Non-operative Management Group Research Articles

Comparison of the Clinical Outcome of Nonoperative Management and Surgical Treatment of Blunt Splenic Trauma

Objective: Nonoperative management is the preferred treatment option of blunt splenic injury in appropriate conditions. Increasing success is achieved with the help of advanced imaging techniques and angioembolization procedure. We aimed to compare clinical outcomes of Nonoperative Management and Surgical Intervention in patients with blunt splenic injury. Methods: Records of 56 patients who were treated by nonoperative management or surgical intervention in our clinic were reviewed retrospectively. Patients were evaluated in terms of age, gender, grade of injury, mortality, length of hospital stay, complications, presence of additional injuries and concomitant disease in both groups. Results: There were 29 patients (51.78%) in the surgery group and 27 patients (48.2%) in the nonoperative management group. Grade of injury was determined significantly higher in surgical treatment group (p<0.001). Additional injury was observed more in the group treated with surgery (p: 0.033). Infectious complication rate was found higher in surgically treated group (<0.001). There was no significant difference between the groups in terms of age, gender, mortality, length of hospital stay, presence of concomitant disease. Conclusion: Nonoperative management is the appropriate method in treatment of blunt splenic injury in patients who were hemodinamically stable and have no signs of peritoneal irritation. Nonoperative management is increasingly being implemented in conjunction with improvements in imaging methods. Angioembolization is a treatment that increases the success rate of nonoperative management and implementation of this method in trauma centers is an important target. Surgical intervention is inevitable in cases when the nonoperative management is inappropriate. Key words: Blunt splenic injury, Nonoperative Management, Splenectomy, Splenoraphy.

Successful Nonoperative Management of High-Grade Blunt Renal Injuries.

Current management of high-grade blunt renal trauma favors a nonoperative approach when possible. We performed a retrospective study of high grade blunt renal injuries at our level I trauma center to determine the indications and success of nonoperative management (NOM). 47 patients with blunt grade IV or V injuries were identified between October 2004 and December 2013. Immediate operative patients (IO) were compared to nonoperatively managed (NOM). Of the 47 patients, 3 (6.4%) were IO and 44 (95.6%) NOM. IO patients had a higher heart rate on admission, 133 versus 100 in NOM (P = 0.01). IO patients had a higher rate of injury to the renal vein or artery (100%) compared to NOM group (18%) (P = 0.01). NOM failed in 3 of 44 patients (6.8%). Two required nonemergent nephrectomy and one required emergent exploration resulting in nephrectomy. Six NOM patients had kidney-related complications (13.6%). The renal salvage rate for the entire cohort was 87.2% and 93.2% for NOM. Nonoperative management for hemodynamically stable patients with high-grade blunt renal trauma is safe with a low risk of complications. Management decisions should consider hemodynamic status and visualization of active renal bleeding as well as injury grade in determining operative management.

Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest

BackgroundOpen reduction and internal fixation (ORIF) of fractured ribs for flail chest is safe and effective but who is most likely to benefit is unknown. Our purpose is to compare ORIF with nonoperative management (NOM) in polytrauma patients. MethodsAlbany Medical Center Hospital Trauma Registry was queried for adult patients with flail chest admitted over 7 years. ResultsEighty-six patients with radiographic flail chest were identified who met inclusion criteria. The 41 ORIF and 45 NOM patients had similar demographics and injury severity. Hospital length of stay and intensive care unit length of stay were significantly longer in the ORIF group than that of the NOM group. There was a trend toward longer time on the ventilator in the ORIF group. ConclusionsIn this retrospective study, patients treated by ORIF had longer hospitalization and ventilator duration. Future studies should be designed to optimally identify patients who are most likely to benefit from ORIF.

