Study Finds Risk Factors for Fistula and Sepsis After Damage-Control Laparotomy

August 28, 2013

By James E. Barone MD

NEW YORK (Reuters Health) Aug 28 - Patients having damage-control laparotomy were at higher risk for intra-abdominal sepsis and fistulas to the abdomen or atmosphere if they had colon resection, high-volume IV resuscitation, or more re-explorations of the abdomen, in a new study.

"Armed with this data, providers can have better discussions of potential complications with survivors of damage control laparotomy and their families," coauthor Joseph J. DuBose told Reuters Health by email.

Using information submitted by 14 level I trauma centers over a two-year period, the American Association for the Surgery of Trauma Open Abdomen Study Group analyzed 517 patients with open abdomens after injury and surgery, including 111 who developed enterocutaneous fistulas, entero-atmospheric fistulas or intra-abdominal sepsis.

The other 406 patients were free of abdominal complications.

Baseline laboratory results and clinical characteristics were similar in both groups, except that patients without abdominal complications had significantly more severe head trauma (p=0.01).

Intraoperative parameters were also similar for both groups, but patients with abdominal complications received more blood products (p=0.05).

The types of operations performed in both groups differed in that patients in the complications cohort underwent bowel resections significantly more often and more frequently had bowel left in discontinuity (both p<0.001).

During the first 48 postoperative hours, the abdominal complications group received larger amounts of both colloids and fluids (both p=0.03).

"The amount of colloid is most likely reflective of patient severity of injury and need for resuscitation," said Dr. DuBose. The increase in colloid relative to crystalloid reflects the ongoing evolution of changes in transfusion practices following trauma, "where we have learned that large volume crystalloid infusions are associated with increased risk of a variety of adverse outcomes."

Patients who developed fistulas or sepsis underwent nearly twice as many re-explorations (4.1 vs 2.2; p<0.001).

On multivariate analysis, factors that predicted enterocutaneous fistulas, entero-atmospheric fistulas or intra-abdominal sepsis were having a large bowel resection (OR 3.56; p<0.001), total fluid intake at 48 hours of 5 to 10 L (OR, 2.11; p=0.02), or more than 10 L (OR, 1.93; p=0.04), and number of re-explorations (OR, 1.14; p<0.001).

Despite the large number of variables in their analysis, the authors could not tell whether sepsis and fistulas led to more explorations or vice versa. Dr. DuBose said, "Additional study is required to determine if sepsis or fistula is the 'chicken or the egg' with regards to failure to achieve primary fascial closure after open abdominal damage-control laparotomy."

SOURCE: http://bit.ly/1dLiZVP

JAMA Surgery 2013.

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