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Mansor S, Ziu N, Bujazia A, Eltarhoni A, Alsharif J. Effectiveness of clinical examination and radiological investigations in the success of selective non-operative management of abdominal gunshot injuries. Turk J Surg 2024; 40:303-311. [PMID: 39980639 PMCID: PMC11831997 DOI: 10.47717/turkjsurg.2024.6597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2024] [Accepted: 11/27/2024] [Indexed: 02/22/2025]
Abstract
Objectives Non-operative management of abdominal gunshot injuries has become the standard care in the selected cases of modern surgery with an acceptable success rate to reduce the incidence of unnecessary laparotomies. In this study, an assessment was conducted to determine how the success of this form of management was impacted by physical examination and radiological investigation. Material and Methods This is a retrospective study that includes all consecutive penetrating abdominal gunshot wound patients who were admitted to the emergency department between February 2011 and December 2018. All patients with superficial gunshot wounds were excluded. The decision to perform a laparotomy on injured patients was the study's primary endpoint while the discharge of patients without surgery was its secondary endpoint. Results Of 429 torso gunshot wound patients, 411 were males. Average age was 29.5 years. Forty-one (9.5%) were initially treated by selective nonoperative management. Five selective non-operative management patients underwent delayed laparotomy within 12 hours after admission without complication. In the end, 36 (88%) of the 41 patients were successfully treated without undergoing surgery, with only one patient developing pleural effusion and no mortality attributed to it. Of all injured patients, 45 (10.5%) patients had a negative laparotomy, with two of them subsequently developing an incisional hernia. Conclusion The success rate of non-operative management of torso gunshot injuries can be increased significantly in stable patients by adopting the strategy of repeated physical examinations alone or in conjunction with simultaneous radiological imaging.
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Affiliation(s)
- Salah Mansor
- Al-Jalaa Teaching Hospital, Department of General Surgery, Benghazi University Faculty of Medicine, Benghazi, Libya
- Department of Surgery, Libyan International Medical University, Benghazi, Libya
| | - Naman Ziu
- Al-Jalaa Teaching Hospital, Department of General Surgery, Benghazi University Faculty of Medicine, Benghazi, Libya
| | - Ayoub Bujazia
- Benghazi Medical Center, Department of Diagnostic Radiology, Benghazi University Faculty of Medicine, Benghazi, Libya
| | - Ahmed Eltarhoni
- Department of Family and Community Medicine, Benghazi University Faculty of Medicine, Benghazi, Libya
| | - Jamal Alsharif
- Ajdabiya Teaching Hospital, Department of General Surgery, Ajdabiya University Faculty of Medicine, Ajdabiya, Libya
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Akgul NC, Erbil OA, Celik Y. Penetrating abdominal stab and gunshot injuries: 10-year experience of a secondary public hospital located in a suburban area with solo surgeons. North Clin Istanb 2024; 11:184-190. [PMID: 39005745 PMCID: PMC11237836 DOI: 10.14744/nci.2023.32858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/14/2023] [Accepted: 08/05/2023] [Indexed: 07/16/2024] Open
Abstract
OBJECTIVE Trauma care systems are life-saving significant implementations of a country's healthcare systems. Trauma care requires well-established trauma settings and organizations with experienced trauma teams including experienced emergency medicine, surgery and anesthesiology staff. This study aimed to investigate the outcomes of penetrating abdominal injuries treated by solo surgeons in a suburban area. METHODS Medical records of the patients who were admitted to the emergency department with penetrating abdominal injuries between January 2012 and December 2021 were retrospectively analyzed. Patients were evaluated based on their injury sites and treatment approaches. RESULTS In total, 110 patients with anterior abdominal penetrating injuries were enrolled in the study; 83 (75.4%) were stabbed and 27 (24.6%) had gunshot wounds. According to the injury site, there were 90 (81.8%) anterior; 11 (11%) right thoracoabdominal and 9 (7.2%) left thoracoabdominal injuries. Fifty-one (61.4%) stab wounds were treated with immediate laparotomy and 21 (41.1%) of these operations resulted in negative or nontherapeutic laparotomy. Also, 32 (38.6%) stab wounds were managed nonoperatively; three (9.3%) failed conservative management and received delayed laparotomy. All gunshot wounds were treated with immediate laparotomy and 14.8% resulted in either negative or nontherapeutic laparotomy. On-call surgeons were found to be more prone to perform immediate laparotomy on weekends when they were on call for 48 or 72 hours. CONCLUSION Being a solo surgeon may increase negative laparotomy rates of penetrating abdominal injuries. This high percentage (41.1%) of negative laparotomy rates can be reduced by establishing well-organized trauma teams.
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3
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Obadiel YA, Albrashi A, Allahabi N, Sharafaddeen M, Ahmed F. Outcomes of Nonoperative Management of Penetrating Abdominal Trauma Injury: A Retrospective Study. Cureus 2024; 16:e58599. [PMID: 38765339 PMCID: PMC11102771 DOI: 10.7759/cureus.58599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND The treatment of penetrating abdominal injuries has changed in recent years with more focus on "nonoperative management" (NOM) to avoid unnecessary laparotomies while identifying injuries early. Although the NOM approach is widely used for stab wounds, its effectiveness in managing abdominal gunshot wounds is controversial. NOM of penetrating abdominal injuries is becoming more dependent on hemodynamic stability and improved noninvasive radiological interventions. The role of NOM is significantly underreported and underestimated in developing countries, particularly in fragile and conflict-affected states such as Yemen. The present study aims to evaluate the clinical outcomes of NOM in penetrating abdominal trauma injury patients and identify factors associated with NOM failure in a low-resource setting. METHODS A retrospective study from January 2021 to December 2022 including patients diagnosed with penetrating abdominal trauma at the General Military Hospital, Sana'a, Yemen, was conducted. Hemodynamically stable patients without peritonitis or clear indications for immediate laparotomy were candidates for NOM and were included in the study. Patients with blunt abdominal injuries, penetrating wounds outside the abdomen, particularly head injury, eviscerated structures, and gastrointestinal hemorrhage, or those pronounced dead on arrival were excluded. The primary outcome was the success and failure rate of NOM necessitating laparotomy. The secondary outcome was the factors associated with NOM failure. RESULTS During the study, 256 patients with penetrating abdominal injury were admitted, with 222 (86.7%) undergoing immediate laparotomy and 34 (13.3%) treated with NOM. The mean age was 27.6±7.4 years. Bump explosions, mostly sharp objects (secondary blast injuries), were the main causes of injury (n=18, 52.9%). Other causes were low-velocity gunshot wounds, stab wound injuries, and shotgun injuries in 14 (41.2%), one (2.9%), and one (2.9%), respectively. The majority of patients (n=25, 55.9%) were admitted within 6-24 hours of the incident. The abdominal computed tomography (CT) scan revealed various injuries in all patients, including hemoperitoneum in 11 (32.4%), pneumoperitoneum in five (14.7%), liver injury in 15 (44.1%), foreign body attached to the wall colon in 23 (67.6%), kidney injury in two (5.9%), and splenic injury in one (2.9%). NOM was successful in 31 (91.2%) patients. NOM failed in three (8.8%). One patient was treated via the laparoscopic procedure, and two patients were treated with laparotomy procedures. Five (14.7%) cases required intensive care unit (ICU) admission, with no deaths or major complications. In univariate analysis, the presence of free intra-abdominal fluid (pneumoperitoneum) on the initial CT scan and the need for ICU admission were associated with NOM failure and were statistically significant (p<0.05). CONCLUSION Our findings support that some penetrating abdominal trauma patients can benefit from NOM. The goal of preventing unnecessary laparotomies should be aligned with a comprehensive comprehension of the clinical signs and symptoms of NOM failure and the necessity for surgical intervention. Serial abdominal examinations remain the foundation of selected NOM; nevertheless, radiological and laboratory tests can be important tools in decision-making. In this study, free intra-abdominal fluid on the initial CT scan and the need for ICU admission were associated with NOM failure.
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Affiliation(s)
- Yasser A Obadiel
- General Surgery, Al-Thawra Modern General Hospital, Sana'a University, Sana'a, YEM
| | - Ali Albrashi
- Surgery, Faculty of Medicine, 21 September University, Sana'a, YEM
| | - Noman Allahabi
- Surgery, Faculty of Medicine, 21 September University, Sana'a, YEM
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4
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Clements TW, Ball CG, Nicol AJ, Edu S, Kirkpatrick AW, Navsaria P. Penetrating renal injuries: an observational study of non-operative management and the impact of opening Gerota's fascia. World J Emerg Surg 2022; 17:35. [PMID: 35725557 PMCID: PMC9208135 DOI: 10.1186/s13017-022-00439-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Non-operative management has become increasingly popular in the treatment of renal trauma. While data are robust in blunt mechanisms, the role of non-operative management in penetrating trauma is less clear. Additionally, there is a paucity of data comparing gunshot and stab wounds. Methods A retrospective review of patients admitted to a high-volume level 1 trauma center (Groote Schuur Hospital, Cape Town) with penetrating abdominal trauma was performed. Patients with renal injuries were identified and compared based on mechanism [gunshot (GSW) vs. stab] and management strategy (operative vs. non-operative). Primary outcomes of interest were mortality and failure of non-operative management. Secondary outcomes of interest were nephrectomy rates, Clavien-Dindo complication rate, hospital length of stay, and overall morbidity rate. Results A total of 150 patients with renal injuries were identified (82 GSW, 68 stab). Overall, 55.2% of patients required emergent/urgent laparotomy. GSWs were more likely to cause grade V injury and concurrent intra-abdominal injuries (p > 0.05). The success rate of non-operative management was 91.6% (89.9% GSW, 92.8% stab, p = 0.64). The absence of hematuria on point of care testing demonstrated a negative predictive value of 98.4% (95% CI 96.8–99.2%). All but 1 patient who failed non-operative management had associated intra-abdominal injuries requiring surgical intervention. Opening of Gerota’s fascia resulted in nephrectomy in 55.6% of cases. There were no statistically significant risk factors for failure of non-operative management identified on univariate logistic regression. Conclusions NOM of penetrating renal injuries can be safely and effectively instituted in both gunshot and stab wounds with a very low number of patients progressing to laparotomy. Most patients fail NOM for associated injuries. During laparotomy, the opening of Gerota’s fascia may lead to increased risk of nephrectomy. Ongoing study with larger populations is required to develop effective predictive models of patients who will fail NOM.
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Affiliation(s)
- Thomas W Clements
- Cumming School of Medicine, University of Calgary, Calgary, Canada.,Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Chad G Ball
- Cumming School of Medicine, University of Calgary, Calgary, Canada.,Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Andrew J Nicol
- Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Sorin Edu
- Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Andrew W Kirkpatrick
- Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Pradeep Navsaria
- Groote Schuur Hospital, University of Cape Town, Main Road, Observatory, Cape Town, 7925, South Africa.
