Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties

Bozzay, Joseph; Walker, Patrick F.; Schechtman, David; Shaikh, Faraz; Stewart, Laveta; Tribble, David R.; Bradley, Matthew John

doi:10.1016/j.jss.2020.07.075

Cited by 15 publications

(11 citation statements)

References 48 publications

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“…3,12,33 While risk factors for abdominal SSIs in civilian trauma have been well described, combat trauma literature is sparse. [3][4][5]10 Bograd and colleagues 12 described a complication rate as high as 40% after DCL from 2003 to 2009 but grouped noninfectious and infectious complications together. Examination of 135 combat casualties who had battlefield exploratory laparotomies found that 10% developed an SSI with a higher proportion among those who had proximal vascular control versus nonproximal control (23% vs. 4%).…”

Section: Discussionmentioning

confidence: 99%

“…7 Damage-control laparotomy (DCL) is frequently performed for combat-injured patients with abdominal injuries. [8][9][10] Accordingly, patients are often left with open abdomens, temporizing hemostasis measures, or in bowel discontinuity until they are evacuated to higher echelons of care for definitive surgical treatment. 1,9,11,12 Characterization of SSI after exploratory laparotomy for battlefield trauma is poorly defined, as prior studies have usually reported short-term and in-theater outcomes, and either broadly grouped or only reported specific infectious categories.…”

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confidence: 99%

“…[19][20][21] We have previously performed an initial assessment of the epidemiology of abdominal SSIs following combat-related laparotomy. 10 The objective of this analysis was to identify risk factors for the development of SSI after exploratory laparotomy in battlefield trauma patients.…”

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confidence: 99%

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Risk factors for abdominal surgical site infection after exploratory laparotomy among combat casualties

Bozzay¹,

Walker²,

Schechtman³

et al. 2021

J Trauma Acute Care Surg

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BACKGROUND:Surgical site infections (SSIs) are well-recognized complications after exploratory laparotomy for abdominal trauma; however, little is known about SSI development after exploration for battlefield abdominal trauma. We examined SSI risk factors after exploratory laparotomy among combat casualties. METHODS:Military personnel with combat injuries sustained in Iraq and Afghanistan (June 2009 to May 2014) who underwent laparotomy and were evacuated to participating US military hospitals were included. Log-binominal regression was used to identify SSI risk factors. RESULTS:Of 4,304 combat casualties, 341 patients underwent a total of 1,053 laparotomies. Abdominal SSIs were diagnosed in 49 patients (14.4%): 8% with organ space SSI, 4% with deep incisional SSI, and 4% with superficial SSIs (4 patients had multiple SSIs).Patients with SSIs had more colorectal (p < 0.001), small bowel (p = 0.010), duodenum (p = 0.006), pancreas (p = 0.032), and abdominal vascular injuries (p = 0.040), as well as prolonged open abdomen (p = 0.004) and more infections diagnosed before the SSI (or final exploratory laparotomy) versus non-SSI patients (p < 0.001). Sustaining colorectal injuries (risk ratio [RR], 3.20; 95% confidence interval [CI], 1.58-6.45), duodenum injuries (RR, 6.71; 95% CI, 1.73-25.58), and being diagnosed with prior infections (RR, 10.34; 95% CI, 5.05-21.10) were independently associated with any SSI development. For either organ space or deep incisional SSIs, non-intra-abdominal infections, fecal diversion, and duodenum injuries were independently associated, while being injured via an improvised explosive device was associated with reduced likelihood compared with penetrating nonblast (e.g., gunshot wounds) injuries. Non-intra-abdominal infections and hypotension were independently associated with organ space SSIs development alone, while sustaining blast injuries were associated with reduced likelihood. CONCLUSION:Despite severity of injuries and the battlefield environment, the combat casualty laparotomy SSI rate is relatively low at 14%, with similar risk factors and rates reported following severe civilian trauma.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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Risk factors for abdominal surgical site infection after exploratory laparotomy among combat casualties

Bozzay¹,

Walker²,

Schechtman³

et al. 2021

J Trauma Acute Care Surg

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“…As noted by Bozzay et al, 14.4% of 341 combat casualties who underwent combat-related exploratory laparotomies developed an abdominal SSI with the majority being organ space or deep incisional (12.0%). 13,16 In this more restricted TIDOS population, the overall proportion of any SSIs was 25.3%, while it was 19.5% for either deep incisional or organ space SSIs and it is possible that distinguishing a true meaningful difference regarding the development of abdominal SSIs between the groups was hindered by the low numbers included in the study.…”

Section: Discussionmentioning

confidence: 91%

Anastomotic Outcomes in Military Exploratory Laparotomies in the Modern Combat Era

