BLUNT SMALL BOWEL PERFORATION (SBP): A MULTICENTER UPDATE 15 YEARS LATER

Background Previous work demonstrated diagnostic delays in blunt small bowel perforation (SBP) with increased mortality and inability of CT scans to reliably exclude the diagnosis. We conducted a follow-up multicenter study to determine if these challenges persist 15 years later. Methods We selected adult cases with blunt injury, ICD-9 or CPT indicating small bowel surgery, no other major injury and at least one abdominal CT within initial 6 hours. Controls had blunt trauma with abdominal CT but not SBP. After IRB approval, data from each center were collected and analyzed. Results Data from 39 centers (10/2013 - 9/2015) showed 127,919 trauma admissions, 94,743 activations. 25 centers were Level 1. Centers submitted 77 cases (mean age 39, 68% male, mean LOS 11.3) and 131 controls (mean age 44, 64.9% male, LOS 3.6). SBP cases were 0.06% of admissions and 0.08% of activations. Mean time to surgery was 8.7 hours (median 3.7). Initial CT showed free air in 31 cases (43%) and none in controls. Initial CT was within normal in 3 cases (4.2%) and 84 controls (64%). 5 cases had a second scan; two showed free air (one had an initial normal scan). One death occurred among cases (mortality 1.4%, time to surgery 16.9 hours). Regression analysis showed gender, abdominal tenderness, distention, peritonitis, bowel wall thickening, free fluid and contrast extravasation were significantly associated with SBP. Conclusions Blunt SBP remains relatively uncommon and continues to present a diagnostic challenge. Trauma centers have shortened time to surgery with decreased case mortality. Initial CT scans continue to miss a small number of cases with potentially serious consequences. We recommend (1) intraperitoneal abnormalities on CT scan should always evoke high suspicion and (2) strong consideration of additional diagnostic/therapeutic intervention by 8 hours after arrival in patients who continue to pose a clinical challenge. STUDY TYPE Observational study LEVEL OF EVIDENCE III Corresponding author: Samir M. Fakhry, MD FACS, Synergy Surgicalists, Department of Surgery, Reston Hospital Center, 1850 Town Center Drive, Suite 309, Reston, VA 20190, Phone: 703-429-1472, Fax: 541-665-5114, samfak7@gmail.com No financial support was provided for this study. All authors declare no financial conflicts of interest. This work was presented at the 77th annual meeting of the American Association for the Surgery of Trauma and 4th World Trauma Congress, September 29, 2018 in San Diego, CA. © 2019 Lippincott Williams & Wilkins, Inc.

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