Selective Nonoperative Management Research Articles

Non-operative management of adhesive small bowel obstruction: Should there be a time limit after which surgery is performed?

The management of adhesive small bowel obstruction (ASBO) has evolved from “the sun should not rise and set on a small bowel obstruction”, implying mandatory immediate surgical exploration to selective non-operative management. Not every patient with adhesive small bowel obstruction meets criteria for non-operative management and treating all comers the same way can lead to catastrophic outcomes. Water Soluble Contrast Medium (WSCM) has important diagnostic and therapeutic utility in the management of ASBO and should be employed ab initio. Laparoscopy has emerged as a reasonable and safe alternative to laparotomy for surgical management of ASBO in carefully selected patients and has distinct advantages.

Selective nonoperative management of liver gunshot injuries.

Nonoperative management (NOM) of gunshot liver injuries (GLI) is infrequently practiced. The aim of this study was to assess the safety of selective NOM of GLI. A prospective, protocol-driven study, which included patients with GLI admitted to a level 1 trauma center, was conducted over a 52-month period. Stable patients without peritonism or sustained hypotension with right-sided thoracoabdominal (RTA) and right upper quadrant (RUQ), penetrating wounds with or without localized RUQ tenderness, underwent contrasted abdominal CT scan to determine the trajectory and organ injury. Patients with established liver and/or kidney injuries, without the evidence of hollow viscus injury, were observed with serial clinical examinations. Outcome parameters included the need for delayed laparotomy, complications, the length of hospital stay and survival. During the study period, 54 (28.3%) patients of a cohort of 191 patients with GLI were selected for NOM of hemodynamic stability, the absence of peritonism and CT imaging. The average Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.841 and 25 (range 4-50), respectively. 21 (39%) patients had simple (Grades I and II) and 33 (61%) patients sustained complex (Grades III to V) liver injuries. Accompanying injuries included 12 (22.2%) kidney, 43 (79.6%) diaphragm, 20 (37.0%) pulmonary contusion, 38 (70.4%) hemothoraces, and 24 (44.4%) rib fractures. Three patients required delayed laparotomy resulting in an overall success of NOM of 94.4%. Complications included: liver abscess (1), biliary fistula (5), intrahepatic A-V fistula (1) and hospital-acquired pneumonia (3). The overall median hospital stay was 6 (IQR 4-11) days, with no deaths. The NOM of carefully selected patients with GLI is safe and associated with minimal morbidity.

Selective nonoperative management of penetrating thoracic injury.

Thoracic penetrating injury is a cause for up to one-fifth of all non-natural deaths. The aim of this study was to determine the success of selective nonoperative management (SNOM) of patients presenting with a penetrating thoracic injury (PTI). This was a prospective study of patients with PTI who presented to a level 1 Trauma Center between April 2012 and August 2012. A total of 248 patients were included in the study, with 5.7% (n=14) requiring immediate emergency surgery. Overall, five of these 248 patients died, resulting in a mortality rate of 2.0%. Primarily 221 patients (89.1%) were managed with SNOM, of whom 15 (6.8%) failed conservative management. Failure of SNOM was primarily caused by complications of chest tube drainage (n=12) (e.g. retained clot, empyema) and delayed development of cardiac tamponade (n=3). The survival rate in the SNOM group was 100%. PTI has a low in-hospital mortality rate. Only 16.5% (41/248) of the patients presenting with PTI will need surgical treatment. The other patients are safe to be treated conservatively according to a protocolized SNOM approach for PTI without any additional mortality. Conservative treatment of patients who were selected for this nonoperative treatment strategy with repeated clinical reassessment was successful in 93.2%.

Non-operative management of blunt hepatic injury: Early return to function, chemical prophylaxis, and elucidation of Grade III injuries

