Abstract
BackgroundThe staged laparotomy in the operative management of emergency general surgery (EGS) patients is an extension of trauma surgeons operating on this population. Indications for its application, however, are not well defined, and are currently based on the lethal triad used in physiologically-decompensated trauma patients. This study sought to determine the acute indications for the staged, rapid source control laparotomy (RSCL) in EGS patients.MethodsAll EGS patients undergoing emergent staged RSCL and non-RSCL over 3 years were studied. Demographics, physiologic parameters, perioperative variables, outcomes, and survival were compared. Logistic regression models determined the influence of physiologic parameters on mortality and postoperative complications. EGS-RSCL indications were defined.Results215 EGS patients underwent emergent laparotomy; 53 (25 %) were staged RSCL. In the 53 patients who underwent a staged RSCL based on the lethal triad, adjusted multivariable regression analysis shows that when used alone, no component of the lethal triad independently improved survival. Staged RSCL may decrease mortality in patients with preoperative severe sepsis / septic shock, and an elevated lactate (≥3); acidosis (pH ≤ 7.25); elderly (≥70); male gender; and multiple comorbidities (≥3). Of the 162 non-RSCL emergent laparotomies, 27 (17 %) required unplanned re-explorations; of these, 17 (63 %) had sepsis preoperatively and 9 (33 %) died.ConclusionsThe acute physiologic indicators that help guide operative decisions in trauma may not confer a similar survival advantage in EGS. To replace the lethal triad, criteria for application of the staged RSCL in EGS need to be defined. Based on these results, the indications should include severe sepsis / septic shock, lactate, acidosis, gender, age, and pre-existing comorbidities. When correctly applied, the staged RSCL may help to improve survival in decompensated EGS patients.
Highlights
The staged laparotomy in the operative management of emergency general surgery (EGS) patients is an extension of trauma surgeons operating on this population
Application of damage control (DC) principles are based on the clinical recognition of a trauma patient who is physiologically decompensated as defined by the lethal triad seen with hemorrhagic shock: acidosis, coagulopathy, and hypothermia
Our results suggest a profile of a patient who may realize a survival benefit from a rapid source control laparotomy (RSCL): a patient with preoperative severe sepsis / septic shock, with an elevated lactate (≥3); acidosis; elderly (≥70); male gender; and multiple comorbidities (≥3)
Summary
The staged laparotomy in the operative management of emergency general surgery (EGS) patients is an extension of trauma surgeons operating on this population. Indications for its application, are not well defined, and are currently based on the lethal triad used in physiologically-decompensated trauma patients. The staged laparotomy in the operative management of select trauma patients is designed to ensure their immediate survival [1,2,3,4,5,6]. Application of DC principles are based on the clinical recognition of a trauma patient who is physiologically decompensated as defined by the lethal triad seen with hemorrhagic shock: acidosis, coagulopathy, and hypothermia. A select group of emergency general surgery (EGS) patients present decompensated, near irreversible physiologic exhaustion and death, but for different reasons, often driven by severe sepsis or septic shock [14]. As a natural extension of trauma surgeons operating on the EGS patient-population, DC principles have been widely applied to the operative management of EGS patients
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