Global variation in patient factors, interventions, and postoperative outcomes for those undergoing trauma laparotomy: an international, prospective, observational cohort study

Abstract

Background: The trauma laparotomy is a definitive intervention for life-threatening abdominal injuries and a cornerstone of trauma care globally. The ability to perform an emergency laparotomy is a recognised marker of safe and effective surgical care within a health system. However, the global variation in the provision, context, and outcomes of the trauma laparotomy is unknown. This study aimed to identify the variation in patient factors, interventions, and postoperative outcomes of those undergoing a trauma laparotomy worldwide.

Methods: We conducted a prospective international observational study in 187 hospitals across 51 countries between April 1 and Dec 31, 2024. Patients who presented with a blunt or penetrating traumatic injury and underwent a laparotomy within 5 days of presentation were eligible, with information on presentation, interventions, and outcomes collected. Countries were stratified by Human Development Index (HDI) tertile and the primary outcome measure was postoperative in-hospital mortality, measured to 30 days. Adjusted mortality risk was calculated using logistic regression analysis. The study was registered to ClinicalTrials.gov (NCT06180668).

Findings: We included 1769 patients, comprising 563 patients (31·8%) from the lower HDI tertile, 714 patients (40·4%) from the middle HDI tertile, and 492 patients (27·8%) from the upper HDI tertile. Median age was 30 years (IQR 23-43) and 1512 patients (85·5%) were male. Patients from upper-HDI countries had a higher Injury Severity Score compared with those in middle-HDI or lower-HDI countries (median 16 [IQR 9-27] vs 9 [8-22] and 9 [4-16], respectively; p<0·0001). Crude mortality was similar across HDI tertiles, with 195 patients (11·0%) overall dying in hospital within 30 days of surgery. After adjustment, we observed higher mortality risk in the lower HDI tertile (odds ratio [OR] 3·57, 95% CI 1·78-7·28, p<0·001) and middle HDI tertile (OR 1·89, 1·06-3·43, p=0·033), compared with the upper HDI tertile.

Interpretation: Patients undergoing a trauma laparotomy in lower-HDI settings were less severely injured and had a higher risk of postoperative death compared with those in higher-HDI settings. There remains an opportunity to improve trauma care globally and expanding access must be matched by the development of quality services.

Funding: Royal College of Surgeons Ratanji Dalal Research Fellowship and Engineering and Physical Sciences Research Council.