j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 1 ( 2 5 7 ) 6 9 e7 8

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.JournalofSurgicalResearch.com

Readmission With Major Abdominal

Complications After Penetrating Abdominal
Trauma

Kamil Hanna, MD, Samer Asmar, MD, Michael Ditillo, DO,

Mohamad Chehab, MD, Muhammad Khurrum, MD, Letitia Bible, MD,
Molly Douglas, MD, and Bellal Joseph, MD*
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine,
University of Arizona, Tucson, Arizona

article info abstract

Article history: Background: Despite improvements in operative techniques, major abdominal complica-
Received 10 March 2020 tions (MACs) continue to occur after penetrating abdominal trauma (PAT). This study
Received in revised form aimed to evaluate the burden of MAC after PAT.
13 July 2020 Methods: The (2012-2015) National Readmission Database was queried for all adult (age
Accepted 18 July 2020
18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy
Available online xxx and were readmitted within 6 mo of index hospitalization discharge. Patients were strat-
ified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC:
Keywords: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial
Major abdominal complications dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal
Readmission complications and mortality, postdischarge, and 6-mo readmission. Regression analysis
Penetrating abdominal trauma was performed.
Damage control laparotomy Results: A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age
was 32  14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control
laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial
dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI
(11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P ¼ 0.03), nonabdominal com-
plications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01)
compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel
perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood
transfusion (P ¼ 0.02) were predictors of MAC.
Conclusions: MAC developed in one in five patients after PAT. FIs have a higher potential for
hollow viscus injury and peritoneal contamination, and are more predictive of MAC and
nonabdominal complications, especially after DCL.
Level of Evidence: Level III Prognostic.
ª 2020 Elsevier Inc. All rights reserved.

