Predicting hollow viscus injury in blunt abdominal trauma with computed tomography

The Diagnosis and Management of Pediatric Blunt Abdominal Trauma-A Comprehensive Review

Blunt abdominal trauma in childhood has always been full of diagnostic and therapeutic challenges that have tested the clinical and radiological skills of pediatric surgeons and radiologists. Despite the guidelines and the studies carried out so far, to this day, there is no absolute consensus on certain points of view. Around the world, a paradigm shift towards non-operative treatment of hemodynamically stable children, with low complication rates, is noticeable. Children with blunt abdominal trauma require a standardized methodology to provide the best possible care with the best possible outcomes. This comprehensive review systematizes knowledge about all aspects of caring for children with blunt abdominal trauma, from pre-hospital to post-hospital care.

Complete Transection of the Abdominal Wall Secondary to Being a Rear Seat-Belted Passenger

Garrett and Braunstein introduced the concept of the "seat belt sign" in motor vehicle collision (MVC) victims. They defined this as abdominal wall bruising from a lap belt. These signs of trauma are not uncommon. However, "seat belt syndrome," a pattern of musculoskeletal and internal organ injuries resulting from deceleration forces exerted by the safety device is rarely seen. Here, we illustrate a case of traumatic closed rupture of the rectus abdominis muscle secondary to seat belt injury. This potential injury is important to recognize and our case will illustrate the need for careful imaging review and clinical assessment to identify associated intra-abdominal injuries.

Prevalence of intra-abdominal injury among patients with seatbelt signs, a systematic review and meta-analysis

INTRODUCTION

The advancement of seat belts have been essential to reducing morbidity and mortality related to motor vehicle collisions (MVCs). The "seat belt sign" (SBS) is an important physical exam finding that has guided management for decades. This study, comprising a systematic review and random-effects meta-analysis, asses the current literature for the likelihood of the SBS relating to intra-abdominal injury and surgical intervention.

METHODS

PubMed and Scopus databases were searched from their beginnings through August 4, 2023 for eligible studies. Outcomes included the prevalence of intra-abdominal injury and need for surgical intervention. Cochrane's Risk of Bias (RoB) tool and the Newcastle-Ottawa Scale (NOS) were applied to assess risk of bias and study quality; Q-statistics and I2 values were used to assess for heterogeneity.

RESULTS

The search yielded nine observational studies involving 3050 patients, 1937 (63.5%) of which had a positive SBS. The pooled prevalence of any intra-abdominal injury was 0.42, (95% CI 0.28-0.58, I2 = 96%) The presence of a SBS was significantly associated with increased odds of intra-abdominal injury (OR 3.62, 95% CI 1.12-11.6, P = 0.03; I2 = 89%), and an increased likelihood of surgical intervention (OR 7.34, 95% CI 2.03-26.54, P < 0.001; I2 = 29%). The measurement for any intra-abdominal injury was associated with high heterogeneity, I2 = 89%.

CONCLUSION

This meta-analysis suggests that the presence of a SBS was associated with a statistically significant higher likelihood of intra-abdominal injury and need for surgical intervention. The study had high heterogeneity, likely due to the technological advancements over the course of this study, including seat belt design and diagnostic imaging sensitivity. Further studies with more recent data are needed to confirm these results.

Index CT-Based Scoring Systems in Operative Blunt Bowel and Mesenteric Injury Identification

INTRODUCTION

Determining the need for surgical management of blunt bowel and mesenteric injury (BBMI) remains a clinical challenge. The Faget score and Bowel Injury Prediction Score (BIPS) have been suggested to address this issue. Their efficacy in determining the need for surgery was examined.

METHODS

A retrospective review of all adult blunt trauma patients hospitalized at a level 1 trauma center between January 2009 and August 2019 who had small bowel, colon, and/or mesenteric injury was conducted. We further analyzed those who underwent preoperative computed tomography (CT) scanning at our institution. Final index CT reports were retrospectively reviewed to calculate the Faget and BIPS CT scores. All images were also independently reviewed by an attending radiologist to determine the BIPS CT score.

RESULTS

During the study period, 14,897 blunt trauma patients were hospitalized, of which 91 had BBMI. Of these, 62 met inclusion criteria. Among patients previously identified as having BBMI in the registry, the retrospectively applied Faget score had a sensitivity of 39.1%, specificity of 81.2%, positive predictive value (PPV) of 85.7%, and negative predictive value (NPV) of 31.7% in identifying patients with operative BBMI. The retrospectively applied BIPS score had a sensitivity of 47.8%, specificity of 87.5%, PPV of 91.7%, and NPV of 36.8% in this cohort. When CT images were reviewed by an attending radiologist using the BIPS criteria, sensitivity was 56.5%, specificity 93.7%, PPV 96.3%, and NPV 42.8%.

CONCLUSIONS

Existing BBMI scoring systems had limited sensitivity but excellent PPV in predicting the need for operative intervention for BBMI. Attending radiologist review of CT images using the BIPS scoring system demonstrated improved accuracy as opposed to retrospective application of the BIPS score to radiology reports.

Development and Validation of a Novel Hollow Viscus Injury Prediction Score for Abdominal Seatbelt Sign: A Pacific Coast Surgical Association Multicenter Study

BACKGROUND

High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification.

STUDY DESIGN

This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC).

RESULTS

Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%.

CONCLUSIONS

This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI.

Introduction of Laparoscopy in an Urban High-Volume Sub-Saharan Trauma Centre

INTRODUCTION

Trauma is a major disease burden in low and middle-income countries like South Africa. Abdominal trauma is one of the leading reasons for emergency surgery. The standard of care for these patients is a laparotomy. In selected trauma patients, laparoscopy has both diagnostic and therapeutic usage. The trauma burden and the number of cases seen in a busy trauma unit make laparoscopy challenging.

AIM

We wanted to describe our journey with laparoscopy in the management of abdominal trauma in a busy urban trauma unit in Johannesburg, South Africa.

METHODS

We reviewed all trauma patients who underwent diagnostic laparoscopy (DL) or therapeutic laparoscopy (TL) between 01 January 2017 and 31 October 2020 for blunt and penetrating abdominal trauma. The demographic data, indications for laparoscopy, injuries identified, procedures performed, intraoperative laparoscopic complications, conversion to laparotomy, morbidity, and mortality were evaluated.

