In this large, international, cross-sectional survey of trauma program directors or leaders, the reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more often in level-1 than level-2 or -3 trauma centers in the United States, Canada, and Australasia. The frequency of use of DC laparotomy also varied significantly across level-1 trauma centers, especially between those that were high- versus lower volume (based on the number of severely injured patients assessed in the last year). Nearly half of high-volume, level-1 trauma centers reported using DC laparotomy at least once weekly. Trauma center and program characteristics that independently predicted higher reported use of DC laparotomy included country of origin (with centers in the United States reporting using DC laparotomy significantly more often than those in Canada), level-1 trauma verification status, and the assessment of a higher number of severely injured (ISS score > 15) patients and patients with penetrating injuries in the last year.
Studying variation in use of DC laparotomy is important because surgeons are at risk of confirmation bias when only those with whom they work reflect their practice . However, to date, only one other study has examined variation in use of DC surgery between trauma centers . In a post-hoc analysis of the PROPPR trial, DC laparotomy was reportedly used among a highly variable 33–83% of patients requiring urgent laparotomy across 12 American level-1 trauma centers between 2012 and 2013 . In the current study, the trauma program directors who were surveyed also reported that the frequency of use of DC laparotomy varied widely across trauma centers, including level-1 trauma centers. Most level-1 trauma centers reported using DC laparotomy at least once a month, and nearly half of high-volume, level-1 trauma centers reported using it at least once weekly. However, 6% of high-volume, level-1 trauma centers reporting never using DC laparotomy during the past year. Reasons for variation in use of DC laparotomy between level-1 trauma centers may include differences in patient injury mechanisms, injury severity, and/or physiology; trauma center experience; trauma surgeon capabilities; and trauma provider education.
Trauma centers in the United States reported using DC laparotomy for trauma more often than those in Canada despite adjustment for level-1 verification status and the volume of severely injured patients and patients with penetrating injuries. This could be because of differences in institutional cultures regarding use of DC laparotomy between countries. It could also be because of unmeasured differences in patient mix between countries aside from injury mechanism or ISS scores (e.g., a higher percentage of patients with high-risk injury patterns, deranged physiology, or who receive significant volumes of resuscitation fluids) or beliefs regarding appropriate indications for use of the procedure . Of the American, Canadian, and Australasian trauma centers included in this study, a nearly equal percentage reported using the procedure less than once every 3 months or never using it, using it once monthly or once every 2–3 months, or using it more than once monthly. Further, more than one-third of level-2 centers reported using DC laparotomy once monthly or more than once monthly and even some level-3 trauma centers reported using the procedure. We assume that many of these level-3 (and likely some level-2) trauma centers may be using DC laparotomy to stabilize critically injured patients before transport to a higher level of trauma care .
In addition to country of origin, other independent predictors of an increased reported use of trauma DC laparotomy included level-1 trauma verification status and the assessment of a higher number of severely injured patients and patients with penetrating injuries in the last year. In the post-hoc analysis of the PROPPR study, the ISS score (OR per-1 point increase = 1.05; 95% CI = 1.02–1.07) of the patients assessed at level-1 trauma centers also predicted an increased odds of use of DC laparotomy . This is likely because high-energy blunt torso trauma often results in high ISS scores and also may produce some of the high-risk injury patterns considered by many surgeons to be appropriate indications for DC laparotomy (e.g., massive pelvic fracture-related hemorrhage or multiple injuries spanning across more than one body cavity that each require surgery) [19, 30, 31]. Further, while patients with penetrating injuries may have a lower ISS score, those with gunshot wounds (and especially shotgun wounds) more often present with certain injury patterns that have been suggested to be appropriate indications for DC laparotomy . These may include a major abdominal vascular injury and multiple associated hollow organ injuries or an injured pancreaticoduodenal complex [19, 32].
The study findings should be considered in the context of its strengths and limitations. First, the opinions of trauma program directors could be argued to be only estimates of the frequency of use of DC laparotomy. We decided to use survey data from trauma program directors instead of registry or other data because there are limited sources of data available that allow for examination of DC laparotomy practice variation between trauma centers. Further, the ordinal responses provided by trauma program directors are likely accurate within a category of the ordinal response provided. Finally, as the results of this study support the variation in use of DC laparotomy practices identified using PROPPR trial data, we believe they are worth reporting. Second, although we used several techniques shown to increase response rates to surveys (and the response rate is above what has been reported by many surveys reported in the trauma or surgery literature), it is possible that respondents’ answers on the reported frequency of use of DC laparotomy differ systematically from those who did not respond to the survey . Third, it could be argued that the data used in this study are somewhat outdated as they are now over 5-years old. However, surgical practice patterns often change slowly [29, 33], and therefore our findings likely still reflect current practice.
This study has important implications for future research, trauma surgery practice, and quality improvement efforts. First, a systematic review of 36 cohort studies found very little evidence to support that use of DC instead of definitive laparotomy in trauma patients was associated with an improvement in mortality or other patient-important outcomes . However, use of the procedure is associated with an increased risk of morbidity, a longer length of intensive care unit and hospital stay, and possibly a reduced quality of life among survivors [7, 11–13, 34–36]. As equipoise now exists among some surgeons about the effectiveness of DC for improving mortality in many patients undergoing urgent laparotomy, there is a need for rigorously-designed randomized trials comparing it to definitive trauma laparotomy . Second, although DC laparotomy is supported by insufficient evidence, nearly half of high-volume, level-1 trauma centers reported using it at least once weekly. One other study reported utilization rates exceeding 80% in some level-1 trauma centers (with most level-1 centers using it among 30% of those undergoing urgent laparotomy) . Some authors have suggested that more comprehensive indications guiding patient selection for use of DC laparotomy may decrease its associated morbidity and costs . However, our group previously compiled a comprehensive list of indications for the procedure that both experts and practicing trauma surgeons consistently agree appropriately indicate its use [7, 31, 32]. Further, a cohort study suggested that most of the indications that highly predicted use of DC laparotomy in practice had an incidence of 2% or less . Collectively, the above may indicate that DC laparotomy is presently overused in trauma centers and that efforts to decrease its use may be necessary until further evidence becomes available. The group that may need to be targeted first include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries. Indeed, some data suggests that utilization rates of DC laparotomy can be safely reduced through quality improvement efforts such as audit-and-feedback without adversely influencing patient outcomes [14, 38, 39].