UROLOGICAL TRAUMA

Impact of obesity in damage control laparotomy patients
Duchesne JC, Schmieg RE Jr, Simmons JD, Islam T, McGinness CL, McSwain NE Jr
Section of Trauma and Critical Care Surgery, Department of Surgery and Anesthesia, Tulane University School of Medicine, New Orleans, Louisiana, USA
J Trauma. 2009; 67: 108-12

• Background: Obesity is an independent predictor of increased morbidity and mortality in critically injured trauma patients. We hypothesized that obese patients in need of damage control laparotomy (DCL) will encounter an increase incidence of postsurgical complications with a concomitant increase mortality when compared with a cohort of nonobese patients.
  Methods: All adult trauma patients who underwent DCL during a 4-year period at a Level I Trauma Center were retrospectively reviewed. Patients were categorized into nonobese (body mass index [BMI] < or = 29 kg/m), obese (BMI 30-39 kg/m), and severely obese (BMI > or = 40 kg/m) groups. Outcome measures included the occurrence of postoperative infectious complications, failure of primary abdominal wall fascial closure, acute respiratory distress syndrome, acute renal insufficiency, multiple system organ failure, days of ventilator support, hospital length of stay, and death.
  Results: During a 4-year period, 12,759 adult trauma patients were admitted to our Level I Trauma Center of which 1,812 (14.2%) underwent emergent laparotomy. Of these, 104 (5.7%) were treated with DCL: nonobese, n = 51 (49%); obese, n = 38 (37%); and severely obese, n = 15 (14%). In a multivariate adjusted model, multiple system organ failure was 1.82 times more likely in severely obese (95% CI: 1.14-2.90) and 1.74 times more likely in the obese patients (95% CI: 1.14-2.66) when compared with patients with normal BMI after DCL (p < 0.01). In the severely obese patients undergoing DCL, significantly elevated prevalence ratios (PR) for development of postoperative infectious complications, acute renal insufficiency, and failure of primary abdominal wall fascial closure were 1.75, 3.07, and 2.62, respectively. Days of ventilator support, length of stay, and mortality rates were significantly higher in severely obese patients (24 days, 27 days, and 60%) compared with obese (14 days, 14 days, and 21%) and nonobese (9.8 days, 14 days, and 28%) patients.
  Conclusion: Severe obesity was significantly associated with adverse outcomes and increased resource utilization in trauma patients treated with DCL. Measures to improve outcomes in this vulnerable patient population must be directed at multiple levels of health care.

Body mass index affects time to definitive closure after damage control surgery
Haricharan RN, Dooley AC, Weinberg JA, McGwin G Jr, MacLennan PA, Griffin RL, Rue LW 3rd, Reiff DA
Section of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
J Trauma. 2009; 66: 1683-7

• Background: A growing body of literature demonstrates that irrespective of the mechanism of injury, obesity is associated with significantly worse morbidity and mortality after trauma. Among patients requiring damage control laparotomy (DCL), clinical experience suggests that obesity affects time to definitive closure though this association has never been demonstrated quantitatively.
  Methods: All patients at an academic Level I trauma center requiring a DCL between January 2002 and December 2006 (N = 148) were included. Information pertaining to demographic, injury, and clinical characteristics was abstracted from patient medical records. The risk of specific complications including pneumonia, renal failure, and sepsis was compared between normal and overweight/obese patients, as measured by body mass index (BMI). The lengths of intensive care unit (ICU) stay and mechanical ventilation as well as time to abdominal closure were also compared.
  Results: The risk of pneumonia, sepsis, and renal failure was 2.05-times, 1.77-times, and 2.84-times higher among overweight patients compared with patients with a normal BMI. The risk of pneumonia, sepsis, and renal failure was 2.01-times, 4.24-times, and 1.85-times higher among obese patients compared with those with a normal BMI. Obese patients also had a significantly longer ICU length of stay (28.7 days vs. 15.1 days; p < 0.0001), longer hospitalization (39.3 days vs. 27.0 days; p = 0.008), and time to definitive closure (8.4 days vs. 3.9 days; p = 0.03) compared with patients with a normal BMI.
  Conclusions: Among patients requiring DCL, those who are overweight or obese have a prolonged time to definitive closure. These patients also experience a significantly longer ICU course and a higher risk of pneumonia.

• Editorial Comment
  Obesity has reached epidemic proportions in the US and across the globe. Surgical management of the morbidly obese is difficult and time consuming, and prone to more complications and prolonged hospitalizations. In the trauma literature, obesity is an independent factor in a negative impact as to overall morbidity and mortality.
  The concept of damage control is rarely discussed in the urologic literature but is an important management method that all Urologists should be familiar with. Urology and damage control were first championed by Michael Coburn of Ben Taub Hospital, a major trauma center in Houston, Texas. The concept entails that patients that are critically injured are best managed by temporizing surgical measures to quickly stop bleeding, and fecal and urinary leakage, avoid definitive reconstruction, and plan on a later staged operation, after the patient has been resuscitated in the Intensive Care Unit. The concept is that the fatal triad of a cold, coagulopathic and acidotic patient has a high degree of dying – and that such patients need to have surgery aborted and the adverse parameters corrected. To minimize the time on the operating room table a quick abdominal closure is needed. During the drug wars in the early 1990s in Bogotá, Colombia, the surgery services were overwhelmed and decided to do damage control surgeries and not to close the fascia, but instead sew an opened 3-liter saline bag to the skin edges. By not closing the fascia avoids intra abdominal compartment syndrome and allows the bowel edema time to resolve and allow for delayed closure. The use of the “Bogotá bag” was a major advance in the management of the critically ill patient. The “Bogotá bag” has been modified in to the current use of the “VAC PAC”. This entails taking the fluoroscopy cover plastic sheet and fenestrating it with multiple small slits. The sheet in then placed under the fascia. Two lap pads are placed on top of the plastic sheet and 2 JP drains placed on top of the lap pads, and then covered with gauze. At the skin level a large adhesive VY drape is stuck to the skin and the JPs placed to wall suction. Making the “VAC PAC” takes less then 5 minutes and helps control peritoneal fluid and bowel edema. In the critically injured Urology patients, the “VAC PAC” should be more liberally used. The use of damage control in urology mainly applies to the injured ureter, where the ureter can either be ligated, or a pediatric feeding tube or ureteral stent placed up the cut ureteral edge and the stent pulled quickly through the skin. Here, definitive measures such as a Psoas hitch or Boari flap are deferred to another day when the patient is stable. Attempting definitive repairs in the critically injured patient is unwise and risks death.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
E-mail: brandess@wudosis.wustl.edu