Need For Laparotomy In Patients Research Articles

Moderate Intra‐abdominal Free Fluid on Computed Tomogram in Patients with Blunt Trauma Abdomen: Time to Shun Non‐operative Approach

We have read with interest the article by Mahmood et al. [1] on the significance of detection of intra-abdominal free fluid sans solid organ injury on computed tomogram (CT) in hemodynamically stable patients with blunt trauma abdomen (BTA). Their retrospective analysis of 122 cases reaffirms the importance of thorough and repeated clinical examination in the decision-making process for laparotomy in patients with mesenteric and bowel injury. The authors applied multivariate logistic regression analysis for identifying the predictors associated with therapeutic laparotomy. Odds ratio (OR) was calculated for the risk factors to ascertain their relationship with therapeutic laparotomy. The OR is a measure of association between an exposure of interest and a certain outcome. In other words, it is a ratio between the odds that a particular exposure will result in an outcome to the odds that the same outcome will result in absence of that exposure. Apart from identifying the exposure as a potential risk factor for a defined outcome, the OR also determines the magnitude of effect of that particular exposure on the outcome. The exposure is said to have no effect on the outcome when the OR is one. A value greater than one suggests a positive association between the exposure and the outcome, whereas a value less than one suggests a negative association between them. In the study by Mahmood et al. age, mechanism of injury, and presence of seat belt sign were found to have statistically significant positive association with therapeutic laparotomy following calculation of OR; however, two of these predictors had very wide confidence intervals, implying very low precision of the results. The logistic regression table outlining the predictors for therapeutic laparotomy depicts significant p value with a high OR and a wide confidence interval for the mild amount of abdominal fluid evident on CT scan. We think the presented data points show otherwise, in that a moderate rather than a mild amount of free fluid on CT scan has a stronger association with therapeutic laparotomy. The logistic regression analysis for a moderate amount of free fluid on CT scan as a predictor for therapeutic laparotomy revealed an OR of 8.66 (p = 0.0001) and a CI at 3.03–24.7 (statpages.org/logistic.html). In light of the above observations, a moderate amount of free fluid on CT of the abdomen should have been considered a strong predictor for therapeutic laparotomy. The authors overlooked this fact and concluded that CT scans are inaccurate for the prediction of bowel injury and the need for laparotomy. They have also advocated against immediate celiotomy in patients with abdominal injury. We think their opinion is nonspecific and not in sync with the objectives and the results of their study. While the role of clinical examination in deciding the need for laparotomy in patients with BTA is undisputed, detection of moderate free fluid on CT scan should tilt the balance in favor of laparotomy in patients with equivocal findings on clinical examination of the abdomen.

Endoscopic therapy of small-bowel polyps by double-balloon enteroscopy in patients with Peutz-Jeghers syndrome

Peutz-Jeghers syndrome (PJS) is a hereditary disorder characterized by mucocutaneous pigmentations and hamartomatous polyps mainly in the small bowel. These polyps may cause complications such as intussusception. To assess therapeutic efficacy and safety of double-balloon enteroscopy (DBE) for detection and treatment of small-bowel polyps in patients with PJS. Prospective cohort study. Tertiary-care referral center. This study involved 13 patients with PJS, defined as a proven STK11 gene mutation or according to international diagnostic criteria. DBE with enteroscopic removal of pedunculated polyps of > or =10 mm. Location, number and size of small-bowel polyps, polypectomy data, and complications and long-term complications associated with development of small-intestine polyps. Thirteen patients with PJS (8 male, mean age 31 years) underwent 29 DBE procedures. Ten patients (77%) had a history of partial small-bowel resection because of small-bowel polyps. Small-bowel polyps were found in all 13 patients. The majority of polyps (94%) were located in the proximal jejunum. A total of 82 polyps of > or =10 mm were detected, and 79 (96%) were endoscopically removed without complications. After the introduction of DBE, no small-intestine-polyp-related complications occurred during a follow-up period of 356 person-months. Small number of patients. DBE is clinically useful and safe for diagnosis and therapy of small-bowel polyps in patients with PJS, even in patients with a history of extensive abdominal surgery. DBE may decrease the need for laparotomy in patients with PJS.

Decision-making in surgical neonatal necrotizing enterocolitis

Aim:To know whether laboratory or clinical parameters can predict disease progression, need for laparotomy in patients managed with peritoneal drain and mortality in surgical neonatal necrotizing enterocolitis patients.Materials and Methods:The study was retrospectively carried out on 27 neonates over a period of one and a half year. All neonates who had surgical neonatal necrotizing enterocolitis in the form of bowel perforation, positive paracentesis, abdominal wall erythema and abdominal lump were included. Patients with Bell's stage I and those developing enterocolitis after surgery were excluded. The patients were evaluated with parameters, namely, clinical, laboratory and radiological. These included age and stage at presentation, primary symptom/sign at presentation with laboratory parameters of blood counts, pH, base deficit, platelet counts, electrolytes and random blood sugar levels. A comparison was done between survivors and nonsurvivors, patients with primary peritoneal drainage versus those requiring laparotomy after drain, Bell' stage II versus III patients and operated versus nonoperated patients. Statistical significance was observed in the above mentioned comparisons.Results:There were 22 male and 5 females patients with mean birth weight of 1.85 kg. Age at presentation ranged from 2 to 19 days, mean 9.25 days. Mortality was 37% (10/27). Majority of the stage II patients presented with feed intolerance and abdominal distension. The neonates with severe disease had abdominal distension with wall erythema. Sixty percent of the patients had shock at the time of admission. In the comparison of peritoneal drain only and patients with peritoneal drain followed by laparotomy patients, it was observed that neonates who were acidotic and had higher base deficit had more chances of requirement of laparotomy. They also had progressive fall in platelets counts. There was no difference in the birth weight, gestational age, total counts, serum electrolytes, blood sugar and other measured parameters; thus, these carry negligible predictive value to judge deteriorating neonate. In the remaining of the comparison, patients not presenting with shock were more likely to survive.Conclusion:In the present study, neonate with persistently low pH, higher base deficit and presentation with shock predicted need for laparotomy in drain managed patients as well as chances of survival.

