Research

Original Investigation

Independent Predictors of Enteric Fistula and Abdominal

Sepsis After Damage Control Laparotomy
Results From the Prospective AAST Open Abdomen Registry
Matthew J. Bradley, MD; Joseph J. DuBose, MD; Thomas M. Scalea, MD; John B. Holcomb, MD;
Binod Shrestha, MD; Obi Okoye, MD; Kenji Inaba, MD; Tiffany K. Bee, MD; Timothy C. Fabian, MD;
James F. Whelan, MD; Rao R. Ivatury, MD; for the AAST Open Abdomen Study Group

Invited Commentary
IMPORTANCE Enterocutaneous fistula (ECF), enteroatmospheric fistula (EAF), and page 955
intra-abdominal sepsis/abscess (IAS) are major challenges for surgeons caring for patients
undergoing damage control laparotomy after trauma.

OBJECTIVE To determine independent predictors of ECF, EAF, or IAS in patients undergoing

damage control laparotomy after trauma, using the AAST Open Abdomen Registry.

DESIGN The AAST Open Abdomen registry of patients with an open abdomen following
damage control laparotomy was used to identify patients who developed ECF, EAF, or IAS and
to compare these patients with those without these complications. Univariate analyses were
performed to compare these groups of patients. Variables from univariate analyses differing
at P < .20 were entered into a stepwise logistic regression model to identify independent risk
factors for ECF, EAF, or IAS.

SETTING Fourteen level I trauma centers.

PARTICIPANTS A total of 517 patients with an open abdomen following damage control
laparotomy.

MAIN OUTCOMES AND MEASURES Complication of ECF, EAF, or IAS.

RESULTS More patients in the ECF/EAF/IAS group than in the group without these
complications underwent bowel resection (63 of 111 patients [57%] vs 133 of 406 patients
[33%]; P < .001). Within the first 48 hours after surgery, the ECF/EAF/IAS group received
more colloids (P < .03) and total fluids (P < .03) than did the group without these
complications. The ECF/EAF/IAS group underwent almost twice as many abdominal
reexplorations as did the group without these complications (mean [SD] number, 4.1 [4.1] vs
2.2 [3.4]; P < .001). After multivariate analysis, the independent predictors of ECF/EAF/IAS
were a large bowel resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-6.76]; P < .001),
a total fluid intake at 48 hours of between 5 and 10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or
more than 10 L (AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and an increasing number of
reexplorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001).

CONCLUSIONS AND RELEVANCE Large bowel resection, large-volume fluid resuscitation, and Author Affiliations: Author
an increasing number of abdominal reexplorations were statistically significant predictors of affiliations are listed at the end of this
article.
ECF, EAF, or IAS in patients with an open abdomen after damage control laparotomy.
Group Information: The AAST
(American Association for the
Surgery of Trauma) Open Abdomen
Study Group members are listed at
the end of this article.
Corresponding Author: Joseph J.
DuBose, MD, Division of Trauma and
Acute Care Surgery, University of
Maryland Medical System, R. Adams
Cowley Shock Trauma Center, 22 S
JAMA Surg. 2013;148(10):947-954. doi:10.1001/jamasurg.2013.2514 Greene St, T5R46, Baltimore, MD
Published online August 21, 2013. 21201 (jjd3c@yahoo.com).

947

Copyright 2013 American Medical Association. All rights reserved.

Downloaded From: http://archsurg.jamanetwork.com/ on 05/17/2015

 Research Original Investigation ECF, EAF, and IAS After Damage Control Laparotomy

O
pen abdominal (OA) management has emerged as a
common component in the treatment of severe ab-
dominal trauma and complex surgical pathologies.1,2
As experience with this practice has evolved, however, so has
an increasing appreciation of the potential complications as-
sociated with the use of OA management. Enterocutaneous fis-
tula (ECF), intra-abdominal sepsis/abscess (IAS), deep soft tis-
sue infection, and ventral incisional hernia are a few of the
challenges surgeons face with regard to caring for these pa-
tients. An ECF, which is often referred to as an enteroatmo-
spheric fistula (EAF) in the setting of an open abdomen, is one
of the most devastating of posttraumatic complications in this
patient population. With an incidence of 4.5% to 25%,3-7 EAFs
are associated with considerable morbidity and mortality.8 An
EAF combined with an IAS represents one of the most signifi-
cant management dilemmas in this population.
To date, however, the risk factors for EAF and IAS follow-
ing OA management has not been well elucidated. The pri-
mary aim of the present study was to use the American Asso-
ciation for the Surgery of Trauma (AAST) Open Abdomen
Registry9 to determine the independent predictors for the oc-
currence of EAF or IAS in patients undergoing damage con-
trol laparotomy after trauma. It is our hope that, by identify-
ing these risk factors, additional study can be focused on
mitigating their effect on subsequent outcomes among
patients.
Methods
Our study used the AAST Open Abdomen registry, which was
c reated through a prospective obser vational multi-
institutional study sponsored by the AAST. The study proto-
col was approved by the AAST Multi-Institution Trials Com-
mittee, and each participating center obtained approval from
its own institutional review board. Patients with an open ab-
domen following damage control laparotomy were prospec-
tively enrolled over a 2-year period from 2010 through 2011.
The inclusion criterion was nonclosure of fascia following the
initial trauma laparotomy. Patients younger than 18 years of
age and pregnant patients were excluded from the present
study.
Participating centers on the AAST multicenter study por-
tal securely uploaded data. These data were subsequently col-
lected at the end of the study period and analyzed by the prin-
cipal investigators. All patients included in the present study
had basic demographic data, admission laboratory values, in-
traoperative details, injury patterns, fluid use (both intraop-
eratively and postoperatively for the first 48 hours), ventila-
tor settings, and OA management documented. All variables
were defined using a data dictionary specifically designed for
the study to promote uniformity of data collection. These in-
cluded the definition of intraoperative acidosis as any pH mea-