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Diagnostic performance of triple-contrast versus single-contrast multi-detector computed tomography for the evaluation of penetrating bowel injury. Emerg Radiol 2022; 29:519-529. [PMID: 35322323 DOI: 10.1007/s10140-022-02038-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Selecting groups of low-risk penetrating trauma patients to forego laparotomy can be challenging. The presence of bowel injury may prevent non-operative management. Optimal CT technique to detect bowel injury related to penetrating injury is controversial. Our goal is to compare the diagnostic performance of triple-contrast (oral, rectal, and IV) against IV contrast-only CT, for the detection of bowel injury from penetrating abdominopelvic trauma, using surgical diagnosis as the reference standard. METHODS Nine hundred ninety-seven patients who underwent CT for penetrating torso trauma at a single institution between 2009 and 2016 in our HIPPA-compliant and institutional review board-approved retrospective cohort study. A total of 143 patients, including 15 females and 123 males underwent a pre-operative CT, followed by exploratory laparotomy. Of these, 56 patients received triple-contrast CT. CT examinations were independently reviewed by two radiologists, blinded to surgical outcome and clinical presentation. Results were stratified by contrast type and injury mechanism and were compared based upon diagnostic performance indicators of sensitivity, specificity, negative predictive value, and positive predictive value. Area under the receiving operating characteristics curves were analyzed for determination of diagnostic accuracy. RESULTS Bowel injury was present in 45 out of 143 patients (10 on triple-contrast group and 35 on IV contrast-only group). Specificity and accuracy were higher with triple-contrast CT (98% specific, 97-99% accurate) compared to IV contrast-only CT (66% specific, 78-79% accurate). Sensitivity was highest with IV contrast-only CT (91% sensitive) compared with triple-contrast CT (75% sensitive), although this difference was not statistically significant. Triple-contrast technique increased diagnostic accuracy for both radiologists regardless of mechanism of injury. CONCLUSION In our retrospective single-institution cohort study, triple-contrast MDCT had greater accuracy, specificity, and positive predictive values when compared to IV contrast-only CT in evaluating for bowel injury from penetrating wounds.
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6
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Lee H, Kong V, Cheung C, Thirayan V, Rajaretnam N, Elsabagh A, Bruce J, Laing G, Manchev V, Clarke D. Trends in the Management of Abdominal Gunshot Wounds Over the Last Decade: A South African Experience. World J Surg 2022; 46:998-1005. [PMID: 35147739 DOI: 10.1007/s00268-022-06469-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study aimed to review our decade-long experience with the management of abdominal gunshot wounds (GSWs), to document trends in our approach and to develop an evidence base for our contemporary management algorithms in a major trauma in South Africa. MATERIALS AND METHODS This was a retrospective study that included all adult patients with abdominal GSWs between January 2013 and October 2020 managed at a major trauma centre in South Africa. RESULT Five hundred and ninety-six cases were included (87% male, mean age: 32 years). The median Injury Severity Score (ISS) was 12. 52% (309/596) of cases had indications of immediate laparotomy and proceeded directly to the operating room without any CT imaging. Of this cohort, the laparotomy was positive in 292 and in the remainder (5%) was negative. Of the remaining 287 cases, 209 underwent a CT scan (35%). 78 were managed without any CT imaging. Of the 78 who did not undergo CT scan, all were managed without any operation and discharged home well. Of the 209 who underwent CT scan, 99 were observed and only one case in this group subsequently required a laparotomy. The remaining 110 cases underwent a laparotomy, which was negative in 7. There were correlations with increasing use of CT, as well as a decrease in those proceeding directly to laparotomy. The overall morbidity rate was 8% (47/596). 32% (190/596) require intensive care unit (ICU) admission. The overall mortality rate was 8% (67/596). CONCLUSIONS The management of abdominal GSWs has continued to evolve. There is now a well-defined role for selective non-operative management in this group of patients and relies on accurate CT assessment. CT scan is now an important component in the management of abdominal GSW even in our resource-constrained environment.
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Affiliation(s)
- Hong Lee
- Department of Surgery, Royal Adelaide Hospital, Port Rd, Adelaide, 5000, Australia.
| | - Victor Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Cynthia Cheung
- Department of Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Varun Thirayan
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand
| | | | - Abdallah Elsabagh
- Department of Surgery, Princess Alexandra Hospital, Brisbane, Australia
| | - John Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Grant Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Vasil Manchev
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
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7
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Islam S, Ramnarine M, Maughn A, Chandolu K, Naraynsingh V. Conservative Management of Gunshot Wound to Anterior Abdomen in a Resource-Poor Setting in the Caribbean. Cureus 2021; 13:e16789. [PMID: 34513396 PMCID: PMC8405173 DOI: 10.7759/cureus.16789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2021] [Indexed: 11/05/2022] Open
Abstract
Previously, the management of gunshot wounds (GSWs) to the anterior abdomen required exploratory laparotomy; however, this was associated with a considerable number of non-therapeutic surgeries. The use of non-operative management (NOM) of GSW to the abdomen is controversial, with many surgeons sceptical to accept this into their practice. The NOM of GSW to the abdomen employed in a selected group of patients has been shown to be safe and acceptable. Penetrating GSW to the thoraco-abdomen, back and lateral abdomen has been the most successful compared to the anterior penetrating wound. Most of the anterior GSWs to the abdomen are associated with viscus injury and require exploratory laparotomy. We report the case of a 58-year-old male who presented with a single GSW to the epigastrium with a contrast computed tomography scan demonstrating grade 3 liver lacerations, contusion to the right adrenal gland, with moderate free fluids in the retroperitoneum and the pelvis. The patient was haemodynamically stable and managed successfully with NOM. It is one of the safe routes of anterior penetration of GSW to the abdomen and treated with conservative management.
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Affiliation(s)
- Shariful Islam
- General Surgery, San Fernando General Hospital, San Fernando, TTO
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Malini Ramnarine
- General Surgery, San Fernando General Hospital, San Fernando, TTO
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Anthony Maughn
- General Surgery, San Fernando General Hospital, San Fernando, TTO
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Kiran Chandolu
- Radiology, San Fernando General Hospital, San Fernando, TTO
| | - Vijay Naraynsingh
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
- Surgery, Medical Associates Hospital, St. Joseph, TTO
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8
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Choi EJ, Choi S, Kang BH. Indications for Laparotomy in Patients with Abdominal Penetrating Injuries Presenting with Ambiguous Computed Tomography Findings. JOURNAL OF TRAUMA AND INJURY 2021. [DOI: 10.20408/jti.2020.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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9
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Ahmed M, Mikael A, Gorski Y, Mahmoud A, Cordero R. Nonoperative Management of Penetrating Right Thoracoabdominal Injury. Cureus 2021; 13:e15170. [PMID: 34168931 PMCID: PMC8216229 DOI: 10.7759/cureus.15170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Penetrating thoracoabdominal injuries caused by stabbing or firearms are seen on an almost daily basis at trauma centers in the USA. The nonoperative management of carefully selected hemodynamically stable patients is still under dispute. We present a case of right thoracoabdominal firearm injury managed nonoperatively.
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Affiliation(s)
| | | | - Yara Gorski
- Surgery, Temecula Valley Hospital, Temecula, USA
| | - Ahmed Mahmoud
- Surgery, Riverside Community Hospital, Riverside, USA
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10
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Abstract
The management of patients with penetrating abdominal trauma has significantly changed in recent years. While exploratory laparotomy was the gold standard in Germany in all patients up to the 1970s, selective nonoperative management (SNOM) is increasingly being discussed in hemodynamically stable patients without pathological findings in computed tomography (CT) scan or extended focussed assessment with sonography for trauma (eFAST). A standard algorithm taking a balance between invasiveness, patient safety and the use of resources into account has still to be implemented in Germany. The presented algorithm includes an immediate laparotomy in hemodynamically unstable patients as damage control surgery followed by a second look procedure after 48 h. Hemodynamically stable patients should primarily undergo diagnostic laparoscopy and be treated by early total care surgery, depending on the clinical and diagnostic imaging findings. Patients without clinical symptoms or pathological findings in imaging studies should be treated according to SNOM with close clinical controls.
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Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, Biffl W, Peitzman A, Horer T, Abu-Zidan FM, Sartelli M, Fraga GP, Cicuttin E, Ansaloni L, Parra MW, Millán M, DeAngelis N, Inaba K, Velmahos G, Maier R, Khokha V, Sakakushev B, Augustin G, di Saverio S, Pikoulis E, Chirica M, Reva V, Leppaniemi A, Manchev V, Chiarugi M, Damaskos D, Weber D, Parry N, Demetrashvili Z, Civil I, Napolitano L, Corbella D, Catena F. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020; 15:24. [PMID: 32228707 PMCID: PMC7106618 DOI: 10.1186/s13017-020-00302-7] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy.
| | - Raul Coimbra
- Riverside University Health System, CECORC Research Center, Loma Linda University, Loma Linda, USA
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | - Felipe Vega
- Department of Surgery, Hospital Angeles Lomas, Huixquilucan, Mexico
| | | | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital La Jolla, San Diego, CA, USA
| | - Andrew Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, FL, USA
| | - Mauricio Millán
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Nicola DeAngelis
- Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | - Kenji Inaba
- General and Trauma Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - George Velmahos
- General and Emergency Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Salomone di Saverio
- General and Trauma Surgery Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mircea Chirica
- Chirurgie Digestive, CHUGA-CHU Grenoble Alpes, Grenoble, France
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | | | - Ian Civil
- Trauma Surgery, Auckland University Hospital, Auckland, New Zealand
| | - Lena Napolitano
- Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
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Warhadapande S, Dariushnia SR, Kokabi N, O'Connell WG, Newsome JM, Findeiss LK, Majdalany BS. Clinical Approach to and Work-up of Bleeding Patients. Semin Intervent Radiol 2020; 37:24-30. [PMID: 32139967 DOI: 10.1055/s-0039-3402017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A bleeding patient is a common consult for interventional radiologists. Prompt triage, preprocedural evaluation specific to the site of hemorrhage, and knowledge of resuscitative strategies allow for a potentially life-saving procedure to be appropriately and safely performed. Having a firm understanding of the clinical work-up and management of a bleeding patient has never been more important. In this article, a discussion of the clinical approach and work-up of a bleeding patient for whom interventional radiology is consulted is followed by a discussion of etiology-specific preprocedural work-up.