Quickshot Presentation at the American College of Surgeons Clinical Congress, San Francisco, California, October 27-31, 2019.
* Corresponding author. Division of Trauma, Critical Care, and Emergency Surgery, Department of Surgery, University of Arizona, 1501 N.
Campbell Avenue, Room 5411 P.O. Box 245063 Tucson, AZ 85724. Tel.: þ1 520 626 5056; fax: þ1 520 626 5016.
E-mail address: bjoseph@surgery.arizona.edu (B. Joseph).
0022-4804/$ e see front matter ª 2020 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jss.2020.07.060
70 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 1 ( 2 5 7 ) 6 9 e7 8
Introduction
Penetrating trauma is one of the major causes of death glob-
ally, and it is a significant portion of the global trauma burden.
According to estimates, penetrating trauma accounts for 15%-
45% of injuries incurred in the civilian urban population.1,2
Penetrating abdominal trauma (PAT) is usually caused by a
stab or gunshot wound, and it entails injuries to the small
bowel (50%), large bowel (40%), solid organs such as the liver
(30%), and the vascular system (25%).2 Although the optimal
management of patients with PAT has been debated for de-
cades and varies based on institutional protocols,3 exploratory
laparotomy remains the standard of care as a safe approach
for the timely identification and treatment of solid organ and
hollow viscus injuries.4 However, open abdominal exploration
is associated with significant postoperative morbidity, espe-
cially in the setting of damage control laparotomy (DCL),
which is usually performed in severely injured and physio-
logically deranged patients.5
The rising number of nonfatal injuries6 places a significant
burden on the health care system in terms of the spectrum of
long-term sequelae that often require readmission. Despite
improvements in operative techniques, resuscitation, and
peritoneal irrigation, major abdominal complications (MACs)
such as intra-abdominal abscesses (IAAs) continue to occur
after PAT, and they account for much of the late morbidity
associated with PAT.7 Although there are multiple reasons
why PAT patients with MACs are likely to be readmitted, the
identification of patients with a higher risk injury pattern
would raise the index of suspicion for early detection and
intervention. In the setting of PAT, fecal contamination,
foreign bodies, multiple visceral injuries, extensive peritoneal
contamination, anastomotic leaks, and continued bleeding
predispose patients to MAC.7 Because there is a paucity of
recent data evaluating the long-term occurrence of MAC after
PAT, our aim was to evaluate the long-term burden of MAC
and the time of occurrence after PAT. We hypothesized that
the 6-mo incidence of MAC is high in operatively managed
patients with PAT and is associated with a unique set of pre-
dictors that allow the identification of patients at risk.
Methods
Data sources
We performed a 4-y analysis of the (2012-2015) Healthcare
Cost and Utilization Project Nationwide Readmission Data-
base (NRD), which is provided by the Agency for Healthcare
Research and Quality. It contains 15 million annual admis-
sions and provides longitudinal information about a nation-
ally representative sample of patients after index hospital
admission and subsequent readmissions throughout 1 y
within the same state. Sample weights can be used to derive
national estimates.8 The database uses an identifier to track
patients across admissions to different hospitals. These fea-
tures make the NRD the largest, most accurate, and compre-
hensive source of hospital readmission data in the United
States. Institutional review board approval was exempted
because the NRD only contains deidentified data.
Study population
We identified all adult (age
18 y) trauma patients with
penetrating injuries who underwent exploratory laparotomy
and were readmitted within 6 mo of index hospitalization
discharge. In the NRD, patients cannot be followed from year
to year. We selected patients who were admitted in the first
6 mo of the year to ensure a follow-up period of at least 6-
12 mo. To maintain consistency across patients, the follow-up
period was then limited to 6 mo for all patients. Patients who
were discharged from the emergency department are not
included in the database. Survey weights were applied for
national estimates according to the Healthcare Cost and Uti-
lization Project standards.8 We excluded pediatric patients
and patients who did not undergo an exploratory laparotomy
(nonoperative management) and those who underwent lapa-
roscopy. To reduce heterogeneity in the patient sample and
wide variations in injury patterns and severity, we decided to
be restrictive in our inclusion and exclusion criteria and select
adult patients with operatively managed PAT using the open
approach (i.e., patients who had indications for exploratory
laparotomy).
Patient stratification
Patients were stratified into two groups based on the cause of
their PAT: firearm injuries (FIs) and stab injuries (SIs).
Data points and definitions
For each patient, we abstracted the following data points from
the database: demographic characteristics (age, gender, pri-
mary payer, and household income), comorbidities (Charlson
Comorbidity Index), injury parameters (median Injury
Severity Score [ISS] and interquartile range, body regions
Abbreviated Injury Scale, small and large bowel injury, hepatic
injury, biliary-pancreatic injury, gastric injury, splenic injury,
as well as kidney, ureter, and bladder injuries). Injury patterns
and physiological derangements were decoded using corre-
