Non-operative Management Group Research Articles

Traumatic Liver Injury in Hong Kong: The Management Strategy and Outcome

IntroductionManagement of liver injury is challenging and evolving. The aim of this article is to review the outcome of traumatic liver injury in Chinese people in Hong Kong.Materials & methodsRecords of 40 patients with hepatic injury who received treatment at the Prince of Wales Hospital between December 2000 and May 2005 were reviewed. Demographic data, severity of liver injury, Injury Severity Score (ISS), haemodynamic status and Glasgow Coma Scale (GCS) score on admission, investigations made, concomitant injuries, management scheme, and outcome of patients were analysed.ResultsThere were 23 male and 17 female patients with a mean age of 31.3 (SD=15.4) years. Road traffic accident was the most common injury mechanism (65%). Half of the patients were treated by non‐operative management (NOM). None of them required surgery during subsequent management. Patients in the operative management (OM) group had a significantly higher ISS (p=0.026), but there was no significant difference in the mortality rate between the OM and NOM groups. Patients with stable haemodynamic status and who were treated non‐operatively had a significantly shorter hospital stay (p=0.006). High grade liver injury (OR=8.0, 95% CI=1.2 to 53.8, p=0.03) and ISS greater than 25 (OR=21.6, 95% CI=2.0 to 225.3, p=0.01) were independent risk factors for mortality on multivariate analysis.ConclusionsNon‐operative management of liver injury can be safely accomplished in haemodynamically stable patients, with the possible benefit of a shorter hospital stay.

A Prospective Study of Blunt Abdominal Trauma at the University of Calabar Teaching Hospital, Nigeria.

Blunt abdominal trauma (BAT) usually results from motor vehicle accidents, assaults, and recreational accidents or falls. This communication is a 3-year report of an ongoing study aimed at providing the current BAT prevalence in our center. It is hoped that this would assist in a better design of prevention and emergency trauma response systems to cope with this epidemic. All of the patients admitted to the University of Calabar Teaching Hospital (UCTH), Calabar, Nigeria, from February 2005 to January 2008 were prospectively studied based on a questionnaire. Hemodynamic stability and sonography formed the basis for selecting patients for non-operative management (NOM); others were offered laparotomy. In total, 4,391 emergencies were seen during the study period, of which 1,654 (38%) were due to trauma. Seventy-nine patients with abdominal trauma accounted for 4.8% of trauma cases. Forty-two (53%) patients suffered BAT and their ages ranged from 14 and 56 years (mean 28.4 years), with a male:female ratio of 2.5:1. Road traffic accidents accounted for 13 (87%) and 26 (96%) patients in the NOM and laparotomy groups, respectively. The most commonly injured organ was the spleen in both groups: 8 (50%) and 15 (56%) in the NOM and laparotomy groups, respectively. Fifteen (36%) patients were managed successfully in the NOM group. Trauma was mainly due to road traffic injuries. Hemodynamic stability and ultrasonography effectively selected patients for NOM. The establishment of trauma systems, provision of ancillary diagnostic and monitoring facilities, well-designed roads and traffic infrastructure, and health education on road safety would reduce injury, morbidity, and mortality.

Blunt Splenic Injuries in the Adolescent Trauma Population: The Role of Angiography and Embolization

Splenic artery embolization (SAE) improves non-operative splenic salvage rates in adults, but its utility and safety in the pediatric population is less well defined. Because adolescent trauma patients are often triaged to adult trauma centers, we were interested in evaluating SAE in this particular population. We hypothesize that angiography and embolization is a safe and effective adjunct to non-operative management in the adolescent population. A retrospective review of all patients aged 13-17 years admitted to our Level I Trauma Center with blunt splenic injury from 1997-2005 was performed. We reviewed patient demographics, operative reports, admission, and follow-up abdominal computed tomography (ACT) results, angiographic reports, and patient outcomes. A total of 97 patients were reviewed. Eighteen patients underwent immediate surgery, and 79 of the remaining patients had planned non-operative management. Of those participating in non-operative management, 35/79 (44%) were initially observed and 44/79 (56%) underwent initial angiography, 23/44 having embolization. Patients in the embolization group had an overall high grade of injury (American Association for the Surgery of Trauma mean grade 3.3, SD 0.6). The overall splenic salvage rate was 96% (76/79) in the non-operative management group; 100% splenic salvage was seen in the observational group; 100% salvage was also seen in patients with negative angiography, and 87% salvage (20/23) in the splenic artery embolization group. Splenic artery embolization may be a valuable adjunct in adolescent blunt splenic injury, especially in higher grade injuries or with evidence of splenic vascular injury on ACT.

