Successful Nonoperative Management Research Articles

Fusobacterium Nucleatum : An Atypical Cause of Pyogenic Liver Abscess in an Apparently Immunocompetent Patient

Pyogenic liver abscess is an uncommon but potentially lethal infection if left untreated. Enteric bacteria and anaerobes are the most common causative organisms of pyogenic liver abscess. Although most infections are of a polymicrobial nature, monomicrobial infections are possible. An immunocompromised status and the presence of periodontal disease are the risk factors for liver abscess caused by these rare, monomicrobial anaerobic infections. Here, we report on a successful non-operative management of a case of multiloculated pyogenic liver abscess caused by Fusobacterium nucleatum in a young, healthy, immunocompetent male patient. The diagnosis was established by radiological imaging and was based on a positive aspirate culture, whereas the mainstay of treatment comprised percutaneous drainage and a prolonged course of antibiotics. Thus, the patient was successfully treated with a 2-week course of intravenous imipenem/cilastatin while he was on percutaneous drainage, and he is now doing well.

Incidence of adhesive small bowel obstruction and outcome of management

Background: Small bowel obstruction (SBO) is a common surgical condition that leads to emergency admission. Adhesions are the single most common cause for SBO, accounting for 60% of cases. The occurrence of adhesive SBO (ASBO) is higher following specific surgeries including colorectal, high gynaecological and paediatric surgeries. Initially, all patients are treated conservatively, but in case they fail to improve, surgical management is considered. Aim & Objectives: The objective of the study is to assess the number of patients admitted at Rashid Hospital with ASBO and the outcomes of their management. Materials and Methods: A retrospective study was conducted on patients who were admitted with ASBO from April 2017 until December 2019. A total of number of 85 patients who met the inclusion criteria were enrolled in the study. Those with underlying inflammatory bowel disease, abdominal tuberculosis and small bowel tumours were excluded. The outcomes of non-operative management (NOM) in terms of success rate, length of hospital stay and surgical intervention were assessed. Result: A total of 303 records were reviewed, of which 85 met the inclusion criteria (50 males and 35 females). The most common type of previous abdominal surgeries includes lower gastrointestinal (38.8%) and gynaecological surgeries (12.9%). Seventy-eight patients who underwent NOM had a success rate of 77.6% (n = 59) with a mean length of stay (LOS) of 3.5 days. Seventeen patients (22.4%) needed surgical intervention after a mean of 3.5 days. These patients were found to have intra-abdominal bands in 52.9% of the cases (P = 0.191). During the time period set for the study, the recurrence rate of patients who had successful NOM versus those who needed surgical intervention was 12% and 35.3%, respectively (P = 0.061). Sixty per cent of these recurrent cases were treated non-operatively on the second admission to the hospital whereas 40% required surgical intervention. Conclusion: NOM for ASBO has a shorter LOS and a lower recurrence rate as compared to those who required surgical management.

Abscess management in left-sided diverticulitis

Despite the high success rate of initial nonoperative management in patients with a diverticulitis-related pericolonic abscess, about 20% of these patients will require urgent colectomy. While recurrence rates after successful medical management of diverticular abscesses are high, it is within the standard of care to consider both interval elective resection and long-term nonoperative management. In summary, a decision regarding elective resection after successful nonoperative management of diverticular abscess should balance the individual patient's risk of recurrence and the associated potential morbidity and mortality versus the risk of an elective surgery.

Decision-making in pediatric blunt solid organ injury: A deep learning approach to predict massive transfusion, need for operative management, and mortality risk