Walker

Bozzay

Schechtman

et al. 2022

The American Surgeon™

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Background Intestinal anastomoses in military settings are performed in severely injured patients who often undergo damage control laparotomy in austere environments. We describe anastomotic outcomes of patients from recent wars. Methods Military personnel with combat-related intra-abdominal injuries (June 2009-December 2014) requiring laparotomy with resection and anastomosis were analyzed. Patients were evacuated from Iraq or Afghanistan to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals. Results Among 341 patients who underwent 1053 laparotomies, 87 (25.5%) required ≥1 anastomosis. Stapled anastomosis only was performed in 57.5% of patients, while hand-sewn only was performed in 14.9%, and 9.2% had both stapled and hand-sewn techniques (type unknown for 18.4%). Anastomotic failure occurred in 15% of patients. Those with anastomotic failure required more anastomoses (median 2 anastomoses, interquartile range [IQR] 1-3 vs. 1 anastomosis, IQR 1-2, P = .03) and more total laparotomies (median 5 laparotomies, IQR 3-12 vs. 3, IQR 2-4, P = .01). There were no leaks in patients that had only hand-sewn anastomoses, though a significant difference was not seen with those who had stapled anastomoses. While there was an increasing trend regarding surgical site infections (SSIs) with anastomotic failure after excluding superficial SSIs, it was not significant. There was no difference in mortality. Discussion Military trauma patients have a similar anastomotic failure rate to civilian trauma patients. Patients with anastomotic failure were more likely to have had more anastomoses and more total laparotomies. No definitive conclusions can be drawn about anastomotic outcome differences between hand-sewn and stapled techniques.

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“…Severe abdominal injuries generally require exploratory laparotomy (ex-lap) to diagnose and allow for repair of injured structures (1,2). Patient outcomes following con ict-related ex-laps have mostly been studied in military hospitals associated with countries a liated to North Atlantic Treaty Organization (NATO) (3,4).…”

Section: Introductionmentioning

confidence: 99%

Exploratory Laparotomy During the Battle of Mosul, 2016–2017: Results from a Tertiary Civilian Hospital in Erbil, Iraqi Kurdistan

Muhrbeck

Egelko

Haweizy

et al. 2023

Preprint

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Background: The Battle of Mosul (2016–2017) was an urban conflict resulting in over 9000s civilian deaths. Emergency Management Centre (EMC), located 90km from Mosul, was designated as a civilian-run trauma centre as part of the novel Mosul Trauma Pathway. Patients necessitating ex-lap provide a unique window into the system of care delivery in conflicts, given the importance of timely, resource-intensive care. However, there is insufficient knowledge regarding the presentation and outcomes for conflict-related ex-lap in civilian institutions. Methods: This is a descriptive study using routinely collected data for all patients who underwent ex-lap at EMC for injuries sustained during the battle of Mosul. Differences in demographics, pre-hospital/hospital course, and New Injury Severity Scores (NISS) were analysed using student t-test, Hotelling T-squared, and linear regression. Results: During the battle, 1832 patients with conflict-related injuries were admitted to EMC. Some 73/1832 (4.0%) underwent ex-lap, of whom 22/73 (30.1%) were children and 40/73 (54.8%) were non-combatant adults. Men constituted 51/73 (69%) patients. Bullets caused 19/73 (26.0%) injuries, while ordnances caused 52/73 (71.2%). Information regarding hospital course was available for 47/73 (64.4%) patients. Children had prolonged time from injury to first laparotomy compared to adults (600 vs 208 minutes, p<0.05). Median LOS was 6 days (IQR 4–9.5); however, 11/47 (23%) patients left against medical advice. Post-operative complications occurred in 11/47 (23.4%) patients; 6/11 (54.5%) were surgical site infections. There were 12 (25.5%) patients who underwent relaparotomies after index surgery elsewhere; 10/12 (83.3%) were for failed repairs or missed injuries. Median NISS was 18 (IQR 12–27). NISS were significantly higher for women (vs men; 28.5 vs 19.8), children (vs adults; 28.8 vs 20), and relaparotomy patients (vs primary laparotomy patients; 32.0 vs 19.0). Some 3 patients died, 2 of whom were relaparotomies. Conclusion: At this civilian tertiary trauma centre, conflict-related exploratory laparotomies were associated with low morbidity and mortality. Long transport times, high rates of repeat laparotomies, and high numbers of patients leaving against medical advice raise questions regarding continuity of care along the Mosul Trauma Pathway. Registration: The study protocol was registered at Clinicaltrails.gov, ID NCT03490305, prior to collection of data.

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Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties

Cited by 15 publications

References 48 publications

Risk factors for abdominal surgical site infection after exploratory laparotomy among combat casualties

Risk factors for abdominal surgical site infection after exploratory laparotomy among combat casualties

Anastomotic Outcomes in Military Exploratory Laparotomies in the Modern Combat Era

Exploratory Laparotomy During the Battle of Mosul, 2016–2017: Results from a Tertiary Civilian Hospital in Erbil, Iraqi Kurdistan

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