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Affiliation(s)
- Shantanu Warhadapande
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sean R Dariushnia
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Nima Kokabi
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - William G O'Connell
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Janice M Newsome
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Laura K Findeiss
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Bill S Majdalany
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
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Teuben M, Spijkerman R, Pfeifer R, Blokhuis T, Huige J, Pape HC, Leenen L. Selective non-operative management for penetrating splenic trauma: a systematic review. Eur J Trauma Emerg Surg 2019; 45:979-985. [PMID: 30972434 PMCID: PMC6910899 DOI: 10.1007/s00068-019-01117-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 03/27/2019] [Indexed: 12/02/2022]
Abstract
Introduction The treatment of abdominal solid organ injuries has shifted towards non-operative management (NOM). However, the feasibility of NOM for penetrating splenic trauma is unclear and outcome is believed to be worse than NOM for penetrating liver and kidney injuries. Hence, the aim of the current systematic review was to evaluate the feasibility of selective NOM in penetrating splenic injury. Methods A review of literature was performed using Pubmed, Embase and Cochrane databases. Studies on adult patients treated by NOM for splenic injuries were included and outcome was documented and compared. Results Five articles from exclusively level-1 and level-2-traumacenters were selected and a total of 608 cases of penetrating splenic injury were included. Nonoperative management was applied in 123 patients (20.4%, range 17–33%). An overall failure rate of NOM of 18% was calculated. Mortality was not seen in patients selected for nonoperative management. Contra-indicatons for NOM included hemodynamic instability, absence of abdominal CT-scanning to rule out concurrent injuries and peritonitis. Conclusions This review demonstrates that non-operative management for penetrating splenic trauma in highly selected patients has been utilized in several well-equipped and experienced trauma centers. NOM of penetrating splenic injury in selected patients is not associated with increased morbidity nor mortality. Data on the less well-equipped and experienced trauma centers are not available. More prospective studies are required to further define exact selection criteria for non-operative management in splenic trauma. Electronic supplementary material The online version of this article (10.1007/s00068-019-01117-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michel Teuben
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland.
| | - Roy Spijkerman
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Taco Blokhuis
- Department of Surgery, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Josephine Huige
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | | | - Luke Leenen
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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14
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Abstract
BACKGROUND The presence of abdominal injuries has a major impact on the mortality of severely injured patients. For injuries that require surgery, laparotomy is still the gold standard for early surgical care; however, there is increasing evidence that laparoscopy may be an alternative in the early clinical care of polytrauma patients. OBJECTIVE The present registry-based study analyzed the utilization and the outcome of laparoscopy in severely injured patients with abdominal trauma in Germany. MATERIAL AND METHODS A retrospective analysis of 12,447 patients retrieved from the TraumaRegister DGU® (TR-DGU) was performed. The primary inclusion criteria were an injury severity score (ISS) ≥ 9 and an abbreviated injury scale (AIS) [abdomen] ≥ 1. The included patients were grouped according to early treatment management: (1) laparoscopy, (2) laparotomy and (3) non-operative management (NOM). Finally, group-specific patient characteristics and outcome were analyzed. RESULTS The majority of patients were treated by NOM (52.4%, n = 6069), followed by laparotomy (50,6%, n = 6295) and laparoscopy (0.7%, n = 83). The majority of laparoscopies were performed in patients with an AIS [abdomen] ≤ 3 (86.7%). The ISS of the laparoscopy group was significantly lower compared to that of the laparotomy and NOM groups (ISS 23.4 vs. 34.5 vs. 28.2, respectively, p ≤ 0.001). The standardized mortality rate (SMR), defined as the ratio between observed and expected mortality, was lowest in the patients receiving laparoscopy followed by laparotomy and NOM (SMR 0.688 vs. 0.931 vs. 0.932, respectively, p-value = 0.2128) without achieving statistical significance. CONCLUSION Despite being rarely employed the data indicate the effectiveness of laparoscopy for the early treatment of severely injured, hemodynamically stable patients with an AIS [abdomen] ≤ 3.
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Al Rawahi AN, Al Hinai FA, Boyd JM, Doig CJ, Ball CG, Velmahos GC, Kirkpatrick AW, Navsaria PH, Roberts DJ. Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis. World J Emerg Surg 2018; 13:55. [PMID: 30505340 PMCID: PMC6260713 DOI: 10.1186/s13017-018-0215-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/05/2018] [Indexed: 01/05/2023] Open
Abstract
Background Although mandatory laparotomy has been standard of care for patients with abdominal gunshot wounds (GSWs) for decades, this approach is associated with non-therapeutic operations, morbidity, and long hospital stays. This systematic review and meta-analysis sought to summarize outcomes of selective nonoperative management (SNOM) of civilian abdominal GSWs. Methods We searched electronic databases (March 1966-April 1, 2017) and reference lists of articles included in the systematic review for studies reporting outcomes of SNOM of civilian abdominal GSWs. We meta-analyzed the associated risks of SNOM-related failure (defined as laparotomy during hospital admission), mortality, and morbidity across included studies using DerSimonian and Laird random-effects models. Between-study heterogeneity was assessed by calculating I2 statistics and conducting tests of homogeneity. Results Of 7155 citations identified, we included 41 studies [n = 22,847 patients with abdominal GSWs, of whom 6777 (29.7%) underwent SNOM]. The pooled risk of failure of SNOM in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis was 7.0% [95% confidence interval (CI) = 3.9-10.1%; I2 = 92.6%, homogeneity p < 0.001] while the pooled mortality associated with use of SNOM in this patient population was 0.4% (95% CI = 0.2-0.6%; I2 = 0%, homogeneity p > 0.99). In patients who failed SNOM, the pooled estimate of the risk of therapeutic laparotomy was 68.0% (95% CI = 58.3-77.7%; I2 = 91.5%; homogeneity p < 0.001). Risks of failure of SNOM were lowest in studies that evaluated patients with right thoracoabdomen (3.4%; 95% CI = 0-7.0%; I2 = 0%; homogeneity p = 0.45), flank (7.0%; 95% CI = 3.9-10.1%), and back (3.1%; 95% CI = 0-6.5%) GSWs and highest in those that evaluated patients with anterior abdomen (13.2%; 95% CI = 6.3-20.1%) GSWs. In patients who underwent mandatory abdominopelvic computed tomography (CT), the pooled risk of failure was 4.1% versus 8.3% in those who underwent selective CT (p = 0.08). The overall sample-size-weighted mean hospital length of stay among patients who underwent SNOM was 6 days versus 10 days if they failed SNOM or developed an in-hospital complication. Conclusions SNOM of abdominal GSWs is safe when conducted in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis. Failure of SNOM may be lower in patients with GSWs to the back, flank, or right thoracoabdomen and be decreased by mandatory use of abdominopelvic CT scans.
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Affiliation(s)
| | - Fatma A. Al Hinai
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
| | - Jamie M. Boyd
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
| | - Christopher J. Doig
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
| | - Chad G. Ball
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
- Regional Trauma Program, University of Calgary and the Foothills Medical Centre, Calgary, Alberta Canada
| | - George C. Velmahos
- Division of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Andrew W. Kirkpatrick
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
- Regional Trauma Program, University of Calgary and the Foothills Medical Centre, Calgary, Alberta Canada
| | - Pradeep H. Navsaria
- Department of Surgery, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
- Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Derek J. Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Civic Campus, Room A280, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9 Canada
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16
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Matsevych OY, Koto MZ, Balabyeki M, Mashego LD, Aldous C. Diagnostic laparoscopy or selective non-operative management for stable patients with penetrating abdominal trauma: What to choose? J Minim Access Surg 2018; 15:130-136. [PMID: 30178773 PMCID: PMC6438062 DOI: 10.4103/jmas.jmas_72_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Selective non-operative management (NOM) and diagnostic laparoscopy (DL) are well-accepted approaches in the management of stable patients with penetrating abdominal trauma (PAT). The aim of this pilot study was to investigate the advantages and disadvantages of early DL in stable asymptomatic or minimally symptomatic patients with PAT as opposed to NOM, a standard of care in this scenario. The secondary aim was to suggest possible indications for DL. Methods Patients managed with DL or NOM over a 12-month period were included in this study. The age, gender, mechanism and location of injuries, trauma scores, haemodynamic and metabolic parameters, intraoperative findings and length of hospital stay (LOS) were recorded and correlated with outcomes. Results Thirty-six patients were in the NOM group and 35 in the DL group. Stab wounds were more common. The most common location of injury was the anterior abdominal wall in the NOM group and the lower chest in the DL group. Computed tomography (CT) scan was performed more often in the NOM group (75% vs. 17.1%). The injury severity score (ISS), New ISS and PAT Index were higher in the DL group. Nearly 23 (66%) patients in the DL group had a penetration of the peritoneum, but no significant abdominal injuries. LOS in the NOM group was 2 days versus 3.1 days in the DL group. There were no missed injuries, complications or mortality. Conclusion NOM is a preferred modality for minimally symptomatic stable patients. However, there is a risk of missed injuries and delayed treatment. DL accurately visualizes injuries, decreases unnecessary CT scans and avoids nontherapeutic laparotomies.
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Affiliation(s)
- Oleh Yevhenovych Matsevych
- Department of Surgery, Sefako Makgatho Health Sciences University, Dr. George Mukhari Academic Hospital, Pretoria; University of KwaZulu-Natal, Nelson R Mandela (NRMSM) Campus, Durban, South Africa
| | - Modise Zacharia Koto
- Department of Surgery, Sefako Makgatho Health Sciences University, Dr. George Mukhari Academic Hospital, Pretoria; University of KwaZulu-Natal, Nelson R Mandela (NRMSM) Campus, Durban, South Africa
| | - Moses Balabyeki
- Department of Surgery, Sefako Makgatho Health Sciences University, Dr. George Mukhari Academic Hospital, Pretoria, South Africa
| | - Lehlogonolo David Mashego
- Department of Surgery, Sefako Makgatho Health Sciences University, Dr. George Mukhari Academic Hospital, Pretoria, South Africa
| | - Colleen Aldous
- University of KwaZulu-Natal, Nelson R Mandela (NRMSM) Campus, Durban, South Africa
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17
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İflazoğlu N, Üreyen O, Öner OZ, Meral UM, Yülüklü M. Non-operative management of abdominal gunshot injuries: Is it safe in all cases? Turk J Surg 2018; 34:38-42. [PMID: 29756105 DOI: 10.5152/turkjsurg.2017.3795] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/25/2017] [Indexed: 11/22/2022]
Abstract
Objective In line with advances in diagnostic methods and expectation of a decrease in the number of negative laparotomies, selective non-operative management of abdominal gunshot wounds has been increasingly used over the last three decades. We aim to detect the possibility of treatment without surgery and present our experience in selected cases referred from Syria to a hospital at the Turkish-Syrian border. Material and Methods Between February 2012 and June 2014, patients admitted with abdominal gunshot wounds were analyzed. Computed tomography was performed for all patients on admission. Patients who were hemodynamically stable and did not have symptoms of peritonitis at the time of presentation were included in the study. The primary outcome parameters were mortality and morbidity. Successful selective non-operative management (Group 1) and unsuccessful selective non-operative management (Group 2) groups were compared in terms of complications, blood transfusion, injury site, injury severity score (ISS), and hospital stay. Results Of 158 truncal injury patients, 18 were considered feasible for selective non-operative management. Of these, 14 (78%) patients were treated without surgery. Other Four patients were operated upon progressively increasing abdominal pain and tenderness during follow-up. On diagnostic exploration, all of these cases had intestinal perforations. No mortality was observed in selective non-operative management. There was no statistically significant difference between Group 1 and Group 2, in terms of length of hospital stay (96 and 127 h, respectively). Also, there was no difference between groups in terms of blood transfusion necessity, injury site, complication rate, and injury severity score (p>0.05). Conclusion Decision making on patient selection for selective non-operative management is critical to ensure favorable outcomes. It is not possible to predict the success of selective non-operative management in advance. Cautious clinical examination and close monitoring of these patients is vital; however, emergency laparotomy should be performed in case of change in vital signs and positive symptoms concerning peritonitis.
