Category Archives: Abdomen

Activity Guidelines After Solid Organ Injury: How Important Are They?

October 4, 2024 The Trauma Pro Leave a comment

Just about every practice guideline out there regarding liver and spleen injury has some physical activity restrictions associated with it. The accepted dogma is that moving around too much, climbing stairs, lifting objects, or getting tackled while playing rugby could exacerbate the injury and lead to complications or surgery.

But is it true? Activity restrictions after solid organ injury have been around longer than I have been a trauma surgeon. And the more people I poll on what they do, the more and very different answers I get. And there are no decent papers published that look critically at this question. Until now.

A pediatric multi-center study of study on adherence to activity restrictions was published last year. Ten Level I pediatric trauma centers in the US tabulated their experience with solid organ injuries over 3.75 years from 2013 to 2016. Only patients with successful nonoperative management of their injury were included, and those with high-grade renal or pancreatic injuries were excluded.

Since this was a pediatric study, the American Pediatric Surgical Association (APSA) practice guideline was followed (activity restriction = organ injury grade + 2 weeks). Activity restrictions included all sports, any recreational activity with wheels, or any activity involving both feet off the ground. Patients with Grade III-V injuries were seen at an office visit after 2 weeks, and lower grade injuries had a phone follow-up.

Adherence to guidelines was assessed by a follow-up phone call two months after injury. Clinical outcomes assessed at 60 days included an unplanned return to the emergency department (ED), re-admission, complications, and development of new bleeding confirmed by surgery, ultrasound, or computed tomography (CT) at 60 days post-injury.

Here are the factoids:

Of the 1007 patients in the study, some 56% were either excluded (178) or lost to follow-up (463)
Of the remaining 366, roughly 46% had a liver injury, 44% spleen, and the remaining 10% had both
Median age was 10, so this was actually a younger population
76% of patients claimed they abided by the guidelines, 14% said they did not, and 10% “didn’t know.” This means they probably did not.
For the 279 patients who said they adhered to activity restrictions, 13% returned to the ED, and half were admitted to the hospital
Of the 49 patients who admitted they did not follow the guidelines, 8% returned to the ED at some point, and none were readmitted
The most common reasons for returning to ED were abdominal pain, anorexia, fatigue, dizziness, and shoulder pain
There were no delayed operations in either of the groups

Bottom line: There were no significant differences between the compliant and noncompliant groups. Unfortunately, the authors did not include an analysis of the “I don’t know if I complied” group, which would have been interesting. However, there is one issue I always worry about in these low-number-of-subjects studies that don’t show a significant difference between groups. Did they have the statistical power to show such a difference? If not, then we still don’t know the answer. And unfortunately, I’m not able to guess the numbers well enough to do the power calculation for this study.

I am still intrigued by this study! Our trauma program originally set a fixed time period (6 weeks) of limited activity in our practice guideline for pediatric solid organ injury patients. This was reduced based on our experience of no delayed complications and guidance from our sister pediatric trauma center at Children’s Hospital in Minneapolis. We are also moving toward making a similar change to our adult practice guidelines. But even our current guideline of injury grade + 2 weeks is probably too much.

Too many centers wait too long to make changes in their practice guidelines. They bide their time waiting for new, published research that they can lean on for their changes. Unfortunately, they will be waiting for a long time because many of our questions are not interesting enough for acceptance by the usual journals. Rely on the expertise and experience of your colleagues and then make those changes. Be sure to follow with your performance improvement program to make sure that they actually do work as well as you think!

Reference: Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI). J Ped Surg 54:335-339, 2019.

Abdomen, Technique, Video

Video: Minimally Invasive Repair Of Rectal Injuries

April 2, 2024 The Trauma Pro Leave a comment

Extraperitoneal rectal injury repair has evolved considerably over the past 40 years. Way back when, this injury automatically triggered exploration, diverting colostomy with washout of the distal colon, and presacral drain insertion (remember those?).

We eventually backed off on the presacral drains (pun intended), which didn’t make a lot of sense anyway. And we gave up on dissecting down deep into the pelvis to approach the injury. This only served to contaminate an otherwise pristine peritoneal cavity. Ditto for the distal rectal washout. So we have been performing a diverting colostomy as the primary method of treatment for years.

A Brief Report in the British Medical Journal Open shows us what may very well be the next stage in treating these injuries. Whereas they were previously left to heal on their own followed by colostomy closure after a few months, these authors from Sunnybrook Health Sciences Centre in Toronto are promoting a minimally invasive approach to definitive management.

They detail two cases, one an impalement by a steel rod through the rectum and bladder, and one stab to the buttock. The authors dealt with the non-rectal injuries using conventional techniques. The rectal injuries were repaired using trans-anal minimally invasive surgery (TAMIS). Both were discharged without complications.

Here is a video of the technique used in the stab victim (no audio):

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Bottom line: It’s about time! As long as there is not a destructive injury to the extraperitoneal rectum, this seems like a great technique to try. It may very well eliminate the need for a diverting colostomy.

