INTRODUCTION

Background

Uncontrolled hemorrhage remains the leading cause of preventable death in trauma, accounting for approximately 30% to 40% of trauma mortality [1]. In patients with non-compressible torso hemorrhage and hemorrhagic shock, resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a valuable adjunct to temporarily control bleeding and maintain central perfusion while definitive surgical intervention is prepared [2]. Zone I REBOA, positioned between the left subclavian artery and the celiac trunk, is particularly effective for intra-abdominal and pelvic hemorrhage [3].

Damage control surgery (DCS) is a well-established approach to severely injured patients, prioritizing physiological restoration over anatomical repair [4]. The fundamental principle involves abbreviated surgical intervention to control hemorrhage and contamination, followed by intensive care unit (ICU) resuscitation to correct the "diamond of death" of hypothermia, acidosis, coagulopathy, and hypocalcemia before definitive repair [5]. An inevitable consequence of DCS is the open abdomen (OA), where temporary abdominal closure (TAC) facilitates subsequent return to the operating room [6].

OA management presents significant challenges, as prolonged OA duration is associated with serious complications, including enteroatmospheric fistula (EAF), intra-abdominal abscess, frozen abdomen, and planned ventral hernia [7,8]. EAF incidence ranges from 5%–55%, carrying mortality rates of 40%–70% [9]. Patients who fail to achieve fascial closure have ventral hernia rates of 32%–51% at 1 year [10]. Consequently, early and successful definitive fascial closure (DFC) is a critical goal in OA management.

Several factors influencing DFC have been identified, including the number of relaparotomies, initial Sequential Organ Failure Assessment (SOFA) score, intra-abdominal complications, and resuscitation volumes [11–13]. The American Association for the Surgery of Trauma (AAST) multicenter study reported a DFC rate of 66% in trauma patients with OA [11]. Negative pressure wound therapy (NPWT) has become the standard TAC technique, with fascial closure rates of 72%–82% depending on the system employed [14].

Objectives

Despite increasing adoption of REBOA in trauma resuscitation, its relationship with OA management and DFC outcomes remains uninvestigated. Theoretically, REBOA may influence DFC through several mechanisms. For example, by reducing hemorrhage and transfusion requirements, REBOA could attenuate the inflammatory response and visceral edema that impede fascial closure. Conversely, ischemia-reperfusion injury from aortic occlusion may exacerbate systemic inflammation and tissue edema [15]. This study, therefore, investigated the impact of zone I REBOA on the achievement and timing of DFC in trauma patients with massive hemorrhage following DCS with OA.

METHODS

Ethics statement

This study was approved by the Institutional Review Board of Dankook University Hospital (No. DKUH 2024-04-003). Informed consent was waived due to the use of deidentified data and the retrospective nature of the study. The study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.

Study design and patient selection

This retrospective cohort study was conducted at a single level I regional trauma center between January 2015 and August 2022. All trauma patients who received massive transfusion during the study period were identified. Massive transfusion was defined as ≥5 units of packed red blood cells (RBCs) within 4 hours or ≥10 units within 24 hours of admission [16]. Patients were excluded if they met any of the following criteria: (1) severe traumatic brain injury (Abbreviated Injury Scale [AIS] head ≥4); (2) no laparotomy performed; (3) death on arrival or before surgical intervention; (4) transfer to another facility before definitive management; (5) intraoperative death during initial surgery; (6) age ≤15 years; or (7) zone II or III REBOA placement. Zone I REBOA was defined as balloon placement between the left subclavian artery and the celiac trunk, confirmed by portable radiography or fluoroscopy.

REBOA procedure

REBOA was performed by trained trauma surgeons per institutional protocol. Femoral artery access was obtained percutaneously or via surgical cutdown. A 7-Fr sheath was inserted, followed by advancement of the RESCUE balloon catheter (Tokai Medical Products) to zone I, with position confirmed by serial chest radiograph. Balloon inflation and deflation were titrated to hemodynamic response to achieve permissive hypotension.

OA management

Damage control laparotomy was performed according to established principles. The decision to leave the abdomen open was made by the attending trauma surgeon based on physiological derangement, need for reassessment, or inability to achieve tension-free fascial closure [4,6]. TAC was achieved using commercial NPWT systems as the primary method. Patients were returned to the operating room at 24- to 48-hour intervals for washout, reassessment, and attempted DFC, defined as primary approximation of the fascial edges without mesh or component separation techniques.

