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Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review

Abstract

Background

Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes).

Methods

We searched 11 databases (1950–April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions.

Results

Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications.

Conclusions

Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

Background

In patients requiring operative intervention after major trauma, surgeons must decide whether to perform a definitive or damage control (DC) procedure [1, 2]. As opposed to definitive surgery (where all injuries requiring repair are repaired and the explored cavity closed), DC surgery involves quickly controlling exsanguinating hemorrhage and/or gross contamination using one or more abbreviated (or DC) interventions [2]. The patient is subsequently admitted to the intensive care unit (ICU) for ongoing resuscitation with the goal of restoring pre-injury physiology before returning to the operating room for additional surgery [2,3,4].

Although widely assumed to reduce mortality in critically injured patients [5], survivors of DC surgery have been reported to have a high risk of complications (e.g., intra-abdominal sepsis, enteric fistulae, and complex ventral herniae) and often suffer long lengths of ICU and hospital stay [2, 4, 6,7,8,9,10,11]. It is therefore important to ensure that DC surgery is only performed on patients in which the expected survival benefit of the procedure outweighs its expected risk of negative consequences [1]. Despite this, the benefit/risk profile of using DC surgery in different clinical situations has not been comprehensively evaluated, and several authors have recently reported data suggesting that substantial variation in use of DC surgery exists across trauma centers or that it may be overused [12,13,14,15].

We hypothesize that variation in use of DC surgery may be at least partially explained by the uncertainty that exists as to when the procedure is indicated [1, 2]. Thus, we recently initiated a program of research to develop evidence-informed indications for the appropriate use of DC surgery and DC interventions in civilian trauma patients [1,2,3, 16,17,18]. The purpose of this systematic review and meta-analysis was to determine which indications for DC surgery and DC interventions in civilian trauma patients have evidence supporting that they are reliable and/or valid (and in which clinical situations evidence supports use of DC or that DC improves outcomes). The data reported in this study therefore provide a comprehensive assessment of the reported studies evaluating whether use of DC instead of definitive surgery is associated with improved outcomes in injured patients.

Methods

Protocol

Study methods were pre-specified in a protocol developed according to the Preferred Reporting Items in Systematic Reviews and Meta-analyses [19] and Meta-analysis of Observational Studies in Epidemiology [20] statements.

Search strategy

Using published search strategies designed for identifying indications for DC surgery and DC interventions in trauma patients, we searched MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and the Cochrane Library from their inception to April 1, 2019 without restrictions (see Supplementary Table 1 in our published protocol paper [1] for details of our electronic bibliographic database search strategies). We also used the PubMed “related articles” feature and searched references from included and relevant review articles and abstracts from conferences held between 2009 and 2015, including meetings of the American Association for the Surgery of Trauma (AAST), Australasian Trauma Society, Eastern Association for the Surgery of Trauma (EAST), Trauma Association of Canada, and Western Trauma Association (WTA). To identify unpublished studies, we searched 12 trauma organizational websites [1] and Google Scholar (the first 10 web pages) using combinations of the terms trauma, injury, abbreviated surgery, bailout surgery, damage control, damage control surgery, indication, and predictor.

Study selection

Two investigators (D.J.R., N.B.) independently screened the titles and abstracts of citations identified by the search and selected articles for full-text review. We included full-text studies that reported original data on the reliability or validity of suggested indications for DC surgery or DC interventions in civilian trauma patients. We excluded studies that included only patients injured in combat or by thermal mechanisms or focused exclusively on DC for emergency general or vascular surgery or orthopedic or neurologic injuries. Study eligibility disagreements were resolved by consensus between the two investigators.

Definitions

An indication was defined as a clinical finding/circumstance or scenario that reportedly advised use of DC surgery (or a DC intervention) over definitive surgery (or a definitive surgical intervention) [1]. DC surgery was broadly defined as a multi-step operative intervention, which included an abbreviated initial surgical procedure that aimed to rapidly control bleeding and/or gross contamination [1]. We did not predefine DC interventions. Instead, we included articles that satisfied the above criteria where an indication was reported for a surgical intervention suggested by authors to constitute DC or an abbreviated surgical technique [e.g., temporary abdominal closure (TAC)/open abdominal management after trauma laparotomy] [1, 2].