Background: Selective non-operative management of blunt hepatic trauma has shown decreased mortality and iatrogenic injury. Evidence-based recommendations are difficult to obtain regarding management of Grade III hepatic injuries and safe timing to implement return to function measures (enteral intake, chemical deep vein thrombosis [DVT] prophylaxis, and ambulation). Materials and Methods: This is a prospective, observational study of 130 trauma patients with blunt hepatic injuries over 2 years. A guideline was utilized to emphasize early hepatobiliary iminodiacetic acid scan and return to function measures at 24 h after injury. Patients were treated non-operatively with endoscopic retrograde cholangiopancreatography, percutaneous drainage, or embolization per evidence-based guidelines. Results: Fifty-seven patients suffered Grade III–V blunt liver injury. The biliary leak rate was higher for Grade IV and V liver injuries than Grade III (48%, 43%, and 12%, respectively) compared to lower grade injuries (0%). There was no significant difference in complications from initiation of chemical DVT prophylaxis, ambulation, or early enteral intake as a function of grade of hepatic injury. The average time to progression of treatment was 24 h and independent of the grade of liver injury. High-grade liver injuries were associated with lower age, increased injury severity score, and increased Intensive Care Unit length of stay. Conclusions: Trauma providers should consider Grade III liver injuries as low-grade injuries and treat accordingly. However, Grade IV and V injuries fail non-operative management more often than other grade injuries. Early enteral nutrition, chemical DVT prophylaxis, and ambulation are safe regardless of the grade of hepatic injury. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement, Systems-based practice.

Selective Nonoperative Management of Pharyngoesophageal Injuries Is Safe

Tatum, James M. MD; Barmparas, Galinos MD; Dhillon, Navpreet K. MD; Margulies, Daniel R. MD, FACS; Nicol, Andrew MD, PhD; Edu, Sorin MD; Ley, Eric J. MD, FACS; Navsaria, Pradeep H. MBChB, FACS Author Information

Non-operative management for penetrating splenic trauma: how far can we go to save splenic function?

BackgroundSelective non-operative management (NOM) for the treatment of blunt splenic trauma is safe. Currently, the feasibility of selective NOM for penetrating splenic injury (PSI) is unclear. Unfortunately, little is known about the success rate of spleen-preserving surgical procedures. The aim of this study was to investigate the outcome of selective NOM for penetrating splenic injuries.MethodsA dual-centre study is performed in two level-one trauma centres. All identified patients treated for PSI were identified. Patients were grouped based on the treatment they received. Group one consisted of splenectomised patients, the second group included patients treated by a spleen-preserving surgical intervention, and group three included those patients who were treated by NOM.ResultsA total of 118 patients with a median age of 27 and a median ISS of 25 (interquartile range (IQR) 16–34) were included. Ninety-six patients required operative intervention, of whom 45 underwent a total splenectomy and 51 underwent spleen-preserving surgical procedures. Furthermore, 22 patients (12 stab wounds and 10 gunshot wounds) were treated by NOM. There were several anticipated significant differences in the baseline encountered. The median hospitalization time was 8 (5–12) days, with no significant differences between the groups. The splenectomy group had significantly more intensive care unit (ICU) days (2(0–6) vs. 0(0–1)) and ventilation days (1(0–3) vs. 0(0–0)) compared to the NOM group. Mortality was only noted in the splenectomy group.ConclusionsSpleen-preserving surgical therapy for PSI is a feasible treatment modality and is not associated with increased mortality. Moreover, a select group of patients can be treated without any surgical intervention at all.

Selective non-operative management of abdominal stab wounds is a safe and cost effective strategy: A South African experience.

INTRODUCTION Selective non-operative management (SNOM) of abdominal stab wounds is well established in South Africa. SNOM reduces the morbidity associated with negative laparotomies while being safe. Despite steady advances in technology (including laparoscopy, computed tomography [CT] and point-of-care sonography), our approach has remained clinically driven. Assessments of financial implications are limited in the literature. The aim of this study was to review isolated penetrating abdominal trauma and analyse associated incurred expenses. METHODS Patients data across the Pietermaritzburg Metropolitan Trauma Service (PMTS) are captured prospectively into the regional electronic trauma registry. A bottom-up microcosting technique produced estimated average costs for our defined clinical protocols. RESULTS Between January 2012 and April 2015, 501 patients were treated for an isolated abdominal stab wound. Over one third (38%) were managed successfully with SNOM, 5% underwent a negative laparotomy and over half (57%) required a therapeutic laparotomy. Over five years, the PMTS can expect to spend a minimum of ZAR 20,479,800 (GBP 1,246,840) for isolated penetrating abdominal stab wounds alone. CONCLUSIONS Provided a stringent policy is followed, in carefully selected patients, SNOM is effective in detecting those who require further intervention. It minimises the risks associated with unnecessary surgical interventions. SNOM will continue to be clinically driven and promulgated in our environment.

