SURGICAL TREATMENT AND MORTALITY IN PATIENTS WITH ABDOMINAL INJURIES IN POLYTRAUMA
Federal Scientific Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Abdominal injuries present the most severe category among all injuries. Their rate is 3.6-18.8 % [1]. The mortality in patients with abdominal injury in combination with locomotor injury is 38 %, in closed concomitant thoracoabdominal injury ‒ 47.3 %, in closed abdominal injury in combination with severe traumatic brain injury ‒ 72.3 % [2]. As for amount of diagnostic errors, closed abdominal injury takes one of the leading parts in emergency surgery, particularly at prehospital stage and during 3 hours after trauma [3, 4].
Reliable data of abdominal injuries are achievable with revision in major surgery, but according to diagnostic purposes major surgery is characterized with high injury rate and frequent development of postsurgical complications [5, 6].
Severity of state in patients with abdominal injuries with polytrauma makes strict demands for choice of volume of diagnostic and remedial measures [2].
Therefore, the specific interest is related to improvement in diagnostic techniques and surgical tactics for increasing efficiency of treatment of patients with abdominal injuries with polytrauma. The practical significance of the unsolved issues made foundations for realization of this study.
Research objective ‒ to identify the features and the factors influencing on surgical outcomes and mortality among patients with abdominal injuries with polytrauma.
MATERIALS AND METHODS
The information was taken from the computerized polytrauma database after approval from the ethical committee of Clinical Center of Miners’ Health Protection.
The present work is based on the analysis of 361 patients with abdominal injuries with polytrauma, including 263 (72.8 %) men and 98 (17.2 %) women (mean age of 37.5 ± 5.90) admitted to Clinical Center of Miners’ Health Protection during 2 hours after injury in 2003-2013 (table 1).
Traumatic shock of degrees II-III was diagnosed in all patients (APACHE-III > 80). The approximate blood loss was 1,200-2,500 ml (20-50 % of circulating blood volume [CBV]). Individual estimation of blood loss was realized with sum of external and cavity hemorrhage with consideration of approximate blood loss in fractures.
The inclusion criteria were age of 16-65, severe concomitant abdominal injuries, state severity with ISS > 30, blood loss > 20 % of CBV. Characteristics of abdominal injuries were evaluated with Abbreviated Injury Scale (AIS). The patients with severe potentially life-threatening isolated injuries were excluded.
The most common combinations of injuries were injuries to abdomen and head (62.3 %), injuries to abdomen and extremities (58.7 %), injuries to chest and abdomen (57.1 %) (table 1).
| Table 1 | ||||||||
| Characteristics of patients with abdominal injuries in polytrauma (n = 361) | ||||||||
| Notes: 1 – arithmetic mean ± error of the mean; | |
| APACHE III – Acute Physiology and Chronic Health (Knaus W., 1985) | |
| SAPS II – New Simplified Acute Physiology Score (Le Gall J. R. et al., 1993; Lemeshow S., Saulnier F., 1994) | |
| SOFA – Sequential Organ Failure Assessment (Vincent JL et al., 1996); | |
| ISS – Injury Severity Score (Baker S.P., O’Neill B., Haddon W., Long W.B., 1974). |
All patients received emergent procedures (according to vital signs) during 24 hours after hospital admission.
Abdominal injury was diagnosed on the basis of clinical and instrumental examination.
The treatment scheme for the patients with abdominal injury included diagnostic and surgical procedures oriented to early diagnostics of injuries, as well as to optimal terms and sequence of surgical interventions and rational intensive care.
Standard surgical tactics included operations (laparoscopy, laparotomy, if required, and damage control laparotomy), stabilization for bone fractures in locomotor injuries, creation of fraise holes and trepanations in traumatic brain injuries.
Surgical procedures were supplemented with adequate intensive care with PEEP ventilation. Artificial lung ventilation (ALV) was performed for all patients.
The analysis included demographic (age, gender, mechanism and characteristics of an injury according to AIS) and clinical indices (ISS, GCS, heart rate [HR], systolic blood pressure [SBP], number of abdominal operations, ALV time, duration of ICU stay, hospital treatment duration, complications, mortality).
The statistical preparation of the data was performed with IBM SPSS Statistics 20. Quantitative variables are presented as M ± m (mean arithmetic ± error in mean), M (SD). Qualitative variables are presented as absolute and relative (%) values. Comparison of qualitative values was performed with Fisher’s exact test and chi-square test. Student’s t-test was used for estimation of reliability of differences depending on type of distribution of quantitative variables. The critical level of significance was p < 0.05.