Indication reliability was defined as the degree to which the same decision to conduct DC was made when surgeons were provided the same clinical finding/scenario (test-retest) or when encountered by the same surgeon (intra-rater) or different surgeons (inter-rater). Validity included content, construct, and criterion validity (see Table 1 for detailed definitions of these measures) [21, 22]. Content validity was defined as the extent to which surgeons reported that they would perform DC in a given clinical scenario or that an indication predicted use of DC in practice [21, 22]. Construct validity referred to how well one indication or a combination of indications and demographic variables predicted poor outcomes in patients not treated with DC (i.e., the extent to which an indication was associated with a higher probability of poor outcomes in patients treated with definitive surgery and therefore should be considered as a potential indication for DC) [21, 22]. Criterion validity referred to the extent to which the utilization or conduct of DC instead of definitive surgery for one or more indications was associated with improved patient outcomes [21, 22].

Table 1 Definitions of indications for use of damage control content, construct, and criterion validity

Data extraction

Two investigators (D.J.R., N.B.) independently extracted data from included studies into pilot-tested tables summarizing characteristics of the included studies and the content, construct, and criterion validity of suggested indications for DC surgery and DC interventions (Table 1). An interpreter assisted with data extraction for one Russian [23] and two Mandarin Chinese [24, 25] language studies. We extracted data on (1) study design, setting, and participants; (2) suggested indications for DC surgery or DC interventions as reported by study authors; and (3) measures of indication reliability and validity. For content validity, we extracted data on the percentage of surgeons that reported that they would perform DC in a given clinical scenario or odds ratios (ORs) or hazard ratios (HRs) [with surrounding 95% confidence intervals (CIs)] indicating the degree to which that indication predicted use of DC in practice. For construct validity, we extracted data on how well one indication or a combination of indications predicted outcomes in patients not treated with DC. Finally, for criterion validity, we extracted data on the extent to which the utilization or conduct of DC instead of definitive surgery for one or more indications was associated with patient outcomes. Outcomes of interest for the assessment of construct and criterion validity included survival, development of coagulopathy, reported measures of morbidity, and lengths of hospital and ICU stay. Outcomes were extracted at the longest follow-up duration. When both unadjusted and adjusted outcome estimates were reported, the most adjusted estimate was extracted.

Risk of bias assessment

The same two investigators independently evaluated study risk of bias. Cohort studies were assessed using an expanded version of the Quality in Prognosis Studies tool [26, 27], which included questions regarding study participation and attrition; indication or outcome description and measurement; confounding measurement and account; whether the operative profile chosen (i.e., DC versus definitive surgery) may have varied in relation to the indication of interest; and methods and reporting of statistical analyses (see Supplemental Digital Content 1 for the operationalized list of quality domains evaluated) [26,27,28]. For cross-sectional studies, we evaluated sampling methods, response rates, and whether the reported methods would permit replication; sample was representative of the population; questionnaire was adequately described, pretested, and had evidence of reliability and/or validity; statistical methods; and if all respondents were accounted for [29]. The assessment of statistical analyses incorporated recommendations for appraising logistic regression models [30, 31]. Disagreements regarding risk of bias assessments were resolved by consensus.

Data synthesis

We used directed qualitative content analysis to group unique indications into the subcategories and categories of a previously developed framework for conceptualizing indications for DC [3, 32]. We then used a vote counting scale [33] to incorporate our risk of bias assessments into the synthesis of evidence regarding whether indications were reliable and/or valid [26]. The aggregate scale summarized strength of evidence as (1) not reported, (2) inconclusive (no evidence or a low to moderate association in the setting of an overall high amount of bias in at least one quality domain), (3) a consistently strong association in the setting of an overall high amount of bias in only one quality domain, (4) a consistently low to moderate association in the setting of an overall moderate amount of bias in one or more quality domains, (5) a consistently low to moderate association with a low amount of bias in all quality domains or a consistently strong association with an overall moderate amount of bias in one or more study quality domains, and (6) a consistently strong association with a low overall amount of bias in all study domains.