RESULTS

A total of 54 patients who had laparoscopy were included in the study. The median age was 29 years (IQR 25-25). Most injuries were penetrating 85.2% (n = 46/54) and 14.8% blunt trauma. Most patients were males, 94.4% (n = 51/54). Indications for laparoscopy included diaphragm evaluation (40.7%), pneumoperitoneum for evaluation of potential bowel injury (16.7%), free fluid with no evidence of solid organ injury (12.9%) and colostomy (5.5%). There were 8 (14.8%) cases converted to laparotomy. There were no missed injuries or mortality in the study group.

CONCLUSION

Laparoscopy in selected trauma patients is safe even in a busy trauma unit. It is associated with less morbidity and shortened hospital length of stay.

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.

Do signs of abdominal wall injury on computed tomography predict intra-abdominal injury in trauma patients with a seatbelt sign?

BACKGROUND

A seatbelt sign in patients with blunt abdominal injury is associated with both abdominal wall and intra-abdominal injuries. This study aimed to assess the association between signs of abdominal wall injury on computed tomography (CT) and rates of intra-abdominal injury in patients with a blunt abdominal injury and a clinical seatbelt sign.

METHODS

This study includes hemodynamically stable trauma patients with blunt abdominal injury and a clinical seatbelt sign who were hospitalized in two regional trauma centers in Israel, during 2014-2019. All data were collected via the medical center's trauma registry in both centers.

RESULTS

We identified 123 stable blunt abdominal trauma patients with a seatbelt sign, of which 101 (82.1%) and 22 (17.9%) had a low-grade and high-grade abdominal wall injury according to CT findings, respectively. Laparotomy rates were significantly higher in patients with signs of high-grade abdominal wall injury (p<0.0001). No differences in the timing of laparotomy between low and high-grade injuries were found.

CONCLUSIONS

In stable patients with blunt abdominal trauma and a clinical seatbelt sign, the severity of abdominal wall injury, as represented by CT findings, may predict a need for surgical treatment.

Trauma de recto penetrante: revisión de tema

Introducción. En la actualidad, el trauma de recto continúa siendo una situación clínica compleja y temida por ser potencialmente mortal. Su detección y manejo temprano es la piedra angular para impactar tanto en la mortalidad como en la morbilidad de los pacientes. Hoy en día, aun existe debate sobre la aproximación quirúrgica ideal en el trauma de recto y las decisiones de manejo intraoperatorias se ven enormemente afectadas por la experiencia y preferencias del cirujano. Métodos. Se realizó una búsqueda de la literatura en las bases de datos de PubMed, Clinical Key, Google Scholar y SciELO utilizando las palabras claves descritas y se seleccionaron los artículos mas relevantes publicados en los últimos 20 años; se tuvieron en cuenta los artículos escritos en ingles y español. Discusión. El recto es el órgano menos frecuentemente lesionado en trauma, sin embargo, las implicaciones clínicas que conlleva pasar por alto este tipo de lesiones pueden ser devastadoras para el paciente. Las opciones para el diagnóstico incluyen el tacto rectal, la tomografía computarizada y la rectosigmoidoscopia. El manejo quirúrgico va a depender de la localización, el grado de la lesión y las lesiones asociadas. Conclusión. El conocimiento de la anatomía, el mecanismo de trauma y las lesiones asociadas permitirán al cirujano realizar una aproximación clínico-quirúrgica adecuada que lleve a desenlaces clínicos óptimos de los pacientes que se presentan con trauma de recto.

Application of Computed Tomography in the Identification of Hollow Viscus Injuries in Blunt Trauma Patients

Purpose: Despite advances in diagnostic and imaging technologies, the diagnosis of traumatic hollow viscus injury (HVI) remains a great challenge in clinical practice. This study aimed to determine the accuracy of computed tomography (CT) in the diagnosis of HVI in emergent blunt trauma patients.Methods: The study was conducted on patients with abdominal trauma who were admitted to our center, regional emergency center, Kyung Hee University Medical Center, between January 2008 and December 2018. The clinical data of patients with abdominal trauma who underwent CT and abdominal surgery within 24 hours of hospitalization were analyzed to determine the diagnostic capacity of CT.Results: In total, 156 patients were included in the study. There were 88 cases of blunt trauma. Among these patients, 27 were diagnosed with HVI using CT, and 38 patients were diagnosed with HVI in the operating room. The median injury severity score for these patients was 10.0, the revised trauma score was 7.841, and the trauma injury severity score was 0.96. The sensitivity and specificity of CT in predicting HVI in these patients were 65.8%, and 96.0%, respectively. The positive and negative predictive values were 92.6%, and 78.7%, respectively.Conclusion: In urgent situations, CT findings alone are insufficient for diagnosing HVI. Further research on the HVI diagnostic capacity of CT is required.

Diagnostic Accuracy of Computed Tomography for the Prediction of the Need for Laparotomy for Traumatic Hollow Viscus Injury: Systematic Review and Meta-Analysis

BACKGROUND

Traumatic hollow viscus injury (THVI) is one of the most difficult challenges in the trauma setting. Computed tomography (CT) is the most common modality used to diagnose THVI; however, various performance outcomes of CT have been reported. We conducted a systematic review and meta-analysis to analyze how precise and reliable CT is as a tool for the assessment of THVI.

METHOD

A systematic review and meta-analysis were conducted on studies on the use of CT to diagnose THVI. Publications were retrieved by performing structured searches in databases, review articles and major textbooks. For the statistical analysis, summary receiver operating characteristic (SROC) curves were constructed using hierarchical models.

RESULTS

Sixteen studies enrolling 12,514 patients were eligible for the final analysis. The summary sensitivity and specificity of CT for the diagnosis of THVI were 0.678 (95% CI: 0.501-0.809) and 0.969 (95% CI: 0.920-0.989), respectively. The summary false positive rate was 0.031 (95% CI 0.011-0.071).

CONCLUSION

In this meta-analysis, we found that CT had indeterminate sensitivity and excellent specificity for the diagnosis of THVI.