sponding International Classification of Diseases (ICD)-9
diagnostic codes as shown in Appendix 1. We also decoded
physiological derangements (hypothermia, coagulopathy, and
acidosis) and management approach (DCL, definitive lapa-
rotomy [DL]). In addition, data were collected on the index
admission length of stay, readmission, and 6-mo incidence of
nonabdominal complications (defined as the occurrence of
any of the following complications: acute respiratory distress
syndrome, pneumonia, myocardial infarction, pulmonary
embolism, deep vein thrombosis, and acute renal failure).
MAC was defined as the occurrence of IAA, superficial surgical
site infection (SSI), or fascial dehiscence within 6 mo post-
operatively. The list of nonabdominal complications was
included based on the American College of Surgeons Trauma
Quality Improvement Program data abstraction. Quality
improvement programs have specified a number of pertinent
nonabdominal complications to be tracked and recorded in
 hanna et al  abdominal complications after trauma
patients with trauma from multiple centers for quality
improvement and benchmarking.9 We reported the 6-mo
incidence of superficial SSI, which is a superficial infection
located at the surgical incision. We also collected data on
hospital charges throughout the patients’ index hospitaliza-
tion along with hospital-related variables, such as bed size
(categorized into small, medium, or large based on variable
cutoff points depending on the urban-rural designation of the
hospital), ownership, location, and teaching status.
Damage control versus definitive management
Temporary abdominal closure, as used in the setting of
damage control surgery, is not defined by a single ICD-9 code.
Patients who underwent an exploratory laparotomy were
identified using the two ICD-9 codes: 54.11 and 54.19 (explor-
atory laparotomy and other laparotomy, respectively). DCL was
defined as a second laparotomy based on the recurrence of the
same two ICD-9 codes or the additional presence of the ICD-9
code 54.12 (reopening of recent laparotomy site). The number of
code recurrences was also used to decode the number of
abdominal re-explorations. DL was defined as those without a
second laparotomy or a reopening of a recent laparotomy site.
Transferred patients
On the transfer of patients to another institution, the NRD
does not allow the hospitalization at the receiving hospital to
be counted as a readmission. The database collapses the pairs
of records representing a transfer into a single “combined”
record and removes the original separate discharge records.
Outcome measures
Primary outcome measures were the 6-mo incidence of MAC:
IAA, superficial SSI, and fascial dehiscence. Secondary out-
comes were the 6-mo incidence of nonabdominal complica-
tions (acute respiratory distress syndrome, pneumonia,
myocardial infarction, pulmonary embolism, deep vein
thrombosis, and acute renal failure), mortality, and read-
mission. Both primary and secondary outcomes were
collected in the postdischarge period.
Statistical analysis
To decide on the optimal statistical test to compare variables
across the two groups, we performed normality testing
including the Shapiro-Wilk test, the Kolmogorov-Smirnov
test, visual inspection of histograms for continuous vari-
ables, and Q-Q plots to assess alignment with normal theo-
retical quantiles. Continuous parametric data were reported
as means (with standard deviations), continuous nonpara-
metric data were reported as medians (with interquartile
ranges), and categorical data were reported as proportions. To
analyze the differences between the two groups on a univar-
iate level, we used the chi-square tests for categorical vari-
ables, the Mann-Whitney U-tests for continuous
nonparametric data, and the independent Student t-tests for
continuous parametric data.
71
A multivariable logistic regression model was used to
perform the analysis to determine the predictors of MAC
within 6 mo postoperatively, while adjusting for measurable
confounding variables. In this regression analysis, we
adjusted for demographic characteristics (age, gender, pri-
mary expected payer, and median household income), indi-
vidual comorbidities (hypertension, diabetes mellitus, chronic
obstructive pulmonary disease, congestive heart failure, pe-
ripheral vascular disease, liver failure, chronic kidney disease,
obesity, alcohol use disorder, autoimmune disease, and being
underweight), injury parameters (ISS, body regions Abbrevi-
ated Injury Scale, bowel, hepatic, biliary-pancreatic, gastric,
splenic, and kidney, ureter, and bladder injuries), manage-
ment approach (DCL versus DL), admission physiological de-
rangements (hypothermia, coagulopathy, and acidosis), and
hospital parameters.
To evaluate the association between each potential pre-
dictor variable and the development of MAC, we performed a
univariate analysis. Potential predictors with a P value <0.2
were then included in the multivariable logistic regression
model. Variables were considered significant predictors of
MAC at a P value <0.05. We then performed the Hosmer-
Lemeshow test to assess the fitness of our overall model. In
our logistic regression model, the Hosmer-Lemeshow test
exceeded 0.05 and the tolerance was >0.1 for all independent
variables with a variance inflation factor of <10.0. A Kaplan-
Meier survival analysis was performed to ascertain the me-
dian time to developing MAC in both groups. The median time
to developing MAC was compared using the log-rank test. A
subanalysis comparing outcomes among patients who un-
