Small bowel injuries: mechanisms, patterns, and outcome

Performance of three predictive scores to avoid delayed diagnosis of significant blunt bowel and mesenteric injury: A 12-year retrospective cohort study

BACKGROUND

Avoiding missed diagnosis and therapeutic delay for significant blunt bowel and mesenteric injuries (sBBMIs) after trauma is still challenging despite the widespread use of computed tomography (CT). Several scoring tools aiming at reducing this risk have been published. The purpose of the present work was to assess the incidence of delayed (>24 hours) diagnosis for sBBMI patients and to compare the predictive performance of three previously published scores using clinical, radiological, and laboratory findings: the Bowel Injury Prediction Score (BIPS) and the scores developed by Raharimanantsoa Score (RS) and by Faget Score (FS).

METHODS

A population-based retrospective observational cohort study was conducted; it included adult trauma patients after road traffic crashes admitted to Lausanne University Hospital, Switzerland, between 2008 and 2019 (n = 1,258) with reliable information about sBBMI status (n = 1,164) and for whom all items for score calculation were available (n = 917). The three scores were retrospectively applied on all patients to assess their predictive performance.

RESULTS

The incidence of sBBMI after road traffic crash was 3.3% (38 of 1,164), and in 18% (7 of 38), there was a diagnostic and treatment delay of more than 24 hours. The diagnostic performances of the FS, the RS, and the BIPS to predict sBBMI, expressed as the area under the receiver operating characteristic curve, were 95.3% (95% confidence interval [CI], 92.7-97.9%), 89.2% (95% CI, 83.2-95.3%), and 87.6% (95% CI, 81.8-93.3%) respectively.

CONCLUSION

The present study confirms that diagnostic delays for sBBMI still occur despite the widespread use of abdominal CT. When CT findings during the initial assessment are negative or equivocal for sBBMI, using a score may be helpful to select patients for early diagnostic laparoscopy. The FS had the best individual diagnostic performance. However, the BIPS or the RS, relying on clinical and laboratory variables, may be helpful to select patients for early diagnostic laparoscopy when there are unspecific CT signs of bowel or mesenteric injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Intestinal obstruction caused by small bowel entrapment within a lumbar fracture: A case report

INTRODUCTION

Intestinal obstruction associated with traumatic vertebral fracture is extremely rare. We report a case of obstructive small bowel injury caused by entrapment of the small intestine at the fracture site of the 5th lumbar vertebra due to trauma.

CASE PRESENTATION

A 55-year-old man fell from a height of 4 m and visited the emergency room of a local hospital with complain of back pain. During the examination, a 5th lumbar vertebral body fracture and left psoas muscle hematoma were observed, and the patient was admitted to the neurosurgery department for conservative treatment. The patient received conservative treatment for 2 days, but new symptoms of intestinal obstruction and fever occurred. A neurosurgeon at the hospital suspected duodenal perforation and transferred the patient to the regional trauma center for treatment. Our medical staff reviewed the patient's symptoms and imaging data and decided to perform an emergency operation because of small bowel entrapment in the 5th lumbar vertebrae fracture and perforation of the small intestine. We found that the small bowel, approximately 160 cm below the ligament of Treitz, was incarcerated at the 5th lumbar vertebral fracture site. After careful manual reduction of the entrapment of the small intestine, a small bowel resection of 25 cm, including the injury site, was performed with anastomosis.

CONCLUSION

If symptoms of intestinal obstruction are observed in patients with traumatic spinal injury, medical staff must consider the exceedingly rare possibility of bowel entrapment.

Penetrating colon trauma-the effect of concomitant small bowel injury on outcome

INTRODUCTION

There is limited evidence to suggest that patients with penetrating colon injury have higher complication rates when there is concomitant small bowel (SB) injury.

AIM

We performed a retrospective study looking at outcomes of penetrating colonic trauma in patients with- and without concomitant SB injury.

METHODS

We interrogated our electronic registry over an eight-year period (2012-2020) for all patients over 18 years who had sustained penetrating colon injury and who had survived beyond 72 h. Demographic data, admission physiology, and Injury Severity Score (ISS) were recorded. Two groups of patients were observed: those with colonic injury (no SB injury) and those with combined colon and SB injury. Outcomes observed included leak rates, length of Intensive Care Unit (ICU) stay, length of hospital stay (LOS), morbidity and mortality.