Nonoperative management of rectal cancer after chemoradiation opposed to resection after complete clinical response. A comparative study

IntroductionSurgery is the standard treatment of rectal cancer after neoadjuvant therapy. Some authors advocate a nonoperative management (NOM) after complete clinical response (cCR) following chemoradiotherapy (CRT). We compare our results with NOM to standard resection in a retrospective analysis. MethodsRectal adenocarcinomas submitted to NOM after CRT between September 2002 and December 2013 were compared to surgical patients that had pathological complete response (pCR) during the same period. Endpoints were Overall Survival (OS), Disease Free Survival (DFS), Local Relapse (LR) and Distant Relapse (DR). ResultsForty-two NOM patients compared to 69 pCR patients operated after a median interval of 35 weeks after CRT. NOM tumors were distal (83.3% vs 59.4%, p = 0.011), less obstructive (26.2% vs 54.4%, p = 0.005) and had a lower digital rectal score (p = 0.024). Twelve (28.0%) recurrences in NOM group and eight (11.5%) in the surgical group occurred after a follow-up of 47.7 and 46.7 months respectively. Isolated LR occurred in five (11%) NOM patients and one (1.4%) in the surgical group. Four (80%) LR were surgically salvaged in NOM group. No difference in OS was found (71.6% vs 89.9%, p = 0.316) but there was a higher DFS favoring surgical group (60.9% vs 82.8%, p = 0.011). Distal tumors had worse OS compared to proximal tumors in surgical group (5-year OS of 85.5% vs 96.2%, p = 0.038). ConclusionThe NOM achieved OS comparable to surgical treatment and spared patients from surgical morbidity but it resulted in more recurrences. This approach cannot be advocated routinely and controlled trials are warranted.

Organ preservation in patients with rectal cancer with clinical complete response after neoadjuvant therapy.

509 Background: Nonoperative management (NOM) of rectal cancer following a clinical complete response (cCR) to neoadjuvant therapy is a non-standard approach. We review our experience with NOM to evaluate safety and efficacy. Methods: A retrospective review of prospectively collected data between 2006 and 2014 was conducted. We compared patients completing neoadjuvant therapy for stage I to III rectal cancers who: a) achieved cCR and were treated with NOM, or b) underwent standard total mesorectal excision (TME) and achieved a pathologic complete response (pCR). Kaplan-Meier estimates and the log-rank test were used. Results: Seventy-three patients underwent NOM after cCR. From 369 rectal resections performed, 72 (20%) achieved pCR and form the comparison group. Median follow-up across both groups was 3.3 years. Rectal preservation was achieved in 56 (77%) of the patients treated with NOM. Of the 19 NOM patients with local regrowth, 18 were salvaged successfully with standard TME (n=16) or local excision (n=2), with one patient pending a salvage operation (n=1). No significant differences were noted in the number of distant recurrences between the NOM and pCR groups. Four-year disease-specific survival and overall survival between the two groups were not significantly different. Conclusions: In this highly selected group of patients with cCR to neoadjuvant treatment, NOM with surgical salvage of local tumor regrowth achieved local control in all patients. The oncologic outcome for NOM patients at 4 years was comparable to patients with pCR after rectal resection. These data continue to suggest that NOM does not compromise oncologic outcome, and that preservation of the rectum is achieved in a majority of patients. [Table: see text]

Comparison between operative versus non-operative management of traumatic liver injury.

Backgrounds/AimsThe aim of this study was to compare operative versus non-operative management of patients with liver injury and to ascertain the differences of the clinical features.MethodsFrom April 2000 to July 2012, 191 patients were admitted to Seoul St. Mary's Hospital and St. Vincent's Hospital for liver injuries. Of these, 148 patients were included in this study. All patients were diagnosed using computed tomography (CT). The liver injury was graded in accordance with the American Association for the Surgery of Trauma liver injury scoring scale. Patients were divided into two groups: those who underwent surgery and those treated with non-operative management (NOM). There was a comparison between these two groups concerning the clinical characteristics, grade of liver injury, hemodynamic stability, laboratory findings, and mortality.ResultsAccording to the 148 patient records evaluated, 108 (72.9%) patients were treated with NOM, and 40 (27.1%) underwent surgery. Patients treated with NOM had significantly fewer severe injuries as rated using the Revised Traumatic Injury Scale, Injury Severity Score, and Glasgow Coma Scale. Grade of liver injury and number of patients with extravasation of contrast dye on CT and hemoperitoneum were higher in the operative group than in the NOM group. There were significant differences between the two groups for: heart rate, respiratory rate, systolic blood pressure, and mean hemoglobin levels at admission and after 4 hours. The operative group experienced a significantly higher mortality than the NOM group.ConclusionsThe results of our study suggest that hemodynamic stability and the following should be considered for deciding the treatment for liver injuries: grade of liver injury, amount of blood loss, and injury scales scores.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Non-operative management attempted for selective high grade blunt hepatosplenic trauma is a feasible strategy.