Унифицированный подход к лечению больных с проникающими колото-резаными ранениями брюшной полости

За період з 2010 до 2015 р., за даними МОЗ України, загальний показник смертності в Україні перебуває на рівні 14,5–16,3 ‰. При цьому, в 6 % всіх випадків смерті причиною були травми. Відкрита проникаюча травма живота залишається однією з основних причин летальних випадків. Втім, ножові поранення зустрічаються майже в три рази частіше, ніж вогнепальні [3]. В останні роки в світі переглянули підходи до ведення хворих із проникаючими пораненнями, схилившись у бік вибіркового застосування операційного і неопераційного методів лікування [2]. Значного поширення набув метод селективного неопераційного лікування хворих з проникаючими пораненнями черевної порожнини [4, 10, 14]. Суть даного методу полягає в тому, що, застосовуючи сучасні діагностичні методи, а також клінічний моніторинг стану хворого, в певних випадках можна обійтися без застосування лапаротомії. Дана методика дозволяє в 55 % випадків ножових поранень вести хворих, не вдаючись до операційного втручання, скоротити кількість непотрібних лапаротомій до 9–19 %, зменшити тривалість перебування хворих у стаціонарі до 3,9 дня порівняно з 6 при лапаротомії, а також знизити матеріальні витрати на лікування пацієнтів.При відборі хворих для неопераційного ведення краще орієнтуватися на дані загальноклінічних досліджень (загальна чутливість і специфічність серійного клінічного обстеження черевної порожнини становить 87,3 і 93,5 % відповідно) [10]. Доброю допомогою є дані комп’ютерної томографії, однак чутливість і специфічність даного методу коливається у різних авторів від 60 до 90 % [4, 9, 11, 13]. Діагностична цінність ультразвукового дослідження в перші години після отриманої травми становить всього 46 % [12], а оглядової рентгенографії – 2,6 % [7]. Застосування лапароскопії в діагностиці і лікуванні колото-різаних поранень черевної стінки є пріоритетним методом у разі стабільної гемодинаміки у хворих [8].

Selective non-operative management of anterior abdominal stab wounds with emphasis on the value of follow-up abdominal CT scanning

Background and aim Selective non-operative management of patients with penetrating abdominal stabs is the preferred treatment strategy. The present study aimed to assess the efficacy and safety of non-operative management with emphasis on the value of follow-up abdominal CT scanning in management of patients with penetrating anterior abdominal stab. Patients and methods This is a retrospective chart review of stable patients with anterior abdominal stab wounds. Patients were divided in terms of initial decisions into two groups: laparotomy group and non-operative management group. Abdominal CT scan was performed for patients in the non-operative management group on admission and follow-up CT scanning was performed in cases of clinical and/or biochemical deterioration. Results The laparotomy group included 82 patients and 68.2% of them had unnecessary laparotomies. The non-operative management group comprised 97 patients and 90.7% of them did not require subsequent laparotomy. Abdominal CT scan had a sensitivity of 88.9% and specificity of 100% in detection of intra-abdominal injuries. Follow-up CT scanning detected bowel injuries missed by initial CT scan in three patients. The non-operative management group had significantly lower post-operative complication rate than the laparotomy group (4.1% vs. 18.3%), with a significantly shorter length of stay. Conclusions Non-operative management is the optimal management strategy for stable patients with penetrating anterior abdominal stab to decrease unnecessary laparotomy rates, hospital stay and costs. Follow-up abdominal CT scanning facilitated the decision making for patients selected for non-operative management and is highly sensitive in the diagnosis of patients who require subsequent exploration.

Successful selective non-operative management of abdominal gunshot wounds: the ballistic aspect

Successful selective non-operative management of abdominal gunshot wounds: the ballistic aspect

Selective Nonoperative Management of Abdominal Gunshot Wounds from Heresy to Adoption: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCoNECT)

Selective nonoperative management (SNOM) of abdominal gunshot wounds is being practiced in certain trauma centers, but its broader acceptance in the surgical community is unknown. We hypothesized that SNOM has been adopted in New England as an acceptable method of abdominal gunshot wound management. We reviewed the medical records of abdominal gunshot wound patients admitted from January 1996 to June 2015, in 10 New England Level I and II trauma centers. Outcomes included the incidence, success, and failure of SNOM, and morbidity and mortality related to SNOM. Of 922 patients, 707 (77%) received immediate laparotomy (IMMLAP) and 215 (23%) were managed by SNOM. Compared with IMMLAP patients, those with SNOM had a lower median Injury Severity Score (16 vs 8; p < 0.001), lower incidence of complications (34.7% vs 8.5%; p < 0.001) and mortality (5.2% vs 0.5%; p= 0.002), and shorter ICU and hospital stays (median days 1 of 8 vs 0 of 2, respectively; p < 0.001). One SNOM patient died after 3days due to a gunshot wound to the head. The overall incidence of SNOM increased from 18% before 2010 to 27% in the following years (p= 0.001). Eighteen patients (8.4%) had unsuccessful SNOM and underwent delayed laparotomy at an average of 12.5 hours (range 141 minutes to 48 hours) after arrival. Nine of them (4.2%) experienced complications that were not directly related to the delayed laparotomy, and none died. The rate of nontherapeutic laparotomies was 14.7% among IMMLAP and 5.5% among delayed laparotomy patients (p= 0.49). Selective nonoperative management of abdominal gunshot wounds, despite being a heresy only a few years ago, has now been established as an acceptable method of management inLevel I and II trauma centers in New England.

