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Original Investigation |

Independent Predictors of Enteric Fistula and Abdominal Sepsis After Damage Control Laparotomy:  Results From the Prospective AAST Open Abdomen Registry

Matthew J. Bradley, MD1; Joseph J. DuBose, MD1; Thomas M. Scalea, MD1; John B. Holcomb, MD2; Binod Shrestha, MD2; Obi Okoye, MD3; Kenji Inaba, MD3; Tiffany K. Bee, MD4; Timothy C. Fabian, MD4; James F. Whelan, MD5; Rao R. Ivatury, MD5 ; for the AAST Open Abdomen Study Group
[+] Author Affiliations
1Division of Trauma and Acute Care Surgery, University of Maryland Medical System, R. Adams Cowley Shock Trauma Center, Baltimore
2Division of Trauma and Acute Care Surgery, University of Texas Medical School at Houston
3Division of Trauma and Acute Care Surgery, Los Angeles County and University of Southern California Medical Center
4Division of Trauma and Acute Care Surgery, University of Tennessee, Memphis
5Division of Trauma and Acute Care Surgery, Medical College of Virginia, Richmond
JAMA Surg. 2013;148(10):947-955. doi:10.1001/jamasurg.2013.2514.
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Importance  Enterocutaneous fistula (ECF), enteroatmospheric fistula (EAF), and intra-abdominal sepsis/abscess (IAS) are major challenges for surgeons caring for patients undergoing damage control laparotomy after trauma.

Objective  To determine independent predictors of ECF, EAF, or IAS in patients undergoing damage control laparotomy after trauma, using the AAST Open Abdomen Registry.

Design  The AAST Open Abdomen registry of patients with an open abdomen following damage control laparotomy was used to identify patients who developed ECF, EAF, or IAS and to compare these patients with those without these complications. Univariate analyses were performed to compare these groups of patients. Variables from univariate analyses differing at P < .20 were entered into a stepwise logistic regression model to identify independent risk factors for ECF, EAF, or IAS.

Setting  Fourteen level I trauma centers.

Participants  A total of 517 patients with an open abdomen following damage control laparotomy.

Main Outcomes and Measures  Complication of ECF, EAF, or IAS.

Results  More patients in the ECF/EAF/IAS group than in the group without these complications underwent bowel resection (63 of 111 patients [57%] vs 133 of 406 patients [33%]; P < .001). Within the first 48 hours after surgery, the ECF/EAF/IAS group received more colloids (P < .03) and total fluids (P < .03) than did the group without these complications. The ECF/EAF/IAS group underwent almost twice as many abdominal reexplorations as did the group without these complications (mean [SD] number, 4.1 [4.1] vs 2.2 [3.4]; P < .001). After multivariate analysis, the independent predictors of ECF/EAF/IAS were a large bowel resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-6.76]; P < .001), a total fluid intake at 48 hours of between 5 and 10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or more than 10 L (AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and an increasing number of reexplorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001).

Conclusions and Relevance  Large bowel resection, large-volume fluid resuscitation, and an increasing number of abdominal reexplorations were statistically significant predictors of ECF, EAF, or IAS in patients with an open abdomen after damage control laparotomy.

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