Are we doing too many non-therapeutic laparotomies in trauma? An analysis of the National Trauma Data Bank.

BACKGROUND: Exploratory laparotomy (EL) has been the definitive diagnostic and therapeutic modality for operative abdominal trauma in the US. Recently, many trauma centers have started using diagnostic laparoscopy (DL) in stable trauma patients in an effort to reduce the incidence of non-therapeutic laparotomy (NL). We aim to evaluate the incidence of NL in the trauma population in the US and compare the outcomes between DL and NL. METHODS: Using ICD-9 codes, the National Trauma Data Bank (2010-2015) was queried for patients undergoing any abdominal surgical intervention. Patients were divided into two groups: diagnostic laparoscopy (DL) and exploratory laparotomy (EL). Hemodynamically unstable patients on arrival and patients with abbreviated injury score (AIS) > 3 were excluded. Patients in EL group without any codes for gastrointestinal, diaphragmatic, hepatic, splenic, vascular, or urological procedures were considered to have undergone NL. After excluding patients who were converted to open from the DL group, multivariate regression models were used to analyze the outcomes of DL vs NL group with respect to mortality, length of stay, and complications. RESULTS: A total of 3197 patients underwent NL vs 1323 patients who underwent DL. Compared to DL group, the NL group were older (mean age: 35 vs. 31, P < 0.01). Rate of penetrating injury was 77% vs 86% for patients in NL vs DL. On multivariate analysis, NL was associated with increased mortality (OR 4.5, 95% CI 2.1-9.7), higher rate of complications (OR 2.2, 95% CI 1.4-3.3), and a longer hospital stay (OR 2.7, 95% CI 2.1-3.5). NL was also associated with higher rates of pneumonia, VTE, ARDS, and cardiac arrest. CONCLUSION: With increasing experience in minimally invasive surgery, DL should be a part of the armamentarium of trauma surgeons. This study supports that in well-selected trauma patients DL has favorable outcomes compared to NL. These findings warrant further investigation.

Laparotomía no-terapéutica en trauma penetrante abdominal y su relación con el estado de intoxicación por alcohol y drogas / Non-therapeutic laparotomy in penetrating abdominal trauma and its relation with the state of alcohol and drugs intoxication

Objetivo: Describir las características de la población sometida a laparotomía exploradora (LAPE) por trauma penetrante abdominal, cuyo resultado fue no terapéutico y observar si el estado de intoxicación por alcohol y/o drogas influye en la realización del procedimiento. Sede: Hospital General de Ciudad Juárez (segundo nivel de atención). Diseño: Estudio prospectivo y de cohorte. Análisis estadístico: Promedios como medida de resumen, prueba exacta de Fisher y prueba de chi cuadrada. Pacientes y métodos: Se estudiaron pacientes con diagnóstico de trauma penetrante abdominal, sometidos a laparotomía exploradora por sospecha de lesión a órgano intraabdominal o retroperitoneal. Las variables fueron: edad, género, estado de intoxicación, tipo de sustancia consumida, mecanismo de lesión, indicación de cirugía, hallazgos quirúrgicos, complicaciones postquirúrgicas y mortalidad. Resultados: Se estudiaron 480 pacientes, 79% fueron sometidos a laparotomía terapéutica y 21% a laparotomía no terapéutica. La incidencia de laparotomía no terapéutica fue de 35% en los heridos por arma blanca y de 13% para los heridos por arma de fuego (p < 0.0001). El estado de intoxicación por alcohol y/o drogas estuvo presente en 87% de los pacientes con laparotomía terapéutica, mientras que en el grupo de pacientes con laparotomía no-terapéutica en el 85%, sin diferencia significativa. En los pacientes sometidos a laparotomía no-terapéutica se encontraron 28 lesiones a órgano intraabdominal. El hemoperitoneo promedio fue de 200 ml (± 100). El tiempo quirúrgico promedio de 94 minutos (± 25). Ocurrieron 17 infecciones de sitio quirúrgico, mortalidad nula y estancia hospitalaria promedio de 4 días (± 2). Conclusión: La laparotomía no-terapéutica no está relacionada a una evaluación prequirúrgica en un paciente con intoxicación alcohólica y/o por drogas.

