, Baltimore, MD 21201; email: jjd3c@yahoo.com.

© 2013 Lippincott Williams & Wilkins, Inc.