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

Abstract Introduction The 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 methods Analysis 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. Results Patients, 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). Conclusion NOM 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.


II Goedecke et al.: Patterns and outcomes of blunt abdominal trauma
This is In all, the data work up is adequate and nicely discussed. To justify the conclusion that "non-operative management is successful for the vast majority of blunt abdominal trauma..." one certain subgroup of patients, however, has to examined more closely: Patients with non-operative management failure (NOM failure). All diagnostic efforts are done to minimise this group of patients in whom delay of diagnosis of hollow organ injury or serious intraabdominal bleeding might lead to high morbidity or even mortality. It is mentioned that pts. with NOM failure required a significantly longer period of treatment in the ICU. How was the mortality in this group, and was there a similar outcome to the patients who were treated with early laparotomy in doubt? How was there rate of "negative" (i.e. "unnecessary") laparotomies in the cohort who underwent primarily operative treatment? A delay of 35 hours in regard to hollow organ injury in 6/142 patients might justify an early laparoscopy in a high risk cohort. Can the authors predict which injury pattern/diagnostic findings could identify these patients who would benefit from operative management (other than the seatbelt sign taken from the literature). Laparoscopy obviously has no role in the algorithm of the presenting trauma center, has it? What was the rate of laparoscopies in the cohort who underwent operative treatment? This retrospective analysis would certainly convey a more important message for the daily routine in other centres if characteristics for the patients that would benefit from early operation were developed by this analysis. Minor points: -table 1-3 need legends with the abbreviations explained.
-"source of mortality" (= "old age..."): you mean contributing factors? was that a univariate analysis? a multivariate analysis would be necessary and interesting! - Mar 2, 2018 Dear Editors, At first, we would like to thank the editorial board and the reviewers for the constructive criticism and for giving us the possibility to resubmit our manuscript. Thanks to the constructive reviews we are able to submit a clearly strenghtened paper now. Sincerely yours, Maximilian Goedecke -Pat. with NOM failure. How was the mortality in this group, and was there a similar outcome to the patients who were treated with early laparotomy in doubt? -One Patient with NOM failure died (8%) which is higher than the average mortality (5%) but the case number is a little bit small for further statistical testing. Patients with HWI and initially NOM had a slightly lower outcome (Glasgow Outcome Scale) than Patients with early laparotomy (not significant). It is difficult to compare the cases because of the different injury severity. A patient who needed an immediate laparotomy was usually in worse condition than patients who were treated with NOM.
-How was there rate of "negative" (i.e. "unnecessary") laparotomies in the cohort who underwent primarily operative treatment? -An injury was detected in every surgery and bleeding was treated, if that was necessary is difficult to tell from a retrospective standpoint. From our point of view a prospective study is needed to answer that question correctly -Can the authors predict which injury pattern/diagnostic findings could identify these patients who would benefit from operative management (other than the seatbelt sign taken from the literature).
-Unfortunately we cannot. For example: In one patient the hollow viscus injury could not be detected by two CT-Scans, Ultrasound nor contrast enema. And was finally detected by laparoscopie -Laparoscopy obviously has no role in the algorithm of the presenting trauma center, has it? What was the rate of laparoscopies in the cohort who underwent operative treatment? -It does has. Especially in the diagnostic of HWI, but in this study they lead to a laparotomie for further treatment and were not further classified.
-table 1-3 need legends with the abbreviations explained.
-done -"source of mortality" (= "old age..."): you mean contributing factors? was that a univariate analysis? a multivariate analysis would be necessary and interesting! -done - 4 Please judge the overall scientific quality of the manuscript.
3 Are you willing to review the revision of this manuscript? Yes

Comments to Author:
Although the authors state in the response that all the suggestions of the reviewer were taken care of ("done"), almost nothing was changed in the manuscript. I still think the manuscript could benefit from some of suggestions.

Authors' Response to Reviewer Comments
Apr 15, 2018 Dear Editors, At first, we would like to thank the editorial board and the reviewers for the constructive criticism and for giving us the possibility to resubmit our manuscript. Thanks to the constructive reviews we are able to submit a clearly strenghtened paper now. Sincerely yours, Maximilian Goedecke -We performed a multivariate analysis and added them to results as well as in the Method area.
-The table legends explain the abbreviations now -We explained the Scores more detailed in the Method section and also added to new tables the scores as mentioned. Due to the high quantity of the scores in the AAST, we just showed an example of the spleen scoring. Also a few more citations were used. 3 Please judge the overall scientific quality of the manuscript.

