Role of Conservative Management in Stab Penetrating Trauma to the Anterior Abdomen

Role of Conservative Management in Stab Penetrating Trauma to the Anterior Abdomen

Maher M Elzeiny, MD; Mohamed I Kassem, MD.

Department of Surgery, Gastrointestinal Surgery Unit, Faculty of medicine, Alexandria University, Egypt

Background/Purpose: Abdominal trauma is one of the major causes of death in trauma patients; abdominal trauma is the second leading cause of trauma deaths. This study was designed to evaluate the role of conservative management for selected cases of vitally stable patients who presented with stab penetrating trauma to the anterior abdomen with no evidence of peritonitis; hence avoiding unnecessary laparotomies aiming at reducing the hospital stay time and reducing morbidity and mortality.

Patients and methods: This prospective study was carried on 56 patients from May 2013 to October 2014. The work was done in the Emergency unit of the Alexandria Main University Hospital with stab penetrating trauma to the anterior abdomen.  Patients were selected for "selective non operative management SNOM."

Results: 44 patients were males (78.57%) and 12 patients were females (21.42%). 24 patients (42.85%) were less than 30 years, 22 patients (39.28%) from 30-45 years and 10 patients (17.85%) more than 45 years. The age ranged from 18 to 60 years with mean age of 33.3. Sixteen cases (28.5%) had suspicious abdominal examination after admission. On exploration 11 cases were positive and 5 cases were negative. 34 cases (60.7%) had free abdominal examination on admission, 26 cases were managed conservatively without complications, and hence they were saved unnecessary laparotomy while 8 cases were explored for other causes.

Conclusions: SNOM for abdominal stab wounds is no longer a novelty; its practice is now standard in most trauma centers. Vitally unstable cases with suspected internal haemorrhage should be immediately transferred to do exploratory laparotomy. It was concluded that SNOM of abdominal stab wounds is safe and preferred strategy for minimizing the days in hospital, hospital costs, as well as avoiding unnecessary laparotomies.

Key words: Stab wounds, Selective non operative management, Evisceration, Anterior abdomen.

Abbreviations: SNOM: Selective non operative management, FAST: Focused abdominal sonography for trauma

Introduction:

Abdominal  trauma  accounts  for  8-10% of all trauma admissions to trauma centers; when  unrecognized,  abdominal  trauma  is one of the major causes of death in trauma patients. Abdominal trauma is the second leading cause of (preventable) trauma deaths. Increased incidences of deaths are secondary to hemorrhage and delay in receiving surgical intervention.1

Penetrating  abdominal  trauma  can  be

life  threatening  because  abdominal  organs, especially those in the retroperitoneal space, can bleed profusely, and the space can hold a great deal of blood. If the pancreas is injured, it may be further injured by its own secretions, in a process called autodigestion. Injuries of the liver are common because of the size and location of the organ, present a serious risk for shock because the liver tissue is delicate and have a large blood supply and capacity. The intestines, taking a large part of the lower

abdomen, are also at risk of perforation.2,3,4

Stab and gunshot wounds account for most patient presentations of penetrating abdominal trauma, Stab wounds are encountered three times more often than gunshot wounds, but have  a  lower  mortality  because  of  their lower velocity and less invasive tract. As a result of their greater force and extensive missile  tract,  gunshot  wounds  account  for up to 90% of the mortality associated with penetrating abdominal trauma. Injury to the bowel (small, then large) is most often found, followed by hepatic injury, regardless of type of penetrating injury.4 Stab wounds produce peritoneal violation in up to 70% of instances, but of these only one fourth to one third will require operative intervention. Stab wounds are classified in thirds. One third does not penetrate the peritoneal cavity, one third penetrates but do not damage and one third penetrate causing significant injury.4,5

There are a large number of patients with penetrating abdominal trauma who have normal vital signs and negative abdominal examination when referred to trauma centers. A great deal of controversy exists between authorities about screening these patients for emergency laparotomy.Although the presence of classic indications such as shock, visceral evisceration and peritoneal irritation suggests laparotomy after penetrating abdominal stab wounds,  the  trend  has  moved  in  the  past two decades from mandatory exploration to selective approach.1–6  Even in the presence of peritoneal violation, a significant number of patients have no major intra-abdominal injury requiring an operation.6 Mandatory laparotomy for penetrating abdominal stab wounds   leads   to   unnecessary   operations in 38–40% of patients, and postoperative morbidity ranges from 3% to 16%.7,8

