John A Harvin1, John P Sharpe, Martin A Croce, Michael D Goodman, Timothy A Pritts, Elizabeth D Dauer, Benjamin J Moran, Rachel D Rodriguez, Ben L Zarzaur, Laura A Kreiner, Jeffrey A Claridge, John B Holcomb. 1. From the Department of Surgery, The University of Texas McGovern Medical School at Houston (J.A.H., J.B.H.), Houston, Texas; The Department of Surgery, The University of Tennessee Health Science Center (J.P.S., M.A.C.), Memphis, Tennessee; The Department of Surgery, The University of Cincinnati College of Medicine(M.D.G., T.A.P.), Cincinnati, Ohio; The Department of Surgery, Temple University School of Medicine (E.D.D., B.J.M.), Philadelphia, Pennsylvania; the Department of Surgery, Indiana University School of Medicine (R.D.R., B.L.Z.), Indianapolis, Indiana; and The Department of Surgery, MetroHealth System (L.A.K., J.A.C.), Cleveland, Ohio.
Abstract
BACKGROUND: In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization. METHODS: In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression. RESULTS: Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60-1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively. CONCLUSION: In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days. LEVEL OF EVIDENCE: Therapeutic/care management, level III.
BACKGROUND: In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization. METHODS: In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression. RESULTS: Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60-1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively. CONCLUSION: In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days. LEVEL OF EVIDENCE: Therapeutic/care management, level III.
Authors: Quinton M Hatch; Lisa M Osterhout; Asma Ashraf; Jeanette Podbielski; Rosemary A Kozar; Charles E Wade; John B Holcomb; Bryan A Cotton Journal: J Trauma Date: 2011-06
Authors: John A Harvin; Lillian S Kao; Mike K Liang; Sasha D Adams; Michelle K McNutt; Joseph D Love; Laura J Moore; Charles E Wade; Bryan A Cotton; John B Holcomb Journal: J Am Coll Surg Date: 2017-04-23 Impact factor: 6.113
Authors: Quinton M Hatch; Lisa M Osterhout; Jeanette Podbielski; Rosemary A Kozar; Charles E Wade; John B Holcomb; Bryan A Cotton Journal: J Trauma Date: 2011-12
Authors: Joseph J Dubose; Thomas M Scalea; John B Holcomb; Binod Shrestha; Obi Okoye; Kenji Inaba; Tiffany K Bee; Timothy C Fabian; James Whelan; Rao R Ivatury Journal: J Trauma Acute Care Surg Date: 2013-01 Impact factor: 3.313
Authors: Bryan A Cotton; John A Harvin; Vadim Kostousouv; Kristin M Minei; Zayde A Radwan; Herbert Schöchl; Charles E Wade; John B Holcomb; Nena Matijevic Journal: J Trauma Acute Care Surg Date: 2012-08 Impact factor: 3.313
Authors: Pedro G R Teixeira; Kenji Inaba; Joseph Dubose; Ali Salim; Carlos Brown; Peter Rhee; Timothy Browder; Demetrios Demetriades Journal: Am Surg Date: 2009-01 Impact factor: 0.688
Authors: Clay Cothren Burlew; Ernest E Moore; Joseph Cuschieri; Gregory J Jurkovich; Panna Codner; Ram Nirula; D Millar; Mitchell J Cohen; Matthew E Kutcher; James Haan; Heather G MacNew; Gage Ochsner; Susan E Rowell; Michael S Truitt; Forrest O Moore; Fredric M Pieracci; Krista L Kaups Journal: J Trauma Acute Care Surg Date: 2012-12 Impact factor: 3.313