Nathalie Chereau1, Mathilde Wagner2, Christophe Tresallet1, Olivier Lucidarme2, Mathieu Raux3, Fabrice Menegaux4. 1. Department of General Surgery, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Pierre et Marie Curie (Paris VI), 75651 Paris, France. 2. Department of Radiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Pierre et Marie Curie (Paris VI), 75651 Paris, France. 3. Department of Anesthesiology, Critical Care, Emergency Medicine and Surgery, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Pierre et Marie Curie (Paris VI), 75651 Paris, France. 4. Department of General Surgery, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Pierre et Marie Curie (Paris VI), 75651 Paris, France. Electronic address: fabrice.menegaux@aphp.fr.
Abstract
BACKGROUND: The diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high. PATIENTS AND METHODS: Blunt abdominal trauma patients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR≥1. CT findings, DPL and surgery results, and global outcome were analyzed. RESULTS: Thirty-seven were included in the study (27 males, median age of 30 years (range, 17-69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion (p=0.02) and small bowel wall abnormalities (p=0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59-100]) and 43% (CI 95% [25-63]). The sensitivity remained 100% (CI 95% [59-100]) when the ratio was ≥4 (n=10 patients), and the specificity reached 90% (CI 95% [73-98]). CONCLUSION: DPL is sensitive for the diagnosis of BBMI in stable trauma patients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR≥1. Indications for exploratory laparotomy could be restricted to patients with a CCR≥4 to improve the specificity of diagnosis management.
BACKGROUND: The diagnosis of small bowel and mesenteric injuries (BBMI) after blunt abdominal trauma remains difficult, which results in delayed treatment and increased mortality and morbidity. Diagnostic peritoneal lavage (DPL) in patients with 1 or 2 abnormal CT findings that are suggestive of BBMI was proposed, but the rate of unnecessary surgical exploration remains high. PATIENTS AND METHODS: Blunt abdominal traumapatients with 1 or 2 CT findings predictive of BBMI from 2001 to 2014 underwent a DPL with calculation of a cell count ratio (CCR) dividing the ratio of white blood cells (WBCs) to red blood cells (RBCs) (WBC/RBC ratio) in the lavage fluid by the WBC/RBC ratio in peripheral blood. Surgical exploration of the abdomen was performed immediately in cases with a CCR≥1. CT findings, DPL and surgery results, and global outcome were analyzed. RESULTS: Thirty-seven were included in the study (27 males, median age of 30 years (range, 17-69 years)). Exploratory laparotomy was performed in 24 patients (65%). Sixteen patients (67%) had BBMI: 7 hollow organ perforations or tears (29%), including 4 bowel resection with primary anastomosis and 3 single sutures, and 9 patients had mesenteric injuries. CT findings associated with BBMI and hollow organ perforation were large peritoneal effusion (p=0.02) and small bowel wall abnormalities (p=0.002). No postoperative complications were observed. Sensitivity and specificity of DPL for the diagnosis of bowel injuries were respectively 100% (CI 95% [59-100]) and 43% (CI 95% [25-63]). The sensitivity remained 100% (CI 95% [59-100]) when the ratio was ≥4 (n=10 patients), and the specificity reached 90% (CI 95% [73-98]). CONCLUSION: DPL is sensitive for the diagnosis of BBMI in stable traumapatients with 1 or 2 unexplained CT abnormalities, but specificity is low with a high rate of nontherapeutic laparotomy in case of CCR≥1. Indications for exploratory laparotomy could be restricted to patients with a CCR≥4 to improve the specificity of diagnosis management.
Authors: Luke Smyth; Cino Bendinelli; Nicholas Lee; Matthew G Reeds; Eu Jhin Loh; Francesco Amico; Zsolt J Balogh; Salomone Di Saverio; Dieter Weber; Richard Peter Ten Broek; Fikri M Abu-Zidan; Giampiero Campanelli; Solomon Gurmu Beka; Massimo Chiarugi; Vishal G Shelat; Edward Tan; Ernest Moore; Luigi Bonavina; Rifat Latifi; Andreas Hecker; Jim Khan; Raul Coimbra; Giovanni D Tebala; Kjetil Søreide; Imtiaz Wani; Kenji Inaba; Andrew W Kirkpatrick; Kaoru Koike; Gabriele Sganga; Walter L Biffl; Osvaldo Chiara; Thomas M Scalea; Gustavo P Fraga; Andrew B Peitzman; Fausto Catena Journal: World J Emerg Surg Date: 2022-03-04 Impact factor: 5.469
Authors: Federico Coccolini; Leslie Kobayashi; Yoram Kluger; Ernest E Moore; Luca Ansaloni; Walt Biffl; Ari Leppaniemi; Goran Augustin; Viktor Reva; Imitiaz Wani; Andrew Kirkpatrick; Fikri Abu-Zidan; Enrico Cicuttin; Gustavo Pereira Fraga; Carlos Ordonez; Emmanuil Pikoulis; Maria Grazia Sibilla; Ron Maier; Yosuke Matsumura; Peter T Masiakos; Vladimir Khokha; Alain Chichom Mefire; Rao Ivatury; Francesco Favi; Vassil Manchev; Massimo Sartelli; Fernando Machado; Junichi Matsumoto; Massimo Chiarugi; Catherine Arvieux; Fausto Catena; Raul Coimbra Journal: World J Emerg Surg Date: 2019-12-11 Impact factor: 5.469