损伤控制开胸手术的趋势、技术及结果：一项东部创伤外科学会多中心试验

Damage control thoracotomy trends, techniques, and outcomes: An EAST multicenter trial.

作者信息

Douglas Anthony D, Puzio Teddy, Murphy Partick, Nahmias Jeffry, Bugaev Nikolay, Kaafarani Haytham, Tatebe Leah, Robinson Bryce, Carrick Matthew, Finch Jordan, Smith Harrison, Hoefer Leah, Keskey Robert, Snyder Andrew, LeClair Madison J, Turay David, Wang Gerald, Capron Gweniviere, Cheung Dillon, Valgardsson Atli, Bankhead Brittany, Liveris Anna, Taylor John, Cromer Dominic, Goldenberg-Sandau Anna, Powers Taylor, Ratnasekera Asanthi, Seng Sirivan, Figueroa Juan, Mulita Francesk, Panagiotopoulos Ioannis, Ramos Juan, Villalobos Liz, Frederick Nicole, Favors Lauren, Maxwell Robert, Spalding Chance, Kurian Anna, Sperwer Kimberly, Senekijan Lara, Gebran Anthony, Burke Rachel, Dalavayi Satya, Hoshal Gillian, Cocanour Christine, Chang Grace, Meagher Ashley

机构信息

From the Department of Surgery (A.D.D., N.B., J.Finch., H.S., M.J.L.), Indiana University School of Medicine, Indianapolis, Indiana; Department of Surgery (T.Puzio), University of Texas Houston, Houston, Texas; Department of Surgery (P.M., J.Figueroa), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (J.N., D.C.), University of California Irvine, Irvine, California; Department of Surgery (H.K., A.G.), Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery (L.T.), Northwestern Medical Center, Chicago, Illinois; Department of Surgery (B.R.), University of Washington, Seattle, Washington; Department of Surgery (M.C.), Envision Physician Services Dallas LLC, Dallas, Texas; Department of Surgery (L.H., R.K.), University of Chicago Medicine, Chicago, Illinois; Department of Surgery (A.S.), University of Washington School of Medicine, Seattle, Washington; Department of Surgery (D.T.), Mayo Clinic College of Medicine and Science, Rochester, Wisconsin; Department of Surgery (G.W.), University Illinois Chicago, Chicago, Illinois; Department of Surgery (G.Capron), Cook County Health, Chicago, Illinois; Department of Surgery (A.V., B.B., A.K.), Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas; Department of Surgery (A.L.), Albert Einstein Medical Center, New York, New York; Department of Surgery (J.T., D.C.), University of Liverpool School of Medicine, Liverpool, UK; Department of Surgery (A.G.-S., T.Powers), Cooper Medical School of Rowan University, Camden, New Jersey; Department of Surgery (A.R., S.S.), Crozer Chester Medical Center, Upland, California; Department of Surgery (F.M., G.-I.P.), University General Hospital of Patras, Rio, Greece; Department of Surgery (J.R.), Hospital Dr. Sotero del Rio, Santiago de Chile, Chile; Department of Surgery (L.V.), Loma Linda University, Loma Linda, California; Department of Surgery (N.F.), Texas Health Harris Methodist Hospital, Fort Worth, Texas; Department of Surgery (L.F., R.M.), The University of Tennessee at Chattanooga, Chattanooga, Tennessee; Department of Surgery (C.S., K.S.), Grant Medical Center, Columbus, Ohio; Department of Surgery (L.S.), Alameda County Medical Center, Oakland, California; Department of Surgery (R.B.), Spartanburg Regional Medical Center, Spartanburg, South Carolina; Department of Surgery (S.D.), University of Kentucky College of Medicine, Lexington, Lexington; Department of Surgery (G.H., C.C.), University of California Davis Medical Center, Sacramento, California; Department of Surgery (G.Chang), University of Illinois Chicago, Chicago, Illinois; and Department of Surgery (A.D.M.), Indiana University Health, Indianapolis, Indianapolis, IN.

