Sew it up! A western trauma association multi-institutional study of enteric injury management in the postinjury open abdomen

Clay Cothren Burlew, Ernest E. Moore, Joseph Cuschieri, Gregory Jurkovich, Panna Codner, Kody Crowell, Ram Nirula, James Haan, Susan E. Rowell, Catherine M. Kato, Heather MacNew, M. Gage Ochsner, Paul B. Harrison, Cynthia Fusco, Angela Sauaia, Krista L. Kaups

Research output: Contribution to journalArticle

56 Citations (Scopus)

Abstract

Background: Use of damae control surgery techniques has reduced mortality in critically injured patients but at the cost of the open abdomen. With the option of delayed definitive management of enteric injuries, the question of intestinal repair/anastomosis or definitive stoma creation has been posed with no clear consensus. The purpose of this study was to determine outcomes on the basis of management of enteric injuries in patients relegated to the postinjury open abdomen. Methods: Patients requiring an open abdomen after trauma from January 1, 2002 to December 31, 2007 were reviewed. Type of bowel repair was categorized as immediate repair, immediate anastomosis, delayed anastomosis, stoma and a combination. Logistic regression was used to determine independent effect of risk factors on leak development. Result: During the 6-year study period, 204 patients suffered enteric injuries and were managed with an open abdomen. The majority was men (77%) sustaining blunt trauma (66%) with a mean age of 37.1 years ± 1.2 years and median Injury Severity Score of 27 (interquartile range = 20-41). Injury patterns included 81 (40%) small bowel, 37 (18%) colonic, and 86 (42%) combined injuries. Enteric injuries were managed with immediate repair (58), immediate anastomosis (15), delayed anastomosis (96), stoma (10), and a combination (22); three patients died before definitive repair. Sixty-one patients suffered intra-abdominal complications: 35 (17%) abscesses, 15 (7%) leaks, and 11 (5%) enterocutaneous fistulas. The majority of patients with leaks had a delayed anastomosis; one patient had a right colon repair. Leak rate increased as one progresses toward the left colon (small bowel anastomoses, 3% leak rate; right colon, 3%; transverse colon, 20%; left colon, 45%). There were no differences in emergency department physiology, injury severity, transfusions, crystalloids, or demographic characteristics between patients with and without leak. Leak cases had higher 12-hour heart rate (148 vs. 125, p = 0.02) and higher 12-hour base deficit (13.7 vs. 9.7, p = 0.04), suggesting persistent shock and consequent hypoperfusion were related to leak development. There was a significant trend toward higher incidence of leak with closure day (χ2 for trend, p = 0.01), with closure after day 5 having a four times higher likelihood of developing leak (3% vs. 12%, p = 0.02). Conclusion: Repair or anastomosis of intestinal injuries should be considered in all patients. However, leak rate increases with fascial closure beyond day 5 and with left-sided colonic anastomoses. Investigating the physiologic basis for intestinal vulnerability of the left colon and in the open abdomen is warranted.

Original languageEnglish (US)
Pages (from-to)273-277
Number of pages5
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume70
Issue number2
DOIs
StatePublished - Feb 1 2011
Externally publishedYes

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Abdomen
Wounds and Injuries
Colon
Intestinal Fistula
Transverse Colon
Injury Severity Score
Abscess
Hospital Emergency Service
Shock
Heart Rate
Logistic Models
Demography
Mortality
Incidence

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Sew it up! A western trauma association multi-institutional study of enteric injury management in the postinjury open abdomen. / Burlew, Clay Cothren; Moore, Ernest E.; Cuschieri, Joseph; Jurkovich, Gregory; Codner, Panna; Crowell, Kody; Nirula, Ram; Haan, James; Rowell, Susan E.; Kato, Catherine M.; MacNew, Heather; Ochsner, M. Gage; Harrison, Paul B.; Fusco, Cynthia; Sauaia, Angela; Kaups, Krista L.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 70, No. 2, 01.02.2011, p. 273-277.