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Affiliation(s)
- Nidal İflazoğlu
- Department of General Surgery, Kilis State Hospital, Kilis, Turkey
| | - Orhan Üreyen
- Department of General Surgery, Bozyaka Training and Research Hospital, İzmir, Turkey
| | - Osman Zekai Öner
- Department of General Surgery, Antalya Training and Research Hospital, Antalya, Turkey
| | - Ulvi Mehmet Meral
- Department of General Surgery, İzmir Military Hospital, İzmir, Turkey
| | - Murat Yülüklü
- Department of General Surgery, Afyon State Hospital, Afyonkarahisar, Turkey
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18
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Navsaria P, Nicol A, Krige J, Edu S, Chowdhury S. Selective nonoperative management of liver gunshot injuries. Eur J Trauma Emerg Surg 2018; 45:323-328. [PMID: 29368085 DOI: 10.1007/s00068-018-0913-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 01/20/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Nonoperative management (NOM) of gunshot liver injuries (GLI) is infrequently practiced. The aim of this study was to assess the safety of selective NOM of GLI. METHODS A prospective, protocol-driven study, which included patients with GLI admitted to a level 1 trauma center, was conducted over a 52-month period. Stable patients without peritonism or sustained hypotension with right-sided thoracoabdominal (RTA) and right upper quadrant (RUQ), penetrating wounds with or without localized RUQ tenderness, underwent contrasted abdominal CT scan to determine the trajectory and organ injury. Patients with established liver and/or kidney injuries, without the evidence of hollow viscus injury, were observed with serial clinical examinations. Outcome parameters included the need for delayed laparotomy, complications, the length of hospital stay and survival. RESULTS During the study period, 54 (28.3%) patients of a cohort of 191 patients with GLI were selected for NOM of hemodynamic stability, the absence of peritonism and CT imaging. The average Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.841 and 25 (range 4-50), respectively. 21 (39%) patients had simple (Grades I and II) and 33 (61%) patients sustained complex (Grades III to V) liver injuries. Accompanying injuries included 12 (22.2%) kidney, 43 (79.6%) diaphragm, 20 (37.0%) pulmonary contusion, 38 (70.4%) hemothoraces, and 24 (44.4%) rib fractures. Three patients required delayed laparotomy resulting in an overall success of NOM of 94.4%. Complications included: liver abscess (1), biliary fistula (5), intrahepatic A-V fistula (1) and hospital-acquired pneumonia (3). The overall median hospital stay was 6 (IQR 4-11) days, with no deaths. CONCLUSION The NOM of carefully selected patients with GLI is safe and associated with minimal morbidity.
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Affiliation(s)
- Pradeep Navsaria
- Trauma Center, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa.
| | - Andrew Nicol
- Trauma Center, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Jake Krige
- Surgical Gastroenterology, University of Cape Town , Cape Town, South Africa
| | - Sorin Edu
- Trauma Center, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Sharfuddin Chowdhury
- Trauma Center, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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19
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Dayananda K, Kong VY, Bruce JL, Oosthuizen GV, Laing GL, Clarke DL. Selective non-operative management of abdominal stab wounds is a safe and cost effective strategy: A South African experience. Ann R Coll Surg Engl 2017; 99:490-496. [PMID: 28660819 DOI: 10.1308/rcsann.2017.0075] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Selective non-operative management (SNOM) of abdominal stab wounds is well established in South Africa. SNOM reduces the morbidity associated with negative laparotomies while being safe. Despite steady advances in technology (including laparoscopy, computed tomography [CT] and point-of-care sonography), our approach has remained clinically driven. Assessments of financial implications are limited in the literature. The aim of this study was to review isolated penetrating abdominal trauma and analyse associated incurred expenses. METHODS Patients data across the Pietermaritzburg Metropolitan Trauma Service (PMTS) are captured prospectively into the regional electronic trauma registry. A bottom-up microcosting technique produced estimated average costs for our defined clinical protocols. RESULTS Between January 2012 and April 2015, 501 patients were treated for an isolated abdominal stab wound. Over one third (38%) were managed successfully with SNOM, 5% underwent a negative laparotomy and over half (57%) required a therapeutic laparotomy. Over five years, the PMTS can expect to spend a minimum of ZAR 20,479,800 (GBP 1,246,840) for isolated penetrating abdominal stab wounds alone. CONCLUSIONS Provided a stringent policy is followed, in carefully selected patients, SNOM is effective in detecting those who require further intervention. It minimises the risks associated with unnecessary surgical interventions. SNOM will continue to be clinically driven and promulgated in our environment.
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Affiliation(s)
- Kss Dayananda
- University of Kwa-Zulu Natal , Durban , South Africa
| | - V Y Kong
- University of Kwa-Zulu Natal , Durban , South Africa
| | - J L Bruce
- University of Kwa-Zulu Natal , Durban , South Africa
| | | | - G L Laing
- University of Kwa-Zulu Natal , Durban , South Africa
| | - D L Clarke
- University of Kwa-Zulu Natal , Durban , South Africa.,University of the Witwatersr and, Johannesburg, , South Africa
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20
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van den Hout WJ, van der Wilden GM, Boot F, Idenburg FJ, Rhemrev SJ, Hoencamp R. Early CT scanning in the emergency department in patients with penetrating injuries: does it affect outcome? Eur J Trauma Emerg Surg 2017; 44:607-614. [PMID: 28868591 PMCID: PMC6096612 DOI: 10.1007/s00068-017-0831-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 08/24/2017] [Indexed: 02/03/2023]
Abstract
Background To be a level I trauma center in the Netherlands a computed tomography (CT) scanner in the emergency department (ED) is considered desirable, as it is presumed that this optimizes the diagnostic process and that therapy can be directed based on these findings. Aim of this study was to assess the effects of implementing a CT scanner in the ED on outcomes in patients with penetrating injuries. Methods In this retrospective descriptive study, patients with penetrating injuries (shot and/or stab wounds), presented between 2000 and 2014 were analysed using the hospital’s electronic database, and data from the West Netherlands trauma registry and the financial department. Results 405 patients were included: performing a CT scan upon arrival increased significantly from 26.7 to 67.0% (p = 0.00) after implementation of a CT scanner in the ED, with the mean cost of a CT being 96.85 euros. Overall mortality decreased from 6.9 to 3.7%, although not statistically significant. Intensive care unit admission (ICU-admission) and median hospital length of stay (H-LOS) decreased from 30.9 to 24.5% resp. 3.2 to 1.8 days (p ≤ 0.05). Overall mortality, adjusted for injury severity score (ISS), revised trauma score (RTS), and types of injuries, did not change significantly. Conclusion Patients with penetrating injuries more often received a CT scan on admission after implementation of a CT scanner in the ED. Early CT scanning is useful since it significantly reduces ICU-admissions and decreases H-LOS. It is a cheap and non-invasive diagnostic tool with significant clinical impact, resulting in directed treatment, and improvement of outcomes.
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Affiliation(s)
- W J van den Hout
- Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - G M van der Wilden
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands.
- Division of Surgery, Department of Traumatology, Alrijne Hospital, Simon, Smitweg 1, 2353 GA, Leiderdorp, The Netherlands.
| | - F Boot
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands
| | - F J Idenburg
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands
| | - S J Rhemrev
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands
| | - R Hoencamp
- Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Division of Surgery, Department of Traumatology, Alrijne Hospital, Simon, Smitweg 1, 2353 GA, Leiderdorp, The Netherlands
- Ministry of Defense, The Hague, The Netherlands
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21
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Mingoli A, La Torre M, Migliori E, Cirillo B, Zambon M, Sapienza P, Brachini G. Operative and nonoperative management for renal trauma: comparison of outcomes. A systematic review and meta-analysis. Ther Clin Risk Manag 2017; 13:1127-1138. [PMID: 28894376 PMCID: PMC5584778 DOI: 10.2147/tcrm.s139194] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Preservation of kidney and renal function is the goal of nonoperative management (NOM) of renal trauma (RT). The advantages of NOM for minor blunt RT have already been clearly described, but its value for major blunt and penetrating RT is still under debate. We present a systematic review and meta-analysis on NOM for RT, which was compared with the operative management (OM) with respect to mortality, morbidity, and length of hospital stay (LOS). Methods The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed for this study. A systematic search was performed on Embase, Medline, Cochrane, and PubMed for studies published up to December 2015, without language restrictions, which compared NOM versus OM for renal injuries. Results Twenty nonrandomized retrospective cohort studies comprising 13,824 patients with blunt (2,998) or penetrating (10,826) RT were identified. When all RT were considered (American Association for the Surgery of Trauma grades 1–5), NOM was associated with lower mortality and morbidity rates compared to OM (8.3% vs 17.1%, odds ratio [OR] 0.471; 95% confidence interval [CI] 0.404–0.548; P<0.001 and 2% vs 53.3%, OR 0.0484; 95% CI 0.0279–0.0839, P<0.001). Likewise, NOM represented the gold standard treatment resulting in a lower mortality rate compared to OM even when only high-grade RT was considered (9.1% vs 17.9%, OR 0.332; 95% CI 0.155–0.708; P=0.004), be they blunt (4.1% vs 8.1%, OR 0.275; 95% CI 0.0957–0.788; P=0.016) or penetrating (9.1% vs 18.1%, OR 0.468; 95% CI 0.398–0.0552; P<0.001). Conclusion Our meta-analysis demonstrated that NOM for RT is the treatment of choice not only for AAST grades 1 and 2, but also for higher grade blunt and penetrating RT.
