The results of this study showed that primary DH for traumatic massive hemoperitoneum with hemodynamic instability improved a long-term mortality compared with DCL. Supporting this concept are the data from Harvin et al. showing that DCL was associated with increased mortality (10). Although Harvin et al. focused on the patients requiring emergent laparotomy for all severe abdominal trauma, the present study may be the first to focus on traumatic massive hemoperitoneum with hemodynamic instability, which most likely leads to DCL.
There were many possible explanations as to why primary DH improved a long-term outcome. First, primary DH needs only one-time surgery. Patients with severe abdominal injury often have severe concomitant injuries. In particular, a severe brain injury and orthopedic injuries including spinal, pelvic and femoral fractures require both early surgical intervention and multidisciplinary management. A severe head injury requires the head-up position. Early definitive fixations for spinal, pelvic, and femoral fractures are always necessary for early mobilization to prevent pneumonia and venous thromboembolism. Although DCL with an open abdomen and re-operations interfere with the management of these concomitant injuries, primary DH requiring only one-time surgery can allow us to dedicate subsequent management to concomitant injuries. The present data of all patients showed that the mortality rate of brain injury, sepsis, or multiple organ injury was low. Second, hepato-biliary-pancreatic (HBP) surgery has evolved over the decades. Traumatic massive hemoperitoneum is often caused by HBP injuries; therefore, an HBP surgical procedure is often necessary. Currently, establishment of surgical procedures and development of energy devices, surgical staplers, and electrocautery have made hepatectomy and pancreatectomy technically easier and faster. Finally, DCR has evolved and become well known. DCR aims at preventing or reversing coagulopathy through permissive hypotension, limiting crystalloids, and delivering higher ratios of plasma and platelets. Thus, the implementation of DCR allowed us to perform DH requiring a prolonged surgical procedure. In absolute terms, DH potentially has a greater hemostatic effect than DCL.
The present in-hospital, 48-hour mortality, and 28-day mortality rates of all patients (including cardiac arrest on admission) were 27.6%, 14.7%, and 21.2%, respectively. In 2002, Clarke et al. published data from 1986 to 1999 reporting a mortality rate of 40% for hypotensive trauma patients undergoing laparotomy within 90 minutes of arrival (7). In 2017, Harvin et al. reported that the mortality rate of hypotensive trauma patients undergoing emergent laparotomy was 46% (11). In 2020, Traynor et al. reported that the in-hospital mortality rate of patients who underwent DCL in high-income countries was 29% (12). Even though these studies excluded patients with cardiac arrest on admission or intra-operative death, the present outcomes including patients with cardiac arrest or intra-operative death were superior to these reports. The present data were satisfactory compared with these other reports, affirming our surgical strategy based on mandatory DH.
The aim of DCL is to avoid the lethal triad that is described as the metabolic derangement of hypothermia, coagulopathy, and metabolic acidosis (6). The tenet that the lethal triad leads to a “vicious, bloody cycle” and subsequent irreversible physiological exhaustion is emphasized far too much in abdominal trauma surgery. When the concept of “Damage Control” was first described in 1983 (13), HBP surgery was still a high-risk procedure, and DCR had not yet been established. At that time, expeditious hemostasis with abdominal packing was the only optimal procedure to avoid the lethal triad. However, with current development of HBP surgery and established DCR, DCL is no longer required. Higa et al. reported improved mortality and no abdominal compartment syndrome in severe abdominal trauma requiring laparotomy, despite a decrease in the rate of DCL at three years, and they pointed out the overuse of DCL (14).
This study has several limitations. First, the small sample size and single-center design limit the power and generalizability of the present findings. Second, although propensity scores were used to balance the groups’ characteristics, there could be some other unmeasurable confounders and potential bias. Finally, the short-term outcome might be largely affected by the attending surgeons. Since there was no clear-cut indication for DCL, attending surgeons had to select the optimal procedures based on each patient’s clinical status, severity of the injured organ, and concomitant injuries. Therefore, multi-institutional, prospective, observational studies will be useful in resolving these limitations and remaining questions.