BackgroundThe principal triggers for intervention in the setting of pediatric blunt solid organ injury (BSOI) are declining hemoglobin values and hemodynamic instability. The clinical management of BSOI is, however, complex. We therefore hypothesized that state-of-art machine learning (computer-based) algorithms could be leveraged to discover new combinations of clinical variables that might herald the need for an escalation in care. We developed algorithms to predict the need for massive transfusion (MT), failure of non-operative management (NOM), mortality, and successful non-operative management without intervention, all within 4 hours of emergency department (ED) presentation. MethodsChildren (≤18 years) who sustained a BSOI (liver, spleen, and/or kidney) between 2009 and 2018 were identified in the trauma registry at a pediatric level 1 trauma center. Deep learning models were developed using clinical values [vital signs, shock index-pediatric adjusted (SIPA), organ injured, and blood products received], laboratory results [hemoglobin, base deficit, INR, lactate, thromboelastography (TEG)], and imaging findings [focused assessment with sonography in trauma (FAST) and grade of injury on computed tomography scan] from pre-hospital to ED settings for prediction of MT, failure of NOM, mortality, and successful NOM without intervention. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) were used to evaluate each model's performance. ResultsA total of 477 patients were included, of which 5.7% required MT (27/477), 7.2% failed NOM (34/477), 4.4% died (21/477), and 89.1% had successful NOM (425/477). The accuracy of the models in the validation set was as follows: MT (90.5%), failure of NOM (83.8%), mortality (91.9%), and successful NOM without intervention (90.3%). Serial vital signs, the grade of organ injury, hemoglobin, and positive FAST had low correlations with outcomes. ConclusionDeep learning-based models using a combination of clinical, laboratory and radiographic features can predict the need for emergent intervention (MT, angioembolization, or operative management) and mortality with high accuracy and sensitivity using data available in the first 4 hours of admission. Further research is needed to externally validate and determine the feasibility of prospectively applying this framework to improve care and outcomes. Level of EvidenceIII Study TypeRetrospective comparative study (Prognosis/Care Management).

A Reappraisal of Outcome of Elective Surgery After Successful Non-Operative Management of an Intra-Abdominal Abscess Complicating Ileocolonic Crohn's Disease: A Subgroup Analysis of a Nationwide Prospective Cohort.

Few prospective data exist on outcomes of surgery in Crohn's disease [CD] complicated by an intra-abdominal abscess after resolution of this abscess by antibiotics optionally combined with drainage. From 2013 to 2015, all patients undergoing elective surgery for CD after successful non-operative management of an intra-abdominal abscess [Abscess-CD group] were selected from a nationwide multicentre prospective cohort. Resolution of the abscess had to be computed tomography/magnetic resonance-proven prior to surgery. Abscess-CD group patients were 1:1 matched to uncomplicated CD [Non-Penetrating-CD group] using a propensity score. Postoperative results and long-term outcomes were compared between the two groups. Among 592 patients included in the registry, 63 [11%] fulfilled the inclusion criteria. The abscess measured 37 ± 20 mm and was primarily managed with antibiotics combined with drainage in 14 patients and nutritional support in 45 patients. At surgery, a residual fluid collection was found in 16 patients [25%]. Systemic steroids within 3 months before surgery [p = 0.013] and the absence of preoperative enteral support [p = 0.001] were identified as the two significant risk factors for the persistence of a fluid collection. After propensity score matching, there was no significant difference between the Abscess-CD and Non-Penetrating-CD groups in the rates of primary anastomosis [84% vs 90% respectively, p = 0.283], overall [28% vs 15% respectively, p = 0.077] and severe postoperative morbidity [7% vs 7% respectively, p = 1.000]. One-year recurrence rates for endoscopic recurrence were 41% in the Abscess-CD and 51% in the Non-Penetrating-CD group [p = 0.159]. Surgery after successful non-operative management of intra-abdominal abscess complicating CD provides good early and long-term outcomes.

Predictive Value of Alvarado Score and Pediatric Appendicitis Score in the Success of Nonoperative Management for Simple Acute Appendicitis in Children.

During the past decade, nonoperative management (NOM) for simple acute appendicitis (SAA) in children has been proven safe with noninferior complications rate. The aim of this study was to examine Alvarado score and pediatric appendicitis score (PAS) together with other factors in predicting failure of NOM in children presenting with SAA. Patients aged 5 to 18 years admitted to our department between 2017 and 2019 diagnosed with SAA were given a choice between surgical management and NOM. We divided the NOM patients into two groups: successful treatment and failed NOM, comparing their files for Alvarado score and PAS and other clinical and demographic factors, with a mean follow-up of 7 months. Failure was determined as need for appendectomy following conservative treatment due to any reason. A total of 85 patients answered criteria and chose NOM. Overall failure rate was 32.9%. We found no difference in the mean Alvarado score and PAS as well as in each component of both scores between success and failed NOM groups. However, when using the risk classification of the scores, we found a significant correlation between high-risk Alvarado score and failed NOM. After adjusting for age, gender, duration of symptoms, diagnosis of tip appendicitis, and presence of appendicolith, the odds of failure were four times higher among high-risk Alvarado group. Alvarado score of 7 or higher, older age, and diagnosis of an appendicolith on imaging are possible predictors for failure of NOM for SAA in children.

