Non-surgical follow-up success in blunt abdominal trauma. Can we protect patients with blunt abdominal trauma from surgery?

Year 2021, Volume: 4 Issue: 3, 295 - 299, 21.05.2021

Murat Baki Yıldırım , İbrahim Tayfun Şahiner , Murat Kendirci , Bulut Özkan , Murathan Erkent , Ramazan Topcu , Settar Bostanoğlu

https://doi.org/10.32322/jhsm.896899

Abstract

Abstract
Backgrounds
Abdominal traumas have an important place in the emergency room. The two organs that are most injured in blunt abdominal trauma are the liver and spleen. Historically, surgical intervention was adopted as a treatment method for liver and spleen traumas. However, with the development of imaging methods, the possibility of non-surgical follow-up was obtained. In this study, the advantages and disadvantages of conservative treatment for surgical intervention were investigated.
Methods
The patients with complaints of blunt abdominal trauma, who were admitted to the third step research center emergency service during the 27-month period and were referred to general surgery, were retrospectively examined. The demographic data of the patients, the degree of injured organs, treatment methods and hospitalization duration were obtained by file screening. The frequency, minimum, maximum, average, and standard deviation were obtained for parametric data. A total of 91 patients were included in the study.
Results
Of patients, 58,2% (n = 53) was monitored conservatively, 34,1% (n = 31) had splenectomy and 4,4% (n = 4) underwent the primary repair due to isolated liver injury, and both splenectomy and liver primary repair were performed in 3.3% (n = 3) because of multiple solid organ injury. We observed that the injuries of non-surgical spleen trauma patients changed between grade I and III. All patients with grade IV-V injuries underwent splenectomy. However, the patients, who had a decrease in hematocrit in their follow-up and whose hematocrit did not rise despite erythrocyte replacement, were operated.
Conclusions
Medical monitoring protects patients from complications brought by surgery but poses a risk for delayed rupture of the spleen. In this study, patients with non-surgical follow up were not required to undergo surgery. The success rate of the patients with grade IV-V liver laceration was reported before as 60-70% in non-surgical follow-up. In this study, it is cleared that both liver trauma and spleen trauma should be given a chance to be followed up without surgery.

