images Vol. 5, No. 1; 2021; pp 13–23
DOI: 10.26676/jevtm.v5i1.168

*Damage Control Resuscitation Committee

Derek J. Roberts MD PhD, Juan Duchesne MD, Megan L. Brenner MD MS, Bruno Pereira MD, Bryan A. Cotton MD MPH, Andrew W. Kirkpatrick MD MHSc, Mansoor Khan MBBS PhD, Paula Ferrada MD, Tal M. Hörer MD PhD, David Kauvar MD, Carlos Ordonez MD, Artai Priouzram MD

Corresponding author:

Derek J Roberts MD PhD FRCSC, Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Civic Campus, Room A280, 1053 Carling Avenue, Ottawa, Ontario, Canada, K1Y 4E9.

Email: Derek.Roberts01@gmail.com

© 2021 CC BY-NC 4.0 – in cooperation with Depts. of Cardiothoracic/Vascular Surgery, General Surgery and Anesthesia, Örebro University Hospital and Örebro University, Sweden

 

 

Indications for the Appropriate Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients

Derek J Roberts MD PhD1,2, Juan Duchesne MD3, Megan L Brenner MD MS4, Bruno Pereira MD5, Bryan A Cotton MD MPH6, Andrew W Kirkpatrick MD MHSc7,8 and Mansoor Khan MBBS PhD9 for the Damage Control Resuscitation Committee*

1Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada

2The O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada

3Department of Surgery Tulane, New Orleans, Louisiana, USA

4Department of Surgery, University of California Riverside, Riverside, California, USA

5Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil

6Department of Surgery, University of Texas Health Science Center, Houston, Texas, USA

7Regional Trauma Services and the Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada

8Canadian Forces Health Services, Canada

9Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK

 

 

In patients undergoing emergent operation for trauma, surgeons must decide whether to perform a definitive or damage control (DC) procedure. DC surgery (abbreviated initial surgery followed by planned reoperation after a period of resuscitation in the intensive care unit) has been suggested to most benefit those injured patients more likely to succumb to the “vicious cycle” of hypothermia, acidosis and coagulopathy, and/or postoperative abdominal compartment syndrome (ACS) than the failure to complete all organ repairs. However, currently there exists no unbiased evidence to support that DC surgery benefits injured patients. Further, the procedure is associated with substantial morbidity, long durations of intensive care unit and hospital stay, increased healthcare resource utilization, and possibly a reduced quality of life among survivors. Therefore, it is important to ensure that DC laparotomy is only utilized in situations where the expected procedural benefits are predicted to outweigh the expected procedural harms. In this manuscript, we review the comparative effectiveness and safety of DC surgery when used for different procedural indications. We also review recent studies suggesting variation in use of DC surgery between trauma centers and the potential harms associated with overuse of the procedure. We also review published consensus indications for the appropriate use of DC surgery and specific abdominal, pelvic, and vascular DC interventions in civilian trauma patients. We conclude by providing recommendations as to how the above list of published appropriateness indications may be used to reduce overuse of DC surgery and guide medical and surgical education, quality improvement, and surgical practice.

Keywords: Damage Control Surgery; Damage Control Interventions; Indications; Wounds and Injuries

Received: 28 October 2020; Accepted: 8 January 2021

 

 

 

INTRODUCTION

In patients undergoing emergent operation for trauma, surgeons must decide whether to perform a definitive or damage control (DC) procedure [1–4]. In contrast to definitive laparotomy, DC laparotomy includes an abbreviated initial operation that aims to rapidly control the “compelling source” of hemorrhage and/or contamination using what Feliciano originally termed “rapid conservative operative techniques” (now also referred to as DC interventions) [5–8]. The patient is subsequently admitted to the intensive care unit (ICU) after temporary abdominal closure (TAC) for ongoing resuscitation before returning to the operating room for additional surgery and/or primary abdominal fascial closure (i.e., fascia-to-fascia re-approximation within the index hospitalization) [1,5,6].

DC surgery has been suggested to most benefit injured patients more likely to die from physiological exhaustion secondary to the “vicious cycle” of hypothermia, acidosis and coagulopathy, and/or postoperative abdominal compartment syndrome (ACS) than the failure to complete all organ repairs [6,9,10]. However, currently there exists no unbiased, randomized evidence to support that DC surgery significantly benefits injured patients [1,5]. Further, the procedure is associated with substantial morbidity, long lengths of ICU and hospital stay, increased healthcare resource utilization, and possibly a reduced quality of life among survivors [11–15].