BackgroundThere is growing evidence of clinical data recently for successful outcomes of non-operative management (NOM) for blunt hepatic and spleen injuries (BHSI). However, the effectiveness of NOM for high-grade BHSI remains undefined. The aim of the present study was to review our experience with NOM in high-grade BHSI and compare results with the existing related data worldwide.MethodsIn this retrospectively protocol-driven study, 150 patients with grade 3–5 BHSI were enrolled during a 3-year period. Patients were divided into immediate laparotomy (immediate OP) and initial non-operative (initial NOM) groups according to hemodynamic status judged by duty trauma surgeon. Patients who received initial NOM were divided into successful NOM (s-NOM) and failed NOM (f-NOM) subgroups according to conservative treatment failure. We analyzed the clinical characteristics and the outcomes of patients.ResultsTwenty-eight (18.7%) patients underwent immediate operations, and the remaining 122 (81.3%) were initially treated with NOM. Compared with the initial NOM group, the immediate OP group had significantly lower hemoglobin levels, a higher incidence of tube thoracostomy, contrast extravasation and large hemoperitoneum on computed tomography, a higher injury severity score, increased need for transfusions, and longer length of stay (LOS) in the intensive care unit (ICU) and hospitalization. Further analysis of the initial NOM group indicated that NOM had failed in 6 (4.9%) cases. Compared with the s-NOM subgroup, f-NOM patients had significantly lower hemoglobin levels, more hospitalized transfusions, and longer ICU LOS.ConclusionsNOM of high-grade BHSI in selected patients is a feasible strategy. Notwithstanding, patients with initial low hemoglobin level and a high number of blood transfusions in the ICU are associated with a high risk for NOM failure.

Editorial: Evidence-based medicine

Bakhsheshian et al. present a review paper evaluating the current state of evidence-based medicine in the nonoperative management of traumatic thoracolumbar burst fractures.1 They performed a systematic review according to the Cochrane guidelines. This paper is very well written. They identified 45 papers, over 20 years, which primarily investigated nonoperative management, and found 9 of the 45 papers had either Level I or II evidence. The authors have comprehensively reviewed these 9 papers. They excluded papers that assessed osteoporotic or pathological fractures. They determined that for neurologically intact patients, better outcomes were often achieved with conservative treatment regimens compared to operative management. They clearly identified fewer complications in the nonoperative management groups, and often the functional outcomes were superior in the group that did not undergo surgery. The nonoperative management techniques evaluated included bed rest, closed reductions, orthoses, and body casts. They also demonstrated that the presence of a neurological deficit is not necessarily a contraindication to nonoperative treatment; however, they acknowledge that this question has not been satisfactorily addressed in the current literature. They attempted to compare different conservative treatment approaches but their review did not allow for concluding that a specific conservative treatment technique was better than the others. A potential shortcoming of this paper is that the degree of kyphosis present, an indirect indicator of posterior ligamentous complex integrity, was not always stated (it was stated in the paper by Wood et al. and was an exclusion criterion). In reviewing these nonoperative management papers, it appears that they predominantly assessed lesser degrees of severity of bone and/or ligamentous injury. The majority of cases involved patients without neurological deficits. What is readily apparent is that all burst fractures, or what are reported as burst fractures, are not alike. Thoracolumbar burst fractures with significant neurological findings or with gross instability likely require surgical intervention; however, this review paper demonstrates that some lesser “burst” fractures likely are managed quite successfully with conservative treatment regimens. Importantly, the authors recognized the importance of both neurological and functional outcomes in this review. (http://thejns.org/doi/abs/10.3171/2014.5.FOCUS14190)

Western Trauma Association Critical Decisions in Trauma

Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American College of Surgeons and the American Association for the Surgery of Trauma. The American College Surgeons is accredited by the ACCME to provide continuing medical education for physicians. AMA PRA Category 1 Creditsi The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Crediti. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Of theAMAPRACategory 1 Crediti listed above, a maximum of 1 credit meets the requirements for self-assessment.