Statistical analyses

Inter-investigator agreement regarding full-text article inclusion was quantified using kappa (κ) statistics [34]. We summarized dichotomous data using counts (percentages) and compared them using ORs with 95% CIs or Fisher’s exact tests. We combined adjusted ORs for indications with similar definitions using Mantel-Haenszel-weighted DerSimonian and Laird random-effects models [35]. Heterogeneity in these estimates were assessed using I2 statistics and tests of homogeneity [36, 37]. We considered two-sided p values < 0.05 statistically significant. Stata MP version 13.1 (Stata Corp., College Station, TX) was used for statistical analyses.

Results

Study selection

Among 34,979 citations identified by the search, we included 36 cohort studies (n = 8160 total trauma patients) [14, 15, 23, 25, 38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68] and three cross-sectional surveys (n = 481 total surgeon respondents) [69,70,71,72] in the systematic review (Fig. 1). Agreement between investigators on full-text article inclusion was excellent (κ-statistic, 0.72; 95% CI, 0.60 to 0.83).

Fig. 1
figure1

Flow of articles through the systematic review. Where CPG indicates clinical practice guideline and DC, damage control

Description of included studies

Characteristics of included cohort and cross-sectional studies are presented in Table 2 and Supplemental Digital Content 2, respectively. In total, 67% of the cohort studies were published on or after the year 2000 and 91.7% were conducted in single centers and 66.7% in the USA. Five (13.9%) cohort studies collected data prospectively. Studies describing age and Injury Severity Scale (ISS) scores reported enrolling severely injured (mean/median ISS score range, 17.8–41) young adults (mean/median age range, 26–51.9 years).

Table 2 Characteristics of the 36 cohort studies included in the systematic review

The three cross-sectional studies described results of two surveys of AAST members (administered in 1997–1998 [72] and 2005 [69]) and one of Trauma Association of Canada surgeon members (administered in 2004; results of which were reported across two publications) [70, 71]. Surgeon response rates varied from 26% [69] to 84% [70, 71]. Of the respondents, two studies reported that 73–85% practiced in academic centers [69, 72] and one that 45% specialized in trauma and critical care [69].

Risk of bias assessment

The risk of bias assessment for the 36 included cohort studies is outlined in Supplemental Digital File 3. Nine (25.0%) studies were at high risk of study participation bias, 17 (47.2%) reported outcome comparisons at high risk of confounding, and 28 (77.8%) did not report follow-up duration. Six of the nine studies at high risk of study participation bias evaluated the construct validity of indications among patients treated only with DC surgery (and therefore outcomes associated with these variables are better interpreted as predictors of poor outcome after DC surgery rather than measures of indication construct validity) [47, 48, 56, 61, 63, 66]. Of the 17 cohort studies that adjusted estimates using logistic regression, these analyses were at a moderate risk of bias in 12 studies and a high risk of bias in one study, largely because of a low or unclear number of events per variable and inadequate reporting of methods used to select predictor variables and/or build models (Supplemental Digital Content 4).

The risk of bias assessment for the three included cross-sectional studies is included in Supplemental Digital File 5. Two studies described methods that would permit replication, identified a sample that was likely representative of the broader trauma surgical community, and adequately described the questionnaire (or provided it as supplementary material) [70,71,72]; however, only one reported that the questionnaire was pretested [70, 71] and none provided evidence of questionnaire reliability or validity.

Reliability and validity of indications for use of DC surgery and DC interventions

The 39 included studies assessed the content, construct, and criterion validity of 116 indications for DC surgery (median per article, 3; range, 1–7) and 32 indications for TAC/open abdominal management (median per article, 7; range, 1–12). No studies evaluated the reliability of indications for DC surgery or DC interventions.

Content validity

The cross-sectional studies [69,70,71,72] evaluated the content validity of indications for TAC after trauma laparotomy by asking surgeons whether open abdominal management was indicated in different clinical situations (see Table 3 for assessments of content validity in cross-sectional and cohort studies). Most respondents supported use of TAC when they were unable to close the fascia (or closure was subjectively tight), there was massive visceral edema, planned reoperation was required (e.g., to remove packs or perform a “re-look” laparotomy), or signs of abdominal compartment syndrome developed upon attempted fascial closure [69,70,71,72].