Many authors stressed that omental, intestinal evisceration, air under the diaphragm and blood on abdominal paracentesis; none of these signs were an absolute criterion for mandatory  exploration  and  that  Selective Non Operative Management (SNOM) could be offered, even if with a heightened index of suspicion for injury and lowered threshold for an operation.9

It was concluded9,10 that in the appropriate environment, SNOM of penetrating abdominal solid organ injuries has a high success  rate  and  a  low  complication  rate. The   appropriate   environment   constituted a trauma center with a dedicated in-house team that could monitor and serially examine the  patient  during  the  observation  period. In  a  prospective  randomized  study11  with stab wounds to the anterior abdomen; were assigned to nonoperative management.

This study was designed to evaluate the role of conservative management for selected cases of vitally stable patients presented with penetrating trauma to the anterior abdomen with no evidence of peritonitis; hence avoiding unnecessary laparotomies aiming at reducing the hospital stay time and reducing morbidity and mortality.

Patients:

This work was conducted on 56 patients who were presented to the emergency unit of the Alexandria Main University Hospital with penetrating trauma to the anterior abdomen from May 2013 to October 2014. Patients were selected for SNOM according to the following criteria:

Inclusion criteria:

•   Patients  presenting  with  stab penetrating wounds to the anterior abdomen.

•       Positive  findings  on  local  wound

exploration (peritoneal violation).

Exclusion criteria:

•      Vital instability on admission of the patient.

•      Signs of peritonitis on admission of the patient.

After approval of local ethics committee, all patients included in the study were informed well about the management plan, possible benefits and side effects, and had an informed written consent.

Methods:

All patients in the present study were subjected to the following in order:

- Complete history taking; stressed on the mode of trauma, weapon used, time lapse

Figure (1): FAST can be a rapid method to identify intraperitoneal heamorrage.

Figure (2): A 23 years old male patient presented to our ER ward by omentum evisceration at the umbilical region of anterior abdomen following stab wound.

Figure (3): A 28 years old patient presented to our ER ward by evisceration of omentum at the left iliac fossa of anterior abdomen following a stab wound.

Figure (4): A 50 years old patient presented to our ER ward by 2 stab wounds showing evisceration of small bowel loops at the epigastric region of anterior abdomen.

Table 1: The relation between vital stability and laparotomy on admission.

Table 2: The relation between findings of abdominal examination and the need for laparotomy.

Table 3. U/S categories of free I. P. Collection and significant laparotomy.

I.P. Collection = intraperitoneal collection (equivalent to McKenney scores).

between the trauma and hospital admission.

- Thorough serial physical examination

at admission including:

- Clinical :

 - Vital signs :

  - Arterial blood pressure, pulse.

  - Temperature:  Basal  temperature

of the patient was recorded.

 - Local abdominal examination :

  - Complete abdominal examination; stressed on signs of peritonitis (hyperaesthesia of the skin, superficial tenderness, rebound tenderness and board like rigidity).

Patients who would not undergo laparotomy on the basis of the previous measures were subjected to the following:

- Lab. :

 - Complete blood count: Rise of white

blood count indicated peritonitis whereas fall

of  heamoglobin  or  heamatocrit  indicated ongoing process of bleeding.

- Imaging:

 - Ultrasonography of the abdomen; Focused Abdominal Sonography for Trauma (FAST). To confidently exclude significant intraperitoneal  injury  in  patients  with negative FAST scan findings and for patients with positive FAST findings additional investigations were required (Fig. 1).

 - According to the protocols applied by Diagnostic Radiology department of Alexandria Main University Hospital ; the results of FAST was categorized into 4 main categories :

- Free    (no    free   intraperitoneal    fluid

collection).