derwent DCL was performed to evaluate the effect of the
number of subsequent laparotomies on outcomes. We
considered a P value of <0.05 as statistically significant. All
statistical analyses were performed using the Statistical
Package for the Social Sciences (SPSS, version 23; SPSS, Inc,
Armonk, NY).
Results
A total of 4799 patients with trauma met the inclusion and
exclusion criteria of the study, of which 4473 survived their
index admission and were followed longitudinally. Figure 1
represents the patient flow diagram. The mean age was
33  14 y and 87% were male. Most patients belonged to the
lowest income quartile (48%) and were covered by Medicaid
(32%), followed by self-pay (24%) and private insurance (20%).
In addition, 37% of patients had associated comorbidities
(Charlson Comorbidity Index >0). In terms of their injuries,
most patients sustained moderate injuries, as the median ISS
was 10 (4-18), and 35% sustained serious injuries (ISS >15).
The most commonly injured organ was the small bowel
(15%), followed by the liver (12%), large bowel (10%), genito-
urinary organs (8%), and biliary-pancreatic organs (5%).
Moreover, 17% of the sample had at least one element of
hypotension, coagulopathy, or hypothermia. A total of 1031
(23%) patients underwent DCL, and the remaining patients
underwent a DL. Of those who underwent DCL, the median
number of subsequent laparotomies was 1 (1-2). The median
index hospital length of stay was 7 (3-13) d, and the median
72 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 1 ( 2 5 7 ) 6 9 e7 8
Fig. 1 e Patient flow diagram.
index hospitalization health care charges were $72,200
($36,569-$157,650). Most patients were admitted to hospitals
of large bed size (69%), which were private nonprofit owned
(63%) and were located in large metropolitan areas (60%).
Overall, 82% of patients were admitted to teaching hospitals.
Table 1 outlines the baseline characteristics of the study
sample.
In comparison to patients with SIs, patients with FIs were
younger (P < 0.01), more likely to be male (P < 0.01), in the
lowest income quartile (P < 0.01), and covered by Medicare
(P < 0.01). However, patients with FIs were less likely to have
comorbid conditions (P < 0.01) relative to those in the SI group.
In terms of their injuries, victims of FIs had a higher ISS
(P < 0.01) and a greater proportion of serious injuries (P < 0.01)
relative to those in the SI group. They were also more likely to
sustain small bowel (P < 0.01), large bowel (P < 0.01), hepatic
(P < 0.01), biliary-pancreatic (P < 0.01), and genitourinary in-
juries (P < 0.01). A higher proportion of patients in the FI group
underwent DCL (P < 0.01) relative to those in the SI group.
The usage of a cell saver transfusion was restricted to 1% of
the patient population. For these patients, 67% had hepatic
injuries, 48% had biliary-pancreatic injuries, 20% had kidney-
ureter-bladder injuries, 10% had omental injuries, and 4.1%
had small and large bowel injuries.
The overall 6-mo incidence of MAC was 22% (IAA 19%, SSI
7%, and fascial dehiscence 4%), postdischarge mortality was
7%, and 19% of the patients were readmitted within 6 mo. On
univariate analysis, patients with FIs were more likely to
develop an IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%;
P < 0.01), fascial dehiscence (5% versus 3%; P ¼ 0.03), and
nonabdominal complications (54% versus 24%; P < 0.01) within
6 mo postoperatively than patients with SI. In addition, pa-
tients with FI had a higher rate of 6-mo postdischarge
mortality (8% versus 6%; P < 0.01). Table 2 outlines the uni-
variate analysis of outcomes. On Kaplan-Meier survival anal-
ysis, the overall median time to developing MAC was 8 (6-13)
d. Patients in the FI group had a significantly shorter time to
developing MAC relative to patients with SI (7 [6-12] versus 10
[8-14] d; P < 0.01). Figure 2 outlines the development of MAC
over time for the two study groups.
On multivariable regression analysis, FIs were an inde-
pendent predictor of MAC (odds ratio [OR] 1.4 [1.11-1.77];
P < 0.01) relative to SIs. Other significant predictors were
DCL (OR 1.63 [1.19-2.24]; P < 0.01) versus DL, large bowel
penetration (OR 2.56 [1.98-3.3]; P < 0.01), biliary-pancreatic
injury (OR 1.64 [1.13-2.36]; P < 0.01), hepatic injury (OR 1.57
[1.21-2.04]; P < 0.01), age
65 y (OR 1.13 [1.09-1.27]; P < 0.01),
packed red blood cell (PRBC) transfusion (OR 1.27 [1.04-1.56];
P ¼ 0.02). Of all the comorbidities included in the model, the
presence of alcohol use disorder (OR 2.69 [2.14-3.33]; P < 0.01),
diabetes mellitus (OR 3.31 [2.13-5.14]; P < 0.01), autoimmune
diseases (OR 5.21 [3.05-6.17]; P < 0.01), and being underweight
(OR 1.51 [1.12-2.03]; P < 0.01) were associated with the occur-
rence of MAC. However, cell saver transfusion was not asso-
ciated with the occurrence of MAC (OR 0.68 [0.52-1.27];
P ¼ 0.65). Table 3 outlines the independent predictors of
MAC obtained from multivariable regression analysis.
On subanalysis of patients who underwent DCL, 1031 pa-
tients were identified and restratified into those who under-
went a single subsequent laparotomy (SL) (824 [80%]) and
those who underwent more than one SL (207 [20%]). Relative to
those who underwent one SL, those who underwent more
than one SL had higher rates of IAA (34% versus 26%; P < 0.01),
SSI (26% versus 15%; P < 0.01), fascial dehiscence (87% versus
77%; P < 0.01), and 6-mo postdischarge mortality (6% versus
2%; P ¼ 0.004). However, no difference was found in the rate of
 hanna et al  abdominal complications after trauma 73

