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Shideler BL, Berera DC, Knowlton LM, Knight AW. Delayed hollow viscus injury with an occult seatbelt abrasion presenting as a small bowel obstruction. Trauma Case Rep 2023; 48:100934. [PMID: 38098811 PMCID: PMC10719448 DOI: 10.1016/j.tcr.2023.100934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 12/17/2023] Open
Abstract
We present the case of a previously healthy 29-year-old male who presented with a small bowel obstruction in the absence of previous abdominal surgery who was found to have evidence of an occult seatbeltabrasion and ultimately multifocal hollow viscus injury secondary to blunt abdominal trauma at the time of exploratory laparotomy. Hollow viscus injury is a rare, but potentially life-threatening, complication of blunt abdominal trauma. While cross-sectional imaging is an important diagnostic tool, results must be considered within a patient's clinical context as delays in surgical management can lead to significant morbidity and mortality.
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Affiliation(s)
| | - Danielle C. Berera
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Lisa M. Knowlton
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Ariel W. Knight
- Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
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Dehne LM, Foertsch MJ, Droege CA, Makley AT, Mosher DR, Philpott CD, Sagi HC, Mueller EW, Droege ME. Antibiotic Duration Following Abdominal Gunshot Injuries With Associated Pelvis or Spine Involvement: A 20-Year Single-Center Experience. J Surg Res 2023; 291:97-104. [PMID: 37354706 DOI: 10.1016/j.jss.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 05/04/2023] [Accepted: 05/15/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Optimal antimicrobial prophylaxis duration following gunshot wounds (GSW) to the abdomen with an associated orthopedic fracture is unknown. This study evaluated the safety and efficacy of short versus long courses of prophylactic antibiotics following penetrating hollow viscus injury with communicating orthopedic fracture. METHODS This retrospective study included adult patients admitted to the trauma service over a 20-y period who sustained an abdominal GSW with hollow viscus injury and communicating spine or pelvic fractures. Patients were stratified into cohorts based on prophylactic antibiotic duration: short course (SC, ≤48 h) and long course (>48 h). The primary outcome was the incidence of osteomyelitis and meningitis up to 1-y postinjury. Secondary outcomes included hospital length of stay and the incidence of multidrug-resistant organisms and Clostridioides difficile infections. Risk factors for osteomyelitis and meningitis were determined. RESULTS A total of 125 patients were included with 45 (36%) in the SC group. Median prophylactic antibiotic durations were SC, 1 (interquartile range [IQR], 1-2) versus long course, 7 (IQR, 5-7) d (P < 0.001). There was no difference in osteomyelitis and meningitis incidence (2 [4.4%] versus 4 [5%], P = 0.77). Median hospital length of stay (7 [IQR, 6-11] versus 9 [IQR, 6-15] d, P = 0.072) and incidence of multidrug-resistant organisms (6 [13.3%] versus 13 [16.3%], P = 0.86) and Clostridioides difficile infections (0 [0%] versus 1 [1.3%], P = 0.77) were similar between groups. There were no independent risk factors identified for osteomyelitis or meningitis. CONCLUSIONS A shorter course of antibiotic prophylaxis ≤48 h may be adequate following abdominal GSW that traverses a hollow viscus and results in pelvic fracture or spinal column injury.
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Affiliation(s)
- Lauren Michelle Dehne
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio.