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Affiliation(s)
- Andrea Mingoli
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Marco La Torre
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Emanuele Migliori
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Bruno Cirillo
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Martina Zambon
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Paolo Sapienza
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Gioia Brachini
- Emergency Department.,Department of Surgery P Valdoni, Policlinico Umberto I, Sapienza University, Rome, Italy
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Abstract
In the last 30 years, the management of liver injury has evolved significantly. The advancement of imaging studies has played an important role in the conservative approach for management. A shift from operative to nonoperative management for most hemodynamically stable patients with hepatic injury has been prompted by speed and sensitivity of diagnostic imaging and by advances in critical care monitoring. In this review article, the up-to-date recommendation on the management approach of liver trauma will be discussed.
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Affiliation(s)
- Hanan M Alghamdi
- Department of Surgery, King Fahd Hospital of the University, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
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23
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Bennett S, Amath A, Knight H, Lampron J. Conservative versus operative management in stable patients with penetrating abdominal trauma: the experience of a Canadian level 1 trauma centre. Can J Surg 2017; 59:317-21. [PMID: 27668329 DOI: 10.1503/cjs.015615] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The goal of conservative management (CM) of penetrating abdominal trauma is to avoid nontherapeutic laparotomies while identifying injuries early. Factors that may predict CM failure are not well established, and the experience of CM has not been well described in the Canadian context. METHODS We searched a Canadian level 1 trauma centre database for all penetrating abdominal traumas treated between 2004 and 2014. Hemodynamically stable patients without peritonitis and without clear indications for immediate surgery were considered potential candidates for CM, and were included in the study. We compared those who were managed with CM with those who underwent immediate operative management (OM). Outcomes included mortality and length of stay (LOS). Further analysis was performed to identify predictors of CM failure. RESULTS A total of 72 patients with penetrating abdominal trauma were classified as potential candidates for CM. Ten patients were managed with OM, and 62 with CM, with 9 (14.5%) ultimately failing CM and requiring laparotomy. The OM and CM groups were similar in terms of age, sex, injury severity, mechanism and number of injuries. There were no deaths in either group. The LOS in the intensive care (ICU)/trauma unit was 4.8 ± 3.2 days in the OM group and 2.9 ± 2.6 days in the CM group (p = 0.039). The only predictor for CM failure was intra-abdominal fluid on computed tomography (CT) scan (odds ratio 5.3, 95% confidence interval 1.01-28.19). CONCLUSION In select patients with penetrating abdominal trauma, CM is safe and results in a reduced LOS in the ICU/trauma unit of 1.9 days. Fluid on CT scan is a predictor for failure.
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Affiliation(s)
- Sean Bennett
- From the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Bennett, Lampron); the Ottawa Hospital Research Institute, Ottawa, Ont. (Bennett, Lampron); the Ottawa Hospital, Ottawa, Ont. (Bennett, Knight, Lampron); and the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Amath)
| | - Aysah Amath
- From the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Bennett, Lampron); the Ottawa Hospital Research Institute, Ottawa, Ont. (Bennett, Lampron); the Ottawa Hospital, Ottawa, Ont. (Bennett, Knight, Lampron); and the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Amath)
| | - Heather Knight
- From the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Bennett, Lampron); the Ottawa Hospital Research Institute, Ottawa, Ont. (Bennett, Lampron); the Ottawa Hospital, Ottawa, Ont. (Bennett, Knight, Lampron); and the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Amath)
| | - Jacinthe Lampron
- From the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Bennett, Lampron); the Ottawa Hospital Research Institute, Ottawa, Ont. (Bennett, Lampron); the Ottawa Hospital, Ottawa, Ont. (Bennett, Knight, Lampron); and the Faculty of Medicine, University of Ottawa, Ottawa, Ont. (Amath)
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24
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Coccolini F, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Ceresoli M, Montori G, Sartelli M, Weber D, Fraga G, Naidoo N, Moore FA, Zanini N, Ansaloni L. WSES classification and guidelines for liver trauma. World J Emerg Surg 2016; 11:50. [PMID: 27766112 PMCID: PMC5057434 DOI: 10.1186/s13017-016-0105-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/13/2016] [Indexed: 11/10/2022] Open
Abstract
The severity of liver injuries has been universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale. In determining the optimal treatment strategy, however, the haemodynamic status and associated injuries should be considered. Thus the management of liver trauma is ultimately based on the anatomy of the injury and the physiology of the patient. This paper presents the World Society of Emergency Surgery (WSES) classification of liver trauma and the management Guidelines.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore Hospital, Parma, Italy
| | | | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Walter Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Marco Ceresoli
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Gustavo Fraga
- Faculdade de Ciências Médicas (FCM)-Unicamp, Campinas, SP Brazil
| | - Noel Naidoo
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | | | - Nicola Zanini
- General Surgery Department, Infermi Hospital, Rimini, Italy
| | - Luca Ansaloni
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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25
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Lennquist Montán K, Riddez L, Lennquist S, Olsberg AC, Lindberg H, Gryth D, Örtenwall P. Assessment of hospital surge capacity using the MACSIM simulation system: a pilot study. Eur J Trauma Emerg Surg 2016; 43:525-539. [PMID: 27334386 DOI: 10.1007/s00068-016-0686-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 05/28/2016] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to use a simulation model developed for the scientific evaluation of methodology in disaster medicine to test surge capacity (SC) in a major hospital responding to a simulated major incident with a scenario copied from a real incident. METHODS The tested hospital was illustrated on a system of magnetic boards, where available resources, staff, and patients treated in the hospital at the time of the test were illustrated. Casualties were illustrated with simulation cards supplying all data required to determine procedures for diagnosis and treatment, which all were connected to real consumption of time and resources. RESULTS The first capacity-limiting factor was the number of resuscitation teams that could work parallel in the emergency department (ED). This made it necessary to refer severely injured to other hospitals. At this time, surgery (OR) and intensive care (ICU) had considerable remaining capacity. Thus, the reception of casualties could be restarted when the ED had been cleared. The next limiting factor was lack of ventilators in the ICU, which permanently set the limit for SC. At this time, there was still residual OR capacity. With access to more ventilators, the full surgical capacity of the hospital could have been utilized. CONCLUSIONS The tested model was evaluated as an accurate tool to determine SC. The results illustrate that SC cannot be determined by testing one single function in the hospital, since all functions interact with each other and different functions can be identified as limiting factors at different times during the response.
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Affiliation(s)
- K Lennquist Montán
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Centre for Prehospital and Disaster Medicine, Regionens Hus, 405 44, Gothenburg, Sweden. .,, Åsevägen 1, 182 39, Danderyd, Sweden.
| | - L Riddez
- Department of Molecular Medicine and Surgery, Karolinska Institute, Solna, Sweden
| | - S Lennquist
- Department of Surgery (professor emeritus), University of Linköping, Linköping, Sweden
| | - A C Olsberg
- Emergency Department, Karolinska University Hospital, Solna, Sweden
| | - H Lindberg
- Stockholm County Council, Stockholm, Sweden
| | - D Gryth
- Department of Physiology and Pharmacology, Karolinska Institute, Solna, Sweden
| | - P Örtenwall
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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26
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Ahn S, Kim DJ, Paik KY, Chung JH, Park WC, Kim W, Lee IK. A Comparison of Self-Inflicted Stab Wounds Versus Assault-Induced Stab Wounds. Trauma Mon 2016; 21:e25304. [PMID: 28184363 PMCID: PMC5292019 DOI: 10.5812/traumamon.25304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 12/15/2014] [Accepted: 12/19/2014] [Indexed: 11/18/2022] Open
Abstract
Background Although self-inflicted and assault-induced knife injuries might have different mortality and morbidity rates, no studies have actually evaluated the importance of the cause of knife injuries in terms of patient outcomes and treatment strategies. Objectives The aims of this study were to assess the difference between the outcomes of patients presenting with self-inflicted stab wounds (SISW) versus assault-induced stab wounds (AISW). Patients and Methods A retrospective review of the relevant electronic medical records was performed for the period between January 2000 and December 2012 for patients who were referred to the department of surgery for stab wounds by the trauma team. The patients were divided into either SISW (n = 10) or AISW groups (n = 11), depending on the cause of the injury. Results A total of 19 patients had undergone exploratory laparotomy. Of the nine patients with SISW undergoing this procedure, no injury was found in seven of the patients. In the AISW group, eight of the ten laparotomies were therapeutic. Three patients in the AISW group died during hospital admission. The average number of stab wounds was 1.2 for the SISW group and 3.5 for the AISW group. Organ injuries were more frequent in the AISW group, affecting the lung (2), diaphragm (3), liver (5), small bowel (2), colon (2), and kidney (1). Conclusions Although evaluations of the initial vital signs and physical examinations are still important, the history regarding the source of the stab wounds (AISW vs. SISW) may be helpful in determining the appropriate treatment methods and predicting patient outcomes.
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Affiliation(s)
- Sanghyun Ahn
- Departments of Surgery, Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Dong Jin Kim
- Departments of Surgery, Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Kwang Yeol Paik
- Departments of Surgery, Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Jae Hee Chung
- Departments of Surgery, Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Woo-Chan Park
- Departments of Surgery, Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Wook Kim
- Departments of Surgery, Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - In Kyu Lee
- Departments of Surgery, Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
- Corresponding author: In Kyu Lee, Departments of Surgery, Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea. Tel: +82-237791063, Fax: +82-27860802, E-mail:
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27
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Kones O, Akarsu C, Dogan H, Okuturlar Y, Dural AC, Karabulut M, Gemici E, Alis H. Is non-operative approach applicable for penetrating injuries of the left thoraco-abdominal region? Turk J Emerg Med 2016; 16:22-5. [PMID: 27239634 PMCID: PMC4882199 DOI: 10.1016/j.tjem.2016.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 10/14/2015] [Accepted: 11/06/2015] [Indexed: 11/24/2022] Open
Abstract
Objectives Currently, diagnostic laparoscopy (DL) is recommended for the left thoraco-abdominal region penetrating injuries (LTARP). However, organ and diaphragmatic injury may not be detected in all of these patients. Our aim is to focus on this LTARP patient group without any operative findings and to highlight the evaluation of diagnostic tools in the high-tech era for a possible selected conservative treatment. Material and methods The patients who were admitted to ED due to LTARP, and who underwent routine DL were evaluated retrospectively in terms of demographic, clinical, radiological, and operative findings of the patients. Results The current study included 79 patients with LTARP. In 44 of 79 patients, abdominal injury was not detected. In 30 patients an isolated diaphragmatic injury was revealed and in 4 patients a visceral injury was accompanying to diaphragmatic injury. Surgical findings revealed that the diaphragm was the organ most likely to sustain injury. In patients with more than one positive diagnostic findings need for surgery rate was 61.5%, however; in patients with one positive diagnostic finding (n = 53), positive surgical finding rate was only 35.8%, (p = 0.03). Regarding the combined use of all diagnostic tools in these patients; such as physical examination, plain chest X-ray, and computed tomography, when this method was used for pre-operative diagnosis, sensitivity was measured as 82.7%, specificity 84.1%, PPV 77.4% and NPV 88.1%. Conclusion Although DL is reliable for diagnosis of diaphragmatic and visceral injury in patients with LTARP. However, individual decision making for laparoscopic intervention is needed to prevent morbidity of an unnecessary operation under emergent setting due to high rates of negative intraabdominal findings.