Table 1 e Baseline characteristics of the study sample.

Variables Overall Firearm injury Stab injury P
(n ¼ 4473) (n ¼ 2326) (n ¼ 2147) value
Demographic characteristics
Age (y), mean  SD 33  13 31  13 35  14 <0.01
Male, n (%) 3869 (87) 2126 (90) 1743 (82) <0.01
Primary expected payer, n (%)
Medicare 285 (6) 70 (3) 215 (10) <0.01
Medicaid 1441 (32) 861 (37) 580 (27) <0.01
Private insurance 891 (20) 419 (18) 472 (22) <0.01
Self-pay 1072 (24) 535 (23) 537 (25) <0.01
Other 786 (18) 442 (19) 344 (16) <0.01
Median household income, n (%)
$1-$37,999 2162 (48) 1325 (56) 837 (40) <0.01
$38,000e$47,999 893 (20) 475 (20) 418 (20) <0.01
$48,000e$63,999 848 (19) 320 (14) 528 (25) <0.01

$64,000 425 (10) 162 (7) 263 (12) <0.01
Comorbidities
CCI >0, n (%) 1653 (37) 683 (29) 970 (45) <0.01
Injury parameters
ISS, median (IQR) 15 (6-19) 19 (8-22) 10 (3-16) <0.01
ISS
15, n (%) 1795 (40) 1280 (54) 515 (24) <0.01
AIS, median (IQR)
Head and neck 2 (1-3) 2 (1-2) 2 (1-3) <0.01
Thorax 1 (1-3) 1 (1-2) 2 (1-3) <0.01
Abdomen 3 (2-3) 3 (3-3) 3 (2-3) <0.01
Extremity 1 (1-1) 1 (1-1) 1 (1-1) <0.01
Hypothermia, n (%) 78 (2) 65 (3) 13 (0.6) 0.001
Coagulopathy, n (%) 38 (1) 22 (0.9) 16 (0.7) 0.001
Acidosis, n (%) 543 (12) 323 (14) 220 (10) <0.01
Intraoperative intervention
Gastric injury, n (%) 476 (11) 326 (14) 150 (7) <0.01
Small bowel injury, n (%) 645 (14) 544 (23) 101 (5) <0.01
Large bowel injury, n (%) 452 (10) 390 (17) 62 (3) <0.01
Hepatic injury, n (%) 539 (12) 418 (18) 121 (6) <0.01
Splenic injury, n (%) 428 (10) 256 (11) 172 (8) <0.01
Biliary-pancreatic injury, n (%) 203 (5) 148 (6) 55 (3) <0.01
Omental injury, n (%) 210 (5) 97 (4) 113 (5) 0.054
KUB injury, n (%) 342 (8) 295 (13) 47 (2) <0.01
Anastomosis, n (%) 237 (5) 194 (8) 43 (2) <0.01
Ostomy, n (%) 162 (4) 129 (6) 33 (2) <0.01
Damage control laparotomy, n (%) 1031 (23) 830 (35) 201 (10) <0.01
Number of relaparotomies, median (IQR) 1 (1-2) 1 (1-2) 1 (1-2) 0.074
Packed RBC transfusion, n (%) 1352 (30) 837 (36) 515 (24) <0.01
Cell saver transfusion, n (%) 49 (1) 42 (2) 7 (0.3) <0.01
Total parenteral nutrition 95 (2) 77 (3) 18 (1) <0.01
LOS (d), median (IQR) 7 (5-18) 9 (5-20) 5 (3-9) <0.01
Index hospitalization health care charges, $1000, 80 (41-190) 109 (50-240) 50 (31-94) <0.01
median (IQR)
Hospital variables
Bed size
Small 447 (10) 140 (6) 279 (13) <0.01
(continued)
74 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 1 ( 2 5 7 ) 6 9 e7 8

Table 1 e (continued )
Variables Overall Firearm injury Stab injury P
(n ¼ 4473) (n ¼ 2326) (n ¼ 2147) value
Medium 939 (21) 582 (25) 386 (18) <0.01
Large 3086 (69) 1605 (69) 1481 (69) 0.13
Ownership
Government 1163 (26) 628 (27) 537 (25) 0.14
Private nonprofit 2818 (63) 1465 (63) 1374 (64) 0.38
Private investor owned 492 (11) 233 (10) 258 (12) 0.17
Location
Large metropolitan 2684 (60) 1535 (66) 1181 (55) <0.01
Small metropolitan 1655 (37) 768 (33) 859 (40) <0.01
Micropolitan 89 (2) 23 (1) 86 (4) <0.01
Rural 45 (1) 23 (1) 21 (1) 0.88
Teaching hospital 3668 (82) 1977 (85) 1696 (79) <0.01

AIS ¼ Abbreviated Injury Scale; CCI ¼ Charlson Comorbidity Index; IQR ¼ interquartile range; ISS ¼ Injury Severity Score; KUB ¼ kidney-ureter-
bladder; LOS ¼ length of stay; RBC ¼ red blood cell; SD ¼ standard deviation.