Table 3 Content validity (surgeons would performed damage control in that clinical scenario or the indication predicts use of damage control in practice) of reported indications for use of damage control surgery or damage control interventions in civilian trauma patients

Of the cohort studies that evaluated indication content validity (i.e., whether the indication predicted use of DC in practice), Hirshberg et al. reported that an artificial neural network containing torso bullet wound location/trajectory pattern and systolic blood pressure (BP) in the emergency department (ED) had a high sensitivity (83%) and specificity (93%) for identifying patients treated with DC laparotomy [55]. Further, Watson et al. reported that a major abdominal vascular injury was independently associated with the decision to conduct DC laparotomy among patients enrolled in in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized trial [15]. Another study by Leppäniemi et al. reported that all patients with a AAST grade III–V liver and IV–V spleen injury underwent DC laparotomy while 42% of those without this injury pattern did not (p = 0.02) [46]. Finally, Savage et al. reported that packed red blood cell (PRBC) transfusion volumes exceeding the critical administration threshold (≥ 3 U PRBCs in 1 hour of the first 24 h of injury) were independently associated with a dose-dependent increase in use of DC laparotomy [39].

Construct validity

The construct validity of indications (or predictive models containing a combination of indications, other clinical findings, and/or baseline demographic variables) for DC surgery was evaluated in 23 studies, which examined associations between indications and survival or coagulopathy (Table 4). Three studies reported that a high ISS score, preoperative hypothermia, an elevated base deficit in the pre- or intraoperative setting, and the identification of a combined pancreas and abdominal vascular injury during operation were independently associated with decreased survival in patients mostly treated with definitive surgery, suggesting that DC should be considered in these high-risk scenarios [44, 57, 64]. Interestingly, however, a preoperative pH < 7.20 was also independently associated with decreased survival among injured patients who received DC laparotomy in another study (suggesting that it was also a poor prognostic factor among those treated with DC) [47]. Two other studies evaluated the association between development of a laboratory-confirmed coagulopathy (variably defined), a clinical scenario where DC has long been recommended over definitive surgery, and an ISS score > 25, systolic BP < 70 mmHg, or lowest temperature < 34 °C or pH < 7.1 in trauma patients transfused > 10 units of PRBCs in the first 6 or 24 h [50, 60]. Among these studies, the pooled adjusted OR for development of a laboratory-confirmed coagulopathy among patients with an ISS score > 25 was 6.11 (95% CI, 1.68–22.16; I2 = 0%; heterogeneity p = 0.65), systolic BP < 70 mmHg was 1.66 (95% CI, 0.15–19.10; I2 = 79.5%; heterogeneity p = 0.03), lowest temperature < 34 °C was 7.12 (95% CI, 2.53–20.05; I2 = 0%; heterogeneity p = 0.74), and lowest pH < 7.1 was 4.14 (95% CI, 0.60–28.67; I2 = 74.2%; heterogeneity p = 0.05).

Table 4 Construct validity (how well one indication or a combination of indications and demographic variables predicted patient outcomes in patients not treated with damage control) of reported indications for use of damage control surgery in civilian trauma patients

Criterion validity

Two studies evaluated outcomes associated with implementation or utilization of indications for DC surgery while 14 compared outcomes of patients treated with DC versus definitive surgery in different clinical situations (Table 5). Rice et al. reported that, when compared to only minor deviations, moderate or major deviations from a protocol that suggested use of DC surgery in injured patients with a temperature < 35 °C, lactate > 4 mmol/L (or more than twice the upper limit of normal), or corrected pH < 7.3 was independently associated with reduced survival [43]. Asensio et al. reported that implementing a guideline that suggested use of DC surgery for trauma patients with one of 12 different clinical findings/events was associated with a decreased unadjusted odds of infections, an increased unadjusted odds of abdominal wall closure, and reduced unadjusted lengths of ICU and hospital stay [52].