Therefore, it is important to ensure that DC surgery is only utilized in situations where the expected procedural benefits are predicted to outweigh the expected procedural harms [2,3]. However, several studies have reported that the procedure may presently be overused [3,16,17], which is concerning as overuse of DC laparotomy has increasingly been reported to be associated with increased morbidity and mortality [18,19]. Our group has therefore suggested that injured patient outcomes may improve with more selective use of DC laparotomy [2–4].

In this article, we review the comparative effectiveness and safety of DC versus definitive trauma surgery when used for different procedural indications. We also review studies that suggest significant variation in use of DC laparotomy among trauma centers and the potential harm associated with overuse of the procedure. Finally, we review results of recent studies conducted by the Indications for Trauma Damage Control Surgery International Study Group. Their work created a list of pre- and intraoperative clinical scenarios that nine experts in trauma surgery and a large cohort of surgeons who regularly operate on injured patients in level-1 to -3 trauma centers agreed appropriately indicated use of DC surgery in civilian trauma patients [1–4,6]. We conclude by providing recommendations on how to use the above list of published appropriateness indications to reduce overuse of DC surgery and guide medical and surgical education, quality improvement, future research, and surgical practice.

COMPARATIVE EFFECTIVENESS AND SAFETY OF TRAUMA DC SURGERY

Although one study began enrolling patients as early as 2016, to date no randomized controlled trial (RCT) that compares DC and definitive surgery in trauma patients has been completed [1,20,21]. A Cochrane systematic review of DC laparotomy for abdominal trauma conducted in 2012 identified a small number of observational studies and no RCTs [1,21]. In June 2016, Harvin et al. began enrolling patients aged 16 years or older undergoing emergent laparotomy (defined as admission directly to the operating room from the emergency department within 90 min of arrival) into a pragmatic, single-center, parallel group, pilot RCT comparing DC and definitive laparotomy [20]. Inclusion criteria require that the attending surgeon must believe that one or more predefined potential indications for DC laparotomy exist [20]. Results of this RCT were originally expected in 2020.

Another systematic review conducted by our group in 2018 identified two cohort studies [22,23] that evaluated outcomes associated with implementation or utilization of indications for DC surgery [24]. Rice et al. reported that, when compared with minor deviations, moderate or major deviations from a protocol that suggested using DC surgery for patients with a temperature <35°C, lactate >4 mmol/L (or greater than twice the upper limit of normal), or corrected pH <7.3 were independently associated with a significantly reduced survival at 90 days [22,24]. Asensio et al. developed a guideline that suggested use of DC surgery in patients who received more than 4 L of packed red blood cells (PRBCs), more than 5 L of PRBCs and whole blood combined, or a total operating room fluid (PRBCs and whole blood, other blood products, and crystalloid) volume replacement of more than 12 L; had a temperature <34°C, serum [HCO3-] ≤15 mEq/L, or arterial pH ≤7.2 during operation; were found to have a thoracic or abdominal vascular injury or complex hepatic injury requiring packing; required emergency department or operating room thoracotomy; or developed intraoperative coagulopathy or dysrhythmias [23,24]. In this study, use of this guideline was associated with a significantly decreased unadjusted odds of intra-abdominal abscesses, extra-abdominal infections, and abdominal fistulae; a significantly increased unadjusted odds of abdominal closure; and significantly reduced unadjusted lengths of ICU and hospital stay [23,24].

We also identified 14 other cohort studies [18,19,25–36] that compared outcomes of patients treated with DC versus definitive laparotomy in different clinical situations [24]. Stone et al., Rotondo et al., and Chinnery et al. reported a significant improvement in unadjusted survival with use of DC or staged laparotomy instead of definitive laparotomy for those that developed a coagulopathy during operation, received more than 10 U PRBCs and had one or more major abdominal vascular and two or more abdominal visceral injuries, or had combined abdominal vascular and pancreas gunshot injuries, respectively [25–27]. However, because the type of surgery (DC or definitive laparotomy) for the patients enrolled in these and the other 11 cohort studies identified by the systematic review mentioned above were not randomly assigned, these studies are likely confounded by indication [6]. This confounding occurs because surgeons choose to perform DC laparotomy based on patient, provider, and hospital characteristics, and these characteristics likely influence outcomes [37].

