Mesenteric injury after blunt abdominal trauma.

OBJECTIVE: To present our experience of mesenteric injuries after blunt abdominal trauma. DESIGN: Retrospective study. SETTING: University hospital, Greece. SUBJECTS: 31 patients with mesenteric injuries out of 333 who required operations for blunt abdominal trauma between March 1978 and March 1998. 21 were diagnosed within 6 hours (median 160 min, early group) and in 10 the diagnosis was delayed (median 21 hours, range 15 hours-7 days, delayed group). INTERVENTIONS: Emergency laparotomy. MAIN OUTCOME MEASURES: Mortality, morbidity, and hospital stay. RESULTS: There were no deaths. The diagnosis was confirmed by diagnostic peritoneal lavage in 17/21 patients in the early group whereas 7/10 in the delayed group were diagnosed by clinical examination alone. Most of the injuries (n = 23) were caused by road traffic accidents. 30 patients had injured the small bowel mesentery and 4 the large bowel mesentery. 25 of the 31 patients had associated injuries. There were no complications in the early group, compared with 6 wound infections and 1 case of small bowel obstruction in the delayed group (p < 0.0001). Median hospital stay in the early group was 11 days (range 3-24) compared with 23 days (range 10-61) in the delayed group (p = 0.004). CONCLUSION: Because delay in diagnosis is significantly associated with morbidity and duration of hospital stay we recommend that all patients admitted with blunt abdominal trauma should have a diagnostic peritoneal lavage as soon as possible     

Gall bladder injuries as part of the spectrum of civilian abdominal trauma in South Africa

BACKGROUND: Trauma to the gall bladder is rare, but when missed or improperly managed it may be associated with significant morbidity. The aim of the present study was to review the management and outcomes of gall bladder trauma in a trauma centre. METHODS: Forty-three patients with gall bladder injury due to abdominal trauma were reviewed over a 3-year period. Surgical management, associated injuries, morbidity and mortality rates were determined. RESULTS: Among 1242 patients undergoing laparotomy for acute trauma, 43 patients (3.46%) with gall bladder injuries were identified. Forty patients sustained penetrating injuries (37 with gunshot wounds and three with stab wounds), and three patients suffered from blunt trauma. All patients with gall bladder injury underwent abdominal exploration because of associated intra-abdominal injuries. Thirty-six patients were treated with cholecystectomy, four patients underwent primary suture repair of the gall bladder perforation, while three patients with gall bladder injury were treated without any surgical intervention at laparotomy. No complications could be attributed to the gall bladder trauma or surgery. CONCLUSION: Cholecystectomy is the preferred procedure of choice for gall bladder injuries and is associated with no morbidity.     

Management of penetrating and blunt diaphragmatic injury

The past 5 years' experience with diaphragmatic injuries at the University of Texas Health Science Center in San Antonio was reviewed to refine the clinical signs and appropriate treatment. During this period 102 patients were treated. Ninety-three patients incurred penetrating trauma to the diaphragm and nine patients suffered blunt trauma. Chest X-rays were normal in 40 patients, a hemo- and/or pneumothorax was present in 57, herniated abdominal viscera in four, and free air in one. Peritoneal lavage was positive in six of seven patients with blunt diaphragmatic injury, but was falsely negative in two of five patients (20%) with penetrating diaphragmatic injury. Eighty-nine patients (87%) experienced 137 associated injuries (excluding hemo- and/or pneumothorax). Nine patients (8.8%) had an isolated diaphragmatic injury. Four patients (4%) had a diaphragmatic injury associated with only a hemo- and/or pneumothorax. All patients, except for three with injuries recognized late, were operated upon immediately. Two patients had a missed diaphragmatic injury at initial laparotomy. There was one death in the series from a consumption coagulopathy. It was concluded that injuries to the diaphragm should be suspected in all patients with severe blunt torso trauma or with penetrating injuries near the diaphragm. Because of the nonspecificity of X-rays and the 20% false negative rate for peritoneal lavage, we believe that missed injuries and morbidity can be minimized by immediate laparotomy for all patients with abdominal and low thoracic penetrating injuries. Care must be taken not to overlook associated injuries.     

Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma

BACKGROUND: Our institution was one of the first to report the use of laparoscopy in the management of penetrating abdominal trauma (PAT) in 1977. Despite early interest, laparoscopy was rarely used. Changes in 1995 resulted in an increase in interest and use of laparoscopy. We present our recent experience with laparoscopy. METHODS: Our trauma registry and operative log were used to identify patients with blunt and penetrating injuries to the abdomen, back, and flank who underwent laparotomy or laparoscopy during the past 5 years. Patient demographics, operative findings, complications, and length of stay were reviewed. The number of laparoscopic explorations, therapeutic, nontherapeutic, and negative laparotomies were trended. RESULTS: There were 429 abdominal explorations for trauma. The rate of laparoscopy after penetrating injury increased from 8.7% to 16%, and after stab wounds from 19.4% to 27%. There was an associated decrease in the negative laparotomy rate. Laparoscopy prevented unnecessary laparotomy in 25 patients with PAT. Four patients with diaphragm injuries underwent repair laparoscopically. CONCLUSION: An aggressive laparoscopic program can improve patient management after PAT.     

Post traumatic acquired multiple mesenteric defects

INTRODUCTIONInternal intestinal hernia has been defined as a bulging of the intestines through a normal or an abnormal peritoneal or mesenteric opening.¹ Internal hernias are a rare cause of small-bowel obstruction, with a reported incidence of 0.2–0.9%.²PRESENTATION OF CASEIn this report, the patient presented with multiple episodes of intestinal obstruction. High index of suspicion aided the appropriate management of this case. An abdominal CT revealed signs of small bowel obstruction. With negative signs and symptoms indicating adhesions, malignancy or inflammatory causes, mesenteric defect was suspected. When the patient underwent laparotomy, multiple mesenteric defects were found.DISCUSSIONIn the adult population, acquired mesenteric defects are more common than congenital defects. They can be caused by bowel surgery or abdominal trauma.¹¹ Patients with a history of blunt abdominal trauma may present with late complication caused by a missed diagnosis of an associated injury, such as bowel mesenteric injuries.In this case, the author describes a patient who developed multiple attacks of small bowel obstruction. He had no previous history of similar symptoms but did give a history of recent abdominal trauma managed conservatively. An abdominal CT was performed, and it showed signs of a mesenteric defect. In such a case, early operative intervention is essential to decrease morbidity and increase survival. ¹⁶CONCLUSIONThe diagnosis of post traumatic mesenteric injuries can be missed in conservatively managed trauma cases. For this reason, the decision of non-operative approach should be made following the exclusion of associated injuries.     

A prospective analysis of diagnostic laparoscopy in trauma.

OBJECTIVE: This study was performed to assess current and potential future application for laparoscopy (DL) in the diagnosis of penetrating and blunt injuries. Efficacy, safety, and cost analyses were performed. SUMMARY BACKGROUND DATA: Diagnostic peritoneal lavage (DPL) and computed tomography (CT) have been the mainstays in recent years for diagnosis of equivocal nontherapeutic laparotomy, whereas CT is not helpful for the vast majority of penetrating wounds. DL may be a useful adjunct to fill in these gaps. METHODS: Hemodynamically stable patients with equivocal evidence of intraabdominal injury were prospectively entered into the protocol. DL was performed under general anesthesia; patients with wounds penetrating the peritoneum or blunt injury with significant organ injury underwent laparotomy. RESULTS: Over 19 months, 182 patients (55% stab, 36% GSW, 9% blunt) were studied. No peritoneal penetration was found at DL in 55% of penetrating wounds with 66% of the remainder having therapeutic laparotomy, 17% nontherapeutic laparotomy, and 17% negative laparotomy. Therapeutic laparotomy was performed in 53% of blunt injuries after DL. Tension pneumothorax occurred in one patient and one had an iatrogenic small bowel injury. Charges for DL were $3,325 per patient compared with $3,320 for a similar group undergoing negative laparotomy before this protocol. CONCLUSIONS: DL is a safe modality for trauma. With current technology, DL is most efficacious for evaluation of equivocal penetrating wounds. Significant cost savings would be gained by performance under local anesthesia. Development of miniaturized optics, bowel clamps, retractors, and stapling devices will reduce overall costs and permit some therapeutic applications for laparoscopy in trauma management.     