6-mo readmission (34% versus 23%; P ¼ 0.116). Table 4 outlines
the results of the subanalysis of patients who underwent DCL.
Discussion
The results of our study indicate that in a cohort of operatively
managed PAT patients with moderate to severe injury who
underwent exploratory laparotomy on admission, approxi-
mately one in five patients will develop MAC within 6 mo
postoperatively. They also indicate that there is a spectrum of
MAC (i.e., IAA, fascial dehiscence, and SSIs) that can occur
with significant rates in the postdischarge period. The data
demonstrated multiple factors that increase the likelihood of
MAC, including firearm involvement, patient age, and man-
agement approach (DCL versus DL). These complications may
require the escalation of the acuity of care and lead to multiple
organ failure, abdominal wall defects, and possibly gastroin-
testinal tract fistulae.10 Understanding these factors is of
paramount importance to clinicians who need to risk stratify
patients and gauge their index of suspicion in the setting of a
readmission event. The identification of patients at high risk
also promotes preventive practices that improve the quality of
care and reduce readmission rates.
Despite multiple improvements in operative interventions,
peritoneal irrigation, the range of available antibiotics, and
critical care, the incidence of MAC remains relatively high,
and it should be taken into consideration when evaluating the
safety and quality of care at trauma centers. There are no
recent reports describing the overall incidence of MAC over a
long-term period, and many studies evaluating these com-
plications vary in terms of their follow-up period. Morales
et al.11 conducted a prospective cohort study of 916 abdominal
trauma patients who underwent an exploratory laparotomy
aiming to estimate the incidence of intra-abdominal in-
fections over 30 d after operative intervention and to identify
pertinent risk factors that contribute to the overall incidence.
They reported that the incidence of abdominal infections was
11%, which is lower than the incidence reported in our study.
Despite a comparable ISS between the two cohorts, there are
multiple reasons that could potentially explain this discrep-
ancy. They studied a relatively younger patient population
and used an age cutoff of 12 y. There was also a significantly
lower rate of utilization of DCL as only 2% of their patients
underwent an abbreviated procedure. We hypothesize that

Table 2 e Univariate analysis results.

Major abdominal complications Firearm injury (n ¼ 2326) Stab injury (n ¼ 2147) P value
IAA, n (%) 628 (27) 214 (10) <0.01
Time to abscess (d), median (IQR) 7 (6-12) 10 (8-14) <0.01
SSI, n (%) 255 (11) 64 (3) <0.01
Fascial dehiscence, n (%) 116 (5) 64 (3) 0.03
Nonabdominal complications, n (%) 1276 (54) 506 (24) <0.01
6-mo readmission, n (%) 418 (18) 429 (20) 0.097
6-mo postdischarge mortality, n (%) 186 (8) 128 (6) <0.01

