Ann Surg Treat Res.  2018 Jan;94(1):44-48. 10.4174/astr.2018.94.1.44.

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

• Park HC
• Kim JW
• Kim MJ
• Lee BH

• KMID: 2405338
• DOI: http://doi.org/10.4174/astr.2018.94.1.44

Abstract

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.

Keyword

Conservative treatment; Injuries; Surgery; Trauma

MeSH Terms

Emergencies
Female
Hematoma
Humans
Male
Postoperative Complications

Reference

1. Pal JD, Victorino GP. Defining the role of computed tomography in blunt abdominal trauma: use in the hemodynamically stable patient with a depressed level of consciousness. Arch Surg. 2002; 137:1029–1032.

2. Petrosoniak A, Engels PT, Hamilton P, Tien HC. Detection of significant bowel and mesenteric injuries in blunt abdominal trauma with 64-slice computed tomography. J Trauma Acute Care Surg. 2013; 74:1081–1086.

3. Joseph DK, Kunac A, Kinler RL, Staff I, Butler KL. Diagnosing blunt hollow viscus injury: is computed tomography the answer? Am J Surg. 2013; 205:414–418.

4. Brownstein MR, Bunting T, Meyer AA, Fakhry SM. Diagnosis and management of blunt small bowel injury: a survey of the membership of the American Association for the Surgery of Trauma. J Trauma. 2000; 48:402–407.

5. Sherck J, Shatney C, Sensaki K, Selivanov V. The accuracy of computed tomography in the diagnosis of blunt small-bowel perforation. Am J Surg. 1994; 168:670–675.

6. Ekeh AP, Saxe J, Walusimbi M, Tchorz KM, Woods RJ, Anderson HL 3rd, et al. Diagnosis of blunt intestinal and mesenteric injury in the era of multidetector CT technology: are results better? J Trauma. 2008; 65:354–359.

7. Bhagvan S, Turai M, Holden A, Ng A, Civil I. Predicting hollow viscus injury in blunt abdominal trauma with computed tomography. World J Surg. 2013; 37:123–126.

8. Mahmood I, Tawfek Z, Abdelrahman Y, Siddiuqqi T, Abdelrahman H, El-Menyar A, et al. Significance of computed tomography finding of intra-abdominal free fluid without solid organ injury after blunt abdominal trauma: time for laparotomy on demand. World J Surg. 2014; 38:1411–1415.

9. Fischer RP, Miller-Crotchett P, Reed RL 2nd. Gastrointestinal disruption: the hazard of nonoperative management in adults with blunt abdominal injury. J Trauma. 1988; 28:1445–1449.

10. Fakhry SM, Brownstein M, Watts DD, Baker CC, Oller D. 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. J Trauma. 2000; 48:408–414.

11. Malinoski DJ, Patel MS, Yakar DO, Green D, Qureshi F, Inaba K, et al. A diagnostic delay of 5 hours increases the risk of death after blunt hollow viscus injury. J Trauma. 2010; 69:84–87.

12. Ozturk H, Dokucu AI, Onen A, Otcu S, Gedik S, Azal OF. Non-operative management of isolated solid organ injuries due to blunt abdominal trauma in children: a fifteen-year experience. Eur J Pediatr Surg. 2004; 14:29–34.

13. Sim J, Lee J, Lee JC, Heo Y, Wang H, Jung K. Risk factors for mortality of severe trauma based on 3 years' data at a single Korean institution. Ann Surg Treat Res. 2015; 89:215–219.

14. Walker ML, Akpele I, Spence SD, Henderson V. The role of repeat computed tomography scan in the evaluation of blunt bowel injury. Am Surg. 2012; 78:979–985.

15. Kaban GK, Novitsky YW, Perugini RA, Haveran L, Czerniach D, Kelly JJ, et al. Use of laparoscopy in evaluation and treatment of penetrating and blunt abdominal injuries. Surg Innov. 2008; 15:26–31.

16. Johnson JJ, Garwe T, Raines AR, Thurman JB, Carter S, Bender JS, et al. The use of laparoscopy in the diagnosis and treatment of blunt and penetrating abdominal injuries: 10-year experience at a level 1 trauma center. Am J Surg. 2013; 205:317–320.

17. Faria GR, Almeida AB, Moreira H, Barbosa E, Correia-da-Silva P, Costa-Maia J. Prognostic factors for traumatic bowel injuries: killing time. World J Surg. 2012; 36:807–812.

18. Matsushima K, Mangel PS, Schaefer EW, Frankel HL. Blunt hollow viscus and mesenteric injury: still underrecognized. World J Surg. 2013; 37:759–765.

19. Subramanian V, Raju RS, Vyas FL, Joseph P, Sitaram V. Delayed jejunal perforation following blunt abdominal trauma. Ann R Coll Surg Engl. 2010; 92:W23–W24.

20. Ertugrul G, Coskun M, Sevinc M, Ertugrul F, Toydemir T. Delayed presentation of a sigmoid colon injury following blunt abdominal trauma: a case report. J Med Case Rep. 2012; 6:247.

21. Letton RW Jr, Worrell V, Tuggle DW. American Pediatric Surgical Association Committee on Trauma Blunt Intestinal Injury Study Group. Delay in diagnosis and treatment of blunt intestinal perforation does not adversely affect prognosis in the pediatric trauma patient. J Trauma. 2010; 68:790–795.

22. Al-Hassani A, Tuma M, Mahmood I, Afifi I, Almadani A, El-Menyar A, et al. Dilemma of blunt bowel injury: what are the factors affecting early diagnosis and outcomes. Am Surg. 2013; 79:922–927.

23. Chichom Mefire A, Weledji PE, Verla VS, Lidwine NM. Diagnostic and therapeutic challenges of isolated small bowel perforations after blunt abdominal injury in low income settings: analysis of twenty three new cases. Injury. 2014; 45:141–145.