Research output: Contribution to journalArticle

Burlew, CC, Moore, EE, Cuschieri, J, Jurkovich, G, Codner, P, Crowell, K, Nirula, R, Haan, J, Rowell, SE, Kato, CM, MacNew, H, Ochsner, MG, Harrison, PB, Fusco, C, Sauaia, A & Kaups, KL 2011, 'Sew it up! A western trauma association multi-institutional study of enteric injury management in the postinjury open abdomen', Journal of Trauma - Injury, Infection and Critical Care, vol. 70, no. 2, pp. 273-277. https://doi.org/10.1097/TA.0b013e3182050eb7
Burlew, Clay Cothren ; Moore, Ernest E. ; Cuschieri, Joseph ; Jurkovich, Gregory ; Codner, Panna ; Crowell, Kody ; Nirula, Ram ; Haan, James ; Rowell, Susan E. ; Kato, Catherine M. ; MacNew, Heather ; Ochsner, M. Gage ; Harrison, Paul B. ; Fusco, Cynthia ; Sauaia, Angela ; Kaups, Krista L. / Sew it up! A western trauma association multi-institutional study of enteric injury management in the postinjury open abdomen. In: Journal of Trauma - Injury, Infection and Critical Care. 2011 ; Vol. 70, No. 2. pp. 273-277.
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abstract = "Background: Use of damae control surgery techniques has reduced mortality in critically injured patients but at the cost of the open abdomen. With the option of delayed definitive management of enteric injuries, the question of intestinal repair/anastomosis or definitive stoma creation has been posed with no clear consensus. The purpose of this study was to determine outcomes on the basis of management of enteric injuries in patients relegated to the postinjury open abdomen. Methods: Patients requiring an open abdomen after trauma from January 1, 2002 to December 31, 2007 were reviewed. Type of bowel repair was categorized as immediate repair, immediate anastomosis, delayed anastomosis, stoma and a combination. Logistic regression was used to determine independent effect of risk factors on leak development. Result: During the 6-year study period, 204 patients suffered enteric injuries and were managed with an open abdomen. The majority was men (77{\%}) sustaining blunt trauma (66{\%}) with a mean age of 37.1 years ± 1.2 years and median Injury Severity Score of 27 (interquartile range = 20-41). Injury patterns included 81 (40{\%}) small bowel, 37 (18{\%}) colonic, and 86 (42{\%}) combined injuries. Enteric injuries were managed with immediate repair (58), immediate anastomosis (15), delayed anastomosis (96), stoma (10), and a combination (22); three patients died before definitive repair. Sixty-one patients suffered intra-abdominal complications: 35 (17{\%}) abscesses, 15 (7{\%}) leaks, and 11 (5{\%}) enterocutaneous fistulas. The majority of patients with leaks had a delayed anastomosis; one patient had a right colon repair. Leak rate increased as one progresses toward the left colon (small bowel anastomoses, 3{\%} leak rate; right colon, 3{\%}; transverse colon, 20{\%}; left colon, 45{\%}). There were no differences in emergency department physiology, injury severity, transfusions, crystalloids, or demographic characteristics between patients with and without leak. Leak cases had higher 12-hour heart rate (148 vs. 125, p = 0.02) and higher 12-hour base deficit (13.7 vs. 9.7, p = 0.04), suggesting persistent shock and consequent hypoperfusion were related to leak development. There was a significant trend toward higher incidence of leak with closure day (χ2 for trend, p = 0.01), with closure after day 5 having a four times higher likelihood of developing leak (3{\%} vs. 12{\%}, p = 0.02). Conclusion: Repair or anastomosis of intestinal injuries should be considered in all patients. However, leak rate increases with fascial closure beyond day 5 and with left-sided colonic anastomoses. Investigating the physiologic basis for intestinal vulnerability of the left colon and in the open abdomen is warranted.",
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T1 - Sew it up! A western trauma association multi-institutional study of enteric injury management in the postinjury open abdomen

AU - Burlew, Clay Cothren

AU - Moore, Ernest E.

AU - Cuschieri, Joseph

AU - Jurkovich, Gregory

AU - Codner, Panna

AU - Crowell, Kody

AU - Nirula, Ram

AU - Haan, James

AU - Rowell, Susan E.

AU - Kato, Catherine M.

AU - MacNew, Heather

AU - Ochsner, M. Gage

AU - Harrison, Paul B.

AU - Fusco, Cynthia

AU - Sauaia, Angela

AU - Kaups, Krista L.

