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

Definitions of hospital-acquired pneumonia in trauma research: a systematic review

PURPOSE

What are reported definitions of HAP in trauma patient research?

METHODS

A systematic review was performed using the PubMed/MEDLINE database. We included all English, Dutch, and German original research papers in adult trauma patients reporting diagnostic criteria for hospital-acquired pneumonia diagnosis. The risk of bias was assessed using the MINORS criteria.

RESULTS

Forty-six out of 5749 non-duplicate studies were included. Forty-seven unique criteria were reported and divided into five categories: clinical, laboratory, microbiological, radiologic, and miscellaneous. Eighteen studies used 33 unique guideline criteria; 28 studies used 36 unique non-guideline criteria.

CONCLUSION

Clinical criteria for diagnosing HAP-both guideline and non-guideline-are widespread with no clear consensus, leading to restrictions in adequately comparing the available literature on HAP in trauma patients. Studies should at least report how a diagnosis was made, but preferably, they would use pre-defined guideline criteria for pneumonia diagnosis in a research setting. Ideally, one internationally accepted set of criteria is used to diagnose hospital-acquired pneumonia.

LEVEL OF EVIDENCE

Level III.

Role of laparoscopy in management of patients with anterior abdominal stab wounds

BACKGROUND

In this retrospective cohort study, we assessed the utility of laparoscopic surgery for diagnostic and therapeutic purposes in patients with anterior abdominal stab wounds (AASWs). We also investigated patient characteristics that might suggest a greater suitability of laparoscopic interventions.

METHODS

Over a 25-year span, we analyzed AASW patients who had operations, categorizing them based on the presence of significant intra-abdominal injuries and whether they received laparoscopic surgery or laparotomy. We compared variables such as preoperative conditions, surgical details, and postoperative outcomes. We further evaluated the criteria indicating the necessity of direct laparotomies and traits linked to overlooked injuries in laparoscopic surgeries.

RESULTS

Of 142 AASWs surgical patients, laparoscopic surgery was conducted on 89 (62.7%) patients. Only 2 (2.2%) had overlooked injuries after the procedure. Among patients without significant injuries, those receiving laparoscopic surgery had less blood loss than those receiving laparotomy (30.0 vs. 150.0 ml, p = 0.004). Patients who underwent laparoscopic surgery also had shorter hospital stays (significant injuries: 6.0 vs. 11.0 days, p < 0.001; no significant injuries: 5.0 vs. 6.5 days, p = 0.014). Surgical complications and overlooked injury rates were comparable between both surgical methods. Bowel evisceration correlated with higher laparotomy odds (odds ratio = 16.224, p < 0.001), while omental evisceration did not (p = 0.107).

CONCLUSIONS

Laparoscopy is a safe and effective method for patients with AASWs, fulfilling both diagnostic and therapeutic needs. For stable AASW patients, laparoscopy could be the preferred method, reducing superfluous nontherapeutic laparotomies.

Negative laparotomy rates and outcomes following blunt traumatic injury in the United States

INTRODUCTION

Exploratory laparotomy remains the mainstay of treatment following blunt abdominal trauma. However, the decision to operate can be difficult in hemodynamically stable patients with unreliable physical exams or equivocal imaging findings. The risk of a negative laparotomy and the subsequent complications must be weighed against the potential morbidity and mortality of a missed abdominal injury. Our study aims to evaluate trends and the effect of negative laparotomies on morbidity and mortality in adults with blunt traumatic injuries in the United States.

METHODS

We reviewed the National Trauma Data Bank (2007-2019) for adults with blunt traumatic injuries who underwent an exploratory laparotomy. Positive or negative laparotomy of abdominal injury was compared. We performed bivariate analysis and a modified Poisson regression to estimate the effect of negative laparotomy on mortality. A sub-analysis of patients who underwent computed tomography (CT) of the abdomen and pelvis was performed.

RESULTS

92,800 patients met the inclusion criteria of the primary analysis. Negative laparotomy rates were 12.0% in this population, down-trending throughout the study. Negative laparotomy patients had a significantly higher crude mortality (31.1% vs. 20.5%, p < 0.001), despite lower injury severity scores (20 (10-29) vs. 25 (16-35), p < 0.001) than positive laparotomy patients. Patients that underwent negative laparotomy had a 33% higher risk for mortality (RR1.33, 95% CI 1.28-1.37, P < 0.001) than positive laparotomy patients after adjusting for pertinent covariates. Patients that underwent CT abdomen/pelvis imaging (n = 45,654) had a lower rate of negative laparotomy (11.1%) and decreased difference in crude mortality (22.6% vs. 14.1%, p < 0.001) compared to positive laparotomy patients. However, the relative risk for mortality remained high at 37% (RR 1.37, 95% CI 1.29 - 1.46, p < 0.001) for this sub-cohort.

CONCLUSION

Negative laparotomy rates in adults with blunt traumatic injuries are trending down in the United States but remains substantial and may show improvement with increased use of diagnostic imaging. Negative laparotomy has a relative risk for mortality of 33% despite lower injury severity. Thus, surgical exploration in this population should be thoughtfully undertaken with appropriate evaluation via physical exam and diagnostic imaging to prevent unnecessary morbidity and mortality.

Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds

BACKGROUND

Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW.

METHODS

This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed.

RESULTS

Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99).

CONCLUSION

While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria; Level II.

The role of diagnostic laparoscopy for trauma at a high-volume level one center

Background

The role of minimally invasive surgery in trauma has continued to evolve over the past 20 years. Diagnostic laparoscopy (DL) has become increasingly utilized for the diagnosis and management of both blunt and penetrating injuries.

Objective

While the safety and feasibility of laparoscopy has been established for penetrating thoracoabdominal trauma, it remains a controversial tool for other injury patterns due to the concern for complications and missed injuries. We sought to examine the role of laparoscopy for the initial management of traumatic injuries at our urban Level 1 trauma center.

Methods

All trauma patients who underwent DL for blunt or penetrating trauma between 2009 and 2018 were retrospectively reviewed. Demographic data, indications for DL, injuries identified, rate of conversion to open surgery, and outcomes were evaluated.

Results

A total of 316 patients were included in the cohort. The mean age was 34.9 years old (± 13.7), mean GCS 14 (± 3), and median ISS 10 (4–18). A total of 110/316 patients (35%) sustained blunt injury and 206/316 patients (65%) sustained penetrating injury. Indications for DL included evaluation for peritoneal violation (152/316, 48%), free fluid without evidence of solid organ injury (52/316, 16%), evaluation of bowel injury (42/316, 13%), and evaluation for diaphragmatic injury (35/316, 11%). Of all DLs, 178/316 (56%) were negative for injury requiring intervention, which was 58% of blunt cases and 55% of penetrating cases. There were no missed injuries noted. Average hospital length of stay was significantly shorter for patients that underwent DL vs conversion to open exploration (2.2 days vs. 4.5 days, p < 0.05).

Conclusion

In this single institution, retrospective study, the high volume of cases appears to show that DL is a reliable tool for detecting injury and avoiding potential negative or non-therapeutic laparotomies. However, when injuries were present, the high rate of conversion to open exploration suggests that its utility for therapeutic intervention warrants further study.

Outcomes after single-look trauma laparotomy: A large population-based study

BACKGROUND

Outcomes following damage control laparotomy for trauma have been studied in detail. However, outcomes following a single operation, or "single-look trauma laparotomy" (SLTL), have not. We evaluated the association between SLTL and both short-term and long-term outcomes in a large population-based data set.

METHODS

The California Office of Statewide Health Planning and Development patient discharge database was evaluated for calendar years 2007 through 2014. Injured patients with SLTL during their index admission were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Diagnosis and procedure codes were used to identify specific abdominal organ injuries, surgical interventions, and perioperative complications. Subsequent acute care admissions were examined for postoperative complications and related surgical interventions. Clinical characteristics, injuries, surgical interventions, and outcomes were analyzed by mechanism of injury.