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Figure 1 Color map of respondents’ appropriateness ratings of published candidate pre- and intraoperative indications for use of damage control surgery stratified by surgeon- and trauma center-level characteristics. ANZ indicates Australia and New Zealand (i.e., Australasia); BP, blood pressure; ED, emergency department; GSWs, gunshot wounds; INR, international normalized ratio; ISS, injury severity scale; PT, prothrombin time; PTT, partial thromboplastin time. Interpolated median values halfway between two integers were rounded up. Disagreement was defined as at least 33% of respondents rating the indication as 1–2 (significant harm–harm) on the Likert Scale and at least another 33% rating it 4–5 (benefit–significant benefit). Figure and Figure legend reprinted from reference [4], copyright (2016), with permission from Elsevier. The Creative Commons license does not apply to this content. Use of the material in any format is prohibited without written permission from the publisher, Elsevier.

Therefore, very little valid or unbiased observational studies exist to support use of DC over definitive surgery in different clinical situations.

VARIATION IN AND POTENTIAL OVERUSE OF TRAUMA DC LAPAROTOMY BETWEEN CENTERS

Several authors have recently reported data suggesting that a variation in use of DC laparotomy may exist among trauma centers or that the procedure may currently be overused [3,4,6]. In a recently reported post-hoc analysis of the PROPPR randomized trial, DC surgery was used for 33% to 83% of patients requiring urgent laparotomy across 12 of the participating institutions [38]. Interestingly, although there was no significant adjusted mortality difference among these centers, the unadjusted risk of sepsis and ventilator-associated pneumonia was higher among those treated with DC laparotomy [38]. Therefore, some have suggested that decreasing use of DC among individual trauma centers may not necessarily influence injured patient mortality but may decrease their morbidity [38].

Table 1 Reported descriptions of thoracic, abdominal/pelvic, and vascular interventions identified as constituting damage control [44].

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Table 2 Highest rated candidate indications for use of damage control surgery in civilian trauma patients.

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Variation in use of DC across trauma centers could relate to increasing use of the procedure for indications other than those previously suggested to be appropriate or validated in the literature [1,6,24]. In support of this, one retrospective cohort study by Hatch et al. reported that one in five patients who received DC laparotomy at a level-1 trauma center between 2004 and 2008 failed to have at least one traditional indication for use of the procedure [1,6,39]. In this study, only 33% of the patients who underwent DC laparotomy were acidotic, 43% hypothermic, and 48% coagulopathic on arrival at the ICU after operation [1,6,24,39]. Although the ideal rate of use of DC during emergent laparotomy is presently unknown, it was estimated in one cohort study to range between 19% and 27% across six American, level-1 trauma centers [40].

Some evidence suggests that overuse of DC laparotomy may be associated with increased morbidity and mortality [3,4,18,19,39,41]. Martin et al. reported that, when compared with patients with a severe abdominal injury who underwent therapeutic definitive laparotomy, use of DC laparotomy in patients with an arrival systolic blood pressure (BP) >90 mmHg, no severe traumatic brain injury (TBI) (head Abbreviated Injury Scale score <3), and no combined abdominal injuries was independently associated with significantly increased odds of major postoperative complications and a significantly increased adjusted length of hospital stay [18]. In another propensity-matched cohort study, Harvin et al. reported that use of DC instead of definitive laparotomy [for intra-abdominal packing (68%), second-look laparotomy (6%), hemodynamic instability (15%), to expedite postoperative care or intervention (8%), abdominal compartment syndrome prophylaxis (1%), contamination (1%), or other/unclear reasons (1%)] was associated with a significantly increased incidence of gastrointestinal (GI) ileus and bleeding, abdominal fascial dehiscence, superficial surgical site infection (SSI), and death [19]. Finally, in a follow-up study by Harvin et al. in 2019, injured patients who underwent DC laparotomy across six American, level-1 trauma centers and were judged by majority faculty vote to have been candidates for definitive laparotomy were matched 1:1 with those who underwent definitive trauma laparotomy at these centers using propensity scores [42]. In this study, for those whom surgeons had equipoise regarding use of DC or definitive laparotomy, definitive laparotomy was associated with a significantly higher probability of fewer hospital-free, ventilator-free, and ICU-free days, suggesting that use of definitive laparotomy in this setting may decrease hospital resource utilization [42]. However, the two groups demonstrated a similar probability of major abdominal complications [42].

