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01-04-2021 | Laparotomy | Original Article

Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic–therapeutic algorithm

Authors: Alessandro Michele Bonomi, Stefano Granieri, Shailvi Gupta, Michele Altomare, Stefano Piero Bernardo Cioffi, Fabrizio Sammartano, Stefania Cimbanassi, Osvaldo Chiara

Published in: Updates in Surgery | Issue 2/2021

Abstract

Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, −LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1–3 h). OM was 7.8%—not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.

Watts DD, Fakhry SM (2003) Incidence of hollow viscus injury in blunt trauma: an analysis from 275,557 trauma admissions from the EAST multi-institutional trial. J Trauma 54(2):289–294CrossRef

Williams MD, Watts DD, Fakhry SM (2003) Colon injury after blunt abdominal trauma: results of the east multi-institutional hollow viscus injury study. J Trauma 55(5):906–912CrossRef

Biffl WL, Leppaniemi A (2015) Management guidelines for penetrating abdominal trauma. World J Surg 39(6):1373–1380CrossRef

Bège T, Brunet C, Berdah SV (2016) Hollow viscus injury due to blunt trauma: a review. J Visc Surg 153(4):61–68CrossRef

Fakhry SM, Watts DD, Luchette FA (2003) Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis from 275,557 trauma admissions from the East multi-institutional HVI trial. J Trauma 54(2):295–306CrossRef

Ekeh AP, Saxe J, Walusimbi M et al (2008) Diagnosis of blunt intestinal and mesenteric injury in the era of multidetector CT technology—are results better? J Trauma 65(2):354–359PubMed

Rodriguez C, Barone JE, Wilbanks TO et al (2002) Isolated free fluid on computed tomographic scan in blunt abdominal trauma: a systematic review of incidence and management. J Trauma 53(1):79–85CrossRef

Marek AP, Deisler RF, Sutherland JB et al (2014) CT scan-detected pneumoperitoneum: an unreliable predictor of intra-abdominal injury in blunt trauma. Injury 45(1):116–121CrossRef

Banz VM, Butt MU, Zimmermann H et al (2009) Free abdominal fluid without obvious solid organ injury upon CT imaging: an actual problem or simply over-diagnosing? J Trauma Manag Outcomes 3:10CrossRef

10.

Bates DDB, Wasserman M, Malek A et al (2017) Multidetector CT of surgically proven blunt bowel and mesenteric injury. Radiographics 37:613–625CrossRef

11.

Abdel-Aziz H, Dunham CM (2019) Effectiveness of computed tomography scanning to detect blunt bowel and mesenteric injuries requiring surgical intervention: a systematic literature review. Am J Surg 218(1):201–210CrossRef

12.

Atri M, Hanson JM, Grinblat L et al (2008) Surgically important bowel and/or mesenteric injury in blunt trauma: accuracy of multidetector CT for evaluation. Radiology 249(2):524–533CrossRef

13.

Soto JA, Anderson SW (2012) Multidetector CT of blunt abdominal trauma. Radiology 265(3):678–693CrossRef

14.

Faria GR, Almeida AB, Moreira H et al (2012) Prognostic factors for traumatic bowel injuries: killing time. World J Surg 36(4):807–812CrossRef

15.

Baron BJ, Benabbas R, Kohler C et al (2018) Accuracy of computed tomography in diagnosis of intra-abdominal injuries in stable patients with anterior abdominal stab wounds: a systematic review and meta-analysis. Acad Emerg Med 25(7):744–757CrossRef

16.

Tan KK, Liu JZ, Go TS et al (2010) Computed tomography has an important role in hollow viscus and mesenteric injuries after blunt abdominal trauma. Injury 41(5):475–478CrossRef

17.

Holmes JF, McGahan JP, Wisner DH (2012) Rate of intra-abdominal injury after a normal abdominal computed tomographic scan in adults with blunt trauma. Am J Emerg Med 30(4):574–579CrossRef

18.

Petrosoniak A, Engels PT, Hamilton P et al (2013) Detection of significant bowel and mesenteric injuries in blunt abdominal trauma with 64-slice computed tomography. J Trauma 74(4):1081–1086CrossRef

19.

Benjamin ER, Siboni S, Haltmeier T et al (2015) Negative finding from computed tomography of the abdomen after blunt trauma. JAMA Surg 150(12):1194CrossRef

20.

Kendall J, Kestler A, Whitaker K et al (2011) Blunt abdominal trauma patients are at very low risk for intra-abdominal injury after emergency department observation. West J Emerg Med 12(4):496–504CrossRef

21.

Pal JD, Victorino GP (2002) Defining the role of computed tomography in blunt abdominal trauma: use in the hemodynamically stable patient with a depressed level of consciousness. Arch Surg 137(9):1029–1033CrossRef

22.

Fakhry SM, Brownstein M, Watts DD et al (2000) Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. J Trauma 48(3):408–415CrossRef

23.

Malinoski DJ, Madhukar SP, Didem OY et al (2010) A diagnostic delay of 5 hours increases the risk of death after blunt hollow viscus injury. J Trauma 69(1):84–87PubMed

24.

Biffl WL, Krista LK, Cothren CC et al (2009) Management of patients with anterior abdominal stab wounds: a western trauma association multicenter trial. J Trauma 66(5):1294–1301PubMed

25.

Inaba K, Castelo Branco B, Moe D et al (2012) Prospective evaluation of selective nonoperative management of torso gunshot wounds: when is it safe to discharge? J Trauma 72(4):884–891

26.

Mohammadi A, Ghasemirad M (2012) Evaluation of gastrointestinal injury in blunt abdominal trauma ‘FAST is not reliable’: the role of repeated ultrasonography. World J Emerg Surg 7(1):2CrossRef

27.

Brooke M, Victorino GP (2017) Repeat computed tomography is highly sensitive in determining need for delayed exploration in blunt abdominal trauma. J Surg Res 219:116–121CrossRef

28.

Mitsuhide K, Juniki S, Atsushi N et al (2005) Computed tomographic scanning and selective laparoscopy in the diagnosis of blunt bowel injury: a prospective study. J Trauma 58(4):696–703CrossRef

29.

Lin HF, Chen YD, Lin KL et al (2015) Laparoscopy decreases the laparotomy rate for hemodynamically stable patients with blunt hollow viscus and mesenteric injuries. Am J Surg 210(2):326–333CrossRef

30.

Uranues S, Popa DE, Diaconescu B et al (2015) Laparoscopy in penetrating abdominal trauma. World J Surg 39(6):1381–1388CrossRef

31.

Elbanna KY, Mohammed MF, Huang SC et al (2018) Delayed manifestations of abdominal trauma: follow-up abdominopelvic CT in posttraumatic patients. Abdom Radiol 43(7):1642–1655CrossRef

32.

Zarour A, El-Menyar A, Khattabi M et al (2014) A novel practical scoring for early diagnosis of traumatic bowel injury without obvious solid organ injury in hemodynamically stable patients. Int J Surg 12(4):340–345CrossRef

33.

McNutt MK, Chinapuvvula NR, Beckmann NM et al (2015) Early surgical intervention for blunt bowel injury: The Bowel Injury Prediction Score (BIPS). J Trauma 78(1):105–111CrossRef

34.

Raharimanantsoa M, Zingg T, Thiery A et al (2018) Proposal of a new preliminary scoring tool for early identification of significant blunt bowel and mesenteric injuries in patients at risk after road traffic crashes. Eur J Trauma Emerg Surg 44(5):779–785CrossRef

35.

Ng AKT, Simons RK, Torreggiani WC et al (2002) Intra-abdominal free fluid without solid organ injury in blunt abdominal trauma: an indication for laparotomy. J Trauma 52(6):1134–1140CrossRef

36.

Jost E, Roberts DJ, Penney T et al (2017) Accuracy of clinical, laboratory, and computed tomography findings for identyfing hollow viscus injury in blunt trauma patients with unexeplained intraperitoneal free fluid without solid organ injury. Am J Surg 213:874–880CrossRef

Title: Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic–therapeutic algorithm
Authors: Alessandro Michele Bonomi
Stefano Granieri
Shailvi Gupta
Michele Altomare
Stefano Piero Bernardo Cioffi
Fabrizio Sammartano
Stefania Cimbanassi
Osvaldo Chiara
Publication date: 01-04-2021
Publisher: Springer International Publishing
Keywords: Laparotomy
Laparotomy
Published in: Updates in Surgery / Issue 2/2021
Print ISSN: 2038-131X
Electronic ISSN: 2038-3312
DOI: https://doi.org/10.1007/s13304-020-00929-w

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Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic–therapeutic algorithm

Abstract

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