Table 5 Criterion validity (extent to which the utilization or conduct of damage control instead of definitive surgery for one or more indications was associated with patient outcomes) of reported indications for use of damage control surgery or damage control interventions

Of the remaining 14 studies, Chinnery et al., Rotondo et al., and Stone et al. observed a large improvement in unadjusted survival when DC or staged laparotomy was used instead of definitive surgery to manage unstable patients with combined abdominal vascular and pancreas gunshot injuries, who received > 10 U PRBCs and had ≥ 1 major abdominal vascular and ≥ 2 abdominal visceral injuries, or that developed a coagulopathy during operation, respectively [44, 62, 68]. In contrast, Harvin et al. reported that after matching injured patients on propensity scores created using 17 different variables, use of DC instead of definitive laparotomy (for intra-abdominal packing, a second-look laparotomy, hemodynamic instability, to expedite postoperative care or intervention, or for other reasons) was associated with a significantly increased incidence of gastrointestinal (GI) ileus, GI bleeding, abdominal fascial dehiscence, superficial surgical site infection, and death [38]. Moreover, Martin et al. reported that use of DC laparotomy in trauma patients with an arrival systolic BP > 90 mmHg, no severe TBI, and no combined abdominal injuries was associated with an increased adjusted odds of major postoperative complications and an increased adjusted length of hospital stay when compared to patients with a severe abdominal injury who underwent therapeutic definitive laparotomy [14].

Narrative synthesis of validity of indications for use of DC surgery

The narrative synthesis of the aggregate evidence for use of indications for DC surgery is presented in Table 6. Of the 59 unique indications identified using directed qualitative content analysis, two had moderate or strong evidence of content validity [upper quadrant abdominal gunshot wound with a horizontal shift trajectory (e.g., from the right to the left upper quadrant) and a systolic BP < 105 mmHg or right upper quadrant wound with a bullet retained in the same quadrant and a systolic BP < 90 mmHg). Further, nine had moderate or strong evidence of construct validity (high ISS score, preoperative hypothermia, unstable patients with combined abdominal vascular and pancreas gunshot injuries, and transfusion > 10 U PRBCs and ISS score > 25 or lowest temperature < 34 °C in the pre- or intraoperative setting) and six had moderate or strong evidence of criterion validity (pre- or intraoperative hypothermia, increased lactate, or decreased pH).

Table 6 Narrative (vote counting) synthesis of evidence for indications for use of damage control surgery in civilian trauma patients

Discussion

This systematic review is the first to comprehensively compile and critically analyze the evidence for use of DC surgery and DC interventions in civilian trauma patients. We identified 39 studies that evaluated the content, construct, and/or criterion validity of 116 indications for DC surgery. Most were single-center cohort studies that recruited relatively small samples of critically injured patients. Of the 59 unique indications identified using content analysis, 10 had evidence of content validity (i.e., surgeons self-reported that they would perform DC in that clinical scenario or the indication predicted use of DC in practice), nine had evidence of construct validity (i.e., were associated with poor outcomes in patients largely treated with definitive surgery, suggesting that DC be considered in these high-risk scenarios), and six had evidence of criterion validity (may be associated with improved outcomes when utilized or when DC was performed instead of definitive surgery).

Most included studies attempted to validate indications for use of DC surgery by assessing if they were associated with poor outcomes (i.e., coagulopathy or reduced survival); however, few studies subsequently sought to determine if DC improves survival in these situations and nearly one quarter of these studies included patients who only underwent DC (and therefore outcomes associated with these variables are better interpreted as predictors of poor outcome after DC surgery than measures of indication construct validity). Further, some physiology-based indications were associated with reduced survival in patients managed with definitive surgery [an elevated preoperative BD [57] and DC surgery [a preoperative pH < 7.20 [47]. This last finding suggests that although several measures of physiological compromise have been assessed by both international experts and practicing surgeons to be highly appropriate indications for use of DC [3, 16, 17], some data suggest that there may be a point beyond which physiologic derangements have progressed too far for DC surgery to improve survival [49].

We identified only six indications that had evidence to support that their utilization or the conduct of DC surgery may improve patient survival. These indications represent those with the most evidence to support their use and include the finding of hypothermia or acidosis, development of a coagulopathy during operation, or the identification of two injury patterns that preclude expedient definitive repair (combined abdominal vascular and pancreas gunshot injuries and ≥ 1 major abdominal vascular and ≥ 2 abdominal visceral injuries in patients who have received > 10 U PRBCs) [44, 62, 68]. However, as these were observational studies and operative profile (i.e., DC versus definitive surgery) was not randomly assigned, there were likely other, unmeasured reasons why surgeons chose to perform DC in these studies that are related to the risk of future outcomes (i.e., the studies were likely confounded by indication) [73].