Factors affecting the outcome of patients with splenic trauma

This is a report of 546 consecutive patients with penetrating and blunt splenic trauma seen over a 17 1/2-year period (1980-1997). The etiology of the splenic injuries and the associated mortality rates were: blunt injuries 45 of 298 (15%), gunshot wounds 48 of 199 (24%), and stab wounds four of 49 (8%). The overall mortality rate was 97 of 546 (18%). The most significant risk factors for death were all associated with major blood loss: transfusion requirements > or = 6 units of blood, low initial operating room blood pressure, associated abdominal vascular injuries, and performance of a thoracotomy. The two most important organs injured in conjunction with the spleen that were significant predictors of postoperative infectious complications were colon and pancreas. The need for splenectomy was most significantly correlated with higher grades of splenic injury especially grades IV and V. The evolution in management of blunt splenic trauma has led to a significant improvement in splenic preservation and avoidance of laparotomy for many patients. Operative splenic salvage is reduced in patients subjected to laparotomy who are candidates for nonoperative treatment. Improved results with splenic injury should be obtained by rapid control of bleeding. This may require more liberal criterial in selecting patients with splenic trauma for early operative treatment.     

Acute tracheobronchial injury

We reviewed our experience with tracheal and bronchial trauma from 1977 to 1988. There were 22 patients with tracheobronchial injuries treated in this period. Seventeen (77%) of the injuries were due to penetrating trauma and five (23%) were due to blunt trauma. Thirteen patients had major associated injuries, including six esophageal injuries. The most common physical findings were tachypnea (13 patients) and subcutaneous emphysema (nine patients). Eight patients presented with airway obstruction. All patients with penetrating cervical tracheal injuries underwent neck exploration and primary repair. All blunt injuries were diagnosed by bronchoscopy. Three patients with blunt injuries were treated with primary repair. Two patients with blunt chest trauma and small bronchial tears were treated nonoperatively with good results. All three deaths (14% mortality rate) were due to associated injuries. We conclude that patients with penetrating tracheobronchial injuries should be managed by surgical exploration and primary repair, although selected patients with blunt injury may be treated nonoperatively.     

Laparoscopy as diagnostic-therapeutic method in abdominal traumatism in the pediatric age

The management of blunt abdominal traumatism with a moderate amount of free peritoneal fluid and without solid organ injury as well as the one of minimal penetrating trauma is controversial. We present three cases of blunt abdominal trauma and two of penetrating trauma that underwent diagnostic laparoscopy in our department. We found a small bowel perforation in one of the cases of blunt trauma that was repaired by externalization of the jejuna loop by one of the ports. In the other two cases we found intestinal and mesenteric contusions and free fluid that were treated by peritoneal drainage. One of the cases of penetrating trauma presented omentum evisceration with no other injuries and the second presented a gastric perforation that needed reconversion to laparotomy. In our experience and according to literature, laparoscopy should be taken into account as a diagnostic procedure and sometimes also therapeutic in selected cases of both blunt and penetrating abdominal trauma in pediatric population.     

