Among the 712 patients with a readmission record, there were 1822 total subsequent admissions (range, 3–74). Despite detailed analysis, no variables were found to be statistically significantly associated with postdischarge complications. During the 1822 subsequent admissions, 206 (11.3%) included a related surgical procedure. However, no variables were found to be associated with the risk of requiring a surgical procedure.
In this population-based study, we identified more than 2100 injured patients who underwent SLTL during their index admission. One third of these patients required readmission, and more than 30% were due to a surgical complication. Small-bowel obstruction was the most common cause for readmission followed by incisional hernia and infection. Among those who were readmitted, penetrating mechanism of injury was more common but was associated with a markedly longer time to the first readmission. However, overall, almost 90% of those readmitted were managed nonoperatively.
The outcomes following SLTL described in our study have not been previously evaluated. In contrast, outcomes associated with the index admission after the surgical management of abdominal trauma have been studied in detail. The reported mortality rate during the index admission following traumatic injury requiring laparotomy ranges from 13% to 28%, with studies examining damage-control laparotomy reporting rates at the higher end of this range.1,2,6,18–21 Using the OSHPD database, we found a similar mortality rate of 13% during the index admission after SLTL. We also found that patients with blunt trauma requiring SLTL had significantly higher rates of mortality than patients with a penetrating mechanism of injury. This finding is likely related to their significantly higher ISS. The higher rates of mortality and injury severity characteristic of our blunt-injured SLTL patients also comports with previously published reports.1,19,20,22
Our study is unique in that we were able to identify a significant number of injured patients who required SLTL and had subsequent follow-up during the 8-year study period. There is limited published literature examining complications in traumatically injured patients beyond the index admission. In the largest study to date, Li et al.18 examined long-term outcomes after trauma laparotomy among 484 patients over an 11-year period. They found that rates of small-bowel obstruction and incisional hernia were significantly higher in patients who underwent surgical management of traumatic injuries compared with patients managed nonoperatively. In their smaller cohort, the authors noted a rate of readmission for small-bowel obstruction (6.6%) similar to that in our cohort (6.0%). However, their overall rate (10.5%) of incisional hernia was higher than ours (4.0%). This may have been due to their inclusion of patients requiring multiple laparotomies during the index admission. Moreover, while Li et al.18 identified specific mechanisms, they failed to describe differences in the rates of complications between blunt and penetrating mechanism. In our study, we did not identify differences in the rates of complications based on mechanism.
The rates of readmission and small-bowel obstruction in our cohort are also similar to those identified in emergency and elective general surgery studies. In a 10-year study of more than 12,000 patients undergoing open lower abdominal surgery, Parker et al.23 found the rate of readmission to be 32.6% and the rate of readmission for adhesive small-bowel obstruction to be 7.3%. We found a similar rate of small-bowel obstruction at readmission (6.0%). However, in a more recent study, the same group reported a rate of readmission for adhesive small-bowel obstruction of l3.8%.9 A meta-analysis of more than 400,000 patients undergoing laparotomy found an overall incidence of small-bowel obstruction of 4.6%.16 Those findings suggest that our rate of less than 10% likely reflects the true risk of subsequent small-bowel obstruction after SLTL.
The rate of incisional hernia on readmission in our cohort (4.0%) was lower than the rates for elective and nontraumatic emergency laparotomy. Studies conducted among cohorts in those settings have reported rates ranging from 9% to 20% with 1 year of follow-up and up to 23% with 3 years of follow-up.11,12 The higher rates of incisional hernia identified in their cohorts may be due to more thorough follow-up compared with that in our study, which relied on hospital readmissions to identify complications. The difference may also be related to the older mean age of their cohorts compared to the cohort in our study (64 years vs. 37 years). Age greater than 45 years has previously been shown to be a risk factor for incisional hernia.24,25
Our study has limitations. The administrative nature of our data set, which relied on the ICD-9-CM coding system, precluded providing a full description of the circumstances of each admission or the patients’ specific details including vital signs or laboratory data. Additionally, identification of complications during the 8-year study period relied on readmissions to licensed nonfederal hospitals in the state of California. Thus, our data set did not include data collected at outpatient facilities. Moreover, given the time period described, our patients had varying lengths of follow-up depending on the date of their index admission. We were also unable to evaluate patients who either received treatment and subsequently left the state or received care at federal or unlicensed facilities. Finally, more than 1600 patients were excluded from our study. To focus solely on SLTL, 109 patients were excluded because they required multiple laparotomies during their index hospitalization. Nearly 1500 patients were excluded because of a missing mechanism of injury. These patients were eliminated to ensure our cohort truly reflected the population of interest.
J.M.B. conducted the literature search. J.M.B., J.B., R.Y.C., M.J.S., L.E.W., W.J.B., C.E.D., C.B.S., and V.B. designed the study. J.M.B., J.B., and R.Y.C. acquired and analyzed the data. J.M.B., J.B., R.Y.C., M.J.S., L.E.W., W.J.B., C.E.D., C.B.S., and V.B. participated in drafting the article and critically revising it. All authors approved the final version of the manuscript.
The authors declare no conflicts of interest.
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ADIL H. HAIDER, M.D., M.P.H. (Boston, Massachusetts): Good afternoon. Come on, you can do better than that – good afternoon. Are we waking up? Alright, great. Good afternoon.
Thank you to the Association for inviting me to discuss this important paper. I say it’s important, but it’s also very timely, as it’s directly responsive to the National Academies of Science, Engineering and Medicine’s recent report on developing a national trauma care system to achieve zero preventable deaths.
The report calls for, and I quote, “development of mechanisms for incorporating long-term outcomes like patient-centered outcomes, functional outcomes, and mortality data at one year.”
