|Year : 2014 | Volume
| Issue : 3 | Page : 75-79
Damage control surgery/laparostomy in nontrauma emergency abdominal surgery: A new concept of care
Asri Che Jusoh, Ong Yanzie
Department of General Surgical, Kuala Krai District Hospital, Kuala Krai, Kelantan, Malaysia
|Date of Web Publication||15-Dec-2014|
Asri Che Jusoh
Department of General Surgery, Kuala Krai Hospital, 18000 Kuala Krai, Kelantan
Source of Support: None, Conflict of Interest: None
Introduction: The established success of damage control surgery (DCS) in trauma of torso motivates surgeon to apply similar concept in managing complicated intra-abdominal sepsis. The main objective of this study is to audit our new practice of such in nontrauma emergency abdominal surgery. Materials and Methods: We retrospectively reviewed all emergency abdominal surgeries (nontrauma) done from February 2013 to February 2014. All patients who had damage control procedures done for complicated intra-abdominal sepsis were analyzed. Results: A total of 60 patients were operated within that period. Six patients (10%) had undergone DCS with or without laparostomy. All were male with mean age of 48.5-year-old (26-61-years-old). Most were in ASA 3 (83%, 5 patients) with only one in ASA 4. Primary indications were ischemic bowel with mesenteric vein thrombosis (3 patients, 50%), abdominal compartment syndrome (ACS), bleeding post near total splenectomy for splenic abscess and gangrenous proctitis with purulent peritonitis. Nearly, all patients (5 patients, 83.3%) were severely acidotic with pH <7.2 intra-operatively, which triggered the DCS. Nevertheless, only 3 patients (50%) benefited from laparostomy and all of them achieved complete fascial closure within 2.6 days (mean). Their mean total Intensive Care Unit (ICU) stay was 15 days (9-32 days). Overall predicted mean Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity mortality rate was 51%. However, the observed (actual) mortality rate was only 33% (2 patients). Conclusion: The result of the practice of DCS in the septic abdomen is very encouraging. It appears able to reduce the mortality by 35%. A comparative analysis with larger series is therefore warranted to further confirm the findings.
Keywords: Damage control surgery, intra-abdominal sepsis, laparostomy
|How to cite this article:|
Jusoh AC, Yanzie O. Damage control surgery/laparostomy in nontrauma emergency abdominal surgery: A new concept of care
. Saudi Surg J 2014;2:75-9
|How to cite this URL:|
Jusoh AC, Yanzie O. Damage control surgery/laparostomy in nontrauma emergency abdominal surgery: A new concept of care
. Saudi Surg J [serial online] 2014 [cited 2019 May 21];2:75-9. Available from: http://www.saudisurgj.org/text.asp?2014/2/3/75/147022
| Introduction|| |
Damage control surgery (DCS) is a standard treatment care for an injured patient with severe physiological compromise who requires surgical intervention.  It refers to the sequence of abbreviated initial laparotomy with the goal of control of hemorrhage and contamination, followed by period of resuscitation, subsequent operation, and definitive closure. Correction of metabolic failure rather than anatomic perfection is mandatory for immediate survival.  Realization of that concept, it subsequently applied in severely ill surgical patient in nontrauma setting. Even though, no randomized controlled trials exist for the use of DCS, many retrospective reviews and prospective observational trials demonstrating improved outcomes in both trauma and acute care surgery populations. 
Therefore, since January 2013 we have decided to embark on this approach in nontrauma setting. The main objective of our study is to audit our recent practice of DCS in complicated intra-abdominal sepsis and to compare the predicted morbidity and mortality based on Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) over observed (actual) rate.
| Materials and Methods|| |
We retrospectively reviewed all emergency abdominal surgeries (nontrauma) done at our hospital from February 2013 to February 2014. Our center is a district hospital consists of 170 beds and a surgical unit run by two senior surgeons. All adult patients (aged >12-year-old) who had DCS done for complicated intra-abdominal sepsis were analyzed. Demographic, ASA and preoperative physiological data were recorded. Decision to perform DCS with or without laparostomy was made following discussion between surgeon and anesthetist usually during the first 30 min of surgery after analyzing the latest arterial blood gases. Parameters that trigger the DCS used were the same as in trauma (pH <7.2, BE> −8, hypothermia, T <35°C and coagulopathy) were documented. Complete surgical diagnosis was then ascertained after surgery.