Non-operative Management of Blunt abdominal trauma in a Tertiary Care Hospital of Nepal

Background: To assess the feasibility of Non-operative management of Blunt abdominal trauma in a teaching hospital of Nepal. Methods: A prospective observational study was carried out over a period of 3 years including 52 cases of blunt abdominal trauma in a teaching hospital in western part of Nepal. Patient and trauma characteristics of the cases, different modalities of treatment and outcomes were evaluated. All the cases were divided in 3 groups: Operative group, Non-Operative Management and Non-Operative Failure group. Operative group and non-operative management group were compared using Fischer Exact Test for categorical variable and student’s “t” test for continuous variable. Results: There were 36% of cases in operative group, 61% in non-operative management group and 2% in non-operative management failure group. Non-operative management was successful in 97% of cases. Injury severity score, admission hematocrit and hemodynamic status were significantly different between non-operative management and Operative group. Non-operative management failure occurred in 1 case and was secondary to delayed hepatic hemorrhage. Conclusion: Non-operative management of Blunt abdominal trauma can be attempted with high degree of success. Hemodynamic and clinical instability rather than severity of the organ injury is the predictor of failure in non-operative management. Spleen and bowel injury are the most common organ that usually land up in operative group because of hemodynamic instability in splenic injury and peritoneal contamination in bowel injury. Close surveillance in an intensive care unit is always desirable. Nepal Journal of Medical Sciences | Volume 02 | Number 01 | Jan-Jun 2013 | Page 38-41 DOI: http://dx.doi.org/10.3126/njms.v2i1.7650

Complications arising from splenic artery embolization: a review of an 11-year experience

BackgroundSplenic artery embolization (SAE) is a staple adjunct in the management of blunt splenic trauma. We examined complications of SAE over an 11-year period. MethodsPatients who underwent SAE were identified. Demographic data and the location of the SAE—proximal, distal, or combined—were noted. Major and minor complications were identified. ResultsOf 1,383 patients with blunt splenic trauma, 298 (21.5%) underwent operative management, and 1,085 (78.5%) underwent nonoperative management (NOM). SAE was performed in 8.1% of the NOM group. Major complications which occurred in 14% of patients, included splenic abscesses, infarction, cysts, and contrast-induced renal insufficiency. Three-fourths of patients with major complications underwent distal embolization. There were more complications in patients who underwent distal embolization (24% distal vs 6% proximal alone; P = .02). Minor complications, which occurred in 34% of patients, included left-sided pleural effusions, coil migration, and fever. ConclusionsSAE is a useful tool for managing splenic injuries. Major and minor complications can occur. Distal embolization is associated with more major complications.

Nonoperative Management of Rectal Cancer With Complete Clinical Response After Neoadjuvant Therapy

Nonoperative management (NOM) of rectal cancer after a complete clinical response (cCR) to neoadjuvant therapy is controversial. In this article, we retrospectively reviewed the outcomes of patients managed with selective NOM after a cCR to neoadjuvant treatment and compared these with patients who underwent standard rectal resection with a pathological complete response (pCR). Patients completing neoadjuvant chemoradiotherapy (CRT) for stage I to III rectal cancer between January 2006 and August 2010 were retrospectively reviewed. Median follow-up was calculated in months after completion of CRT. Thirty-two patients (median follow-up 28 months) were treated by NOM after a cCR. Among 265 treated by CRT and rectal resection, 57 patients (22%) had a pCR and formed the control group (median follow-up 43 months). Factors associated with selective use of NOM included lower pretreatment stage, older age, and distal tumor location (P < 0.05). In the NOM group, 6 recurred locally (median 11 months, range 7-14), 3 of whom also had concurrent distant recurrence. All 6 local failures were controlled by salvage rectal resection with no further local recurrence of disease (median follow-up 17 months). In the rectal resection/pCR group, there were no local failures. The 2-year distant disease-free survival (88% vs 98%, P = 0.27) and overall survival (96% vs 100%, P = 0.56) were similar for NOM and rectal resection/pCR groups. Rectal resection was successfully avoided in 81% of patients selected for NOM. When combined with salvage surgery, NOM appears to achieve similar local and distant disease control compared with patients with a pCR treated by rectal resection. Longer follow-up and prospective trials are warranted to evaluate this promising treatment option.

