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Surgical versus non‐surgical management of abdominal injury

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Abstract

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Background

Injury to the abdomen can be blunt or penetrating. Abdominal injury can damage internal organs such as the liver, spleen, kidneys, and intestine. There are controversies about the best approach to manage abdominal injuries.

Objectives

To assess the effects of surgical and non‐surgical interventions in the management of abdominal trauma.

Search methods

We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (The Cochrane Library 2012, issue 1), MEDLINE, PubMed, EMBASE, ISI Web of Science: Science Citation Index Expanded (SCI‐EXPANDED), and ISI Web of Science: Conference Proceedings Citation Index‐Science (CPCI‐S) all until January 2012; CINAHL until January 2009. We also searched the reference lists of all eligible studies and the trial registers www.controlled‐trials.com and www.clinicaltrials.gov in January 2012.

Selection criteria

Randomised controlled trials of surgical and non surgical interventions among patients with abdominal injury who are haemodynamically stable and with no signs of peritonitis.

Data collection and analysis

Two review authors independently applied the search criteria. One study involving participants with penetrating abdominal injury met the inclusion criteria. Data were extracted by two authors using a standard data extraction form.

Main results

One study including 51 participants with moderate risk of bias was included. Participants were randomised to surgery or an observation protocol. There were no deaths among the participants. Seven participants had complications; 5 (18.5%) in the surgical group and 2 (8.3%) in the non‐surgical group; the difference was not statistically significant (p = 0.42; Fischer's exact). Among the 27 who had surgery six (22.2%) surgeries were negative laparotomies, and 15 (55.6%) were non‐therapeutic.

Authors' conclusions

Based on the findings of one study involving 51 participants, which was at moderate risk of bias, there is no evidence to support the use of surgery over observation for people with abdominal trauma.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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Surgery versus observation for people with abdominal injury

Injury to the abdomen is common and can be blunt from road traffic crashes or falls; or penetrating from gun shots or stabbing. These injuries are usually associated with injury to the abdominal organs such as the liver, spleen, kidneys, intestine and its covering. Massive bleeding or leakage of abdominal content into the abdominal cavity can occur which may threaten a patient's life. Physical examination of patients, though the most accurate method of assessing people, is insufficient to determine the extent of damage. Surgical interventions have the propensity to increase morbidity and cost of care. There are reports that injuries can be missed even when surgery is carried out.

Letting a person naturally heal from their injury (observation) or suggesting hospital bed rest (known as selective non‐operative management (SNOM)) are ways to manage abdominal trauma so long as the patient has no sign of internal bleeding or abdominal infection (peritonitis).

The authors of this review sought to identify every study where people with an abdominal injury were randomised to surgery or observation. The authors searched a variety of medical databases but only identified one study including 51 people. The study was conducted in Finland between 1992 and 1994 and involved people with penetrating abdominal injuries. None of the people in the study died, and there was no difference in the number of people with medical complications between the study groups. People who were observed were in the hospital for fewer days, and the cost of their care was less than those randomised to receive surgery. The review authors considered the study to be at moderate risk of bias since only part of the randomisation process was described and the study protocol was not available to enable full assessment of overall quality. One of the harms mentioned by the study authors was that surgery was performed on some patients who did not actually need it. Unnecessary surgery can potentially subject people to infection and medical error.

Based on the findings of one small study, there is no evidence to support the use of surgery over observation for people with abdominal trauma so long as they show no signs of bleeding or infection.

The authors recommend that future randomised controlled studies clearly report the type of injury, number of damaged organs, extent of damage of internal organs, and complications in the people included.