The Current Diagnostic Accuracy on Free Peritoneal Fluid in Computed Tomography to Determinate the Necessity of Surgery in Blunt Bowel and Mesenteric Trauma-Systemic Review and Meta-Analysis

Traumatic bowel mesenteric injury (TBMI) is a challenge in trauma care. The presence of free peritoneal fluid (FF) in computed tomography (CT) was considered the indication for surgical intervention. However, conservative treatment should be applied for minor injuries. We conduct a systematic review to analyze how reliable the FF is to assess the TBMI. Publications were retrieved by structured searching among databases, review articles and major textbooks. For statistical analysis, summary receiver operating characteristic curves (SROCs) were computed using hierarchical models. Fourteen studies enrolling 4336 patients were eligible for final qualitative analysis. The SROC line was created by a hierarchical summary receiver operating characteristic model. The summary sensitivity of FF to predict surgical TBMI was 0.793 (95% CI: 0.635-0.894), and the summary specificity of FF to predict surgical TBMI was 0.733 (95% CI: 0.468-0.896). The diagnostic odds ratio was 10.531 (95% CI: 5.556-19.961). This study represents the most robust evidence (level 3a) to date that FF is not the absolute but an acceptable indicator for surgically important TBMI. However, there is still a need for randomized controlled trials to confirm.

How long of a postponement in surgery can a blunt hollow viscus injury patient tolerate? A retrospective study from the National Trauma Data Bank

BACKGROUND

In the management of patients with blunt abdominal trauma, delayed diagnosis and treatment of hollow viscus injury can occur. We assessed the effect of the time to surgery on the outcomes of blunt hollow viscus injury patients.

METHODS

The National Trauma Data Bank was queried from 2012 to 2015 to identify patients with blunt hollow viscus injury for inclusion. Patients with unstable hemodynamics, concomitant intra-abdominal organ injuries, or other severe extra-abdominal injuries were excluded. Inverse probability of treatment weighting and multivariate logistic regression were used to evaluate the effect of the time to surgery on the outcomes.

RESULTS

In total, 2,997 patients with blunt hollow viscus injury were studied; the mean time to abdominal surgery was 6.7 hours. Twenty-two hours was selected as a cutoff value for further analyses because of an observed transition zone at that time in the distribution of mortality and severe sepsis rates. After adjustment, patients who underwent surgery within 22 hours had a significantly lower mortality rate (1.2% vs 4.2%), lower sepsis rate (0.9% vs 4.5%), shorter hospital length of stay (8.7 vs 12.0 days), and shorter intensive care unit length of stay (1.4 vs 3.3 days). In patients who underwent surgery within 22 hours, neither mortality nor sepsis were affected significantly by the time to surgery.

CONCLUSION

In the management of patients with blunt hollow viscus injury, early surgical treatment is needed. Patients with isolated blunt hollow viscus injury may have a poor outcome if they undergo abdominal surgery more than 22 hours after arrival in the emergency department.

Iliac ecchymosis, a valuable sign for hollow viscus injuries in blunt pelvic trauma patients

PURPOSE

Pelvic fractures are characterized by high energy injuries and often accompanied with abdominal and pelvic organ injury. CT has been applied for several decades to evaluate blunt pelvic trauma patients. However, it has a certain rate of inaccurate diagnosis of abdominal hollow viscus injury (HVI), especially in the early stage after injury. The delayed diagnosis of HVI could result in a high morbidity and mortality. The bowel injury prediction score (BIPS) applied 3 clinical variables to determine whether an early surgical intervention for blunt HVI was necessary. We recently found another clinical variable (iliac ecchymosis, IE) which appeared at the early stage of injury, could be predicted for HVI. The main objective of this study was to explore the novel combination of IE and BIPS to enhance the early diagnosis rate of HVI, and thus reduce complications and mortalities.

METHODS

We conducted a retrospective analysis from January 2008 to December 2018 and recorded blunt pelvic trauma patients in our hospital. The inclusion criteria were patients who were verified with pelvic fractures using abdomen and pelvis CT scan in the emergency department before any surgical intervention. The exclusion criteria were abdominal CT insufficiency before operation, abdominal surgery before CT scan, and CT mesenteric injury grade being 5. The MBIPS was defined as BIPS plus IE, which was calculated according to 4 variables: white blood cell counts of 17.0 or greater, abdominal tenderness, CT scan grade for mesenteric injury of 4 or higher, and the location of IE. Each clinical variable counted 1 score, totally 4 scores. The location and severity of IE was also noted.

RESULTS

In total, 635 cases were hospitalized and 62 patients were enrolled in this study. Of these included patients, 77.4% (40 males and 8 females) were operated by exploratory laparotomy and 22.6% (8 males and 6 females) were treated conservatively. In the 48 patients underwent surgical intervention, 46 were confirmed with HVI (45 with IE and 1 without IE). In 46 patients confirmed without HVI, only 3 patients had IE and the rest had no IE. The sensitivity and specificity of IE in predicting HVI was calculated as 97.8% (45/46) and 81.3% (13/16), respectively. The median MBIPS score for surgery group was 2, while 0 for the conservative treatment group. The incidence of HVI in patients with MBIPS score ≥ 2 was significantly higher than that in patients with MBIPS score less than ≤ 2 (OR = 17.3, p < 0.001).

CONCLUSION

IE can be recognized as an indirect sign of HVI because of the high sensitivity and specificity, which is a valuable sign for HVI in blunt pelvic trauma patients. MBIPS can be used to predict HVI in blunt pelvic trauma patients. When the MBIPS score is ≥ 2, HVI is strongly suggested.

Incidence, outcomes and effect of delayed intervention in patients with hollow viscus injury due to major trauma in the Northern region of New Zealand

BACKGROUND

Patients with hollow viscus injury (HVI) are often a cause for diagnostic uncertainty. The incidence and outcomes of patients suffering hollow viscus injury secondary to major trauma have not been previously described in New Zealand. These metrics are important to guide quality improvement and resource allocation. The aim of our study is to define the incidence, outcomes and effect of delayed intervention on patients admitted to hospital with hollow viscus injury secondary to blunt abdominal trauma in the Northern region of New Zealand.

METHODS

A 4-year multicentre retrospective study was performed in the Northern region of New Zealand between 1 July 2015 and 30 June 2019. A primary cohort of patients with confirmed hollow viscus injury secondary to blunt abdominal injury, who underwent a laparotomy, were assessed. The primary outcome measures were incidence, 30-day mortality and morbidity. Secondary outcomes included the effect of timing of surgical intervention.

RESULTS

The incidence of hollow viscus injury in the region was 2.03 per 100 000. The 30-day mortality rate was 5% and the 30-day morbidity rate was 82%. Immediate surgical intervention was carried out in 36%, early surgical intervention in 56% and delayed surgical intervention in 8%.