Those indications with evidence suggesting that they may be associated with poor outcomes or that outcomes may be improved with use of DC surgery represent targets for focused future research efforts (Table 6). As studies cannot deliver an unbiased and meaningful assessment of validity if the type of operative procedure varies in relation to the indication of interest [28], subsequent study of indications for DC surgery must compare the outcomes of performing DC versus definitive surgery in patients with well-defined indications. This should begin with prospective cohort studies designed to estimate the causal effects of DC surgery by controlling for confounding by indication using multivariate adjustment, propensity scores, or other techniques [73]. A randomized controlled trial would provide the least biased estimates of the benefit/harm ratio of DC compared to definitive surgery in different clinical circumstances. Initial trials should randomize patients to DC or definitive surgery in those clinical circumstances with the greatest uncertainty about the potential role of DC surgery (i.e., those indications listed in Table 6 that have no or equivalent evidence of content, construct, and criterion validity). While the above studies are being designed and conducted, creation of a list of DC consensus indications may allow for the conduct of quality improvement or knowledge translation interventions to decrease overutilization of DC in trauma patients.

Collectively, the above data suggest that there exists little evidence to support the high DC surgery utilization rates reported by many level 1 trauma centers. In a recently reported post-hoc analysis of the PROPPR randomized trial, DC was used among 33% to 83% of patients requiring urgent laparotomy across 12 of the participating institutions [15]. Interestingly, although there was no significant adjusted mortality difference between these centers, the unadjusted risk of sepsis and ventilator-associated pneumonia was higher among those treated with DC laparotomy, suggesting that decreasing use of DC among individual trauma centers may not influence mortality, but may decrease associated morbidity [15]. These findings are supported by two studies included in this systematic review, which both reported that use of DC laparotomy among lower risk cohorts of injured patients was associated with increased complications and longer hospital lengths of stay [14, 38]. As these findings may have been influenced by differences in patient characteristics between groups in the above studies, they should be interpreted cautiously and confirmed by future studies.

This study has potential limitations. First, some of the indications evaluated in this systematic review were dependent on a single clinical finding. While experts and practicing surgeons have previously reported that they would conduct DC surgery when encountered with certain single clinical findings (e.g., massive destruction of the pancreatic head) [3, 16, 17], surgeons frequently decide to conduct DC surgery only after considering multiple clinical findings simultaneously (Table 6). Second, many of the indications assessed in the studies included in this systematic review included static physiologic or laboratory values as decision thresholds. As surveys have suggested that practicing surgeons believe that unless physiologic derangements are persistent during operation that it is likely safe to attempt a definitive trauma operation, arguably more important than any static value are the trends in these values during the early resuscitation and operative phases. Third, as our systematic review included studies of patients mostly undergoing DC surgery for torso trauma, our findings likely cannot be generalized to patients undergoing emergency general, orthopedic, or military surgery. Finally, although most of the studies included in this systematic review were reported after the year 2000, our findings must be interpreted within the context of the time range over which they were published (1983–2017). Recent changes in resuscitation practices have likely resulted in a decrease in the frequency of the need for open abdominal management because of post-injury abdominal visceral swelling [74,75,76]. Moreover, some have suggested that novel resuscitation strategies may potentially prevent or treat the lethal triad, which would suggest that the threshold used to select patients presenting with deranged physiology for DC surgery could potentially rise in the future pending the results of ongoing research [77].

Conclusions

This systematic review identified a large number of indications for use of DC surgery in civilian trauma patients. Few had evidence of validity or that they were associated with improved outcomes when utilized or when DC was performed instead of definitive surgery. Appropriately designed prospective observational studies comparing the benefit-risk profile associated with conduct of DC versus definitive surgery for patients resuscitated according to currently accepted standards and treated with the indications identified in this study are therefore urgently required. In the interim, our findings support that DC should be used with respect for the uncertainty regarding its effectiveness, and only in those circumstances where definitive surgery cannot be entertained.

