Can we omit surgery in patients with isolated free fluid following blunt abdominal injury? A systematic review and meta-analysis

Abstract

Background: Management of isolated free fluid following blunt abdominal injury in hemodynamically stable patients is still controversial with respect to nonoperative management (NOM) versus immediate laparotomy. This meta-analysis was performed to identify significant intra-abdominal injuries that require therapeutic laparotomy, thus helping in decision-making during initial management. Method: We systematically reviewed the PubMed and SCOPUS databases from 2000 to 2020. The primary outcome of interest was identification of significant intra-abdominal injuries requiring therapeutic laparotomy. We performed the meta-analysis using a random-effects model. Results: Eight studies involving 7763 patients were evaluated. Isolated free fluid was present in 722 (9.3%) patients. Their median age was 35.82 years, and their average Injury Severity Score was 17.1. The major mechanism of injury was motor vehicle accidents (31.2%). Of 722 patients, 490 underwent initial NOM and 232 underwent immediate laparotomy. The success rate of initial NOM was 98% [95% confidence interval (CI), 0.959–1.002]. The failure rate of initial NOM was 7.4% (95% CI, 0.023–0.126). Significant intra-abdominal injuries were identified in 39.2% of patients (95% CI, 0.127–0.657). Most of the significant intra-abdominal organ injuries were mesenteric injury in 23% of patients (95% CI, −0.004–0.463) and bowel injury in 18.4% (95% CI, 0.098–0.271). A moderate to large amount of fluid on computed tomography and abdominal tenderness were associated with laparotomy (p = 0.000 and 0.040, respectively), but neither was a significant risk factor for therapeutic laparotomy or significant intra-abdominal injury. Conclusions: Isolated free fluid following blunt abdominal injury in hemodynamically stable patients does not mandate immediate or delayed laparotomy. Initial NOM can be considered with hemodynamic monitoring of early warning signs of sepsis (e.g., using the Quick Sequential Organ Failure Assessment), and serial abdominal examination might help to detect significant intra-abdominal injury requiring therapeutic laparotomy. In patients suspected to have injury after initial NOM and in patients who cannot cooperate, diagnostic laparoscopy will play an important role in minimally invasive diagnosis.