CONCLUSION

The incidence of hollow viscus injury is in keeping with similar studies, but with lower mortality and higher morbidity. The rate of immediate or early surgical intervention was high. These findings are important to clinicians managing patients with major trauma and those involved in planning and allocation of resources.

Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis

BACKGROUND

Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT.

METHODS

A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project.

RESULTS

In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model.

CONCLUSIONS

ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.

Findings requiring immediate surgery in blunt abdominal trauma patients with isolated free fluid without solid organ injury on abdominal computed tomography: Retrospective laboratory, clinical and radiologic analysis. A case control study

BACKGROUND

Determining surgical treatment is difficult in blunt abdominal trauma (BAT) patients with isolated free fluid without solid organ injury (IFFWSOI) on abdominal computed tomography (CT). We investigated the laboratory, clinical, and radiologic features of BAT patients with IFFWSOI on abdominal CT requiring surgery.

METHODS

A retrospective medical record review was performed for patients treated at our government-established regional tertiary trauma center from March 2014 to August 2018. A total of 501 patients were identified and reviewed. Patients were divided into Surgery and No Surgery groups for analysis. The Surgery group included patients who underwent surgery during the index admission, while the No Surgery group included patients who did not undergo surgery.

RESULTS

There were significantly more cases of severe fluid collection (61.5% vs. 11.8%; p < 0.001), car accidents (69.2% vs. 35.3%; p = 0.018), and abdominal pain (87.2% vs. 58.8%; p = 0.031) at the emergency department in the Surgery group. Regarding laboratory studies performed at the emergency department, only the median amylase level was significantly higher in the No Surgery group (54.5 U/L vs. 62.5 U/L; p = 0.048). On multivariate logistic regression analysis with adjustments for age and sex, the odds ratio (OR) for severe fluid collection on abdominal CT to predict surgery was 13.52 (p = 0.006), while the OR for abdominal pain was 7.34 (p = 0.036) and the OR for car accident was 2.14 (p = 0.329). In addition, a multivariate logistic regression with adjustment for age, sex, delta neutrophil index, and C-reactive protein, showed the same propensity as the other model, although statistical significance was retained only for severe fluid collection.

CONCLUSION

Surgical treatment should be actively considered in the presence of a large volume of intra-abdominal free fluid, especially when concomitant with abdominal pain or after car accidents in BAT patients without solid organ injury.

No need for surgery? Patterns and outcomes of blunt abdominal trauma

Introduction

The management of a patient suffering from blunt abdominal trauma (BAT) remains a challenge for the emergency physician. Within the last few years, the standard therapy for hemodynamically stable patients with BAT has transitioned to a non-operative approach. The purpose of this study is to evaluate the outcome of patients with BAT and to determine the reasons for failure of non-operative management (NOM).

Materials and methods

Analysis of 176 consecutive patients treated for BAT was conducted in a German level 1 trauma center from 2004 to 2011. Abdominal injuries were classified according to the American Association for the Surgery of Trauma (AAST). Patients included were demonstrated to have objective abdominal trauma with either free fluid on focused assessment with sonography for trauma (FAST) or computed tomography (CT), or proven organ injury.

Results

Patients, 142 of 176 (80.7%), with BAT were initially managed non-operatively, with a success rate of 90%. The rates of NOM success were higher among those with less severe injuries; 100% with Abbreviated Injury Scale (AIS) of 1. In total, 125 patients (71.0%) were managed non-operatively, and 51 (29.0%) required surgical intervention. NOM failure occurred in 9.2% of the patients, the most common reason being initially undiagnosed intestinal perforation (46.2%). Positive correlation was identified (r = 0.512; p < 0.001) between the ISS (injury severity score) and the NACA (National Advisory Committee of Aeronautics) score. The delay in operation in NOM failure was 6 h in patients with underlying hepatic or splenic rupture and 34 h with intestinal perforation. The overall mortality of 5.1% was attributed especially to old age (p = 0.016), high severity of injury (p < 0.001), and greater need for blood transfusion (p < 0.001).

Conclusion

NOM was successful for the vast majority of blunt abdominal trauma patients, especially those with less severe injuries. NOM failure and operative delay were most commonly due to occult hollow viscus injury (HVI), the detection of which was achieved by close clinical observation and abdominal ultrasound in conjunction with monitoring for rising markers of infection and by multidetector computed tomography (MDCT) if additionally indicated. Based on this concept, the delay in operation in patients with NOM failure was short. This study underscores the feasibility and benefit of NOM in BAT.

Traumatic rectal injuries: Is the combination of computed tomography and rigid proctoscopy sufficient?

BACKGROUND

There are no clear guidelines for the best test or combination of tests to identify traumatic rectal injuries. We hypothesize that computed tomography (CT) and rigid proctoscopy (RP) will identify all injuries.

METHODS

American Association for the Surgery of Trauma multi-institutional retrospective study (2004-2015) of patients who sustained a traumatic rectal injury. Patients with known rectal injuries who underwent both CT and RP as part of their diagnostic workup were included. Only patients with full thickness injuries (American Association for the Surgery of Trauma grade II-V) were included. Computed tomography findings of rectal injury, perirectal stranding, or rectal wall thickening and RP findings of blood, mucosal abnormalities, or laceration were considered positive.

RESULTS

One hundred six patients were identified. Mean age was 32 years, 85(79%) were male, and 67(63%) involved penetrating mechanisms. A total of 36 (34%) and 100 (94%) patients had positive CT and RP findings, respectively. Only 3 (3%) patients had both a negative CT and negative RP. On further review, each of these three patients had intraperitoneal injuries and had indirect evidence of rectal injury on CT scan including pneumoperitoneum or sacral fracture.

CONCLUSION

As stand-alone tests, neither CT nor RP can adequately identify traumatic rectal injuries. However, the combination of both test demonstrates a sensitivity of 97%. Intraperitoneal injuries may be missed by both CT and RP, so patients with a high index of suspicion and/or indirect evidence of rectal injury on CT scan may necessitate laparotomy for definitive diagnosis.

LEVEL OF EVIDENCE

Diagnostic, level IV.

Surgical intervention for blunt bowel and mesenteric injury: indications and time intervals

PURPOSE

Decision making in management of blunt bowel and mesenteric injury (BBMI) is difficult. This study aimed to identify indicators for laparotomy and appropriate time intervals to surgery.