Non-operative management of blunt abdominal trauma. Is it safe and feasible in a district general hospital?

BackgroundTo evaluate the feasibility and safety of non-operative management (NOM) of blunt abdominal trauma in a district general hospital with middle volume trauma case load.MethodsProspective protocol-driven study including 30 consecutive patients who have been treated in our Department during a 30-month-period. Demographic, medical and trauma characteristics, type of treatment and outcome were examined. Patients were divided in 3 groups: those who underwent immediate laparotomy (OP group), those who had a successful NOM (NOM-S group) and those with a NOM failure (NOM-F group).ResultsNOM was applied in 73.3% (22 patients) of all blunt abdominal injuries with a failure rate of 13.6% (3 patients). Injury severity score (ISS), admission hematocrit, hemodynamic status and need for transfusion were significantly different between NOM and OP group. NOM failure occurred mainly in patients with splenic trauma.ConclusionAccording to our experience, the hemodynamically stable or easily stabilized trauma patient can be admitted in a non-ICU ward with the provision of close monitoring. Splenic injury, especially with multiple-site free intra-abdominal fluid in abdominal computed tomography, carries a high risk for NOM failure. In this series, the main criterion for a laparotomy in a NOM patient was hemodynamic deterioration after a second rapid fluid load.

Selective Nonoperative Management of Low-Grade Blunt Pancreatic Injury: Are We There Yet?

Nonoperative management (NOM) of low-grade blunt pancreatic injuries (LGBPI) diagnosed by computed tomographic (CT) abnormalities of the pancreas in the adult hemodynamically stable (HDS) patient has not been previously defined. We report our experience of patients with LGBPI at a single Level I Trauma Center. Adult HDS patients during a 5-year period with blunt pancreatic injuries with an abbreviated injury score of </=2 were identified through the hospital trauma registry. Management, complications, and outcome were reviewed. Patients who underwent initial emergency laparotomy, died on hospital day one, or had a Glasgow Coma Scale of three were excluded. Failure of NOM was defined by need for subsequent exploratory laparotomy or development of a pancreatic complication. Data are reported as mean +/- SEM. A total of 120 patients were identified as having blunt pancreatic injury of which 35, with pancreatic abbreviated injury score of </=2, were blunt HDS patients with abdominal CT evidence of pancreatic injury. Amylase elevation was noted in 23 of 35 (68.5%) patients with positive CT scan findings of LGBPI. Study population consisted of 20 male patients and 15 female patients, age 32 +/- 13.22, injury severity score 21 +/- 10.08, systolic pressure 123 +/- 27.06 with mean base deficit -3.78 +/- 2. Of these 12 (34.28%) patients had an associated intra-abdominal solid organ injury. Five patients failed NOM (F-NOM), one had missed small bowel injury, three had pancreatic abscess, of which one developed a pancreatic fistula which resolved with medical management, and one F-NOM for blunt liver injury with missed bowel injury. No death in the F-NOM group and two deaths (5.71%) in the successful NOM (S-NOM) group unrelated to the pancreas. The average length of stay was 11 days +/- 9.71 days. NOM of LGBPI diagnosed by CT was successful in the majority of HDS patients, with low morbidity and mortality. We propose a management algorithm for NOM of LGBPI in which the role for early ductal injury detection with endoscopic retrograde cholangio-pancreatogram or magnetic retrograde cholangio-pancreatogram should be incorporated to better analyze the most appropriate treatment.

Effect of non-operative management (NOM) of splenic ruptureversussplenectomy on the distribution of peripheral blood lymphocyte populations and cytokine production by T cells

Post-traumatic splenectomy is associated with increased postoperative morbidity and mortality and long-term impairment of humoral and cellular immunity. Alternatives to surgery have been developed to minimize or avoid the immediate and/or long-term complications of splenectomy. Herein we investigated the long-term effect of non-operative management (NOM) of the traumatic rupture of the spleen on the distribution of peripheral blood (PB) lymphocyte populations and cytokine production by T cells. PB samples were drawn from six NOM patients, 13 age-matched adults who had undergone splenectomy after trauma (SP patients) and 31 age-matched controls. Cellular phenotypes and the intracellular production of interferon (IFN)-gamma, interleukin (IL)-2, IL-4 and IL-10 cytokines in T cells were determined in whole blood +/- mitogens by flow cytometry. NOM patients did not show any changes in the absolute numbers of lymphocytes or the distribution of their subsets, compared to the controls. In contrast, SP patients showed a sustained increase in the percentage and/or absolute numbers of lymphocytes, CD8 T cells, activated CD8 T cells, natural killer (NK) T cells, NK cells and gammadelta T cells, and a reduction in naive CD4 T cells. The constitutive or induced cytokine production by T cells of the NOM group was similar to the control group, whereas SP patients had increased percentages of constitutive IL-2- and IFN-gamma-producing CD8 T cells and IFN-gamma-producing CD4 T cells. Our findings indicate collectively that the healing process in NOM does not affect the architecture of the spleen to such an extent that it would lead to long-term alterations of the proportions of PB lymphocytes or the T cell cytokine profiles.

Liver injuries—Improved results with a formal protocol including angiography

We hypothesised that a formal treatment protocol for liver injuries including angiography would increase the non-operative management (NOM) rate and would be efficient as an adjunct to damage control surgery. During the 4-year period from 1 August 2000, a total of 138 adult patients with liver injuries were admitted to the largest trauma centre in Norway and prospectively included in the institutional trauma registry. On 1 August 2002, a protocol mandating angiography in all NOM patients with OIS grades 3-5 liver injuries and after packing of the liver was implemented. All patients admitted during the subsequent 2-year period (group 2) were compared with the previous 2 years as historic controls (group 1). Fifty-five patients were included in group 1 and 59 in group 2. The groups were statistically comparable, both with a mean ISS of 31. Patients selected for NOM increased from 28 (51%) to 45 (76%) (p<0.05), without increasing failure rate, liver-related complications, mortality or transfusion rate. Angiography was performed in 26 patients in group 2 (44%). Only nine patients underwent embolisation (35%), and five of these were in the NOM group. Angiography was negative in the eight NOM stable patients with OIS grade 3 injury. The implementation of a formal NOM protocol decreased total laparotomy rate and seemed to improve patient outcome without jeopardising patient safety. Surprisingly few of the patients undergoing angiography required embolisation. Angiography is not indicated in stable OIS grade 3 liver injuries, and the protocol in our institution has been adjusted accordingly. AE seems to be a valuable adjunct to DCS with packing of liver injuries.

Nonoperative Management of Blunt Splenic Trauma in the Elderly: Does Age Play a Role?

Nonoperative management (NOM) of blunt splenic injury has become more frequent in the past several decades. Criteria that predict successful NOM remain poorly defined, and one factor that has been studied previously has been patient age. Previous studies have defined older patients as those greater than 55 years of age, but no studies have compared younger patients (55-75 years) with older patients (75+ years) within this age group. A total of 1008 patients > or =55 years of age who sustained blunt splenic injury between 1993 and 2001 were analyzed from the Pennsylvania Trauma Systems Foundation database. Statistical analysis was performed using regression analysis. Data was expressed as mean +/- SD, and a P value of < or = 0.05 was considered significant. Patients were classified as operative management (OM; 39.9%) or NOM (60.1%) according to their initial plan of treatment. Of the patients in the NOM group, 75.3 per cent were successfully managed nonoperatively (SNOM), whereas 24.7 per cent eventually required surgery. The Injury Severity Score of the OM group was highest (34) compared with the SNOM group (22) and failed NOM (FNOM; 27) groups. The mean splenic injury grade for OM, SNOM, and FNOM was 3.5, 2.4, and 3.3, respectively. The number of pre-existing conditions did not differ among the three groups. An upward trend in the failure rate of NOM was observed with increasing age (19.0%, 27.1%, and 28.3%, respectively) for three age groups, 55-64, 65-74, and 75+, but this trend was not statistically significant. Mortality rate was highest in the OM group (35.6%) compared with the successful (16.7%) and failed NOM (17.9%). Hospital length of stay (LOS) and intensive care unit (ICU) LOS were highest among patients who failed NOM (mean hospital LOS = 20.7 days, mean ICU LOS = 13.2 days) compared with OM (17.2 and 10.4, respectively) and successful NOM (12.4 and 6.9, respectively). The majority of patients > or = 55 years with blunt splenic injuries can be managed nonoperatively when carefully selected. In the subset of patients older than 55 years of age, increasing age is associated with a trend toward higher failure rates. Mortality was high regardless of management, and failure of NOM in older patients is associated with significantly longer hospital and ICU LOS.

Nonoperative Management of Traumatic Splenic Injuries: Is There a Role for Proximal Splenic Artery Embolization?

The objective of our study was to evaluate our experience with transcatheter proximal (i.e., main) splenic artery embolization (TPSAE) in the nonsurgical management of patients with grade III-V splenic injuries, according to the American Association for the Surgery of Trauma (AAST) guidelines, and patients with splenic injuries associated with CT evidence of active contrast extravasation or blush (or cases meeting both criteria). The records of patients with traumatic splenic injuries admitted during a 52-month period were retrospectively reviewed for patient age and sex, mechanism of injury, injury severity score (ISS), RBC transfusion requirements, AAST splenic injury CT grade, presence of active contrast extravasation or blush on CT examination, and amount of hemoperitoneum on CT examination. Demographics, CT findings, transfusion requirements, and outcome were compared using the Student's t test or chi-square test in patients undergoing standard nonoperative management and nonoperative management TPSAE-that is, TPSAE followed by nonoperative management. Of the 79 identified patients with splenic trauma, 67 were managed nonoperatively. Thirty-seven patients (28 men, nine women; mean age, 40 years; mean ISS, 28.8) underwent nonoperative management TPSAE and 30 patients (27 men, three women; mean age, 37 years; mean ISS, 25.1) underwent nonoperative management. Age, sex, and ISS were not significantly different between the two groups. TPSAE was always technically feasible. Splenic injuries were significantly more severe in the nonoperative management TPSAE group than in the nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p < 0.0001), active contrast extravasation or blush (38% [14/37] vs 3% [1/30], respectively; p = 0.0005), and hemoperitoneum grade (1.6 vs 0.8, respectively; p = 0.0006). Secondary splenectomy rate was lower in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30]). No procedure-related complications were encountered during early and delayed clinical follow-up. TPSAE is a feasible and safe adjunct to observation in the nonoperative management of severe traumatic splenic injuries. The secondary splenectomy rate using nonoperative management TPSAE (2.7%) is among the lowest reported despite a selection of severe injuries.

Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma

Meguid AA, Bair HA, Howells GA, et al (William Beaumont Hospital, Royal Oak, MI) There has been significant evolution in the management of blunt splenic trauma over the past 30 years. The trend toward nonoperative management of blunt splenic injury in adults has now been accepted as the standard of care in pediatric patients as well. However, recent reports have shown increased mortality rates and failure rates associated with nonoperative management of blunt splenic injury and have prompted questions regarding the appropriate criteria for nonoperative management. The authors of this study have prospectively applied criteria developed from 15 years of experience in the nonoperative management of blunt splenic injury. These criteria are hemodynamic stability on admission or after initial resuscitation with up to 2 L of crystalloid infusion, no physical findings or any associated injuries necessitating laparotomy, and a transfusion requirement attributable to the splenic injury of 2 units or less. The most recent results with application of these criteria to the treatment of blunt splenic trauma are presented. From 1994 through 2000, a total of 99 patients presented with splenic injury. Of these patients, 31 (31%) patients underwent splenectomy resulting from hemodynamic instability, leaving 68 patients for inclusion in this report. During the observation period, 8 (12%) of the 68 patients who initially met criteria for nonoperative management had hemodynamic instability develop and underwent splenectomy. All the nonoperative management failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the nonoperative management group or in the group that failed nonoperative management, and neither group had associated morbidities from the splenic injury. There were no significant differences between the nonoperative management group and the failed nonoperative management group in terms of demographics, clinical findings, or outcome measures. It would appear from these findings that established criteria for intervention and careful observation in an intensive care setting for a minimum of 72 hours will reduce the morbidity or mortality associated with blunt splenic trauma in adults.

Prospective Evaluation of Criteria for the Nonoperative Management of Blunt Splenic Trauma

Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults.

Outcome of nonoperative management of asymptomatic high-grade carotid stenosis

The purpose of this study was to determine the outcome of nonoperative management (NOM) of asymptomatic high-grade (80% to 99%) carotid stenosis. From April 1994 to December 2000, asymptomatic high-grade (80% to 99%) carotid stenosis was identified in 196 carotid arteries in 180 male veterans. Of the original number identified, 137 carotid endarterectomies (CEs) were performed in 123 patients (OP group) and 59 carotid arteries in 57 patients were managed nonoperatively (NOM group.) The NOM group was further subdivided into those patients who refused care (NOM-R group; n = 21; 36.8%) versus those who were not offered CE on the basis of comorbid conditions (NOM-C group; n = 36; 63.2%). Clinical follow-up was obtained to determine rates of neurologic events, patient survival, and progression to occlusion. During the follow-up period, a total of 13 ipsilateral neurologic events occurred: two amaurosis fugax (15.4%), two transient ischemic attacks (15.4%), and nine strokes (69.2%). The NOM-R group had a significantly lower ipsilateral neurologic event-free rate when compared with the OP group at both 18 months (81% +/- 9.8% versus 96% +/- 1.8%; P <.02) and 2 years (81% +/- 10.6% versus 95% +/- 2.1%; P <.04.) However, the NOM-C group and the OP group had no significant difference in their ipsilateral neurologic event-free rate out to 3 years (96% +/- 6.8% versus 95% +/- 2.7%). As would be expected, the NOM-C group had a much lower patient survival rate when compared with either the OP group (59% +/- 9.2% versus 84% +/- 3.6% at 2 years; P <.002) or the NOM-R group (59% +/- 9.2% versus 100% at 2 years; p <.0001). The cumulative patency rate of carotid arteries in the NOM group was 86% +/- 7.6% at 3 years. Progression to occlusion was associated with a neurologic event in two of five occurrences. No carotid artery progressed to occlusion in the OP froup. Although CE is the preferred treatment for asymptomatic high-grade carotid stenosis, NOM is an acceptable alternative in selected patients at high risk with diminished life expectancy.

Initial nonoperative management for periappendiceal abscess.

Our goal was to compare initial operative and nonoperative management for periappendiceal abscess complicating appendicitis. This study is a retrospective review of 155 consecutive patients with appendicitis complicated by periappendiceal abscess treated between 1992 and 1998. Eighty-eight patients were treated initially nonoperatively, and 67 patients were treated operatively. All patients had localized abdominal tenderness and either computed tomography or intraoperative documentation of an abscess. Our patient population consisted of 107 males and 48 females, with an average age of 33 (range, 16-75) years. Age, gender, comorbidity, white blood cell count, temperature, and heart rate did not differ significantly between groups. For the initial nonoperative management group, the failure rate was 5.8 percent and the appendicitis recurrence rate was 8 percent after a mean follow-up of 36 weeks. The response to treatment of the initial nonoperative group and the initial operative group was compared by length of stay (9 +/- 5 days vs. 9 +/- 3 days; P = not significant), days until white blood cell count normalized (3.8 +/- 4 days vs. 3.1 +/- 3 days; P = not significant), days until temperature normalized (3.2 +/- 3 days vs. 3.1 +/- 2 days; P = not significant), and days until a regular diet was tolerated (4.7 +/- 4 days vs. 4.6 +/- 3 days; P = not significant). Complication rate was significantly lower in the nonoperative group (17 vs. 36 percent; P = 0.008). Initial nonoperative management of appendicitis complicated by periappendiceal abscess is safe and effective. Patients undergoing initial nonoperative management have a lower rate of complications, but they are at risk for recurrent appendicitis.

Le traitement actuel des traumatismes fermés du foie: son intérêt et ses pièges. Á propos d'une série de 130 cas

Study aim The management of blunt hepatic trauma has been modified by the development of conservative methods. Risks and pitfalls of this new approach must be determined. Patients and methods From January 1985 to September 1998, 130 patients with blunt hepatic trauma were treated by the same team. Among them, 38 patients were referred from another centre (21 already having undergone operations). Eighty patients (61%) had an initial non operative management and 50 patients (39%) underwent emergency laparotomy. Perihepatic packing was performed in 24 patients, hepatic sutures in 22, limited hepatic resection in six, and major hepatectomy in two patients only. Results There were three deaths in the non operative management group (mortality rate: 3.5%) and 11 patients required a secondary laparotomy: four for haemorrhage, one for enteric injury, two for acute pancreatitis, one for bile leakage, one for subphrenic abscess, one for acute cholecystis. There were 14 deaths in the emergency laparotomy group (mortality rate: 28%), including four intraoperative deaths due to haemorrhage and two due to abdominal compartment syndrome. Conclusions In the nonoperative management group a close clinical survey of the patient is necessary and a secondary laparotomy often indicated. In the operative management group, early packing requires reintervention if the patient is unstable. Alternative means of temporary closure may allow coverage without tension in order to avoid the abdominal compartment syndrome.

Nonoperative management for extensive hepatic and splenic injuries with significant hemoperitoneum in adults.

Although several retrospective studies have been published concerning nonoperative management of minor liver and spleen injuries, few studies have prospectively analyzed the results of nonoperative management for higher-grade liver and spleen injuries. Is it possible to manage extensive hepatic or splenic injuries with hemoperitoneum nonoperatively? The current study was conducted to evaluate the safety of nonoperative management of blunt hepatic and splenic trauma with significant hemoperitoneum in hemodynamically stable patients regardless of injury severity. We used the nonoperative methods prospectively to treat consecutive patients with blunt spleen or liver injury during a 35-month period. Patients with unstable conditions underwent emergency laparotomies, and those who were stable underwent abdominal computed tomography for further evaluation. We analyzed the clinical characteristics and the success rate of this method thoroughly. Twenty-four patients with severe hepatic or splenic injuries treated nonoperatively were included in this study. Among these 24 patients, 18 (75%) with hepatic or splenic injuries had grades of III or greater on the Organ Injury Scale. Twenty patients (83.3%) had moderate to large amounts of hemoperitoneum. Four patients (16.7%) failed at observation and underwent emergency celiotomy, two for liver-related and two for spleen-related causes. There were no differences between the nonoperative and operative management groups in terms of mean age, initial systolic blood pressure, initial heart rate, emergency room fluid requirement except emergency blood transfusion, abdominal complications, and hospital length of stay. We suggest that nonoperative management may be undertaken successfully in appropriately designed areas with close observation for the hemodynamic stable patient.

Selective surgical management of renal stab wounds.

Patients with stab wounds and haematuria were selected for surgical exploration if they had signs of severe blood loss, an associated intra-abdominal laceration or major abnormality on the intravenous urogram (IVU). Patients without these signs were selected for non-operative management, consisting of bed rest, an intravenous antibiotic for 24 h and regular observation. Of 95 patients, 60 (63%) were selected for non-operative management (Group 1) and 35 (37%) were selected for primary surgical exploration (Group 2). At surgery in Group 2, a major renal injury and/or associated intra-abdominal laceration was found in 31 patients. Thus a probably unnecessary operation was performed in only 4 patients (4% of the whole group of 95 patients). Renal complications occurred in 12 of the 60 patients (20%) in Group 1 and consisted mainly of secondary haemorrhage caused by an arteriovenous fistula (AVF) or pseudo-aneurysm. Management of the renal complications included segmental artery embolisation in 6, nephrectomy in 2, heminephrectomy in 1, open surgical ligation of an AVF in 1 and spontaneous resolution in 2 patients. The mean period of hospitalisation was significantly shorter in Group 1 (6.1 days) than in Group 2 patients (9.9 days). Comparing the Group 1 patients who developed renal complications with those who did not, we would recommend more aggressive selection for surgery of those patients exhibiting clinical signs of shock, a fall in haemoglobin during observation, a palpable abdominal mass, a haemothorax and/or pneumothorax ipsilateral to the renal injury, and IVU signs of extravasation, non-function, delayed excretion or hydroureteronephrosis due to blood clots.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonoperative Management of Renal Stab Wounds

A prospective clinical study of 54 patients with stab wounds and hematuria was conducted to evaluate the safety of selective nonoperative management compared to mandatory surgical exploration of these patients. In the absence of signs of severe blood loss, associated intra-abdominal injury or major abnormality on the excretory urogram patients were randomized to undergo mandatory surgery (group 1) or nonoperative management (group 2). Patients with signs of severe blood loss, associated intra-abdominal injury or gross abnormality on excretory urography were selected for an operation (group 3).The rate of probably needless operations (defined as minor renal injury without associated intra-abdominal lacerations) was 78 per cent in group 1 and O per cent in group 3.Pulmonary complications occurred in 33 per cent of the patients in group 1, 4 per cent in group 2 and 38 per cent in group 3.Despite an operation delayed renal hemorrhage occurred in 1 patient (5 per cent) in group 1 and 2 (15 per cent) in group 3, and resulted in nephrectomy in 2 of these patients. No instance of secondary hemorrhage occurred in group 2 patients. The mean length of hospitalization was 9, 5 and 11 days in groups 1 to 3, respectively.Our results indicate that the selective nonoperative management of patients with renal stab wounds can lead to a decrease in the rate of unnecessary operations, postoperative complications and length of hospitalization compared to a policy of mandatory surgical intervention.