RESULTS

A total of 450 patients were eligible for analysis, of which 257 had colon injury without SB injury and 193 had a combination of colon and SB injury. There was no difference in mechanism of injury between groups. Admission physiology was similar between groups but arterial blood gas values were worse in the combined group. Rates of damage control surgery and ICU admission were higher in the combined group. Primary repair was done in equal proportions between groups but anastomosis was more frequently performed in the combined group. There was no difference in complication rates, including gastro-intestinal complications and suture line leaks. Length of ICU stay, LOS, and mortality were similar between groups. Univariable analysis demonstrated that the presence of concomitant small bowel injury was not an independent risk factor for colonic suture line failure or death.

CONCLUSION

There is no evidence from this data that the presence of a combined penetrating colon and SB injury should change management priorities. Each injury should be treated on its own merit, in the context of the patient's physiology.

Hydrogel-based 3D bioprints repair rat small intestine injuries and integrate into native intestinal tissue

3D Printing has become a mainstay of industry, with several applications in the medical field. One area that could benefit from 3D printing is intestinal failure due to injury or genetic malformations. We bioprinted cylindrical tubes from rat vascular cells that were sized to form biopatches. 2 mm enterotomies were made in the small intestine of male Sprague-Dawley rats, and sealed with biopatches. These intestinal segments were connected to an ex vivo perfusion device that provided independent extraluminal and intraluminal perfusion. The fluorescence signal of fluorescein isothiocyanate (FITC)-inulin in the intraluminal perfusate, a non-absorbable fluorescent marker of intestinal integrity, was measured every 15 min over 90 min, and used to assess the integrity of the segments under both continuous perfusion and alternate-flow perfusion. Enterotomies were made an inch away from the ileocecal junction in male Wistar rats and sealed with biopatches. The animals were monitored daily and euthanized at post-operative days 7, 14, 21, and 30. Blinded histopathological analysis was conducted to compare the patch segments to native intestine. Biopatch-sealed intestinal segments withstood both continuous and pulsatile flow rates without leakage of FITC-inulin above the control baseline. 21 of 26 animals survived with normal activity, weight gain, and stool output. Histopathology of the explanted segments showed progressive villi and crypt formation over the enterotomies, with complete restoration of the epithelium by 30 days. This study presents a novel application of 3D bioprinting to develop a universal repair patch that can seal lesions in vivo, and fully integrate into the native intestine.

Isolated Jejunal Perforation and Mesentery Injury following a Kick on the Abdomen of a College Student: A Case Report from a District Hospital in Northern Ghana

Introduction. Isolated jejunal perforation from blunt abdominal trauma is an extremely rare intra-abdominal injury that poses a huge diagnostic challenge. Delay in diagnosis and initiation of treatment often leads to significant morbidity and mortality. Diagnosis particularly in resource-poor settings may be extremely challenging and often relies on a high index of suspicion. This is due to lack of adequate diagnostic facilities and human resource to deal with the condition with resulting high occurrence of adverse outcomes. Case Presentation. We report a case of isolated jejunal perforation with associated mesentery injury in a young college student who sustained a kick to his abdomen while playing soccer. This is an unusual presentation since most reported cases often resulted from motor vehicular accidents, bicycle handlebar, and fall from a height. We emphasized the role of critical level of suspicion with a good history and physical examination as the major source of diagnosis since diagnostic procedures, such as abdominal ultrasonography and computed tomography, are largely unavailable in most resource-constraint settings. Early surgical intervention following diagnosis leads to good recovery and reduced mortality. Conclusion. Sufficient vigilance and suspicions of small bowel perforation should always be considered after blunt trauma even when symptoms and physical findings are minimal and when diagnostic capacity is limited.

Avoiding delayed diagnosis of significant blunt bowel and mesenteric injuries: Can a scoring tool make the difference? A 7-year retrospective cohort study

INTRODUCTION

Significant blunt bowel and mesenteric injuries (sBBMI) are frequently missed despite the widespread use of computed tomography (CT). Early treatment improves the outcome related to these injuries. The aim of this study was to assess the prevalence of sBBMI, the incidence of delayed diagnosis and to test the performance of the Bowel Injury Prediction Score (BIPS), determined by the white blood cell (WBC) count, presence or absence of abdominal tenderness and CT grade of mesenteric injury.