RESULTS

There were 2113 patients with SLTL during their index admission; 712 (33.7%) had at least one readmission to an acute care facility. Median time to first readmission was 110 days. Penetrating mechanism was more common than blunt (60.6% vs. 39.4%). Compared to patients with penetrating injury, blunt-injured patients had a significantly higher median Injury Severity Score (9 vs. 18, p < 0.0001) and a significantly higher mortality rate during the index admission (4.1% vs. 27.0%, p < 0.0001). More than 30% of SLTL patients requiring readmission had a surgery-related complication. The most common primary reasons for readmission were bowel obstruction (17.7%), incisional hernia (11.8%), and infection (9.1%). There was no significant association between mechanism of injury and development of surgery-related complications requiring readmission.

CONCLUSIONS

Patients with SLTL had postinjury morbidity and mortality, and more than 30% required readmission. Complication rates for SLTL were comparable to those reported for emergency general surgery procedures. Patients should be educated on signs and symptoms of the most common complications before discharge following SLTL. Further investigation should focus on the factors associated with the development of these complications.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Selective nonoperative management of penetrating abdominal trauma at a level 1 Canadian trauma centre: a quest for perfection

Background

Many patients who sustain penetrating abdominal trauma can be managed nonoperatively. The Eastern Association for the Surgery of Trauma (EAST) has published guidelines on selective nonoperative management (SNOM), and this approach is well established. The purpose of this study is to assess the management of penetrating abdominal trauma, including the selection of patients for SNOM and the use of this approach, at a Canadian level 1 trauma centre.

Methods

We used the Hamilton Health Sciences trauma registry to compile data on patients aged 16 years and older who sustained penetrating abdominal trauma from Jan. 1, 2011, to Dec. 31, 2017. Hemodynamically stable, nonperitonitic patients without evisceration or impalement were considered potentially eligible for SNOM. We compared the SNOM group of patients with the immediate operative (IOR) group. Our primary outcome was SNOM failure; secondary outcomes included length of stay, repeat imaging, computed tomography (CT) protocol, laparoscopy in left thoracoabdominal trauma, and nontherapeutic and negative laparotomies.

Results

We included 191 patients with penetrating abdominal trauma; 123 underwent SNOM and 68 underwent IOR. Of the 68 patients in the IOR group, 4 underwent nontherapeutic laparotomies. Of the 123 patients in the SNOM group, this approach failed in 7 (5.7%). Patients who were successfully managed with SNOM had an average length of stay of 25.4 hours (7.9–43.0 h), with no repeat imaging in 34/35 (97.1%). Only 5 of the 47 patients with flank/back wounds had a CT scan that included luminal contrast. Only 3 of the 58 patients with left thoracoabdominal wounds underwent same-admission laparoscopy, all demonstrating diaphragmatic defects.

Conclusion

Our study demonstrates a high rate of compliance with the EAST SNOM guidelines, including minimal failure rate of SNOM and an efficient use of resources as demonstrated by reduced length of stay and minimal use of reimaging. We identified 2 opportunities for improvement: improved use of luminal contrast CT in patients with flank/back wounds and improved use of diagnostic laparoscopy in patients with left thoracoabdominal wounds.

The Prognosis of Blunt Bowel and Mesenteric Injury-the Pitfall in the Contemporary Image Survey

Delayed diagnosis and intervention of blunt bowel and mesenteric injury (BBMI) is a hazard because of poor prognosis. Computed tomography (CT) is the standard imaging tool to evaluate blunt abdominal trauma (BAT). However, a high missed diagnosis rate for BMMI was reported. In this study, we would like to evaluate the presentation of CT in BBMI. Moreover, we want to evaluate the impact of deferred surgical intervention of BBMI on final prognosis. We performed a retrospective study from 2013–2017, including patients with BAT and BBMI who underwent surgical intervention. We evaluated clinical characteristics, CT images, and surgical timing, as well as analyzed the prognosis of BBMI. There were 6164 BAT patients and 188 BMI patients included. The most common characteristics of CT were free fluid (71.3%), free air (43.6%), and mesenteric infiltration (23.4%). There were no single characteristics of a CT image that can predict BBMI significantly. However, under close monitoring, we find that deferred intervention did not prolong the hospital and intensive care unit stays and did not worsen the prognosis and mortality.

Nonsurgical management of traumatic pneumoperitoneum in a cat

OBJECTIVE

To describe the nonsurgical management of a cat with traumatic pneumoperitoneum.

CASE SERIES SUMMARY

A 4-year-old cat was presented following vehicular polytrauma. Thoracic radiographs revealed 4 rib fractures, a scapular fracture, and pneumothorax. Abdominal ultrasound revealed a small volume of free abdominal fluid. Computed tomography showed a mild pneumoretroperitoneum and a pneumoperitoneum in the region of the porta hepatis. The cat was managed conservatively with close monitoring. Exploratory laparotomy was not pursued given patient stability and static serial imaging studies revealing no indications for surgical intervention. After 6 days, the pneumoperitoneum was no longer detectable.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first report of successful nonsurgical management of traumatic pneumoperitoneum in a cat.

Impact of self-inflicted injury on nontherapeutic laparotomy in patients with abdominal stab wounds

INTRODUCTION

Because Japan has high suicide rates and low violent crime rates, it is likely that most abdominal stab wounds (ASWs) in Japan are self-inflicted. Although physical examination is one of the most important factors in surgical decision making, such evaluations can be difficult in patients with self-inflicted ASWs due to patient agitation and uncooperative behavior. Therefore, the self-inflicted nature of an injury may strongly affect clinical practice, particularly in Japan, but its influence remains uncertain. We hypothesized that the rates of exploratory laparotomy and nontherapeutic laparotomy (NTL) would be higher in self-inflicted patients.

METHODS

We reviewed ASW patients from 2004 to 2014 in the Japan Trauma Data Bank. The rates of exploratory laparotomy and NTL were compared between self-inflicted and non-self-inflicted ASWs.

RESULTS

Of the 1705 eligible patients, 1302 patients (76.4%) had self-inflicted ASWs, and 403 patients (23.6%) had non-self-inflicted ASWs. Self-inflicted patients had a significantly higher rate of psychiatric history, but lower injury severity. The in-hospital mortality rate was similar between the two groups (4.5% vs. 5.2%, p = 0.576). Self-inflicted patients had significantly higher rates of exploratory laparotomy and NTL (69.1% vs. 56.7%, p < 0.001, 22.5% vs. 13.6%, p = 0.03, respectively). Self-inflicted patients were also associated with significantly longer hospital stays (10.0 [5.0-21.0] vs. 9.0 [4.0-18.0] days, P = 0.045). In a multivariable analysis, self-inflicted patients were independently associated with exploratory laparotomy (odds ratio [OR], 2.05; 95% confidence interval [CI]: 1.55-2.72) and NTL (OR, 1.61; 95% CI: 1.01-2.56).

CONCLUSION

ASWs in Japan were predominantly self-inflicted. The clinical patterns of self-inflicted ASWs had some unique features. Patients with self-inflicted ASWs had higher rates of laparotomy and NTL. Further studies are needed to develop a useful protocol specific to self-inflicted ASWs.

Electroacupuncture Alleviates Surgical Trauma-Induced Hypothalamus Pituitary Adrenal Axis Hyperactivity Via microRNA-142

Electroacupuncture (EA) could improve the hyperactivity of the hypothalamus pituitary adrenal (HPA) axis induced by hepatectomy. However, its underlying mechanism still remains largely unclear. Here, we found that hypothalamic corticotrophin releasing hormone (CRH) modulates the function of the HPA axis, while hepatectomy induced an HPA axis disorder and EA application could regulate the hypothalamic CRH. We first demonstrated that microRNAs (miRNAs) target on CRH via bioinformatics analysis and screened them in the primary hypothalamic neurons. MicroR-142 (miR-142) and miR-376c were identified to inhibit CRH at the mRNA and protein levels, and a dual luciferase reporter assay confirmed their binding to the 3'-untranslated regions (3'-UTR) of CRH. Further analyses revealed a decrease in hypothalamic miR-142 expression in the hepatectomy rats and an increase in miR-142 and miR-376c after EA intervention. Importantly, the improvement effect of EA on the HPA axis regulatory function in hepatectomy rats was blocked by miR-142 antagomir. Our findings illustrated that EA could up-regulate hypothalamic miR-142 expression and decrease the CRH level to alleviate the hyperactivity of the HPA axis induced by hepatectomy.