Table 1. Basic Demographic and Clinical Characteristics of Patients With Open Abdomens

Patients, No./Total No. (%)

No Abdominal
All Complications ECF, EAF, or IAS P
Characteristic (N = 517) (n = 406) (n = 111) Value
Age, mean (SD), y 39.1 (17.3) 39.0 (17.6) 39.2 (16.1) .94
Age of ≥55 y 104/517 (20.1) 85/406 (20.9) 19/111 (17.1) .37
Male sex 409/517 (79.1) 317/406 (78.1) 92/111 (82.9) .29
Mechanism type
Penetrating 200/517 (38.7) 151/406 (37.2) 49/111 (44.1)
GSW 160/517 (30.9) 118/406 (29.1) 42/111 (37.8)
Shotgun injury 4/517 (0.8) 3/406 (0.7) 1/111 (0.9)
Stab wound 32/517 (6.2) 26/406 (6.4) 6/111 (5.4)
Other 4/517 (0.4) 4/406 (1.0) 0/111 (0.0)
Blunt 317/517 (61.3) 255/406 (62.8) 62/111 (55.9)
MVC 180/517 (34.8) 149/406 (36.7) 31/111 (27.9) .30
MCC 36/517 (7.0) 30/406 (7.4) 6/111 (5.4)
Fall 28/517 (5.4) 24/406 (5.9) 4/111 (3.6)
Auto vs ped 35/517 (6.8) 26/406 (6.4) 9/111 (8.1)
Machinery 7/517 (1.4) 6/406 (1.5) 1/111 (0.1)
Assault 6/517 (1.2) 3/406 (0.7) 3/111 (2.7)
Other 25/517 (4.8) 17/406 (4.2) 8/111 (7.2)
Abbreviations: AIS, Abbreviated
Injury severity indices Injury Score; Auto, automobile;
AIS ≥ 3 EAF, enteroatmospheric fistula;
Head 109/426 (25.6) 95/334 (28.4) 14/92 (15.2) .01 ECF, enterocutaneous fistula;
GSW, gunshot wound;
Chest 272/465 (58.5) 215/364 (59.1) 57/101 (56.4) .64 IAS, intra-abdominal sepsis/abscess;
Abdomen 414/496 (83.5) 322/388 (83.0) 92/108 (85.2) .59 ISS, Injury Severity Score;
ISS, mean (SD) 28.2 (13.7) 28.3 (13.4) 27.9 (14.5) .79 MCC, motorcycle collision;
ped, pedestrian; MVC, motor vehicle
ISS ≥ 15 431/505 (85.3) 340/395 (86.1) 91/110 (82.7) .38 collision.

948 JAMA Surgery October 2013 Volume 148, Number 10 jamasurgery.com

Copyright 2013 American Medical Association. All rights reserved.

Downloaded From: http://archsurg.jamanetwork.com/ on 05/17/2015

 ECF, EAF, and IAS After Damage Control Laparotomy Original Investigation Research

Table 2. Laboratory Test Results at Admission for Patients With Open Abdomens

Patients, No./Total No. (%)

No Abdominal
All Complications ECF, EAF, or IAS
Value (N = 517) (n = 406) (n = 111) P Value
Hemoglobin, g/dL
Mean (SD) 11.7 (3.0) 11.7 (3.2) 11.6 (2.5) .74
<7.0 21/515 (4.1) 17/404 (4.2) 4/111 (3.6)
7.0-7.9 26/515 (5.0) 21/404 (5.2) 5/111 (4.5)
.97
8.0-9.9 87/515 (16.9) 69/404 (17.1) 18/111 (16.2)
≥10.0 381/515 (74.0) 297/404 (73.5) 84/111 (75.7)
pH
Mean (SD) 7.28 (1.33) 7.22 (0.21) 7.51 (2.88) .82
<7.00 30/504 (6.0) 26/398 (6.5) 4/106 (3.8)
7.00-7.19 152/504 (30.2) 116/398 (29.1) 36/106 (34.0)
.37
7.20-7.39 284/504 (56.3) 223/398 (56.0) 61/106 (57.5)
≥7.40 38/504 (7.5) 33/398 (8.3) 5/106 (4.7)
INR
Mean (SD) 1.35 (0.59) 1.35 (0.46) 1.35 (0.93) .93
<1.20 225/505 (44.6) 170/396 (42.9) 55/109 (50.5)
1.20-1.59 203/505 (40.2) 161/396 (40.7) 42/109 (38.5)
.39
1.60-1.99 50/505 (9.9) 43/396 (10.9) 7/109 (6.4)
Abbreviations:
≥2.00 27/505 (5.3) 22/396 (5.6) 5/109 (4.6) EAF, enteroatmospheric fistula;
Lactate, mg/dL ECF, enterocutaneous fistula;
IAS, intra-abdominal sepsis/abscess;
Mean (SD) 5.5 (6.5) 5.4 (6.0) 5.9 (8.0) .44
INR, international normalized ratio.
<2.5 94/449 (20.9) 75/355 (21.1) 19/94 (20.2) SI conversion factors: To convert
2.5-4.9 187/449 (41.6) 151/355 (42.5) 36/94 (38.3) hemoglobin to grams per liter,
.82
5.0-7.4 80/449 (17.8) 62/355 (17.5) 18/94 (19.1) multiply by 10.0; and to convert
lactate to millimoles per liter, multiply
≥7.5 88/449 (19.6) 67/355 (18.9) 21/94 (22.3) by 0.111.