PY - 2011/2/1

Y1 - 2011/2/1

N2 - Background: Use of damae control surgery techniques has reduced mortality in critically injured patients but at the cost of the open abdomen. With the option of delayed definitive management of enteric injuries, the question of intestinal repair/anastomosis or definitive stoma creation has been posed with no clear consensus. The purpose of this study was to determine outcomes on the basis of management of enteric injuries in patients relegated to the postinjury open abdomen. Methods: Patients requiring an open abdomen after trauma from January 1, 2002 to December 31, 2007 were reviewed. Type of bowel repair was categorized as immediate repair, immediate anastomosis, delayed anastomosis, stoma and a combination. Logistic regression was used to determine independent effect of risk factors on leak development. Result: During the 6-year study period, 204 patients suffered enteric injuries and were managed with an open abdomen. The majority was men (77%) sustaining blunt trauma (66%) with a mean age of 37.1 years ± 1.2 years and median Injury Severity Score of 27 (interquartile range = 20-41). Injury patterns included 81 (40%) small bowel, 37 (18%) colonic, and 86 (42%) combined injuries. Enteric injuries were managed with immediate repair (58), immediate anastomosis (15), delayed anastomosis (96), stoma (10), and a combination (22); three patients died before definitive repair. Sixty-one patients suffered intra-abdominal complications: 35 (17%) abscesses, 15 (7%) leaks, and 11 (5%) enterocutaneous fistulas. The majority of patients with leaks had a delayed anastomosis; one patient had a right colon repair. Leak rate increased as one progresses toward the left colon (small bowel anastomoses, 3% leak rate; right colon, 3%; transverse colon, 20%; left colon, 45%). There were no differences in emergency department physiology, injury severity, transfusions, crystalloids, or demographic characteristics between patients with and without leak. Leak cases had higher 12-hour heart rate (148 vs. 125, p = 0.02) and higher 12-hour base deficit (13.7 vs. 9.7, p = 0.04), suggesting persistent shock and consequent hypoperfusion were related to leak development. There was a significant trend toward higher incidence of leak with closure day (χ2 for trend, p = 0.01), with closure after day 5 having a four times higher likelihood of developing leak (3% vs. 12%, p = 0.02). Conclusion: Repair or anastomosis of intestinal injuries should be considered in all patients. However, leak rate increases with fascial closure beyond day 5 and with left-sided colonic anastomoses. Investigating the physiologic basis for intestinal vulnerability of the left colon and in the open abdomen is warranted.

AB - Background: Use of damae control surgery techniques has reduced mortality in critically injured patients but at the cost of the open abdomen. With the option of delayed definitive management of enteric injuries, the question of intestinal repair/anastomosis or definitive stoma creation has been posed with no clear consensus. The purpose of this study was to determine outcomes on the basis of management of enteric injuries in patients relegated to the postinjury open abdomen. Methods: Patients requiring an open abdomen after trauma from January 1, 2002 to December 31, 2007 were reviewed. Type of bowel repair was categorized as immediate repair, immediate anastomosis, delayed anastomosis, stoma and a combination. Logistic regression was used to determine independent effect of risk factors on leak development. Result: During the 6-year study period, 204 patients suffered enteric injuries and were managed with an open abdomen. The majority was men (77%) sustaining blunt trauma (66%) with a mean age of 37.1 years ± 1.2 years and median Injury Severity Score of 27 (interquartile range = 20-41). Injury patterns included 81 (40%) small bowel, 37 (18%) colonic, and 86 (42%) combined injuries. Enteric injuries were managed with immediate repair (58), immediate anastomosis (15), delayed anastomosis (96), stoma (10), and a combination (22); three patients died before definitive repair. Sixty-one patients suffered intra-abdominal complications: 35 (17%) abscesses, 15 (7%) leaks, and 11 (5%) enterocutaneous fistulas. The majority of patients with leaks had a delayed anastomosis; one patient had a right colon repair. Leak rate increased as one progresses toward the left colon (small bowel anastomoses, 3% leak rate; right colon, 3%; transverse colon, 20%; left colon, 45%). There were no differences in emergency department physiology, injury severity, transfusions, crystalloids, or demographic characteristics between patients with and without leak. Leak cases had higher 12-hour heart rate (148 vs. 125, p = 0.02) and higher 12-hour base deficit (13.7 vs. 9.7, p = 0.04), suggesting persistent shock and consequent hypoperfusion were related to leak development. There was a significant trend toward higher incidence of leak with closure day (χ2 for trend, p = 0.01), with closure after day 5 having a four times higher likelihood of developing leak (3% vs. 12%, p = 0.02). Conclusion: Repair or anastomosis of intestinal injuries should be considered in all patients. However, leak rate increases with fascial closure beyond day 5 and with left-sided colonic anastomoses. Investigating the physiologic basis for intestinal vulnerability of the left colon and in the open abdomen is warranted.

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