- Minimal     collection    (equivalent     to

McKenney score 1)

- Mild      collection.      (equivalent      to

McKenney score 2)

- Moderate collection. (equivalent to McKenney score 3) {This correlation was applied in 2004 in a thesis submitted to the radiology department, Alexandria University, McKenney et al12,13 evaluated a scoring system that measured the depth of fluid in the deepest pocket, and 1 point was added for fluid in each of the other areas (four areas maximum)}.

 - CT scan: ( plain cuts in cases with negative FAST findings and with IV contrast in cases with positive FAST to identify the source of bleeding):

  - Evidence  of  pneumoperitoneum

was considered as an indication of laparotomy.

  - Evident solid organ injury, (liver or spleen), with active contrast extravasation was an indication of laparotomy.

- Local wound exploration :

 - Local wound exploration was done

under local anaesthesia.

 - If omentum was protruding through the wound, it was returned into the peritoneal cavity.

 - Evisceration of organs - other than omentum - was considered an indication for immediate laparotomy.

Patients who would not undergo laparotomy on the basis of the previous measures were selected for "selective non operative management SNOM" and were subjected to the following:

Thorough   serial    physical    examination

every 4 hours for the first 24 hours; then every

6 hours for the next 24 hours; including vital signs and abdominal examination.

Follow up:

Patients who were managed conservatively were followed up for 3 months after discharge by clinical re-evaluation and ultrasonography and multislice CT abdomen and pelvis if needed.

Results:

Age and gender: 44 patients were males (78.57%) where 12 patients were females (21.42%).  24  patients  (42.85%)  were  less

than 30 years, 22 patients (39.28%) from 30-

45 years and 10 patients (17.85%) more than

45 years. The age ranged from 18 to 60 years with mean age of 33.3.

Mode of trauma: The fifty six patients presented by stab wounds (4 of them had 2 stab wounds).

Site of trauma: Eighteen patients (30%) were stabbed in the epigastrium, 6 patients (10%) in the umbilical region, 5 patients (8.9%)   in   the   right   hypochondrium,   6 patients  (10%)  in  the  left  hypochondrium,

7 patients (11.67%) in the left lumbar, 2 patients (33.34%) in the right lumbar region,

6 patients (10.7%) in the right iliac fossa and

6 patients (10%) in the left iliac fossa. Nine cases  (18.34%)  presented  by  evisceration

{7 (11.67%) cases presented with omentum evisceration, 1 (1.7%) case presented with evisceration of the small intestine and the last case (1.7%) presented by colon evisceration} Figures (2, 3,4).

On admission: Out of 56 patients, 6 patients (10.7%) were vitally unstable with suspected internal haemorrhage after about 4 hours from admission during close follow up period. They were immediately transferred to do exploratory laparotomy. The six explorations were positive Table (1).

- One of these cases was injured by two stab  wounds  in  the  right  hypochondrium and umbilical region, exploration revealed injury to the stomach, Duodenum (11st part), transverse colon and small intestine.

- In the other 5 cases: The small intestine was injured in 2 cases but the colon, liver and spleen each injured in 1 case.

Therefore according to our results, vital instability was a good indicator to the actual need for laparotomy, whereas vital stability did not exclude the need for laparotomy.

The remaining 50 patients (89.28%) were evaluated using 3 main tools:

-Abdominal examination.

- Ultrasonography.

- CT scan.

Abdominal examination: Table (2)

In this study abdominal examination was considered as an indication for laparotomy regardless of other investigations:

- 16 cases (28.5%) had suspicious abdominal examination after admission during close follow up (within 24 hours from admission), on exploration 11 cases (19.6%) were positive and 5 cases (8.33%) were negative.

- 34 cases (60. 71%) had free abdominal examination  on  admission,  26  cases (46.42%) of them passed conservative without complications, hence were saved from unnecessary laparotomy while 8 cases (14.28%) were explored for other causes:

● 4 cases had –ve explorations:

 • 3 cases had delayed explorations; 24 hours after admission due to vital instability and increase in the free intraperitoneal collection by U/S, the source of bleeding was parietal from the anterior abdominal wall muscles.

 •   One   case   was   explored   due   to

pneumoperitoneum on CT scan.

● 4 cases had +ve explorations:

 • 2 cases were explored due to active contrast extravasations on the basis of CT scan, one case from the liver (required surgical repair), the other case from the spleen (required splenectomy).