In the Modern Era of CT, Do Blunt Trauma Patients with Markers for Blunt Bowel or Mesenteric Injury Still Require Exploratory Laparotomy?

After blunt trauma, certain CT markers, such as free intraperitoneal air, strongly suggest bowel perforation, whereas other markers, including free intraperitoneal fluid without solid organ injury, may be merely suspicious for acute injury. The present study aims to delineate the safety of non-operative management for markers of blunt bowel or mesenteric injury (BBMI) that are suspicious for significant bowel injury after blunt trauma. This was a retrospective review of adult blunt trauma patients with abdominopelvic CT scans on admission to a Level I trauma center between 2012 and 2014. Patients with CT evidence of acute BBMI without solid organ injury were included. The CT markers for BBMI included free intraperitoneal fluid, bowel hematoma, bowel wall thickening, mesenteric edema, hematoma and stranding. Two thousand blunt trauma cases were reviewed, and 94 patients (4.7%) met inclusion criteria. The average Injury Severity Score was 13.6 ± 10.1 and the median hospital stay was four days. The most common finding was free fluid (74 patients, 78.7%). The majority of patients (92, 97.9%) remained asymptomatic or clinically improved without abdominal surgery. After a change in abdominal examination, two patients (2.1%) underwent laparotomy with bowel perforation found in only one patient. Thus, 93 patients did not have a surgically significant injury, indicating that these markers demonstrate 1.1 per cent positive predictive value for bowel perforation. The presence of these markers after blunt trauma does not mandate laparotomy, though it should prompt thorough and continued vigilance toward the abdomen.

Early diagnosis of hollow viscus injury using intestinal fatty acid-binding protein in blunt trauma patients

A delay in diagnosing hollow viscus injury (HVI) causes an increase in mortality and morbidity. HVI remains a challenge to diagnose, and there is no specific diagnostic biomarker for HVI. We evaluated the utility of intestinal fatty acid-binding protein (I-FABP) in diagnosing HVI in blunt trauma patients. Within a 5-year period, 93 consecutive patients with clinically suspected HVI at our trauma center were prospectively enrolled. The diagnostic performance of I-FABP for HVI was compared with that of other various parameters (physical, laboratory, and radiographic findings). HVI was diagnosed in 13 patients (14%), and non-HVI was diagnosed in 80 patients (86%). The level of I-FABP was significantly higher in patients with HVI than in those with non-HVI (P = 0.014; area under the curve, 0.71). The sensitivity, specificity, positive predictive value, and negative predictive value were 76.9%, 70.0%, 29.4%, and 94.9%, respectively (P = 0.003). However, all other biomarkers were not significantly different between the groups. Presence of extraluminal air, bowel wall thickening on computed tomography (CT), and peritonitis signs were significantly higher in patients with HVI (P < 0.05). Of 49 patients (52.7%) who had a negative I-FABP and negative peritonitis signs, none developed HVI (sensitivity, 100%; negative predictive value, 100%). This is the first study that demonstrated the diagnostic value of a biomarker for HVI. I-FABP has a higher negative predictive value compared to traditional diagnostic tests. Although the accuracy of I-FABP alone was insufficient, the combination of I-FABP and other findings can enhance diagnostic ability.

The early management of gunshot wounds Part II: the abdomen, extremities and special situations

The management of gunshot wounds of the abdomen and extremities is evolving with centres who treat large volumes of such injuries tending to the application of a policy of selective non-operative management. This article discusses the management of gunshot wounds to the abdomen and extremities and reviews the evidence supporting these changing practices. Special situations such as wounding by shotguns or air rifles are also examined as are the special considerations needed when dealing with the gunshot injured pregnant women or in a child.

Epidemiology and outcome of penetrating injuries in a Western European urban region

PURPOSE

Severe life-threatening injuries in Western Europe are mostly caused by blunt trauma. However, penetrating trauma might be more common in urban regions, but their characteristics have not been fully elucidated.

METHODS

Retrospective analysis of data from patients admitted to our urban university level I trauma center between 2008 and 2013 with suspicion of severe multiple injuries. Collection of data was performed prospectively using a PC-supported online documentation program including epidemiological, clinical and outcome parameters.

RESULTS

Out of 2095 trauma room patients admitted over the 6-year time period 194 (9.3 %) suffered from penetrating trauma. The mean Injury Severity Score (ISS) was 12.3 ± 14.1 points. In 62.4 % (n = 121) the penetrating injuries were caused by interpersonal violence or attempted suicide, 98 of these by stabbing and 23 by firearms. We observed a widespread injury pattern where mainly head, thorax and abdomen were afflicted. Subgroup analysis for self-inflicted injuries showed higher ISS (19.8 ± 21.8 points) than for blunt trauma (15.5 ± 14.6 points). In 82.5 % of all penetrating trauma a surgical treatment was performed, 43.8 % of the patients received intensive care unit treatment with mean duration of 7.4 ± 9.3 days. Immediate emergency surgical treatment had to be performed in 8.0 vs. 2.3 % in blunt trauma (p < 0.001). Infectious complications of the penetrating wounds were observed in 7.8 %.

CONCLUSIONS

Specific characteristics of penetrating trauma in urban regions can be identified. Compared to nationwide data, penetrating trauma was more frequent in our collective (9.3 vs. 5.0 %), which may be due to higher crime rates in urban areas. Especially, self-inflicted penetrating trauma often results in most severe injuries.

Bowel obstructions and incisional hernias following trauma laparotomy and the nonoperative therapy of solid organ injuries: A retrospective population-based analysis

BACKGROUND

Small bowel obstruction (SBO) and incisional hernia (IH) represent the most common long-term complications of laparotomy. They may also be more common among injured patients than for elective/nontrauma emergency scenarios. Unfortunately, the population-based incidence of SBO and IH following trauma laparotomy is unknown. The aim of this study was to define the long-term, population-based incidence of SBO and IH following both trauma laparotomy as well as the nonoperative therapy of solid organ injuries.

METHODS

All injured patients admitted to a Level 1 trauma center (2002-2013) who underwent (1) a laparotomy or nonoperative care of (2) splenic and/or (3) hepatic injuries were linked with the Alberta Health Services Discharge Database to identify all readmissions for subsequent SBO and/or IH within the province. Standard statistical methodology was used (p < 0.05).

RESULTS

Of 484 patients who underwent a trauma laparotomy, 29 (6%) and 42 (9%) required readmission for SBO and IH, respectively (0.13 SBO and 0.10 IH admissions per patient year). Patients who underwent nonoperative management of their liver and/or spleen injuries displayed long-term SBO rates of 1% (6 of 619) and 0.7% (4 of 606), respectively. The rate of SBO and IH in patients with unnecessary laparotomies was equivalent to therapeutic procedures (p = 0.183). Topical hemostatic agents, repeat laparotomies, and injury pattern did not alter SBO or IH rates (p > 0.05).

CONCLUSION

The population-based, long-term rate of clinically relevant SBO and IH following trauma laparotomies is 15%. This increases to 19% on a per-admission basis. Nontherapeutic scenarios, injury pattern, topical hemostatics, and open abdomens did not alter complication rates.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma

BACKGROUND

Ultrasonography (performed by means of a four-quadrant, focused assessment of sonography for trauma (FAST)) is regarded as a key instrument for the initial assessment of patients with suspected blunt abdominal and thoraco-abdominal trauma in the emergency department setting. FAST has a high specificity but low sensitivity in detecting and excluding visceral injuries. Proponents of FAST argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of unnecessary multi-detector computed tomography (MDCT) scans, and enable quicker triage to surgical and non-surgical care. Given the proven accuracy, increasing availability of, and indication for, MDCT among patients with blunt abdominal and multiple injuries, we aimed to compile the best available evidence of the use of FAST-based assessment compared with other primary trauma assessment protocols.

