Non operative management of abdominal trauma – a 10 years review

Abstract

IntroductionDue to high rate of operative mortality and morbidity non-operative management of blunt liver and spleen trauma was widely accepted in stable pediatric patients, but the general surgeons were skeptical to adopt it for adults. The current study is analysis of so far largest sample (1071) of hemodynamically stable blunt liver, spleen, kidney and pancreatic trauma patients managed non operatively irrespective of severity of a single /multiple solid organ injury or other associated injuries with high rate of success.MethodsExperience of 1071 blunt abdominal trauma patients treated by NOM at a tertiary care National Trauma Centre in Oman (from Jan 2001 to Dec 2011) was reviewed, analyzed to determine the indications, methods and results of NOM. Hemodynamic stability along with ultra sound, CT scan and repeated clinical examination were the sheet anchors of NOM. The patients were grouped as (1) managed by NOM successfully, (2) failure of NOM and (3) directly subjected to surgery.ResultsDuring the 10 year period, 5400 polytrauma patients were evaluated for abdominal trauma of which 1285 had abdominal injuries, the largest sample study till date. Based on initial findings 1071 patients were admitted for NOM. Out of 1071 patients initially selected 963 (89.91%) were managed non operatively, the remaining 108 (10.08%) were subjected to laparotomy due to failure of NOM. Laparotomy was performed on 214(19.98%) patients as they were unstable on admission or had evidence of hollow viscous injury.ConclusionNOM for blunt abdominal injuries was found to be highly successful in 89.98% of the patients in our study. Management depended on clinical and hemodynamic stability of the patient. A patient under NOM should be admitted to intensive care / high dependency for at least 48-72 hours for close monitoring of vital signs, repeated clinical examinations and follow up investigations as indicated.

The efficacy and safety of non operative management in abdominal injury in a high volume but resource stretched setting

“…1,6 73% was due to blunt injury lesser than 44% from Orissa, India. 7 This discrepancy may be due to the prevalence of interpersonal violence.…”

“…Only 62 patients (48%) were decided to be managed Non Operatively against 89.91% in Oman. 6 Hemodynamic stability and absence of peritoneal signs were the main consideration for NOM irrespective of severity of organ injury. All of them had detailed USG/CT for the amount of fluid in the abdomen and the severity of organ injury.…”

“…4,6 Patients who are haemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy (level 1). 2 Bleeding in 34%, peritonitis in 44%, bleeding and peritonitis in 4% and others that included evisceration, tension viscerothorax and impaled foreign body in 18%.…”

“…3 Failure rate of 34% in NOM compares well with 33% in a prospective study by Velmahos but far higher than 10.06% and 10%. 4,6,7 AIS 16 (4-44) and ISS 16 (9-53) for NOM (F) lower than ISS of 21.8 by Christine et al 14 Failure was due to intestinal /mesenteric injuries (38%) (8/21) followed by liver 17% (4/21) and multiple solid organs 8% (2/21). 30% (6/21) had multiple solid organ and extra abdominal injuries.…”

Evaluation of the outcome of non-operative management in blunt abdominal solid organ injury

“…In our study we had also monitored abdomen girth chart but it was not statistically significant and it did not influence the decision to conversion to laparotomy. 15,16 57% patients in non-operative group required blood transfusion whereas all the 15 (100%) patients who failed conservative management and underwent surgery required blood transfusion. Mean no of blood products used in converted cases were 3.4 and in NOM are 1.2.…”