Penetrating abdominal trauma in the era of selective conservatism: a prospective cohort study in a level 1 trauma center.

Global trend has seen management shift towards selective conservatism in penetrating abdominal trauma (PAT). The purpose of this study is to compare the presentation; management; and outcomes of patients with PAT managed operatively versus non-operatively. Prospective cohort study of all patients Ùpresenting with PAT to Groote Schuur Hospital, Cape Town from 01 May 2015 to 30 April 2017. Presentation; management; and outcomes of patients were compared. Univariate predictors of delayed operative management (DOM) were explored. Over the 2-year study period, 805 patients with PAT were managed. There were 502 (62.4%); and 303 (37.6%) patients with gunshot (GSW) and stab wounds (SW), respectively. The majority were young men (94.7%), with a mean age of 28.3years (95% CI 27.7-28.9) and median ISS of 13 (IQR 9-22). Successful non-operative management was achieved in 304 (37.7%) patients, and 501 (62.5%) were managed operatively. Of the operative cases, 477 (59.3%) underwent immediate laparotomy and 24 (3.0%) DOM. On univariate analysis, number; location; and mechanism of injuries were not associated with DOM. Rates of therapeutic laparotomy were achieved in 90.3% in the immediate, and 80.3% in the DOM cohorts. The mortality rate was 1.3, 11.3 and 0% in the in the NOM, immediate laparotomy and DOM subgroups, respectively. The rate of complications was no different in the immediate and DOM cohorts (p > 0.05). Patients with PAT in the absence of haemodynamic instability; peritonism; organ evisceration; positive radiological findings, or an unreliable clinical examination, can be managed expectantly without increased morbidity or mortality.

The Risk of Incarceration During Nonoperative Management of Incisional Hernias: A Population-based Analysis of 30,998 Patients.

The aim of the study was to quantify the risk of incarceration of incisional hernias. Operative repair is the definitive treatment for incisional ventral hernias but is often deferred if the perceived risk of elective operation is elevated secondary to comorbid conditions. The risk of incarceration during nonoperative management (NOM) factors into shared decision making by patient and surgeon; however, the incidence of acute incarceration remains largely unknown. A retrospective analysis of adult patients with an International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis of incisional hernia was conducted from 2010 to 2017 in 15 hospitals of a single healthcare system. The primary outcome was incarceration necessitating emergent operation. The secondary outcome was 30-, 90-, and 365-day mortality. Univariate and multivariate analyses were used to determine independent predictors of incarceration. Among 30,998 patients with an incisional hernia (mean age 58.1 ± 15.9 years; 52.7% female), 23,022 (78.1%) underwent NOM of whom 540 (2.3%) experienced incarceration, yielding a 1- and 5-year cumulative incidence of 1.24% and 2.59%, respectively. Independent variables associated with incarceration included: age older than 40 years, female sex, current smoker, body mass index 30 or greater, and a hernia-related inpatient admission. All-cause mortality rates at 30, 90, and 365 days were significantly higher in the incarceration group at 7.2%, 10%, and 14% versus 1.1%, 2.3%, and 5.3% in patients undergoing successful NOM, respectively. Incarceration is an uncommon complication of NOM but is associated with a significant risk of death. Tailored decision making for elective repair and considering the aforementioned risk factors for incarceration provides an initial step toward mitigating the excess morbidity and mortality of an incarceration event.

The Nonoperative Instability Severity Index Score (NISIS): A Simple Tool to Guide Operative Versus Nonoperative Treatment of the Unstable Shoulder.

The management of the adolescent athlete after initial shoulder instability remains controversial. Individual risk factors in athletes with shoulder instability who are managed nonoperatively can be integrated into a scoring system that can predict successful return to sport. Retrospective cohort study. Level 4. A total of 57 scholastic athletes with primary anterior shoulder instability who were managed nonoperatively were reviewed. Success was defined as a return to index sport at the same level and playing at least 1 subsequent season without missed time as a result of the shoulder. Patient-specific risk factors were individually evaluated, and odds ratios were calculated. A 10-point Nonoperative Injury Severity Index Score (NISIS) incorporated the risk factors for failure. This score was then retrospectively applied with regression analysis and a chi-square analysis to determine the overall optimal score that predicted failure of nonoperative management. In total, 6 risk factors for failure were included in the NISIS: age (>15 years), bone loss, type of instability, type of sport (contact vs noncontact), male sex, and arm dominance. Overall, 79% of patients treated nonoperatively were able to successfully return to sport. Nearly all (97%) low-risk patients (NISIS <7) successfully returned to sport, while only 59% of high-risk patients returned to sport, a relative risk of 12.2 (P = 0.001). High-risk patients with unipolar bone loss successfully returned (100%), but 67% of high-risk patients with bipolar bone loss failed. The NISIS is a simple and effective clinical tool to determine successful nonoperative management following anterior shoulder instability and may be helpful in guiding decision making when presented with the unstable shoulder in the scholastic athlete.

