Complications after negative laparotomy for trauma: long-term follow-up in a health maintenance organization

Blunt bowel and mesenteric injuries: the role of screening computed tomography

BACKGROUND

Early generation scanners have demonstrated poor sensitivity detecting blunt bowel/mesenteric injuries (BBMI). This study was aimed at determining the accuracy and role of helical scanners in BBMI.

METHODS

Retrospective chart review of patients with BBMI, or computed tomographic scans suspicious of BBMI, from August of 1995 to December of 1998.

RESULTS

One hundred of 8,112 scans (1.2%) were suspicious of BBMI. Of these suspicious scans, 53 patients had BBMI (true positive-TP) and 47 patients did not (false positive-FP). Seven patients with negative scans had BBMI (false negative-FN). Computed tomography contributed toward early surgery in 77% of patients who may have been delayed. Six patients developed intra-abdominal abscess. The abscess group had a significantly longer time interval from injury to surgery. Multiple findings were seen in 57% of true positive scans, whereas in 13% of false positive scans (p < 0.0001). An algorithm for management of BBMI is presented.

CONCLUSION

Helical scanners have high accuracy in detecting BBMI. Single versus multiple findings are useful in managing these injuries.

Free fluid on abdominal computed tomography scan after blunt trauma does not mandate exploratory laparotomy in children

BACKGROUND/PURPOSE

The isolated finding of free intraperitoneal fluid on abdominal computed tomography (CT) scan after blunt trauma in adults is considered an indication for laparotomy by many trauma surgeons. The authors wished to determine if these guidelines are applicable to children.

METHODS

A retrospective chart review was conducted. The authors included all children (< or =12 years of age) sustaining blunt abdominal trauma who were admitted to our institution between January 1, 1994 and November 1, 1998.

RESULTS

There were 814 children admitted, and 437 had abdominal CT scans. Thirty-four studies showed free fluid associated with solid organ injuries, spine or pelvic fractures, or pneumoperitoneum, and were excluded. Thirty-two children had free fluid without associated injuries and formed the basis for the study. Five of these children underwent laparotomy based on the CT finding alone. The remaining 27 were observed with serial abdominal examinations and did not require surgical intervention. Only 1 of the 5 children who underwent surgery for the finding of isolated free fluid had a therapeutic laparotomy. In comparison, during the same period, 38 children underwent laparotomy after blunt injury based only on physical examination findings with a therapeutic laparotomy rate of 68%. The therapeutic laparotomy rate was significantly higher when the procedure was based solely on clinical examination as compared with the isolated finding or free fluid on the abdominal CT (26 of 38 v 1 of 5, P < .05).

CONCLUSION

In contrast to adults, finding isolated free fluid on abdominal CT scans in children after blunt trauma does not dictate immediate surgical exploration.

Diagnosis and management of blunt small bowel injury: a survey of the membership of the American Association for the Surgery of Trauma

BACKGROUND

Blunt small bowel injury (SBI) may be difficult to diagnose accurately. Diagnostic delays are associated with increased morbidity and mortality.

METHODS

A cross-sectional survey of members of the American Association for the Surgery of Trauma was conducted. A Likert-type multiple-choice scale was used to evaluate use and usefulness of diagnostic and laboratory tests. Data were analyzed by using univariate and multivariate techniques.

RESULTS

A total of 461 of the 702 members (68%) surveyed responded, of which 133 members (29%) were excluded because they did not currently manage adult SBI. Of the remaining 328 respondents, 244 members (74%) reported prior experience as the most important influence on their current practice of diagnosing blunt SBI. None of the standard laboratory tests were reported as useful. Seventy-seven percent of respondents use computed tomographic (CT) scan most or all of the time for diagnosis (p < 0.05 compared with other modalities). Most respondents estimated their annual incidence of SBI at 5% with a >15% frequency of delay in diagnosis. Forty-four percent of the respondents estimated the mortality associated with a delay in diagnosis at < or =5%. Respondents varied significantly in their management of the patient with an unreliable abdominal exam and a CT scan finding of isolated free fluid. In patients with head injuries, 28% observe, 12% repeat the CT scan, 42% perform diagnostic peritoneal lavage, and 16% operate. For intoxicated patients, 51% observe, 11% repeat the CT scan, 26% perform diagnostic peritoneal lavage, and 10% operate. A more aggressive approach with diagnostic and operative intervention was significantly (p < 0.05) advocated by respondents practicing without residents, more than 15 years out from residency, or by those with a perception of higher morbidity and mortality from delays in diagnosis.

CONCLUSION

There is significant variation in the diagnostic approach to the patient with suspected SBI. The perceived mortality of delayed diagnosis is much less than reported. Those surgeons with more experience or perception of greater morbidity and mortality from a delayed diagnosis are more aggressive. Further investigation into the diagnosis and treatment of this injury is needed.

Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience

OBJECTIVE

Blunt small bowel injury (SBI) is uncommon, and its timely diagnosis may be difficult. The impact of operative delays on morbidity and mortality has been unclear. The purpose of this study was to determine the relationship of diagnostic delays to morbidity and mortality in blunt SBI.

METHODS

Patients with blunt SBI with perforation were identified from the registries of eight trauma centers (1989-1997). Patients with duodenal injuries were excluded. Data were extracted by individual chart review. Patients were classified as multi-trauma (group 1) or near-isolated SBI (group 2 with Abbreviated Injury Scale score < 2 for other body areas). Time to operation and its impact on mortality and morbidity was determined for each patient.

RESULTS

A total of 198 patients met inclusion criteria: 66.2% were male, mean age was 35.2 years (range, 1-90 years) and mean Injury Severity Score was 16.7 (range, 9-47). 100 patients had multiple injuries (group 1). There were 21 deaths (10.6%) with 9 (4.5%) attributable to delay in operation for SBI. In patients with near-isolated SBI, the incidence of mortality increased with time to operative intervention (within 8 hours: 2%; 8-16 hours: 9.1%; 16-24 hours: 16.7%; greater than 24 hours: 30.8%, p = 0.009) as did the incidence of complications. Delays as short as 8 hours 5 minutes and 11 hours 15 minutes were associated with mortality attributable to SBI. The rates of delay in diagnosis were not significantly associated with age, gender, intoxication, transfer status, or presence of associated injuries.

CONCLUSION

Delays in the diagnosis of SBI are directly responsible for almost half the deaths in this series. Even relatively brief delays (as little as 8 hours) result in morbidity and mortality directly attributable to "missed" SBI. Further investigation into the prompt diagnosis of this injury is needed.

The role of computed tomography in selective management of gunshot wounds to the abdomen and flank

OBJECTIVE

To determine whether computed tomography (CT) is an accurate diagnostic modality for the triage of hemodynamically stable patients with gunshot wounds of the abdomen and flank.

METHODS

A chart review of 83 trauma patients for whom abdominal CT was used as initial screening.

RESULTS

In 53 patients, CT revealed no evidence of peritoneal penetration, and in 15 patients, there was evidence of either peritoneal penetration or liver injury. There were no false results in these patients. Among 15 patients with questionable peritoneal penetration, cavitary endoscopy was performed in 11 and exploratory laparotomy was performed in 3, and 1 patient was initially observed and subsequently underwent exploratory surgery for a missed colonic injury.

CONCLUSION

In selected centers and in hemodynamically stable patients with abdominal and flank gunshot wounds, abdominal CT can be an effective and safe initial screening modality to document the presence or absence of peritoneal penetration and to manage nonoperatively stable patients with liver injuries. If there is any question of peritoneal penetration, cavitary endoscopy should be part of the protocol of nonoperative management.

Incidence and significance of free fluid on abdominal computed tomographic scan in blunt trauma

OBJECTIVE

To determine the incidence and significance of free fluid on abdominal CT in blunt trauma.

DESIGN

Retrospective chart review.

METHODS

All blunt trauma patients with an abdominal computed tomographic scan from August of 1993 to December of 1995 were identified from the trauma registry at a Level 1 trauma center. A total of 1,159 computed tomographic scans were performed; records of 18 patients were excluded for incomplete records. Official reports of computed tomographic scans were reviewed for free fluid, solid organ injury, bladder injury, and pelvic fracture.

RESULTS

Free fluid without solid organ injury was found in 3% (34 of 1141). Laparotomy was performed because of free fluid in 13 patients. There were six small bowel injuries and one diaphragm injury for a therapeutic laparotomy rate of 54%. Ten patients had trace free fluid and did not undergo laparotomy; none had a missed small bowel injury.

CONCLUSIONS

The presence of more than trace amounts of free fluid without solid organ injury in patients with blunt trauma is a strong indication for exploratory laparotomy. Patients with isolated trace amounts of free fluid can be safely observed.

Penetrating thoracoabdominal trauma

Penetrating injuries to the thoracoabdominal region represent a complex and diverse population of injuries. The clinician managing such cases must be able to consider all potential injuries, rapidly recognize life-threatening sequelae, and precisely diagnose and quickly manage these patients. The diverse nature of some of the potential presentations of patients with penetrating thoracoabdominal trauma is discussed. The most recent advances and controversies involving the evaluation and management of patients with penetrating thoracoabdominal trauma are also discussed.

The emerging role of bedside ultrasonography in trauma care

Ultrasonography has emerged as a primary imaging modality in the evaluation of the trauma victim. Both emergency physicians and surgeons have been proven capable of performing this rapid, noninvasive evaluation of the chest and abdomen. This article describes the trauma ultrasound examination and illustrates how bedside ultrasonography can be incorporated into routine trauma care.