N. Z. Hansraj1, A. Pasley1,2, D. G. Harris1, J. J. Diaz1,2, B. Bruns1,2 1University Of Maryland,Acute Care Surgery,Baltimore, MD, USA 2University Of Maryland,Trauma,Baltimore, MD, USA
Introduction: Previous work from our institution illustrates a 28% rate of open abdomen (OA) utilization for emergency general surgery (EGS) patients undergoing laparotomy, with 27% of those left open to facilitate “second-look” (SL). With varying reports on the utility of SL laparotomy, the purpose of the current study is to determine whether EGS OA patients managed with SL laparotomy required additional bowel resection. We hypothesize that many of these SL patients could be managed with single-stage operative therapy and thus decrease the number of OA patients.
Methods: This is a retrospective review of prospectively collected data from Jun 2013-Jun 2014, evaluating EGS patients managed with an OA who required bowel resection in either index or SL laparotomy. Demographics, co-morbidities, and clinical variables were collected. Indication for resection at SL, complications, and mortality rates were recorded. Charlson co-morbidity index (CCI) was calculated. Fischer exact t-test was used for statistical analysis.
Results: 96 patients were managed with OA of which 59 (61%) of those underwent bowel resection and 50 (86%) were left in discontinuity. The mean age of the patients undergoing bowel resection was 62y, with 31 males. Comorbidities included prior MI in 10, DM in 22, CKD in 12, and PVD in 26 patients, with mean CCI of 3. The mean time to SL laparotomy was 25-hours. In the 59 patients with OA and bowel resection, 18 (30%) required resection at SL. Of those 18 patients, 60% (11) had questionable areas while 39% (7) had normal appearing bowel at the end of the index operation. Of those 18 requiring resection at SL, 14 had resection at index operation and only 4 did not. At SL laparotomy, 47% (28/59) of the cohort had fascia closed. Further evaluation of causation for resection at SL laparotomy included: evolution of existing ischemia in 6, new onset ischemia in 5, staple line revision in 4, and “other” causes in 3. Preoperative shock at pre-index operation was a predictor of need for further resection. Leaks, dehiscence, and surgical site infections were higher in the SL no resection group, though not statistically significant. The mean length of stay was 32.8 days, with 23 ICU days, and 19 Ventilator days, with no difference between the groups. The Mortality rate in the SL resection group was 50% (9/18) versus 39% (16/41) in the SL no resection group.
Conclusion: As nearly one-third of patients undergoing SL laparotomy required additional resection, with 39% of those having normal appearing bowel at index operation, SL laparotomy appears to be a justifiable indication for EGS OA techniques.