| | - Madeline Jane Foertsch
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Christopher Allen Droege
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Amy Teres Makley
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Carolyn Dosen Philpott
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Henry Claude Sagi
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eric William Mueller
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Molly Elizabeth Droege
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
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Litwin A, Coulter AP, Romanelli J, Tirabassi M. Use of minimally invasive surgery for the management of hollow viscus traumatic injuries. Surg Endosc 2022; 36:8421-9. [PMID: 35229212 DOI: 10.1007/s00464-022-09102-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The objective of this study is to assess surgical outcomes following the initial use of laparoscopy versus laparotomy when managing patients with hollow viscus injuries due to trauma. METHODS Using the database from the American College of Surgeons Trauma Quality Improvement Program we identified all patients from 2015-2017 with ICD-10 Diagnosis codes for hollow viscus trauma. Types of procedures were identified by ICD-10 PCS codes. Patient outcomes were stratified by major trauma(ISS > 15) and minor trauma. Continuous variables were compared by ANOVA and categorical variables compared by Chi-Square. Analysis performed using STATA 16. RESULTS We identified 16,284 patients that matched inclusion criteria within the study time frame. Of those, 1986 patients received a surgical intervention, 1911(96%) were open and 75(4%) were laparoscopic. In blunt trauma there were 106 diagnostic procedures, 87(82%) were open and 19(18%) were laparoscopic. There were 574 therapeutic procedures, 543(95%) were open and 31(5%) were laparoscopic. In penetrating trauma there were 223 diagnostic procedures, 215(96%) were open and 8(4%) were laparoscopic. There were 1039 therapeutic procedures for penetrating trauma, 1023(98%) were open and 16(2%) were laparoscopic. For minor trauma, mean length of stay(days) after open surgery was 5 while for laparoscopy it was 2 (p = 0.04). There were 203 complications noted in the open group and 7 in the laparoscopic group (p = 0.19). For major trauma, mean length of stay(days) after open surgery was 5 and 6 for laparoscopy p = 0.54). There were 242 complications in the open group and 1 in the laparoscopic group (p = 0.07). There was no noted significant difference noted in the disposition at discharge in either group in both major and minor trauma. CONCLUSIONS For those that required surgery for hollow viscous injury, laparoscopy appeared to be safe, had less adverse outcomes and was underutilized, particularly when only a diagnostic procedure was required.
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Simmonds I, Towle-Miller LM, Myneni AA, Gray J, Jordan JM, Schwaitzberg SD, Hoffman AB, Noyes K. Is New York State good at managing hollow viscus injury? Surg Endosc 2022; 36:6789-6800. [PMID: 34997346 DOI: 10.1007/s00464-021-08964-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/12/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND There are an estimated 100,000 cases of abdominal injury (ABI) in the USA, annually resulting in over $12 billion in direct medical cost and $18 billion in lost productivity. This study assesses the timeliness, safety, and efficacy of the surgical management of abdominal injuries (ABIs), hollow viscus injuries (HVIs), and colonic injuries (CIs) for patients residing in New York State (NYS). METHODS Using data from NYS's Statewide Planning and Research Cooperative System (SPARCS), we identified all trauma patients with ABI admitted between 2006 and 2015. We subdivided ABI into HVI and CI using diagnosis and procedure codes and examined processes of care and outcomes adjusting for patient characteristics, injury severity score, structural, and process indicators. RESULTS We identified 31,043 hospitalized patients with ABI, 71% were incurred from blunt forces. Most patients with ABI (72%) were treated at a Level I/II trauma center (TC) and 7% patients were transferred to Level I/II TC. Failure to be treated at Level I/II TC was associated with 16% increased hazard of death. HVI was diagnosed in 23% of ABI patients (n = 7294); 18% experienced delayed hollow viscus repair (dHVR); dHVR was associated with a 76% increased hazard of death. CI was diagnosed in 9% of ABI patients (n = 2921) and 18% experienced dHVR. Seventy-five percent of CI were repaired primarily (n = 1354). Less than 37% of stomas were reversed by 4 years of index trauma. CONCLUSION Most abdominal trauma in NYS was caused by motor vehicle accidents, falls, and assault. dHVR and not being treated at Level I/II TC were associated with worse outcomes. More research is needed to reduce under-triage and delays in the operative treatment of blunt abdominal trauma.
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Affiliation(s)
- Iman Simmonds
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Lorin M Towle-Miller
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Ajay A Myneni
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Justin Gray
- Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Jeffrey M Jordan
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Steven D Schwaitzberg
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Aaron B Hoffman
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Katia Noyes
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA. .,Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA.
