title: Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy.
abstract: BACKGROUND
  Damage control laparotomy (DCL) is a lifesaving technique initially employed to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. Recently, it has been recognized that DCL itself carries significant morbidity and may be overutilized. The purpose of this study was to determine (1) whether early fascial closure is associated with a reduction in postoperative complications and (2) whether patients at our institution met traditional DCL indications (acidosis, hypothermia, and coagulopathy).
  
  
  METHODS
  This is a retrospective review of all patients undergoing immediate laparotomy at a Level I trauma center between 2004 and 2008. DCL was defined as temporary abdominal closure at the initial surgery. Early closure was defined as primary fascial closure at initial take back laparotomy. Patients were excluded if they died before first take back. Acidosis (pH <7.30), hypothermia (temperature <95.0°F), and coagulopathy (international normalized ratio >1.5) were measured on intensive care unit (ICU) arrival.
  
  
  RESULTS
  Totally, 925 patients were eligible. Thirty percent had DCL employed. Of these, 86 subjects (34%) were closed at first take back while 161 (66%) were not. Both groups were similar in demographics, injury severity score, resuscitation volumes, blood products, and prehospital, emergency department, and operating room vital signs. Univariate analyses noted that intra-abdominal abscesses (8.4% vs. 21.3%), respiratory failure (14.4% vs. 37.1%), sepsis (8.4% vs. 25.1%), and renal failure (3.6% vs. 25.1%) were lower in patients closed at first take back (all <0.05). Controlling for age, gender, injury severity score, and transfusions, logistic regression analysis noted that closure at the first take back was associated with a reduction in infectious (odds ratio, 0.28; 95% confidence interval [CI], 0.12-0.66; p = 0.004) and noninfectious abdominal complications (odds ratio, 0.23; 95% CI, 0.09-0.56; p = 0.001) as well as wound (odds ratio, 0.31; 95% CI, 0.13-0.72; p = 0.007) and pulmonary complications (odds ratio, 0.35; CI, 0.20-0.62; p < 0.001). Of patients closed at the initial take back, 78% were acidotic (35%), coagulopathic (49%), or hypothermic (44%) on initial ICU admission.
  
  
  CONCLUSIONS
  Early fascial closure is an independent predictor of reduced complications in DCL patients. One in five patients closed at initial take back did not meet any of the traditional indications for DCL upon initial ICU admission. This may represent an overutilization of this valuable technique, exposing patients to increased complications. Further efforts should be directed at achieving both early facial closure as well as redefining the appropriate indications for DCL.
authors.affiliation: Department of Surgery, The University of Texas Health Science Center, Houston, Texas 77030, USA.
authors.forename: Quinton M
authors.initials: QM
authors.lastname: Hatch
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Osterhout
authors.forename: Jeanette
authors.initials: J
authors.lastname: Podbielski
authors.forename: Rosemary A
authors.initials: RA
authors.lastname: Kozar
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
mesh_terms: D000007:Abdominal Injuries / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D000704:Analysis of Variance; D016009:Chi-Square Distribution; D015331:Cohort Studies; D004638:Emergency Treatment / Q000379:methods; D000071938:Fasciotomy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D009102:Multiple Organ Failure / Q000209:etiology / Q000517:prevention & control*; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000175:diagnosis / Q000517:prevention & control* / Q000601:surgery*; D011237:Predictive Value of Tests; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D013536:Suture Techniques; D014193:Trauma Centers; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology*