Need For Therapeutic Laparotomy Research Articles

Parameters for therapeutic laparotomy in blunt trauma abdomen

Background: The rapid identification of potentially life threatening intra-abdominal injury is critical for patients who sustain blunt abdominal trauma. There has been a shift from operative to non-operative management (NOM) in hemodynamically stable blunt trauma abdomen patients. The aim of present study was to determine the certain clinical and radiological parameters for therapeutic laparotomy (TL) in blunt trauma abdomen in adult patients.Methods: A prospective observational study was conducted on victims of blunt trauma who presented to our level II Emergency Department from May 2012 to June 2014. Their clinical, laboratory and radiological parameters were collected, evaluated and analyzed. A previously developed ultrasound scoring system was applied to FAST findings. Patients were followed to determine if they underwent TL or NOM.Results: A total of 7750 polytrauma patients with suspected blunt trauma abdomen underwent FAST. 338 (4.36%) patients had a positive FAST, out of which 144 were included, 93 (64.58%) patients were selected for NOM, and 51 (35.4%) patients underwent TL. NOM was successful in 76 (81.73%) patients, whereas 17 (18.27%) failed NOM and were operated. Using recursive partitioning analysis, the most important predictor for a TL, was whether the patient has an ED SBP of ≤90mmHg while other parameters include, ED pulse rate >110/min; total fast score >3; large amount of hemoperitoneum; presence of abdominal guarding, pallor and polytrauma.Conclusions: There are certain immediately available clinical, and radiological parameters, which if validated by a prospective, large sample size study could help in deriving a decision rule or even a scoring system that would determine the need for therapeutic laparotomy in blunt trauma abdomen patients.

Emergency Ultrasound Predicting the Need for Therapeutic Laparotomy among Blunt Abdominal Trauma Patients in a Sub-Saharan African Hospital

Background. The trauma burden globally accounts for high levels of mortality and morbidity. Blunt abdominal trauma (BAT) contributes significantly to this burden. Patient's evaluation for BAT remains a diagnostic challenge for emergency physicians. SSORTT gives a score that can predict the need for laparotomy. The objective of this study was to assess the accuracy of SSORTT score in predicting the need for a therapeutic laparotomy after BAT. Method. A prospective observational study. Eligible patients were evaluated for shock and the presence of haemoperitoneum using a portable ultrasound machine. Further evaluation of patients following the standard of care (SOC) protocol was done. The accuracy of SSORTT score in predicting therapeutic laparotomy was compared to SOC. Results. In total, 195 patients were evaluated; M : F ratio was 6 : 1. The commonest injuries were to the head 80 (42%) and the abdomen 54 (28%). A SSORTT score of >2 appropriately identified patients that needed a therapeutic laparotomy (with sensitivity 90%, specificity 90%, PPV 53%, and NPV 98%). The overall mortality rate was 17%. Conclusion. Patients with a SSORTT score of 2 and above had a high likelihood of requiring a therapeutic laparotomy. SSORTT scoring should be adopted for routine practice in low technology settings.

The utility of diagnostic laparoscopy in the evaluation of anterior abdominal stab wounds

Background To assess if diagnostic laparoscopy (DL) is superior to nonoperative modes (serial abdominal examination with/without computed axial tomography [CAT] and diagnostic peritoneal lavage) in determining the need for therapeutic laparotomy (TL) after anterior abdominal stab wound (ASW). Methods Retrospective review of ASW patients. Patients were divided into group A (DL/exploratory laparotomy) to identify peritoneal violation (PV) and group B (initial nonoperative modes). Results Seventy-three patients met inclusion criteria. In group A (n = 38), 29 patients (76%) had PV by DL and underwent exploratory laparotomy. Only 10 (35%) underwent TL (sensitivity for PV = 100%; specificity and positive predictive value of PV in determining need for TL = 29% and 33%, respectively). In group B (n = 35), 7 patients (20%) underwent TL, yielding an improved specificity (96%) and positive predictive value (88%). Conclusions We find no role for DL in the evaluation of ASW patients solely to determine PV.

Association Between a Positive ED FAST Examination and Therapeutic Laparotomy in Normotensive Blunt Trauma Patients

Although a positive FAST (focused assessment with sonography for trauma) examination in hypotensive blunt trauma patients generally suggests the need for emergent laparotomy, this finding’s significance in normotensive trauma patients is unclear. We tested the association between a positive FAST and the need for therapeutic laparotomy in normotensive blunt trauma patients. This was a retrospective cohort analysis of consecutive normotensive blunt trauma patients presenting to two trauma centers. The outcome was therapeutic laparotomy. The unadjusted association between a positive FAST and laparotomy was odds ratio (OR) 116 (95% confidence interval [CI] 49.5–273). This association persisted after adjusting for confounding variables (OR 44.6, 95% CI 1.77–1124). Thirty-seven percent of patients with a positive FAST required therapeutic laparotomy vs. 0.5% with a negative FAST. Among normotensive blunt trauma patients, there was a strong association between a positive FAST and the need for therapeutic laparotomy. Very few normotensive patients with a negative FAST required therapeutic laparotomy.

The Utility of Sonography for the Triage of Blunt Abdominal Trauma Patients to Exploratory Laparotomy

The purpose of this study was to assess the utility of focused abdominal sonography for trauma (FAST) in the triage of hypotensive and normotensive blunt abdominal trauma patients to exploratory laparotomy. Data entered in a trauma registry database were retrospectively reviewed and were correlated with medical records, radiology reports, and surgical laparotomy reports. In the setting of blunt abdominal trauma, hypotensive patients were compared with normotensive patients who underwent FAST. During the 6-year study period, 4,029 patients with blunt abdominal trauma underwent sonography, 122 of whom were hypotensive on arrival and underwent FAST. Of 87 hypotensive patients with positive findings on FAST, 69 (79%) were taken directly to exploratory laparotomy without the need for CT. In predicting the need for therapeutic laparotomy in hypotensive patients, the sensitivity of FAST was 85%, specificity was 60%, and accuracy was 77%. Of the 3,907 normotensive patients, 3,584 had negative FAST findings, whereas 323 had positive FAST findings. In normotensive patients, the sensitivity of FAST was 85%, specificity was 96%, and accuracy was 96%. In the combined patient population (all hypotensive and normotensive patients), 4,029 patients with blunt abdominal trauma underwent sonography: 3,619 had negative and 410 had positive FAST findings. In all patients regardless of blood pressure, the sensitivity of FAST was 85%, specificity was 96%, and accuracy was 95%. Hypotensive patients screened in the emergency department with positive FAST findings may be triaged directly to therapeutic laparotomy, depending on the results of the sonography examination, without the need for CT.

Suicide Bombing Attacks

To report the distribution and types of injuries in victims of suicide bombing attacks and to identify external signs that would guide triage and initial management. There is a need for information on the degree to which external injuries indicate internal injuries requiring emergency triage. The medical charts and the trauma registry database of all patients who were admitted to the Hadassah Hospital in Jerusalem from August 2001 to August 2004 following a suicide bombing attack were reviewed and analyzed for injury characteristics, number of body areas injured, presence of blast lung injury (BLI), and need for therapeutic laparotomy. Logistic analysis was performed to identify predictors of BLI and intra-abdominal injury. The study population consisted of 154 patients who were injured as a result of 17 attacks. Twenty-eight patients suffered from BLI (18.2%) and 13 patients (8.4%) underwent therapeutic laparotomy. Patients with penetrating head injury and those with > or =4 body areas injured were significantly more likely to suffer from BLI (odds ratio, 3.47 and 4.12, respectively, P < 0.05). Patients with penetrating torso injury and those with > or =4 body areas injured were significantly more likely to suffer from intra-abdominal injury (odds ratio, 22.27 and 4.89, respectively, P < 0.05). Easily recognizable external signs of trauma can be used to predict the occurrence of BLI and intra-abdominal injury. The importance of these signs needs to be incorporated into triage protocols and used to direct victims to the appropriate level of care both from the scene and in the hospital.

The fast is positive, now what? Derivation of a clinical decision rule to determine the need for therapeutic laparotomy in adults with blunt torso trauma and a positive trauma ultrasound

Introduction: The object of this study was to derive a clinical decision rule for therapeutic laparotomy among adult blunt trauma patients with a positive abdominal ultrasound for trauma (FAST) examination. Methods: We retrospectively reviewed the trauma registry and medical records of all critical trauma patients who underwent a FAST examination in the emergency department (ED) in a university Level I trauma center over a 3-year period. Blunt trauma patients aged >16 years who had a positive FAST examination (defined as the presence of intraperitoneal fluid) were eligible. We selected seven clinical and ultrasound variables available during ED resuscitation for analysis: age, presence of an episode of hypotension (systolic blood pressure <90 torr in the ED), presence of abdominal tenderness, chest injury, pelvic fracture, femur fracture, and FAST fluid location (right upper quadrant [RUQ] only; RUQ plus other location; other location only). The primary outcome variable was whether a laparotomy was performed and whether this laparotomy was needed to provide the definitive surgical intervention (“therapeutic laparotomy”). We analyzed the variables using binary recursive partitioning analysis to create a decision rule. Results: There were 2336 FAST examinations performed during the study period, resulting in 230 (9.8%) positive examinations in patients meeting inclusion criteria. There were 135 patients who had therapeutic laparotomies and 95 who did not need laparotomy. The groups were similar in baseline characteristics. In the recursive partitioning analysis, the first node in the decision tree was the presence of fluid in the RUQ. Of the 144 patients with RUQ fluid, 105 (73%, 95% confidence interval [CI] 64%–80%) required therapeutic laparotomy. Of the 86 patients without RUQ fluid, 30 (35%, 95% CI 25%–46%) nevertheless required therapeutic laparotomies, and the variables blood pressure, femur fracture, abdominal tenderness, and age further divided these patient into high- and low-risk groups. Of the 12 patients without RUQ fluid who had normal blood pressures, no femur fractures, no abdominal tenderness, and were aged 60 years and younger, none (95% CI 0%–22%) required therapeutic laparotomy. In conclusion, given a positive FAST examination, the presence of fluid in the RUQ is an important predictor of the need for therapeutic laparotomy. Conclusion: In the absence of fluid in the RUQ, there are other clinical variables that may allow for the development of a clinical decision rule regarding the need for therapeutic laparotomy.

Shock index combined with focused abdominal sonography for trauma examination as a predictor for therapeutic laparotomy in blunt trauma

Study objectives: The focused abdominal sonography for trauma (FAST) examination was developed to help rapidly identify those blunt trauma patients who require emergency laparotomy. Since then, the clinical use of the FAST examination has expanded. When applied to hemodynamically stable blunt trauma patients, the FAST examination is less sensitive for any injury and particularly the need for laparotomy. Combining FAST results with a measure of hemodynamic stability might better predict the need for emergency laparotomy as a therapeutic intervention and thus give a more meaningful predictive value to the positive test. We therefore sought to determine whether a first measured shock index of 1 or greater, when combined with a positive FAST examination, better predicts the need for therapeutic laparotomy in blunt trauma patients than FAST alone. Methods: This is a retrospective, case-control study using the institutional trauma database at an American College of Surgeons–verified Level I trauma center during 2003. Patients were included in the study if injured by blunt mechanism and if they required the highest level of trauma team activation by standardized institutional criteria. Patients were excluded if they had previous peritoneal lavage or transfusion or were younger than 14 years. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the test (positive FAST plus shock index ≥1) for therapeutic laparotomy were calculated, along with 95% confidence intervals (CIs). The first emergency department recorded values for heart rate and systolic blood pressure were used to calculate the shock index. Results: Four hundred ninety-one patients were included in the study, 27 of whom underwent emergency laparotomy (rate 5.50%). Two of these laparotomies were classified as nontherapeutic. Of the 464 patients without laparotomy, 303 (65.3%) were men, with a mean age of 37.2 years. Of the patients with laparotomy, 17 (63.0%) were men, with a mean age of 38.4 years. Motor vehicle collisions were the mechanism of injury in 50.4% and 66.7% of those without and with laparotomy, respectively. The mean presenting Glasgow Coma Scale score was 12 versus 8 for those without and with laparotomy, and the mean Injury Severity Score was 16.9 versus 33.7 for those without and with laparotomy. Three hundred forty-four patients had FAST results recorded for analysis. The sensitivity of a positive FAST examination plus shock index of 1 or greater for therapeutic laparotomy was 44.0% (95% CI 26.3 to 62.8%), specificity 99.4% (95% CI 98.0 to 99.9%), and PPV 84.6% (95% CI 60.5 to 97.1), whereas the NPV was 95.7% (95% CI 93.2 to 97.6). Conclusion: Although the sensitivity for a positive FAST examination and a shock index of 1 or greater to predict therapeutic laparotomy is low, the PPV of the test is quite high. The combination of FAST results plus first measured vital signs (even if they later respond to intravenous fluid or transfusion) indicates a high likelihood of the need for therapeutic laparotomy.

The role of laparoscopy in blunt abdominal trauma.

In a collective analysis of 11 reports with a total of 355 blunt abdominal trauma patients, the sensitivity and specificity of diagnostic laparoscopy in predicting the eventual need for therapeutic laparotomy were 94% and 98%, respectively, with an overall accuracy of 97%. Although fairly accurate and safe (morbidity rate about 1.2%), the invasiveness, cost and time-consuming nature of diagnostic laparoscopy limit its routine use in trauma patients. It could, however, be useful in selecting patients with minor or nonbleeding injuries for nonoperative management after positive peritoneal lavage or computed tomography, and in excluding occult bowel and diaphragmatic injuries in patients with equivocal findings, thereby reducing the number of unnecessary laparotomies. With the improvement of laparoscopic techniques and instrumentation, more injuries can probably be managed laparoscopically with all the benefits observed with the shift from open to laparoscopic procedures in other patient populations, and it is likely that laparoscopy will find its place as an integral part of evaluating and treating patients with blunt abdominal trauma. At present, however, laparoscopy cannot be recommended as a routine tool for evaluating patients with blunt abdominal trauma, except in controlled clinical trials.

Ultrasonography for the evaluation of hemoperitoneum during resuscitation: a simple scoring system.

To assess the need for therapeutic laparotomy in patients with blunt abdominal trauma (BAT), ultrasonography (US) and a simple US scoring system were used to estimate the amount of hemoperitoneum during resuscitation. In group I (BAT with a US score > or = 3), 24 of 25 patients (96%) required therapeutic laparotomy. In group II (BAT with a US score < 3), therapeutic laparotomy was required in only 9 of 24 patients (38%); nonsurgical treatment may be justified in hemodynamically stable patients. Appropriate decisions can be made to perform urgent laparotomy when intra-abdominal bleeding is the culprit in BAT patients. Unnecessary laparotomy can be avoided when the major site of blood loss is not in the abdomen. Ultrasonography, an initial rapid screening procedure in BAT patients, is useful for trauma surgeons in decision making during resuscitation.