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Abstract
BACKGROUND No guidelines exist for management of hemodynamically stable children with suspected hollow viscus injury. We sought to determine factors contributing to surgeon management of these patients. METHODS Surgeon members of the Eastern Association for the Surgery of Trauma and American Pediatric Surgical Association completed a survey on 3 blunt abdominal injury scenarios: (1) isolated, (2) with multisystem injury, and (3) with traumatic brain injury (TBI), and a penetrating injury scenario. Multivariable logistic regression was used to determine factors associated with initial management of observation vs. operation for blunt injury and observation vs. local wound exploration versus laparoscopy for penetrating injury. RESULTS Of 394 surgeons (response rate 22.3%), 50.3% were pediatric surgeons. For scenarios 1-3, 32.2%, 49.3%, and 60.7% of surgeons chose operation over observation, respectively. Compared to isolated blunt injury, surgeons were more likely to choose operation for patients with multisystem injury (aOR 2.20, 95%CI: 1.78-2.72) or TBI (aOR 3.60, 95%CI: 2.79-4.66). Pediatric surgeons were less likely to choose operation (aOR 0.32, 95%CI: 0.22-0.44). For penetrating injury, 39.1%, 29.5%, and 31.5% of surgeons chose observation, local wound exploration, and laparoscopy, respectively. CONCLUSIONS Large variation exists in management of hemodynamically stable children with suspected hollow viscus injury. Although patient injury characteristics account for some variation, surgeon factors such as type of surgeon also play a role. Evidence-based practice guidelines should be developed to standardize care. TYPE OF STUDY Cross-Sectional Survey. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Elissa K Butler
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195, USA; Department of Surgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.
| | - Jonathan I Groner
- Center for Pediatric Trauma Research, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Monica S Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Anesthesiology & Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Eileen M Bulger
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195, USA
| | - Frederick P Rivara
- Harborview Injury Prevention & Research Center, University of Washington, 325 9th Ave Box 359960, Seattle, WA 98122, USA; Department of Pediatrics, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
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Achatz G, Schwabe K, Brill S, Zischek C, Schmidt R, Friemert B, Beltzer C. Diagnostic options for blunt abdominal trauma. Eur J Trauma Emerg Surg 2020; 48:3575-3589. [PMID: 32577779 DOI: 10.1007/s00068-020-01405-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/18/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Physical examination, laboratory tests, ultrasound, conventional radiography, multislice computed tomography (MSCT), and diagnostic laparoscopy are used for diagnosing blunt abdominal trauma. In this article, we investigate and evaluate the usefulness and limitations of various diagnostic modalities on the basis of a comprehensive review of the literature. METHODS We searched commonly used databases in order to obtain information about the aforementioned diagnostic modalities. Relevant articles were included in the literature review. On the basis of the results of our comprehensive analysis of the literature and a current case, we offer a diagnostic algorithm. RESULTS A total of 86 studies were included in the review. Ecchymosis of the abdominal wall (seat belt sign) is a clinical sign that has a high predictive value. Laboratory values such as those for haematocrit, haemoglobin, base excess or deficit, and international normalised ratio (INR) are prognostic parameters that are useful in guiding therapy. Extended focused assessment with sonography for trauma (eFAST) has become a well established component of the trauma room algorithm but is of limited usefulness in the diagnosis of blunt abdominal trauma. Compared with all other diagnostic modalities, MSCT has the highest sensitivity and specificity. Diagnostic laparoscopy is an invasive technique that may also serve as a therapeutic tool and is particularly suited for haemodynamically stable patients with suspected hollow viscus injuries. CONCLUSIONS MSCT is the gold standard diagnostic modality for blunt abdominal trauma because of its high sensitivity and specificity in detecting relevant intra-abdominal injuries. In many cases, however, clinical, laboratory and imaging findings must be interpreted jointly for an adequate evaluation of a patient's injuries and for treatment planning since these data supplement and complement one another. Patients with blunt abdominal trauma should be admitted for clinical observation over a minimum period of 24 h since there is no investigation that can reliably rule out intra-abdominal injuries.