Conservative Salvage of a Penetrating Grade IV Renal Injury with Extravasation

Penetrating abdominal injuries have traditionally been managed with surgical exploration. The recent trend in renal trauma is selective nonoperative management, even if laparotomy is performed for associated injuries. This case describes the salvage of a grade IV kidney injury secondary to gunshot wound. A large perinephric hematoma and associated hollow viscus injury were discovered on CT scan. The patient underwent laparotomy for colonic repair. The perinephric hematoma appeared non-pulsatile, nonexpanding, and not actively bleeding, and thus was not explored. The injured kidney healed and the patient did not require nephrectomy

Five-Year Retrospective Review of Blunt Renal Injuries at a Level I Trauma Center

We report the experience of a Level I trauma center in the management of blunt renal injury during a 5-year period, with special attention to those treated using angiography with embolization. The institutional trauma registry was queried for all patients with blunt renal injury between September 1, 2009 and August 30, 2014. Each injury was graded using the American Association for the Surgery of Trauma guidelines. Patients that underwent angiography with embolization were reviewed for case-specific information including imaging findings, treatment, materials used, clinical course, and mortality. The registry identified 48 blunt renal injury patients. Median Injury Severity Score was higher and hospital length of stay was significantly longer in those with blunt renal injury when compared with those without blunt renal injury (P < 0.001). The majority of patients with blunt renal injury were managed nonoperatively. Mortality was three out of 48 patients (5%). Nine patients underwent exploratory laparotomy. These operations were always performed for reasons other than the renal trauma (e.g., splenic injury, free fluid, free air). No patient underwent invasive renal operation. Six patients were treated using angiography with embolization. Of the six, one patient died of pulmonary septic complications. We conclude that selective nonoperative management is the mainstay of treatment for blunt renal injury. Angiography with embolization is a useful modality for cases of ongoing bleeding, and is typically preferable to nephrectomy in our experience.

Penetrating abdominal stab wounds – current practice and recommendations

This retrospective study reviews current practice in managing penetrating abdominal stab wounds in our centre and evaluates patients who can be safely managed non-operatively. The records of patients admitted to Rashid Hospital with isolated abdominal stab injuries from January 2011 to December 2015 were reviewed. We reviewed the patients’ demographic data, clinical findings, diagnostic tests and surgical interventions. Patients were eligible for inclusion if they had a penetrating stab injury and fulfilled the criteria for conservative management (i.e. were haemodynamically stable, with localized tenderness and no evisceration). Patients were excluded if they were haemodynamically unstable or had evisceration and generalized tenderness. A total of 66 patients with abdominal stab wounds were admitted between January 2011 and December 2015; 44 of these had penetrating injuries. The mean age of the patients was 28 years; 62 (94%) were men and four (6%) were women. A total of 29 patients fulfilled the inclusion criteria, but only six were treated fully conservatively. Twenty-three (35%) patients underwent surgery; 13 (57%) procedures were non-therapeutic and 10 (43%) were therapeutic. Selective non-operative management for stable patients without signs of peritonitis is an effective tool for decreasing the number of unnecessary laparotomies, but this should be practised in a specialized trauma centre and performed by experienced clinicians (preferably by the same team). The use of triple-contrast abdominal computerized tomography can reduce the rate of negative findings at laparotomy. Diagnostic laparoscopy is safe and decreases both the requirement for non-therapeutic laparotomy and length of hospital stay.

Selective Non Operative Management of Blunt Liver Trauma: Is It Still a Challenge?