Diagnostic laparotomy for abdominal trauma. A university hospital experience

Following the experience of World War II, exploratory laparotomy in all patients with penetrating abdominal trauma was deemed mandatory until 1960 when Shaftan reported his experience with selective laparotomy. In 1973, Nance et al. reported on selective observation of abdominal stab wounds. There seems to be little controversy over mandatory laparotomy for abdominal gunshot wounds. Blunt trauma is generally managed expectantly with the adjunctive use of peritoneal lavage, CT scanning, and serial examinations of the abdomen. Despite the selective approach and the use of adjunctive diagnostic methods, exploratory laparotomy continues to be the most accurate method used to diagnose the presence of intra-abdominal injury. In order to examine our experience with diagnostic laparotomy for trauma, both blunt and penetrating, a retrospective study of 494 consecutive patients undergoing exploratory laparotomy over the past 4 years was undertaken. Abdominal stab wounds were explored under local anesthesia, and, if found to penetrate the posterior fascia, laparotomy was accomplished. All patients with abdominal gunshot wounds underwent exploration. Exploratory laparotomy in patients with blunt abdominal trauma was mandated by clinical signs, positive peritoneal lavage, or positive CT scan. All patients with unexplained shock and/or signs of peritoneal irritation underwent urgent laparotomy. In this series of 494 patients, 99 or 20 per cent of the entire group had a negative exploration (30% for stab wounds, 16% for gunshot wounds, and 19% for blunt abdominal trauma). The morbidity for the negative laparotomy group was limited to five patients with postoperative atelectasis. There were no anesthesia complications, iatrogenic intraoperative injuries, or wound infections. There were five deaths but none were laparotomy-related.(ABSTRACT TRUNCATED AT 250 WORDS)     

Review of 9 Cases of Diaphragmatic Injury Following Blunt Trauma Chest; 3 Years Experience

Diaphragmatic injuries can occur with both blunt and penetrating trauma which can be associated with herniation of abdominal viscera into the thoracic cavity. Diaphragmatic injuries can occur with blunt trauma chest in 1–7 % of patients. Retrospectively for last 3 years all cases blunt trauma chest admitted to surgery were reviewed and a study of cases of diaphragmatic rupture was done. We analysed 496 patients of blunt trauma chest retrospectively for period of three years. Nine patients have diaphragmatic injuries, all were males, six presented acutely three were chronic. In six patients laparotomy was done, four subcostal and two midline incisions were preferred. In chronic cases thoracotomy was done. Left sided injury predominates and rib fractures are most common associated finding. Diagnosis in majority of cases is made by Computerised tomography scan. Subcostal incision may be used in patients with isolated diaphragmatic injury in acute presentation while thoracotomy is preferred in late cases. Most common morbidity is pulmonary complications     

Liver lacerations--a marker of severe but sometimes subtle intra-abdominal injuries in adults

Experience with conservative management of solid viscus injuries from abdominal trauma in children has produced the impetus for a similar management in adults. To explore the implications of such a policy, we reviewed the records of 82 patients with hepatic injuries noted at laparotomy. Indications for laparotomy were positive findings on diagnostic peritoneal lavage (DPL) or CT scan, or a history of penetrating trauma. The liver injuries were graded according to severity: grade I, 19 patients; grade II, 20 patients (low severity = LS); grade III, 14 patients; grade IV, 6 patients (high severity = HS). Twenty-three injuries were not classified by the operating surgeon. Of the 53 patients with blunt hepatic trauma, 23 (43%) had concomitant injuries that required operative intervention. Twenty-nine patients had penetrating liver injuries. Fourteen (48%) had associated injuries requiring intervention. Patients most likely to have nonoperative management, those with grade I and grade II liver injuries (LS), comprised 48 of the total. In this subgroup there were 26 (54.2%) associated injuries requiring operative intervention. Shock could not be used as a factor to differentiate patients not requiring operative intervention. Nineteen of the LS patients requiring operative intervention secondary to associated injury were never in shock. In adult trauma victims positive DPL findings secondary to minor hepatic injuries that might not require operative intervention serve as a marker for associated injuries that do require operation. The risk of nonoperative management of hepatic injuries based upon radiologic diagnosis is not the result of complications from the hepatic injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute diaphragmatic injuries