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Affiliation(s)
- Gerhard Achatz
- Department for Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, Sportstraumatology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany.
| | - Kerstin Schwabe
- Department for General-, Visceral- and Thoracic-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Sebastian Brill
- Department for General-, Visceral- and Thoracic-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Christoph Zischek
- Department for Vascular- and Endovascular-Surgery, German Armed Forces Hospital Ulm, Ulm, Germany
| | - Roland Schmidt
- Department for General-, Visceral- and Thoracic-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Benedikt Friemert
- Department for Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, Sportstraumatology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Christian Beltzer
- Department for General-, Visceral- and Thoracic-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
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D'Elia MA, Grant RI, Kolozsvari NO, Matar MM. Motor vehicle collision with seatbelt sign and traumatic abdominal wall hernia should raise suspicion for hollow viscus injury. Trauma Case Rep 2019; 22:100206. [PMID: 31193627 DOI: 10.1016/j.tcr.2019.100206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2019] [Indexed: 11/23/2022] Open
Abstract
Diagnosing hollow viscus injury following motor vehicle collision (MVC) requires a high index of suspicion. Here we present two cases of high velocity MVC, with 3-point restrained occupants, who presented with a seatbelt sign and associated acute traumatic flank herniation. Both patients underwent a computer tomography (CT) scan which did not identify any hollow viscus injuries. Significant injuries were ultimately identified in the operating room (OR). The presence of a seatbelt sign and underlying acute traumatic hernia should prompt a heightened level of suspicion for intra-abdominal injury, particularly hollow viscus. A heightened level of suspision and a lower threshold for operative exploration is suggested to avoid the morbidity and mortality associated with a delayed diagnosis of hollow viscus injury.
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Abdel-Aziz H, Dunham CM. Effectiveness of computed tomography scanning to detect blunt bowel and mesenteric injuries requiring surgical intervention: A systematic literature review. Am J Surg 2018; 218:201-210. [PMID: 30201138 DOI: 10.1016/j.amjsurg.2018.08.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/02/2018] [Accepted: 08/26/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Computed tomography (CT) diagnostic accuracy for blunt bowel and mesenteric injuries (BBMI) is controversial. DATA SOURCES A literature review to compute aggregate CT performance and individual CT sign sensitivity, specificity, and positive predictive value (PPV) for operative BBMI. CONCLUSIONS Sensitivity, specificity, and PPV were: overall CT performance 85.3%, 96.1%, 51.4%; abnormal wall enhancement 30.1%, 95.7%, 64.0%; bowel wall discontinuity 22.3%, 99.0%, 87.9%; bowel wall hematoma 22.5%, 100%, 19.5%; bowel wall thickening 35.2%, 96.5%, 32.1%; free air 32.0%, 98.7%, 57.1%; free fluid 65.6%, 85.0%, 25.5%; mesenteric air 27.6%, 99.1%, 85.3%; mesenteric extravasation 22.9%, 99.6%, 73.9%; mesenteric hematoma/fluid 33.9%, 98.7%, 52.8%; mesenteric stranding/streaking 34.3%, 91.8%, 31.6%; mesenteric vessel beading 32.1%, 97.2%, 60.4%; mesenteric vessel termination 31.6%, 97.2%, 63.5%; oral contrast extravasation 10.0%, 100%, 100%; retroperitoneal air 9.4%, 94.9%, 55.6%; and retroperitoneal fluid 44.2%, 49.4%, 38.5%. Sensitivity, specificity, and PPV vary substantially among known signs. Other clinical factors are necessary for comprehensive BBMI identification.
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Affiliation(s)
- Hiba Abdel-Aziz
- Department of Surgical Education, Northeast Ohio Medical University, 4209 State Route 44, Rootstown, OH, USA.
| | - C Michael Dunham
- Trauma/Neuroscience Research Department, St. Elizabeth Youngstown Hospital, 1044 Belmont Ave, Youngstown, OH, USA.