Table 3 Indications for use of thoracic, abdominal/pelvic, and vascular damage control interventions that were rated to be appropriate by a panel of experts.*

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PUBLISHED APPROPRIATENESS INDICATIONS FOR USE OF DC SURGERY AND DC INTERVENTIONS IN CIVILIAN TRAUMA PATIENTS

We previously hypothesized that variation in use of DC surgery among trauma centers may occur when surgeons are uncertain which operative profile is best across the large number of varying clinical situations encountered in practice [4,6,43,44]. This uncertainty is likely exacerbated by the limited available data evaluating the effectiveness and safety of DC surgery and DC interventions and the risks of bias associated with existing evidence on the topic [4,6,43,44]. Further, conducting RCTs evaluating DC laparotomy is difficult for many reasons, most importantly the lack of equipoise among surgeons regarding its likely superior outcomes when used instead of definitive laparotomy in certain clinical situations (e.g., a juxtahepatic venous injury) [45]. Despite this, however, surgeons must decide when to use DC (or specific DC interventions) over definitive surgery (or specific definitive surgical interventions) in their practices [6,44].

In 2013, Roberts et al. and the Indications for Trauma Damage Control Surgery International Study Group began a program of research to develop evidence-informed indications for the appropriate use of DC surgery and DC interventions in civilian trauma patients [1–5,44]. We first conducted a scoping review that aimed to identify a comprehensive list of the reported indications for use of DC surgery and DC interventions and examine the content and evidence on which these indications were based [2,24,44]. An indication was defined as “a clinical finding/scenario that advised use of DC surgery (or a DC intervention) over definitive surgery (or a definitive surgical intervention)” [3]. This study identified 270 peer-reviewed articles that reported 1,107 indications for DC surgery and 424 indications for 16 different DC interventions (see Table 1 for our previously published definitions of abdominal, pelvic, and vascular DC interventions) [2,24,46–61]. Of note, bilateral internal iliac artery ligation should only be performed in carefully selected patients, given the risk of pelvic ischemia associated with this intervention (which may lead to bilateral buttock claudication or necrosis, vasculogenic impotence, colorectal ischemia or necrosis, and spinal cord injury).

We subsequently conducted a qualitative content analysis to synthesize the above published indications into 123 codes representing uniquely reported indications for DC surgery and 101 codes representing uniquely reported indications for 16 different DC interventions [3, 44]. An international panel of nine different trauma surgery experts located in the United States (n = 3), Canada (n = 1), the United Kingdom (n = 1), Finland (n = 1), Australia (n = 1), and South Africa (n = 2) then rated 101 (82%) of the unique indications for DC surgery and 78 (77%) of the unique indications for DC interventions to be appropriate for use in surgical practice [3,44]. The highest rated indications for DC surgery and those rated to be appropriate for the individual DC interventions are listed in Table 2 and Table 3, respectively [3,44].

We then surveyed the opinions of 366 surgeons who regularly treat injured patients in the United States, Canada, Australia, and New Zealand on the appropriateness of many of the indications for DC surgery rated in the previous expert appropriateness rating study [4]. Of the 366 surveyed surgeons, 201 (56%) responded and rated 15 (78.9%) preoperative and 23 (95.8%) intraoperative indications to be appropriate for use in their practices [4]. Ratings of appropriateness were consistent across subgroups of surgeons with different training, experience, and practice settings, suggesting that practicing surgeons have relatively consistent opinions regarding use of DC surgery in certain clinical scenarios (see Figure 1 for a color map of respondents’ appropriateness ratings reported in this study stratified by surgeon- and trauma center-level characteristics) [4]. Nearly 90% of the respondents also agreed that injured patients who present with physiological derangements that significantly improve or reverse during operation were candidates for definitive instead of DC laparotomy [4].

