To, The Director, Research& Training Monitoring Cell, College of Physicians & Surgeons Pakistan, 7th Central Street,

Phase-II, D.H.A. KARACHI. Dear Sir, Enclosed herewith please find research protocol titled: Retroperitoneal Organ injuries following blunt trauma abdomen Prepared by Dr. Irfan Ashraf As a prerequisite for FCPS-11 in subject of: General Surgery Was submitted on: RTMC allotted Registration Number: SGR-2008-032-4097 FCPS-I Roll Number was: 42007 Month was March in year 2008 Trainees Signature: Name of Supervisor: Qualification: Designation: Name of Training Institution: __________________________ Dr. Farooq Ahmad MBBS, FCPS Professor of Surgery Department of Surgery Quaid e Azam medical college/ BVH Bahawalpur Department of Surgery

Department:

Yours Sincerely, Supervisors Signature________________ Official Stamp____________

RETROPERITONEAL ORGAN INJURIES FOLLOWING BLUNT TRAUMA ABDOMEN

Dr. Irfan Ashraf MBBS

Dr. Farooq Ahmad MBBS, FCPS Professor of Surgery

Department of Surgery Quaid i Azam Medical College/ BVH Bahawalpur

INTRODUCTION:
Trauma is defined as damage to the body by exchange with environmental energy that is beyond body's resilience.1 Trauma deaths continue to burden society despite the advancement of strategies to affect a decrease. Trauma is the most common cause of death and disability in the age of 12-70 years. 2, 3 Abdomen is among the commonly injured regions of the body due to large surface area.4 The retroperitoneum is that portion of the abdomen posterior to the peritoneal cavity extending from the diaphragm to the pelvic inlet. It is separated from the peritoneum anteriorly by the posterior peritoneal fascia and is bounded posteriorly by the fascia transversalis. It contains portions of the colon and duodenum as well as the pancreas, kidneys, adrenal glands, abdominal aorta, and inferior vena cava (IVC). The retroperitoneum is one of the most challenging areas of the abdomen. Injuries of the retroperitoneal organs occur mainly in patients with polytrauma. Spine and paraspinal muscles provide an effective protection against blunt trauma from behind. Anteriorly the thin peritoneal layer is just a biological border. Therefore injuries of the abdominal and retroperitoneal organs frequently occur together. Direct clinical examinations are limited by the specific anatomical situation; further invasive diagnostic procedures deal mainly with indirect effects of retroperitoneal injuries. Massive hemorrhage with consequent retroperitoneal hematoma is the dominant pathophysiologic event; mortality is high. Retroperitoneal injuries are among the most lethal injuries sustained by trauma patients and the most common modes of injury include automobile accident, fall from height, interpersonal conflicts and animal hits.3 Blunt abdominal and pelvic trauma can cause significant and sometimes lifethreatening injuries to retroperitoneal structures. Retroperitoneal organ injuries are

known to occur in a significant minority of blunt abdominal trauma cases (12% of hemodynamically stable patients evaluated at one center) 5. In our surgical unit, trauma constitutes one of the most common reasons for hospital admission. In a recent study by Macleod 1, kidney was damaged in 20% patients, duodenum injuries occurred in 25% whereas pancreas was injured in 5% cases. Overall mortality rate due to retroperitoneal organ injuries was 17%. Automobile accidents accounted for 69.4% of the victims, the motorcycle 11.7%, and 9.3% were pedestrians. Due to inadequate sample size 4, and retrospective data of local published studies9, a study is proposed to document the pattern of retroperitoneal injuries following blunt trauma abdomen presenting to a tertiary care hospital.

OBJECTIVES: To assess the frequency, mode of injury and grade of retroperitoneal organs (kidney, duodenum and pancreas) injuries following blunt abdominal trauma.

OPERATIONAL DEFINITIONS:

Blunt abdominal injury: Patients presenting with history of injury to the abdomen which has not penetrated the abdominal wall, will be regarded as blunt abdominal injury. This will be assessed in the presence of one or all of the following signs of tenderness, rigidity, and bruising of the abdominal wall following blunt abdominal injury. Mode of injury: It will be recorded on the basis of the clinical history of the patient as Road traffic accident, fall from height and physical assault. Grade of injury: Injuries to retroperitoneal organs will be graded during exploratory laparotomy according to classification devised by Organ Injury Scaling Committee of the American Association for the Surgery of Trauma.1, 4, 9 MATERIAL AND METHODS: STUDY DESIGN: This will be a cross sectional study. STUDY SETTING: Department of Surgery, Bahawal Victoria Hospital Bahawalpur STUDY DURATION: Six months after the approval of synopsis. SAMPLE SIZE: A total of 76 consecutive cases sustaining blunt trauma abdomen. The appropriate sample size for the study is based on the least proportion of mode of injury and frequencies of various retroperitoneal organ injuries mentioned in previous studies, with the consideration that Pancreas is injured in 5%, kidney in 20% and Duodenum in 25% of cases following blunt trauma abdomen.1, 10, 11 SAMPLING TECHNIQUE:

Purposive non-probability sampling SAMPLE SELECTION: Inclusion criteria: Patients of both gender and age above 12 and below 70 presenting with history of blunt trauma abdomen and undergoing exploratory laparotomy will be included in the study. The diagnosis of blunt abdominal trauma will be made on the basis of presence of tenderness, rigidity, and bruise on the abdominal wall. Exclusion criteria: Patients managed non-operatively will be excluded from the study. Patients suffering any kind of penetrating abdominal injury will also be excluded. Moribund patients who are ASA-5 will also be excluded from the study.

DATA COLLECTION: All the patients admitted to Department of Surgery with history of blunt trauma abdomen fulfilling the inclusion criteria will be entered in the study after informed written consent. Case sheets of the admitted patients will be screened for various variables such as: age and sex of the patients, mode of the blunt abdominal injury and operative findings. Intra-abdominal injuries involving the Kidney, duodenum and pancreas will be noted on a pre-designed Proforma (Annexure) attached during the operative procedure. The scale devised by the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma1, 3, 4, 9 will be used to grade injuries to various organs. Grading of injuries will be verified by attending consultant.

DATA ANALYSIS:

The data will be analyzed by computer software SPSS version 10. Descriptive statistical tests will be performed. Mean and standard deviation for age will be calculated. The qualitative data like gender, mode of injury and grade of injury of individual retroperitoneal organs (Duodenum, Pancreas, and Kidney) will be labeled as frequency distribution table.

REFERENCES:
1. Macleod JBA, Cohn SM, Johnson EW, McKinney MG. Trauma deaths in the first hour: are they all unsalvageable injuries? Am J Surg. 2007;193:195-9.

2. Bhan C, Forshaw MJ, Bew DP, Kapadia YK. Diagnostic peritoneal lavage and ultrasonography for blunt abdominal trauma: attitudes and training of current general surgical trainees. Eur J Emerg Med. 2007;14:212-5. 3. Kuncir EJ, Velmahos GC. Diagnostic peritoneal aspiration--the foster child of DPL: a prospective observational study. Int J Surg. 2007;5:167-71. 4. Khan JS, Iqbal N, Gardezi JR. Pattern of visceral injuries following blunt abdominal trauma in motor vehicular accidents. J Coll Physicians Surg Pak. 2006;16:645-7. 5. Zaydfudim V, Cotton BA, Kim BD. Pancreatic transection after a sports injury. J Trauma. 2010;69:E33. 6. Sica G, Bocchini G, Guida F, Tanga M, Guaglione M, Scaglione M. Multidetector computed tomography in the diagnosis and management of renal trauma. Radiol Med. 2010;115:936-49. 7. Ahmed N, Vernick JJ. Pancreatic injury. South Med J. 2009;102:1253-6. 8. Terreros A, Zimmerman S. Duodenal hematoma from a fall down the stairs. J Trauma Nurs. 2009;16:166-8. 9. Mirza B, Ijaz L, Iqbal S, Sheikh A. Partial avulsion of common bile duct and duodenal perforation in a blunt abdominal trauma. APSP J Case Rep. 2010;1:19. 10. Celik A, Altinli E, Onur E, Sumer A, Koksal N. Isolated duodenal rupture due to blunt abdominal trauma. IJC CM Case Rep.2006;10:44-6 11. Bhattacharjee HK, Misra MC, Kumar S, Bansal VK. Duodenal perforation following blunt abdominal trauma. J Emerg Trauma Shock. 2011;4(4):514517.

Annexure

PROFORMA
Name:.. S/O, W/O:.

Age/Sex:../. Date of admission:.. Presenting complaints: Mode of injury Road traffic accident Fall from height Physical assault

Registration No:...

Address:

OPERATIVE FINDINGS: ORGAN INJURED 1. Pancreas 2. Duodenum 3. Kidney GRADE

SIGNATURE OF DOCTOR