Impact on family of management strategies for perforated appendicitis in children

Background/PurposeThe purpose of this study was to examine the impact on the family of immediate appendectomy compared with initial nonoperative management for perforated appendicitis in children. MethodsSixty-six prospectively identified families of children with perforated appendicitis completed a daily activity journal and the Impact on Family Scale at presentation and at completion of therapy. ResultsThere were no significant differences in postoperative surgical site infections or number of missed school or employment days between the immediate appendectomy group (n = 40) and the initial nonoperative management group (n = 26). Impact on Family Scale total scores decreased over time for both groups, but this improvement over time was significant only in the initial nonoperative management group (P < .01). ConclusionsImmediate appendectomy or initial nonoperative management can effectively manage perforated appendicitis in children with no statistically significant differences in the number of missed school or employment days. Greater improvements in family impact are associated with initial nonoperative management as measured by the Impact on Family Scale at completion of therapy.

Current management of pancreatic trauma

Although pancreatic trauma is uncommon, it poses a diagnostic and therapeutic challenge. Any delay in diagnosis raises morbidity and mortality. This study highlights the current management and outcome in patients of pancreatic trauma at a single tertiary care center. This is a retrospective analysis of prospectively collected data of 24 patients diagnosed to have pancreatic trauma. Collected data was analyzed for age, gender, mechanism of injury, hemodynamic status at presentation, initial serum amylase levels, CECT abdomen findings, AAST-OIS grade of pancreatic injury, injury to other organs, management, complications and outcome. The mean age of these 24 patients was 25 years; 19 were male and 5 females. The mechanisms of pancreatic trauma included blunt abdominal trauma in 21 (87.5%) cases and penetrating injury in 3 (12.5%). Seven (29.16%) patients were managed by non-operative management and 17 (70.83%) underwent surgery. Complications were more frequent in the operative group as compared to the non-operative group. Neither endocrine deficiency nor any mortality was noted in the non-operative management group; while there were 2 cases of endocrine deficiency and 3 mortalities in the operative group. Pancreatic trauma is more common in young male patients and more commonly inflicted by motor vehicles accidents. Low grade blunt pancreatic injury in hemodynamically stable patients and selected patients with high grade blunt pancreatic injury can be managed successfully by non-operative management with no increase in morbidity or mortality and most patients with high grade blunt pancreatic injury and those having penetrating injuries need surgical intervention.

Role of Splenic Artery Embolization in Management of Traumatic Splenic Injuries: A Prospective Study

The objective of our study was to evaluate the role of splenic artery embolization (SAE) in the management of traumatic splenic injuries. From September 2008 to September 2010, a total of 67 patients underwent nonoperative management (NOM) for blunt splenic injuries. Twenty-two patients were excluded from the study because of associated significant other organ injuries. Twenty-five patients underwent SAE followed by NOM (group A) and 20 patients underwent standard NOM (group B). Improvement in clinical and laboratory parameters during hospital stay were compared between two groups using Chi-square test and Mann-Whitney test. SAE was always technically feasible. The mean length of the total hospital stay was lower in the group A patients (5.4 vs. 6.6day, [P = 0.050]). There was significant increase in hemoglobin and hematocrit levels and systolic blood pressure (SBP) in group A patients after SAE, whereas in group B patients there was decrease in hemoglobin and hematocrit levels and only slight increase in SBP (pre- and early posttreatment relative change in hemoglobin [P = 0.002], hematocrit [P = 0.001], and SBP [P = 0.017]). Secondary splenectomy rate was lower in group A (4% [1/25] vs. 15% [3/20] [P = 0.309]). No procedure-related complications were encountered during the hospital stay and follow-up. Minor complications of pleural effusion, fever, pain, and insignificant splenic infarct noted in 9 (36%) patients. SAE is a technically feasible, safe, and effective method in the management of splenic injuries. Use of SAE as an adjunct to NOM of splenic injuries results improvement in hemoglobin, hematocrit levels, and SBP. SAE also reduces secondary splenectomy rate and hospital stay.

Laparoscopic posterior sectoral bile duct injury: the emerging role of nonoperative management with improved long-term results after delayed diagnosis

Right posterior sectoral bile duct (RPSD) anomalies seen in up to 8% of the population rarely are injured at laparoscopic cholecystectomy. Paucity of data on the management of these injuries led the authors to conduct this study aimed at reviewing management strategies for laparoscopic RPSD injuries at a specialist center. Of 221 patients, 15 (6.7%; 4 men; mean age, 51 years; range, 21-75 years) treated between 1992 and 2009 for injuries to the RPSD were followed up for a median of 58 months (range, 7-208 months). Case notes, imaging, and follow-up data were reviewed. The RPSD injury was immediately recognized in 3 (20%) of the 15 patients, whereas in the remaining patients, biliary injury was suspected on day 1 (range, 1-18 days) due to bile leak/biloma. The diagnosis of RPSD injury was made by a combination of investigations including endoscopic retrograde cholangiopancreatography (ERCP) (n = 11), drain tube cholangiogram (n = 10), on-table cholangiogram (n = 3), and nuclear scan (n = 3). An intact common bile duct and absence of RPSD were identified on cholangiography (ERCP and on-table cholangiogram), whereas drain tube cholangiogram demonstrated a leaking RPSD in all cases. The majority of the patients (8/15, 53%) were managed nonoperatively with combined percutaneous drainage and endoscopic stenting, whereas six patients (40%) were managed with biliary reconstruction (immediate: n = 2; delayed 14-87 days: n = 4). Clinical and radiologic confirmation of complete cessation of bile leak was demonstrated 56 days (range, 7-62 days) after injury. The long-term outcome included a dilated right duct system with transient elevation of liver function tests in two patients (1 each in the nonoperative and surgical management groups), whereas the remaining patients all remain well at this writing. Bile leak in the presence of an intact common duct shown on cholangiogram should raise the suspicion of an RPSD injury. Expertise is needed to interpret the absence of RPSD in these cases. Drain tube cholangiogram is an important adjunctive investigation. In selected cases, the results of nonoperative management alone is comparable with the results of reconstruction.

Does Splenic Embolization and Grade of Splenic Injury Impact Nonoperative Management in Patients Sustaining Blunt Splenic Trauma?

Nonoperative management (NOM) for blunt splenic trauma (BST) is an established practice. The impact of splenic embolization (SE) in the algorithm for NOM has not been well studied. This study evaluates the role of SE and spleen injury grade on failure of NOM. Retrospective cohort of trauma registry over a 7-year period (2000-2006) for patients who suffered BST was studied. Data including demographics, splenic injury grade, and SE were recorded. Characteristics were compared between the successful and failed NOM groups. Kaplan-Meier, life table, and Cox-proportional hazard regression analyses were performed. Of the 499 patients who suffered BST, 407 (81.6%) patients had successful NOM and 92 (18.4%) patients failed NOM (including splenectomies performed within 1 hour of admission). Failed NOM group had a higher splenic injury grade compared with the successful NOM group (P < 0.0001). Seventy-five per cent underwent a splenectomy within 7.7 hours of admission. Nearly all grade I and II splenic injuries that failed NOM occurred by 24 hours. Grade 3 and 4 injuries that failed NOM occurred by 150 hours. SE was protective against splenectomy (Hazard Ratio (HR) 0.18, 95% confidence interval: 0.06-0.55, P = 0.004), whereas splenic injury grades III or higher was associated with increased risk of splenectomy (grade III: HR 5.26, P = 0.003; grade IV: HR 6.84, P = 0.002; grade V: HR 9.81, P = 0.002) compared with those with splenic injury grade I. Splenic embolization is a protective measure to reduce the failure of NOM. Spleen injury grade III and higher was significantly associated with NOM failure and would require a 5-day inpatient observation.

Efficacy and safety of non-operative management of blunt liver trauma.

The liver is the most frequently affected organ during blunt abdominal trauma. Blunt liver trauma management has changed in the last two decades with the introduction of the computed tomography (CT) scan and non-operative management of stable patients. To determine the incidence, efficacy, and failure rate of blunt liver trauma non-operative management as well as the risk factors associated with such treatment in a level 1 trauma center in Colombia. We conducted an observational descriptive study on patients with blunt liver trauma who were admitted to a level 1 trauma center in Colombia. The evaluated outcomes were indications of immediate surgical treatment and the success of non-operative management. A total of 73 patients were studied. The most common mechanism of trauma continues to be motor vehicle crashes. In 14 patients (19.2%), immediate surgical intervention was necessary and we observed a Revised Trauma Score (RTS) above 7.8 and intra-abdominal injuries as risk factors. Three patients died (21.4%). Fifty-nine patients (80.8%) received non-operative management, which failed in seven patients (11.2%). Age, severity of liver injury, and intra-abdominal injuries were not risk factors in the failure of non-operative management. Mortality in the non-operative management group was 1.7%. Non-operative management is the treatment of choice for polytraumatized patients with blunt liver trauma who are hemodynamically stable. Non-operative management is an effective and safe treatment strategy. However, patients with an RTS score under 7.8 and other intra-abdominal non-liver injuries are at increased risk for an immediate surgical intervention.

Comparison Between Immediate Appendectomy Versus Nonoperative Management For Pediatric Perforated Appendicitis With Intraabdominal Abscess

Introduction: The impact of nonoperative management (NOM) on children with perforated appendicitis compared to immediate appendecomy (IA) remains unclear. This study identifies factors associated with NOM and compares outcomes between NOM and IA. Methods: Children 1-18 y/o with perforated appendicitis and intraabdominal abscess were extracted from California's Patient Discharge Database,1999-2006. NOM was defined as drainage for appendiceal abscess and no appendectomy within 2 days of admission. NOM failures required operations within 4 weeks of presentation. Patient and hospital characteristics, initial hospital course, and readmissions were compared between NOM and IA. Hospital volumes were stratified into quartiles, where the “top” and “bottom” quartiles were labeled as “high” and “low” volume hospitals respectively. P<0.01 was considered significant. Results: Overall, 17,039 children with perforated appendicitis were treated at 359 different hospitals with volumes ranging from 1-117 cases/yr. Only 408 (2.4%) underwent NOM, while 16.631 (97.6%) had IA. NOM rate increased from 1.6% in 1999 to 4.4% in 2006 (p<0.001). NOM had longer initial (7.5 vs 5.4 days, p<0.001) and cumulative (9.3 vs 5.8 days, p<0.001) length of stay, higher cumulative hospital charges ($40k vs $31k, p<0.001), and more home health assistance (9 vs 2%, p<0.001). Furthermore, NOM had higher readmission rates (57 vs 11%, p<0.001), and more serious complications (14 vs 9%, p<0.005). Postoperative infection rate (3 vs 6%, p=NS) and readmit abscess drainage rate (2 vs 5%, p=NS) were similar. Multivariate analysis demonstrated children who had NOM compared to IA were more likely to be white (33 vs 27%, OR 1.49, p<0.005), girls (52 vs 38%, OR 1.75, p<0.001), with private insurance (45 vs 37%, OR 1.51, p<0.001), and to be treated at a high volume (48 vs 32%, OR 2.45, p<0.001) and children's hospitals (46 vs 26%, OR 2.50, p<0.001). NOM failure occurred in 148 (37%), 18% failed during the initial hospitalization. There were 79 children who underwent interval appendectomy (19%), and 181 (44%) did not undergo appendectomy. The rate of extensive bowel resections at appendectomy was similar (1 vs 1%, p=NS). The rate of laparoscopy was higher in the NOM group (51 vs 31%, p<0.001). Conclusions: Although the use of NOM increased steadily over time, there is no clear advantage of NOM compared to IA. NOM had longer hospitalizations, higher charges, more readmissions, and a higher complication rate. The rates of bowel resections were similar between the two groups. Large prospective randomized trials are needed to identify unique patient populations that would benefit from NOM vs. IA.