surement of less than 7.35 intraoperatively and the definition
of intraoperative hypothermia as a recorded temperature be-
low 35.0°C at any point during the initial operation.
The incidence of EAF and IAS in the AAST Open Abdo-
men Registry has been previously reported.9 Enteric fistula was
defined as any leakage of the enteric contents from the lu-
men of the gastrointestinal tract (excluding created osto-
mies). They were termed enterocutaneous (ie, ECF) when com-
municating to an epithelialized external opening and
enteroatmospheric (ie, EAF) when draining freely into the open
abdomen field itself (the most common occurrence in the set-
ting of an open abdomen). An IAS was defined as a nonfreely
draining collection associated with such enteric leakage
sources. The primary aim of the present study was to use the
AAST Open Abdomen Registry to determine the independent
predictors for the occurrence of these complications in pa-
tients undergoing damage control laparotomy after trauma.
This secondary end point was a priori defined in the design of
the original AAST Open Abdomen Study.9
Patients who developed an ECF, EAF, or IAS were com-
pared with those who did not. Univariate analyses were per-
formed to compare these 2 groups of patients. The student t
test was used to compare continuous variables, and the Pear-
son χ2 test or the Fisher exact test was used to compare pro-
portions. Two-tailed comparisons were used in all cases when
available. Variables from the univariate analysis differing at
P < .20, as well as clinically important variables, were en-
tered into a stepwise logistic regression model to identify in-
dependent risk factors for the development of ECF, EAF, or IAS.
Results
A total of 517 patients from the 14 level I trauma centers par-
ticipating in our study were included. The mean (SD) age of
the patients enrolled was 39 (17) years, with 20% of this popu-
lation 55 years of age or older. The majority of the patients were
male (79%) and were predominantly victims of blunt trauma
(61%). Severe abdominal injury (Abbreviated Injury Score of
≥3) was a common condition in this population (84%) and was
associated with a global injury burden (ie, 85% of these pa-
tients had a Injury Severity Score of ≥15). The mean (SD) time
to successful definitive fascial closure was 4.48 (7.94) days. In
comparison, patients whose primary fascial closure was un-
successful had a mean (SD) time to attempt at closure (ie, ini-
tial visceral coverage) of 11.45 (13.97) days (P < .001).
Patients were divided into 2 subpopulations: those who had
a documented ECF, EAF, or IAS after damage control lapa-
rotomy and those who did not (Table 1). Among the various
demographic and clinical characteristics compared between
these 2 groups, only a head injury with an Abbreviated Injury
Score of 3 or greater was significantly different, with half as
many patients in the ECF/EAF/IAS group sustaining severe head
injury compared with patients in the group without compli-

jamasurgery.com JAMA Surgery October 2013 Volume 148, Number 10 949

Copyright 2013 American Medical Association. All rights reserved.

Downloaded From: http://archsurg.jamanetwork.com/ on 05/17/2015

 Research Original Investigation ECF, EAF, and IAS After Damage Control Laparotomy

Table 3. Intraoperative Considerations for Patients With Open Abdomens

Patients, No./Total No. (%)

No Abdominal
All Complications ECF, EAF, or IAS P
Consideration (N = 517) (n = 406) (n = 111) Value
Time from injury to operating room, h
<1 178/510 (34.9) 141/402 (35.1) 37/108 (34.3)
1-2 127/510 (24.9) 100/402 (24.9) 27/108 (25.0)
2-3 64/510 (12.5) 49/402 (12.2) 15/108 (13.9) .36
3-6 82/510 (16.1) 70/402 (10.4) 12/108 (11.1)
>6 59/510 (11.6) 42/402 (10.4) 17/108 (15.7)
Indication for open abdomen
Damage control 351/508 (69.1) 273/397 (68.8) 78/111 (70.3)
To facilitate early reexploration 2/508 (0.4) 1/197 (0.3) 1/111 (0.9)
.65
Decompression of abdomen 21/508 (4.1) 18/397 (4.5) 3/111 (2.7)
Other 134/508 (26.4) 105/397 (26.4) 29/111 (26.1)
Intraoperative conditions
Perioperative antibiotics 459/517 (88.8) 357/406 (87.9) 102/111 (91.9) .24
Estimated blood loss of ≥5 L 72/510 (14.1) 51/400 (12.8) 21/110 (19.1) .09
Intraoperative crystalloids, L
<5 382/508 (75.2) 306/399 (76.7) 76/109 (69.7)
5-10 104/508 (20.5) 77/399 (19.3) 27/109 (24.8) .33
>10 22/508 (4.3) 16/399 (4.0) 6/109 (5.5)
Intraoperative blood products, L
<5 379/513 (73.9) 306/404 (75.7) 73/109 (67.0)
5-10 84/513 (16.4) 65/404 (16.1) 19/109 (17.4) .05
>10 50/513 (9.7) 33/404 (8.2) 17/109 (15.6)
Fluid balance in operating room, L
<5 269/505 (53.3) 219/397 (55.2) 50/108 (46.3)
5-10 163/505 (32.3) 128/397 (32.2) 35/108 (32.4) .06
>10 73/505 (14.5) 50/397 (12.6) 23/108 (21.3)
Damage control indicators
Acidosis 363/517 (70.2) 270/406 (68.7) 84/111 (75.7) .16 Abbreviations:
Hypothermia 159/517 (30.8) 127/406 (31.3) 32/111 (28.8) .62 EAF, enteroatmospheric fistula;
ECF, enterocutaneous fistula;
Clinical coagulopathy 219/517 (42.4) 170/406 (41.9) 49/111 (44.1) .67 IAS, intra-abdominal sepsis/abscess.