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Harmston C, Ward JBM, Patel A. Clinical outcomes and effect of delayed intervention in patients with hollow viscus injury due to blunt abdominal trauma: a systematic review. Eur J Trauma Emerg Surg 2018; 44:369-376. [PMID: 29302699 DOI: 10.1007/s00068-018-0902-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/01/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Hollow viscus injury (HVI) due to blunt abdominal trauma remains a diagnostic challenge, often presenting late and results in delayed intervention. Despite several treatment algorithms, there is currently no consensus on how to manage patients with HVI. The aim of this review was to define clinical outcomes and the effect of delayed intervention in patients with HVI due to blunt abdominal trauma. The primary outcome of interest was difference in mortality between groups. METHODS Based on the preferred reporting items for systematic reviews and meta-analyses statement, a literature search was performed. Studies comparing clinical outcomes in adult patients with hollow viscus injury due to blunt abdominal trauma undergoing early or delayed laparotomy were included. Two independent reviewers screened the abstracts. RESULTS In all, 2288 articles were retrieved. After screening, 11 studies were included. Outcomes in 3812 patients were reported. Overall mortality was 17%. Ten studies reported no difference in mortality between groups. A statistical increase in morbidity was described in five studies, and a trend to increased morbidity was seen in a further two studies. Two studies reported increased mortality in delayed intervention in isolated bowel injury. CONCLUSIONS This systematic review summarises the results of studies considering outcomes in patients with HVI due to blunt abdominal trauma who have early vs delayed intervention. Overall mortality was significant at 17%. If all patients with hollow viscus injury are considered, the majority of studies do not show an increase in mortality. As patients with isolated bowel injuries have higher mortality in the studies reviewed, to improve outcomes in this subset further investigation is warranted.
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Affiliation(s)
| | | | - Abhilasha Patel
- University Hospitals of North Staffordshire, West Midlands, UK
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10
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Abstract
Hollow viscus injury is common with penetrating trauma to the torso and infrequent with a blunt traumatic mechanism of injury. The diagnosis in hemodynamically unstable patients is often made in the operating room. In hemodynamically stable patients, the diagnosis can be difficult due to additional injuries. Although computed tomography remains the diagnostic tool of choice in hemodynamically stable patients, it has lower reported sensitivity and specificity with hollow viscus injury. However, even short delays in diagnosis increase morbidity and mortality significantly. Operative management of stomach, duodenal, small bowel, and colon injuries is reviewed.
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11
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Abstract
Gastric perforations following blunt abdominal trauma are rare, accounting for < 2% of all blunt abdominal injuries. Isolated blunt gastric ruptures are uncommon. They are usually associated with other solid visceral injuries. Injuries to the stomach are associated with the highest mortality of all hollow viscus injuries. Severity of the injury, timing of presentation and presentation following the last meal as well as concomitant injuries are important prognostic factors. Imaging modalities may be unreliable in making a diagnosis and thus clinical vigilance is mandatory. We present a patient with gastric perforation following blunt abdominal trauma and review the literature.
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Affiliation(s)
| | | | | | - S. Mewa Kinoo
- Corresponding author at: Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, 719 Umbilo Road, Congella 4013, Durban, South Africa.Department of SurgeryNelson R Mandela School of MedicineUniversity of KwaZulu-Natal719 Umbilo RoadCongella 4013DurbanSouth Africa
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12
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Abstract
Appendicitis is a frequently encountered surgical problem in the Emergency Department (ED). Appendicitis typically results from obstruction of the appendiceal lumen, although trauma has been reported as an infrequent cause of acute appendicitis. Intestinal injury and hollow viscus injury following blunt abdominal trauma are well reported in the literature but traumatic appendicitis is much less common. The pathophysiology is uncertain but likely results from several mechanisms, either in isolation or combination. These include direct compression/crush injury, shearing injury, or from indirect obstruction of the appendiceal lumen by an ileocecal hematoma or traumatic impaction of stool into the appendix. Presentation typically mirrors that of non-traumatic appendicitis with nausea, anorexia, fever, and right lower quadrant abdominal tenderness and/or peritonitis. Evaluation for traumatic appendicitis requires a careful history and physical exam. Imaging with ultrasound or computed tomography is recommended if the history and physical do not reveal an acute surgical indication. Treatment includes intravenous antibiotics and surgical consultation for appendectomy. This case highlights a patient who developed acute appendicitis following blunt trauma to the abdomen sustained during a motor vehicle accident. Appendicitis must be considered as part of the differential diagnosis in any patient who presents to the ED with abdominal pain, including those whose pain begins after sustaining blunt trauma to the abdomen. Because appendicitis following trauma is uncommon, timely diagnosis requires a high index of suspicion.
