Are the Benefits of Rapid Source Control Laparotomy (RSCL) Realized Following Acute Colonic Perforation?

Author(s):

Mattheew Rosenzweig; Yen-Hong Kuo; Ayolola Onayemi; Jason Sciarretta; John Davis; Nasim Ahmed

Background:

Rapid Source Control Laparotomy (RSCL) in general surgery is an extension of damage-control laparotomy (DCL) in trauma. Studies have shown a mortality benefit in trauma patients with temporizing surgery in patients with the lethal triad of acidosis, hypothermia, coagulopathy, followed by aggressive resuscitation and definitive fascial closure. The benefits of RSCL in general surgery has not been extensively studied.

Hypothesis:

We hypothesize that the patients with RSCL will have a poorer outcome than those treated with conventional surgery.

Methods:

Three years of data (2014-2016) from The American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) was assessed. The patient populations were separated into Group 1: patients with no fascial closure after the initial operation and Group 2: patients with fascial closure. The primary outcome of the study was thirty-day mortality, with secondary analyses evaluating complications and length of stay. Univariate analysis was initially performed followed by propensity score matching.

Results:

Out of 1,381 patients, who satisfied the inclusion criteria, 396 (29%) patients were in group 1 and 985 (71%) patients were in group 2. There were significant differences between the groups on univariate analysis regarding the following comorbidities: diabetes, P=0.008, ascites, P=0.035, congestive heart failure, P <0.001, renal failure requiring dialysis, P <0.001, weight loss P=0.023, bleeding disorder,  P=0.028, preoperative requirement for  blood transfusion,  P<0.001 , presence of  septic shocks, P<0.001 and mechanical ventilation, P <0.001.

After propensity score matching, only the following significant differences were found. The presence of septic shock (52.1% vs 34.7%, P<0.001) was significantly higher in Group 1. The median hospital length of stay was longer (median [95% CI] 20[18-22] versus 14 [13-16], P<0.001) in Group 1 and Group 2 respectively. A larger number of patients in Group 1 went to a rehabilitation facility than in Group 2 ([18.7%] versus [11.2%], P=0.006). The paired matched analysis showed significant 30 days  mortality in patients when the fascia was not closed  group1 (32.6% ) compared to when the fascia was closed group 2( 16.9%), P<0.001.

Conclusions:

Patients presenting with acute colonic perforation and having RSCL had a higher rate of septic shock, prolonged hospital stay, were more likely to be discharged to an extended care facility and had a mortality rate twice as high as patients whose fascia was closed.  These data provide evidence to suggest that RSCL may not be beneficial for the routine use perforated colon surgery.