cations (95 of 334 of patients without complications [28%] vs
14 of 92 of patients with [15%]; P = .01). There was no statisti-
cally significant difference in laboratory test results at admis-
sion or in intraoperative management between the 2 groups
(Table 2). Sixty percent of the patients were operated on within
the first 2 hours of injury, and 69% were left with an open ab-
domen for damage control laparotomy. Acidosis was the most
common of the “deadly triad” indicators cited for damage con-
trol laparotomy, specifically referenced in 70% of patients
(Table 3). Perioperative antibiotics were administered to most
patients (88%), and only a minority of patients (14%) had an
estimated blood loss of 5 L or greater. The majority of pa-
tients received less than 5 L of crystalloids (75%) and less than
5 L of intraoperative blood products (74%).
Among the operative interventions (Table 4), univariate
analysis revealed that patients in the ECF/EAF/IAS group re-
quired more bowel resections than did patients in the group
without complications (63 of 111 patients with complications
[57%] vs 133 of 406 patients without [33%]; P < .001) and were
more commonly left with bowel in discontinuity after the ini-
tial surgery (44 of 111 patients with complications [40%] vs 76
of 406 patients without [19%]; P < .001). In the first 24 hours
after surgery, significantly more patients in the ECF/EAF/IAS
group than in the group of patients without complications re-
ceived higher volumes of crystalloid (5-10 L or >10 L; P = .02).
Within the first 48 hours after surgery, the ECF/EAF/IAS group
received more colloids (mean [SD] volume, 1937.4 [4751.8] L
vs 1091.8 [3089.6] L; P < .03) and total fluids (mean [SD] vol-
ume, 10 081.6 [9580.7] L vs 7866.5 [9394.9] L; P < .03) than did
the group of patients without complications (Table 5). The ECF/
EAF/IAS group also underwent almost twice as many abdomi-
nal reexplorations as did the group of patients without com-
plications (mean [SD] number, 4.1 [4.1] vs 2.2 [3.4]; P < .001).
After multivariate analysis, we found that the indepen-
dent predictors of ECF/EAF/IAS development were large bowel
resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-
6.76]; P < .001), total fluid intake at 48 hours between 5 and
10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or greater than 10 L
(AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and number of reex-
plorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001) (Table 6).

950 JAMA Surgery October 2013 Volume 148, Number 10 jamasurgery.com

Copyright 2013 American Medical Association. All rights reserved.

Downloaded From: http://archsurg.jamanetwork.com/ on 05/17/2015

 ECF, EAF, and IAS After Damage Control Laparotomy Original Investigation Research

Table 4. Operative Intervention for Patients With Open Abdomens

Patients, No./Total No. (%)

No Abdominal
All Complications ECF, EAF, or IAS
Intervention (N = 517) (n = 406) (n = 111) P Value
Abdominal packing 363/517 (70.2) 287/406 (70.7) 76/111 (68.5) .65
Packs, mean (SD), No. 4.0 (5.2) 3.9 (4.8) 4.4 (6.3) .32
Gastric injury repair 62/517 (12.0) 46/406 (11.3) 16/111 (14.4) .38
Diaphragm injury repair 68/517 (13.2) 53/406 (13.1) 15/111 (13.5) .90
Bowel resection 196/517 (37.9) 133/406 (32.8) 63/111 (56.8) <.001
Mean (SD), No. 1.5 (0.8) 1.5 (0.9) 1.4 (0.7) .29
Small bowel 109/517 (21.1) 79/406 (19.5) 30/111 (27.0)
<.001
Large bowel 87/517 (16.8) 54/406 (13.3) 33/111 (29.7)
Bowel left in discontinuity 120/517 (23.2) 76/406 (18.7) 44/111 (39.6) <.001
Hepatic intervention 196/517 (37.9) 154/406 (37.9) 42/111 (37.8) .99
Packing 91/517 (17.6) 72/406 (17.7) 19/111 (17.1)
Hepatorrhaphy 67/517 (13.0) 53/406 (13.1) 14/111 (12.6)
.89
Resection 18/517 (3.5) 15/406 (3.7) 3/111 (2.7)
Other 20/517 (3.9) 14/406 (3.4) 6/111 (5.4)
Splenectomy 122/517 (23.6) 90/406 (22.2) 32/111 (28.8) .14
Nephrectomy 35/517 (6.8) 25/406 (6.2) 10/111 (9.0) .29
Vascular injury repair 144/517 (27.9) 112/406 (27.6) 32/111 (28.8) .80
Thoracotomy
Emergency 10/517 (1.9) 8/406 (2.0) 2/111 (1.8) .91
Posterolateral 6/517 (1.2) 5/406 (1.2) 1/111 (0.9) .77 Abbreviations:
Anterolateral 28/517 (5.4) 23/406 (5.7) 5/111 (4.5) .81 EAF, Enteroatmospheric fistula;
ECF, enterocutaneous fistula;
Other 304/517 (58.8) 238/406 (58.6) 66/111 (59.5) .87 IAS, intra-abdominal sepsis/abscess.

resection, large volume resuscitation, and an increasing num-

Discussion
The development of fistula after trauma can lead to a host
of complications, including malnutrition, fluid losses, elec-
trolyte abnormalities, and complex wound care issues.10 As
a result, fistulas are associated with considerable morbidity
and mortality. In a study of more than 2000 patients under-
going laparotomy for trauma, Teixeira et al8 found that the
patients who developed a fistula had a signific antly
increased length of intensive care unit stay (mean [SD]
duration, 28.5 [30.5] days vs 7.6 [9.3] days; P = .004) and
hospital stay (82.1 [100.8] days vs 16.2 [17.3] days; P < .001)
compared with patients who did not. In addition, the mean
hospital charges were significantly higher in those patients
with postlaparotomy fistulas than in those without
($539 309 vs $126 996; P < .001). In another review of 2224
patients requiring laparotomy after trauma over a 10-year
time frame, Fischer and colleagues11 found a mortality rate
of 14% after an average 59-day intensive care unit length of
stay for those patients who developed an ECF. These inves-
tigations highlight the significant burden associated with
the development of fistula after trauma.
Despite the adverse sequelae associated with fistulas, little
is known about the risk factors for their development, specifi-
cally in the setting of OA management. To our knowledge, our
study represents the largest series to date identifying the in-
dependent predictors of ECF/EAF/IAS in OA management af-
ter damage control laparotomy. Our data show that large bowel
ber of reexplorations were statistically significant indepen-
dent predictors for the development of a fistula in an open ab-
domen after trauma.
Multiple studies have suggested that the method of anas-
tomosis does not likely influence the rate of anastomotic com-
plications. A large multicenter prospective study of 297 pa-
tients sponsored by the AAST and conducted by Demtriades
et al12 compared the incidence of colon-related complica-
tions between patients with a hand-sewn anastomosis and pa-
tients with a stapled anastomosis after colon resection follow-
ing penetrating trauma. These investigators12 found that there
was no difference in the incidence of anastomotic leak or fis-
tula between the 2 groups of patients.
Although current data suggest that the type of anasto-
mosis has not been shown to be a risk factor for the devel-
opment of fistula, we found that the location of resection
(specifically the large bowel) can be a significant risk factor.
The aforementioned large study by Teixeira et al8 had simi-
lar findings. This group of investigators8 determined that
89% of patients with an ECF had a hollow viscus organ
injury and that 69% of these patients had sustained a
colonic injury. Our data did not account for the specific
location of the colonic resection, and therefore we were
unable to relate the specific location of the colon injury to
the subsequent risk for fistula. Current literature, however,
supports that the risk for complications after colonic resec-
tion for injury (abscess, leak, or fistula) is not dependent on
the specific location of the original colonic injury.13