OBJECTIVES

To assess the effects of diagnostic algorithms using ultrasonography including in FAST examinations in the emergency department in relation to the early, late, and overall mortality of patients with suspected blunt abdominal trauma.

SEARCH METHODS

The most recent search was run on 30th June 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), clinical trials registers, and screened reference lists. Trial authors were contacted for further information and individual patient data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). Participants were patients with blunt torso, abdominal, or multiple trauma undergoing diagnostic investigations for abdominal organ injury. The intervention was diagnostic algorithms comprising emergency ultrasonography (US). The control was diagnostic algorithms without US examinations (for example, primary computed tomography (CT) or diagnostic peritoneal lavage (DPL)). Outcomes were mortality, use of CT or invasive procedures (DPL, laparoscopy, laparotomy), and cost-effectiveness.

DATA COLLECTION AND ANALYSIS

Two authors (DS and CG) independently selected trials for inclusion, assessed methodological quality, and extracted data. Methodological quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible, data were pooled and relative risks (RRs), risk differences (RDs), and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed-effect or random-effects models as appropriate.

MAIN RESULTS

We identified four studies meeting our inclusion criteria. Overall, trials were of poor to moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. Strong heterogeneity amongst the trials prompted discussion between the review authors as to whether the data should or should not be pooled; we decided in favour of a quantitative synthesis to provide a rough impression about the effect sizes achievable with US-based triage algorithms. We pooled mortality data from three trials involving 1254 patients; the RR in favour of the FAST arm was 1.00 (95% CI 0.50 to 2.00). FAST-based pathways reduced the number of CT scans (random-effects model RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result was unclear.

AUTHORS' CONCLUSIONS

The experimental evidence justifying FAST-based clinical pathways in diagnosing patients with suspected abdominal or multiple blunt trauma remains poor. Because of strong heterogeneity between the trial results, the quantitative information provided by this review may only be used in an exploratory fashion. It is unlikely that FAST will ever be investigated by means of a confirmatory, large-scale RCT in the future. Thus, this Cochrane Review may be regarded as a review which provides the best available evidence for clinical practice guidelines and management recommendations. It can only be concluded from the few head-to-head studies that negative US scans are likely to reduce the incidence of MDCT scans which, given the low sensitivity of FAST (or reliability of negative results), may adversely affect the diagnostic yield of the trauma survey. At best, US has no negative impact on mortality or morbidity. Assuming that major blunt abdominal or multiple trauma is associated with 15% mortality and a CT-based diagnostic work-up is considered the current standard of care, 874, 3495, or 21,838 patients are needed per intervention group to demonstrate non-inferiority of FAST to CT-based algorithms with non-inferiority margins of 5%, 2.5%, and 1%, power of 90%, and a type-I error alpha of 5%.

Management of stab wounds to the anterior abdominal wall

The meeting of the Publication "Evidence Based Telemedicine - Trauma and Emergency Surgery" (TBE-CiTE), through literature review, selected three recent articles on the treatment of victims stab wounds to the abdominal wall. The first study looked at the role of computed tomography (CT) in the treatment of patients with stab wounds to the abdominal wall. The second examined the use of laparoscopy over serial physical examinations to evaluate patients in need of laparotomy. The third did a review of surgical exploration of the abdominal wound, use of diagnostic peritoneal lavage and CT for the early identification of significant lesions and the best time for intervention. There was consensus to laparotomy in the presence of hemodynamic instability or signs of peritonitis, or evisceration. The wound should be explored under local anesthesia and if there is no injury to the aponeurosis the patient can be discharged. In the presence of penetration into the abdominal cavity, serial abdominal examinations are safe without CT. Laparoscopy is well indicated when there is doubt about any intracavitary lesion, in centers experienced in this method.

An abdominal computed tomography may be safe in selected hypotensive trauma patients with positive Focused Assessment with Sonography in Trauma examination

BACKGROUND

Positive Focused Assessment with Sonography in Trauma examination and hypotension often indicate urgent surgery. An abdomen/pelvis computed tomography (apCT) may allow less invasive management but the delay may be associated with adverse outcomes.

METHODS

Patients in the Prospective Observational Multicenter Major Trauma Transfusion study with hypotension and a positive Focused Assessment with Sonography in Trauma (HF+) examination who underwent a CT (apCT+) were compared with those who did not.

RESULTS

Of the 92 HF+ identified, 32 (35%) underwent apCT during initial evaluation and apCT was associated with decreased odds of an emergency operation (odds ratio .11, 95% confidence interval .001 to .116) and increased odds of angiographic intervention (odds ratio 14.3, 95% confidence interval 1.5 to 135). There was no significant difference in 30-day mortality or need for dialysis.

CONCLUSIONS

An apCT in HF+ patients is associated with reduced odds of emergency surgery, but not mortality. Select HF+ patients can safely undergo apCT to obtain clinically useful information.

Complications after laparotomy for trauma: a retrospective analysis in a level I trauma centre

PURPOSE

Laparotomy is a potential life-saving procedure after traumatic abdominal injury. There is limited literature about morbidity and mortality rates after trauma laparotomy. The primary aim of this study is to describe the complications which may occur due to laparotomy for trauma.

METHODS

Retrospective evaluated single-centre study with data registry up to 1 year after initial laparotomy for trauma was performed in a level 1 trauma centre in The Netherlands. Between January 2000 and January 2011, a total of 2390 severely injured trauma patients (ISS ≥ 16) were transported to the VUMC. Patient demographics; mechanism of injury; injury patterns defined by Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and Revised Trauma Score (RTS); surgical interventions and findings; and morbidity and mortality were documented.

RESULTS

A total of 92 trauma patients who underwent a trauma laparotomy met the inclusion criteria. Of these patients, 71 % were male. Median age was 37 years. Median ISS was 27. Mechanisms of injury comprised of car accidents (20 %), fall from height (17 %), motorcycle accidents (12 %), pedestrian/cyclist hit by a vehicle (9 %) and other in three patients (5 %). Penetrating injuries accounted for 37 % of the injuries, consisting of stab wounds (21 %) and gunshot wounds (16 %). Complications classified by the Clavien-Dindo Classification of Surgical Complications showed grade I complications in 21 patients (23 %), grade II in 36 patients (39 %), grade III in 21 patients (23 %), grade IV in 2 patients (2 %) and grade V in 16 patients (17 %).

CONCLUSION

Laparotomy for trauma has a high complication rate resulting in significant morbidity and mortality. Most events occur in the early postoperative period. Further prospective research needs to be conducted in order to identify possibilities to improve care in the future.

The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis

OBJECTIVES

Acute mesenteric ischemia is an infrequent cause of abdominal pain in emergency department (ED) patients; however, mortality for this condition is high. Rapid diagnosis and surgery are key to survival, but presenting signs are often vague or variable, and there is no pathognomonic laboratory screening test. A systematic review and meta-analysis of the available literature was performed to determine diagnostic test characteristics of patient symptoms, objective signs, laboratory studies, and diagnostic modalities to help rule in or out the diagnosis of acute mesenteric ischemia in the ED.

METHODS

In concordance with published guidelines for systematic reviews, the medical literature was searched for relevant articles. The Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) for systematic reviews was used to evaluate the overall quality of the trials included. Summary estimates of diagnostic accuracy were computed by using a random-effects model to combine studies. Those studies without data to fully complete a two-by-two table were not included in the meta-analysis portion of the project.

RESULTS

The literature search identified 1,149 potentially relevant studies, of which 23 were included in the final analysis. The quality of the diagnostic studies was highly variable. A total of 1,970 patients were included in the combined population of all included studies. The prevalence of acute mesenteric ischemia ranged from 8% to 60%. There was a pooled sensitivity for l-lactate of 86% (95% confidence interval [CI] = 73% to 94%) and a pooled specificity of 44% (95% CI = 32% to 55%). There was a pooled sensitivity for D-dimer of 96% (95% CI = 89% to 99%) and a pooled specificity of 40% (95% CI = 33% to 47%). For computed tomography (CT), we found a pooled sensitivity of 94% (95% CI = 90% to 97%) and specificity of 95% (95% CI = 93% to 97%). The positive likelihood ratio (+LR) for a positive CT was 17.5 (95% CI = 5.99 to 51.29), and the negative likelihood ratio (-LR) was 0.09 (95% CI = 0.05 to 0.17). The pooled operative mortality rate for mesenteric ischemia was 47% (95% CI = 40% to 54%). Given these findings, the test threshold of 2.1% (below this pretest probability, do not test further) and a treatment threshold of 74% (above this pretest probability, proceed to surgical management) were calculated.