PATIENTS AND METHODS

Single-centre, registry-based retrospective cohort study, screening all consecutive trauma patients admitted to Lausanne University Hospital Trauma Centre from 2008 to 2015 after a road traffic accident. All patients with reliable information about the presence or absence of sBBMI who underwent abdominal CT and for whom calculation of the BIPS was possible were included for analysis. The incidence of delayed (>24h after admission) diagnosis in the patient group with sBBMI was determined and the diagnostic performance of the BIPS for sBBMI was assessed.

RESULTS

For analysis, 766 patients with reliable information about the presence or absence of sBBMI were included. The prevalence of sBBMI was 3.1% (24/766). In 24% (5/21) of stable trauma patients undergoing CT, a diagnostic delay of more than 24h occurred. Abdominal tenderness (p<0.0001) and CT grade ≥4 (p<0.0001) were associated with sBBMI, whereas CT grade 4 alone (p=0.93) and WBC count ≥17G/l (p=0.30) were not. A BIPS ≥2 had a sensitivity of 89% (95% CI, 67-99), specificity of 89% (95% CI, 86-91), positive likelihood ratio of 8 (95% CI, 6.1-10), negative likelihood ratio of 0.12 (95% CI, 0.03-0.44), positive predictive value (PPV) of 19% (95% CI, 15-24) and negative predictive value (NPV) of 99.7% (95% CI, 98.7-99.9). CT alone identified 79% (15/19) and the BIPS 89% (17/19) of patients with sBBMI (p=0.66).

CONCLUSIONS

Diagnostic delays in patients with sBBMI are common (24%), despite the routine use of abdominal CT. Application of the BIPS on the present cohort would have led to a high number of non-therapeutic abdominal explorations without identifying significantly more sBBMI early than CT alone.

Death due to isolated jejunal tear following blunt abdominal trauma

Small intestinal injury following blunt abdominal trauma has been widely reported. Isolated jejunal tear which is caused by blunt abdominal trauma is rare and is most often seen in road traffic accidents. Here, we report a case of isolated jejunal tear in a 24-year-old male truck driver. He was admitted to a tertiary care hospital in a South Indian Metropolitan city with complaints of acute abdominal pain and tiredness following alleged accidental blunt trauma sustained to abdomen due to steering wheel impact. An isolated jejunal tear and adjacent mesenteric contusion and tear were missed by the treating physician even after preliminary investigations, and thus, the conservative management was instituted. The condition deteriorated gradually, and he succumbed to death. The autopsy revealed transverse tear of jejunum almost involving whole of its circumference on the antimesenteric border and peritonitis. Proper use of radio-diagnostic techniques and timely undertaken explorative laparotomy would have saved the life.

Prognostic factors for traumatic bowel injuries: killing time

BACKGROUND

Intestinal rupture/perforation after abdominal trauma is a rare complication, but it is related to significant morbidity and mortality. Our objective is to identify determinants of prognosis in patients surgically treated for a bowel injury (small bowel and colon) after abdominal trauma.

METHODS

The present study is a retrospective analysis of 102 patients seen at our hospital during a 10-year period in whom laparotomy for traumatic bowel injury was performed. Predictors for morbidity and mortality were assessed in univariate and multivariate analysis models.

RESULTS

Mean age at diagnosis was 40 years, and most patients were male. There was a slight preponderance of blunt abdominal trauma, and the most frequent mechanism of injury was motor vehicle accident. In 75% of patients there was a small bowel lesion, and the colon was affected in 47%. There was no statistical relation between stoma construction and mortality, but an increase in morbidity was ultimately dependent on the severity of the underlying trauma. The univariate determinants of mortality were the new injury severity score (NISS) and American Society of Anesthesiologists (ASA) scores, the presence of blunt trauma and multiple intestinal or extra-abdominal lesions, and the elapsed time to surgery. The occurrence of postoperative complications was related to all these factors, as well as to tachycardia, hypotension, and bleeding. In multivariate analysis ASA score (p = 0.015), NISS (p = 0.002), time to surgery (p = 0.007), and presence of colonic lesions (p = 0.02) were identified as independent prognostic factors for postoperative morbidity.