出版信息

J Trauma Acute Care Surg. 2025 Sep 1;99(3):460-467. doi: 10.1097/TA.0000000000004492. Epub 2025 May 28.

DOI:10.1097/TA.0000000000004492

PMID:40435348

Abstract

BACKGROUND

Damage-control thoracotomy (DCT) lacks evidence regarding frequency of use, optimal technique, and outcomes. This Eastern Association for the Surgery of Trauma multicenter trial aimed to examine DCT usage over the last decade, evaluate types of temporary closure, and assess associated outcomes.

METHODS

An international retrospective cohort study of thoracotomies from 2008 to 2020 at 25 centers was performed. Patients age 16 years or older undergoing thoracotomy within 24 hours of admission who survived to intensive care unit (ICU) admission were included. Mixed logistic regression was used to assess complications associated with closure type, trends in DCT utilization, and mortality. Competing risk regression model was used to determine trends in ICU-free days for DCT over time.

RESULTS

Nine hundred twenty-two thoracotomy operations were performed, of those 402 (44%) were DCT. Most injuries were penetrating (n = 609, 66%) and the most common mechanism was gunshot wound. Damage-control thoracotomy patients were significantly more injured and ill on presentation. Fifty-four percent of DCT began in the emergency department. Most common temporary closure types included skin only (n = 103, 25%), commercial vacuum device (n = 123,30%), and adhesive dressing (n = 129, 32%). Frequent complications following DCT were pneumonia (n = 57, 14%), acute renal failure (n = 53,13%), and sepsis (n = 41, 10%). Mortality rate in the DCT group was 61%, versus 17% for definitive thoracotomy (n < 0.001). Utilization of DCT has increased in a linear fashion during the study period, as well as ICU-free days out of 30 (odds ratio, 1.66; 95% confidence interval, 1.18-2.33); however, mortality has not changed over time (odds ratio, 0.61; 95% confidence interval, 0.22-1.98). After mixed logistic regression, there was no difference in complications based on closure type.

CONCLUSION

The use of DCT is increasing over time with improved ICU-free days, but without improved mortality. Mechanism of temporary closure should be determined based on operator's experience and institutional resources.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

摘要

背景

损伤控制开胸术（DCT）在使用频率、最佳技术和治疗结果方面缺乏相关证据。这项由东部创伤外科学会开展的多中心试验旨在研究过去十年中DCT的使用情况，评估临时闭合的类型，并评估相关治疗结果。

方法

对2008年至2020年期间25个中心的开胸手术进行了一项国际回顾性队列研究。纳入年龄在16岁及以上、入院后24小时内接受开胸手术且存活至重症监护病房（ICU）的患者。采用混合逻辑回归分析评估与闭合类型、DCT使用趋势和死亡率相关的并发症。使用竞争风险回归模型确定DCT随时间推移无ICU天数的趋势。

结果

共进行了922例开胸手术，其中402例（44%）为DCT。大多数损伤为穿透伤（n = 609，66%），最常见的致伤机制是枪伤。接受损伤控制开胸术的患者在就诊时受伤更严重、病情更危重。54%的DCT在急诊科开始实施。最常见的临时闭合类型包括仅缝合皮肤（n = 103，25%）、商用负压装置（n = 123，30%）和粘贴敷料（n = 129，32%）。DCT术后常见的并发症包括肺炎（n = 57，14%）、急性肾衰竭（n = 53，13%）和脓毒症（n = 41，10%）。DCT组的死亡率为61%，而确定性开胸术组为17%（P < 0.001）。在研究期间，DCT的使用呈线性增加趋势，30天内无ICU天数也呈增加趋势（优势比，1.66；95%置信区间，1.18 - 2.33）；然而，死亡率并未随时间变化（优势比，0.61；95%置信区间，0.22 - 1.98）。经过混合逻辑回归分析，基于闭合类型的并发症无差异。