Identifying Radiographic and Clinical Indicators to Reduce the Occurrence of Nontherapeutic Laparotomy for Blunt Bowel and Mesenteric Injury

Abstract

Background Roughly 5% of patients with blunt abdominal trauma (BAT) have a blunt bowel and/or mesenteric injury (BBMI). Determining the need for operative management in these patients can be challenging when hemodynamically stable. Single center studies have proposed scoring systems based on CT findings to guide management. Our study aimed to determine the predictability of abdominopelvic CT scan (CT A/P) findings in conjunction with clinical exam to determine the necessity of operative intervention for BBMI. Methods Patients presenting from 2017 to 2022 to the University of South Alabama Level 1 Trauma Center after motor vehicle collision were retrospectively reviewed. Patients with CT findings suggestive of BBMI were further analyzed, noting CT findings, Glasgow coma scale (GCS), shock index, abdominal exam, operative or nonoperative management, and intraoperative intervention. Results 1098 patients with BAT underwent CT A/P. 139 patients had ≥1 finding suggestive of BBMI. 38 patients underwent surgical exploration and 30 had surgically confirmed BBMI. 27 patients required intervention for BBMI. Univariate analysis indicated that pneumoperitoneum ( p < 0.0001), active extravasation of contrast ( p = 0.0001), hemoperitoneum without solid organ injury (SOI) ( p < 0.0001), peritonitis ( p < 0.0001), and mesenteric stranding( p < 0.05) were significantly associated with intervention. Conclusion In total, 30 patients had surgically confirmed BBMI. Active extravasation, pneumoperitoneum, hemoperitoneum without SOI, mesenteric stranding, and peritonitis were significant indicators of BBMI requiring intervention. CT and clinical findings cannot reliably predict the need for surgical intervention without ≥1 of these findings. Initial nonoperative management with serial clinical exams should be strongly considered to reduce incidence of nontherapeutic laparotomies.

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

“…However, nontherapeutic LTs have complication rates of 8% to 41%. 22 To avoid nontherapeutic interventions without delaying treatment in patients with unclear CT findings, several risk scores have been developed. Faget et al 29 have proposed a scoring system exclusively based on nine CT criteria, with a sensitivity of 96.4%, a specificity of 91.5%, a PPVof 56.2%, and an NPVof 99.6%.…”

“…17,18 However, false-negative CT rates of up to 13% have been reported for sBBMI, 19,20 especially in the setting of multiple-injury patients with concurrent solid organ or bladder injuries. 21,22 Hence, missing a diagnosis of sBBMI is still an issue, leading to delayed surgical treatment and to its negative impact on survival. 4,23 This is particularly true when managing blunt abdominal trauma patients with a CT showing unspecific or no signs of blunt bowel and mesenteric injury (BBMI), especially in the presence of clinical findings or in obtunded patients with an unreliable physical examination.…”

“…4,23 This is particularly true when managing blunt abdominal trauma patients with a CT showing unspecific or no signs of blunt bowel and mesenteric injury (BBMI), especially in the presence of clinical findings or in obtunded patients with an unreliable physical examination. 22 For these situations and given the potential consequences of delayed diagnosis, surgical exploration is recommended. Because of its morbidity rates of 8% to 41%, nontherapeutic exploratory LT should be avoided.…”

Blunt abdominal trauma: watch and wait

“…When considering the selection of patients for watchful waiting strategies in cases of risk of mesenteric and bowel injuries, it is crucial to conduct a careful clinical evaluation and utilize specific CECT signs based on the most recent clinical practice guidelines and studies [9–11].…”