But remember, this is only a case report. We don’t know about antibiotic duration, followup imaging, longer term complications, or anything really. A larger series of cases is warranted to provide these answers. This will take some time due to the low frequency of this injury. So if you try it, build your own series and publish it so we all can learn!

Reference: Minimally invasive approach to low-velocity penetrating extraperitoneal rectal trauma. Trauma Surg Acute Care Open. 2020 May 12;5(1):e000396. doi: 10.1136/tsaco-2019-000396. PMID: 32426526; PMCID: PMC7228675.

Abdomen

The Handoff In Damage Control Surgery

March 5, 2024 The Trauma Pro Leave a comment

Damage control surgery is now over 30 years old! We continue to refine the techniques and closure techniques/devices, and have developed novel ways to speed closure of the abdominal wall in order to avoid pesky hernias. But the process itself is time intensive, and typically several days pass with regular returns to OR until closure is achieved. This is one of the prime areas in which human error can occur, especially with modern service-style coverage of trauma patients.

In the old days, trauma patients were admitted by their surgeon, and that person provided their care nearly continuously until discharge. He or she rounded on them daily, took them back to the OR when needed, and then discharged them.

This is less practical (and desirable) in this day and age. And even if it seems possible, it’s not. No one can be on call 24 hours a day, and provide comprehensive care to every patient, around the clock. Many trauma programs have adopted a “service model”, where patients are admitted to a defined care team and managed by them. The team is led by a surgeon, but that person may change on a weekly (or in some cases nearly daily) basis. I call this the “interchangeable head” model, and to make it work there must be excellent handoffs during any leadership change.

In some cases, a patient may undergo a damage control procedure by one surgeon, but another must do the takeback and possibly the definitive closure. In this case, the handoff is critical! It is paramount that the next surgeon know everything about the first case so that they can perform the correct procedure.

How can this be accomplished? Here are some tips:

Do not rely on the medical record and previous operative note. It may not be available, and there is usually some loss of information in recording it anyway. Don’t believe it.
Ideally, meet face to face with the previous surgeon(s). Get the blow by blow description of exactly everything that was done and how. Also discuss what still needs to be done, and when. Try to maintain a uniform philosophy of patient care across surgeons.
If face to face is not possible, a telephone call is acceptable. The discussion is exactly the same.
If the surgery occurred at an outside hospital and was then transferred, you must call the initial surgeon to have this discussion before going to the OR!
If something unexpected is encountered during the case, make sure you have contact information so you can call during the case.

Applying these concepts will decrease the possibility of error, as well as the likelihood of any iatrogenic harm to these complex patients.

In my next post, I’ll review a new paper from the Eastern Association for the Surgery of Trauma (EAST) that performs a systematic review and meta-analysis of handoffs in acute care surgery (which includes damage control, of course) and proposes a practice management guideline.

Abdomen, Solid organ

Use Of A Solid Organ Injury Protocol For Pediatrics

February 23, 2024 The Trauma Pro Leave a comment

Kids are frequent flyers when it comes to abdominal injury, with about 15% of their injuries involving this anatomic area. Solid organ injuries, mainly the liver and spleen, are the most prevalent ones. The American Pediatric Surgical Association (APSA) published a practice guideline way back in 2000 that outlined a consistent way to care for children with solid organ injuries.

Unfortunately, they were very conservative, recommending days of bedrest, extended NPO status, very frequent blood draws, and a lengthy hospital stay. Many hospitals, including mine, developed less conservative management routines, noting that children nearly always tolerate liver and spleen injury better than adults.

The trauma group at Vanderbilt modified the APSA guidelines and, more recently, made additional changes based on a new algorithm released by the organization. This new guideline moved away from organ injury grade-based factors and embraced hemodynamic status as the overall guide to care. The Vanderbilt group performed a retrospective study comparing hospital and ICU length of stay, patient costs, readmission, and death rates using the two guidelines.

Under the old protocol, grade I-III injuries were admitted to a floor bed and higher grades to an ICU at the discretion of the surgeon. The minimum hospital stay was, at minimum, the organ injury grade. Children were kept NPO overnight and placed on bed rest for nearly one day per injury grade.

With the new protocol, children were admitted to the floor if their vital signs normalized after volume resuscitation. Hematocrit was obtained on admission and possibly again after 6 hours, then only repeated if < 21 or a change in vitals was noted. There were no diet or activity restrictions. Children with abnormal vital signs after volume were admitted to the ICU and kept on bed rest until they normalized. Labs were drawn regularly. Length of stay was based on meeting pain control, diet, and activity goals.

Here are the factoids:

There were 176 children (age < 18) enrolled in the old protocol during a four-year period and 170 in the new protocol over 3.5 years
Both groups were similar demographically and in injury grade and ISS
ICU length of stay was “significantly” shorter under the new protocol (.54 vs .78 days)
Hospital length of stay was also “significantly” shorter (2.9 vs 3.5 days)
Inflation-adjusted costs were slightly higher under the new protocol ($68,042 vs $65,437) even though the authors claim the opposite in the abstract once injury grade and ISS are factored in
Survival was the same at 99.4%
Readmission rates were significantly higher under the new protocol (7.1% vs 2.3%)

The authors’ conclusions parroted these results and recommended larger studies to detail any cost advantage and identify the cause for the difference in readmission rates.