Keywords

Blunt, trauma, non-operatif management, liver, spleen

References

• Smith SR, Morris L, Spreadborough S, et al. Management of blunt splenic injury in a UK major trauma centre and predicting the failure of non-operative management: a retrospective, cross-sectional study. Eur J Trauma Emerg Surg 2018; 44: 397–406.
• Coccolini F, Montori G, Catena F, et al. splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 2017; 12: 40.
• Burlew CC, Moore EE. Trauma. In: Brunicardi FC, Andersan DK, Biliar TR, et al (eds). Schwartz’s Principles of Surgery. United State of America, McGraw-Hill Medical Publishing, 2015, p: 129-88.
• Afifi I, Abayazeed S, El-Menyar A, et al. Blunt liver trauma: a descriptive analysis from a level I trauma center. BMC Surg 2018; 18: 42.
• Yanar H, Ertekin C, Taviloglu K, et al. Non-operative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma 2008; 64: 943-8.
• Boese CK, Hackl M, Muller LP, et al. Non-operative management of blunt hepatic trauma: A systematic review. J Trauma Acute Care Surg 2015; 79: 654-60.
• Walker ML. Nonoperative management of the damaged spleen: a community surgeon looks back. Am Surg 2017; 83: 502–6.
• Brady RR, Bandari M, Kerssens JJ, et al. Splenic trauma in Scotland: demographics and outcomes. World J Surg 2007; 31: 2111–6.
• Okus A, Sevinc B, Ay S, et al. Conservative management of abdominal injuries. Ulus Cerrahi Derg 2013; 29: 153-7.
• Van der Wilden GM, Velmahos GC, Emhoff T, et al. Successful non-operative management of the most severe blunt liver injuries: a multicenter study of the research consortium of new England centers for trauma. Arch Surg 2012; 147: 423-8.
• Hassan R, Abd Aziz A, Md Ralib AR, et al. Computed tomography of blunt spleen injury: a pictorial review. Malays J Med Sci. 2011 Jan; 18: 60-7.
• Federle MP, Courcoulas AP, Powell M, et al. Blunt splenic injury in adults: clinical and CT criteria for management, with emphasis on active extravasation. Radiology 1998; 206: 137-42.
• Kokabi N, Shuaib W, Xing M, et al. Intra-abdominal solid organ injuries: an enhanced management algorithm. Can Assoc Radiol J 2014; 65: 301-9.
• Yiannoullou P, Hall C, Newton K, et al. A review of the management of blunt splenic trauma in England and Wales: have regional trauma networks influenced management strategies and outcomes? Ann R Coll Surg Engl 2017; 99: 63–9.
• Oh JS, Mentzer CJ, Abuzeid AM, et al. Delayed Splenic Rupture with Normal Admission CT Scan after Blunt Trauma. Am Surg 2016; 82: e223-4.
• Riezzo I, Di Battista B, De Salvia A, et al. Delayed splenic rupture: dating the sub-capsular hemorrhage as a useful task to evaluate causal relationships with trauma. Forensic Sci Int 2014; 234: 64-71.
• Stassen NA, Bhullar I, Cheng JD, et al. Selective non-operative management of blunt splenic injury: an eastern association for the surgery of trauma practice management guideline. J Trauma 2012; 73: 294–300.
• Parks NA, Davis JW, Forman D, et al. Observation for non-operative management of blunt liver injuries: how long is long enough? J Trauma 2011; 70: 626-9.
• Suen K, Skandarajah AR, Knowles B, et al. Changes in the management of liver trauma leading to reduced mortality: 15-year experience in a major trauma centre. ANZ J Surg 2016; 86: 894-9.
• Gaarder C, Gaski IA, Næss PA. Spleen and liver injuries: when to operate. Curr Opin Crit Care 2017; 23: 520–6.
• Kim KH, Kim JS, Kim WW. Outcome of children with blunt liver or spleen injuries: experience from a single institution in Korea. Int J Surg 2017; 38: 105–108.
• Kong VY, Jeetoo D, Naidoo LC, et al. Isolated free intra-abdominal fluid on CT in blunt trauma: The continued diagnostic dilemma. Chin J Traumatol 2015; 18: 357-9.
• Sharma OP, Oswanski MF, Singer D, et al. Assessment of non-operative management of blunt spleen and liver trauma. Am Surg 2005; 71: 379–86.
• Olthof DC, Joosse P, van der Vlies CH, et al. Prognostic factors for the failure of non-operative management in adults with blunt splenic injury. J Trauma 2013; 74: 546–57.
• Melikian R, Goldberg S, Strife BJ, et al. Comparison of MDCT protocols in trauma patients with suspected splenic injury: superior results with protocol that includes arterial and portal venous phase imaging. Diagn Interv Radiol 2016; 22: 395-9.
• Tugnoli G, Bianchi E, Biscardi A, et al. Non-operative management of blunt splenic injury in adults: there is (still) a long way to go. The results of the Bologna-Maggiore hospital trauma center experience and development of a clinical algorithm. Surg Today 2015; 45: 1210–7.
• Norrman G, Tingstedt B, Ekelund M, et al. Non-operative management of blunt liver trauma: feasible and safe also in centres with a low trauma incidence. HPB (Oxford) 2009; 11: 50-6.
• Alamri Y, Moon D, Yen DA, et al. Ten-year experience of splenic trauma in New Zealand: the rise of non-operative management. N Z Med J 2017; 130: 11-8.
• Mehta N, Babu S, Venugopal K. An experience with blunt abdominal trauma: evaluation, management and outcome. Clin Pract. 2014; 4: 599.
• El-Matbouly M, Jabbour G, El-Menyar A, et al. Blunt splenic trauma: assessment, management and outcomes. Surgeon 2016; 14: 52–8.