IAA ¼ intra-abdominal abscess; IQR ¼ interquartile range; Non-abdominal complications ¼ ¼ acute respiratory distress syndrome, pneumonia,
myocardial infarction, pulmonary embolism, deep vein thrombosis, or acute renal failure; SSI ¼ surgical site infection.
 hanna et al  abdominal complications after trauma
Fig. 2 e Major abdominal complication development over time. Color version of figure is available online.
the major reason for the observed discrepancy is the differ-
ences in the mechanism of injury between the two patient
cohorts. Only 10% of their patient sample sustained PAT,
whereas the majority sustained a blunt abdominal trauma
unlike our patient cohort where all patients presented with
PAT. When examining their data for the rate of abdominal
infections including only patients with SIs or FIs, the inci-
dence would be 18.1%, which is roughly in line with the
findings of our study.
On multivariable logistic regression analysis after adjust-
ing for measurable imbalances between the two groups, we
observed that FIs had higher odds of MAC. Although different
weapons have the potential to lead to injuries of varying
severity, stabbing weapons are usually more localized and
may have a lower depth of penetration, thus limiting the
insult to the peritoneal cavity.12 FI, however, may traverse the
abdomen through a certain trajectory and at a higher velocity
of penetration, resulting in the potential to cause more dam-
age.11 Consequently, the degree of peritoneal contamination
may differ when considering the weapon causing PAT. All
these circumstances may dictate the eventual probability of
infection. Not surprisingly, injuries with a higher potential for
peritoneal contamination were found to be independent pre-
dictors of MAC, such as large bowel penetration, biliary-
pancreatic injury, and hepatic injuries. Regardless of injury
patterns and operative interventions, there are also pertinent
intraoperative variables that played a role in determining the
incidence of MAC.
Receiving a PRBC transfusion, which could be intra-
operative or not intraoperative, was found to be indepen-
dently associated with adverse outcomes. This is in
agreement with the existing body of literature.13,14 The
mechanisms behind this association are not fully understood,
75
but could be related to immunologic alterations and immu-
nologically active substances, such as cytokines, histamine,
and proinflammatory lipids usually found in stored PRBC
units.15 Intraoperative cell salvage was not commonly used in
our patient cohort, and it did not increase the odds of MAC.
However, its usage was restricted to patients with relatively
lower peritoneal contamination. A randomized controlled
trial by Bowley et al.16 concluded that the use of cell salvage
did not lead to an increase in the rates of infection and mor-
tality in patients with PAT. Although the effect of cell salvage
on infection rates is in line with the findings of that particular
trial, our results do not completely support this conclusion
given the low overall rate of utilization of cell salvage and
lower degree of peritoneal contamination.
Patients who underwent DCL had significantly higher rates
of complications. Apparently, the rates of MAC were
augmented when the number of re-exploration events was
higher. George et al.17 conducted a matched analysis
comparing DL to DCL. Although there were sample size limi-
tations in the study that could have led to a type 2 error, pa-
tients who underwent DCL had clinically significant higher
rates of MAC and fascial dehiscence. This could be attributed
to the morbidity of temporary abdominal closure.18-22 A trial is
being conducted regarding this question to provide definitive
answers on the benefits and risks of DCL.23 Regardless of the
impact of DCL, the percentage of patients who underwent DCL
in our patient cohort approaches the upper limit of what was
reported in the literature. According to estimates, up to 25% of
trauma patients undergoing emergent exploration of the
abdomen may be unsuitable for primary fascial closure at the
index operation.24
Multiple measures can be taken to limit the occurrence of
MAC. Timely exploration of the abdomen25 to control
76 j o u r n a l o f s u r g i c a l r e s e a r c h  j a n u a r y 2 0 2 1 ( 2 5 7 ) 6 9 e7 8

