Traumatic colon injury in damage control laparotomy-A multicenter trial: Is it safe to do a delayed anastomosis?

BACKGROUND: Delayed colonic anastomosis after damage control laparotomy (DCL) is an alternative to colostomies during a single laparotomy (SL) in high-risk patients. However, literature suggests increased colonic leak rates up to 27% with DCL, and various reported risk factors. We evaluated our regional experience to determine if delayed colonic anastomosis was associated with worse outcomes. METHODS: A multicenter retrospective cohort study was performed across three Level I trauma centers encompassing traumatic colon injuries from January 2006 through June 2014. Patients with rectal injuries or mortality within 24 hours were excluded. Patient and injury characteristics, complications, and interventions were compared between SL and DCL groups. Regional readmission data were utilized to capture complications within 6 months of index trauma. RESULTS: Of 267 patients, 69% had penetrating injuries, 21% underwent DCL, and the mortality rate was 4.9%. Overall, 176 received primary repair (26 in DCL), 90 had resection and anastomosis (28 in DCL), and 26 had a stoma created (10 end colostomies and 2 loop ileostomies in DCL). Thirty-five of 56 DCL patients had definitive colonic repair subsequent to their index operation. DCL patients were more likely to be hypotensive; require more resuscitation; and suffer acute kidney injury, pneumonia, adult respiratory distress syndrome, and death. Five enteric leaks (1.9%) and three enterocutaneous fistulas (ECF, 1.1%) were identified, proportionately distributed between DCL and SL (p = 1.00, p = 0.51). No difference was seen in intraperitoneal abscesses (p = 0.13) or surgical site infections (SSI, p = 0.70) between cohorts. Among SL patients, pancreas injuries portended an increased risk of intraperitoneal abscesses (p = 0.0002), as did liver injuries in DCL patients (p = 0.06). CONCLUSIONS: DCL was not associated with increased enteric leaks, ECF, SSI, or intraperitoneal abscesses despite nearly two-thirds having delayed repair. Despite this being a multicenter study, it is underpowered, and a prospective trial would better demonstrate risks of DCL in colon trauma. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Trauma patient readmissions: Why do they come back for more?

BACKGROUND: Hospital readmissions are a frequent challenge. Speculation exists that rates of readmission following traumatic injury will be publicly disclosed. The primary aim of this study was to characterize and model 1-year readmission patterns to multiple institutions among patients originally admitted to a single, urban Level I trauma center. Additional analyses within the superutilizers subgroup identified predictors of 30-day readmissions as well as patient loyalty for readmission to their index hospital. We hypothesized that hospital readmission among trauma patients would be associated with socioeconomic, demographic, and clinical features and superutilizers would be identifiable during initial hospitalization. METHODS: Data were retrospectively gathered for 2,411 unique trauma patients admitted to a Level I American College of Surgeons-certified trauma center over 1 year, with readmissions identified 1 year after index admission. A regional hospital database was queried for readmissions. Outcomes of all readmission encounters were analyzed using a binary logistic regression model including demographic, diagnoses, Injury Severity Score (ISS), procedures, Elixhauser comorbidities, insurance, and disposition data. Subset analysis of superutilizers was also performed to examine patterns among superutilizers. RESULTS: A total of 434 patients (21%) were readmitted during the study period, accounting for 720 readmission encounters. Sixty-three patients accounting for 269 encounters were identified as superutilizers (3+ readmissions). A total of 136 patients (6%) were readmitted within 30 days of initial discharge. Fifty-seven percent of readmissions returned to the originating hospital. CONCLUSION: Complications including comorbid disease (diabetes and congestive heart failure), septicemia, weight loss, and trauma recidivism distinguish the superutilizer trauma patient. Having Medicaid funding increased the odds of readmission by 274%. It is imperative that interventions be developed and targeted toward those at high risk of superutilization of health care resources to curb spending. These results strongly support continuation of longitudinal readmission research in trauma patients conducted in multicenter settings. LEVEL OF EVIDENCE: Epidemiologic study, level III.