jamasurgery.com JAMA Surgery October 2013 Volume 148, Number 10 951

Copyright 2013 American Medical Association. All rights reserved.

Downloaded From: http://archsurg.jamanetwork.com/ on 05/17/2015

 Research Original Investigation ECF, EAF, and IAS After Damage Control Laparotomy

Table 5. Data on Management of Open Abdomen

Patients, No./Total No. (%)

No Abdominal
All Complications ECF, EAF, or IAS P
Type of Management (N = 517) (n = 406) (n = 111) Value
Negative pressure dressing 489/517 (94.6) 383/406 (94.3) 106/111 (95.5) .63
Continuous NPWT 488/489 (99.8) 382/383 (99.7) 106/106 (100.0) .99
Pressure, mean (SEM), mm Hg 106.1 (52.3) 106.6 (56.4) 104.3 (33.8) .69
Type of device
Noncommercial apparatus 196/517 (37.9) 149/406 (36.7) 47/111 (42.3)
KCI device
.49
ABThera 180/517 (34.8) 146/406 (36.0) 34/111 (30.6)
Wound VAC 141/517 (27.3) 111/406 (27.3) 30/111 (27.0)
Postoperative fluids
Crystalloids at 24 h, mean (SEM), L 6584.1 (8410.7) 6452.2 (9134) 7058.4 (5014.9) .50
<5 267/509 (52.5) 221/398 (55.5) 46/111 (41.4)
5-10 150/509 (29.5) 113/398 (28.4) 37/111 (33.3) .02
>10 92/509 (18.1) 64/398 (16.1) 28/111 (25.2)
Colloids at 24 h, mean (SEM), L 1655.0 (3843.9) 1506.1 (3623.6) 2190.4 (4527.2) .10
<5 470/510 (92.2) 371/399 (93.0) 99/111 (89.2)
5-10 18/510 (3.5) 14/399 (3.5) 4/111 (3.6) .24
>10 22/510 (4.3) 14/399 (3.5) 8/111 (7.2)
Crystalloids at 48 h, mean (SEM), L 7074.6 (7893.2) 6774.7 (8158.3) 8144.2 (6790.9) .11
<5 477/507 (94.1) 374/396 (94.4) 103/111 (92.8)
5-10 13/507 (2.6) 12/396 (3.0) 1/111 (0.9) .07
>10 17/507 (3.4) 10/396 (2.5) 7/111 (6.3)
Colloids at 48 h, mean (SEM), L 1276.9 (3533.1) 1091.8 (3089.6) 1937.4 (4751.8) .03
<5 283/506 (55.9) 230/395 (58.2) 53/111 (47.7)
5-10 110/506 (21.7) 84/395 (21.3) 26/111 (23.4) .10
>10 113/506 (22.3) 81/395 (20.5) 32/111 (28.8)
Total fluid intake at 24 h, mean (SEM), L 8239.1 (9694.8) 7958.3 (10198.5) 9248.8 (7568.1) .22 Abbreviations:
Total fluid intake at 48 h, mean (SEM), L 8351.5 (9470.9) 7866.5 (9394.9) 10081.6 (9580.7) .03 EAF, enteroatmospheric fistula;
ECF, enterocutaneous fistula;
Time to reexploration, mean (SD), h 36.0 (23.1) 36.0 (23.1) 36.0 (23.4) .98 IAS, intra-abdominal sepsis/abscess;
Reexplorations, mean (SD), No. 2.6 (3.7) 2.2 (3.4) 4.1 (4.1) <.001 KPI, Kinetics Concepts, Inc;
Postoperative antibiotics 291/517 (56.3) 228/406 (56.2) 63/111 (56.8) .91 NPWT, negative pressure wound
therapy; VAC, vacuum-assisted
Peak airway pressure, mean (SD), mm Hg 29.1 (9.7) 28.8 (9.3) 30.0 (11.0) .26 closure.