Perspectives on Pediatric Appendicitis and Appendectomy During the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic.

Journal of Laparoendoscopic & Advanced Surgical TechniquesVol. 30, No. 4 Research BriefFree AccessPerspectives on Pediatric Appendicitis and Appendectomy During the Severe Acute Respiratory Syndrome Coronavirus 2 PandemicStephanie F. Polites and Kenneth S. AzarowStephanie F. PolitesDepartment of Surgery, Oregon Health & Science University, Portland, Oregon.Search for more papers by this author and Kenneth S. AzarowAddress correspondence to: Kenneth S. Azarow, MD, Department of Surgery, Oregon Health & Science University, L223, 3181 Sam Jackson Pk Rd., Portland, OR 97239 E-mail Address: azarow@ohsu.eduDepartment of Surgery, Oregon Health & Science University, Portland, Oregon.Search for more papers by this authorPublished Online:16 Apr 2020https://doi.org/10.1089/lap.2020.0197AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Hospitals that care for children face the intersection of acute appendicitis and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This is complicated by reports of gastrointestinal symptoms in SARS-CoV-2, including in children.1,2 The management of pediatric appendicitis during this pandemic must be considered in the context of individual hospitals' SARS-CoV-2 testing, bed, staff, and personal protective equipment (PPE) capacity. Hospitals that also care for adults may be strained by SARS-CoV-2 patients while children's hospitals may receive an influx of patients in an attempt to consolidate pediatric care.3Some hospitals will test all children with appendicitis for SARS-CoV-2 or test based on symptoms and observe on antibiotics until results return. Others will assume SARS-CoV-2 positivity. Although appendectomy should not be impacted by restrictions on elective procedures,3 several institutions routinely perform nonoperative management (NOM) for uncomplicated appendicitis (UA). Duration of disability is decreased with NOM though length of stay is increased and 1 in 10 children require appendectomy before discharge.4 NOM avoids aerosolization during intubation and laparoscopy, avoids general anesthesia for children with a possible respiratory illness, and is particularly suited to hospitals with capacity to observe UA patients for >24 hours. Endpoints for successful NOM in children with SARS-CoV-2 may require modification due to viral symptoms, including fever.For hospitals with strained resources, appendectomy for UA may be favored due to earlier anticipated discharge, which increases availability of beds, staff, and PPE in the system. Such hospitals may find immediate appendectomy with SARS-CoV-2 precautions more efficient than waiting for SARS-CoV-2 results. This is contingent on operating rooms having adequate resources and technology to protect staff. Postoperatively, strong consideration should be given to same-day discharge.5When surgery is performed, anterooms for donning and doffing PPE should be utilized if available and minimum necessary staff should participate.6 Hospitals must allocate PPE, including N-95 respirator masks with face shield, or powered air purifying respirators, for intubation based on recent recommendations.7 For confirmed or suspected SARS-CoV-2 patients, surgical staff require similar PPE, as laparoscopy carries a theoretical risk of viral transmission through aerosolization.8 Measures to reduce aerosol exposure include reduced insufflation and cauterization settings, liberal use of suction, meticulous hemostasis at trocar sites, and filtering of carbon dioxide insufflation for aerosols.8,9 Greater operating room turnover time should be expected.Resources should be rationed between SARS-CoV-2 patients and those ill from other conditions with similar severity, including complicated appendicitis (CA).10 Patients with CA with abscess may undergo initial NOM or operative management, although data supporting NOM should not be extrapolated to patients without abscess.11 Interval appendectomy (IA) after NOM has outcomes similar to upfront appendectomy. Based on the status of the pandemic, postponement of IA may be considered. Appendectomy should not be delayed in recurrent appendicitis.11In conclusion, management of acute appendicitis in children will be challenged by the SARS-CoV-2 pandemic. With comparable outcomes for operative and NOM of UA, hospitals must consider capacity and resources in determining the best course of action.Disclosure StatementNo competing financial interests exist.Funding InformationNo funding was received for this article.

Operative versus non-operative management of blunt pancreatic trauma in children: Systematic review and meta-analysis

AIMBlunt abdominal trauma is the major cause of abdominal injury in children. No clear guidelines exist for the initial management of blunt pancreatic trauma in children. The aim of this study was to perform a systematic review and meta-analysis of initially non-operative versus initially operative treatment in children with blunt pancreatic injury. METHODSStudies including children (<18 years) with blunt pancreatic injuries published in any language after year 1990 were included. Total of 849 studies were identified by searching PubMed, Scopus, CINAHL and Cochrane Database. After review, 42 studies met inclusion criteria and were included in this systematic review. There were 1754 patients, of whom 1095 were initially managed non-operatively (NOM), and 659 operatively (OM). Primary outcome was non-operative management success rate, and secondary outcomes were mortality, complications (including specifically pseudocysts and pancreatic fistulas), percent of patients and days on total parenteral nutrition (TPN), length of hospital stay and readmissions. RESULTSThere was no difference in mortality between NOM and OM groups. The incidence of pseudocysts was significantly higher in NOM group compared to OM (P<0.001), especially for AAST grade III or higher (P<0.00001). Overall incidence of pancreatic fistulas was significantly lower for NOM group (p = 0.02) but no difference was observed for AAST grades III or higher (p = 0.49). There was no difference in the length of hospital stay (P = 0.31). Duration of total parenteral nutrition was not different for all AAST grades (P = 0.35), but was significantly shorter for OM group for AAST grades III and higher (p = 0.0001). There was no overall difference in readmissions (P = 0.94). Overall success rate of initial non-operative treatment was 87%. CONCLUSIONSMost patients with pancreatic trauma can initially be treated non-operatively, while early surgical treatment may benefit patients with lesions of the main pancreatic duct. ERCP offers both highly accurate diagnosis and potential treatment of ductal injuries.

Successful non-operative management of extensive pneumomediastinum and pneumoperitoneum

Background: A 70 year old male presented with acute left flank pain and was found to have extensive free air in both the mediastinal and peritoneal cavities. He was managed successfully without surgery. Case: A 70 year old male presented with left flank pain that began an hour prior to arrival. He had a history of obstructive sleep apnea that had been treated with continuous positive airway pressure therapy (CPAP) at home for many years. His vital signs, physical exam, and laboratory testing were all unremarkable. However, imaging findings were impressive for massive pneumoperitoneum and pneumomediastinum. Given his clinical stability, operative exploration was deferred, and he was admitted for observation and bowel rest. He was discharged less than 48 hours after admission without incident. His history of home CPAP therapy was the only attributable cause for the ominous findings seen on his imaging. Recognizing that this was a case of benign free air saved this patient from the morbidity and potential for death that comes with an unnecessary operative exploration. Conclusion: Continuous positive airway pressure therapy can result in benign free air within the mediastinal and peritoneal cavities. Evaluating the complete clinical scenario will allow for recognition of similar cases in which these grim findings are not indicative of surgical disease, thus avoiding the iatrogenesis of unnecessary surgery.

Nonoperative management of splenic injury in closely monitored patients with reduced consciousness is safe and feasible

BackgroundTreatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma.MethodsOur prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14–15) of impaired mental status. Outcome was compared.ResultsA total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6–12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups.ConclusionThis study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.

Discussion on: What predicts successful nonoperative management with botulinum toxin for anal fissure?

DR. MICHAEL VALENTE (Cleveland, Ohio): This is a well-done retrospective review looking at potential predictors of success of nonoperative treatment with botulinum toxin. I have a few questions for clarification. What predicts successful nonoperative management with botulinum toxin for anal fissure?The American Journal of SurgeryVol. 219Issue 3PreviewThis is a retrospective study looking at predictors of successful non-operative management of anal fissures using botulinum toxin. We demonstrated that 60% of patients have responded to injection and 26% ultimately underwent subsequent surgery. We have shown that male sex index is associated with a decreased response to injection and higher likelihood of future surgery, and similar to previous studies patient satisfaction at the first follow up procedure was a good predictor of future success. Full-Text PDF

What predicts successful nonoperative management with botulinum toxin for anal fissure?