As the above studies did not measure how surgeons actually practiced, their assessments of appropriateness may have reflected idealized practices [4,62]. We therefore recently reported the results of a study that sought to determine the accuracy of the above-published appropriateness indications for predicting use of DC surgery among patients undergoing emergent laparotomy at a large, level-1 trauma center in the United States [62]. In this study, two published preoperative indications (a systolic BP persistently <90 mmHg or core body temperature <34°C) produced moderate changes in the pre-test probability of patients undergoing DC laparotomy [62]. Five published intraoperative indications produced large and often conclusive changes in the pre-test probability of conducting DC during emergent laparotomy, including the finding of a devascularized or completely disrupted pancreas, duodenum, or pancreaticoduodenal complex during operation; an estimated intraoperative blood loss greater than 4 L; administration of more than 10 U PRBCs in the pre- and/or intraoperative period; and a systolic BP persistently <90 mmHg or arterial pH persistently <7.2 during operation [62]. Many of the indications that produced large shifts in the pre-test probability of conducting DC laparotomy were uncommonly encountered in practice (i.e., their incidence was <2%) [62]. Finally, a small number of published appropriateness indications were independently associated with the conduct of DC laparotomy even after adjusting for the simultaneous presence of other indications, suggesting that some surgeons may choose to conduct the procedure when they encounter certain single clinical findings [62].

IMPLICATIONS OF RECENT RESEARCH AND RECOMMENDATIONS

In recent years, wide variation has been reported in the rates of use of DC laparotomy among North American trauma centers [3,16,17]. This variation may be explained by several factors, including differences in surgeon equipoise regarding the benefit of the procedure in different clinical situations and the lack of valid data supporting that DC laparotomy improves survival in severely injured patients. The possible overuse of DC laparotomy across these trauma centers is concerning as some recent data suggest that when DC is used instead of definitive laparotomy in patients in whom surgeons have equipoise between the two, use of DC laparotomy is associated with increased resource utilization [42]. Other studies have also suggested that use of DC instead of definitive laparotomy when DC laparotomy is not indicated may be associated not only with increased resource utilization, but with higher morbidity and possibly mortality [18,19].

Table 4 Unadjusted and adjusted odds of performing damage control laparotomy by published pre- and intraoperative appropriateness indications.

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Table 4 summarizes those published indications that have been rated to be appropriate for use in practice by experts and practicing surgeons [62]. We also provide estimates of the unadjusted and adjusted (i.e., adjusted for the simultaneous presence of the other indications listed in the table) odds of undergoing DC laparotomy for each of these different indications [62]. Although the intraoperative findings of an expanding or difficult-to-access pelvic hematoma or juxtahepatic venous injury were previously rated to be appropriate indications for use of DC laparotomy in our expert appropriateness rating study [3] and cross-sectional survey of practicing surgeons [4], we do not yet have data on their ability to predict use of the procedure in practice [62]. Despite this, experts and practicing surgeons strongly suggest using DC surgery in these situations.

The indications listed in Table 4 may be used to educate surgical trainees on the appropriate, yet limited use of DC laparotomy and guide trauma center quality improvement practices aimed at reducing inappropriate use of the procedure. The group at the Red Duke Trauma Institute at Memorial Hermann Hospital-Texas Medical Center recently reported a decrease in the rate of use of DC laparotomy from 39% between 2011 and 2013 to 23% between 2013 and 2015 using a multifaceted quality improvement initiative that included audit and feedback for every DC laparotomy case [63]. The indications listed in Table 4 may also be used to guide the development of prospective observational and randomized studies aimed at understanding in which clinical situations DC laparotomy may offer a survival benefit over definitive laparotomy in injured patients. In our opinion, it is now time for these studies to be conducted.

CONCLUSIONS

Although DC surgery may benefit select, critically injured patients, it may currently be overused in some trauma centers. This is concerning as some studies have reported that overuse of this technique may be associated with increased healthcare utilization, morbidity, and potentially mortality. The published DC surgery appropriateness indications outlined in this manuscript may be used to reduce overuse of DC surgery and guide medical and surgical education, quality improvement, future research, and surgical practice.

Ethics Statement

(1)  All the authors mentioned in the manuscript have agreed to authorship, read and approved the manuscript, and given consent for submission and subsequent publication of the manuscript.

(2)  The authors declare that they have read and abided by the JEVTM statement of ethical standards including rules of informed consent and ethical committee approval as stated in the article.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Funding

Dr. Roberts’ research is supported by funding from the Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.

Author Contributions

All authors have contributed to the writing and editing of this manuscript.

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