Duchesne Juan C, Schmieg Robert E, Simmons Jon D, Islam Tareq, McGinness Clifton L, McSwain Norman E
Section of Trauma and Critical Care Surgery, Department of Surgery and Anesthesia, Tulane University School of Medicine, New Orleans, Louisiana 70112-2699, USA.
J Trauma. 2009 Jul;67(1):108-12; discussion 112-4. doi: 10.1097/TA.0b013e3181a92ce0.
Obesity is an independent predictor of increased morbidity and mortality in critically injured trauma patients. We hypothesized that obese patients in need of damage control laparotomy (DCL) will encounter an increase incidence of postsurgical complications with a concomitant increase mortality when compared with a cohort of nonobese patients.
All adult trauma patients who underwent DCL during a 4-year period at a Level I Trauma Center were retrospectively reviewed. Patients were categorized into nonobese (body mass index [BMI] < or = 29 kg/m), obese (BMI 30-39 kg/m), and severely obese (BMI > or = 40 kg/m) groups. Outcome measures included the occurrence of postoperative infectious complications, failure of primary abdominal wall fascial closure, acute respiratory distress syndrome, acute renal insufficiency, multiple system organ failure, days of ventilator support, hospital length of stay, and death.
During a 4-year period, 12,759 adult trauma patients were admitted to our Level I Trauma Center of which 1,812 (14.2%) underwent emergent laparotomy. Of these, 104 (5.7%) were treated with DCL: nonobese, n = 51 (49%); obese, n = 38 (37%); and severely obese, n = 15 (14%). In a multivariate adjusted model, multiple system organ failure was 1.82 times more likely in severely obese (95% CI: 1.14-2.90) and 1.74 times more likely in the obese patients (95% CI: 1.14-2.66) when compared with patients with normal BMI after DCL (p < 0.01). In the severely obese patients undergoing DCL, significantly elevated prevalence ratios (PR) for development of postoperative infectious complications, acute renal insufficiency, and failure of primary abdominal wall fascial closure were 1.75, 3.07, and 2.62, respectively. Days of ventilator support, length of stay, and mortality rates were significantly higher in severely obese patients (24 days, 27 days, and 60%) compared with obese (14 days, 14 days, and 21%) and nonobese (9.8 days, 14 days, and 28%) patients.
Severe obesity was significantly associated with adverse outcomes and increased resource utilization in trauma patients treated with DCL. Measures to improve outcomes in this vulnerable patient population must be directed at multiple levels of health care.
肥胖是严重创伤患者发病率和死亡率增加的独立预测因素。我们假设，与非肥胖患者队列相比，需要实施损伤控制剖腹术（DCL）的肥胖患者术后并发症发生率会增加，死亡率也会随之上升。
对一家一级创伤中心4年内接受DCL的所有成年创伤患者进行回顾性研究。患者被分为非肥胖组（体重指数[BMI]≤29kg/m²）、肥胖组（BMI 30 - 39kg/m²）和重度肥胖组（BMI≥40kg/m²）。观察指标包括术后感染并发症的发生情况、一期腹壁筋膜关闭失败、急性呼吸窘迫综合征、急性肾功能不全、多系统器官衰竭、呼吸机支持天数、住院时间和死亡情况。
在4年期间，12759例成年创伤患者入住我们的一级创伤中心，其中1812例（14.2%）接受了急诊剖腹术。其中，104例（5.7%）接受了DCL治疗：非肥胖患者51例（49%），肥胖患者38例（37%），重度肥胖患者15例（14%）。在多变量调整模型中，与DCL后BMI正常的患者相比，重度肥胖患者发生多系统器官衰竭的可能性高1.82倍（95%置信区间：1.14 - 2.90），肥胖患者高1.74倍（95%置信区间：1.14 - 2.66）（p<0.01）。在接受DCL的重度肥胖患者中，术后感染并发症、急性肾功能不全和一期腹壁筋膜关闭失败的患病率比值（PR）显著升高，分别为1.75、3.07和2.62。与肥胖患者（14天、14天和21%）和非肥胖患者（9.8天、14天和28%）相比，重度肥胖患者的呼吸机支持天数、住院时间和死亡率显著更高（分别为24天、27天和60%）。
重度肥胖与接受DCL治疗的创伤患者的不良结局和资源利用增加显著相关。改善这一脆弱患者群体结局的措施必须针对多个医疗保健层面。
