Comparison of abdominal damage control surgery in combat versus civilian trauma.
ABSTRACT The majority of individuals who perform damage control surgery in the military arena are trained in civilian venues. Therefore, it is important to compare and contrast damage control performed in civilian and military settings. In contrast to civilian trauma, which is primarily caused by blunt injury and addressed at one or two surgical facilities, combat casualties primarily sustain explosion-related injuries and undergo treatment at multiple levels of care across continents. We aimed to compare patients undergoing abdominal damage control surgery across these two very different settings.
Parallel retrospective reviews were conducted over 2 years (2005-2006) in a combat setting and at a US Level I trauma center. Patients were examined during the first 7 days after injury.
The civilian population (CP) was older (40 vs. 23; p < 0.01) with a higher injury severity score (35 vs. 27; p < 0.02). The CP experienced greater blunt injury than the military population (MP) (83 vs. 4%; p < 0.01). Explosion-related injury was only present in the MP (64%). At baseline, the CP presented with lower systolic blood pressure (108 vs. 126) and larger base deficit (9.8 vs. 6.5; p < 0.05). The MP underwent more surgeries (3.5 vs. 2.9; p = 0.02) with similar rates of fascial closure (48.7% vs. 70.0%; p = 0.11). Complication rates were similar between the CP and the MP (43% vs. 58%, respectively; p = 0.14).
Military and civilian trauma patients who undergo damage control surgery experience similar fascial closure rates despite differing demographics and widely disparate mechanisms of injury. The MP undergoes a greater number of procedures than the CP, but complication rates do not differ between the groups.
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ABSTRACT: OBJECTIVE To evaluate factors that are predictive of delayed abdominal closure in patients injured during military conflict. DESIGN, SETTING, AND PATIENTS Seventy-one patients managed with an open abdomen were identified from records at Landstuhl Regional Medical Center from 2005 and 2006. Follow-up data were available from Walter Reed Army Medical Center. Records were reviewed through all echelons of care. Ordinal logistic regression was used to predict delayed abdominal closure. RESULTS Patients sustained injury from blunt (n = 2), penetrating (n = 30), and blast (n = 39) mechanisms. The median Injury Severity Score was 25 (interquartile range, 17-34). Abdominal injury was observed in 85% of patients, and 48% underwent a massive transfusion. The median time to transfer to the United States was 5.3 days (interquartile range, 4.3-6.8 days). Abdomens were definitively closed downrange (11%), at Landstuhl Regional Medical Center (33%), or at Walter Reed Army Medical Center (56%). The median time until abdominal closure was 13 days (interquartile range, 4-40 days) in 2005 compared with 4 days (interquartile range, 1-14.5 days) in 2006 (P = .02). The multivariate model identified massive transfusion (odds ratio, 3.9), presence of complications (odds ratio, 5.1), and an injury date in 2005 (odds ratio, 3.4) as independently predictive variables for later abdominal closure. CONCLUSIONS Massive transfusion, occurrence of complications, and earlier injury date were predictive of delayed abdominal closure in casualties managed with an open abdomen. These data suggest an evolving approach to the management of severely injured combat casualties that involves earlier abdominal closure.Archives of surgery (Chicago, Ill.: 1960) 09/2012; 148(1):1-6. DOI:10.1001/2013.jamasurg.4 · 4.30 Impact Factor
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ABSTRACT: Background Limited data exist examining the use of fecal diversion in combatants from modern armed conflicts. Characterization of factors leading to colostomy creation is an initial step towards optimizing and individualizing combat casualty care. Methods A retrospective review of the US Department of Defense Trauma Registry database was performed for all US and coalition troops with colorectal injuries sustained during combat operations in Iraq and Afghanistan over 8 years. Colostomy rate, anatomic injury location, mechanism of injury, demographic, and initial physiologic parameters were examined. Univariate and multivariate analyses were conducted. Results Eight hundred sixty-seven coalition military personnel with colorectal injuries were identified. The overall colostomy rate was 36.9%. Rectal injuries had the highest diversion rate (55.9%), followed by left-sided (40.8%) and right-sided (19.4%) locations (p < 0.0001). Gunshot wounds (GSW) underwent diversion more often than blast injuries (42.6% vs. 30.9% respectively, P < 0.0008). Injury Severity Score ≥ 16 (40.6% vs. 29.9%, P = 0.0018) and damage control surgery (DCS) (48.2% vs. 31.4%, P < 0.0001) were associated with higher diversion rates. On multivariate analysis, significant predictors for colostomy creation were injury location: rectal vs. left colon, (OR=2.2), rectal vs. right colon (OR=7.5), left vs. right colon (OR=3.4), GSW (OR=2.0), ISS ≥ 16 (OR=1.7), and DCS (OR=1.6). Conclusions In this exploratory study of 320 combat-related colostomies, distal colon and rectal injuries continue to be diverted at higher rates independent of other co-morbidities. Additional outcomes-directed research is needed to determine whether such surgical management is beneficial in all patients.Surgery 06/2014; DOI:10.1016/j.surg.2014.01.010 · 3.11 Impact Factor