are also other measures, such as the early initiation of broad

Table 3 e Multivariable logistic regression analysis.
spectrum antibiotics based on community- and hospital-
Major abdominal aOR 95% CI P acquired infections,31 copious irrigation, source control,
complications value
effective control of peritoneal contamination, adequate
Firearm injury versus stab injury 1.40 1.11- <0.01 debridement or drainage during the initial operation,10 and
1.77 stoma creation when the risk of anastomotic leak is high.32
DCL versus DL 1.63 1.19- <0.01 The limitations of this study are attributed to the retro-
2.24 spective nature of the analysis, the effect of unmeasurable
Large bowel penetration 2.56 1.98- <0.01 confounding factors (intraoperative interventions, peritoneal
3.30 irrigation, and antibiotic use), and erroneous database en-
Biliary-pancreatic injury 1.64 1.14- <0.01 tries. Patients with nonoperatively managed PAT were not
2.36 included, and the entire spectrum of MAC after any PAT was
Hepatic injury 1.57 1.21- <0.01 not evaluated based on the selected patient cohort. Patients
2.04 with laparoscopy or nonoperatively managed PAT were
Age
65 y 1.13 1.09- <0.01 excluded, and the findings of the study are only generalizable
1.27 to PAT patients who underwent an exploratory laparotomy.
Packed RBC transfusion 1.27 1.04- 0.02 As a result, we may have underestimated the overall burden
1.56 of MAC. To reduce heterogeneity in the patient sample and
Cell saver transfusion 0.68 0.52- 0.65 wide variations in injury patterns and severity, we decided to
1.27 be restrictive in our inclusion and exclusion criteria and
Alcohol use disorder 2.69 2.14- <0.01 select patients with operatively managed PAT using the open
3.33 approach, that is, patients who had indications for explor-
Diabetes mellitus 3.31 2.13- <0.01 atory laparotomy. The study duration was also restricted to
5.14 2011-2015. However, because practice patterns can change
Autoimmune diseases 5.21 3.05- <0.01 with time, more recent nationwide data are needed. Recent
6.17 versions of the NRD have undergone significant changes in
Underweight 1.51 1.12- <0.01 the way diagnostic and procedure data are coded. To prevent
2.03 variations and nonuniformity in the way the data are
Model was adjusted for demographic characteristics (age, gender, analyzed we could not include data from more recent ver-
primary expected payer, and median household income), individ- sions of the database. Because of the retrospective nature of
ual comorbidities, injury parameters (ISS, body regions’ AIS, bowel, the analysis, the cause of death cannot be discerned using
hepatic, biliary-pancreatic, gastric, splenic, and KUB injuries),
this database. The NRD includes mortality only when
management approach (DCL versus DL), admission physiological
derangements (hypothermia, coagulopathy, and acidosis), and
occurring in the context of a hospital admission (index
hospital parameters. admission or any readmission event postdischarge). In
aOR ¼ adjusted odds ratio; AIS ¼ Abbreviated Injury Scale; CI ¼ addition, the NRD tracks patients only on readmission when
confidence interval; DCL ¼ damage control laparotomy; occurring within the same state. Patients may be missed if
DL ¼ definitive laparotomy; ISS ¼ Injury Severity Score; KUB ¼ they were not readmitted or if they were managed in an
kidney-ureter-bladder; RBC ¼ red blood cell.
outpatient setting. Thus, it is possible that we have under-
estimated the incidence. Because pediatric patients were
excluded, the findings of this study are nongeneralizable to
hemorrhage26,27 could reduce transfusion requirements, this unique patient population. However, this study fills a gap
which is a risk factor for infections. The selective use of DCL is in the literature on the burden of MAC in adult patients with
another strategy.28-30 Aiming for fascial closure during the PAT, which had not been previously well described. It also
first exploratory laparotomy, if the patient’s physiology per- ascertains the contribution of the different perioperative
mits, could avert the morbidity of MAC. Furthermore, there factors to the overall burden.

Table 4 e Subanalysis of the patients who underwent damage control laparotomy.

Major abdominal complications 1 SL (n ¼ 824) >1 SL (n ¼ 207) P value
IAA, n (%) 216 (26) 71 (34) <0.01
SSI, n (%) 123 (15) 53 (26) <0.01
Fascial dehiscence, n (%) 85 (10) 47 (23) <0.01
Nonabdominal complications, n (%) 635 (77) 181 (87) <0.01
6-mo readmission, n (%) 192 (23) 71 (34) 0.116
6-mo postdischarge mortality, n (%) 16 (2) 12 (6)c 0.004

IAA ¼ intra-abdominal abscess; Nonabdominal complications ¼ acute respiratory distress syndrome, pneumonia, myocardial infarction,
pulmonary embolism, deep vein thrombosis, or acute renal failure; SL ¼ subsequent laparotomy; SSI ¼ surgical site infection.
 hanna et al  abdominal complications after trauma
Conclusions
One in five patients develops MAC after PAT. In contrast to an
SI, an FI has a higher potential for hollow viscus injury and
peritoneal contamination, and it is more predictive of both
MAC and nonabdominal complications, especially in the
setting of DCL. The incidence of MAC remains relatively high
and should be taken into consideration when evaluating the
safety and quality of care at trauma centers.
Acknowledgment
This research is the authors own work and did not receive any
specific grant from funding agencies in the public, commer-
cial, or not-for-profit sectors.
Author contributions: B.J., K.H., S.A., M.K., and L.B. designed
this study. Mic.D., M.K., B.J., K.H., and S.A. searched the liter-
ature. Mic.D., M.C., Mol.D., S.A., K.H., and B.J. collected the data.
Mol.D., S.A., K.H., and B.J. analyzed the data. All authors
participated in data interpretation and manuscript
preparation.
Disclosures
The authors reported no proprietary or commercial interest in
any product mentioned or concept discussed in this article.
There are no identifiable conflicts of interests to report.
Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jss.2020.07.060.
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