Predicted mortality and morbidity using P-POSSUM were calculated and compared with the observed (actual) rate. Other parameters analyzed were primary indication for DCS, time taken for complete fascial closure (for laparostomy cases) and total Intensive Care Unit (ICU) stay.
| Results|| |
A total of 60 patients were operated for intra-abdominal sepsis within that period. Only six patients (10%) required damage control procedures. All were male with mean age of 48.5-year-old (26-61-years-old) and most were ASA 3 (83%, 5 patients). Primary indications for DCS were ischemic bowel secondary to mesenteric vein thrombosis (3 patients, 50%), abdominal compartment syndrome (ACS), bleeding post near total splenectomy for splenic abscess and gangrenous proctitis with generalized purulent peritonitis [[Table 1] and [Table 2]]. Nearly, all patients (5 patients, 83%) were severely acidotic with pH <7.2 intra-operatively which triggered the DCS. Nevertheless, only 3 patients (50%) benefited from laparostomy and all of them achieved complete fascial closure within 2.6 days (mean).
All the three cases of ischemic bowel secondary to mesenteric thrombosis had stapled resection with removal of necrotic bowel only during initial laparotomy. Anastomoses were deferred until subsequent surgery. Only one of them had a laparostomy as a prophylaxis for ACS. We overlooked the risk for intra-abdominal hypertension by closing the fascia primarily during pancolectomy for anastomotic leak postreversal of Hartmann's. 12 h after the surgery, he developed ACS which required a laparostomy as it cannot be controlled medically. A man with gangrenous proctitis had proximal stapled transection and peritoneal lavage during initial surgery with laparostomy created. 2 days later, a re-laparotomy and Hartmann's procedure was done. It is becoming a routine practice for us to measure an intra-vesical pressure at the end of laparotomy (closure of fascia) in high risk septic cases or at least monitor the trend of airway pressure. Doubtful cases or those with high intra-abdominal pressure (approaching 20 mmHg) will go to ICU with a laparostomy. Their mean total ICU stay was 15 days (9-32 days).
All of them developed major morbidities [Table 2]. Our overall predicted mean (P-POSSUM) mortality rate was 51%. It reflects the severity and complexity of the cases. One in two patients were expected to die, fortunately the observed (actual) mean mortality rate was only 33% (2 patients) [Table 3]. The latter had a predicted mortality rate of 93% and 52% respectively [Table 2]. In fact, the latter patient died of massive nonvariceal upper gastrointestinal bleeding rather than uncontrolled intra-abdominal sepsis. As expected, the other patient died following surgery due to uncontrolled multi-organ failures.
| Discussion|| |
Damage control surgery has been associated with improved outcomes and decreased mortality in severely injured trauma patients.  Its indication has been further expanded to include abdominal sepsis, ACS, and prolonged or extensive elective surgery recently.  The concept was formalized by Rotondo and colleagues 20 years ago where they focused on abbreviation of initial laparotomy after control of hemorrhage and contamination. Its philosophy is to limit the initial laparotomy before established physiological failures called lethal triad (acidosis, hypothermia, and coagulopathy). ,
In contrast to trauma where fewer than 30% will be benefited from DCS, precise incidence in nontrauma cannot be accurately ascertained yet.  Person et al. reviewed 291 nontrauma laparotomies, of those 31 patients (10.7%) required abbreviated laparotomy. The commonest indications were peritonitis (48.4%) followed by mesenteric ischemia (32.3%).  Interestingly, their incidence was almost comparable to ours (10%). On the other hand, Weber et al. estimated the incidence should be around few percents only. 
Correct patient selection is a complex procedure with multi-factorial decision and a challenge to clinician. In our series, decision was made together with an anesthetist within half an hour of surgery. Few trigger points which were similar as in trauma have been published but validated variably such as hypothermia (<35°C), acidosis (pH <7.2), BE <−8 and coagulopathy. , Majority of ours were severely acidotic (66%) intra-operatively with only one patient (16%) had DCS and laparostomy for a planned re-look surgery. In their review, Regner et al. had brilliantly discussed trigger factors for DCS either in trauma or nontrauma.  Despite of many factors existed and analyzed, the only level I evidence for the use of DCS and laparostomy is for the treatment of ACS.
There are few established phases of DCS. Phase 0 was added in severe intraabdominal sepsis in order to stress the importance of preoperative resuscitation, which expected to be longer than in trauma. , Phase 1 is a preliminary surgery to control the source in septic abdomen using a combination of resection and wide drainage following which the surgery is truncated.  Finlay et al. reviewed 14 patients who were subjected to DCS. Only bowel resection (no stoma or anastomoses) was done during this phase. The latter was created during a subsequent laparotomy.  Similarly, Kafka-Ritsch et al. clearly demonstrated the feasibility of DCS in complicated diverticulitis (Hichey's grade III and IV). During this phase, none had Hartmann's procedure, majority (88%) had limited resection with the former done during second look laparotomy.  Similarly with ours, all three cases of ischemic bowel had stapled resection only with no anastomoses. The sigmoid colon was stapled and peritoneal cavity was lavaged in gangrenous proctitis with generalized peritonitis. We had overlooked the risk for intra-abdominal hypertension and compartment syndrome during an index surgery in case 3 [Table 2]. As a result, a redo laparotomy and laparostomy was created. Therefore, crux of issue beyond source control is prevention of ACS (due to aggressive resuscitation) as delay recognition and treatment is associated with very high morbidity and mortality. 
