Damage-control surgery in patients with nontraumatic abdominal emergencies: A systematic review and meta-analysis

Abstract

BACKGROUNDAfter the successful implementation in trauma, damage-control surgery (DCS) is being increasingly used in patients with nontraumatic emergencies. However, the role of DCS in the nontrauma setting is not well defined. The aim of this study was to investigate the effect of DCS on mortality in patients with nontraumatic abdominal emergencies.METHODSSystematic literature search was done using PubMed. Original articles addressing nontrauma DCS were included. Two meta-analyses were performed, comparing (1) mortality in patients undergoing nontrauma DCS versus conventional surgery (CS) and (2) the observed versus expected mortality rate in the DCS group. Expected mortality was derived from Acute Physiology And Chronic Health Evaluation, Simplified Acute Physiology Score, and Portsmouth Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity scores.RESULTSA total of five nonrandomized prospective and 16 retrospective studies were included. Nontrauma DCS was performed in 1,238 and nontrauma CS in 936 patients. Frequent indications for surgery in the DCS group were (weighted proportions) hollow viscus perforation (28.5%), mesenteric ischemia (26.5%), anastomotic leak and postoperative peritonitis (19.6%), nontraumatic hemorrhage (18.4%), abdominal compartment syndrome (17.8%), bowel obstruction (15.5%), and pancreatitis (12.9%). In meta-analysis 1, including eight studies, mortality was not significantly different between the nontrauma DCS and CS group (risk difference, 0.09; 95% confidence interval, −0.06 to 0.24). Meta-analysis 2, including 14 studies, revealed a significantly lower observed than expected mortality rate in patients undergoing nontrauma DCS (risk difference, −0.18; 95% confidence interval, −0.29 to −0.06).CONCLUSIONThis meta-analysis revealed no significantly different mortality in patients undergoing nontrauma DCS versus CS. However, observed mortality was significantly lower than the expected mortality rate in the DCS group, suggesting a benefit of the DCS approach. Based on these two findings, the effect of DCS on mortality in patients with nontraumatic abdominal emergencies remains unclear. Further prospective investigation into this topic is warranted.LEVEL OF EVIDENCESystematic review and meta-analysis, level III.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2—Emergency Laparotomy: Intra‐ and Postoperative Care

“…A systematic review and meta-analysis of patients with non-trauma abdominal emergencies reported no difference regarding mortality between DCS or conventional management. However, the analysis used studies that compared observed and expected mortality, with a lower rate of observed mortality in patients with DCS [ 55 ].…”

Intraoperative Surgical Strategy in Abdominal Emergency Surgery

“…Internationally, the use of DCS in non‐trauma emergencies has been reported as being used with great variety, but usually to a wider extent (8–25%) than we presented here [21, 23]. A recent meta‐analysis found no difference in mortality in patients undergoing non‐trauma DCS compared to conventional surgery [24]. The WSES guidelines [17] recommend considering open abdomen treatment following surgical management of acute mesenteric ischemia and abdominal compartment syndrome, but also urges caution when applying DCS on wider indications.…”

Predictors for surgical site infection in patients undergoing therapeutic or prophylactic intra-abdominal onlay mesh (IPOM) implantation in clean and contaminated surgical fields

“…Adding to the risk of SSI, a contaminated abdomen is typically found in patients undergoing laparotomy for abdominal emergencies, which was identified as an independent predictor for SSI, too. To overcome SSI in presence of IPOM, damage-control surgery principles with delayed abdominal closure may help to reduce the rate of SSI in this group of patients [ 23 ]. However, in selected cases, the benefits of IPOM placement, such as definitive abdominal closure, outweigh the risk for SSI and may be the only available treatment option.…”