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Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study
George C Velmahos1, Konstantinos G Toutouzas, Randall Radin
1Department of Surgery, University of Southern California, Los Angeles, California 90033, USA. velmahos@usc.edu
Hypothesis:
Nonoperative management (NOM) of injuries to the liver, spleen, and kidney is highly successful, as shown in retrospective studies, but needs prospective validation. Patients in whom NOM is likely to fail can be identified by specific criteria.
Design:
Prospective observational study.
Setting:
Academic level I trauma center at a county hospital.
Patients:
Two hundred six patients with injuries to the liver (n = 99), spleen (n = 103), and/or kidney (n = 40).
Main Outcome Measures:
Failure of NOM.
Results:
Fifty-seven patients (28%) underwent immediate operation; among the other 149, NOM failed in 33 (22%). The rate of failure for spleen injury (34%) was higher than for liver (17%) or kidney injury (18%) (P<.01). Failure of NOM was due to delayed bleeding from a solid viscus in 20 of the 33 patients. Intestinal injury was detected in only 1 patient initially selected for NOM. Specifically among patients with liver injury, no failure was due to delayed bleeding from the liver. Patients with failed NOM were more likely to have a positive abdominal ultrasonographic finding (61% vs 22%; P<.01), a grade of splenic injury of at least III on computed tomographic scan (CT) (n = 20 [17%] vs n = 16 [48%]; P<.01), and an amount of free fluid of greater than 300 mL on CT (36% vs 8%; P<.01) and to receive blood transfusions during NOM (58% vs 16%; P<.01). The groups were not different with regard to associated extra-abdominal injuries (including head injuries). Mortality was not different, but morbidity was marginally higher in patients with failed NOM (29% vs 45%; P =.08). We identified the following 4 independent risk factors of failure by means of stepwise logistic regression: nonliver (splenic or renal) injury, positive abdominal ultrasonography findings, amount of free fluid on CT of greater than 300 mL, and need for blood transfusion. According to a statistical model, the presence of all 4 independent risk factors predicted NOM failure in 96% of the patients, and the absence of all predicted success in 98%.
Conclusions:
In a prospective study, the rate of NOM failure for solid abdominal organ injuries is higher than the rates reported in retrospective studies. Nonoperative management is less likely to fail in liver injuries than in splenic or kidney injuries. Use of NOM should be exercised with caution if blood transfusion is needed, fluid is identified on the screening ultrasonogram, or a significant quantity of blood is discovered on CT.