The authors harness the power of California’s state-based administrative dataset by using it to study long-term outcomes. And they’re able to do this as they are able to link individual patient’s hospital treatments over time to truly understand what happens to a patient when they get discharged from a hospital.
Their results demonstrate why the National Academies recommends collecting long-term data. A third of patients were readmitted, and a similar third had a complication.
So, I have four questions for you: one is about the cohort; two are about the analytics; and the fourth is more of a philosophical question.
First, about cohorts. You had to exclude about 1,600 patients from a total potential annum of 3,700. Does that impact your analysis? Could you have used some sort of imputation to save nearly 1,400 patients that you had to exclude due to missing this just one variable?
Second, in the analysis you appeared to have dichotomized several variables, leading to some very large groups. For example, for age, you had an above 65 and a below 65 group. That’s very broad. You know, there’s a big difference between a 20-year-old trauma patient and a 50-year-old trauma patient.
Third, you report an index hospitalization mortality of 13 percent. Can you tell us exactly what kind of patients are dying?
And furthermore, could you link these patients in the OSHPD dataset with the Social Security Index data and figure out which patients actually died after they had been discharged? If you could do that, that would be a true game changer.
And four, and this is my philosophical question, do you think there will ever be a time where we can reliably use these kinds of administrative databases to understand long-term outcomes?
Or, must we be investing in prospectively collecting long-term outcome data, just like the National Academies suggest that we should?
And finally, Dr. Bowie, Jason, from your LinkedIn profile, and from your uniform, I realize that you are in the Navy. Thank you for your very fine presentation, and most of all, your service on the water protecting us – I know you were on the U.S.S. Comstock for two years – and on land, where you are trying to make trauma care better. Thank you for your amazing presentation.
DAVID J. DRIES, M.D. (St. Paul, Minnesota): I would like to thank the authors just for giving us a current statement on the treatment facts associated with single-look trauma laparotomy.
I’m wondering, though, is there any way to distinguish where was the original operation done? Did patients get their follow-up care in a different geography or a different type of hospital?
As we heard earlier today, that could have an implication for what type of follow-up care these patients received. Thank you.
JUAN A. ASENSIO, M.D. (Omaha, Nebraska): Very nicely presented study. I couldn't help but notice that the median ISS in your penetrating injury population was nine, so I would presume that the vast majority of these patients were stab wounds, probably not gunshot wounds.
I also did not see any abdominal vascular injuries.
The question is, if you have the data, and (perhaps you do or don’t), could there have been some selectivity in choosing the patients that would have to undergo laparotomy?
Perhaps because a lot of people don’t remember history, and the study is old I should refresh people’s memory. Dr. Robert Lowe in a seminal publication from Cook County Hospital in 1972; warned us about the effects and complications of negative laparotomies, which I presume in many of your patients these laparotomies were negative.
And then of course, Dr. Gerry Shaftan, one of the great members of this society, in 1960, introduced the concept of selectivity. I look forward to your answers.
ROBERT J. WINCHELL, M.D. (New York, New York): I’m just going to take advantage of holding the pen here. You quoted a 13 percent mortality after trauma laparotomy and then warned us about the dangers of doing trauma laparotomies.
So, how do you know that high mortality is not a reason to think that you or we, collectively, didn’t do enough trauma laparotomies, or didn’t do them early enough, and maybe we need to be more aggressive instead of less so?
JASON BOWIE, M.D. (San Diego, California): I’d like to thank Dr. Haider for his discussion and all of you for your thoughtful questions.
With respect to the first question regarding patient exclusions, the exclusion of patients with multiple laparotomies during their index admission, We wanted to focus specifically on patients who had a single trauma laparotomy.
The exclusion of the additional 1,500 patients with a missing mechanism was to make sure we had clean data.
There’s a chance with this administrative dataset that patients that had an injury during a laparotomy for another indication may have been coded as a traumatic injury code. We could have caught these cases as trauma laparotomies versus just an injury during a procedure, so we excluded those patients intentionally to prevent that from happening.
We didn’t find any significant associations when we dichotomized patients into the large groups and generally when you continue to make groups smaller, you find fewer and fewer associations; however, I will discuss the potential of creating additional groups with my co-authors and see if we can identify any additional interesting associations.
With regards to the question of which patients died, as we included in our results, they were the patients with a blunt mechanisms, and higher ISS. As we all would predict, these were patients who were more severely injured.
Pulling the data to include the Social Security numbers and seeing if we can find the patients that are dying as outpatients is a good suggestion. However, it was beyond the scope of this study. It is a very good suggestion for subsequent investigation.
And then finally, I do believe that these administrative databases have a role in understanding long-term patient outcomes. Unfortunately, the granularity that they provide on individual patients during their hospital stays is not the best. However, they do provide valuable information with which we can design concurrent and prospective observational studies.
I think the ideal situation would be combining the two into a single database that we're able to access – that includes the long-term data as well as the granular data that we can get from the local databases.
Dr. Dries, your question on where were the procedures done and where was the follow-up – that was another thing that was beyond the scope of this specific study, but it is possible using this database.
We are able to identify the trauma designation of the hospitals using the OSHPD database, but that’s not something that we did specifically in this study. It would definitely be worth looking at in the future.
Dr. Asensio, the question regarding how many of these patients had a negative laparotomy, is another thing that the database doesn’t allow us to pull, but is an excellent question and something that I would love to answer for you in the future.
And, Dr. Winchell, should we be doing more laparotomies? Should the number be lower? Are these patients dying, are the patients in that 13 percent, maybe should they have been operated on earlier or something along those lines? Another thing I can’t answer from the data that I have, but another excellent question.
Thank you for your time, and I appreciate the honor of the podium today.