Damage Control Thoracotomy: A Systematic Review of Techniques and Outcomes.

ABSTRACT

BACKGROUND: Damage control surgery is the practice of delaying definitive management of traumatic injuries by controlling hemorrhage in the operating room and restoring normal physiology in the intensive care unit prior to definitive therapy. Presently, damage control or "abbreviated" laparotomy is used extensively for abdominal trauma in an unstable patient. The application of a damage control approach in thoracic trauma is less established and there is a paucity of literature supporting or refuting this practice. We aimed to systematically review the current data on damage control thoracotomy (DCT), to identify gaps in the literature and techniques in temporary closure. METHODS: An electronic literature search of Pubmed, MEDLINE, and the Cochrane Database of Collected Reviews from 1972-2018 was performed using the keywords "thoracic," "damage control," and "thoracotomy." Studies were included if they reported the use of DCT following thoracic trauma and included survival as an outcome. RESULTS: Of 723 studies, seven met inclusion criteria for a total of a 130 DCT operations. Gauze packing with temporary closure of the skin with suture was the most frequently reported form of closure. The overall survival rate for the seven studies was 67%. Survival rates ranged from 42-77%. Average injury severity score was 30, and 64% of injuries were penetrating in nature. The most common complications included infections (57%; pneumonia, empyema, wound infection, bacteremia), respiratory failure (21%), ARDS (8%), and renal failure (18%). CONCLUSION: DCT may be associated with improved survival in the critically injured patient population. Delaying definitive operation by temporarily closing the thorax in order to allow time to restore normal physiology may be considered as a strategy in the unstable thoracic trauma patient population. The impact an open chest has on respiratory physiology remains inconclusive as well as best mechanisms of temporary closure. Multi-center studies are required to elucidate these important questions.