CONCLUSIONS

The only modifiable determinant of morbidity seems to be the time to surgery. Only an expeditious evaluation and diagnosis and prompt surgical intervention can improve the prognosis of these patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Blunt abdominal trauma with small bowel injury: are isolated lesions riskier than associated lesions?

PURPOSE

The objective of this study was to compare patients with "isolated" blunt small bowel injury (SBI) to patients with multiple intra-abdominal injuries and analyze whether delayed laparotomy affected outcome.

METHODS

Medical records of patients that suffered a blunt SBI between 1994 and 2005 were reviewed. The patients were divided into two groups: those with isolated SBI and those with other associated intra-abdominal injuries ("non-isolated"). The method of diagnosis, time to operation, small bowel Organ Injury Scale (OIS) assessment (grade >or= 2), injury severity score (ISS), morbidity, and mortality were analyzed.

RESULTS

A total of 90 patients met the inclusion criteria, including 62 (68.9%) isolated cases and 28 (31.1%) non-isolated cases. Isolated cases required more supplementary diagnostic methods than the non-isolated cases. Non-isolated cases had a shorter diagnosis to treatment period (p < .01) and a higher ISS (mean 22.5 vs. 17.2 in "isolated" group). Morbidity (51.6% and 53.6%) and mortality (16.1% and 28.6%) did not differ significantly between the isolated and non-isolated groups. Delays in diagnosis were common in the isolated group, but this did not affect outcome. Patients with associated injuries, and higher ISS, had higher mortality.

CONCLUSIONS

The presence of associated intra-abdominal injuries significantly affected the presentation and time to diagnosis of patients with SBI, but not morbidity or mortality. Delayed surgical treatment in the isolated cases was not associated with an increased incidence of complications. Patients inflicted with more severe associated injuries were less likely to survive the trauma.

Success of microvascular surgery; repair mesenteric injury and prevent short bowel syndrome: a case report

Background

Superior mesenteric injury is a rare entity but when it occurs, short bowel syndrome is one of the uninvited results of the emergency surgical procedures.

Case presentation

We present a 19-year-old boy with blunt abdominal trauma which caused serious mesenteric injury. Because ultrasound revealed free intraabdominal fluid, he underwent emergency laparotomy. Adequate vascularization of approximately 20 cm of proximal jejunal segment and approximately 20 cm of terminal ileum was observed. Nevertheless, the mesentery of the rest of the small intestine segments was ruptured completely. We performed an end-to-end anastomosis between a distal branch of the superior mesenteric artery in the mesentery of the ileal segment and a branch of the superior mesenteric artery using separate sutures of 7.0 monofilament polypropylene. The patient's gastrointestinal passage returned to normal on the postoperative day 2. He recovered without any complication and was discharged from hospital on the postoperative day seven.

Discussion

In this case report, we emphasize the importance of preservation of injured mesenteric artery due to abdominal trauma which could have resulted in short bowel syndrome.

Fatores preditivos de morbimortalidade no trauma de intestino delgado

OBJETIVO: Os objetivos deste estudo foram avaliar o diagnóstico e o tratamento das lesões de intestino delgado e determinar os fatores que influenciaram a morbimortalidade. MÉTODO: Estudo retrospectivo incluindo 410 pacientes com lesão de intestino delgado operados entre janeiro de 1994 e dezembro de 2004. Os dados coletados incluíram: mecanismo de trauma, métodos diagnósticos, tempo transcorrido até a intervenção cirúrgica, grau das lesões, índices de trauma, conduta cirúrgica (sutura ou ressecção e anastomose), morbidade (especialmente fístula) e mortalidade. A comparação entre os grupos foi feita usando os testes de Fisher e Yates. RESULTADOS: O mecanismo de trauma foi penetrante em 321 pacientes (78,3%) e fechado em 89 (21,7%). Houve mais pacientes tratados cirurgicamente com intervalo maior que 6 horas após o trauma no grupo trauma contuso se comparados com trauma penetrante (p<0,05). Sutura da lesão foi feita em 52,2% dos pacientes e ressecção e anastomose em 46,8%, e ambos procedimentos apresentaram a mesma incidência de fístula (4,7%). A morbidade foi de 35,1%. A incidência de fistula foi maior nos pacientes submetidos à laparotomia com mais de 12 horas após o trauma quando comparados com aqueles operados com menos de 12 horas (8,3% vs. 4,3%; sem diferença estatística), mas isto não foi fator determinante para maior mortalidade. A mortalidade foi de 13,7% e foi relacionada com escores de gravidade mais elevados. CONCLUSÃO: A lesão de intestino delgado é freqüente após o trauma abdominal, sendo mais comum nos traumas penetrantes. O diagnóstico desta lesão após trauma fechado pode ser difícil, com demora para o tratamento cirúrgico. A ocorrência de fistula não esteve relacionada aos seguintes fatores analisados: mecanismo de trauma, tempo transcorrido entre o trauma e a operação, conduta cirúrgica, lesões intra-abdominais associadas ou gravidade das lesões. A mortalidade esteve relacionada com lesões associadas.