Damage control resuscitation (DCR) has emerged as a com-
mon component in trauma management, focusing on permis-
sive hypotension, minimizing crystalloids, and maintaining
close blood product transfusion ratios.14,15 Several studies have
demonstrated a survival advantage after civilian trauma when
practices minimizing the use of crystalloids in resuscitation are
used. A retrospective cohort study by Cotton et al16 of 390 pa-
tients who underwent a damage control laparotomy that com-
pared patients who underwent DCR with a group of patients
who were resuscitated with traditional (pre-DCR) practices
found a statistically significant increase in 30-day survival in
the DCR group (AOR, 2.50 [95% CI, 1.10-5.58]; P = .03). The DCR
group also received less crystalloids during the immediate peri-
operative period than did the pre-DCR group (5 L vs 14 L;
P < .05).
In a DCR survival study of 124 patients, Duchesne and
colleagues 17 found a survival benefit for DCR (AOR, 0.19
[95% CI, 0.05-0.33]; P = .005), with less crystalloids given
intraoperatively to the DCR group than to the pre-DCR
group (4.7 L vs 14.2 L; P = .009). Focusing on large-volume
crystalloid infusion and the colon anastomotic leak rate, a
retrospective review by Schnuriger et al18 of 123 patients
who underwent colonic anastomosis following trauma iden-
tified large-volume resuscitation of greater than 10.5 L in
the first 72 hours as an independent predictor of anasto-
motic leakage (AOR, 5.26 [95% CI, 1.14-24.39]; P = .03). Our
study did not account for blood product ratios, but there
were no statistically significant differences between our
study groups with regard to the amount of blood loss or
blood administered. However, there was a significant differ-
ence in the amount of crystalloids given in the immediate
postoperative period, with more crystalloid infused in
t h e E C F/ E A F/ I A S g r o u p t h a n i n t h e g r o u p w it h o u t
complications.
Minimizing bowel manipulation and local trauma to an
edematous, friable bowel may decrease the rate of fistula
development.19,20 Likewise, early primary fascial closure has
been associated with lower complication rates. Miller et al5 per-

952 JAMA Surgery October 2013 Volume 148, Number 10 jamasurgery.com

Copyright 2013 American Medical Association. All rights reserved.