METHODS

We retrospectively reviewed our hospital's trauma registry to identify patients with a diagnosis of BBMI from February 2011 to July 2017. Patients requiring therapeutic surgical treatment (OM group) were compared with those who did not (NOM group). Preoperative risk factors for surgery (with p < 0.1 by univariate analysis) were integrated in a multivariate logistic regression model. In the OM group, we identified relevant factors for time intervals to surgical interventions.

RESULTS

Among 2808 trauma patients admitted to our hospital, 83 (3.0%) had bowel and mesenteric injury; 6 patients with penetrating trauma, 2 lethal, untreated cases, and 2 patients who underwent exploratory laparotomy were excluded. Finally, 73 patients (47 males), with a mean Injury Severity Score (ISS) of 23, were included. Results from univariate analysis identified three relevant factors between the OM and NOM groups: ISS score (p = 0.036), hemodynamic instability (p = 0.041), and free air (p = 0.0018). Multivariate analysis revealed one relevant factor, free air (p = 0.0002). Short intervals between hospital admission and intervention were associated with 7-day mortality (p = 0.029), hemodynamic instability (p = 0.0009), focused assessment with sonography for trauma positive (p < 0.0001), and mesenteric extravasation (p = 0.012).

CONCLUSIONS

Early surgical intervention is essential in cases of hemodynamically unstable BBMI and bowel perforation with free air; nevertheless, it is associated with high mortality. We suggest that prompt transport along with early intervention could significantly lessen mortality.

A big mesenteric rupture after blunt abdominal trauma: A case report and literature review

INTRODUCTION

A blunt abdominal trauma especially in organs less commonly injured (such as small bowel and mesentery injury), are difficult to diagnose.

PRESENTATION OF CASE

We report a case of a blunt abdominal trauma, in a 43 year old male presented in the Emergency Department after a truck vehicle accident. He sustained a chest injury, a pelvic fracture and diffuse abdominal tenderness. The patient had tachycardia (120 pulses/min) and normal blood pressure (120/90mmHg). The computed tomography (CT) showed only free fluid. We placed two chest tubes (due to pneumothorax and hemothorax at both sides) and the patient went to the operating room (OP). An external pelvic osteosynthesis was performed first and then we did an exploratory laparotomy, which revealed a big mesenteric rupture. Finally, an enterectomy (circa 2m) with a fist stage side to side anastomosis was performed.

DISCUSSION

Mesentery and bowel injury constitutes 3-5% of blunt abdominal injuries. The main diagnostic challenge is to identify lesions that require surgery. Diagnostic delay over 8h can lead to high morbidity and mortality rates. Laparotomy is the standard of care in hemodynamically unstable patients.

CONCLUSION

In polytrauma cases with abdominal pain and unclear CT findings the decision to proceed with exploratory laparotomy is better than a conservative treatment, because any surgical delay can lead to severe complications.

Laparoscopic Management of Pediatric Abdominal Trauma: A National Trauma Data Bank Experience

Purpose: To characterize injury patterns and institutional trends associated with the utilization of laparoscopy in the management of pediatric abdominal trauma. Methods: The National Trauma Data Bank (2010-2014) was queried for encounters involving patients ≤14 years who underwent an open or laparoscopic abdominal operation within 48 hours of emergency department arrival. Patient, injury, and hospital characteristics associated with each approach were identified. Multivariate logistic regression was used to evaluate the influence of patient and hospital characteristics on operative approach. Results: Laparoscopy comprised 7.8% (n = 355) of all abdominal trauma operations. Patients undergoing laparoscopy had lower injury severity scores and higher Glasgow Coma Scale scores on arrival compared with laparotomy subjects (P < .001). Laparoscopic patients also had a shorter length of hospital stay (5.0 versus 8.6 days, P < .001), but longer time to the operating room (9.2 versus 6.3 hours, P < .001) compared with their open counterparts. The proportion of cases managed laparoscopically increased from 6.2% in 2010 to 10.1% in 2014 (P = .013), with increase in utilization primarily driven by university hospitals (P = .026) and level I pediatric trauma centers (P = .043). Conversion to laparotomy was uncommon (18.6%), and mortality in the laparoscopic cohort was low (0.4%). Conclusions: Use of laparoscopy has increased in the pediatric abdominal trauma population, typically in a less injured cohort of patients. As familiarity with and availability of minimally invasive techniques increase, this trend will likely continue.

Defining an intra-operative blunt mesenteric injury grading system and its use as a tool for surgical-decision making

BACKGROUND

The mesentery may be injured in trauma and few grading systems describe mesenteric injury severity. We aimed to develop and validate an intra-operative mesenteric injury grading system.

METHODS

A modified Delphi technique was used to generate an intraoperative grading system for blunt mesenteric injury called the mesenteric injury score (MIS). We performed a retrospective review (2010-2016) of patients >15 years old with blunt abdominal trauma. Patient demographics, injury severity score (ISS) and mechanism, clinical, operative, and outcome data were abstracted. The intraoperative grading system was used to describe patient outcomes including duration of stay and management approach. We compared the correlation of abdominal abbreviated injury score, Blunt Injury Prediction Score (BIPS) and the MIS with clinical outcomes using Spearman's rho.

RESULTS

There were fifty-one patients of which 86% were male. Injury mechanisms included motor vehicle accidents (n = 37, 73%), pedestrian vehicle accidents (n = 7, 13%), assaults (n = 4, 8%), falls (n = 2, 4%), and a single airplane crash (2%). Median [IQR] ISS was 16 [10-25] and GCS at hospital admission was 15 [15-15]. The median [IQR] international normalized ratio was 1.2 [1.1-1.5], lactate was 2.7 [1.7-4.9], and hemoglobin was 11.4 [8.6-12.2]. The distributions of MIS included Grade I (3, 5%), Grade II (10, 20%), Grade III (10, 20%), Grade IV, 5 (10%), and Grade V (23, 45%). Increasing mesenteric injury grade was associated with longer duration of stay, need for bowel resection, and damage control laparotomy.

CONCLUSIONS

We developed an intra-operative mesenteric injury grading system (MIS) and provided an initial retrospective validation using a series of patients with blunt abdominal trauma. The proposed MIS corresponded with both the AIS and the BIPS. Future study comparing cross sectional imaging and operative findings based on MIS criteria is needed.

Occult bowel injury after blunt abdominal trauma

BACKGROUND

Following blunt abdominal trauma, bowel injuries are often missed on admission computed tomography (CT) scan.