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Affiliation(s)
- Travis Cobb
- Geisinger Wyoming Valley Medical Center, 1000 East Mountain Boulevard, Wilkes-Barre, PA 18711, United States.
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Jost E, Roberts DJ, Penney T, Brunet G, Ball CG, Kirkpatrick AW. Accuracy of clinical, laboratory, and computed tomography findings for identifying hollow viscus injury in blunt trauma patients with unexplained intraperitoneal free fluid without solid organ injury. Am J Surg 2017; 213:874-880. [PMID: 28351473 DOI: 10.1016/j.amjsurg.2017.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/15/2017] [Accepted: 03/15/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND We sought to define the accuracy of findings for detecting hollow viscus injury (HVI) in patients with blunt abdominal trauma (BAT) and unexplained intra-peritoneal free fluid without solid organ injury (UIPFFWSOI). METHODS We screened all consecutive hemodynamically stable patients presenting to a quaternary-care trauma-centre who had an abdominal computed tomography (CT) scan for BAT and UIPFFWSOI (January 2007-December 2014). RESULTS Of 3796 patients identified during the study period, 39 presented with UIPFFWSOI. Fifteen underwent therapeutic laparotomy. Seatbelt sign (+LR approaches infinity), diffuse peritonitis (+LR approaches infinity), number of CT cuts with fluid (c-statistic = 0.65), and a lower arterial pH at presentation (c-statistic = 0.62) were most predictive of HVI. Patients operated on within 24 h had shorter stays than those operated on later (median 9 vs. 14 days, p = 0.03). CONCLUSIONS Our findings suggest that clinical examination and measurements of intraperitoneal fluid volume may help identify HVIs in BAT patients.
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Affiliation(s)
- Evan Jost
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Derek J Roberts
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Todd Penney
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Grant Brunet
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, AB, Canada; The Regional Trauma Services Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Andrew W Kirkpatrick
- Department of Surgery, University of Calgary, Calgary, AB, Canada; Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada; The Regional Trauma Services Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.
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14
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Abstract
The management of blunt abdominal trauma has evolved over time. While laparotomy is the standard of care in hemodynamically unstable patients, stable patients are usually treated by non-operative management (NOM), incorporating adjuncts such as interventional radiology. However, although NOM has shown good results in solid organ injuries, other lesions, namely those involving the hollow viscus, diaphragm, and mesentery, do not qualify for this approach and need surgical exploration. Laparoscopy can substantially reduce additional surgical aggression. It has both diagnostic and therapeutic potential and, when negative, may reduce the number of unnecessary laparotomies. Although some studies have shown promising results on the use of laparoscopy in blunt abdominal trauma, randomized controlled studies are lacking. Laparoscopy requires adequate training and experience as well as sufficient staffing and equipment.
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Affiliation(s)
- Viktor Justin
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - Selman Uranues
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
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15
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Abstract
Blunt abdominal trauma results in injury to the bowel and mesenteries in 3-5% of cases. The injuries are polymorphic including hematoma, seromuscular tear, perforation, and ischemia. They preferentially involve the small bowel and may result in bleeding and/or peritonitis. An urgent laparotomy is necessary if there is evidence of active bleeding or peritonitis at the initial examination, but these situations are uncommon. The main diagnostic challenge is to promptly and correctly identify lesions that require surgical repair. Diagnostic delay exceeding eight hours before surgical repair is associated with increased morbidity and probably with mortality. Because of this risk, the traditional therapeutic approach has been to operate on all patients with suspected bowel or mesenteric injury. However, this approach leads to a high rate of non-therapeutic laparotomy. A new approach of non-operative management (NOM) may be applicable to hemodynamically stable patients with no signs of perforation or peritonitis, and is being increasingly employed. This attitude has been described in several recent studies, and can be applied to nearly 40% of patients. However, there is no consensual agreement on which criteria or combination of clinical and radiological signs can insure the safety of NOM. When NOM is decided upon at the outset, very close monitoring is mandatory with repeated clinical examinations and interval computerized tomography (CT). Larger multicenter studies are needed to better define the selection criteria and modalities for NOM.