RESULTS AND DISCUSSION
Diagnostic laparoscopy and laparotomy identified injuries to the liver, the spleen, kidneys, the mesentery and vessels in all patients with abdominal trauma (table 2). The mean number of abdominal and retroperitoneal injuries per patient was 1.62 ± 0.03.
| Table 2 | |||||||||
| Types of abdominal and peritoneal injuries in patients with polytrauma (n = 361) | |||||||||
For 86 (23.8 %) patients laparoscopy was the final diagnostic and curative technique for abdominal injuries (table 3). Among them, 27 patients (31.4 %) had no abdominal injuries. For 29 (33.7 %) patients the identified injuries did not require transition to laparotomy, because of absent intraabdominal hemorrhage. Surgery was completed with abdominal draining for dynamic observation. Laparoscopy found hemoperitoneum without continuing bleeding in 30 (34.9 %) patients with polytrauma. Endoscopic hemostasis for superficial liver and splenic wounds was carried out with electrocoagulation. Blood aspiration and abdominal draining were performed for dynamic observation. Hemoperitoneum volume was 278.1 ± 48.8 ml.
| Table 3 | |||||||||
| The identified abdominal injuries in patients with polytrauma during videolaparoscopy (n = 361) | |||||||||
Diagnostic laparoscopy identified indications to conversion of an approach at diagnostic stage in 275 (76.2 %) patients: hemoperitoneum > 300 ml, intraabdominal hemorrhage, parenchymal organ injuries, strained retroperitoneal hematoma, injuries to different parts of entodermal canal, injuries to urethra and bladder. For 190 (69.1 %) patients laparotomy was completed with suturing laparotomy wound (final laparotomy), for 85 (31.9 %) patients laparotomy was realized with damage control technique. Damage control technique was most commonly used for injuries to intestine, the mesentery and abdominal vessels. The amount of laparotomy procedures was 3.63 ± 0.6 per patient (310 laparotomy procedures in 85 patients).
There were no intrasurgical complications. Inflammatory complications (seroma, infiltrates, hematoma) were most common in postsurgical period. 21 % of the patients had systemic complications: acute respiratory distress syndrome and multiple organ insufficiency.
| Table 4 | |||||||
| Types of surgical interventions and amount of surgical manipulations during laparotomy in patients with abdominal injuries in polytrauma (n = 361)
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| Table 5 | ||||||||
Characteristics of clinical values in patients with abdominal injuries in polytrauma (n = 361)
 | ||||||||
| Note: 1 – arithmetic mean ± error in mean. |
The general mortality was 19.9 % (72 patients). The first day mortality was conditioned by extraabdominal injuries. The causes of late death (after 5 days) were systemic complications (table 5). Bleeding was the most frequent cause of early death (66 %). In the late death group the most common causes of death were head injury (39.1 %) and multiple organ insufficiency (47.1 %).
Table 6 demonstrates the univariate comparison of demographic and clinical values in died and survived patients with abdominal injuries in polytrauma.
| Table 6 | ||||||||
| Characteristics of survived and deceased patients with abdominal injuries in polytrauma | ||||||||
| Note: * AIS - Abbreviated Injury Scale; n/s – no significance. |
The comparative analysis of the survived (n = 298) and died (n = 72) patients did not show any significant intergroup differences in gender and injury mechanisms (p > 0.05). Also there were no differences in amount of crystalloids or red blood cells during surgery (p > 0.05).
The significant intergroup differences were registered including age, ISS, injury characteristics according to AIS, GCS, HR and SAP on admission (p < 0.05) (table 6).
The survival group required less laparotomy procedures (2 [1] vs. 4 [2], p = 0.002), and abdominal closure was performed after 3 (1) days on average compared to 15 days (4) (p = 0.001) (table 6). The survived patients had decreased ALV (6 [7] days vs. 11 [6] days, p = 0.034) and ICU stay (12 [8] vs. 20 [8], p = 0.001), and hospital stay (25 [14] days vs. 57 [31], p = 0.001) (table 6).
The most significant result of this study is the fact that the patients who received staged surgical treatment after damage control laparotomy demonstrated improving long-term results. As result, staged surgical approach decreases mortality in patients with abdominal injuries in polytrauma. It is consistent with the data from Rotondo M.F. et al. (1993) [7], Johnson J.W. et al (2001) [8], who showed increasing survival after damage control laparotomy in patients with severe traumatic injuries.
Conversely, influence of damage control laparotomy on long-term results was investigated only in few studies [9, 10]. In most studies the authors oriented to such values as recurrent admission or possibility of resumption of professional and daily activity [9].
At the present time one of the key factors for decreasing mortality is searching ways for decreasing complications and, as result, improving general results of treatment. Restoration of vital functions and subsequent social adaptation are critical in severe traumatic injuries.
CONCLUSION
On the basis of research of demographic data and the clinical results of surgical treatment for the patients with abdominal injuries in polytrauma it was shown that such values as age, HR and SAP on admission, GCS, ISS and injury mechanism according to AIS reflect expression of severe disorders and have significant influence on treatment outcomes and mortality. Staged surgical approach (damage control laparotomy) decreases mortality in patients with abdominal injuries in polytrauma.