METHODS

Multicenter retrospective analysis of 176 adults with moderate-critical blunt abdominal trauma and admission CT scan who underwent operative exploration. Patients with a bowel injury missed on CT (n = 36, 20%) were compared to all other patients (n = 140, 80%).

RESULTS

The missed injury group had greater incidence free fluid without solid organ injury on CT scan (44% vs. 25%, p = 0.038) and visceral adhesions (28% vs. 6%, p = 0.001). Independent predictors of missed bowel injury included prior abdominal inflammation (OR 3.74, 95% CI 1.37-10.18), CT evidence of free fluid in the absence of solid organ injury (OR 2.31, 95% CI 1.03-5.19) and intraoperative identification of visceral adhesions (OR 4.46, 95% CI 1.52-13.13).

CONCLUSIONS

Patients with visceral adhesive disease and indirect evidence of bowel injury on CT scan were more likely to have occult bowel injury.

Laparoscopy for Trauma and the Changes in its Use From 1990 to 2016: A Current Systematic Review and Meta-Analysis

BACKGROUND

The role of laparoscopy in the diagnosis and treatment of stable abdominal trauma patients is still a matter of serious debate and only incomplete data are available.

MATERIALS AND METHODS

We performed a systematic review and meta-analysis of the literature between January 1990 and August 2016.

RESULTS

Overall, 9817 laparoscopies were performed for abdominal trauma; only 26.2% of the cases were converted to a laparotomy. The incidence of therapeutic laparotomies showed a reduction from 69% to 47.5%, whereas the incidence of therapeutic laparoscopies increased from 7.2% to 22.7%.The overall perioperative mortality rate was significantly lower in the laparoscopy group [odds ratio (M-H, random); 95% confidence interval, 0.35 (0.26-0.48)]. The same group showed shorter length of hospital stay [odds ratio (M-H, random); 95% confidence interval, -3.48 (-8.91 to 1.96)].

CONCLUSIONS

This systematic review shows a significant decrease in the use of laparoscopy in trauma patients. Most likely the widespread use of imaging techniques allows a more accurate selection of patients for diagnostic laparoscopy. Infact, a reduction in incidence of nontherapeutic laparotomies is evident in these selected patients undergoing diagnostic laparoscopy. Moreover, the literature reported an increasing trend of therapeutic laparoscopy, demonstrating that it is safe and effective. The small number and poor quality of the studies identified, the retrospective observational nature of the studies (low level of evidence), the high risk of bias, and the high heterogeneity of some outcomes make the applicability of the results of this meta-analysis unclear.

Clinical Impact of Iatrogenic Small Bowel Perforation Secondary to Laparoscopic Cholecystectomy: A Single-center Experience

OBJECTIVE

Bowel, vascular, and biliary injuries during laparoscopic cholecystectomy (LC) have to be addressed with high priority. The focus of this study was on small bowel injury (SBI) and its impact on clinical management.

METHODS

We report 5 cases of SBI in a retrospective database of 2062 consecutive LC between January 2004 and December 2017.

RESULTS

We report isolated iatrogenic SBI in 0.24% (5 of 2062) after LC. We identified 3 cases with SBI associated with the technique of Hasson or related problems with intraoperative relaxation toward the end of the LC. All 5 patients needed at least 1 reoperation. There was no mortality in this series and all patients with iatrogenic SBI got discharged from the clinic in good health. Nevertheless, 3 of 5 patients (60%) with SBI filed a law suit.

CONCLUSIONS

Isolated iatrogenic SBI is a rare but dreaded complication after LC with high impact on patient's health and prone for medicolegal claims. Strict precaution on thorough relaxation throughout the operation, meticulous handling of closing technique of the fascial layer and "eternal vigilance" are mandatory to reduce risks of SBI after LC.

Ability of specific and nonspecific signs of multidetector computed tomography (MDCT) in the diagnosis of blunt surgically important bowel and mesenteric injuries

PURPOSE

To determine the accuracy of MDCT in the evaluation of blunt surgically relevant bowel and/or mesenteric injuries (BMIs) using single specific CT signs together with specific pairs of nonspecific signs.

METHODS

Fifty-four patients examined with MDCT were divided into two groups: a 'surgical' group of 20 patients-which underwent surgery for blunt BMIs-and a control group of 34 'nonsurgical' trauma patients. Two radiologists with different experience performed a double-blind retrospective evaluation of the images, classifying the patients in the two groups by using only single specific signs; then, the images were reviewed in consensus with a third radiologist and sensitivity and specificity were calculated. Subsequently, the frequency of every single sign and of every possible combination of nonspecific signs in the two groups was registered, to find combinations present only in the surgical group; sensitivity and specificity were calculated by using even those specific combinations.

RESULTS

At the first consensual evaluation, sensitivity and specificity were 75 and 100%, respectively. Two combinations of nonspecific signs (focal wall thickening + extraluminal air; focal wall thickening + seat belt sign) were found only in surgical patients that did not present any single specific sign: Sensitivity calculated adding those two combinations was 95%, without a decrease in specificity.

CONCLUSIONS

MDCT is an accurate technique in the evaluation of blunt surgically relevant BMIs. The single specific CT signs were sufficient for the diagnosis in only 75% of the cases; adding the two specific combinations allowed an increase in sensitivity of 20%.

Outcomes of selective surgery in patients with suspected small bowel injury from blunt trauma

Purpose

The role of initial conservative therapy with selective surgery for patients with suspected blunt bowel injury by radiologic evaluation is less clear. The aim of the study is to assess the outcomes of patients who received initial conservative therapy with selective delayed surgery, compared to emergency surgery.

Methods

During this 8-year study, a total of 77 patients who were hemodynamically stable were enrolled, in which computed tomography verified suspected bowel injury from blunt trauma (mesenteric hematoma, mesenteric fat infiltration, bowel wall thickening, and free fluid without solid organ injury) was managed with either initial conservative therapy with selective delayed surgery (group A; n = 42) or emergency surgery (group B; n = 35). The clinical outcomes including the rate of negative or nontherapeutic exploration and postoperative complications, between the groups were compared.

Results

The enrolled patients had a mean age of 41 years including 51 men and 26 women. No difference in the clinical characteristics was found between the groups. In group A, 18 patients underwent delayed surgery and 24 recovered without surgery. Among patients who underwent surgery, 3 (17%) underwent negative or nontherapeutic explorations. In group B, 13 (37%) underwent negative or nontherapeutic explorations. Postoperative complications occurred in 21 patients and there was no difference between the groups.