CONCLUSIONS

The quality of the overall literature base for mesenteric ischemia is varied. Signs, symptoms, and laboratory testing are insufficiently diagnostic for the condition. Only CT angiography had adequate accuracy to establish the diagnosis of acute mesenteric ischemia in lieu of laparotomy.

Increasing time to operation is associated with decreased survival in patients with a positive FAST examination requiring emergent laparotomy

INTRODUCTION

Focused assessment with sonography for trauma (FAST) is commonly used to facilitate the timely diagnosis of life-threatening hemorrhage in injured patients. Most patients with positive findings on FAST require laparotomy. Although it is assumed that an increasing time to operation (T-OR) leads to higher mortality, this relationship has not been quantified. This study sought to determine the impact of T-OR on survival in patients with a positive FAST who required emergent laparotomy.

METHODS

We retrospectively analyzed patients from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study who underwent laparotomy within 90 minutes of presentation and had a FAST performed. Cox proportional hazards models including Injury Severity Score (ISS), age, base deficit, and hospital site were created to examine the impact of increasing T-OR on in-hospital survival at 24 hours and 30 days. The impact of time from the performance of the FAST examination to operation (TFAST-OR) on in-hospital mortality was also examined using the same model.

RESULTS

One hundred fifteen patients met study criteria and had complete data. Increasing T-OR was associated with increased in-hospital mortality at 24 hours (hazard ratio [HR], 1.50 for each 10-minute increase in T-OR; confidence interval [CI], 1.14-1.97; p = 0.003) and 30 days (HR, 1.41; CI, 1.18-2.10; p = 0.002). Increasing TFAST-OR was also associated with higher in-hospital mortality at 24 hours (HR, 1.34; CI, 1.03-1.72; p = 0.03) and 30 days (HR, 1.40; CI, 1.06-1.84; p = 0.02).

CONCLUSION

In patients with a positive FAST who required emergent laparotomy, delay in operation was associated with increased early and late in-hospital mortality. Delays in T-OR in trauma patients with a positive FAST should be minimized.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma

BACKGROUND

Ultrasonography is regarded as the tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. Although its sensitivity is too low for definite exclusion of abdominal organ injury, proponents of ultrasound argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of computed tomography scans and cut costs.

OBJECTIVES

To assess the effects of trauma algorithms that include ultrasound examinations in patients with suspected blunt abdominal trauma.

SEARCH METHODS

We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (The Cochrane Library), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EBSCO), publishers' databases, controlled trials registers and the Internet. Bibliographies of identified articles and conference abstracts were searched for further elligible studies. Trial authors were contacted for further information and individual patient data. The searches were updated in February 2013.

STUDIES

randomised controlled trials (RCTs) and quasi-randomised trials (qRCTs).

PARTICIPANTS

patients with blunt torso, abdominal or multiple trauma undergoing diagnostic investigations for abdominal organ injury.

INTERVENTIONS

diagnostic algorithms comprising emergency ultrasonography (US).

CONTROLS

diagnostic algorithms without ultrasound examinations (for example, primary computed tomography [CT] or diagnostic peritoneal lavage [DPL]).

OUTCOME MEASURES

mortality, use of CT and DPL, cost-effectiveness, laparotomy and negative laparotomy rates, delayed diagnoses, and quality of life.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion, assessed methodological quality and extracted data. Where possible, data were pooled and relative risks (RRs), risk differences (RDs) and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed- or random-effects modelling, as appropriate.

MAIN RESULTS

We identified four studies meeting our inclusion criteria. Overall, trials were of moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. We pooled mortality data from three trials involving 1254 patients; relative risk in favour of the US arm was 1.00 (95% CI 0.50 to 2.00). US-based pathways significantly reduced the number of CT scans (random-effects RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result is unclear. Given the low sensitivity of ultrasound, the reduction in CT scans may either translate to a number needed to treat or number needed to harm of two.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence from RCTs to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.

Non operative management of gunshot wounds on the right thoracoabdomen

OBJECTIVE

To analyze the results after the implementation of the non-operative management (NOM) of the right upper thoracoabdominal gunshot injuries protocol.

METHODS

Prospective study. From January 2005 to December 2011, 115 patients were included into this study. Criteria for inclusion were gunshot wound to the right thoracoabdominal region, haemodynamic stability, no signs of peritonitis, and realized CT scan. The data collected were analysed by the software EXCEL.

RESULTS

Among the 115 patients included in our study, the mean age was 25.8 years old (range, 14-78 years old), of whom 95.6% were male, 62.6% had thoracoabdominal injuries and 37.4% had exclusively abdominal injuries. The averages of trauma scores were RTS 7.7, ISS 14.8 and TRISS 97%. One hundred and nine patients (94.8%) had liver injury, 72 (62.6%) had diaphragm and lung injury, 28 (24.4%) had renal injury. Complications were present in 12 (10.5%) patients, 7 of these related to the thorax. The NOM failure happened in 4 (3.5%) patients, 2 of them due to bile peritonitis, 1 related to bleeding and 1 the laparotomy was unnecessary. The mean hospital stay was 9.4 days. There were 2 deaths due to associated gunshot brain injury. Sixty seven patients (58.3%) were presented in the follow-up after 2 months of trauma. The CT scan showed injury scar in 58 patients (86.5%).

CONCLUSION

NOM of the penetrating right thoracoabdominal injuries must be seen with caution. The NOM of right thoracoabdominal gunshot injuries is safe only in selected cases, followed by well-defined protocols and when performed in places that have adequate infrastructure.

Negative Laparotomy in Trauma: Are We Getting Better?

One of the trauma surgeons’ daily challenges is the balancing act between negative laparotomy and missed abdominal injury. We opted to characterize the indications that prompted a negative trauma exploratory laparotomy and the rate of missed abdominal injuries in an effort to optimize patient selection for laparotomy. At the Los Angeles County + University of Southern California Medical Center, negative laparotomies and missed injuries are consecutively captured and reviewed at the weekly mortality + morbidity (MM) conferences. All written reports of the MM meetings from January 2003 to December 2008 were reviewed to identify all patients who underwent a negative laparotomy or a laparotomy as a result of an initially missed abdominal injury. Over the 6-year study period, a total of 1871 laparotomies were performed, of which 73 (3.9%) were negative. The rate of missed injuries requiring subsequent laparotomy was 1.3 per cent (25 of 1871). The negative laparotomy rate and the rate of missed injuries did not vary significantly during the study period (2.8 to 4.7%, P = 0.875, and 0.7 to 2.9%, P = 0.689). Penetrating mechanisms accounted for the majority of negative laparotomies (58.9%). The primary indication for negative laparotomy was peritonitis (54.8%) followed by hypotension (28.8%) and suspicious computed tomographic scan findings (27.4%). The complication rate after negative laparotomy was 14.5 per cent, and of these, 10.1 per cent were directly related to the procedure. A low but steady rate of negative laparotomies and missed abdominal injuries after trauma remains. Negative laparotomies and missed abdominal injuries when they occur are still associated with significant complication rates and a prolonged length of stay.

In-hospital small bowel obstruction after exploratory laparotomy for trauma

BACKGROUND

The purpose of this study was to examine the incidence and risk factors of in-hospital small bowel obstruction (SBO) after exploratory laparotomy for trauma.

METHODS

A retrospective review of patients surviving over 72 hours after an exploratory laparotomy for trauma. Patients with intestinal obstructive symptoms were reviewed by a consensus panel, which evaluated the clinical, laboratory, and radiologic findings to validate the diagnosis of SBO.

