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Sun Sep 16 14:15:32 BST 2007

I considered this some time ago when deliberating about the
relevance/indications for Damage Control Surgery (DCS). Indeed, I am a great
believer in both the role and benefits of DCS. Yesterday marked the end of
another of our faculty's 3 day trauma course; during which the concept,
principles and reasoning behind DCS is taught (unfortunately, due to course
time restraints, we are only able to introduce the very basics of DCS to
candidates.) I was somewhat surprised at the substantial number of
candidates who were unaware of the existence of DCS, despite the time period
in which it has been in existence (the candidates were surgeons,
anaesthetists, intensivists and emergency physicians.) This is no doubt a
failing of the system within which we work and the slow pace that new
advances/techniques are adopted by clinicians within the NHS framework. In
the U.K., much of the work and benefit of DCS has been pioneered by the
experiences and teachings of the Royal London Hospital Trauma Service (a
very well known and highly regarded service) and, without them, I believe
that we would be experiencing a much greater incidence of morbidity and
mortality of trauma patients - in which prolonged primary definitive
procedures would otherwise be inappropriately performed. 

1.    Are we all applying damage control, open abdomen  techniques, etc. too

often?

Whilst only commenting on the local practice in my region, I do not believe
that we are applying DCS too often here in the UK. In fact, I do not believe
that we are applying it enough. Perhaps people in other parts of the world
have different experiences or have seen different outcomes?

2.    Are we increasing the number of enteric fistulas,  use of expensive 

secondary closure meshes and devices far too often?  

I have seen an increased number of enteric fistulas - but only with numerous
procedures/laparostomies and repeated take backs to theatre (not
statistically significant evidence!)  I have not seen an increase in the
requirements to use secondary closure meshes.

3.    Is there a need to return to a swinging back of a  pendulum?

In my personal opinion, I would have to say that DCS is increasingly being
disseminated and I am not aware of any individuals here in the U.K. who have
experiences of the pendulum having swung too far (as yet!) but I am not best
placed to comment upon this. Do others have any such experiences? I agree it
would be wrong to move too far and inappropriately apply DCS when a primary
definitive procedure is in the patient's best interests - but this would
only be achieved by clinicians applying sound CLINICAL judgment [as they
indeed ought to anyway] and not merely follow protocols or the latest vogue
(as many hospitals would have us perform.) I still perform primary
definitive procedures on stable trauma patients in which DCS is not
required/appropriate.

Any other views??

Matthew

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