Conclusion

Initial conservative therapy with selective delayed surgery did not increased severe postoperative complications and had a low rate of negative or nontherapeutic surgical explorations in hemodynamically stable patients with suspected blunt bowel injury.

Clinical outcomes and effect of delayed intervention in patients with hollow viscus injury due to blunt abdominal trauma: a systematic review

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.

The Predictive Value of Repeated Abdominal Ultrasonography in Patients with Multiple Trauma and Decreased Level of Consciousness: The Experience of a Resource-Limited Centre

Objective

To determine the predictive value of repeated abdominal ultrasonography in patients with multiple trauma and decreased level of consciousness (LOC).

Methods

This prospective cross-sectional study was conducted over a six-month period at Shahid Rajaee Trauma Hospital, Shiraz, Iran. We included hemodynamically stable blunt abdominal trauma patients with a decreased LOC (Glasgow Coma Scale ≤ 13) who were referred to the neurosurgery ICU ward. Included cases underwent 1 contrast-enhanced CT scan and two-time ultrasonographic study of the abdomen with an interval of 48 hours. The diagnostic accuracy of the ultrasonography was determined according to the CT-scan results.

Results

Overall 80 patients with mean age of 37.75 ± 18.67 years were included. There were 17 (21.3%) women and 63 (78.8%) men among the patients. Compared with the CT-Scan, the first ultrasonography showed a sensitivity of 60%, specificity of 80%, PPV of 16.60%, NPV of 96.80%, and a diagnostic accuracy of 70%. The same values for the second ultrasonographic study were 80%, 79%, 20%, 98%, and 79%, respectively. In 4 (5%) patients whose first ultrasonography and CT scan results were negative, the second ultrasonography was positive for injury.

Conclusion

In patients with blunt trauma to the abdomen, when the only indication of abdominal CT scan is a decreased LOC, two ultrasonographic studies can replace a CT imaging.

Surgical Management of Abdominal Trauma: Hollow Viscus Injury

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.

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

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.

Laparoscopy in Blunt Abdominal Trauma: for Whom? When?and Why?

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.

Jejunum and ileum blunt trauma: what has changed with the implementation of multislice computed tomography?

OBJECTIVE

to evaluate the impact of the new technology of multidetector computed tomography (MDCT) in improving the accuracy and early diagnosis of BSBI.

METHODS

patients with blunt small bowel injuries (BSBI) grade> I were identified retrospectively and their CT scans reviewed by an experienced radiologist. Clinical and tomographic findings were analyzed and patients grouped as "pre-MDCT" and "post-MDCT", according to the time of implementation of a 64-slice MDCT.

RESULTS

of the 26 patients with BSBI 16 had CT scans. Motor vehicle collision (62.5%) was the most frequent mechanism of injury. In the pre-MDCT period, five of the 13 patients (38.5%) had abdominal CT, and in the post-MDCT, 11 of 13 patients (84.6%) had the exam. During pre-MDCT, all CT scans were abnormal with findings of pneumoperitoneum (60%), free fluid (40%) and bowel wall enhancement (20%). In the post-MDCT group, all exams but one were abnormal and the most frequent findings were free fluid (90.9%), bowel wall enhancement (72.7%), and pneumoperitoneum (54.5%). However, the rate of delayed laparotomy did not change. The mortality rate in both groups were similar, with 20% during pre-MDCT and 18.2% during post-MDCT.

CONCLUSION

the use of MDCT in abdominal trauma in our service has increased the sensibility of the diagnosis, but has had no impact on outcome so far.

Contemporary characteristics of blunt abdominal trauma in a regional series from the UK

INTRODUCTION Blunt abdominal trauma (BAT) is a common injury in recent trauma series. The characteristics of patients with BAT have changed following the reconfiguration of UK trauma services. The aim of this study was to build a new profile for BAT patients undergoing immediate or delayed laparotomy. METHODS All 5,401 consecutive adults presenting with major trauma between April 2012 and April 2014 in the 3 major trauma centres in the West Midlands were analysed to identify all patients with BAT. A total of 2,793 patients with a mechanism of injury or symptomatology consistent with BAT were identified (52%). Outcomes were analysed using local electronic clinical results systems and notes. RESULTS Of the 2,793 patients, 179 (6.4%) had a mesenteric or hollow viscus injury, 168 (6.0%) had a hepatobiliary injury, 149 (5.4%) had a splenic injury and 46 (1.6%) had a vascular injury. Overall, 103 patients (3.7%) underwent an early (<12 hours) laparotomy while 30 (1.1%) underwent a delayed (>12 hours) laparotomy. Twenty (66.7%) of those undergoing a delayed laparotomy had a hollow viscus injury. In total, 170 deaths occurred among the BAT patients (6.1%). In the early laparotomy group, 53 patients died (51.5%) whereas in the delayed laparotomy group, 6 patients died (20.0%). CONCLUSIONS This series has attempted to provide the characteristics of patients with BAT in a large contemporary UK cohort. BAT was found to be a common type of injury. Early and delayed laparotomy occurred in 3.7% and 1.1% of these patients respectively, mostly because of hollow viscus injury in both cases. Outcomes were comparable with those in the international literature from regions with mature trauma services.

Hollow viscus injury due to blunt trauma: A review

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.

Seat belt syndrome: Delayed or missed intestinal injuries, a case report and review of literature

INTRODUCTION

Seat belt injuries are not uncommon. The use of seat belts is associated with a unique injury profile collectively termed "the seat belt syndrome". The aim is to aid in the early diagnosis of seat belt injuries.

CASE PRESENTATION

Two different patients presented to the emergency after sustaining a motor vehicle accident. Both were the drivers, restrained and had a frontal impact. On presentation they were hemodynamically stable with mild tenderness on the abdomen and the abdominal computed tomography (CT) did not show any signs of bowel or mesenteric injuries. The signs of peritonitis became obvious after 24h in one case and after 3 days in the other.

DISCUSSION

Early diagnosis provides better outcomes for patients with seat belt injuries, but this remains a challenge to trauma surgeons. The typical findings of peritonitis might not be present initially. The presence of abdominal wall ecchymosis (seat belt sign) increases the chance of intraabdominal injuries by eight folds.

