The importance of empiric abdominal computed tomography after urgent laparotomy for trauma: Do they reveal unexpected injuries?

• Published in: Surgery Vol. 156; no. 4; pp. 979 - 987
• Main Authors: Weis, Joshua J., BS, Cunningham, Kelly E., MD, Forsythe, Raquel M., MD, Billiar, Timothy R., MD, Peitzman, Andrew B., MD, Sperry, Jason L., MD, MPH
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-10-2014
• Subjects: Abdominal Injuries - diagnostic imaging; Abdominal Injuries - surgery; Adult; Female; Humans; Laparotomy; Logistic Models; Male; Middle Aged; Multiple Trauma - diagnostic imaging; Multiple Trauma - surgery; Postoperative Care - methods; Retrospective Studies; Surgery; Tomography, X-Ray Computed
• DOI: 10.1016/j.surg.2014.06.044
• EISSN: 1532-7361
• ISSN: 0039-6060

Background Many institutions now use empiric full-body computed tomography (CT) as a standard step in the initial workup of stable trauma patients. Recent data suggest that these scans may reveal unexpected injuries and improve survival in patients with polytrauma. However, patients who are unstable on presentation are often taken to the operating room (OR) without CT. Many of these patients undergo empiric full-body CTs after being stabilized in the OR, yet few data exist regarding how often early postoperative CT reveals unexpected injuries within compartments that have been explored surgically. Thus, the objective of this study was to determine if empiric abdominal/pelvic (ABD) CT after emergent trauma laparotomies are likely to reveal missed injuries requiring urgent management and improve patient management compared with clinical judgment alone. Methods We review retrospectively 496 trauma patients who required urgent exploratory laparotomy at UPMC Presbyterian Hospital from 2007 to 2011. Patients were included if they went to the OR for exploratory laparotomy directly from the emergency department within 2 hours of arrival. Patients were excluded if they received any preoperative ABD CT imaging. Patients who expired in the OR were similarly excluded. Patients were stratified into 2 groups based on whether or not they received an empiric ABD CT in the 24 hours immediately after laparotomy. Medical records were reviewed to look for differences in missed injuries, urgent reexplorations, nontherapeutic interventions, and time to urgent reexploration. Results There were 278 patients who met inclusion at exclusion criteria and constituted the study cohort. Of these patients, 124 underwent early empiric postoperative ABD CT imaging (45%). The remaining 154 patients did not undergo early ABD imaging (no CT group). The overall cohort had a 45% incidence of damage control procedures and a 9% rate of negative laparotomy. The 2 groups were statistically similar in age, presenting vitals, and abdominal Abbreviated Injury Scores. When the ABD CT group was compared with the no CT group, there was no difference in the overall rate of urgent reexplorations (7.3 vs 7.1%; P  = .956), nontherapeutic urgent reexplorations (22 vs 18%; P  = .822), or time to urgent reexploration (14 ± 10 vs 12 ± 10 hours; P  = .686). Out of the 124 ABD CT patients, only 5 (4.0%) were diagnosed with injuries that were not identified at the time of the initial operation or caused by operative technique. When controlling for demographics, mechanism of injury, and injury severity, a logistic regression analysis revealed that early postoperative ABD CT was not associated with any differential risk of the need for further intervention (odds ratio, 0.85; 95% CI, 0.37–1.9; P  = .691). Conclusion The use of ABD CT soon after trauma laparotomy did not provide meaningful improvements in patient care in the cohort studied. Further higher level research is needed to clarify what role empiric ABD CT should play in the early postoperative period.