Downloaded From: http://archsurg.jamanetwork.com/ on 05/17/2015

 ECF, EAF, and IAS After Damage Control Laparotomy
formed a retrospective study of 344 trauma patients requir-
ing open abdomens after initial damage control surgery. They
found a statistically significant difference in the rate of fis-
tula development between the delayed primary facial clo-
sure group and the temporizing fascial closure group (3% vs
30%; P < .001). In addition, they found that the percentage of
all complications, including EAF and abdominal sepsis, was
significantly increased in patients closed after 8 days vs those
patients closed prior to 8 days from initial surgery (52% vs 12%;
P < .01). In a similar retrospective review of more than 200
trauma patients managed with an open abdomen, Burlew and
colleagues21 found that, compared with patients obtaining fas-
cial closure earlier, patients obtaining fascial closure beyond
5 days were 4 times more likely to develop an anastomotic leak
(3% vs 12%; P = .02). These data are consistent with our find-
ings that multiple reexplorations represent significant risk for
the subsequent development of ECF, EAF, or IAS following OA
management in the trauma setting.
A variety of techniques have been reported in the litera-
ture for temporary abdominal closure following damage con-
trol laparotomy. Some of the most commonly used tech-
niques in the modern era include vacuum-assisted closure (VAC
[ie, the V.A.C. System; Kinetics Concepts, Inc]), other nega-
tive pressure therapy dressings, the Wittman patch, or a Bo-
gata silastic bag. A systematic review by Boele van Hens-
broek et al22 of 51 articles and more than 3000 patients reported
the success rates of fascial closure and the morbidity and mor-
tality rates associated with various closure techniques. In their
review, Boele van Hensbroek et al22 determined that the
Wittman path (90%), dynamic retention sutures (85%), and the
VAC dressing (60%) were the methods with the highest fas-
cial closure rate. The lowest mortality rates were associated
with the Wittman patch (17%), the VAC dressing (18%), and dy-
namic retention sutures (23%), whereas the lowest fistula rates
were associated with the Bogata silastic dressing (0%), the
Wittman patch (2%), and the VAC dressing (2.9%). The cur-
rent Eastern Association for the Surgery of Trauma recom-
mendations for temporary abdominal closure, based on level
II data, suggest using the Bogata bag, the Wittman patch, or
the Vacuum pack.23 The authors of these recommendations also
recommend against the use of permanent mesh owing to the
high fistula rates associated with its use.23
The use of the VAC has increased with OA management,
and case series have even reported the use of negative pres-
sure therapy dressing as a successful option for managing EAFs
in open abdomens.24 Other reports, however, have cautioned
its use in the setting of an open abdomen because it has been
suggested as a possible contributor to the development of fis-
tulas. In a prospective randomized trial of 51 patients compar-
ing VAC with polyglactin mesh, Bee et al25 found a fistula rate
of 21% in the VAC group. In a report of 29 patients undergoing
VAC management of open abdomens, Rao and colleagues26
identified 6 patients (21%) who developed a fistula during VAC
treatment. More than 90% of the patients in our registry re-
ceived VAC treatment after their initial damage control lapa-
rotomy for trauma. We were not, however, able to discern if
jamasurgery.com
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ on 05/17/2015
Original Investigation Research
Table 6. Predictors of ECF, EAF, or IAS During Initial Hospitalizationa
Predictor AOR (95% CI) P Value
Large bowel resection 3.56 (1.88-6.76) <.001
Total fluid intake at 48 h
5-10 L 2.11 (1.15-3.88) .02
>10 L 1.93 (1.04-3.57) .04
No. of reexplorations 1.14 (1.06-1.21) <.001
Abbreviations: AOR, adjusted odds ratio; EAF, enteroatmospheric fistula;
ECF, enterocutaneous fistula; IAS, intra-abdominal sepsis/abscess.
a
Other variables in model include intraoperative blood products, estimated
blood loss of greater than 5 L during initial surgery, intraoperative acidosis
during initial surgery, colloids at 24 and 48 h, crystalloids at 24 and 48 h, fluid
balance in operating room, bowel discontinuity, head injury with an
Abbreviated Injury Score of 3 or greater, and splenectomy (model R2 = 0.172;
C statistic, 0.75 [95% CI, 0.70-0.81]; P < .001).
the use of vacuum therapy was associated with a subsequent
risk factor for ECF, EAF, or IAS in the study population.
Although we used a prospective design, our study had im-
portant limitations. Our design could not control for several
potential confounding variables. Correction for variability in
practice among the 14 trauma centers may not be adequately
captured in our analysis and represents one of several impor-
tant limitations inherent in our study design. In addition, the
cause-and-effect relationship between fistula development and
the duration of OA management and the timing/use of vari-
ous closure techniques could not be precisely determined by
our design; a patient’s abdomen may have remained open be-
cause he or she developed a fistula, or the fistula may have de-
veloped because of a prolonged open abdomen. This design
shortcoming hindered our ability to make any meaningful con-
clusions regarding the precise effect of closure or the tech-
nique used for closure on the subsequent development of ECF,
EAF, or IAS. Our data also did not account for the time frame
of fistula development and did not capture whether the fis-
tula was specifically attributed to anastomotic breakdown, al-
though available data suggest that the majority of fistulas may
be associated with anastomotic leak. 27 Additional para-
meters that might have a potential effect on the development
of a fistula and infectious complications, including diabetes,
obesity, and antecedent immunosuppressive medications,
were not included comprehensively in analysis. Our failure to
scrutinize the potential effect of these variables on resulting
complications should be considered in extrapolating our re-
sults to patients with these comorbidities. Finally, because of
the observational design, no control groups were used for com-
parison in our study, which would have been ideal.
The management of trauma patients with open abdo-
mens continues to be challenging and complex, especially in
the event of fistula development. Further studies are war-
ranted to optimize the prevention, treatment, and outcomes
of patients with fistulas in open abdomens after damage con-
trol laparotomy. Studies focusing on resuscitation strategies
and improvements in techniques of early fascial closure are
likely to lead to superior patient outcomes.
JAMA Surgery October 2013 Volume 148, Number 10 953
 Research Original Investigation
ARTICLE INFORMATION
Accepted for Publication: February 13, 2013.
Published Online: August 21, 2013.
doi:10.1001/jamasurg.2013.2514.
Author Affiliations: Division of Trauma and Acute
Care Surgery, University of Maryland Medical
System, R. Adams Cowley Shock Trauma Center,
Baltimore (Bradley, DuBose, Scalea); Division of
Trauma and Acute Care Surgery, University of Texas
Medical School at Houston (Holcomb, Shrestha);
Division of Trauma and Acute Care Surgery, Los
Angeles County and University of Southern
California Medical Center (Okoye, Inaba); Division
of Trauma and Acute Care Surgery, University of
Tennessee, Memphis (Bee, Fabian); Division of
Trauma and Acute Care Surgery, Medical College of
Virginia, Richmond (Whelan, Ivatury).
Author Contributions: Study concept and design:
DuBose, Scalea, Holcomb, Inaba, Ivatury.
Acquisition of data: Bradley, DuBose, Shrestha,
Okoye, Inaba, Bee, Fabian, Whelan, Ivatury.