RESULTS

A total of 571 patients met inclusion criteria. The incidence of early SBO was 3.9%, with 22.7% of these patients requiring surgical intervention. Patients with gastrointestinal (GI) perforation had a significantly higher incidence of SBO, compared with those with no GI perforation (5.7% vs. 1.3%, p = 0.007). A forward logistic regression identified the presence of a GI perforation as the only factor independently associated with early SBO (adjusted odds ratio: 4.39; 95% confidence interval: 1.28-15.15; p = 0.019). The overall hospital stay was significantly longer for SBO patients (27.0 days ± 26.7 days vs. 16.0 days ± 22.8 days; adjusted mean difference: 11.5; 95% confidence interval: 1.6-21.3; p = 0.022). Development of SBO increased the cost by 59.7%.

CONCLUSION

The incidence of in-hospital SBO after laparotomy for trauma is significant at 3.9%. The presence of a GI perforation is independently associated with the development of this complication. Over a fifth of patients with early SBO will require a surgical intervention. The use of preventive strategies may be justified in selected, high-risk patients to reduce the burden associated with early SBO.

Selective nonoperative management of anterior abdominal stab wounds: 1992-2008

BACKGROUND

The use of selective nonoperative management for anterior abdominal stab wounds has evolved into a readily accepted practice. Multiple reports have shown this strategy to be both safe and effective. However, there is a paucity of long-term studies.

METHODS

A retrospective review was performed of all trauma patients presenting for anterior abdominal stab wounds at a Level I trauma center during a 17-year time period. Primary outcomes were the percentage of patients undergoing an exploratory laparotomy and the negative laparotomy rate.

RESULTS

A total of 7,033 patients sustained a stab wound with 1,961 involving the anterior abdomen. The percentage of patients undergoing exploratory laparotomy decreased during the study period from 64.8% to 37.6% (overall 45.8%). The negative laparotomy rate decreased from 21.3% to 8.6% (overall 18.7%). The negative laparotomy rate of patients who underwent exploratory laparotomy immediately did not change over time (13.8%), whereas the negative laparotomy rate of those patients who underwent exploratory laparotomy in a delayed fashion decreased from 25.0% to 6.25%. The overall mortality was 1.9%, with 6.2% mortality for patients undergoing an immediate laparotomy, 0.7% for patients undergoing a delayed laparotomy, and 0.0% for patients managed nonoperatively (p<0.04). The mean length of hospital stay was 6.6 days±0.5 days, with a mean of 9.4 days±0.9 days in patients undergoing an immediate laparotomy, 8.1 days±0.5 days in patients undergo a delayed laparotomy, and 3.8 days±0.2 days in patients managed nonoperatively (p<0.001).

CONCLUSIONS

Selective nonoperative management for stab wounds to the anterior abdomen is associated with a decreased operative rate and decreased negative laparotomy rate over time. Selective nonoperative management is both safe and effective for anterior abdominal stab wounds.

The incidence and risk factors of post-laparotomy adhesive small bowel obstruction

INTRODUCTION

The purpose of this review was to assess the incidence and risk factors for adhesive small bowel obstruction (SBO) following laparotomy.

METHODS

The PubMed database was systematically reviewed to identify studies in the English literature delineating the incidence of adhesive SBO and reporting risk factors for the development of this morbidity.

RESULTS

A total of 446,331 abdominal operations were eligible for inclusion in this analysis. The overall incidence of SBO was 4.6%. The risk of SBO was highly influenced by the type of procedure, with ileal pouch-anal anastomosis being associated with the highest incidence of SBO (1,018 out of 5,268 cases or 19.3%), followed by open colectomy (11,491 out of 121,085 cases or 9.5%). Gynecological procedures were associated with an overall incidence of 11.1% (4,297 out of 38,751 cases) and ranged from 23.9% in open adnexal surgery, to 0.1% after cesarean section. The technique of the procedure (open vs. laparoscopic) also played a major role in the development of adhesive SBO. The incidence was 7.1% in open cholecystectomies vs. 0.2% in laparoscopic; 15.6% in open total abdominal hysterectomies vs. 0.0% in laparoscopic; and 23.9% in open adnexal operations vs. 0.0% in laparoscopic. There was no difference in SBO following laparoscopic or open appendectomies (1.4% vs. 1.3%). Separate closure of the peritoneum, spillage and retention of gallstones during cholecystectomy, and the use of starched gloves all increase the risk for adhesion formation. There is not enough evidence regarding the role of age, gender, and presence of cancer in adhesion formation.

CONCLUSION

Adhesion-related morbidity comprises a significant burden on healthcare resources and prevention is of major importance, especially in high-risk patients. Preventive techniques and special barriers should be considered in high-risk cases.

A civilian perspective on ballistic trauma and gunshot injuries

BACKGROUND

Gun violence is on the rise in some European countries, however most of the literature on gunshot injuries pertains to military weaponry and is difficult to apply to civilians, due to dissimilarities in wound contamination and wounding potential of firearms and ammunition. Gunshot injuries in civilians have more focal injury patterns and should be considered distinct entities.

METHODS

A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed.

RESULTS

Craniocerebral gunshot injuries are often lethal, especially after suicide attempts. The treatment of non space consuming haematomas and the indications for invasive pressure measurement are controversial. Civilian gunshot injuries to the torso mostly intend to kill; however for those patients who do not die at the scene and are hemodynamically stable, insertion of a chest tube is usually the only required procedure for the majority of penetrating chest injuries. In penetrating abdominal injuries there is a trend towards non-operative care, provided that the patient is hemodynamically stable. Spinal gunshots can also often be treated without operation. Gunshot injuries of the extremities are rarely life-threatening but can be associated with severe morbidity.With the exception of craniocerebral, bowel, articular, or severe soft tissue injury, the use of antibiotics is controversial and may depend on the surgeon's preference.

CONCLUSION

The treatment strategy for patients with gunshot injuries to the torso mostly depends on the hemodynamic status of the patient. Whereas hemodynamically unstable patients require immediate operative measures like thoracotomy or laparotomy, hemodynamically stable patients might be treated with minor surgical procedures (e.g. chest tube) or even conservatively.

Has the Pendulum Swung Too Far? The Impact of Missed Abdominal Injuries in the Era of Nonoperative Management

Nonoperative management for traumatic injuries has significantly influenced trauma care during the last decade. We undertook this study to assess the impact of nontherapeutic laparotomies for suspected abdominal injuries compared with delayed laparotomies for questionable abdominal injuries for patients with abdominal trauma. The records of patients admitted to the trauma service between 2002 and 2007 who underwent laparotomies deemed nontherapeutic or delayed were retrospectively reviewed. Demographics, severity of injury, management scheme, and outcome data were analyzed. Sixteen patients underwent delayed laparotomies, whereas 26 patients incurred nontherapeutic laparotomies. Injury severity scores, Glasgow coma scale scores, abdominal abbreviated injury scale score (AIS), and age were similar for both populations. Delayed laparotomies occurred an average of 7 ± 9 days postinjury. Intensive care unit length of stay (26 ± 24 vs 10 ± 6 days), hospital length of stay (40 ± 37 vs 11 ± 10 days), ventilator days (31 ± 29 vs 11 ± 10), and number of abdominal operative procedures (1.9 ± 1.5 vs 1 ± 0) were significantly higher in the delayed laparotomies group versus the nontherapeutic laparotomies group, respectively. Delayed diagnosis of intra-abdominal injuries yielded a significantly increased morbidity and mortality. During the evolving era of technological imaging for traumatic injuries, we must not allow the nonoperative pendulum to swing too far.

Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma

PURPOSE

The finding of isolated free intraperitoneal fluid (FIPF) on computed tomography of the abdomen (CTA) in children after blunt trauma is of unclear clinical significance and raises suspicion for a solid or hollow viscus injury. In our institution, pediatric blunt trauma patients presenting with isolated FIPF on CTA who are hemodynamically stable and have no peritoneal signs on initial physical examination (iPE) have been historically approached nonoperatively. We reviewed our level 1 trauma center experience with this subset of the trauma population and sought to (1) justify an initial nonoperative approach and (2) identify early predictors of the eventual need for surgical exploration.

