Stephen A Smith, DSc, PA-C, John L Fletcher, MD, Lorne H Blackbourn, MD. Brooke Army Medical Center – Dept of General Surgery
Objectives. Axial imaging of acutely injured trauma patients is a useful adjunct for diagnosing traumatic injuries. Unstable trauma patients often bypass computed tomography (CT), proceeding directly to the operating room (OR) for life-saving interventions. Following exploratory laparotomy, trauma surgeons frequently obtain CT scans to, putatively, complete the trauma work-up. This practice of post-laparotomy CT (PLCT) is poorly described in the literature and is the subject of this study.
Methods. A retrospective review of all adult trauma patients admitted to our medical center between 2001 and 2016 was performed to identify patients who underwent trauma laparotomy within 90 minutes of arrival without receiving any pre-operative axial imaging. Subjects were then divided into 2 groups based on whether or not they received a PLCT in the 72 hours immediately following their initial laparotomy. Radiology reports for PLCTs were compared with dictated op-notes, pre-op plain films, and pre-operative medical documentation to identify all previously unknown injuries discovered by PLCT imaging. PLCT-identified injuries were then stratified into “clinically relevant” and incidental findings. Findings were considered clinically relevant if they prompted a new specialty consult, procedure, or unplanned return to the OR.
Results. Twenty-five thousand eight-hundred and forty-nine trauma patients were admitted over the study period. Three-hundred and eighty-eight (1.5%) patients met inclusion criteria. Of those, 169 patients (44%) received PLCT (PLCT group). The remaining 219 patients (56%) had no PLCT (No PLCT group). Groups were well matched with respect to age and ethnicity, whereas a slightly larger percentage of males were present in the No CT group. The PLCT group was more severely injured with respect to injury severity score (ISS) 22 (16,34) vs 9 (1,11); p<0.0001. Significant differences were also observed in presenting vital signs, ICU days, and days hospitalized. Patients with blunt trauma were more likely to receive PLCT (78%) than those with penetrating trauma (33%). Sixty-four percent (N=108) of PLCTs performed identified a new diagnosis and 36% (N=60) of all PLCTs resulted in a clinically relevant intervention. Finally, 56% (N=60) of all PLCT-identified occult injuries required a new consult, unplanned procedure or return to the operating room.
Conclusion. Post-laparotomy CT, at our institution, is a useful tool for diagnosing occult injuries not evident after primary, secondary survey, and exploratory laparotomy. Further, PLCT-identified injuries frequently result in meaningful changes to patient care. Further research, ideally a prospective observational trial, evaluating the utility of axial imaging after laparotomy in trauma is needed.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80425
Program Number: MSS17
Presentation Session: Full-Day Military Surgical Symposium – Trauma/Critical Care Presentations
Presentation Type: MSSPodium