Bottom line: This study leaves a lot to be desired. The authors’ definition of “pediatric” is age < 18. As we all know, there is a big difference in “kids” who are pre- vs post-puberty. The good news is that the mean and median ages are about 11 in the study, so there should be fewer older “kids” to cause interference.

The authors reported hazard ratios for the lengths of stay, which were statistically significantly different. However, their clinical significance is in doubt. A difference of 6 ICU hours? Or two-thirds of a hospital day? I’m not impressed.

Cost differences are basically a wash, and a deep read of the paper shows that many kids did not have an isolated solid organ injury. Non-abdominal injuries could have an Abbreviated Injury Scale score of up to 3. It is easy to imagine that these could impact both length of stay and cost.

Finally, the readmission rates include many problems related to non-abdominal injuries, including the thorax, soft tissues, and even an epidural hematoma. After excluding these non-abdominal complications, the numbers for both protocols are so low it’s hard to believe that a good significance test can be performed.

The authors’ conclusions are correct: more work needs to be done. This paper doesn’t really teach us much since all the conclusions are extremely weak. A much better, prospective, multicenter trial should be performed. Unfortunately, getting buy-in from multiple centers/surgeons to use the same protocol in children is hard.

But with all that being said, there is no reason you can’t adopt something similar to the new protocol at your center. My own experience has shown that a more aggressive guideline gets kids home sooner and healthier and that there is no difference in readmission rates. I just need a bunch of other surgeons to duplicate these results and write them up!

Reference: A Protocol Driven Approach to Reduce Lengths of Stay for Pediatric Blunt Liver and Spleen Injury Patients. Journal of Trauma and Acute Care Surgery ():10.1097/TA.0000000000004259, January 26, 2024. | DOI: 10.1097/TA.0000000000004259

Abdomen, Abstracts, Pharmacy

Best Of AAST #4: Starting VTE Prophylaxis After Solid Organ Injury

September 15, 2023 The Trauma Pro Leave a comment

Venous thromboembolic disease (VTE) continues to be a major issue in trauma patients. Most trauma centers have prophylaxis guidelines to try to reduce this problem. These guidelines typically recognize specific injuries that increase the risk of bleeding if anticoagulants are given. Typical ones include hemorrhagic injuries to the brain, pelvic and spine fractures, and solid organ injuries.

Typically, VTE prophylaxis starts immediately upon admission. But when these high-risk injuries are present, it is usually delayed for a period of time. Unfortunately, that period may be highly variable. Many centers have adopted 2-3 days to delay administration of low molecular weight heparin in patients with solid organ injury.

The AAST initiated a prospective multi-institutional trial comparing early (<48 hours after admission) and late (>48 hours) administration of prophylactic agents. Patients were older than 16 years, had any number of liver, spleen, or kidney injuries, and were initially treated nonoperatively. Patients who were transferred, died in the ED, were pregnant, had a bleeding disorder, or were taking anticoagulants or platelet inhibitors were excluded. A power analysis was performed, and more than the needed number of patients were enrolled.

Here are the factoids:

A total of 1173 patients were enrolled, and there were 589 liver injuries, 569 spleen injuries, and 289 kidney injuries
About 75% of patients (864) had early prophylaxis
Patients were younger (median 34 years), and two-thirds were male, with a median ISS of 22
Early VTE prophylaxis patients had significantly lower rates of VTE (3% vs. 7%)
There was no significant difference in failure of nonoperative management (5% early vs. 7% late)
The early prophylaxis group received fewer units of blood after prophylaxis started (17% vs. 23%)
Patients receiving VTE prophylaxis after 48 hours were 2.2x more likely to develop VTE

The authors concluded that early VTE chemoprophylaxis was associated with lower rates of VTE with no increase in complications. They recommended that it should become the standard of care for these patients.

Bottom line: Seeing such a well-designed and nicely executed study is refreshing. If the facts are borne out in the final manuscript review, this should become the standard of care for VTE prophylaxis in patients with solid organ injuries.

I wish the authors would have stipulated that the chemoprophylaxis was required to be low molecular weight heparin. Unfortunately, there are still more than a few centers using unfractionated heparin. There could be a difference in efficacy and failure rates between the two. This could complicate the statistical analysis. Hopefully, the presenter will address this during the meeting.

I would also like to see a breakdown of when the early VTE prophylaxis actually started. Were they all close to 48 hours? Or were there enough at 24 hours to show this is also safe and effective?

It’s time for everyone to review their VTE prophylaxis guidelines. Get ready to make some major changes in your patients with solid organ injury!

Reference: When is it safe to start VTE prophylaxis after blunt solid organ injury? A prospective AAST multi-institutional trial. AAST 2023, Plenary paper #23.

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