Availability of data and materials

All data included and analyzed in the study have previously been published.

Abbreviations

AAST:

American Association for the Surgery of Trauma

BP:

Blood pressure

CI:

Confidence interval

DC:

Damage control

EAST:

Eastern Association for the Surgery of Trauma

ED:

Emergency department

GI:

Gastrointestinal

HR:

Hazard ratio

ICU:

Intensive care unit

ISS:

Injury Severity Scale

OR:

Odds ratio

PRBC:

Packed red blood cells

PROPPR:

Pragmatic, Randomized Optimal Platelet and Plasma Ratios

TAC:

Temporary abdominal closure

WTA:

Western Trauma Association

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Acknowledgments

Dr. Roberts had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the data analyses. We thank Helen Lee Robertson, MLIS for assisting with the design of the search strategy and the staff of the University of Calgary Health Sciences Library for obtaining copies of articles identified throughout the conduct of the study. Dr. Roberts is supported by an Alberta Innovates—Health Solutions (AIHS) Clinician Fellowship Award, a Knowledge Translation (KT) Canada Strategic Training in Health Research Fellowship, a KT Canada Research Stipend, and funding from the Canadian Institutes of Health Research (CIHR). Dr. Stelfox is supported by an Embedded Clinician Researcher Award from CIHR.

Members of the Indications for Trauma Damage Control Surgery International Study Group include Karim Brohi, MD (Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, United Kingdom); Scott D’Amours, MD (Department of Surgery, University of New South Wales, Liverpool Hospital, Australia); Timothy C. Fabian, MD (Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America); Kenji Inaba, MD (Department of Surgery, University of Southern California, Los Angeles, California, United States of America); Ari K. Leppäniemi, MD, PhD (Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland); Ernest E. Moore, MD (Department of Surgery, University of Colorado, Denver, Colorado, United States of America); Pradeep H. Navsaria, MBChB, MMed (Surg) (Trauma Centre, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa); Andrew J. Nicol, MBChB, PhD (Trauma Centre, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa); and Neil Parry, MD (Divisions of General Surgery and Critical Care, Departments of Surgery and Medicine, Schulich School of Medicine and Dentistry, Western University and the Trauma Program, London Health Sciences Centre, London, Ontario, Canada).

Funding

This study was supported by a Knowledge Translation (KT) Canada Research Stipend, an Alberta Innovates—Health Solutions Clinician Fellowship Award (AIHS), and funding from the Canadian Institutes of Health Research (CIHR). These funders had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the resultant manuscript.

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Study concept and design: DJR. Acquistion of study funding: DJR, DAZ, AWK, HTS. Creation of study protocol: DJR, NB, DAZ, AWK, CGB, PDF, HTS. Literature search: DJR, NB. Extraction and charting of data: DJR, NB. Analysis of data: DJR, NB. Interpretation of data analyses: DJR, NB, DAZ, AWK, CGB, PDF, HTS. Drafting of the manuscript: DJR. Critical revision of the manuscript: DJR, NB, DAZ, AWK, CGB, PDF, HTS. Study supervision: DJR, HTS. All authors read and approved the final manuscript.

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Correspondence to Derek J. Roberts.

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Supplementary Information

Additional file 1.

Supplemental Digital Content 1. Operationalized and Expanded QUIPS Guidelines for Assessing Risk of Bias in Included Studies. .docx file type.

Additional file 2.

Supplemental Digital Content 2. Characteristics of the Three Cross-Sectional Studies Included in the Systematic Review. .docx file type.

Additional file 3.

Supplemental Digital Content 3. Risk of Bias Assessment for the 35 Included Cohort Studies. .docx file type.

Additional file 4.

Supplemental Digital Content 4. Standards for Use and Reporting of Logistic Regression in the Medical Literature.

Additional file 5.

Supplemental Digital Content 5. Risk of Bias Assessment for the Three Included Cross-Sectional Studies.

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Roberts, D.J., Bobrovitz, N., Zygun, D.A. et al. Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review. World J Emerg Surg 16, 10 (2021). https://doi.org/10.1186/s13017-021-00352-5

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Keywords

  • Damage control
  • Indications
  • Major trauma
  • Surgical procedures, operative
  • Systematic review
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