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Affiliation(s)
- Osman Kones
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
| | - Cevher Akarsu
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
| | - Halil Dogan
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Yildiz Okuturlar
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Internal Medicine, Istanbul, Turkey
| | - Ahmet Cem Dural
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
| | - Mehmet Karabulut
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
| | - Eyup Gemici
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
| | - Halil Alis
- Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
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28
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Herfatkar MR, Mobayen MR, Karimian M, Rahmanzade F, Baghernejad Monavar Gilani S, Baghi I. Serial Clinical Examinations of 100 Patients Treated for Anterior Abdominal Wall Stab Wounds: A Cross Sectional Study. Trauma Mon 2016; 20:e24844. [PMID: 26839861 PMCID: PMC4727469 DOI: 10.5812/traumamon.24844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 04/16/2015] [Accepted: 05/13/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The current approach in stab wounds of the anterior abdominal wall is still unclear. OBJECTIVES The goal of this study was to evaluate serial clinical examinations of patients with abdominal wall stab wounds referred to Poursina Hospital in Rasht. PATIENTS AND METHODS In a cross sectional study, 100 cases with stab wounds to the anterior abdominal wall were examined serially (admission time, 4, 8, 12, and 24 hours) after wound exploration. Serial hemoglobin test was performed every 8 hours. Laparotomy was performed in cases who were not hemodynamically stable or who showed symptoms of peritonitis. The results were analyzed with SPSS software version 21. RESULTS Ninety-one men (91%) and 9 women (9%) with mean age of 27 ± 10.7 years were included. Coexisting injuries were prevalent in 12 cases. The duration of hospitalization was 1 day in 31%, 2 days in 30%, 3 - 4 days in 32% and more than 5 days in 7%. Late laparotomy was performed 12 hours after admission in 8% of patients due to peritonitis. There was visceral damage in these cases. No mortality occurred. The cost and duration of hospitalization was significantly higher in cases with coexisting injuries and those who underwent laparotomy. CONCLUSIONS It seems serial clinical examinations are safe and decrease the cost and duration of hospitalization in stable patients with anterior abdominal wall stab wounds.
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Affiliation(s)
- Mohammad Rasool Herfatkar
- Department of Surgery, Guilan Surgery Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Mohammad Reza Mobayen
- Department of Surgery, Guilan Surgery Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Mehdi Karimian
- Department of Surgery, Guilan Surgery Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
| | - Fariba Rahmanzade
- Public Health Center of Guilan, Guilan Surgery Research Center, Rasht, IR Iran
| | | | - Iraj Baghi
- Department of Surgery, Guilan Surgery Research Center, Guilan University of Medical Sciences, Rasht, IR Iran
- Corresponding author: Iraj Baghi, Department of Surgery, Guilan Surgery Research Center, Guilan University of Medical Sciences, Rasht, IR Iran. Tel: +98-9125139506, E-mail:
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29
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Störmann P, Gartner K, Wyen H, Lustenberger T, Marzi I, Wutzler S. Epidemiology and outcome of penetrating injuries in a Western European urban region. Eur J Trauma Emerg Surg 2016; 42:663-669. [PMID: 26762313 DOI: 10.1007/s00068-016-0630-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/04/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Severe life-threatening injuries in Western Europe are mostly caused by blunt trauma. However, penetrating trauma might be more common in urban regions, but their characteristics have not been fully elucidated. METHODS Retrospective analysis of data from patients admitted to our urban university level I trauma center between 2008 and 2013 with suspicion of severe multiple injuries. Collection of data was performed prospectively using a PC-supported online documentation program including epidemiological, clinical and outcome parameters. RESULTS Out of 2095 trauma room patients admitted over the 6-year time period 194 (9.3 %) suffered from penetrating trauma. The mean Injury Severity Score (ISS) was 12.3 ± 14.1 points. In 62.4 % (n = 121) the penetrating injuries were caused by interpersonal violence or attempted suicide, 98 of these by stabbing and 23 by firearms. We observed a widespread injury pattern where mainly head, thorax and abdomen were afflicted. Subgroup analysis for self-inflicted injuries showed higher ISS (19.8 ± 21.8 points) than for blunt trauma (15.5 ± 14.6 points). In 82.5 % of all penetrating trauma a surgical treatment was performed, 43.8 % of the patients received intensive care unit treatment with mean duration of 7.4 ± 9.3 days. Immediate emergency surgical treatment had to be performed in 8.0 vs. 2.3 % in blunt trauma (p < 0.001). Infectious complications of the penetrating wounds were observed in 7.8 %. CONCLUSIONS Specific characteristics of penetrating trauma in urban regions can be identified. Compared to nationwide data, penetrating trauma was more frequent in our collective (9.3 vs. 5.0 %), which may be due to higher crime rates in urban areas. Especially, self-inflicted penetrating trauma often results in most severe injuries.
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Affiliation(s)
- P Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe, University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany.
| | - K Gartner
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe, University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - H Wyen
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe, University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - T Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe, University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - I Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe, University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - S Wutzler
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe, University Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
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30
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Oh SY, Suh GJ. Nonoperative Treatment for Abdominal Injury in Multiple Trauma Patients: Experience in the Metropolitan Tertiary Hospital in Korea (2009~2014). JOURNAL OF TRAUMA AND INJURY 2015. [DOI: 10.20408/jti.2015.28.4.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Seung-Young Oh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
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31
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Saleh AF, Al Sageer E, Elheny A. Management of Liver Trauma in Minia University Hospital, Egypt. Indian J Surg 2015; 78:442-447. [PMID: 28100939 DOI: 10.1007/s12262-015-1393-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 10/30/2015] [Indexed: 11/28/2022] Open
Abstract
The aim of this study is to present the outcome of operative and non-operative management of patients with liver injury treated in a single institution depending on imaging. This study was conducted at the Causality Unit of Minia University Hospital, and included 60 patients with hepatic trauma from March 2012 to January 2013. In our study, males represent 80 % while females represent 20 % of the traumatized patients. The peak age for trauma found was 11-30 years. Blunt trauma is the most common cause of liver injury as it was the cause in 48 patients (80 %). Firearm injuries are the most common cause of penetrating trauma (60 %) followed by stab injuries (40 %). More than one half of our patients (34 out of 60) were treated with non-operative management (NOM) with a high success rate. The operative procedures done were suture hepatorrhaphy (20 cases), non-anatomical resection in one case, anatomical resection in one case, and damage control therapy using pads in two cases. In another two cases, nothing was done as subcapsular hematoma had resolved. Minia University Hospital is a big tertiary Hospital in Egypt at which blunt liver trauma is more common than penetrating liver trauma. Surgery is no longer the only option available. It has been reserved for extensive lesions with condition of hemodynamic instability or for the treatment of the complications. NOM is an effective treatment modality in most cases.
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Affiliation(s)
- Abdel Fattah Saleh
- General Surgery Department, Faculty of Medicine, Minia University, Minya, 6111 Egypt
| | - Emad Al Sageer
- General Surgery Department, Faculty of Medicine, Minia University, Minya, 6111 Egypt
| | - Amr Elheny
- General Surgery Department, Faculty of Medicine, Minia University, Minya, 6111 Egypt
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Stengel D, Rademacher G, Ekkernkamp A, Güthoff C, Mutze S. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev 2015; 2015:CD004446. [PMID: 26368505 PMCID: PMC6464800 DOI: 10.1002/14651858.cd004446.pub4] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ultrasonography (performed by means of a four-quadrant, focused assessment of sonography for trauma (FAST)) is regarded as a key instrument for the initial assessment of patients with suspected blunt abdominal and thoraco-abdominal trauma in the emergency department setting. FAST has a high specificity but low sensitivity in detecting and excluding visceral injuries. Proponents of FAST argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of unnecessary multi-detector computed tomography (MDCT) scans, and enable quicker triage to surgical and non-surgical care. Given the proven accuracy, increasing availability of, and indication for, MDCT among patients with blunt abdominal and multiple injuries, we aimed to compile the best available evidence of the use of FAST-based assessment compared with other primary trauma assessment protocols. OBJECTIVES To assess the effects of diagnostic algorithms using ultrasonography including in FAST examinations in the emergency department in relation to the early, late, and overall mortality of patients with suspected blunt abdominal trauma. SEARCH METHODS The most recent search was run on 30th June 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), clinical trials registers, and screened reference lists. Trial authors were contacted for further information and individual patient data. SELECTION CRITERIA We included randomised controlled trials (RCTs). Participants were patients with blunt torso, abdominal, or multiple trauma undergoing diagnostic investigations for abdominal organ injury. The intervention was diagnostic algorithms comprising emergency ultrasonography (US). The control was diagnostic algorithms without US examinations (for example, primary computed tomography (CT) or diagnostic peritoneal lavage (DPL)). Outcomes were mortality, use of CT or invasive procedures (DPL, laparoscopy, laparotomy), and cost-effectiveness. DATA COLLECTION AND ANALYSIS Two authors (DS and CG) independently selected trials for inclusion, assessed methodological quality, and extracted data. Methodological quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible, data were pooled and relative risks (RRs), risk differences (RDs), and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed-effect or random-effects models as appropriate. MAIN RESULTS We identified four studies meeting our inclusion criteria. Overall, trials were of poor to moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. Strong heterogeneity amongst the trials prompted discussion between the review authors as to whether the data should or should not be pooled; we decided in favour of a quantitative synthesis to provide a rough impression about the effect sizes achievable with US-based triage algorithms. We pooled mortality data from three trials involving 1254 patients; the RR in favour of the FAST arm was 1.00 (95% CI 0.50 to 2.00). FAST-based pathways reduced the number of CT scans (random-effects model RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result was unclear. AUTHORS' CONCLUSIONS The experimental evidence justifying FAST-based clinical pathways in diagnosing patients with suspected abdominal or multiple blunt trauma remains poor. Because of strong heterogeneity between the trial results, the quantitative information provided by this review may only be used in an exploratory fashion. It is unlikely that FAST will ever be investigated by means of a confirmatory, large-scale RCT in the future. Thus, this Cochrane Review may be regarded as a review which provides the best available evidence for clinical practice guidelines and management recommendations. It can only be concluded from the few head-to-head studies that negative US scans are likely to reduce the incidence of MDCT scans which, given the low sensitivity of FAST (or reliability of negative results), may adversely affect the diagnostic yield of the trauma survey. At best, US has no negative impact on mortality or morbidity. Assuming that major blunt abdominal or multiple trauma is associated with 15% mortality and a CT-based diagnostic work-up is considered the current standard of care, 874, 3495, or 21,838 patients are needed per intervention group to demonstrate non-inferiority of FAST to CT-based algorithms with non-inferiority margins of 5%, 2.5%, and 1%, power of 90%, and a type-I error alpha of 5%.
