Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same.
BACKGROUND
Damage control surgery (DCS) and treatment of abdominal compartment syndrome have had major impacts on care of the severely injured. The objective of this study was to see whether advances in critical care, DCS, and recognition of abdominal compartment syndrome have improved survival from penetrating abdominal injury (PAI).


METHODS
The care of 250 consecutive patients requiring laparotomy for PAI (1997-2000) was reviewed retrospectively. Organ injury patterns, survival, and use of DCS and its impact on outcome were compared with a similar experience reported in 1988.


RESULTS
Two hundred fifty patients had a positive laparotomy for PAI. Twenty-seven (10.8%) required abdominal packing and 45 (17.9%) did not have fascial closure. Seven (2.8%) required emergency department thoracotomy and 21 (8.4%) required operating room thoracotomy. Two hundred seventeen (86.8%) survived overall. Small bowel (47.2%), colon (36.4%), and liver (34.4%) were most often injured. Mortality was associated with the number of organs injured (odds ratio, 1.98; 95% confidence interval, 1.65-2.37; p < 0.001). Vascular injury was a risk factor for mortality (p < 0.001), as was need for DCS (p < 0.001), emergency department thoracotomy (p < 0.001), and operating room thoracotomy (p < 0.001). Seventy-nine percent of deaths occurred within 24 hours from refractory hemorrhagic shock. DCS was used in 17.9% (n = 45) versus 7.0% (n = 21) in 1988, with a higher survival rate (73.3% vs. 23.8%, p < 0.001). DCS was associated with significant morbidity including sepsis (42.4%, p < 0.001), intra-abdominal abscess (18.2%, p = 0.009), and gastrointestinal fistula (18.2%, p < 0.001).


CONCLUSIONS
Penetrating abdominal organ injury patterns and survival from PAI have remained similar over the past decade. Death from refractory hemorrhagic shock in the first 24 hours remains the most common cause of mortality. DCS and the open abdomen are being used more frequently with improved survival but result in significant morbidity.
Nicholas
Jeffrey M
JM
Emory University Department of Surgery/Grady Memorial Hospital and Rollins School of Public Health, Atlanta, Georgia 03030, USA. jeffrey_nicholas@emoryhealthcare.org
Rix
Emily Parker
EP
Easley
Kerr Anthony
KA
Feliciano
David V
DV
Cava
Raymond A
RA
Ingram
Walter L
WL
Parry
Neil G
NG
Rozycki
Grace S
GS
Salomone
Jeffrey P
JP
Tremblay
Lorraine N
LN
D000007:Abdominal Injuries / Q000401:mortality / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D003422:Critical Care / Q000379:methods / Q000639:trends; D005260:Female; D005845:Georgia / Q000453:epidemiology; D006801:Humans; D007223:Infant; D015601:Injury Severity Score; D007813:Laparotomy / Q000009:adverse effects / Q000639:trends; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D010818:Practice Patterns, Physicians' / Q000639:trends*; D012189:Retrospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000209:etiology; D012771:Shock, Hemorrhagic / Q000209:etiology; D016019:Survival Analysis; D013908:Thoracotomy / Q000009:adverse effects / Q000639:trends; D014193:Trauma Centers; D016896:Treatment Outcome; D014950:Wounds, Penetrating / Q000401:mortality / Q000601:surgery*