 • 2 cases were explored; 36 hours after admission due to vital instability and increase in the free intraperitoneal collection by U/S, small intestinal perforations were found with bleeding from the mesentery.

Hence abdominal examination could detect the need for laparotomy with the following sensitivity and specificity:

- Sensitivity: 76.9%.

- Specificity: 81.8%.

Ultrasonography:

50 cases were evaluated using U/S as 6 cases were vitally unstable and were explored without any further investigations Table (3).

The table showed that only patients with major free intraperitoneal collection could be operated without further investigations.

CT scan:

46 patients were evaluated using multislice CT abdomen and pelvis (for detection of solid organ injury, collection, pneumoperitoneum,

and follow up) were:

6 cases (10%) had free intraperitoneal air in CT scan (pneumoperitoneum):

- 5 cases had +ve explorations.

- 1 case had –ve exploration.

This study concluded that free intraperitoneal air in CT plus suspicious abdominal examination necessitated laparotomy.

● 2 cases (3.33%) were explored on CT

basis due active contrast extravasation.

Evisceration:

● 7 cases (11.67%) presented with omentum evisceration and none had pneumoperitoneum  on  CT  basis.  4  cases were explored on the basis of suspicious abdominal examination:

- 3 cases showed –ve explorations.

- 1 case showed splenic laceration that required laparotomy.

● 2 cases presented with evisceration of the intestine (1 small intestine and the other was the colon). Both showed perforation on explorations.

Selective Conservative Management:

34 cases (60.71%) were selected for conservative management. 26 cases (46.42%) of them passed conservative without complications, so saved from unnecessary laparotomy.

Only 8 cases out of 34 needed delayed

laparotomy was done:

- 3 cases had bleeding from the anterior abdominal wall muscles.

-    One    case    was    explored    due    to

pneumoperitoneum on CT scan.

- 2 cases were explored due to active contrast extravasations on the basis of CT scan, one case from the liver, the other case from the spleen.

- 2 cases were explored due to vital instability and increase in the free intraperitoneal collection from small intestinal perforation and bleeding from the mesentery.

Discussion:

Leppaniemi et al14 conducted a retrospective analysis of hospital records of

wounds over 4 years, 175 cases were males,

34 females, and mean age 36 years. Lee et al15 conducted a retrospective study by reviewing the medical records of 219 patients with stab wounds  to  the  anterior  abdomen  over  the period of 10 years, the age ranged from 9 years to 64 years, mean age 26.6 years. 89.5

% of the cases were males, and only 10.5%

were females.

This present study was conducted over one and half years on patients with penetrating wounds to the anterior abdominal wall, out of

56 patients, 44 patients were males (78.57%) where  12  patients  were  females  (21.42%). The age ranged from 18 to 60 years with mean age of 33.3. The fifty six patients presented by stab wounds (4 of them had 2 stab wounds).

Certain studies14–16 stated that unexplained

shock is highly accurate as an indicator of intra-abdominal injury and the presence of shock was a mandatory indication for early exploration;  and  this  is  conformed  to  the present study. On the contrary, other studies9 denied shock at admission as an indication for         early    exploration    and    conservative management    was      successfully     offered without complications and with no mortality.

Results  obtained  by  Demetriades  et  al9

were  more  accurate;  311  cases  had  had

normal abdominal findings on examination;

302 cases proved not to have intra-abdominal injuries requiring exploration, only 9 cases needed therapeutic laparotomies; 340 cases had suspicious abdominal examination; 329 cases needed therapeutic laparotomies, while

11 cases proved not to have intra-abdominal injuries  requiring  exploration  (sensitivity:

97.3%, specificity: 96.4%).