The non-therapeutic laparotomy in managing cases with blunt liver injuries is not without risks, so selective non-operative treatment in stable patients was tried in many centers and has become the standard of care of these patients The aim of this study was to assess the feasibility and safety of selective non-operative management of blunt liver injury in our institution <i>Patients and Methods:</i> This prospective study was conducted on 40 patients with blunt liver injury who met our inclusion criteria admitted to Tanta University Hospital during the period from January 2012 to January 2014. All patients were treated by selective non-operative treatment (repeated clinical examination, serial U/S and CT study and follow up) <i>Results:</i> The age of our patients ranged from 26 to 40 years with a mean (±SD) of 31.3 ± 3.77 years. 36 patients were males (90%), while 4 patients (10%), were female. Total length of stay was ranged from 2 days to 15 days with a mean (±SD) of 5.8 ± 3.27 days as regards all cases. Intensive care unit stay was in 2 cases (5%) which FNOM with mean (±SD) of 1.5 ± 0.7 days. CT study was done in all cases (100%), 2 cases (5%) was operated after 6 hours of conservatism in ICU due to hemodynamic instability after initial assessment of stability. <i>Conclusions:</i> Selective non operative management of blunt liver injury in bunt abdominal trauma is safe, efficient, and cost-effective in the appropriate clinical setting and can lead to fewer unnecessary laparotomies in patients with liver injury. Proper patient selection, resources that permit close observation, and frequent abdominal examinations are paramount in obtaining the best results.

Selective nonoperative management of abdominal gunshot wounds with isolated solid organ injury

ObjectiveTo review selective nonoperative management (SNOM) of gunshot wound (GSW) patients with isolated abdominal solid organ injury. MethodsPatients who sustained isolated solid organ injury secondary to GSW from 2003 to 2014 were studied. The use of SNOM over time was analyzed, and comparisons of initial SNOM and operative management (OM) groups were performed. ResultsOf 127 patients, 63 (50%) underwent SNOM. There were no significant differences between the early/late or SNOM/OM groups in demographics, physiologic presentation, or Injury Severity Score. SNOM increased from the early to late cohorts (31%–67%, p < 0.001), without any change in outcomes. SNOM patients had shorter hospital stays (5.8 vs. 10.0 days, p < 0.001), received fewer PRBCs (0.8 vs. 4 units, p < 0.001), and suffered fewer complications (13% vs. 28%, p < 0.05) than the OM group. ConclusionAn increase in SNOM vs. OM was associated with equivalent outcomes. Patients undergoing SNOM received fewer PRBCs and had shorter LOS.

Laparoscopy in Abdominal Trauma

Exploratory laparotomy is the traditional therapeutic approach in patients with abdominal trauma. However, due to potential associated morbidity and mortality, avoiding unnecessary laparotomies is an important issue. While selective nonoperative management has shown good results, certain clinical situations in hemodynamically stable patients, where the need for surgery could be in doubt, call for proactive diagnosis. In these cases, laparoscopy can be used to exclude or diagnose potential injuries requiring surgery. When the surgeon has the necessary expertise, some of these injuries can be treated laparoscopically. Over the last decades, diagnostic and therapeutic applications of laparoscopy have increased, with reported reduction in nontherapeutic laparotomies. Furthermore, shorter duration of hospital stay, faster recovery, and reduced costs have been reported. However, as seen in other minimally access interventions, safe implementation of laparoscopy in trauma care requires adequate surgical training and skills as well as appropriate staffing and equipment.

Feasibility of selective non-operative management for penetrating abdominal trauma in France

In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France. Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis. One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM. Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

Re: Selective Non-operative Management of Patients with Abdominal Trauma-is CECT Scan Mandatory?

Re: Selective Non-operative Management of Patients with Abdominal Trauma-is CECT Scan Mandatory?

Conservative management of gunshot oesophageal injuries: A report of two consecutive exceptional cases.

IntroductionOesophageal trauma carries high mortality and morbidity. For penetrating intrathoracic oesophageal injury, surgical repair has been the standard for decades to avoid its devastating consequences.Case reportBoth patients presented with a thoracoabdominal gunshot wound and retained intraabdominal missile. Although there were no visible signs of perforation on oesophagoscopy or contrast swallow, the presence of an intraluminal bullet highly suggested a thoracic oesophageal injury.DiscussionNon-operative management of intrathoracic oesophageal perforation is controversial. Small perforations or contained leaks diagnosed within 24–48 h in a stable patient with no mediastinitis or empyema can be managed non-operatively with antibiotics and nasogastric feeds. These two case reports support the notion of selective non-operative management of asymptomatic patients with penetrating injury to the oesophagus.