Tobias Zingg1, Fabio Agri2, Mylène Bourgeat3, Bertrand Yersin4, Benoît Romain5, Sabine Schmidt6, Nathalie Keller6, Nicolas Demartines3. 1. Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland. Electronic address: tobias.zingg@chuv.ch. 2. Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland; Department of Emergency Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland. 3. Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland. 4. Department of Emergency Medicine, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland. 5. Department of Visceral Surgery, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland; Department of Digestive Surgery, Strasbourg University Hospital, 1 Avenue Molière, 67000 Strasbourg, France. 6. Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois - CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland.
Abstract
INTRODUCTION: Significant blunt bowel and mesenteric injuries (sBBMI) are frequently missed despite the widespread use of computed tomography (CT). Early treatment improves the outcome related to these injuries. The aim of this study was to assess the prevalence of sBBMI, the incidence of delayed diagnosis and to test the performance of the Bowel Injury Prediction Score (BIPS), determined by the white blood cell (WBC) count, presence or absence of abdominal tenderness and CT grade of mesenteric injury. PATIENTS AND METHODS: Single-centre, registry-based retrospective cohort study, screening all consecutive trauma patients admitted to Lausanne University Hospital Trauma Centre from 2008 to 2015 after a road traffic accident. All patients with reliable information about the presence or absence of sBBMI who underwent abdominal CT and for whom calculation of the BIPS was possible were included for analysis. The incidence of delayed (>24h after admission) diagnosis in the patient group with sBBMI was determined and the diagnostic performance of the BIPS for sBBMI was assessed. RESULTS: For analysis, 766 patients with reliable information about the presence or absence of sBBMI were included. The prevalence of sBBMI was 3.1% (24/766). In 24% (5/21) of stable trauma patients undergoing CT, a diagnostic delay of more than 24h occurred. Abdominal tenderness (p<0.0001) and CT grade ≥4 (p<0.0001) were associated with sBBMI, whereas CT grade 4 alone (p=0.93) and WBC count ≥17G/l (p=0.30) were not. A BIPS ≥2 had a sensitivity of 89% (95% CI, 67-99), specificity of 89% (95% CI, 86-91), positive likelihood ratio of 8 (95% CI, 6.1-10), negative likelihood ratio of 0.12 (95% CI, 0.03-0.44), positive predictive value (PPV) of 19% (95% CI, 15-24) and negative predictive value (NPV) of 99.7% (95% CI, 98.7-99.9). CT alone identified 79% (15/19) and the BIPS 89% (17/19) of patients with sBBMI (p=0.66). CONCLUSIONS: Diagnostic delays in patients with sBBMI are common (24%), despite the routine use of abdominal CT. Application of the BIPS on the present cohort would have led to a high number of non-therapeutic abdominal explorations without identifying significantly more sBBMI early than CT alone.
INTRODUCTION: Significant blunt bowel and mesenteric injuries (sBBMI) are frequently missed despite the widespread use of computed tomography (CT). Early treatment improves the outcome related to these injuries. The aim of this study was to assess the prevalence of sBBMI, the incidence of delayed diagnosis and to test the performance of the Bowel Injury Prediction Score (BIPS), determined by the white blood cell (WBC) count, presence or absence of abdominal tenderness and CT grade of mesenteric injury. PATIENTS AND METHODS: Single-centre, registry-based retrospective cohort study, screening all consecutive traumapatients admitted to Lausanne University Hospital Trauma Centre from 2008 to 2015 after a road traffic accident. All patients with reliable information about the presence or absence of sBBMI who underwent abdominal CT and for whom calculation of the BIPS was possible were included for analysis. The incidence of delayed (>24h after admission) diagnosis in the patient group with sBBMI was determined and the diagnostic performance of the BIPS for sBBMI was assessed. RESULTS: For analysis, 766 patients with reliable information about the presence or absence of sBBMI were included. The prevalence of sBBMI was 3.1% (24/766). In 24% (5/21) of stable traumapatients undergoing CT, a diagnostic delay of more than 24h occurred. Abdominal tenderness (p<0.0001) and CT grade ≥4 (p<0.0001) were associated with sBBMI, whereas CT grade 4 alone (p=0.93) and WBC count ≥17G/l (p=0.30) were not. A BIPS ≥2 had a sensitivity of 89% (95% CI, 67-99), specificity of 89% (95% CI, 86-91), positive likelihood ratio of 8 (95% CI, 6.1-10), negative likelihood ratio of 0.12 (95% CI, 0.03-0.44), positive predictive value (PPV) of 19% (95% CI, 15-24) and negative predictive value (NPV) of 99.7% (95% CI, 98.7-99.9). CT alone identified 79% (15/19) and the BIPS 89% (17/19) of patients with sBBMI (p=0.66). CONCLUSIONS: Diagnostic delays in patients with sBBMI are common (24%), despite the routine use of abdominal CT. Application of the BIPS on the present cohort would have led to a high number of non-therapeutic abdominal explorations without identifying significantly more sBBMI early than CT alone.
Authors: Tyler J Loftus; Megan L Morrow; Lawrence Lottenberg; Martin D Rosenthal; Chasen A Croft; R Stephen Smith; Frederick A Moore; Scott C Brakenridge; Robert Borrego; Philip A Efron; Alicia M Mohr Journal: Am J Surg Date: 2018-11-28 Impact factor: 2.565