Predictors of Intra-abdominal Infection after Temporary Abdominal Closure in Emergency General Surgery

Authors:
Avery A. Thompson, Jillian K. Wothe, Manuel Castillo-Angeles, John Gaspich, Ali Salim, Reza Askari, Kristin A. Madenci

Body of Abstract:
Introduction: Damage control laparotomy (DCL) with temporary abdominal closure (TAC) is well described in trauma, however existing studies in emergency general surgery (EGS) are limited. We aimed to understand risk factors for the development of intra-abdominal infection after definitive abdominal closure among EGS patients undergoing DCL+TAC.

Methods: We performed a ten year retrospective review of our institution’s EGS patients who underwent DCL+TAC. We collected patient characteristics including pre-, intra-, and post-operative factors. We performed multivariable logistic regression to identify potentially modifiable risk factors for the development of intra-abdominal infection (leak or abscess) after definitive closure.

Results: A total of 2,171 patients underwent exploratory laparotomy during the study period (2015-2024). 411 (19%) were EGS patients who underwent DCL+TAC. Median age was 65 (53-73), 41% (N=169) were female, and 82% (N=340) were non-Hispanic White. 330 patients (80%) survived until closure and 94 patients (28%) developed an intra-abdominal infection after definitive closure. On multivariable analysis, age was inversely associated with risk of infection (adjusted OR 0.95 [95% CI 0.92-0.98], p=0.001) (Table 1). Patients who underwent ostomy creation were less likely to develop an infection (adjusted OR 0.33 [95% CI 0.14-0.74], p=0.009). Malnutrition requiring total parenteral nutrition (TPN) or gastrostomy tube placement with initiation of tube feeds was a risk factor for infection, with an adjusted OR of 5.49 (95% CI 2.28-14.60, p<0.001). Patients with bowel ischemia were less likely to develop infection after definitive closure than patients with perforated bowel or intra-abdominal sepsis, with an adjusted OR of 0.26 (95% CI 0.10-0.65, p=0.005). Laparotomy duration, post-operative volume resuscitation and blood transfusion, blood loss, intestinal discontinuity, ventilator days, and pressor use were not independently associated with post-closure infection. Conclusion: EGS patients who undergo DCL+TAC and survive to definitive abdominal closure are at risk for many short- and long-term complications. Diversion via ostomy creation is protective against intra-abdominal infection after definitive closure, likely due to the decreased risk of anastomotic leak. Initiation of supplemental nutrition via TPN or tube feeds via G-tube is likely a marker of illness severity, which overall places these patients at a higher risk of infection. Bowel ischemia, while otherwise morbid, was protective against the development of intra-abdominal infection compared to patients with a bowel perforation or intra-abdominal sepsis. Understanding these potentially modifiable risk factors can help guide intra- and post-operative decision making for this population.