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Published on: November 10, 2023
Damage control thoracotomy trends, techniques, and outcomes: An EAST multicenter trial
Anthony D Douglas1, Teddy Puzio, Partick Murphy
1From the Department of Surgery (A.D.D., N.B., J.Finch., H.S., M.J.L.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Surgery (T.Puzio), University of Texas Houston, Houston, Texas; Department of Surgery (P.M., J.Figueroa), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (J.N., D.C.), University of California Irvine, Irvine, California; Department of Surgery (H.K., A.G.), Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery (L.T.), Northwestern Medical Center, Chicago, Illinois; Department of Surgery (B.R.), University of Washington, Seattle, Washington; Department of Surgery (M.C.), Envision Physician Services Dallas LLC, Dallas, Texas; Department of Surgery (L.H., R.K.), University of Chicago Medicine, Chicago, Illinois; Department of Surgery (A.S.), University of Washington School of Medicine, Seattle, Washington; Department of Surgery (D.T.), Mayo Clinic College of Medicine and Science, Rochester, Wisconsin; Department of Surgery (G.W.), University Illinois Chicago, Chicago, Illinois; Department of Surgery (G.Capron), Cook County Health, Chicago, Illinois; Department of Surgery (A.V., B.B., A.K.), Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas; Department of Surgery (A.L.), Albert Einstein Medical Center, New York, New York; Department of Surgery (J.T., D.C.), University of Liverpool School of Medicine, Liverpool, UK; Department of Surgery (A.G.-S., T.Powers), Cooper Medical School of Rowan University, Camden, New Jersey; Department of Surgery (A.R., S.S.), Crozer Chester Medical Center, Upland, California; Department of Surgery (F.M., G.-I.P.), University General Hospital of Patras, Rio, Greece; Department of Surgery (J.R.), Hospital Dr. Sotero del Rio, Santiago de Chile, Chile; Department of Surgery (L.V.), Loma Linda University, Loma Linda, California; Department of Surgery (N.F.), Texas Health Harris Methodist Hospital, Fort Worth, Texas; Department of Surgery (L.F., R.M.), The University of Tennessee at Chattanooga, Chattanooga, Tennessee; Department of Surgery (C.S., K.S.), Grant Medical Center, Columbus, Ohio; Department of Surgery (L.S.), Alameda County Medical Center, Oakland, California; Department of Surgery (R.B.), Spartanburg Regional Medical Center, Spartanburg, South Carolina; Department of Surgery (S.D.), University of Kentucky College of Medicine, Lexington, Lexington; Department of Surgery (G.H., C.C.), University of California Davis Medical Center, Sacramento, California; Department of Surgery (G.Chang), University of Illinois Chicago, Chicago, Illinois; and Department of Surgery (A.D.M.), Indiana University Health, Indianapolis, Indianapolis, IN.
Background:
Damage-control thoracotomy (DCT) lacks evidence regarding frequency of use, optimal technique, and outcomes. This Eastern Association for the Surgery of Trauma multicenter trial aimed to examine DCT usage over the last decade, evaluate types of temporary closure, and assess associated outcomes.
Methods:
An international retrospective cohort study of thoracotomies from 2008 to 2020 at 25 centers was performed. Patients age 16 years or older undergoing thoracotomy within 24 hours of admission who survived to intensive care unit (ICU) admission were included. Mixed logistic regression was used to assess complications associated with closure type, trends in DCT utilization, and mortality. Competing risk regression model was used to determine trends in ICU-free days for DCT over time.
Results:
Nine hundred twenty-two thoracotomy operations were performed, of those 402 (44%) were DCT. Most injuries were penetrating (n = 609, 66%) and the most common mechanism was gunshot wound. Damage-control thoracotomy patients were significantly more injured and ill on presentation. Fifty-four percent of DCT began in the emergency department. Most common temporary closure types included skin only (n = 103, 25%), commercial vacuum device (n = 123,30%), and adhesive dressing (n = 129, 32%). Frequent complications following DCT were pneumonia (n = 57, 14%), acute renal failure (n = 53,13%), and sepsis (n = 41, 10%). Mortality rate in the DCT group was 61%, versus 17% for definitive thoracotomy (n < 0.001). Utilization of DCT has increased in a linear fashion during the study period, as well as ICU-free days out of 30 (odds ratio, 1.66; 95% confidence interval, 1.18-2.33); however, mortality has not changed over time (odds ratio, 0.61; 95% confidence interval, 0.22-1.98). After mixed logistic regression, there was no difference in complications based on closure type.
Conclusion:
The use of DCT is increasing over time with improved ICU-free days, but without improved mortality. Mechanism of temporary closure should be determined based on operator's experience and institutional resources.
Level Of Evidence:
Therapeutic/Care Management; Level III.
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