Damage control operations in non-trauma patients: defining criteria for the staged rapid source control laparotomy in emergency general surgery

Abstract

BackgroundThe staged laparotomy in the operative management of emergency general surgery (EGS) patients is an extension of trauma surgeons operating on this population. Indications for its application, however, are not well defined, and are currently based on the lethal triad used in physiologically-decompensated trauma patients. This study sought to determine the acute indications for the staged, rapid source control laparotomy (RSCL) in EGS patients.MethodsAll EGS patients undergoing emergent staged RSCL and non-RSCL over 3 years were studied. Demographics, physiologic parameters, perioperative variables, outcomes, and survival were compared. Logistic regression models determined the influence of physiologic parameters on mortality and postoperative complications. EGS-RSCL indications were defined.Results215 EGS patients underwent emergent laparotomy; 53 (25 %) were staged RSCL. In the 53 patients who underwent a staged RSCL based on the lethal triad, adjusted multivariable regression analysis shows that when used alone, no component of the lethal triad independently improved survival. Staged RSCL may decrease mortality in patients with preoperative severe sepsis / septic shock, and an elevated lactate (≥3); acidosis (pH ≤ 7.25); elderly (≥70); male gender; and multiple comorbidities (≥3). Of the 162 non-RSCL emergent laparotomies, 27 (17 %) required unplanned re-explorations; of these, 17 (63 %) had sepsis preoperatively and 9 (33 %) died.ConclusionsThe acute physiologic indicators that help guide operative decisions in trauma may not confer a similar survival advantage in EGS. To replace the lethal triad, criteria for application of the staged RSCL in EGS need to be defined. Based on these results, the indications should include severe sepsis / septic shock, lactate, acidosis, gender, age, and pre-existing comorbidities. When correctly applied, the staged RSCL may help to improve survival in decompensated EGS patients.

Second-look laparostomy for perforated gangrenous gastric volvulus to prevent total gastrectomy

“…Presence of severe sepsis/septic shock, acidosis (pH <7.25), hyperlactaemia (≥3 mmol), old age (>70 years old), multiple comorbidities (≥3) have been proposed as criteria for damage-control surgery in non-trauma patients 19. Our patient fulfilled three criteria: severe sepsis, acidosis and hyperlactaemia.…”

A strategy for improving the prognosis of non‐occlusive mesenteric ischemia (NOMI): a single‐center observational study

“…For patients suspected of having NOMI on the basis of abdominal physical findings, computed tomography (CT) findings, or laboratory findings, we aggressively performed laparotomy to obtain a definite diagnosis. The primary surgery consisted of resection of the ischemic intestinal tract without anastomosis and open abdominal management to shorten the operation time that allows a systematic search for the progression of intestinal necrosis . We carefully treated and observed the patients for 24–48 h in the intensive care unit so as not to miss the progression of necrosis or ischemia of the intestinal tract.…”

“Genuine” Damage Control Laparotomy in Peritonitis: A Twenty-Year Review

“…However, multivariate logistic regression model confirmed that patients with severe sepsis/septic shock causing SIRS, men over the age of 70, lactate ≥ 3, and three or more comorbidities showed survival benefit if managed with rapid source control laparotomy and planned re-exploration (damage control strategy). Interestingly, approximately 50% of patients with severe sepsis/septic shock in the "on-demand" re-laparotomy group, actually required re-exploration [54]. Unfortunately, the most recent study in our investigation involving 164 patients did not specify the type of damage control procedure employed in each case, despite being prospectively done [55].…”

“…One of the most recent studies in our review compared two distinct surgical approaches. Damage control encompassing rapid source control laparotomy with planned re-exploration of the open abdomen (n=53 patients) versus single intervention with ondemand re-laparotomy (n=162 patients) [54]. Results showed that, in contrast to the trauma setting, patients who presented with acidosis (pH ≤ 7.25), coagulopathy, and hypothermia had similar mortality rates regardless of the surgical strategy used.…”