Damage control surgery for abdominal trauma: Cochrane systematic review

Abstract

Assessed as up to date: 2012/12/19

Background

Trauma is one of the leading causes of death in any age group. The 'lethal triad' of acidosis, hypothermia, and coagulopathy has been recognized as a significant cause of death in patients with traumatic injuries. In order to prevent the lethal triad two factors are essential, early control of bleeding and prevention of further heat loss. In patients with major abdominal trauma, damage control surgery (DCS) avoids extensive procedures on unstable patients, stabilizes potentially fatal problems at initial operation, and applies staged surgery after successful initial resuscitation. It is not currently known whether DCS is superior to immediate surgery for patients with major abdominal trauma.

Objectives

To assess the effects of damage control surgery compared to traditional immediate definitive surgical treatment for patients with major abdominal trauma.

Search methods

We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2012, Issue 12 of 12), MEDLINE, EMBASE, Web of Science: Science Citation Index & ISI Proceedings, Current Controlled Trials MetaRegister, Clinicaltrials.gov, Zetoc, and CINAHL for all published and unpublished randomised controlled trials. We did not restrict the searches by language, date, or publication status. The search was through December 2012.

Selection criteria

Randomised controlled trials of damage control surgery versus immediate traditional surgical repair were included in this review. We included patients with major abdominal trauma (Abbreviated Injury Scale > 3) who were undergoing surgery. Patient selection was crucial as patients with relatively simple abdominal injuries should not undergo unnecessary procedures.

Data collection and analysis

Two authors independently evaluated the search results.

Main results

A total of 2551 studies were identified by our search. No randomised controlled trials comparing DCS with immediate and definitive repair in patients with major abdominal trauma were found. A total of 2551 studies were excluded because they were not relevant to the review topic and two studies were excluded with reasons after examining the full-text.

Authors' conclusions

Evidence that supports the efficacy of damage control surgery with respect to traditional laparotomy in patients with major abdominal trauma is limited.

Author(s)

Cirocchi Roberto, Montedori Alessandro, Farinella Eriberto, Bonacini Isabella, Tagliabue Ludovica, Abraha Iosief

Summary

Surgery for unstable trauma patients

Trauma is one of the leading causes of death across all ages. Some patients with major abdominal trauma develop what is known as the 'lethal triad' -- impaired coagulation, metabolic acidosis, and hypothermia. This is a life-threatening condition which significantly contributes to illness and death. To prevent this lethal triad, doctors need to control bleeding and prevent further heat loss.

Traditional management of major abdominal trauma involves surgery to repair the torn organs or abdominal tissue. For trauma patients, immediate surgery may pose a risk as the patient may be in an unstable state because of blood loss.

Damage control surgery (DCS) is an alternative approach. It involves three steps to help the patient. First, a surgeon repairs the major tears, and the patient is cared for in the intensive care unit. Once the patient is stable, surgeons carry out an operation to repair any of the remaining smaller tears. The advantage of the DCS approach is that surgeons only do the more thorough, and therefore longer, surgery once the patient is stable so the chance of an adverse outcome, such as death from severe blood loss, could be lower.

The authors found no published or pending randomised controlled trials that compared DCS with immediate and definitive repair in patients with major abdominal trauma. Evidence that supports efficacy of DCS compared with traditional laparotomy is therefore limited.

Reviewer's Conclusions

Implications for practice

Patients with major trauma are usually unstable and are at risk of complications including bleeding, acidosis, hypothermia, and coagulopathy. Damage control surgery avoids extensive procedures on unstable patients by applying staged surgery after the patient has stabilised. However, its benefits cannot be established as there are no published randomised controlled trials. Good quality randomised controlled trials are needed to produce reliable recommendations.

Implications for research

Good quality randomised controlled trials comparing DCS with immediate surgical repair for patients suffering major abdominal trauma are needed. These prospective trials should have as major outcomes measures short-term mortality and morbidity, and hospital and intensive care unit stays.

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TY - ELEC T1 - Damage control surgery for abdominal trauma: Cochrane systematic review ID - 435050 BT - Cochrane Abstracts UR - https://evidence.unboundmedicine.com/evidence/view/Cochrane/435050/all/Damage_control_surgery_for_abdominal_trauma:_Cochrane_systematic_review DB - Evidence Central DP - Unbound Medicine ER -