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

Maximilian Goedecke; Florian Kühn; Ioannis Stratos; Robin Vasan; Annette Pertschy; Ernst Klar

doi:10.1515/iss-2018-0004

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

Innov Surg Sci. 2019 Oct 14;4(3):100-107. doi: 10.1515/iss-2018-0004. eCollection 2019 Sep.

Authors

Maximilian Goedecke^{1

2}, Florian Kühn³, Ioannis Stratos⁴, Robin Vasan⁵, Annette Pertschy⁶, Ernst Klar¹

Affiliations

¹ Department of General, Visceral, Vascular and Transplantation Surgery, University Medical Center Rostock, Rostock, Germany.
² Department of Oral and Maxillofacial Surgery, Corporate Member of Freie Universität Berlin, Humboldt-Universitätzu Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany.
³ Department of General, Thoracic, Vascular and Transplantation Surgery, University of Munich, Munich, Germany.
⁴ Department of Trauma, Hand and Reconstructive Surgery, University of Cologne, Cologne, Germany.
⁵ Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
⁶ Department of General, Visceral, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany.

Abstract

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.

Keywords: NOM; NOM failure; abdomen; blunt trauma; hepatic rupture; hollow viscus injury; splenic rupture.