Data collection and outcomes

Data were extracted from electronic medical records and the institutional trauma database. Variables included demographics (age, sex), injury characteristics (mechanism, Injury Severity Score [ISS], AIS by body region), physiological parameters on arrival (systolic blood pressure, heart rate, Glasgow Coma Scale score, lactate, base deficit, pH), resuscitation data (RBC units, fresh frozen plasma, platelets, cryoprecipitate, crystalloid volume), operative details (number of laparotomies, bowel perforation, vascular injury), and clinical course (SOFA score, abdominal compartment syndrome [ACS], ICU length of stay, hospital length of stay, mortality).

Primary outcomes were DFC achievement (yes/no) and timing (≤48 hours vs. >48 hours). Secondary outcomes included in-hospital mortality, ICU and hospital length of stay, ventilator days, and complications (EAF, intra-abdominal abscess, ACS). ACS was defined per World Society of the Abdominal Compartment Syndrome (WSACS) consensus criteria as sustained intra-abdominal pressure >20 mmHg associated with new organ dysfunction [17].

Statistical analysis

Continuous variables were expressed as medians with interquartile ranges (IQRs) and compared using the Mann-Whitney U-test. Categorical variables were expressed as frequencies and percentages and compared using the chi-square test or Fisher exact test, as appropriate. Univariate logistic regression identified factors associated with DFC achievement and timing. Variables with P<0.1 in univariate analysis were entered into multivariate logistic regression models. Results were reported as odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was set at P<0.05. All analyses were performed using R ver. 4.5.1 (R Foundation for Statistical Computing).

RESULTS

Patient characteristics

During the study period, 839 trauma patients requiring massive transfusion were identified. After applying exclusion criteria, 229 patients were included in the final analysis (Fig. 1). Of these, 76 (33.2%) underwent OA management (OA+ group) and 153 (66.8%) achieved primary fascial closure (OA− group). Patient characteristics by OA status are presented in Table 1. The OA+ group demonstrated significantly more severe injury and physiological derangement consistent with advanced hemorrhagic shock. REBOA was utilized more frequently in the OA+ group than in the OA− group (47.4% vs. 15.0%, P<0.001), as were angioembolization (36.8% vs. 8.5%, P<0.001) and preperitoneal pelvic packing (9.2% vs. 0.7%, P=0.002). In-hospital mortality was higher in the OA+ group (71.1% vs. 12.4%, P<0.001).

Subgroup analysis I: Predictors of DFC achievement

Among 76 OA patients, 33 (43.4%) achieved DFC while 43 (56.6%) did not. Factors associated with successful DFC are presented in Table 2. Patients who achieved DFC had significantly lower mean 24-hour RBC transfusion volumes (27.7 units vs. 40.8 units, P=0.001), higher rates of bowel perforation (42.4% vs. 16.3%, P=0.023), higher median total number of laparotomies (2.4 vs. 1.1, P<0.001), and lower mean SOFA scores after OA (9.5 vs. 13, P<0.001). REBOA use did not differ between DFC+ and DFC− groups. In-hospital mortality was significantly lower in patients achieving DFC (33.3% vs. 100%, P<0.001).

On univariate logistic regression, variables associated with DFC achievement included 24-hour RBC transfusion volume (OR, 0.95; 95% CI, 0.92–0.98; P=0.003), bowel perforation (OR, 3.79; 95% CI, 1.31–10.98; P=0.014), and post-OA SOFA score (OR, 0.56; 95% CI, 0.43–0.75; P<0.001) (Table 3). Multivariate logistic regression analysis confirmed that bowel perforation (adjusted OR, 6.75; 95% CI, 1.56–29.23; P=0.011) and post-OA SOFA score (adjusted OR, 0.58; 95% CI, 0.43–0.79; P<0.001) were independently associated with DFC achievement.

Subgroup analysis II: Predictors of early DFC (≤48 hours)

Factors associated with early DFC were analyzed (Table 4). Among 33 patients achieving DFC, 24 (72.7%) achieved closure within 48 hours (mean, 28.7 hours), while 9 (27.3%) required more than 48 hours (mean, 72.0 hours). Early DFC patients had a higher proportion of DCS as the OA indication (91.7% vs. 55.6%), while ACS was more common in the late DFC group (44.4% vs. 8.3%, P=0.034). Early DFC patients also had a lower median total number of laparotomies (2.2 vs. 3.0, P=0.008) and lower mean total crystalloid volume between OA and DFC (4,358.3 mL vs. 10,355.6 mL, P=0.017). REBOA use did not differ between groups.