A 5-year experience with 43 patients with acute diaphragmatic injuries is reviewed. Thirty-three of the patients had penetrating trauma, and 10 suffered blunt trauma. All but 1 of the patients had associated intraabdominal trauma. Fifteen had traumatic diaphragmatic hernia at the time of operation. The operative approach was uniformly through the abdomen. Mortality and morbidity were directly related to the number of associated organs injured.Chest roentgenograms in 26 of the 43 patients were interpreted as suspicious or diagnostic of diaphragmatic injury when presented as unknowns to fully trained radiologists, but only 7 of these were originally so interpreted.Delay in operation was a significant contributing factor to morbidity, particularly in patients with thoracic stab wounds. Guidelines suggested to prevent delay include: (1) increased awareness of the possibility of acute diaphragmatic injury, (2) careful evaluation of the plain chest roentgenogram and liberal use of appropriate contrast studies when indicated, (3) prompt repair of recognized diaphragmatic injuries, (4) laparotomy as the operative approach in the acute injury, and (5) appropriate contrast studies after recovery from massive thoracoabdominal trauma and prior to hospital discharge.     

Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the East multi-institutional trial

BACKGROUND: Blunt hollow viscus injury (HVI) is uncommon. No sufficiently large series has studied the prevalence of these injuries in blunt trauma patients. This study defines the prevalence of blunt HVI, in addition to the associated morbidity and mortality rates for this diagnosis on the basis of a series of over 275,000 trauma admissions. METHODS: Patients with blunt small bowel injury (SBI) were identified from the registries of 95 trauma centers for a 2-year period (1998-1999). Each HVI patient (case) was matched by age and Injury Severity Score with a blunt trauma patient receiving an abdominal workup who did not have HVI (control). Patient level data were abstracted by individual chart review. Institution level data were collected on total numbers for trauma admission demographics and on total diagnostic examinations performed. RESULTS: From 275,557 trauma admissions, 227,972 blunt injury patients were identified. HVI was rare, with 2,632 patients identified from this group. Perforating small bowel injury accounted for less than 0.3% of blunt admissions. Mortality and morbidity were high for HVI. Controlling for injury severity, patients with HVI were usually at higher risk of death than non-HVI patients. CONCLUSION: HVI is a rare but deadly phenomenon. The high mortality rates reflect the severity of the HVI and associated injuries. HVI patients should be carefully monitored for related injuries and complications.     

Complications of nonoperative management of high-grade blunt hepatic injuries

BACKGROUND: Nonoperative management of blunt hepatic injuries is highly successful. Complications associated with high-grade injuries, however, have not been well characterized. The purpose of the present study was therefore to define hepatic-related complications and associated treatment modalities in patients undergoing nonoperative management of high-grade blunt hepatic injuries. METHODS: Three hundred thirty-seven patients from two regional Level I trauma centers with grade 3 to 5 blunt hepatic injuries during a 40-month period were reviewed. Complications and treatment of hepatic-related complications in patients not requiring laparotomy in the first 24 hours were identified. RESULTS: Of 337 patients with a grade 3 to 5 injury, 230 (68%) were managed nonoperatively. There were 37 hepatic-related complications in 25 patients (11%); 63% (5 of 8) of patients with grade 5 injuries developed complications, 21% (19 of 92) of patients with grade 4 injuries, but only 1% (1 of 130) of patients with grade 3 injuries. Complications included bleeding in 13 patients managed by angioembolization (n = 12) and laparotomy (n = 1), liver abscesses in 2 patients managed with computed tomography-guided drainage (n = 2) and subsequent laparotomy (n = 1). In one patient with bleeding, hepatic necrosis followed surgical ligation of the right hepatic artery and required delayed hepatic lobectomy. Sixteen biliary complications were managed with endoscopic retrograde cholangiopancreatography and stenting (n = 7), drainage (n = 5), and laparoscopy (n = 4). Three patients had suspected abdominal sepsis and underwent a negative laparotomy, whereas an additional three patients underwent laparotomy for abdominal compartment syndrome. CONCLUSION: Nonoperative management of high-grade liver injuries can be safely accomplished. Mortality is low; however, complications in grade 4 and 5 injuries should be anticipated and may require a combination of operative and nonoperative management strategies.     