Reviewers' Comments to 2 nd Revised Submission
3 Are you willing to review the revision of this manuscript? Yes

Comments to Author:
Dear Authors, unfortunately you did not mark the changes you made in the revised manuscript. However trying to compare the versions it seems that virtually the only sentence that was changed/added from R1 to R2 was : "included were those with either proven organ injury or free fluid on FAST or CT scanning. Initial identification of patients was by means of ICDand therapy classification codes ("German Procedure & Classification Code" OPS). Patient records, discharge letters, radiology results and surgery reports were analyzed on the basis of gender, age, preclinical and clinical vital signs, time and date of hospitalization and discharge, laboratory values, and etiology and treatment of abdominal and other injuries. FAST was performed for all patients, the majority of whom also underwent CT scan." In the methods section you state: "Multivariate Analysis was realized by using a general linear model and Wilks' Lambda as test statistic. " However, neither in R1 nor in R2 I have found the results of the multivariate model in the results section, nor in the tables, nor are they discussed. The same applies to all the other hints the reviewer brought up and that could have been utilzed to improve the discussion for example. If you dont think that the multivariate analysis or any other idea suggested by the reviewer is useful, tell the reviewer. A review's purpose is to improve the manuscript in a dialogue with the reviewer. Despite agreeing in your ‚reply to the reviewer' with several of the critizisms of the reviewer ("done"), you did virtually no changes to the manuscript itself from the first version to R1. From R1 to R2, one single paragraph was changed and three or so references were added. I have devoted considerable time and efforts trying to understand your manuscript and your intentions of the study and suggesting ways to improve it. If it is ignored in such a way, there is no need for review at all...

Authors' Response to Reviewer Comments
Mar 31, 2019 Revision 1) Pat. with NOM failure. How was the mortality in this group, and was there a similar outcome to the patients who were treated with early laparotomy in doubt? One Patient with NOM failure died (8%) which is higher than the average mortality (5%) but the case number is a little bit small for further statistical testing. Patients with HWI and initially NOM had a slightly lower outcome (Glasgow Outcome Scale) than Patients with early laparotomy (not significant). It is difficult to compare the cases because of the different injury severity. A patient who needed an immediate laparotomy was usually in worse condition than patients who were treated with NOM.
2) How was the rate of "negative" (i.e. "unnecessary") laparotomies in the cohort who underwent primarily operative treatment? Due to your comment we reviewed all cases which were immediately treated surgically or supposed to be surgically treated immediately.
(29 patients which were directly transported to the OR and 4 with delay due to triage). The abdominal AIS of those 33 patients were: AIS 2: 1; AIS 3: 9; AIS 4: 14 and AIS 5: 9 patients. We analyzed the 10 patients with an AIS from 2 to 3. The patient with the AIS 2 injury had an AAST II spleen injury which required massive blood transfusion and surgical treatment. From the remaining 9 patients with an abdominal AIS 3, four showed an intestinal injury. Two patients from the remaining 5 required a splenectomy because of the trauma. Blood transfusion was necessary in all 3 of the remaining patients: 2 needed two blood bags and the other one eight (6 of those in the first 24 hours due to a spleen(AIS3), liver (AIS2) and kidney (AIS3) injury). Both patients with an AIS 3 and the transfusion of 2 blood bags had an active bleeding in the CT scan and both received surgical haemostasis. Overall we think a high-grade trauma such as AIS 4-5 cannot be classified as "unnecessary" from the retrospective point of view. We could not show any "negative" laparotomies and added this to the paper. We think that a prospective study is needed to answer this question correctly.
3) Can the authors predict which injury pattern/diagnostic findings could identify these patients who would benefit from operative management (other than the seatbelt sign taken from the literature).
Unfortunately we cannot. For example: In one patient the hollow viscus injury could not be detected by two CT-Scans, Ultrasound nor contrast enema. And was finally detected by laparoscopy 4) Laparoscopy obviously has no role in the algorithm of the presenting trauma center, has it? What was the rate of laparoscopies in the cohort who underwent operative treatment? It does have a role. Especially in the diagnostic of HWI, but in this study all laparoscopies lead to a laparotomy for further treatment and were not further classified. Patients which were treated with an immediate surgical intervention underwent a laparotomy because of the critical conditions.

Comments to Author:
Dear authors, thank you very much for your newest revision and for giving the concept of routine / selective laparoscopy more room in the discussion section. I think it has definitely rendered a bit more balance to the discussion. You obviously do not share my opinion to rather do a fast laparoscopy in a polytraumatized patient with certain injury features than to miss a hollow viscus injury, even if it means ‚unnecessary' laparoscopy for several other patients. (And a delay of 34 hours for missed HVI seems very relevant in my opinion.) But I understand that routine use of laparoscopy for certain trauma patterns depends a lot on the routine use of laparoscopy for liver and splenic surgery as well as colorectal surgery in a department (and the familiarity of the entire team with it) and minimally invasive surgery was definitely not as advanced in your study period between 2004-2011. I addition, recommending laparoscopy would somewhat contradict the tenor of your paper to advocate non-operative management for blunt abdominal trauma. So be it-there is space for different opinions in surgery and even data can be interpreted supporting both sides. Thank you again for using my hints to develop your manuscript, I will now recommend the manuscript for acceptance.