METHODS

Data on all trauma patients less than 14 years of age admitted to our hospital from 2001 to 2006 after Blunt Abdominal Trauma (BAT) whose screening CTA showed FIPF and no other radiographic signs of solid or hollow viscus injury were retrieved from the local trauma registry. Clinical progress, operative findings, and follow-up were obtained by hospital and office chart review, as well as telephone contact. Mechanism of injury (MOI); Injury Severity Score (ISS); Revised Trauma Score; Pediatric Trauma Score (PTS); the presence of abdominal tenderness or external signs of injury on iPE; and quantity, location, and density of the FIPF were statistically analyzed as possible early predictors of the eventual need for surgical exploration.

RESULTS

A total of 670 children admitted to our institution after blunt trauma were evaluated with CTA during the time of enrollment. Isolated FIPF was found in 94 individuals (14%). Mean age was 9.7 (+/-SD 3.2) years; 52% were males. Motor vehicle crash was the most common MOI. Mean PTS was 10.6 (+/-SD 1.8). Mean ISS was 10.2 (+/-SD 7.2). Free intraperitoneal fluid was most commonly found in only one intraperitoneal region (93%). Most patients (97%) were discharged home without undergoing a surgical procedure. Three other patients developed peritonitis on serial physical examination and were surgically explored. Hollow viscus injuries were found in 2 of these individuals and treated with primary repair or segmental bowel resection. All surgical patients enjoyed a full recovery, with no postoperative complications. The presence of abdominal tenderness on iPE and the quantity of FIPF on initial CTA were the only studied variables to reach statistical significance as predictors of the eventual need for operative intervention. Follow-up after hospital discharge was obtained in 46.8% (44/94) and averaged 124.9 weeks.

CONCLUSION

To the best of our knowledge, this is the largest series of pediatric blunt trauma patients with isolated FIPF on CTA ever reported. Our findings justify an initial nonoperative approach for the management of these individuals. Abdominal tenderness on iPE and the quantity of FIPF on initial CTA were predictors of the eventual need for operative intervention.

Diagnosis of bowel and mesenteric injuries in blunt abdominal trauma: a prospective study

PURPOSE

Currently, nonoperative management is the procedure of choice for solid organ injury in patients with a blunt abdominal trauma. Missed blunt bowel and mesenteric injuries (BBMIs) are possible because diagnosis is difficult. The aim of our study was to test a new algorithm for BBMI diagnosis using abdominal ultrasonography (AUS), computed tomography (CT), and diagnostic peritoneal lavage (DPL).

METHODS

We reviewed cases of blunt abdominal injuries over a 10-year period, then we designed an algorithm that was prospectively tested in hemodynamically stable patients over a 2-year period. An abnormal AUS led to helical CT. When the CT showed more than 2 findings suggestive of BBMI, laparotomy was performed. In case of 1 or 2 abnormal CT findings, we performed a DPL and calculated the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid and divided this by the WBC/RBC ratio in peripheral blood. A ratio of 1 or higher was considered positive for BBMI, and a laparotomy was immediately performed. Patients with a ratio of less than 1 were managed nonoperatively.

RESULTS

In the retrospective study, 26 (1%) of 2126 patients admitted to our trauma center for blunt trauma had a BBMI, including 15 (58%) diagnosed after a median delay of 24 hours. In the prospective study, 531 patients were admitted for blunt trauma with multiple injuries, including 131 with abdominal trauma. Computed tomography was performed in 40 patients. There were 2 criteria or more of BBMI in 1 patient, 0 criteria in 27 patients (with an uneventful follow-up), and 1 or 2 criteria in 12 patients who had DPL with a median ratio of 0.82 (ranges, 0.03-9). Five patients had a ratio of 1 or higher. They underwent immediate laparotomy. In all 5 cases, BBMI was found. The 7 patients who had a ratio of less than 1 were observed in ICU and treated for extra-abdominal injuries. No BBMI injury was missed in these patients. The accuracy of the algorithm was 100% (95% confidence interval, 0.99-1.00).

CONCLUSION

The proposed algorithm (based on AUS, CT, and DPL) had a high accuracy to diagnose BBMI while requiring the performance of DPL in only a few (2%) patients.

Complications after therapeutic trauma laparotomy

BACKGROUND

Therapeutic trauma laparotomy (TTL) is a common emergency procedure after traumatic abdominal injury, but it can lead to complications and even death. We explored the role of the time from emergency department (ED) arrival to surgical intervention as a predictor of complications and mortality from TTL.

STUDY DESIGN

This is a retrospective study of 175 patients receiving TTL between July 1997 and October 2003 in a Level I teaching hospital serving a primarily rural population. Mortality after TTL and complications, both general and abdominal, were the main outcomes. Time from ED arrival to operation was the primary exposure. Confounders, including time from injury to ED arrival, age, gender, injury severity, and patient status, were controlled in logistic models.

RESULTS

Of the 175 TTL patients, 23 (13.1%) died, 102 (58.3%) had abdominal complications, and 119 (68.0%) had general complications. Controlling for confounders, patients whose operation began more than 1 hour after ED arrival were 11.3 (95% CI=2.2 to 58.8) times more likely to die and 3.1 (95% CI=1.44 to 6.60) times more likely to have complications.

CONCLUSIONS

The traumatologist has little control over patient treatment and transfer before ED arrival. After arrival the traumatologist can reduce negative outcomes by reducing the time for patient assessment and start of TTL, when warranted.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma

BACKGROUND

Ultrasonography is regarded as the tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. Although its sensitivity is too low for definite exclusion of abdominal organ injury, proponents of ultrasound argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of computed tomography scans and cut costs.

OBJECTIVES

To assess the efficiency and effectiveness of trauma algorithms that include ultrasound examinations in patients with suspected blunt abdominal trauma.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CENTRAL, CCMED, publishers' databases, controlled trials registers and the Internet. Bibliographies of identified articles and congress abstracts were handsearched. Trials were obtained from the Cochrane Injuries Group's trials register. Authors were contacted for further information and individual patient data.

PARTICIPANTS

patients with blunt torso, abdominal or multiple trauma undergoing diagnostic investigations for abdominal organ injury.

INTERVENTIONS

diagnostic algorithms comprising emergency ultrasonography (US).

CONTROLS

diagnostic algorithms without US ultrasound examinations (e.g. primary computed tomography [CT] or diagnostic peritoneal lavage [DPL]).

OUTCOME MEASURES

mortality, use of CT and DPL, cost-effectiveness, laparotomy and negative laparotomy rates, delayed diagnoses, and quality of life.

STUDIES

randomised controlled trials (RCTs) and quasi-randomised trials (qRCTs).

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed methodological quality and extracted data. Where possible, data were pooled and relative risks (RRs), risk differences (RDs) and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed- or random-effects modelling, as appropriate.

MAIN RESULTS

We identified two RCTs with US in the experimental arm and another with US in the control group. We also considered two qRCTs. Overall, trials were of moderate methodological quality. Few authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. We were able to pool data from two trials comprising 1037 patients for primary endpoint analysis (i.e. mortality). The relative risk in favour of the no-US arm was 1.4 (95% CI 0.94 to 2.08). Because of a lack of details, the meaning of this observation remains unclear. There was a marginal benefit with US-based pathways in reducing CT scans (random-effects RD -0.46; 95% CI -1.00 to 0.13), offset by trials of higher methodological rigour. No differences were observed in DPL and laparotomy rates.

AUTHORS' CONCLUSIONS

There is insufficient evidence from RCTs to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.

Computed tomographic scanning without oral contrast solution for blunt bowel and mesenteric injuries in abdominal trauma

BACKGROUND

Computed tomographic (CT) scanning using intravenous and oral contrast material has traditionally been advocated for the evaluation of intra-abdominal injury, including blunt bowel and mesenteric injuries (BBMIs). The necessity of oral contrast in detecting these injuries has recently been called into question. The purpose of this study was to determine the sensitivity and specificity of CT scanning without oral contrast for BBMIs.