Isolated jejunal perforation after blunt thoracoabdominal trauma

A case report of isolated jejunal perforation secondary to a relatively unique mechanism of blunt thoracoabdominal trauma is presented. A thorough and concise review of the multimodal approach that may be necessary to diagnose such a rare clinical problem is discussed.

Missed diagnoses in trauma patients vis-à-vis significance of autopsy

Post-mortem examination is considered to be the gold standard for the critique of medical practice, providing a quality control tool for the retrospective evaluation of diagnoses and treatment. Performing autopsies also facilitates new insight about the pathogenesis of disease and effects of therapy, gives feedback to clinical research protocols, provides epidemiological information and occasionally helps to console and reassure grieving families that death was inevitable. Its significance becomes paramount in cases of missed diagnosis in trauma-related deaths. The true incidence of missed diagnoses in trauma-related deaths is unknown, because autopsy is conducted in only about 50% of injury-related deaths. Few studies have documented the frequency of missed diagnoses leading to deaths specifically in the trauma ICU population. The present study is an attempt to evaluate the incidence and nature of missed injuries and complications in trauma-related deaths given an autopsy rate of close to 100%. This study also sought to identify the primary factors contributing to each missed injury. However, the study is in no way intended to assigning blame to human or system errors. Rather, it is focussed specifically on the issue of whether autopsy can be useful to provide feedback in identifying clinical problems of trauma patients.

Short bowel syndrome after trauma

PURPOSE

Traumatic injury to the intestine and its vasculature is a potential cause of short bowel syndrome (SBS). Our aim was to determine the incidence and mechanisms of traumatic injury to the bowel resulting in massive resection.

METHODS

We reviewed the records of 196 adult patients evaluated with SBS over a 23-year period.

RESULTS

Sixteen (8%) patients had SBS secondary to traumatic injury. Injury to the intestinal blood supply accounted for 81% (n = 13), and direct injury to the bowel wall accounted for the remaining 19% (n = 3). Nineteen associated injuries were present in 11 (67%) patients.

CONCLUSION

Traumatic injury to the abdomen accounts for a small proportion of patients with SBS. These patients often have other associated injuries which might influence their outcome. Early diagnosis of vascular injury, use of second look procedures, appropriate resuscitation, and avoidance of all unnecessary resections may aid in prevention of this serious complication.

Pathophysiology and management of bowel and mesenteric injuries due to blunt trauma

Injuries to the bowel and mesentery are uncommon in blunt trauma and rarely occur in isolation. Delay to diagnosis has a significant impact on morbidity and mortality. The literature tends to focus on the diagnosis of hollow viscus and mesenteric injury, with little written on its management. Studies are usually retrospective with a paucity of comparative trials. The use of computerized tomography (CT) scanning in blunt abdominal trauma has overshadowed other reports. Early-generation scanners had a relatively poor sensitivity in detecting bowel-related injuries, but the CT scan is now the primary modality for imaging stable patients. However radiological signs can be subtle and should be regarded as complementary to meticulous clinical assessment.

Delay in Diagnosis of Hollow Viscus Injuries: Effect on Outcome

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intra-abdominal gastrointestinal tract injuries following blunt trauma: the experience of an Australian trauma centre

AIMS

The aim of the study was to use the extensive experience of an Australian Level I trauma centre to develop guidelines for diagnosis and management of significant gastrointestinal tract injuries (GITIs).