On univariate logistic regression, early DFC was associated with OA indication (ACS vs. DCS: OR, 0.11 [95% CI, 0.02–0.80], P=0.029), total laparotomies (OR, 0.16; 95% CI, 0.03–0.73, P=0.019), and total crystalloid volume (OR, 1.00; 95% CI, 0.99–1.00, P=0.010) (Table 5). None of these factors remained statistically significant on multivariate analysis.

DISCUSSION

This study represents the first investigation of the relationship between REBOA and DFC outcomes in trauma patients with massive hemorrhage. Our principal finding is that zone I REBOA does not significantly influence the achievement or timing of DFC following OA. Despite the theoretical potential for REBOA to affect fascial closure by modulating hemorrhage, transfusion requirements, and ischemia-reperfusion injury, our data do not support a clinically meaningful effect in either direction. Several factors may explain the absence of a REBOA effect on DFC. First, REBOA recipients typically represent a more severely injured population with profound hemorrhagic shock, which may mask any potential benefit [2,3]. In our cohort, REBOA recipients exhibited greater physiological derangement and higher ISSs, consistent with the published literature. Second, the potential benefits of REBOA in reducing hemorrhage and transfusion requirements may be counterbalanced by the deleterious effects of aortic occlusion at the tissue level [15]. Zone I occlusion induces splanchnic ischemia, and reperfusion injury upon balloon deflation increases vascular permeability and promotes visceral edema. Matsumoto et al. [18], in a propensity-matched study, demonstrated that REBOA was associated with significantly higher rates of gastrointestinal dysfunction, including feeding intolerance (77% vs. 27%; OR, 9.1; P=0.002), and emphasized that intra-abdominal hypertension should be carefully monitored in REBOA patients. This combination of increased capillary permeability and resuscitation-induced visceral edema creates conditions unfavorable for primary fascial approximation, potentially explaining the observed association between REBOA and OA management in our cohort.

Independent of REBOA, our study identified several clinically relevant predictors of DFC. The inverse association between transfusion volume and DFC achievement on univariate analysis is consistent with previous literature [19]. Aggressive blood resuscitation promotes dilutional coagulopathy and tissue edema, both of which impede fascial closure [20]. Each additional RBC unit transfused was associated with a 5% reduction in the odds of DFC. However, this association did not remain significant on multivariate analysis, suggesting that the effect of transfusion volume may be mediated through organ dysfunction. The independent association between post-OA SOFA score and DFC achievement supports this interpretation. Higher SOFA scores reflect greater systemic physiological derangement, including respiratory, cardiovascular, and renal dysfunction, which compromise wound healing and tissue integrity [21]. The SOFA score is an established predictor of mortality in trauma populations, and our findings extend its utility to predicting fascial closure outcomes [22]. Clinicians should consider incorporating serial SOFA score assessment into decision-making regarding the timing of definitive closure attempts.

The positive association between bowel perforation and DFC achievement warrants careful interpretation. This finding may reflect selection bias, as patients with isolated bowel injuries without significant vascular trauma may exhibit less hemorrhagic shock and better physiological reserve despite requiring OA for contamination control. Alternatively, aggressive source control may create more favorable conditions for subsequent closure. However, hollow viscus injury is strongly associated with subsequent fistula development, with up to 89% of patients developing EAF having antecedent bowel injury repair [23]. Successful DFC in this context should therefore not be interpreted as definitive success; prolonged surveillance for delayed enteric complications remains warranted.

The predictors of early DFC (≤48 hours) provide practical guidance for clinical management. ACS was the strongest negative predictor, with affected patients having 89% lower odds of early closure. This is consistent with its pathophysiology—massive visceral and retroperitoneal edema precluding fascial approximation [24]. The number of laparotomies was also a significant negative predictor, with each additional operation reducing the odds of early closure by 84%. Multiple relaparotomies contribute to fascial retraction, adhesion formation, and cumulative tissue trauma [25,26]; minimizing return trips to the operating room when clinically feasible is therefore advisable. Finally, the association between crystalloid volume and delayed DFC on univariate analysis reflects the known deleterious effects of aggressive fluid resuscitation on tissue edema and wound healing [27,28]. Although this did not reach significance on multivariate analysis, crystalloid administration exceeding 5 L in the first 24 hours has been associated with increased mortality and complications in trauma patients. Our findings support balanced, blood product-based resuscitation with crystalloid restriction, which also underpins ACS prevention [29].

