NON-OPERATIVE MANAGEMENT OF ABDOMINAL SOLID ORGAN INJURIES FOLLOWING BLUNT TRAUMA IN ADULTS: RESULTS FROM AN INTERNATIONAL CONSENSUS CONFERENCE

ABSTRACTBackgroundNon-operative management (NOM) for blunt solid organ injuries has become the standard of care for patients who are hemodynamically stable, without other indications for explorative laparotomy. Our aims were to develop evidence-based guidelines to correctly identify the indications for NOM in adult blunt trauma patient, the best and most appropriate modality for follow-up, and the best techniques to manage complications.MethodsThe literature since 2000 to 2016 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and meta-analyses] protocol. Sixty-three articles were reviewed by a panel of experts to assign grade of recommendation (GoR) and level of evidence (LoE) using the GRADE [Grading of recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held.ResultsIn stable patients, without other indications for surgery, NOM is the initial treatment of choice for splenic, hepatic and renal injuries, regardless of grade. NOM is indicated in grade I-II pancreatic trauma, without ductal injury. Contrast enhanced computed tomography is mandatory to correctly plan NOM. Angioembolization has proven to be an effective adjunct in NOM to control bleeding, thereby reducing the need for surgery. Endoscopic Retrograde Cholangio Pancreatography is useful to control biliary and pancreatic complications of NOM.ConclusionNOM is feasible even in high grade parenchymal injuries, but logistic and technical resources must be available 24/7 to safely manage the patients. Background Non-operative management (NOM) for blunt solid organ injuries has become the standard of care for patients who are hemodynamically stable, without other indications for explorative laparotomy. Our aims were to develop evidence-based guidelines to correctly identify the indications for NOM in adult blunt trauma patient, the best and most appropriate modality for follow-up, and the best techniques to manage complications. Methods The literature since 2000 to 2016 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and meta-analyses] protocol. Sixty-three articles were reviewed by a panel of experts to assign grade of recommendation (GoR) and level of evidence (LoE) using the GRADE [Grading of recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. Results In stable patients, without other indications for surgery, NOM is the initial treatment of choice for splenic, hepatic and renal injuries, regardless of grade. NOM is indicated in grade I-II pancreatic trauma, without ductal injury. Contrast enhanced computed tomography is mandatory to correctly plan NOM. Angioembolization has proven to be an effective adjunct in NOM to control bleeding, thereby reducing the need for surgery. Endoscopic Retrograde Cholangio Pancreatography is useful to control biliary and pancreatic complications of NOM. Conclusion NOM is feasible even in high grade parenchymal injuries, but logistic and technical resources must be available 24/7 to safely manage the patients. Corresponding Author/Reprints: Osvaldo Chiara, General Surgery-Trauma Team. Grande Ospedale Metropolitano Niguarda, Piazza Benefattori dell’Ospedale, 320162 Milano, Italy, email: ochiara@yahoo.com, Phone. +39 02 6444 5381, Mobile phone +39 320 4398219, Fax +39 02 6444 7210 DISCLOSURE The author O.C. has had a consultant fee with Acelity Company, San Antonio, TX since October 2016 and has speaker fees with Smith and Nephew during 2017 Centro Studi Libera Orlandi, Acelity, Baxter, ItalFarmaco, Johnson&Johnson and Takeda provided the sponsorship. This study was presented at the International Consensus Conference on Non Operative Management of Solid Organ Injuries on December 12, 2016, in Milan, Italy. © 2017 Lippincott Williams & Wilkins, Inc.

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