BackgroundBotulinum toxin has been established as a non-surgical alternative for chronic anal fissures. There is a paucity of data regarding which patients benefit most from this intervention. Methods: We retrospectively collected data from all cases of chronic anal fissures treated with botulinum toxin over seven years to identify predictors of success. Non-responders were defined as any subsequent surgery or reporting satisfaction as poor or fair. Results: Of 91 patients, 60% (n = 55) were responders and 26% (n = 25) underwent subsequent surgery. There were significantly more females among responders (78% vs. 55%, p = 0.02). A higher body mass index tended towards significance among non-responders (30 ± 7 vs. 27 ± 6, p = 0.08). High satisfaction at the first visit was associated with no subsequent surgery (18% vs. 45%, p = 0.002). Conclusions: Botulinum toxin can be successfully used to treat anal fissures in a majority of patients. Primary predictors of success were female sex, satisfaction at the first post-procedure visit and there was a tendency towards a lower body mass index.

No need for surgery? Patterns and outcomes of blunt abdominal trauma.

IntroductionThe management of a patient suffering from blunt abdominal trauma (BAT) remains a challenge for the emergency physician. Within the last few years, the standard therapy for hemodynamically stable patients with BAT has transitioned to a non-operative approach. The purpose of this study is to evaluate the outcome of patients with BAT and to determine the reasons for failure of non-operative management (NOM).Materials and methodsAnalysis of 176 consecutive patients treated for BAT was conducted in a German level 1 trauma center from 2004 to 2011. Abdominal injuries were classified according to the American Association for the Surgery of Trauma (AAST). Patients included were demonstrated to have objective abdominal trauma with either free fluid on focused assessment with sonography for trauma (FAST) or computed tomography (CT), or proven organ injury.ResultsPatients, 142 of 176 (80.7%), with BAT were initially managed non-operatively, with a success rate of 90%. The rates of NOM success were higher among those with less severe injuries; 100% with Abbreviated Injury Scale (AIS) of 1. In total, 125 patients (71.0%) were managed non-operatively, and 51 (29.0%) required surgical intervention. NOM failure occurred in 9.2% of the patients, the most common reason being initially undiagnosed intestinal perforation (46.2%). Positive correlation was identified (r = 0.512; p < 0.001) between the ISS (injury severity score) and the NACA (National Advisory Committee of Aeronautics) score. The delay in operation in NOM failure was 6 h in patients with underlying hepatic or splenic rupture and 34 h with intestinal perforation. The overall mortality of 5.1% was attributed especially to old age (p = 0.016), high severity of injury (p < 0.001), and greater need for blood transfusion (p < 0.001).ConclusionNOM was successful for the vast majority of blunt abdominal trauma patients, especially those with less severe injuries. NOM failure and operative delay were most commonly due to occult hollow viscus injury (HVI), the detection of which was achieved by close clinical observation and abdominal ultrasound in conjunction with monitoring for rising markers of infection and by multidetector computed tomography (MDCT) if additionally indicated. Based on this concept, the delay in operation in patients with NOM failure was short. This study underscores the feasibility and benefit of NOM in BAT.

Successful Non-Operative Management of Multi-Trauma Patient Suffering from Multiple Intra-Abdominal Injuries - A Case Report

Successful Non-Operative Management of Multi-Trauma Patient Suffering from Multiple Intra-Abdominal Injuries - A Case Report

Management of Pediatric Adhesive Small Bowel Obstruction: Do Timing of Surgery and Age Matter?

BackgroundAdhesive small bowel obstruction (ASBO) in children is generally managed with initial observation. However, no clear guidelines exist regarding indications to operate. Our purpose was to compare outcomes of ASBO management to determine whether timing of surgery and patient age should affect management. Materials and methodsA retrospective review of children admitted to a tertiary care children's hospital for ASBO between 2011 and 2015 was performed. Data included demographics, imaging, operative findings, and clinical management, which were analyzed using χ2 test, Fischer's exact test, t-test, analysis of variance, or logistic regression when appropriate. ResultsWe identified 258 admissions for 202 patients. Urgent operation was performed in 12% and the rest had nonoperative management (NOM), which was successful in 54%. Patients younger than 1 y of age were more likely to require operation (odds ratio 3.71, 95% confidence interval [CI] 1.69-8.15; P < 0.01), and patients with prior ASBO were less likely to require operation (odds ratio 0.51, 95% CI 0.31-0.84; P < 0.01). At presentation, fever was most common in patients who had urgent operation (22.3% versus failure of NOM 7.6% versus successful NOM 6.6%; P = 0.02), but there were no differences in leukocytosis or abdominal pain. Excluding urgent operations, bowel resection was more common when operation was delayed more than 48 h (32.6% versus 15.3%; P = 0.04). ConclusionsIn children with adhesive small bowel obstruction, NOM can be successful, but when failure is suspected, early operation before 48 h should be considered to avoid bowel loss, especially in children younger than 1 y of age.