|Table 3: Predicted morbidity, mortality based on P - POSSUM and observed (actual) mortality rate |
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Temporary abdominal closure (TAC) technique adopted should be rapid, contain viscera, avert peritoneal contamination, control and quantify peritoneal effluent, adequate tension but avoid ACS and preserve fascial integrity for future closure. , Temporary vacuum pack described by Paul et al. is the most widely used TAC and current standard of care as in ours. It is consisted of three layers of innermost polyvinyl sheet, followed by moist gauze or towels with drains and outermost large adhesive drapes. 
During phase 2, resuscitation is further continued in ICU with aggressive correction of coagulopathy, acidosis and hypothermia.  Clinical examination and abdominal wall measurements do not correlate with intra-abdominal pressure thus bladder pressure is needed as late detection of ACS is disastrous.  The subsequent phase 3 is a definitive correction phase. Anatomical failure is corrected and anastomosis is created. In our series, Hartman's procedure was done for gangrenous proctitis and small bowel was anastomosed in cases of mesenteric ischemia. The final phase is closure of the abdominal wall. No definite time is allocated as few factors has to be considered such as visceral edema, need to prevent ACS due to ongoing resuscitation and continued source control.  In fact, in 2009, the Open Abdomen Advisory Panel concluded that a central goal is closure of the abdominal defect as quickly as is clinically feasible without precipitating ACS.  Fascial closure rate is known to be higher in trauma ranges 65-100% but much less in sepsis (33%). Similar to Wilde and Loudon series, we managed to obtain total closure in all of our patients. The former believed with suction tubes and Opsite, fascial integrity preserved which subsequently ensures higher rate of final definitive closure. , Other groups had a much lower rates ranging from 35% to 90%. ,
Morbidity related to DCS and/or laparostomy is expectedly high due to nature of the disease and general condition of the patient. All our patients (100%) developed significant morbidities such as ventilator associated pneumonia, acute respiratory distress syndrome and wound infection in accordance to mean predicted morbidity of 95%. Overall morbidities by Sheeraz et al. were much less (68.7%). Persistent wound sepsis was their most common complication.  Earlier studies have shown what determine the morbidity and mortality are duration taken until definitive abdominal closure. Surprisingly, others could not re-confirmed it.  The choice of TAC also will determine the type and rate of complications.  Some authors expressed concern about risk of enteric fistula formation under constant negative intra-abdominal pressure. Fortunately, similar and low rate of bowel fistulas demonstrated with VAC treatment (3%) and polytetrafluoroethylene patch (4%) as compared to prosthetic mesh (23%).  The pronounced benefit of DCS concept was clearly revealed by Kafka-Ritsch et al. where their rate of temporary ostomy was only 28% on discharge despite of extensive peritonitis secondary to complicated diverticulitis. 
In emergency cases and DCS, P-POSSUM is a robust scoring system which accurately predict outcome.  Even though, overall morbidity remained relatively high, application of this technique proved beneficial in reducing mortality rate. ,, Overall predicted mortality (P-POSSUM) in our series was 51%, comparable to Finlay et al. (49.6%).  Three case series including the latter had compare the observed outcome (patient receiving DCS) versus predicted outcome (POSSUM or APACHE). All observed lower than predicted mortality and one study was statistically significant.  An observed mortality rate in ours was 33%, much lower than others such as Gonullu et al. and Rakic et al. (43% and 59% respectively), but higher than Sheeraz et al. (25%). , Based on our current practice, mortality rate can be reduced by 35% (from 51% to 33%). Kafka-Ritsch et al. further re-confirmed the success of the above concept in the management of complicated diverticulitis where in hospital mortality was only 9.8%. 
| Conclusion|| |
Current evidences support the use of DCS with or without laparostomy in nontrauma setting or septic abdomen as it proved save lives. Even though, the evidences were only at level III and IV, not as in trauma (level I) the concept is rapidly adopted by most critical care surgeons. Despite that, correct patient selection is paramount as overuse of the strategy is harmful. Larger comparative analyses are paramount in order to come out with better evidences.
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[Table 1], [Table 2], [Table 3]