METHODS

This was a retrospective study of 74 patients admitted to Westmead Hospital between 1985 and 1996 who had sustained major gastrointestinal tract (GIT) injuries following blunt trauma. The patients were identified from the trauma unit database. Clinical information was retrieved from the database and augmented by a review of the medical records.

RESULTS

Motor vehicle accidents were responsible for 55 (92%) admissions. Laparotomy was performed as a result of a positive diagnostic peritoneal lavage in 26 (35.1%) patients, abdominal signs in 20 (27%), diagnostic findings on computed tomography in 19 (25.7%), haemodynamic instability in eight (10.8%) and a positive contrast study in one (1.4%) patient. There was a total of 95 injuries: one gastric (1.1%), eight duodenal (8.4%), 64 small bowel (67.3%), two appendiceal (2.1%), 19 colonic (20%) and one rectal (1.1%). Thirty day mortality was 23% (17 patients). Seven (9.5%) patients died within 24h of injury, three (4.1%) of which were directly related to the GIT. Ten (13.5%) patients died within 2 weeks of admission, three (4.1%) of which were attributable to the GIT. Thirty day GIT morbidity was 29.7% (22 patients). The development of GIT morbidity was significantly related to a delay to laparotomy of more than 24h (P=0.036) and tachycardia on presentation (P=0.023). Associated injuries, injury severity scores (ISS) and age did not significantly impact on GITI related morbidity and mortality.

DISCUSSION

Major GITIs are associated with a high mortality due to the severity and complexity of associated injuries. Morbidity from GITIs correlates to delays in diagnosis and management.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Small bowel tissue engineering using small intestinal submucosa as a scaffold

BACKGROUND

Small intestinal submucosa (SIS) is an extracellular matrix used in tissue engineering studies to create de novo abdominal wall, urinary bladder, tendons, blood vessels, and dura mater. The purpose of this study is to evaluate the feasibility of using SIS as a scaffold for small bowel regeneration in an in situ xenograft model.

MATERIALS AND METHODS

Twenty-three dogs had a partial defect created on the small bowel wall which was repaired with a SIS patch. Four dogs underwent small bowel resection with placement of an interposed tube of SIS. The animals were followed 2 weeks to 1 year.

RESULTS

Three of the 23 dogs with SIS placed as a patch died shortly after surgery due to leakage from the site. The other 20 dogs survived up to time of elective necropsy with no evidence of intestinal dysfunction. At necropsy, the bowel circumference in the patched area had no stenosis. Histological evaluation showed the presence of a mucosal epithelial layer, varying amount of smooth muscle, sheets of collagen, and a serosal covering. Architecturally, the layers were not well organized in the submucosal region. An abundance of inflammatory cells was present in the early postoperative period but receded with time. All 4 dogs with a tubular segment of SIS interposed had significant problems. One had partial obstruction at 1 month, and 3 died in the early postoperative period due to leakage.

CONCLUSIONS

This preliminary study suggests that SIS patches can be used for small bowel regeneration. Tubular segmental replacement is not feasible at this time.

Small fragment wounds: biophysics, pathophysiology and principles of management

Military surgical doctrine has traditionally taught that all ballistic wounds should be formally managed by surgical intervention. There is now, however, both experimental and clinical evidence supporting the nonoperative treatment of selected small fragment wounds. Low energy-transfer wounds affecting the soft tissues, without neuro-vascular compromise and with stable fracture patterns, may be suitable for early antibiotic treatment. The management of ballistic wounds to the gastrointestinal tract requires surgical intervention but, advances in the treatment of these wounds, especially those involving the colon, may allow more effective treatment with a reduced morbidity.

Imaging in abdominal trauma

Prompt recognition and timely intervention both play a crucial role in managing patients with blunt abdominal trauma. In most cases of multiply injured patients, where physical examination is indeterminate, a rapid and accurate screening method is a valuable adjunct for care-providers. Through the years, different imaging techniques have been utilized for this purpose; among them are diagnostic peritoneal lavage (DPL), ultrasonography (US) and computed tomography (CT). Proponents of each modality have their own beneficial reasons for adopting that particular method of imaging. Needless to say, despite the high sensitivity and specificity values cited for each, all the methods have their own limitations. After having reviewed the advantages and disadvantages of these three modalities, this article suggests that there is not one single modality that is considered the best. Rather, all three can be complementary and the use of each can be appropriate for a particular subset of patients, given a particular clinical situation, and taking into account the resources available.