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Affiliation(s)
- Dirk Stengel
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryWarener Str 7BerlinGermany12683
| | - Grit Rademacher
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
| | - Axel Ekkernkamp
- University HospitalDepartment of Trauma and Reconstructive SurgeryFerdinand‐Sauerbruch‐StraßeGreifswaldGermany17475
| | - Claas Güthoff
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryWarener Str 7BerlinGermany12683
| | - Sven Mutze
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
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Coccolini F, Montori G, Catena F, Di Saverio S, Biffl W, Moore EE, Peitzman AB, Rizoli S, Tugnoli G, Sartelli M, Manfredi R, Ansaloni L. Liver trauma: WSES position paper. World J Emerg Surg 2015; 10:39. [PMID: 26309445 PMCID: PMC4548919 DOI: 10.1186/s13017-015-0030-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/24/2015] [Indexed: 01/13/2023] Open
Abstract
The liver is the most injured organ in abdominal trauma. Road traffic crashes and antisocial, violent behavior account for the majority of liver injuries. The present position paper represents the position of the World Society of Emergency Surgery (WSES) about the management of liver injuries.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | | | | | | | - Andrew B Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, Pensylvania USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Gregorio Tugnoli
- General, Emergency and Trauma Surgery, Maggiore Hospital, Bologna, Italy
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Roberto Manfredi
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
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Yucel M, Bas G, Ozpek A, Basak F, Sisik A, Acar A, Ozdemir BA, Yuksekdag S, Alimoglu O. The predictive value of physical examination in the decision of laparotomy in penetrating anterior abdominal stab injury. Int J Clin Exp Med 2015; 8:11085-11092. [PMID: 26379908 PMCID: PMC4565291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/02/2015] [Indexed: 06/05/2023]
Abstract
A selective conservative treatment for penetrating anterior abdominal stab injuries is an increasingly recognized approach. We analyzed patients who followed-up and treated for penetrating anterior abdominal stab injuries. The anterior region was defined as the area between the arcus costa at the top and the mid-axillary lines at the laterals and the inguinal ligaments and symphysis pubis at the bottom. An emergency laparotomy was performed on patients who were hemodynamically unstable or had symptoms of peritonitis or organ evisceration; the remaining patients were followed-up selectively and conservatively. A total of 175 patients with purely anterior abdominal injuries were included in the study. One hundred and sixty-five of the patients (94.29%) were males and 10 (5.71%) were females; the mean age of the cohort was 30.85 years (range: 14-69 years). While 16 patients (9%) were made an emergency laparotomy due to hemodynamic instability, peritonitis or evisceration, the remaining patients were hospitalized for observation. During the selective conservative follow-up, an early laparotomy was performed in 20 patients (12%), and a late laparotomy was performed in 13 patients (7%); the remaining 126 patients (72%) were discharged after non-operative follow-up. A laparotomy was performed on 49 patients (28%); the laparotomy was therapeutic for 42 patients (86%), non-therapeutic for 4 patients (8%), and negative for 3 patients (6%). A selective conservative approach based on physical examination and clinical follow-up in penetrating anterior abdominal stab injuries is an effective treatment approach.
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Affiliation(s)
- Metin Yucel
- Department of General Surgery, Umraniye Training and Research Hospital Istanbul, Turkey
| | - Gurhan Bas
- Department of General Surgery, Umraniye Training and Research Hospital Istanbul, Turkey
| | - Adnan Ozpek
- Department of General Surgery, Umraniye Training and Research Hospital Istanbul, Turkey
| | - Fatih Basak
- Department of General Surgery, Umraniye Training and Research Hospital Istanbul, Turkey
| | - Abdullah Sisik
- Department of General Surgery, Umraniye Training and Research Hospital Istanbul, Turkey
| | - Aylin Acar
- Department of General Surgery, Umraniye Training and Research Hospital Istanbul, Turkey
| | - Buket Altun Ozdemir
- Department of General Surgery, Umraniye Training and Research Hospital Istanbul, Turkey
| | - Sema Yuksekdag
- Department of General Surgery, Umraniye Training and Research Hospital Istanbul, Turkey
| | - Orhan Alimoglu
- Department of General Surgery, Umraniye Training and Research Hospital Istanbul, Turkey
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More becomes less: management strategy has definitely changed over the past decade of splenic injury--a nationwide population-based study. BIOMED RESEARCH INTERNATIONAL 2015; 2015:124969. [PMID: 25629032 PMCID: PMC4299358 DOI: 10.1155/2015/124969] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 08/14/2014] [Indexed: 11/29/2022]
Abstract
Background. Blunt spleen injury is generally taken as major trauma which is potentially lethal. However, the management strategy has progressively changed to noninvasive treatment over the decade. This study aimed to (1) find out the incidence and trend of strategy change; (2) investigate the effect of change on the mortality rate over the study period; and (3) evaluate the risk factors of mortality. Materials and Methods. We utilized nationwide population-based data to explore the incidence of BSI during a 12-year study period. The demographic characteristics, including gender, age, surgical intervention, blood transfusion, availability of CT scans, and numbers of coexisting injuries, were collected for analysis. Mortality, hospital length of stay, and cost were as outcome variables. Results. 578 splenic injuries were recorded with an estimated incidence of 48 per million per year. The average 12-year overall mortality rate during hospital stay was 5.28% (29/549). There is a trend of decreasing operative management in patients (X2, P = 0.004). The risk factors for mortality in BSI from a multivariate logistic regression analysis were amount of transfusion (OR 1.033, P < 0.001, CI 1.017–1.049), with or without CT obtained (OR 0.347, P = 0.026, CI 0.158–0.889), and numbers of coexisting injuries (OR 1.346, P = 0.043, CI 1.010–1.842). Conclusion. Although uncommon of BSI, management strategy is obviously changed to nonoperative treatment without increasing mortality and blood transfusion under the increase of CT utilization. Patients with more coexisting injuries and more blood transfusion had higher mortality.
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MacGoey P, Navarro A, Beckingham IJ, Cameron IC, Brooks AJ. Selective non-operative management of penetrating liver injuries at a UK tertiary referral centre. Ann R Coll Surg Engl 2014; 96:423-6. [PMID: 25198972 DOI: 10.1308/003588414x13946184901524] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Selective non-operative management (SNOM) of penetrating abdominal injuries has increasingly been applied in North America in the last decade. However, there is less acceptance of SNOM among UK surgeons and there are limited data on UK practice. We aimed to review our management of penetrating liver injuries and, specifically, the application of SNOM. METHODS A retrospective review was performed of patients presenting with penetrating liver injuries between June 2005 and November 2013. RESULTS Thirty-one patients sustained liver injuries due to penetrating trauma. The vast majority (97%) were due to stab wounds. The median injury severity score was 14 and a quarter of patients had concomitant thoracic injuries. Twelve patients (39%) underwent immediate surgery owing to haemodynamic instability, evisceration, retained weapon or diffuse peritonism. Nineteen patients were stable to undergo computed tomography (CT), ten of whom were selected subsequently for SNOM. SNOM was successful in eight cases. Both patients who failed SNOM had arterial phase contrast extravasation evident on their initial CT. Angioembolisation was not employed in either case. All major complications and the only death occurred in the operatively managed group. No significant complications of SNOM were identified and there were no transfusions in the non-operated group. Those undergoing operative management had longer lengths of stay than those undergoing SNOM (median stay 6.5 vs 3.0 days, p<0.05). CONCLUSIONS SNOM is a safe strategy for patients with penetrating liver injuries in a UK setting. Patient selection is critical and CT is a vital triage tool. Arterial phase contrast extravasation may predict failure of SNOM and adjunctive angioembolisation should be considered for this group.
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Affiliation(s)
- P MacGoey
- Nottingham University Hospitals NHS Trust, UK
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Krasniqi AS, Hamza AR, Zejnullahu VA, Sada FE, Bicaj BX. Penetrated sigmoid colon by air gun pellet could be life threatening: A case report. Int J Surg Case Rep 2014; 5:1183-5. [PMID: 25437671 PMCID: PMC4275851 DOI: 10.1016/j.ijscr.2014.11.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 11/07/2014] [Accepted: 11/12/2014] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Air and paintball guns have been in existence for over 400 year. Although serious injury or death can result from the use of such guns, previous literature has not mentioned the issue of the penetration of the sigmoid colon by an air gun pellet. PRESENTATION OF CASE We report a rare case of a 44-year-old Caucasian woman referred to abdominal surgery after an accidental small wound had occurred in the lower left abdominal quadrant that was caused by an air gun pellet. The blood and biochemical analyses were normal but the CT scan revealed the presence of a foreign body – an air gun pellet in the left iliac region of the abdomen. Clinically, during the initial 24 h significant changes were not noticed. After 42 h, however, pain and local tenderness in the lower left abdominal quadrant was expressed. A laparotomy revealed a retained pellet in the wall of the sigmoid colon and a small leak with colonic content with consecutive local peritonitis also occurred. The foreign body was removed and the opening edges in the colon were excised and closed with the primary suture. DISCUSSION The hollow organs of the digestive tract, albeit very rarely penetrated by an air gun pellet, do not typically show all signs of an acute abdomen in the early posttraumatic phase. Such injuries can lead to a pronounced infection, which may cause septic shock if not appropriately treated. CONCLUSION For correct diagnosis, a careful approach and several daily clinical observations are required.
