Nonoperative treatment of blunt injury to solid abdominal organs: A prospective study

George C. Velmahos, Konstantinos G. Toutouzas, Randall Radin, Linda Chan, Demetrios Demetriades, Richard J. Mullins, Clayton H. Shatney, Daniel R. Margulies, Gill Cryer, Michael E. Lekawa, Gail T. Tominaga, David Wisner, Samuel E. Wilson

Research output: Contribution to journalArticle

174 Citations (Scopus)

Abstract

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%) (Pα.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.

Original languageEnglish (US)
Pages (from-to)844-851
Number of pages8
JournalArchives of Surgery
Volume138
Issue number8
DOIs
StatePublished - Aug 1 2003

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Nonpenetrating Wounds
Prospective Studies
Wounds and Injuries
Abdominal Injuries
Liver
Kidney
Blood Transfusion
Therapeutics
Spleen
Retrospective Studies
Hemorrhage
County Hospitals
Viscera
Trauma Centers
Statistical Models
Craniocerebral Trauma
Observational Studies
Ultrasonography
Logistic Models
Outcome Assessment (Health Care)

ASJC Scopus subject areas

  • Surgery

Cite this

Velmahos, G. C., Toutouzas, K. G., Radin, R., Chan, L., Demetriades, D., Mullins, R. J., ... Wilson, S. E. (2003). Nonoperative treatment of blunt injury to solid abdominal organs: A prospective study. Archives of Surgery, 138(8), 844-851. https://doi.org/10.1001/archsurg.138.8.844

Nonoperative treatment of blunt injury to solid abdominal organs : A prospective study. / Velmahos, George C.; Toutouzas, Konstantinos G.; Radin, Randall; Chan, Linda; Demetriades, Demetrios; Mullins, Richard J.; Shatney, Clayton H.; Margulies, Daniel R.; Cryer, Gill; Lekawa, Michael E.; Tominaga, Gail T.; Wisner, David; Wilson, Samuel E.

In: Archives of Surgery, Vol. 138, No. 8, 01.08.2003, p. 844-851.

Research output: Contribution to journalArticle

Velmahos, GC, Toutouzas, KG, Radin, R, Chan, L, Demetriades, D, Mullins, RJ, Shatney, CH, Margulies, DR, Cryer, G, Lekawa, ME, Tominaga, GT, Wisner, D & Wilson, SE 2003, 'Nonoperative treatment of blunt injury to solid abdominal organs: A prospective study', Archives of Surgery, vol. 138, no. 8, pp. 844-851. https://doi.org/10.1001/archsurg.138.8.844
Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D, Mullins RJ et al. Nonoperative treatment of blunt injury to solid abdominal organs: A prospective study. Archives of Surgery. 2003 Aug 1;138(8):844-851. https://doi.org/10.1001/archsurg.138.8.844
Velmahos, George C. ; Toutouzas, Konstantinos G. ; Radin, Randall ; Chan, Linda ; Demetriades, Demetrios ; Mullins, Richard J. ; Shatney, Clayton H. ; Margulies, Daniel R. ; Cryer, Gill ; Lekawa, Michael E. ; Tominaga, Gail T. ; Wisner, David ; Wilson, Samuel E. / Nonoperative treatment of blunt injury to solid abdominal organs : A prospective study. In: Archives of Surgery. 2003 ; Vol. 138, No. 8. pp. 844-851.
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abstract = "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{\%}) (Pα.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.",
author = "Velmahos, {George C.} and Toutouzas, {Konstantinos G.} and Randall Radin and Linda Chan and Demetrios Demetriades and Mullins, {Richard J.} and Shatney, {Clayton H.} and Margulies, {Daniel R.} and Gill Cryer and Lekawa, {Michael E.} and Tominaga, {Gail T.} and David Wisner and Wilson, {Samuel E.}",
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AU - Velmahos, George C.

AU - Toutouzas, Konstantinos G.

AU - Radin, Randall

AU - Chan, Linda

AU - Demetriades, Demetrios

AU - Mullins, Richard J.

AU - Shatney, Clayton H.

AU - Margulies, Daniel R.

AU - Cryer, Gill

AU - Lekawa, Michael E.

AU - Tominaga, Gail T.

AU - Wisner, David

AU - Wilson, Samuel E.

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N2 - 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%) (Pα.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.

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