Effects of other intra-abdominal injuries on the diagnosis, management, and outcome of small bowel trauma

BACKGROUND

Difficulty with and delays in diagnosis are possible causes of increased morbidity and mortality in small bowel injuries. We assessed whether multiple intra-abdominal injuries led to earlier laparotomy and whether this resulted in improved outcome.

METHODS

Patients with small bowel injuries between January 1993 and December 1997 from the trauma database at St. Michael's Hospital in Toronto were assessed after dividing them into those with isolated small bowel injury ("isolated") and those with small bowel injuries in association with other intra-abdominal injuries ("nonisolated"). Parameters compared were age, gender, length of stay, mortality, intra-abdominal complications, mechanism of injury, diagnostic time, and how the diagnosis was made.

RESULTS

Of 1,207 patients, 244 sustained abdominal injuries, and 83 had small bowel injuries (30 patients in the isolated group and 53 in the nonisolated group). Groups were similar with respect to age and gender, yet differed significantly with respect to mechanism and mean Injury Severity Scores (isolated, 18 +/- 8 vs. nonisolated, 30 +/- 15). Outcome differed between groups, as mortality (isolated, 0 of 30 vs. nonisolated, 4 of 53 deaths), length of stay (isolated, 13 +/- 2 vs. nonisolated, 22 +/- 3 days), and patients with intra-abdominal complications (isolated, 5 of 30 vs. nonisolated, 14 of 53 patients) were significantly higher in the nonisolated group. Time to diagnosis was significantly less in the nonisolated group. Decision for laparotomy and diagnosis of small bowel injuries were based more on physical findings in the nonisolated group and on computed tomography in the isolated group.

CONCLUSION

The presence of associated intra-abdominal injuries significantly affects presentation and outcome of patients with small bowel injuries and the selection of diagnostic modalities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Small bowel perforation: is urgent surgery necessary?

BACKGROUND

Controversies regarding how urgent bowel perforation should be diagnosed and treated exist in recent reports. The approach for early diagnosis is also debatable. The purposes of this study were to evaluate the relationship between treatment delay and outcome of small bowel perforation after blunt abdominal trauma and to determine the best assessment plan for the diagnosis of this injury.

METHODS

One hundred eleven consecutive patients with small bowel perforations caused by blunt abdominal trauma were retrospectively reviewed. The patients were divided into four groups according to the time interval between injury and surgery. Hospital stay, time to resume oral intake, and mortality and morbidity rates were compared between groups. Physical signs, laboratory and computed tomographic findings, and the results of diagnostic peritoneal lavage were analyzed to find the most sensitive and specific test for early diagnosis of small bowel perforation.

RESULTS

Delay in surgery for more than 24 hours did not significantly increase the mortality with modern method of treatment; however, complications increased dramatically. Hospital stay and time to resume oral intake increased significantly when surgery was delayed for more than 24 hours. Abdominal tenderness was a common finding, but it was not specific for bowel perforation. Only 40% of the computed tomographic scans were diagnostic for bowel perforations: 50% of them showed suggestive signs, and 10% were considered as negative. Persistence of abdominal signs indicated peritoneal lavage. By using cell count ratio in diagnostic peritoneal lavage and/or increased lavage amylase activity, presence of particulate matter and/or bacteria in the lavage fluid, all patients with intraperitoneal bowel perforation were diagnosed accurately before operation.

CONCLUSION

Small bowel perforation has low mortality and complication rates if it is treated earlier than 24 hours after injury. The principle of "rushing to the operation suite" for a stable blunt abdominal trauma patients without detailed systemic examination is not justified. The priority of treatment for the small bowel perforation should be lower than the limb-threatening injuries. Diagnostic peritoneal lavage provides high sensitivity and specificity rates for the diagnosis of small bowel perforation if a specially designed positive criterion is applied.

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

OBJECTIVE

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

DESIGN

Retrospective chart review.

METHODS

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

RESULTS

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

CONCLUSIONS

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