title: A prospective observational study of abdominal injury management in contemporary military operations: damage control laparotomy is associated with high survivability and low rates of fecal diversion.
abstract: OBJECTIVE
  This study describes the cause, management, and outcomes of abdominal injury in a mature deployed military trauma system, with particular focus on damage control, hollow visceral injury (HVI), and stoma utilization.
  
  
  BACKGROUND
  Damage control laparotomy (DCL) is established in military and civilian practice. However, optimal management of HVI during military DCL remains controversial.
  
  
  METHODS
  We studied abdominal trauma managed over 5 months at the Joint Force Combat Support Hospital, Camp Bastion, Afghanistan (Role 3). Data included demographics, wounding mechanism, injuries sustained, prehospital times, location of first laparotomy (Role 3 or forward), use of DCL or definitive laparotomy, subsequent surgical details, resource utilization, complications, and mortality.
  
  
  RESULTS
  Ninety-four of 636 trauma patients (15%) underwent laparotomy. Military injury mechanisms dominated [44 gunshot wounds (47%), 44 blast (47%), and 6 blunt trauma (6%)]. Seventy-two of 94 patients (77%) underwent DCL. Four patients were palliated. Seventy of 94 (74%) sustained HVI; 44 of 70 (63%) had colonic injury. Repair or resection with anastomosis was performed in 59 of 67 therapeutically managed HVI patients (88%). Six patients were managed with fecal diversion, and 6 patients were evacuated with discontinuous bowel. Anastomotic leaks occurred in 4 of 56 HVI patients (7%) with known outcomes. Median New Injury Severity Score for DCL patients was 29 (interquartile range: 18-41) versus 19.5 (interquartile range: 12-34) for patients undergoing definitive laparotomy (P = 0.016). Overall mortality was 15 of 94 (16%).
  
  
  CONCLUSIONS
  Damage control is now used routinely for battlefield abdominal trauma. In a well-practiced Combat Support Hospital, this strategy is associated with low mortality and infrequent fecal diversion.
authors.affiliation: *202 (Midlands) Field Hospital, Birmingham, West Midlands, United Kingdom †NIHR Surgical Reconstruction & Microbiology Research Centre, Birmingham, West Midlands, United Kingdom ‡Royal Centre for Defence Medicine, Birmingham, West Midlands, United Kingdom §Army Medical Directorate Support Unit ‖US Army Institute of Surgical Research, Houston, TX.
authors.forename: Iain M
authors.initials: IM
authors.lastname: Smith
authors.forename: Zine K M
authors.initials: ZK
authors.lastname: Beech
authors.forename: Jonathan B
authors.initials: JB
authors.lastname: Lundy
authors.forename: Douglas M
authors.initials: DM
authors.lastname: Bowley
mesh_terms: D000007:Abdominal Injuries / Q000401:mortality* / Q000601:surgery*; D000328:Adult; D000714:Anastomosis, Surgical / Q000706:statistics & numerical data; D057868:Anastomotic Leak / Q000453:epidemiology; D001753:Blast Injuries / Q000401:mortality / Q000601:surgery*; D003125:Colostomy / Q000706:statistics & numerical data; D005242:Fecal Incontinence / Q000453:epidemiology / Q000601:surgery; D006801:Humans; D015601:Injury Severity Score; D007813:Laparotomy / Q000379:methods*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008889:Military Personnel / Q000706:statistics & numerical data*; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D040841:Resource Allocation / Q000706:statistics & numerical data; D054047:Surgical Stomas / Q000706:statistics & numerical data*; D015996:Survival Rate; D016896:Treatment Outcome; D014948:Wounds, Gunshot / Q000401:mortality / Q000601:surgery*; D055815:Young Adult