Objective: To describe the characteristics of a population that was subjected to exploratory laparotomy due to penetrating abdominal trauma, with non-therapeutic results and to observe if the degree of alcohol and/or drug intoxications had an influence on performing the procedure. Setting: General Hospital of Ciudad Juárez (second level health care). Design: Prospective and cohort study. Statistical analysis: Averages as summary measure, Fisher's exact test and chi square test. Patients and methods: We studied patients with abdominal penetrating trauma subjected to exploratory laparotomy due to suspicion of intraabdominal organ injury or retroperitoneal injury. Studied variables were: age, gender, degree of intoxication, type of toxic substance ingested, injury mechanisms, indication for surgery, surgical findings, post-surgical complications, and mortality. Results: We studied 480 patients, 79% were subjected to therapeutic laparotomy and 21% to non-therapeutic laparotomy. Incidence of non-therapeutic laparotomy was of 35% in those injured by stabbing, whereas it was of 13% for those injured by fire arms (p < 0.0001). Intoxication due to alcohol and drugs was encountered in 87% of patients with therapeutic laparotomy, whereas in the group of non-therapeutic laparotomy they accounted for 85%, without significant differences. In patients subjected to non-therapeutic laparotomy, 28 injuries to intraabdominal organs were found. The average hemoperitoneum was of 200 ml (± 100). Average surgical time was of 94 min (± 25). Seventeen infections of the surgical site occurred, mortality was nill, and the average in-hospital stay was of 4 days (± 2). Conclusion: Non-therapeutic laparotomy is not related to a presurgical evaluation in a patient with alcohol and/or drugs intoxication.

Trauma abdominal penetrante / Penetrating abdominal trauma

Introducción: el abdomen ocupa el tercer lugar corporal dañado por trauma. La evaluación y la estabilización de los individuos con lesiones en esa región son la piedra angular en los momentos de urgencias. El abordaje diagnóstico y el resultado del tratamiento están influidos por múltiples factores. El mecanismo y los patrones de las lesiones varían. La exploración física es el indicador más confiable para determinar la necesidad de cirugía. El objetivo de esta investigación fue conocer frecuencia, incidencia, factores demográficos, tasa de laparotomías inmediatas y diferidas, y complicaciones asociadas con el trauma abdominal penetrante; así como definir la utilidad del índice de trauma abdominal penetrante (PATI). Material y métodos: estudio observacional, prospectivo, longitudinal, descriptivo, realizado en el Hospital Central “Ignacio Morones Prieto”, San Luis Potosí, México, del 1 de enero al 31 de diciembre de 2005; incluyó pacientes con trauma abdominal penetrante sometidos a laparotomía exploradora. Fueron estudiadas 21 variables y se llevó a cabo análisis estadístico básico, con t de Student, χ2 y ANOVA. Resultados: se operaron 79 pacientes, 93.67 % del sexo masculino; predominaron los pacientes en la tercera década de la vida; numerosas lesiones fueron producidas durante la noche y por violencia interpersonal; 50.6 % estuvo asociado con el consumo de drogas y 63.3 % se debió a instrumento punzocortante. Con más frecuencia las lesiones se localizaron en cuadrante superior izquierdo, inferior derecho y epigastrio, prevaleciendo las heridas únicas; en las asociadas estuvieron involucrados el tórax y las extremidades; de las laparotomías, 92.4 % se realizó en forma inmediata y en 60.53 %, terapéutica. Existieron complicaciones en 39.24 %; 15.19 % fue reintervenido y la mortalidad representó 3.9 %. Conclusión: debido al elevado índice de laparotomías no terapéuticas y negativas, se requiere abordaje más selectivo que incluya la exploración física...

BACKGROUND: The abdomen ranks in third place of body areas injured by trauma. Evaluation and stabilization of these patients form the cornerstone in emergency medicine. Diagnostic approach and treatment outcome are influenced by several factors. Injury mechanism and pattern vary according to geography and there is an association with drugs and alcohol. Physical examination remains the most reliable indicator for surgery. Associated injuries are present in up to 26% of cases. We undertook this study to determine penetrating abdominal trauma incidence and frequency, demographic factors, rate of immediate and delayed laparotomies, and associated complications as well as to define the usefulness of penetrating abdominal trauma index (PATI). METHODS: An observational, prospective, longitudinal descriptive study was carried out at the Hospital Central [quot ]Ignacio Morones Prieto,[quot ] San Luis Potosi, Mexico from January 1, 2005 to December 31, 2005 on patients who underwent exploratory laparotomy for penetrating abdominal trauma. Twenty one variables were studied. Basic statistical analysis, ANOVA, chi(2) and Student's t-test were used. RESULTS: Of the 79 patients who were included, 93.67% were males. The third decade of life was the most affected, with a night presentation being predominant as a result of personal violence. Drug use was observed in 50.6%; stab wounds in 63.3%. The most frequent locations were the left upper and right lower quadrants and epigastrium; solitary wounds were predominant. Associated injuries were most common in the thorax and limbs. Of the laparotomies performed, 92.4% were urgent and 60.53% were therapeutic; 15.19% required reoperations; complications were observed in 39.24%; and mortality rate was 3.9%. CONCLUSIONS: Due to high non-therapeutic and negative laparotomies rates, a more selective approach is needed, including repetitive physical examination and the appropriate use of auxiliary diagnostic studies.