Extrahepatic biliary tract injury: operative management plan

Trauma to the extrahepatic biliary tract is rare but, if overlooked or improperly managed, may be associated with significant morbidity. The following is our most recent 6-year experience with this unusual injury. Among 949 patients undergoing laparotomy for acute trauma, there were 32 (3%) injuries to the gallbladder and five (0.5%) to the common bile duct. All patients with gallbladder injury underwent abdominal exploration because of associated trauma. Cholecystectomy was preferred for 24 (96%) of the 25 with penetrating wounds and three (43%) of the seven with blunt trauma. Nine (28%) patients developed postoperative complications but none were related to the biliary injury. All common bile duct injuries (CBD) were penetrating. Associated intra-abdominal trauma was always present. Partial lacerations were closed primarily over a T-tube. An intrapancreatic CBD lesion was managed by sphincteroplasty and stented with a T-tube. The one patient with complete transection underwent choledochoenterostomy. Postoperative complications were common (50%) but none were related to the biliary injury.     

Diagnostic and therapeutic aspects of rectal trauma. Blunt versus penetrating

In the last 6 years, nine patients with blunt and 16 with penetrating rectal injuries were treated at University Hospital, Jacksonville, Florida. Blunt trauma was caused by vehicular accidents in seven patients and crush injuries in two. Penetrating rectal trauma was due to gunshot wounds in ten patients and foreign body insertion in six. All patients with blunt injury had bright red rectal bleeding, which led to diagnostic sigmoidoscopy. Rectal injury was identified at sigmoidoscopy in 12 patients who had penetrating wounds and at laparotomy in four patients. Thirteen patients who had penetrating rectal trauma had injury to only the rectum or to one additional organ. In contrast, all patients who had blunt rectal trauma had at least three associated injuries. In the penetrating group, 13 patients were treated by colostomy and mucus fistula; three patients with mucosal injury were managed nonoperatively. The only death occurred in a patient whose rectal injury was initially missed. Patients who had blunt rectal trauma were managed with colostomy and mucus fistula. Three patients died postoperatively, two of pelvic bleeding and one of head injury. Hemodynamic stabilization, colostomy and mucus fistula, presacral drainage, and rectal washout constitute proper treatment of patients with blunt or penetrating rectal trauma. Because of the greater number and severity of associated injuries, morbidity and mortality are higher after blunt rectal trauma.     

Abdominal trauma

Summary While a great part of the Anglo-American medical literature addresses the topic of penetrating trauma the German spreaking countries rather publish on blunt abdominal injury. The presented paper discusses the strategic principles of acute clinical management of abdominal trauma on the combined basis of own research results and a comprehensive review of the literature. Blunt abdominal injuries in most cases from a part in the pattern of multiple trauma. The early, first-hours mortality is most often caused by severe traumatic brain injury or abdominal trauma with massive hemorrhage. The prehospital management of penetrating injuries is characterized rather by the concept of ’load and go', whereas the on-scene stabilization of the patient with blunt abdominal injury should precede transport to the adequate hospital. On arrival in the accident and emergency room an immediate blood transfusion is recommended for hemodynamically unstable patients. If then a stabilization is not achieved, an emergency laparotomy should follow. Abdominal stab injuries should be explored by laparoscopy if an intraperitoneal lesion is suspected. If then the possibility of an intestinal lesion is present a laparotomy should be performed directly thereafter. Firearm injuries require open revision in almost all cases. The standard diagnostic technique in blunt abdominal trauma is sonography, assisted by computed tomography and, if indicated, angiography in hemodynamically stable patients. Isolated abdominal injuries without hemodynamic or coagulation disorders allow conservative treatment in the intensive care setting. In severe multiple trauma as well as in manifest shock even the smallest fluid detection should lead to laparotomy. The surgical treatment of splenic rupture is still a matter of discussion. Splenectomy is indicated in patients with severe concomitating injuries or shock whereas in the remainder of cases the total or partial preservation of the spleen should be pursued. Hepatic injuries offer a broad spectrum of operative interventions, ranging from superficial hemostatic measures over compression techniques like ’packing' and ’mesh-wrapping' to atypical and anatomical resections and to liver transplantation in exceptional cases. Lesions of tubular organs and the pancreas pose especially difficult diagnostical problems but regularly allow a rather easy operative treatment.      

Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study

BACKGROUND: Focused Assessment with Sonography for Trauma (FAST) is rapidly establishing its place in the evaluation of blunt abdominal trauma. However, no prospective study specifically evaluates its role in penetrating abdominal trauma. METHODS: Data were collected prospectively in 75 consecutive stable patients with penetrating trauma to the abdomen, flank, or back, from December 1998 to June 1999. Those with an obvious need for emergent laparotomy were excluded. FAST was performed as the initial diagnostic study on all patients. Wound location, type of weapon, and findings of diagnostic peritoneal lavage, triple-contrast computed tomographic scan, or laparotomy were recorded. The presence of peritoneal blood was noted. Data were analyzed using the chi(2) test. RESULTS: Of the 75 patients, there were 32 stab and 43 gunshot wounds. There were 66 male patients and 9 female patients; the mean age was 30 years; 41 had proven abdominal injury and 34 had no injury; and 21 patients had a positive FAST. Nineteen had peritoneal blood and injuries requiring repair at the time of laparotomy. There were two false-positive studies. Fifty-four patients had a negative FAST. In 32 patients, this was a true-negative study. Thirteen patients had a false-negative FAST and had peritoneal blood and significant injury on further evaluation. Nine patients had a negative FAST and no peritoneal blood but still had abdominal injuries requiring operative repair, including liver (four), small bowel (four), diaphragm (three), colon (three), and stomach (one). The overall sensitivity of FAST was 46% and the specificity was 94%. The positive predictive value was 90%, and the negative predictive value was 60%. CONCLUSION: FAST can be a useful initial diagnostic study after penetrating abdominal trauma. A positive FAST is a strong predictor of injury, and patients should proceed directly to laparotomy. If negative, additional diagnostic studies should be performed to rule out occult injury.     

Colon injury after blunt abdominal trauma: results of the EAST Multi-Institutional Hollow Viscus Injury Study

BACKGROUND: Blunt injury to the colon is rare. Few studies of adequate size and design exist to allow clinically useful conclusions. The Eastern Association for the Surgery of Trauma Multi-institutional Hollow Viscus Injury (HVI) Study presents a unique opportunity to definitively study these injuries. METHODS: Patients with blunt HVI were identified from the registries of 95 trauma centers over 2 years (1998-1999). Patients with colon injuries (cases) were compared with blunt trauma patient undergoing a negative laparotomy (controls). Data were abstracted by chart review. RESULTS: Of the 227,972 patients represented, 2,632 (1.0%) had an HVI and 798 had a colonic/rectal injury (0.3%). Of patients diagnosed with HVI, 30.2% had a colon injury. No physical findings or imaging modalities were able to discriminate colonic injury. Logistic regression modeling yielded no clinically useful combination of findings that would reliably predict colonic injury. In patients undergoing laparotomy, presence of colon injury was associated with a higher risk of some complications but not mortality. Colon injury was associated with increased hospital (17.4 vs. 13.1, p < 0.001) and intensive care unit (9.7 vs. 6.9, p = 0.003) length of stay. Almost all colon patients (92.0%) underwent laparotomy within 24 hours of injury. CONCLUSION: Colonic injury after blunt trauma is rare and difficult to diagnose. No diagnostic test or combination of findings reliably excluded blunt colonic injury. Despite the inadequacy of current diagnostic tests, almost all patients with colonic injury were taken to the operating room within 24 hours. Even with relatively prompt surgery, patients with colon injury were at significantly higher risk for serious complications and increased length of stay. In contrast to small bowel perforation, delay in operative intervention appears to be less common but is still associated with serious morbidity.