LAS VEGAS – Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.
For example, the deferred ostomy rate was 16.7% among 72 patients who underwent damage control laparotomy (DCL), which was significantly lower than the primary ostomy rate of 53.6% in 110 patients who underwent a definitive surgical procedure (DSP), Dr. Maria P. Garcia-Garcia reported at the annual meeting of the American Association for the Surgery of Trauma.
Further, the fistula rate was lower among 60 DCL patients who underwent delayed anastomosis, compared with 51 DSP patients who underwent primary anastomosis (26.7% vs. 37.2%), and the mortality rate was lower in the DCL vs. DSP patients (16.7% vs. 24.5%). These differences did not meet statistical significance due to the sample size. Deaths in the DCL group all occurred in those who underwent delayed anastomosis; deaths in the DSP group occurred in 14 ostomy patients and 13 anastomosis patients, said Dr. Garcia-Garcia of Fundacion Valle del Lili, Cali, Colombia.
Disease severity, as measured by APACHE II scores, was similar in the two groups (mean of about 17 for each group). Septic shock was present in 37% at the time of admission. Mean hospital length of stay and mean intensive care unit length of stay did not differ significantly between the groups, nor did the systemic complication rate, or the rates of multiple organ failure and acute respiratory distress syndrome.
Small-bowel perforation occurred in 77 (42.3%), and colon perforation occurred in 105 (57.7%).
The patients included teens and adults aged 16 years or older (mean of 60.3 years) with severe nontrauma secondary peritonitis (NSPT) who were undergoing bowel resection after enteric perforations between 2003 and 2013. The DSP patients underwent either primary anastomosis or primary ostomy, and the DCL patients underwent segmental bowel resection, temporary abdominal closure, and subsequent delayed anastomosis or deferred ostomy.
DCL is a recognized strategy for managing bowel injuries in trauma patients. It was developed in response to the poor outcomes associated with attempting definitive repair, but evidence regarding the role and timing of anastomosis in DCL in NTSP – a condition associated with high morbidity and a 30% in-hospital mortality rate – is lacking, Dr. Garcia-Garcia said, noting that the current findings suggest it is the preferred approach.
“When a definite surgical repair is chosen, there is a 50/50 chance of performing anastomosis or ostomy. However, when a damage control abbreviated laparotomy is performed, there is a high bowel reconstruction success rate of about 80%. Therefore, damage control abbreviated laparotomy is a reliable and safe option in critically ill nontrauma secondary peritonitis patients. At the end of the day it’s your choice: Would you rather leave your patient with an ostomy or tube, or would you give your patient a chance of successful reconstruction without an ostomy?” she said.
Dr. Garcia-Garcia reported having no disclosures.