Leppaniemi et al14 conducted a study which confirmed that early laparotomy based on signs of generalized peritonitis associated with a relatively low risk of a negative operation.  Out  of  36  patients  presented with generalized abdominal tenderness on admission only seven patients had no intra- abdominal injuries requiring surgical repair. Out  of  57  patients  with  a  gastrointestinal tract perforation, 9 underwent immediate laparotomy  for  haemodynamic  instability,

whereas 14 patients showed no initial signs of generalized tenderness or other positive findings. In a study conducted by McKinney et al,12,13 85% of patients with a score ≥3 required a therapeutic laparotomy, whereas

15% of patients with a score of <2 required surgery.  Boulanger  BR  et  al17  stated  that the routine use of sonography in penetrating torso  injury  was  beneficial. The  detection of peritoneal fluid was clinically useful. However,   a   negative   FAST  examination did not exclude abdominal injury, such as a diaphragm or hollow viscus wound, and further investigation or close follow-up was required. The results in the literatures17–20 conformed to the results in our study.

Munera  F  et  al21   stated  that  in  stable

patients  with  gunshot  wounds  to  the abdomen in whom there was no indication for immediate surgery, triple-contrast helical CT could help reduce the number of cases of unnecessary or nontherapeutic laparotomy (negative  laparotomy)  and  could  help identify patients with injuries that might be safely treated without surgery. Chiu WC et al22 reported that CT accurately predicted whether laparotomy was needed in 71/75 (95%) patients. In patients with negative CT,

47/49 (96%) had successful nonoperative management and 1 had negative laparotomy. The  single  CT-missed  peritoneal  violation had a left diaphragm injury at laparotomy.

In the present study, CT scan was used as a useful tool of diagnosing solid organ injuries   and   hollow   viscus   perforations namely  the  stomach,  but  showed  no  role for diagnosis of small intestinal perforation. "Pneumoperitoneum" by CT scan was considered as an absolute indication of laparotomy.

Organ evisceration was mostly accepted as an indication for emergency laparotomy. The need for surgical intervention reached a rate of 70%-80% in cases with penetrating abdominal stab injuries with organ evisceration.23–28 While 2 out of 3 patients with organ evisceration requiring surgical intervention  had  an  intra-abdominal  injury,

1 had no such injury. Omental evisceration,

on  the  other  hand,  was  not  an  indication for routine laparotomy.9,24,25 The omentum was irrigated, cleaned, and reduced to the abdominal cavity. Risk of intra-abdominal injury was higher in such patients compared to those with no evisceration. Laparotomy was therapeutic in 9 of 12 (75%) when performed for a penetrating abdominal stab injury without evisceration, while laparotomy was therapeutic in 12 out of 13 patients (92%) undergoing laparotomy for evisceration.26

The policy of mandatory laparotomy led to many negative laparotomies. In some series up to 53%.29 Although some authors reported no mortality in the negative laparotomy but others could not achieve this results (Mayards found 6.3% mortality rate,30 a negative laparotomy performed as an emergency without any patient preparation, poor anesthetics facilities; untrained anesthetists posed a significant risk. Most patients had full stomach and were prone to aspiration during induction of anesthesia. Nance et al16 stated that the policy of selective observation for 393 stab wounds has reduced the percentage of negative explorations from 53% to 11% and reduced the percentage of patients subjected to exploration from 95% to 45%.

Conclusion and recommendations:

1-    Vitally unstable cases with suspected internal haemorrhage should immediately transferred to do exploratory laparotomy without any further investigations.

2-   Local   abdominal   examination   is the most reliable method for detection of significant intra-abdominal injuries requiring laparotomy and should never be replaced by medical imaging namely US and CT.

3-    Serial clinical evaluation is essential for abdominal stab wound management. Close monitoring and follow-up are mandatory in patients managed non-operatively. Repeated clinical examination - by preferably the same physician - over the 12–24 hours following arrival to the hospital is necessary.

4-  Only patients who have massive internal    hemorrhage    detected    by    US can undergo laparotomy without further investigations.

5-    CT scan can accurately detect internal hemorrhage and significant solid organ injuries requiring laparotomy but caution must still be maintained in diagnosing individual hollow viscus injuries by CT.

6-  Evisceration of omentum following abdominal stab wounds should not be an absolute indication for early laparotomy while evisceration of colon or small intestine should be an indication for early laparotomy without further investigations.

7-  It was concluded that SNOM of abdominal stab wounds, although resulting in delayed laparotomy in some patients, is safe and the preferred strategy for minimizing; the days in the hospital, hospital costs as well as avoiding unnecessary laparotomies.

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