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Affiliation(s)
- T Bège
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
| | - C Brunet
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
| | - S V Berdah
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
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16
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Swaid F, Peleg K, Alfici R, Matter I, Olsha O, Ashkenazi I, Givon A, Kessel B. Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database. Injury 2014; 45:1409-12. [PMID: 24656303 DOI: 10.1016/j.injury.2014.02.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 02/12/2014] [Accepted: 02/20/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Non-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries. METHODS A retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined. RESULTS Of the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H+S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H+S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group. CONCLUSIONS The presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury.
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Affiliation(s)
- Forat Swaid
- General Surgery Department, Bnai-Zion Medical Center, Haifa, Israel.
| | - Kobi Peleg
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Ricardo Alfici
- Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel
| | - Ibrahim Matter
- General Surgery Department, Bnai-Zion Medical Center, Haifa, Israel
| | - Oded Olsha
- Surgery Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Adi Givon
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | | | - Boris Kessel
- Trauma Unit, Hillel Yaffe Medical Center, Hadera, Israel
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17
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Hazlitt M, Hill JB, Gunter OL, Guillamondegui OD. Disparities in trauma: the impact of socioeconomic factors on outcomes following traumatic hollow viscus injury. J Surg Res 2013; 191:6-11. [PMID: 24731764 DOI: 10.1016/j.jss.2013.05.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 05/06/2013] [Accepted: 05/10/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND This piece aims to examine the relationships between hollow viscus injury (HVI) and socioeconomic factors in determining outcomes. HVI has well-defined injury patterns with complex postoperative convalescence and morbidity, representing an ideal focus for identifying potential disparities among a homogeneous injury population. MATERIALS AND METHODS A retrospective review included patients admitted to a level I trauma center with HVI from 2000-2009, as identified in the Trauma Registry of the American College of Surgeons. Patients with concomitant significant solid organ or vasculature injury were excluded. US Census (2000) median household income by zip code was used as socioeconomic proxy. Demographic and injury-related variables were also included. Endpoints were mortality and outcomes associated with HVI morbidity. RESULTS A total of 933 patients with HVI were identified and 256 met inclusion criteria. There were 23 deaths (9.0%), and mortality was not associated with race, gender, income, or payer source. However, lower median household income was significantly associated with longer intervals to ostomy takedown (P = 0.032). Additionally, private payers had significantly lower rates of anastomotic leak (0% [0/73] versus 7.1% [13/183], P = 0.019) and fascial dehiscence (5.5% [4/73] versus 16.9% [31/183], P = 0.016), while self-payers had significantly higher rates of abscess formation, both overall (24% [24/100] versus 10.2% [16/156], P = 0.004) and among penetrating injuries (27.4% [23/84] versus 13.6% [12/88], P = 0.036). CONCLUSIONS Socioeconomic status may not impact overall mortality among trauma patients with hollow viscus injuries, but private insurance appears to be protective of morbidity related to anastomotic leak, fascial dehiscence, and abscess formation. This supports that socioeconomic disparity may exist within long-term outcomes, particularly regarding payer source.
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Affiliation(s)
- Melissa Hazlitt
- Division of Trauma, Department of Surgery, Meharry Medical College, Nashville, Tennessee
| | - J Bradford Hill
- Division of Trauma, Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Oliver L Gunter
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oscar D Guillamondegui
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee.
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