J. Woloski1, S. Wei1, G. E. Hatton1, J. A. Harvin1, C. E. Wade1, C. Green1, V. T. Truong1, C. Pedroza1, L. S. Kao1 1McGovern Medical School at UTHealth,Trauma Surgery,Houston, TX, USA
Introduction: Skin management after fascial closure may influence the risk of superficial surgical site infection (SSSI) development, which occurs in up to 25% of patients after emergent trauma laparotomy. Leaving skin open is thought to decrease SSSI risk, but increases wound care burden and results in poor cosmesis. Given the lack of high-quality evidence guiding skin management after trauma laparotomy, it is unknown whether skin incisions are being closed or left open appropriately. We aimed to characterize skin management in adult trauma laparotomy patients and to determine whether skin closure strategy is associated with SSSI.
Methods: We performed a retrospective cohort study of a trauma laparotomy database between 2011 and 2017 at a high-volume, level-1 trauma center. SSSI diagnoses were determined by chart review according to the Center for Disease Control definition. Patients who never achieved fascial closure and those who died prior to the first recorded SSSI (on postoperative day 2) were excluded. Open versus closed skin management was determined by reviewing operative reports. Open skin entailed use of gauze packing or wound VAC, and closed skin entailed closured with staples (with or without wicks) or sutures. Univariate and multivariable analyses were performed. The multivariable model included variables that generated the best area under the curve (AUC). Inverse probability weighted propensity scores (IPWPS) were used to compare patients’ predicted probability for open versus closed skin management with the skin management strategy they received.
Results: Of 1322 patients, 309 (23%) received open skin management, while 1013 (77%) had skin closure. The overall SSSI rate was 6%. On univariate analysis, there were no significant differences in development of SSSI in open versus closed skin groups (8% versus 6%, p = 0.12). On adjusted analysis, damage control laparotomy, wound class 2, skin closure, large bowel resection, and higher body mass index were significantly associated with SSSI (Table). Skin closure has 3-times higher odds of SSSI development. IPWPS assignment showed that 75% of patients with closed skin had a propensity score of >0.9 for skin closure. In contrast, 11% of patients with open skin had a propensity score of <0.1 for skin closure.
Conclusion: Even though the rate of SSSI was only 6%, almost 25% of trauma patients had initial open skin management. Although there was consistency in the use of skin closure based on patient and wound characteristics, skin closure was associated with higher odds of SSSI. Better predictive models are needed to accurately stratify patients’ risk for SSSI after emergent trauma laparotomy to determine optimal skin management strategy.