Isolated free fluid on computed tomography for blunt abdominal trauma.

The clinical significance of isolated free fluid on abdominal computed tomography (CT) in patients with blunt abdominal trauma is unclear. This audit reviews our unit's experience with isolated free fluid and attempts to refine our clinical algorithms for the assessment of patients with blunt abdominal trauma. All patients who sustained blunt abdominal trauma between December 2012 and December 2017 who were subjected to multidetector CT of the abdomen as part of their initial investigation were included in this study. During the five-year period under review, a total of 1066 patients underwent abdominal CT following blunt poly trauma. A total of 84 (7.9%) patients died. There were 148 (14%) patients with CT finding of isolated free fluid. Of these, 128 (67%) were selected for non-operative management, which included a period of serial abdominal examinations. In this non-operative group, five patients failed their abdominal observations and underwent laparotomy. Findings in these five cases were negative (1), non-therapeutic (1), splenic injury (1), Pancreatic and splenic injury (1) and bladder injury (1). Thirteen patients (10%) died, none of whom had surgery. The causes of death were exsanguination from a major traumatic lower limb injury (1), multiple organ failure (1), traumatic brain injury (10) and spinal cord injury (1). The remaining 20 patients underwent laparotomy. The indications were failed non-operative management (5), abdominal distension (1) and suspicion of a missed hollow viscus injury (14). In this group there were 11 therapeutic and 6 non-therapeutic surgeries and three negative laparotomies. For the 15 patients selected for operative management, the findings were as follows: hollow viscus injury (3), mesenteric bleeds (2), splenic and pancreatic injury (1), liver and bladder injury (1), splenic and bladder injury (1), non-therapeutic (4), negative (3). The finding of isolated free fluid on CT is 98% sensitive and 96% specific for true isolated free fluid (chi square 331.598; P = 0.000). This finding predicts successful non-operative management with a positive predictive value of 93% and a negative predictive value of 96%. In patients with blunt abdominal trauma, the finding of isolated free fluid on abdominal CT alone is no longer an indication for laparotomy. Other clinical factors must be taken into account when deciding on the need for laparotomy, such as haemodynamic status, clinical abdominal findings and the ability to reliably assess the abdomen. In the absence of a clinical indication for urgent laparotomy, patients with isolated free fluid may be observed.

Angioembolization significantly improves vascular injuries in blunt splenic trauma.

Non-operative management (NOM) of blunt splenic injury (BSI) uses angioembolization (AE) or observation (OBS). AE improves the success of NOM. However, how AE improves BSI is unknown. We hypothesized AE would decrease rate of pseudoaneurysm (PSA) presence, PSA size, PSA number, and rate of active extravasation. We performed a retrospective review of computerized tomography (CT)-diagnosed BSI over a 2-year period. Patients undergoing NOM with an initial and repeat CT were included. Patients were excluded if they underwent primary splenectomy after BSI diagnosis or did not have repeat CT imaging. One hundred and fifteen patients with BSI had repeat CT imaging; 55/115 (47.8%) had AE; and 60/115 (52.2%) had OBS. On the initial CT, AE patients had more frequent PSA presence (52.7% vs. 6.7%, p < 0.001), higher median number of PSA (1.0 vs. 0, p < 0.001), higher median PSA size (1.15mm vs. 0mm, p < 0.001), and more frequent rates of active extravasation (10.9% vs. 0%, p = 0.01) compared with OBS patients. On repeat CT compared to the initial CT, AE patients had significant decrease in rate of PSA presence (21.8% vs. 52.7%, p < 0.001), median PSA size (0mm vs. 1.15mm, p < 0.001), median PSA number (p < 0.001), and rate of active extravasation (0% vs. 10.9%, p = 0.03). On repeat CT compared to the initial CT, OBS patients had an increase in rate of PSA presence (18.3% vs. 6.7%, p = 0.04). AE significantly decreases PSA presence, number, and size as well as rates of active extravasation. AE should be standard practice in vascular injuries undergoing NOM to maximize splenic salvage.