D‐dimer as a predictor of the need for laparotomy in patients with unclear non‐traumatic acute abdomen. A preliminary study

Objective. The acute onset of intense abdominal pain requires rapid evaluation, and since D‐dimer level is reported to be useful in the diagnosis of patients with suspected acute superior mesenteric artery occlusion, our aim was to evaluate the value of D‐dimer testing in the diagnosis of acute surgical abdomen with no precise diagnosis. Material and methods. Between July 2004 and June 2006, 93 patients with acute abdomen who required surgical exploration without precise diagnosis were admitted to this prospective clinical study. After surgery, the patients were divided into two groups: group 1 (n = 52), patients who needed immediate laparotomy, and group 2 (n = 41), patients without the need for laparotomy. Blood samples were taken to analyse D‐dimer, white blood cell count and pH level. P‐values of <0.05 were considered statistically significant. Results. There was a positive correlation between the plasma D‐dimer level and leucocyte count. Leucocyte counts >16,800/mm3 (p<0.01) and D‐dimer levels >4.7 µg FEU/mL were more sensitive (p<0.001). Sensitivity was 97.6 % and specificity 61.5 % for D‐dimer level, and 82.9 % and 42.3 %, respectively, for leucocyte count. Metabolic acidosis at admission was the most important factor for mortality (p<0.001). Conclusions. In a patient with acute abdomen without precise diagnosis, a D‐dimer level above the cut‐off value (4.7 µg fibrinogen equivalent units/mL) may be an indicator with high sensitivity for surgical pathology requiring laparotomy.

A Simple Scoring System Derived from FAST Findings and Vital Signs Predicts the Need for Urgent Laparotomy in Patients with Blunt Abdominal Trauma

A Simple Scoring System Derived from FAST Findings and Vital Signs Predicts the Need for Urgent Laparotomy in Patients with Blunt Abdominal Trauma

Operative versus nonoperative management of blunt abdominal trauma: Role of ultrasound-measured intraperitoneal fluid levels

This study's objective was to analyze whether the quantity of free intraperitoneal fluid on ultrasonography, alone or in combination with unstable vital signs, is sensitive in determining the need for laparotomy in patients presenting with blunt trauma. Adult patients who presented with blunt abdominal trauma to 2 level I trauma centers were enrolled. Combined intraperitoneal fluid levels (anechoic stripe) of 5 intraperitoneal areas were measured and defined as small (< 1.0 cm), moderate (> 1.0 cm, < 3.0 cm), or large (> 3.0 cm). Unstable vital signs were defined as pulse > 100 bpm or systolic blood pressure < 90 mmHg. Exploratory laparotomy or computed tomography scan confirmed hemoperitoneum. Of 270 patients entered into the study, ultrasound detected free intraperitoneal fluid in 33 patients. Of the 18 patients with a large fluid accumulation, 16 underwent exploratory laparotomy (89% sensitivity), and all 8 patients with unstable vital signs underwent exploratory laparotomy (100% sensitivity). Of the 10 patients with a moderate fluid accumulation, 6 underwent exploratory laparotomy (60% sensitivity), and 4 of the 6 patients with unstable vital signs underwent exploratory laparotomy (67% sensitivity). A large intraperitoneal fluid accumulation on ultrasonography in combination with unstable vital signs, is sensitive for determining the need for exploratory laparotomy in patients presenting with blunt trauma.

Emergent Abdominal Sonography as a Screening Test in a New Diagnostic Algorithm for Blunt Trauma

Although there is an interest in emergent abdominal sonography (EAS), the clinical utilization of EAS in North America is minimal. The purpose of this study was to develop a new diagnostic algorithm for blunt abdominal injury based on a prospective blinded comparison of EAS, diagnostic peritoneal lavage (DPL), and computed tomography (CT). EAS (+ = fluid, - = no fluid) was performed before the DPL or CT, in 400 patients with a mean Injury Severity Score of 26; 293 had a CT and 107 had a DPL. The EASs required 2.6 +/- 1.2 minutes with 82% < or = 3 minutes. The accuracy of EAS for free fluid was 94% with a positive and negative predictive value of 82 and 96%, respectively. Only 1 of 338 patients with EAS- had an acute therapeutic laparotomy. Three patients with EAS- had a delayed laparotomy based on evolving clinical findings. The radiologists interpretation of the EAS video disagreed with the clinician sonographer in only 3% of cases. Based on these results, a diagnostic algorithm was developed using EAS as a screening test with selective use of DPL and CT. Emergent abdominal sonography performed by clinician sonographers is a rapid and accurate test for peritoneal fluid in blunt trauma victims, and the need for laparotomy in patients with a negative EAS is rare. Our study supports the routine use of EAS as a screening test in a diagnostic algorithm for the evaluation of blunt abdominal trauma.