The 100% mortality in the DFC failure group requires clarification. These deaths were attributable to early physiological deterioration rather than prolonged inability to achieve closure, with most patients dying within 48 hours of initial surgery. Among the four patients surviving beyond this period, two died from hemorrhagic shock and two from multiple organ dysfunction syndrome with septic shock. None underwent attempted abdominal closure due to persistent hemodynamic instability and unresolved visceral edema. This pattern indicates that DFC failure in our cohort was driven by injury severity and inadequate physiological reserve rather than technical difficulty with abdominal wall closure, underscoring that successful DFC demands appropriate surgical technique, adequate resuscitation, and resolution of the shock state.

Limitations

This study has several limitations. First, the retrospective single-center design limits generalizability and introduces potential selection bias. REBOA deployment was at individual clinician discretion, and confounding by indication cannot be excluded. Second, the small sample size may have been insufficient to detect modest effects of REBOA on DFC outcomes, and a larger multicenter study would be required to definitively exclude a clinically meaningful effect. Third, detailed data on REBOA occlusion time, inflation/deflation cycles, and partial versus complete occlusion were not captured, all of which may influence outcomes. Fourth, the study period spans evolving practice patterns in both REBOA and OA management, which may have introduced temporal confounding.

Despite these limitations, our study offers a perspective that may inform clinical practice. While most REBOA literature has focused on survival and hemodynamic endpoints, this analysis draws attention to an underexplored but clinically important outcome: abdominal wall reconstruction following damage control laparotomy. By identifying patient- and resuscitation-related predictors of DFC failure, we provide a framework for risk stratification that extends beyond immediate resuscitation success. The finding that bowel injury independently predicts DFC achievement, while paradoxically increasing subsequent fistula risk, illustrates the complexity of recovery in this population and highlights the need for outcome measures that capture the entire surgical course, not merely the initial resuscitation phase.

Future investigation should move beyond descriptive associations toward understanding underlying mechanisms. Prospective studies incorporating biomarkers of ischemia-reperfusion injury and systemic inflammation could help explain why some patients achieve rapid fascial closure while others progress to chronic OA despite similar injury patterns and resuscitation profiles. Partial REBOA, which may reduce distal ischemia while preserving proximal perfusion benefits, deserves particular attention, as its theoretical advantages have yet to be evaluated against abdominal wall outcomes. Ultimately, the goal is not merely to optimize REBOA technique in isolation, but to optimize the entire trajectory of patient recovery.

Conclusions

Zone I REBOA did not significantly influence the achievement or timing of DFC following OA management in trauma patients with massive hemorrhage. The severity of injury in REBOA recipients and the limited sample size may have affected these findings. Nevertheless, this study identified several clinically relevant predictors of DFC, including transfusion volume, SOFA score, bowel perforation, ACS, number of laparotomies, and crystalloid resuscitation volume, which may assist trauma surgeons in optimizing fascial closure decisions and resuscitation strategies. Future prospective multicenter studies are warranted to evaluate the relationship between REBOA and surgical recovery outcomes more comprehensively.

ARTICLE INFORMATION

Author contributions

Conceptualization: DHK; Data curation: YH; Formal analysis: YH; Investigation: YH; Methodology: DHK; Project administration: DHK; Visualization: YH; Writing–original draft: YH; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

This study was supported by a research fund from Dankook University in 2024.

Acknowledgments

Dr. Han Kyung Ahn made significant contributions during his time as a surgical resident at the hospital, collecting clinical data and presenting an abstract at the Korean Surgical Society. Unfortunately, he is no longer in an academic position and could not be included on the list of authors, but the authors dedicate the honor of this paper's publication to him.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.

Study flowchart. RBC; red blood cell; TBI, traumatic brain injury; ED, emergency department; REBOA, resuscitative endovascular balloon occlusion of the aorta; OA, open abdomen; DFC, definitive fascial closure.

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Figure & Data

References

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