Using the Delphi Method to Establish a Novel and Universal System for Classifying Indications behind Delayed Abdominal Closure
Sachin Doshi, Khushali Shrenik Parikh, Christine Nguyen, David Gomez, Joao B Rezende-Neto
Abdomen, Abdominal injury, Abdominal trauma, Blunt abdominal trauma, Damage control, Damage control surgery, Emergency general surgery, Emergency surgery, Open abdomen, Open abdominal
Citation Information :
Doshi S, Parikh KS, Nguyen C, Gomez D, Rezende-Neto JB. Using the Delphi Method to Establish a Novel and Universal System for Classifying Indications behind Delayed Abdominal Closure. Panam J Trauma Crit Care Emerg Surg 2023; 12 (1):47-55.
Introduction: Delayed fascial closure is a common lifesaving feature of damage control laparotomy but may result in serious complications. Accordingly, it should only be applied when required; however, a paucity of guidelines and framework for research makes knowing when this is challenging. This study aims to evaluate a classification system that facilitates the categorization of clinical reasoning behind delayed fascial closure.
Methods: A literature search on open abdomens in trauma or acute care surgery over 5 years (n = 185) were simplified into 11 unique scenarios. The Delphi method was employed to capture expert opinions from 202 clinical experts internationally. Participants classified each scenario into one or more of three categories—anatomic, physiologic, and/or logistic reason to leave the abdomen open. This is based on a classification system previously proposed by our group. Three rounds of the survey were distributed, with supplemental information provided between rounds, as per the Delphi process.
Results: In the first round, 600 international surgeons and intensivists were approached with 168 responses. In round 2, 24 of 55 traumatologists responded, and in round 3, 10 of 30 trauma surgeons responded. At the end of round 3, a strong consensus for appropriate classification (≥95%) was achieved for scenarios 1 and 2, consensus approval (≥75–94%) for scenarios 3, 6, and 10, and majority approval (≥50–74%) for the remaining scenarios.
Conclusion: This study demonstrates the universality of a classification system for delayed fascial closure in damage control surgery. The previous absence of such a system has been a barrier in the effective study of delayed abdominal closure, given that indications can be widely disparate for the same procedure. Laying this foundation will allow trauma researchers to better understand delayed abdominal closure and ensure its optimized application or lack thereof.
Coccolini F, Biffl W, Catena F, et al. The open abdomen, indications, management and definitive closure. World J Emerg Surg 2015;10:32. DOI: 10.1186/s13017-015-0026-5
Coccolini F, Catena F, Montori G, et al. IROA: the International Register of Open Abdomen: an international effort to better understand the open abdomen: call for participants. World J Emerg Surg 2015;10:37. DOI: 10.1186/s13017-015-0029-2
Rezende-Neto J, Rice T, Abreu ES, et al. Anatomical, physiological, and logistical indications for the open abdomen: a proposal for a new classification system. World J Emerg Surg 2016;11:28. DOI: 10.1186/s13017-016-0083-4
Roberts DJ, Bobrovitz N, Zygun DA, et al. Indications for use of damage control surgery and damage control interventions in civilian trauma patients: a scoping review. J Trauma Acute Care Surg 2015;78(6):1187–1196. DOI: 10.1097/TA.0000000000000647
DuBose JJ, Scalea TM, Holcomb JB, et al. Open abdominal management after damage-control laparotomy for trauma: a prospective observational American Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg 2013;74(1):113–120. DOI: 10.1097/TA.0b013e31827891ce
Sava J, Alam HB, Vercruysse G, et al. Western Trauma Association critical decisions in trauma: management of the open abdomen after damage control surgery. J Trauma Acute Care Surg 2019;87(5):1232–1238. DOI: 10.1097/TA.0000000000002389
Watson JJ, Nielsen J, Hart K, et al. Damage control laparotomy utilization rates are highly variable among level I trauma centers: pragmatic, randomized optimal platelet and plasma ratios findings. J Trauma Acute Care Surg 2017;82(3):481–488. DOI: 10.1097/TA.0000000000001357
Diaz JJ Jr, Cullinane DC, Dutton WD, et al. The management of the open abdomen in trauma and emergency general surgery: part 1—damage control. J Trauma 2010;68(6):1425–1438. DOI: 10.1097/TA.0b013e3181da0da5
Hatch QH, Osterhout LM, Podbielski J, et al. Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy. J Trauma 2011;71(6):1503–1511. DOI: 10.1097/ta.0b013e31823cd78d
Demetriades D, Salim A. Management of the open abdomen. Surg Clin North Am 2014;94(1):131–153. DOI: 10.1016/j.suc.2013.10.010
Cheatham ML, Safcsak K. Longterm impact of abdominal decompression: a prospective comparative analysis. J Am Coll Surg 2008;207(4):573–579. DOI: 10.1016/j.jamcollsurg.2008.05.008
Chen Y, Ye J, Song W, et al. Comparison of outcomes between early fascial closure and delayed abdominal closure in patients with open abdomen: a systematic review and meta-analysis. Gastroenterol Res Pract 2014;2014:784056. DOI: 10.1155/2014/784056
Chiara O, Cimbanassi S, Biffl W, et al. International consensus conference on open abdomen in trauma. J Trauma Acute Care Surg 2016;80(1):173–183. DOI: 10.1097/TA.0000000000000882
Miller RS, Morris JA Jr, Diaz JJ Jr, et al. Complications after 344 damage-control open celiotomies. J Trauma 2005;59(6):1365–1371. DOI: 10.1097/01.ta.0000196004.49422.af
Quyn AJ, Johnston C, Hall D, et al. The open abdomen and temporary abdominal closure systems—historical evolution and systematic review. Colorectal Dis 2012;14(8):e429–e438. DOI: 10.1111/j.1463-1318.2012.03045.x
Chabot E, Nirula R. Open abdomen critical care management principles: resuscitation, fluid balance, nutrition, and ventilator management. Trauma Surg Acute Care Open 2017;2(1):e000063. DOI: 10.1136/tsaco-2016-000063
Björck M, Wanhainen A. Management of abdominal compartment syndrome and the open abdomen. Eur J Vasc Endovasc Surg 2014;47(3):279–287. DOI: 10.1016/j.ejvs.2013.12.014
Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013;39(7):1190–1206. DOI: 10.1007/s00134-013-2906-z
Niederberger M, Spranger J. Delphi technique in health sciences: a map. Front Public Health 2020;8:457. DOI: 10.3389/fpubh.2020.00457
Stewart D, Gibson-Smith K, MacLure K, et al. A modified Delphi study to determine the level of consensus across the European Union on the structures, processes and desired outcomes of the management of polypharmacy in older people. PLoS One 2017;12(11):e0188348. DOI: 10.1371/journal.pone.0188348
Santaguida P, Dolovich L, Oliver D, et al. Protocol for a Delphi consensus exercise to identify a core set of criteria for selecting health related outcome measures (HROM) to be used in primary health care. BMC Fam Pract 2018;19(1):152. DOI: 10.1186/s12875-018-0831-5
Humphrey-Murto S, Varpio L, Wood TJ, et al. The use of the Delphi and other consensus group methods in medical education research: a review. Acad Med 2017;92(10):1491–1498. DOI: 10.1097/ACM.0000000000001812