CONCLUSION

Clinical signs of intestinal injuries might not be obvious on presentation. In the presence of seat belt sign the possibility of bowl injury must be suspected. Admit the patient for observation even if no clinical or radiological findings are present at presentation.

Specific Radiological Findings of Traumatic Gastrointestinal Tract Injuries in Patients with Blunt Chest and Abdominal Trauma

Gastrointestinal hollow viscus injury after blunt chest and abdominal trauma is uncommon and complicates 0.6%-1.2% of all cases of trauma. Early recognition of such injuries significantly decreases morbidity and mortality. Since physical examination is not accurate in detecting such injuries, contrast-enhanced computed tomography has been the mainstay for diagnosis in many emergency departments. This pictorial essay aims to review the incidence, mechanisms, and signs of gastrointestinal hollow viscus injuries in the setting of blunt chest and abdominal trauma.

Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database

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.

A novel practical scoring for early diagnosis of traumatic bowel injury without obvious solid organ injury in hemodynamically stable patients

OBJECTIVES

To develop a scoring tool based on clinical and radiological findings for early diagnosis and intervention in hemodynamically stable patients with traumatic bowel and mesenteric injury (TBMI) without obvious solid organ injury (SOI).

METHODS

A retrospective analysis was conducted for all traumatic abdominal injury patients in Qatar from 2008 to 2011. Data included demographics and clinical, radiological and operative findings. Multivariate logistic regression was performed to analyze the predictors for the need of therapeutic laparotomy.

RESULTS

A total of 105 patients met the inclusion criteria with a mean age of 33 ± 15. Motor Vehicle Crashes (58%) and fall (21%) were the major MOI. Using Receiver operating characteristic curve, Z-score of >9 was the cutoff point (AUC = 0.98) for high probability of the presence of TBMI requiring surgical intervention. Z-Score >9 was found to have sensitivity (96.7%), specificity (97.4%), PPV (93.5%) and NPV (98.7%). Multivariate regression analysis found Z-score (>9) to be an independent predictor for the need of exploratory laparotomy (OR7.0; 95% CI: 2.46-19.78, p = 0.001).

CONCLUSION

This novel tool for early diagnosis of TBMI is found to be simple and helpful in selecting stable patients with free intra-abdominal fluid without SOI for exploratory Laparotomy. However, further prospective studies are warranted.

Laparoscopy in the acute abdomen

Laparoscopy has become a routine procedure in the management of acute abdominal disease and can be considered both an excellent therapeutic and additional diagnostic tool in selected cases. However, a high level of expertise in laparoscopic and emergency surgery is required. Hemodynamic instability, huge abdominal distension, fecal peritonitis and perforated cancer are relative contraindications for the laparoscopic approach. In recent years, abdominal emergencies have increasingly been managed successfully by laparoscopy. In acute appendicitis, acute cholecystitis and perforated peptic ulcer, randomized controlled trials have proven that the laparoscopic approach is as safe and as effective as open surgery, with fewer complications and a quicker postoperative recovery. Other indications such as blunt and penetrating trauma to the abdomen, small bowel occlusion and perforated diverticular disease are under debate, indicating that more randomized controlled trials comparing laparoscopic and open surgery are still necessary.

CT scan-detected pneumoperitoneum: an unreliable predictor of intra-abdominal injury in blunt trauma

INTRODUCTION

Free intra-peritoneal air in blunt trauma is a classic sign associated with hollow viscus injury, traditionally mandating laparotomy. In blunt abdominal trauma, the CT scan has become the diagnostic modality of choice. The increased sensitivity of CT scans may lead to detection of free intra-peritoneal air that is not clinically significant.

OBJECTIVE

To characterize conditions and findings that allow for the safe observation of blunt trauma patients with free air and to propose a patient management algorithm to decrease rates of non-therapeutic laparotomy.

DESIGN

A retrospective review of 5877 blunt trauma patients who had an abdominal CT scan upon admission to our hospital from 2003 to 2011. A secondary CT review was performed by a single radiologist to further characterize the CT findings in the 74 patients with free air reported on initial scan. Management and hospital course were reviewed in these patients.

RESULTS

Of the 74 patients with intra-abdominal free air, 36 patients with a benign clinical picture were observed and 38 patients underwent urgent exploratory laparotomy. Eleven patients received a non-therapeutic laparotomy. The majority (61%) of patients, 45 of 74, had free air and no significant injury suggesting the presence of benign free air. Patients who had intra-abdominal injury also typically had other clinical or radiologic signs of injury. Findings that were highly predictive of intra-abdominal injury in the setting of free air were free fluid (P<0.001), radiographic signs of bowel trauma (P<0.001) as well as clinical and/or radiographic seatbelt sign (P=0.004).

CONCLUSIONS

CT scans may detect free air that is not always clinically significant. Free fluid, seatbelt sign or radiographic signs of bowel trauma in the presence of pneumoperitoneum is highly predictive of injury and these patients should be explored. Based on the results of our study, we created an algorithm to aid in identifying those patients with intra-abdominal free air who may be observed safely.

Conservative management of abdominal injuries

OBJECTIVE

Non-operative management of abdominal injuries has recently become more common. Especially non-operative treatment of blunt abdominal trauma is gaining wide acceptance. In this study, the efficacy of non-operative treatment in abdominal trauma (blunt penetrating) is discussed.

MATERIAL AND METHODS

All patients who received treatment due to abdominal trauma from November 2008 to January 2013 were retrospectively analyzed. The demographic characteristics, type of injury, injured organ, type of treatment (operative vs. nonoperative) and mortality data were evaluated.

RESULTS

The study includes 115 patients treated for abdominal trauma in our department. The mechanism of trauma was stab wounds in 60%, blunt abdominal trauma in 23.5% and gunshot wounds in 16.5%. Forty-two patients (36.5%) were operated for hemodynamic instability and/or peritonitis on admission. The remaining 63.5% of patients (n=73) were treated nonoperatively, 10 of whom required laparotomy during follow-up. The remaining 63 patients were treated with non-operative management. The success rate for non-operative treatment was 86.3% and there was no difference in terms of the types of injuries. The mortality rate was 4.3% (n= 5) in the whole series, but there were no deaths among the patients who had received non-operative treatment. In the whole patient group 54.2% (n=63) were treated nonoperatively.

CONCLUSION

Nonoperative treatment in abdominal trauma is safe and effective. Patients with clinical stability and normal physical examination findings can be treated nonoperatively with close monitoring.