METHODS

We prospectively enrolled 500 consecutive blunt trauma patients who received CT imaging and interpretation (CT-Read1) of the abdomen from July 2000 to November 2001. All patients were imaged without oral contrast, but with intravenous contrast. CT images were reviewed within 24 hours of admission by a research radiologist (CT-Read2) blinded to CT-Read1. For study purposes, true BBMI was determined to be present if either laparotomy or autopsy identified bowel or mesenteric injury, or both CT-Read2 and the hospital discharge summary described bowel or mesenteric injury. Three-month telephone follow-up was also completed.

RESULTS

CT-Read1 detected 19 of 20 bowel and mesenteric injuries. CT-Read1 missed one duodenal perforation. There were two patients with false-positive interpretations of CT-Read1 for bowel injury. The sensitivity and specificity of CT imaging for the detection of BBMIs were 95.0% and 99.6%, respectively.

CONCLUSION

CT imaging of the abdomen without oral contrast for detection of BBMIs compares favorably with CT imaging using oral contrast.

Delay in Diagnosis of Hollow Viscus Injuries: Effect on Outcome

Delay in the recognition of hollow viscus injury may lead to increased morbidity and mortality. Unfortunately the early diagnosis of these injuries remains a diagnostic challenge increasing the likelihood of delay. Patients transferred to Level I trauma centers from outlying institutions may be at increased risk of morbidity from hollow viscus injury, as there is an inherent delay associated with transfer. Herein we reviewed our institution's 11-year experience with the diagnosis and treatment of hollow viscus injury caused by blunt mechanism. Forty-one patients met defined criteria of hollow viscus injury. Patients were stratified into two groups: interval to operating room ≤24 hours versus >24 hours. Length of hospital stay, number of ventilator days, and percentage of patients developing acute respiratory distress syndrome were significantly greater in the >24-hour group. Mortality was not significantly different between the groups (26.7% vs 36.4%). Patients transferred from other institutions were more likely to experience complications and operative delay. In conclusion delay in operative intervention (>24 hours) adversely affected outcomes. Early transfer of patients to Level I trauma centers may improve outcomes. A high index of suspicion and the use of multiple diagnostic modalities may lead to earlier operative treatment and improved outcome.

Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis from 275,557 trauma admissions from the EAST multi-institutional HVI trial

OBJECTIVES

Blunt SBI is infrequent and its diagnosis may be difficult, especially in the face of confounding variables. The purpose of this study was to evaluate methods for making the diagnosis of blunt SBI.

METHODS

Patients with blunt small bowel injury (SBI) were identified from the registries of 95 trauma centers for a 2-year period (1998-1999). Patients with SBI (cases) were matched by age and Injury Severity Score with a blunt trauma patient receiving an abdominal workup who did not have SBI (controls).

RESULTS

Logistic regression models were unable to differentiate SBI with perforation from SBI without perforation. Thirteen percent of patients with documented perforating SBI had normal abdominal computed tomographic scans preoperatively.

CONCLUSION

Alone or in combination, current diagnostic approaches lack sensitivity in the diagnosis of perforated SBI. Improvements in diagnostic methods and approaches are needed to ensure the prompt diagnosis of this uncommon but potentially devastating injury.

Intra-abdominal free fluid without solid organ injury in blunt abdominal trauma: an indication for laparotomy

BACKGROUND

The optimal management of patients sustaining blunt abdominal trauma (BAT), in whom intra-abdominal free fluid but no solid organ injury is found on imaging, remains unclear. The purpose of this study was to determine the incidence and significance of this finding.

METHODS

All patients presenting with suspected BAT to a provincial trauma center over a 30-month period were reviewed. A screening focused abdominal sonogram for trauma scan was obtained in every case. Stable patients with positive or indeterminate scans underwent computed tomographic scanning. Those with free fluid but without visible solid organ injury were studied. Radiologic interpretation, clinical management, and operative findings were analyzed.

RESULTS

Twenty-eight of 1,367 patients (2%) met inclusion criteria. Twenty-one patients (75%) underwent exploratory laparotomy, which for 16 (76%) was therapeutic: bowel injuries were found in 10 patients, mesentery injuries in 6, and injuries to solid organs in 3. In five patients, laparotomy was nontherapeutic. Those with more than a trace of free fluid were significantly more likely to have a therapeutic procedure. Seven patients (25%) were observed, of whom two failed nonoperative management and underwent therapeutic laparotomies within 24 hours of admission for missed colon, splenic, and hepatic injuries. The presence of abdominal seat belt bruising or a Chance-type fracture in the study patients was associated with a 90% and 100% therapeutic laparotomy rate, respectively. Computed tomographic scan findings were variable and were not able to predict injury severity or need for surgery.

CONCLUSION

The finding of more than trace amounts of free fluid in the absence of solid organ injury in BAT is often associated with clinically significant visceral injury. Early laparotomy is recommended for these patients.

Is delayed laparotomy for blunt abdominal trauma a valid quality improvement measure in the era of nonoperative management of abdominal injuries?

BACKGROUND

Review of hemodynamically stable patients who undergo laparotomy for trauma greater than 4 hours after admission is an American College of Surgeons quality improvement filter. We reviewed our recent experience with patients who underwent laparotomy for trauma greater than 4 hours after admission to evaluate the reasons for delay, and to determine whether they were because of failure of nonoperative management or other causes.

METHODS

The registry at our Level I trauma center was searched from January 1998 through December 2000 for patients who required a laparotomy for trauma greater than 4 hours after admission. Of 3,369 admitted blunt trauma patients, 90 (2.7%) underwent laparotomy for trauma, of which 26 (29%) were identified as delayed laparotomies greater than 4 hours after admission.

RESULTS

The most common mechanism of injury was motor vehicle crash, the mean Injury Severity Score was 18, and 65% of the patients had significant distracting injuries. Five patients had laparotomy greater than 24 hours after admission. The average time to the operating room in the remaining patients was 8.6 hours. Clinical examination (61%) findings were the most common indication for operation. Gastrointestinal (GI) tract injury was the most common injury associated with delay in laparotomy (58%).

CONCLUSION

GI tract injuries are the predominant injury leading to delayed laparotomy for blunt trauma (58%). Failed nonoperative management of solid organ injuries occurred less frequently (15%). Future efforts should concentrate on earlier identification of GI tract injury. Delayed laparotomy for blunt abdominal trauma is a valid quality improvement measure.

The impact of major in-hospital complications on functional outcome and quality of life after trauma

BACKGROUND

Little is known about the impact of major in-hospital complications on functional outcome in the short- and long-term period after serious injury. The Trauma Recovery Project (TRP) is a large, prospective, epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life and functional limitation. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to examine the effect of postinjury complications on functional outcomes at discharge and at 6-, 12-, and 18-month follow-up time points in the TRP population.

METHODS

Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included age 18 years or older; admission Glasgow Coma Scale score of 12 or greater; and length of stay greater than 24 hours. Quality of life was measured after injury using the Quality of Well-being (QWB) scale, a sensitive index to the well end of the functioning continuum (range, 0 [death] to 1.000 [optimum functioning]). Major in-hospital complications were assessed for 820 patients and were coded as pulmonary, cardiovascular, gastrointestinal, hepatic, hematologic, infections, renal, musculoskeletal, neurologic, and vascular, on the basis of standardized codes used in the Trauma Registry.

RESULTS

Major in-hospital complications were present in 83 (10.1%) patients. Discharge QWB scores were significantly lower in patients with major complications (0.394 vs. 0.402, p < 0.05). QWB scores were also significantly lower at 6-month follow-up in patients with major complications (0.575 vs. 0.637, p < 0.0001). Types of major complications with significantly lower 6-month follow-up QWB scores were pulmonary, gastrointestinal, infections, and musculoskeletal. Patients with major complications also had significantly lower 12-month (0.626 vs. 0.674, p < 0.01) and 18-month (0.646 vs. 0.681, p < 0.05) follow-up QWB scores. Pulmonary major complications and infections were associated with significantly lower QWB scores at 12-month follow-up.

CONCLUSION

These results provide new evidence that major in-hospital complications may have an important impact on functional outcomes after major trauma.