Analysis and interpretation of data: Bradley,
DuBose, Okoye, Inaba.
Drafting of the manuscript: Bradley, DuBose, Okoye.
Critical revision of the manuscript for important
intellectual content: Bradley, DuBose, Scalea,
Holcomb, Shrestha, Inaba, Bee, Fabian, Whelan,
Ivatury.
Statistical analysis: Bradley, DuBose, Okoye.
Administrative, technical, or material support:
Bradley, DuBose, Scalea.
Study supervision: DuBose, Scalea, Holcomb.
Conflict of Interest Disclosures: None reported.
Group Information: The AAST Open Abdomen
Study Group members were Binod Shrestha, MD,
and John B. Holcomb, MD, University of Texas
Houston Medical Center, Houston; Kenji Inaba, MD,
Obi Okoye, MD, and Agathoklis Konstantinidis, MD,
Los Angeles County and University of Southern
California Hospital; Thomas M. Scalea, MD, Jay
Menaker, MD, and Joseph J. DuBose, MD, R. Adams
Cowley Shock Trauma Center, University of
Maryland Medical Center, Baltimore; James F.
Whelan, MD, Rao R. Ivatury, MD, and Stephanie R.
Goldberg, MD, Virginia Commonwealth University,
Richmond; Martin D. Zielinski, MD, and Donald
Jenkins, MD, Mayo Clinic Trauma Centers,
Rochester, New York; Stephen Rowe, MD, Darrell
Alley, MD, John Berne, MD, and LaDonna Allen, RN,
East Texas Medical Center, Tyler; Paola G. Pieri, MD,
and Starre Haney, RN, MS, Maricopa Integrated
Health System, Phoenix, Arizona; Jeffrey A.
Claridge, MD, and Katherine Kelly, MD, MetroHealth
Medical Center, Cleveland, Ohio; Tiffany K. Bee,
MD, and Timothy C. Fabian, MD, University of
Tennessee Health Science Center, Memphis; Raul
Coimbra, MD, PhD, and Jay Doucet, MD, University
of California San Diego School of Medicine; Ben
Coopwood, MD, David Keith, MD, and Carlos
Brown, MD, University of Texas Southwestern–
Austin, University Medical Center Brackenridge;
James M. Haan, MD, and Jeanette Ward, BA, Via
Christi Hospital, St Francis Campus, Wichita,
Kansas; Stuart M. Leon, MD, Evert Eriksson, MD,
and Debbie Couillard, RN, BSN, The Medical
University of Southern Carolina, Charleston; and
Marc A. de Moya, MD, and Gwendolyn M. van der
Wilden, MSc, Massachusetts General Hospital,
Boston.
954 JAMA Surgery October 2013 Volume 148, Number 10
Copyright 2013 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ on 05/17/2015
Additional Contributions: The AAST Open
Abdomen Study group would like to sincerely thank
the following individuals, without whom this study
could not have been completed: Meghan Spencer,
Rebecca Grace Lopez, MS4, Jinfeng Han, BSN,
Judith S. Katzen, MS, RN, Terry Curry, RN, Sadia Ali,
MPH, and Mary Waage.
Correction: This article was corrected on February
5, 2014, for a misspelling of the surname of an AAST
Open Abdomen Study Group member in the Group
Information section.
REFERENCES
1. Ramsay PT, Mejia VA. Management of
enteroatmospheric fistulae in the open abdomen.
Am Surg. 2010;76(6):637-639.
2. Rotondo MF, Schwab CW, McGonigal MD, et al.
‘Damage control’: an approach for improved
survival in exsanguinating penetrating abdominal
injury. J Trauma. 1993;35(3):375-382, discussion
382-383.
3. Jamshidi R, Schecter WP. Biological dressings for
the management of enteric fistulas in the open
abdomen: a preliminary report. Arch Surg.
2007;142(8):793-796.
4. Tsuei BJ, Skinner JC, Bernard AC, Kearney PA,
Boulanger BR. The open peritoneal cavity: etiology
correlates with the likelihood of fascial closure. Am
Surg. 2004;70(7):652-656.
5. Miller RS, Morris JA Jr, Diaz JJ Jr, Herring MB,
May AK. Complications after 344 damage-control
open celiotomies. J Trauma. 2005;59(6):1365-1371,
discussion 1371-1374.
6. Barker DE, Kaufman HJ, Smith LA, Ciraulo DL,
Richart CL, Burns RP. Vacuum pack technique of
temporary abdominal closure: a 7-year experience
with 112 patients. J Trauma. 2000;48(2):201-206,
discussion 206-207.
7. Kirkpatrick AW, Baxter KA, Simons RK, Germann
E, Lucas CE, Ledgerwood AM. Intra-abdominal
complications after surgical repair of small bowel
injuries: an international review. J Trauma.
2003;55(3):399-406.
8. Teixeira PG, Inaba K, Dubose J, et al.
Enterocutaneous fistula complicating trauma
laparotomy: a major resource burden. Am Surg.
2009;75(1):30-32.
9. DuBose JJ, Scalea TM, Holcomb JB, et al; AAST
Open Abdomen Study Group. Open abdominal
management after damage-control laparotomy for
trauma: a prospective observational American
Association for the Surgery of Trauma multicenter
study. J Trauma Acute Care Surg. 2013;74(1):113-120;
discussion 1120-1122.
10. Majercik S, Kinikini M, White T.
Enteroatmospheric fistula: from soup to nuts. Nutr
Clin Pract. 2012;27(4):507-512.
11. Fischer PE, Fabian TC, Magnotti LJ, et al. A
ten-year review of enterocutaneous fistulas after
laparotomy for trauma. J Trauma.
2009;67(5):924-928.
12. Demetriades D, Murray JA, Chan LS, et al.
Handsewn versus stapled anastomosis in
penetrating colon injuries requiring resection: a
multicenter study. J Trauma. 2002;52(1):117-121.
ECF, EAF, and IAS After Damage Control Laparotomy
13. Murray JA, Demetriades D, Colson M, et al.
Colonic resection in trauma: colostomy versus
anastomosis. J Trauma. 1999;46(2):250-254.
14. Hess JR, Holcomb JB, Hoyt DB. Damage control
resuscitation: the need for specific blood products
to treat the coagulopathy of trauma. Transfusion.
2006;46(5):685-686.
15. Holcomb JB. Damage control resuscitation.
J Trauma. 2007;62(6 suppl):S36-S37.
16. Cotton BA, Reddy N, Hatch QM, et al. Damage
control resuscitation is associated with a reduction
in resuscitation volumes and improvement in
survival in 390 damage control laparotomy
patients. Ann Surg. 2011;254(4):598-605.
17. Duchesne JC, Barbeau JM, Islam TM, Wahl G,
Greiffenstein P, McSwain NE Jr. Damage control
resuscitation: from emergency department to the
operating room. Am Surg. 2011;77(2):201-206.
18. Schnüriger B, Inaba K, Wu T, Eberle BM,
Belzberg H, Demetriades D. Crystalloids after
primary colon resection and anastomosis at initial
trauma laparotomy: excessive volumes are
associated with anastomotic leakage. J Trauma.
2011;70(3):603-610.
19. Campbell A, Chang M, Fabian T, et al; Open
Abdomen Advisory Panel. Management of the open
abdomen: from initial operation to definitive
closure. Am Surg. 2009;75(11 suppl):S1-S22.
20. Jernigan TW, Fabian TC, Croce MA, et al.
Staged management of giant abdominal wall
defects: acute and long-term results. Ann Surg.
2003;238(3):349-355, discussion 355-357.
21. Burlew CC, Moore EE, Cuschieri J, et al; WTA
Study Group. Sew it up! A Western Trauma
Association multi-institutional study of enteric
injury management in the postinjury open
abdomen. J Trauma. 2011;70(2):273-277.
22. Boele van Hensbroek P, Wind J, Dijkgraaf MG,
Busch OR, Goslings JC. Temporary closure of the
open abdomen: a systematic review on delayed
primary fascial closure in patients with an open
abdomen [published correction appears in World J
Surg. 2012;36(2):493]. World J Surg.
2009;33(2):199-207.
23. Diaz JJ Jr, Cullinane DC, Dutton WD, et al. The
management of the open abdomen in trauma and
emergency general surgery: part 1—damage control
[published correction appears in J Trauma.
2010;69(2):470]. J Trauma. 2010;68(6):1425-1438.
24. D’Hondt M, Devriendt D, Van Rooy F, et al.
Treatment of small-bowel fistulae in the open
abdomen with topical negative-pressure therapy.
Am J Surg. 2011;202(2):e20-e24.
25. Bee TK, Croce MA, Magnotti LJ, et al.
Temporary abdominal closure techniques: a
prospective randomized trial comparing polyglactin
910 mesh and vacuum-assisted closure. J Trauma.
2008;65(2):337-342, discussion 342-344.
26. Rao M, Burke D, Finan PJ, Sagar PM. The use of
vacuum-assisted closure of abdominal wounds: a
word of caution. Colorectal Dis. 2007;9(3):
266-268.
27. Berry SM, Fischer JE. Classification and
pathophysiology of enterocutaneous fistulas. Surg
Clin North Am. 1996;76(5):1009-1018.
jamasurgery.com