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Affiliation(s)
- Avdyl S Krasniqi
- Faculty of Medicine, University of Prishtina, 10000 Prishtina, Kosovo; Department of Abdominal Surgery, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo.
| | - Astrit R Hamza
- Faculty of Medicine, University of Prishtina, 10000 Prishtina, Kosovo; Department of Abdominal Surgery, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo
| | - Valon A Zejnullahu
- Department of Abdominal Surgery, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo
| | - Fatos E Sada
- Faculty of Medicine, University of Prishtina, 10000 Prishtina, Kosovo; Department of Anesthesiology and Reanimation, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo
| | - Besnik X Bicaj
- Faculty of Medicine, University of Prishtina, 10000 Prishtina, Kosovo; Department of Abdominal Surgery, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo
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Ball CG. Current management of penetrating torso trauma: nontherapeutic is not good enough anymore. Can J Surg 2014; 57:E36-43. [PMID: 24666458 DOI: 10.1503/cjs.026012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
A highly organized approach to the evaluation and treatment of penetrating torso injuries based on regional anatomy provides rapid diagnostic and therapeutic consistency. It also minimizes delays in diagnosis, missed injuries and nontherapeutic laparotomies. This review discusses an optimal sequence of structured rapid assessments that allow the clinician to rapidly proceed to gold standard therapies with a minimal risk of associated morbidity.
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Affiliation(s)
- Chad G Ball
- From the University of Calgary, Calgary, Alta
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Abstract
Abdominal injury as a result of both blunt and penetrating trauma has an appreciable mortality rate from hemorrhage and sepsis. In this article, we present our experience with the management of abdominal trauma in Durban and investigate factors that influence outcome. We performed a prospective study of patients with abdominal trauma in one surgical ward at King Edward VIII Hospital in Durban over a period of 7 years, from 1998 through 2004. Demographic details, cause of injury, delay before surgery, clinical presentation, findings at surgery, management and outcome were documented. There were 488 patients with abdominal trauma with a mean age of 29.2 ± 10.7 years. There were 440 penetrating injuries (240 firearm wounds; 200 stab wounds) and 48 blunt injuries. The mean delay before surgery was 11.7 ± 16.4 hours, and 55 patients (11%) presented in shock. Four hundred and forty patients underwent laparotomy, and 48 were managed nonoperatively. The Injury Severity Score was 11.1 ± 6.7, and the New Injury Severity Score was 17.1 ± 11.1. One hundred and thirty-seven patients (28%) were admitted to the intensive care unit (ICU), with a mean ICU stay of 3.6 ± 5.5 days. One hundred and thirty-two patients developed complications (28%), and 52 (11%) died. Shock, acidosis, increased transfusion requirements, number of organs injured, and injury severity were all associated with higher mortality. Delay before surgery had no influence on outcome. Hospital stay was 9.2 ± 10.8 days. The majority of abdominal injuries in our environment are due to firearms. Physiological instability, mechanism of injury, severity of injury, and the number of organs injured influence outcome.
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An elusive bullet in the gastrointestinal tract: a rare case of bullet embolism in the gastrointestinal tract and a review of relevant literature. Case Rep Crit Care 2014; 2014:689539. [PMID: 24829839 PMCID: PMC4009998 DOI: 10.1155/2014/689539] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 10/23/2013] [Indexed: 11/17/2022] Open
Abstract
Bullet embolism within the gastrointestinal system is extremely rare. Such bullet injuries are infrequently covered in the general literature, but the surgeon should be aware of the phenomenon. Smaller caliber bullets are more common in civilian gunshot wound (GSW) events. These bullets are able to tumble through the gastrointestinal tract and cause perforation of the intestinal lumen which is small enough to be easily missed. Bullets retained in the abdominal cavity should not be dismissed as fixed and should be carefully monitored to ensure that they do not embolize within the bowel and cause occult lesions during their migration. We present a unique case wherein a bullet caused a minute perforation in the small bowel, before migrating to the distal colon, which resulted in late presentation of sepsis secondary to peritonitis.
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Lin HF, Wu JM, Tu CC, Chen HA, Shih HC. Value of diagnostic and therapeutic laparoscopy for abdominal stab wounds: reply. World J Surg 2013; 37:2721-2. [PMID: 23959338 DOI: 10.1007/s00268-013-2179-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Xu J, Wang H, Song ZW, Shen MD, Shi SH, Zhang W, Zhang M, Zheng SS. Foreign body retained in liver long after gauze packing. World J Gastroenterol 2013; 19:3364-3368. [PMID: 23745042 PMCID: PMC3671092 DOI: 10.3748/wjg.v19.i21.3364] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 05/05/2013] [Accepted: 05/17/2013] [Indexed: 02/06/2023] Open
Abstract
This case report describes a foreign body retained in the liver long after perihepatic gauze packing. A 64-year-old female patient had suffered a rib fracture and liver rupture during a traffic accident in 1973. She discovered a mass in her right hypochondrium. Her hepatic ultrasonography showed a round mass (20.3 cm × 17.3 cm × 16.0 cm in size) with fluid echogenicity in the right lobe of her liver, and a hepatic cystic-solid mass (19.7 cm × 18.5 cm × 15.6 cm in size) was identified in an abdominal computerized tomography scan. Several pieces of gauze were extracted, and brown pus from the hepatic mass was suctioned during her exploratory laparotomy. Histology documented gauze remnants with necrotic material inclusions and fibrotic capsules. To our knowledge, this patient’s case represents the longest time for which a foreign body has been retained in the liver. In addition, we conducted a comprehensive literature review of foreign bodies retained in the liver. Foreign bodies may be introduced into the liver via penetrating trauma, surgical procedures or the ingestion of foreign bodies (which then migrate from the gut). Thus, they can be classified into the following three categories: penetrating, medical and migrated foreign bodies. The details of the case are thoroughly described.
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Sanei B, Mahmoudieh M, Talebzadeh H, Shahabi Shahmiri S, Aghaei Z. Do patients with penetrating abdominal stab wounds require laparotomy? ARCHIVES OF TRAUMA RESEARCH 2013; 2:21-5. [PMID: 24396785 PMCID: PMC3876513 DOI: 10.5812/atr.6617] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 02/23/2013] [Accepted: 03/07/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND The optimal management of hemodynamically stable asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe cost-effective manner. Common evaluation strategies are local wound exploration (LWE), diagnostic peritoneal lavage (DPL), serial clinical assessment (SCAs) and computed tomography (CT) imaging. Making a decision about the right time to operate on a patient with a penetrating abdominal stab wound, especially those who have visceral evisceration, is a continuing challenge. OBJECTIVES Until the year 2010, our strategy was emergency laparotomy in patients with penetrating anterior fascia and those with visceral evisceration. This survey was conducted towards evaluating the results of emergency laparotomy. So, better management can be done in patients with penetrating abdominal stab wounds. PATIENTS AND METHODS This retrospective cross-sectional study was performed on patients with abdominal penetrating trauma who referred to Al- Zahra hospital in Isfahan, Iran from October 2000 to October 2010. It should be noted that patients with abdominal blunt trauma, patients under 14 years old, those with lateral abdomen penetrating trauma and patients who had unstable hemodynamic status were excluded from the study. Medical records of patients were reviewed and demographic and clinical data were collected for all patients including: age, sex, mechanism of trauma and the results of LWE and laparotomy. Data were analyzed with PASW v.20 software. All data were expressed as mean ± SD. The distribution of nominal variables was compared using the Chi-squared test. Also, diagnostic index for LWE were calculated. A two-sided P value less than 0.05 was considered to be statistically significant. RESULTS During the 10 year period of the study, 1100 consecutive patients with stab wounds were admitted to Al-Zahra hospital Isfahan, Iran. In total, about 150 cases had penetrating traumas in the anterior abdomen area. Sixty-three (42%) patients were operated immediately due to shock, visceral evisceration or aspiration of blood via a nasogastric tube on admission. Organ injury was seen in 78% of patients with visceral evisceration. Among these 87 cases, 29 patients' (33.3%) anterior fascia was not penetrated in LWE. So, they were observed for several hours and discharged from the hospital without surgery. While for the remaining 58 patients (66.6%), whose LWE detected penetration of anterior abdominal fascia, laparotomy was performed which showed visceral injuries in 11 (18%) cases. CONCLUSIONS All in all, 82 percent of laparotomies in patients with penetrated anterior abdominal fascia without visceral evisceration, who had no signs of peritoneal irritation, were negative. So, we recommended further evaluation in these patients. However, visceral evisceration is an indication for exploratory laparotomy, since in our study; the majority of patients had organ damages.
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Affiliation(s)
- Behnam Sanei
- Department of Surgery, Isfahan University of Medical Sciences, Isfahan, IR Iran
| | - Mohsen Mahmoudieh
- Department of Surgery, Isfahan University of Medical Sciences, Isfahan, IR Iran
| | - Hamid Talebzadeh
- Department of Surgery, Isfahan University of Medical Sciences, Isfahan, IR Iran
- Corresponding author: Hamid Talebzadeh, Department of Surgery, Isfahan University of Medical Sciences, Isfahan, IR Iran. Tel: +98-3112255838, Fax: +98-3112335030, E-mail:
| | | | - Zahra Aghaei
- Department of Surgery, Isfahan University of Medical Sciences, Isfahan, IR Iran
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Penetrating cardiac injury and the significance of chest computed tomography findings. Emerg Radiol 2013; 20:279-84. [PMID: 23471527 DOI: 10.1007/s10140-013-1113-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 02/25/2013] [Indexed: 10/27/2022]
Abstract
In rare circumstances, hemodynamically stable patients can harbor serious penetrating cardiac injuries. We hypothesized that chest computed tomography (CCT) is potentially useful in evaluation. The records of all patients admitted to our center with wounds to the precordium or who sustained a hemothorax or pneumothorax after penetrating torso injuries over a 48-month period were reviewed. Those having an admission CCT were studied. The potential diagnostic value of hemopericardium (HPC) and pneumopericardium (PPC) on CCT was examined. Most of the 333 patients were male [293 (88.0 %)] with a roughly equal distribution of gunshot [189 (56.8 %)] and stab [144 (43.2 %)] wounds. Mean age was 28.7 ± 12.6 years. Thirteen (3.9 %) patients had cardiac injuries that were operatively managed. Eleven (3.3 %) CCT studies demonstrated HPC and/or PPC. Ten of these patients had an injury with one false positive. Retained hemothorax and proximity findings on the three false negative CCT studies led to video-assisted thoracoscopic surgery or subxiphoid exploration with diagnosis of the injury. HPC and/or PPC on CCT had a sensitivity of 76.9 %, specificity of 99.7 %, positive predictive value of 90.9 %, and negative predictive value (NPV) of 99.1 % for cardiac injuries. However, including all findings that changed management, CCT had a sensitivity and NPV of 100 %. CCT is a potentially useful modality for the evaluation of cardiac injuries in high-risk stable patients. The presence of HPC and/or PPC on CCT after penetrating thoracic trauma is highly indicative of a significant cardiac injury.
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Omari A, Bani-Yaseen M, Khammash M, Qasaimeh G, Eqab F, Jaddou H. Patterns of anterior abdominal stab wounds and their management at Princess Basma teaching hospital, North of Jordan. World J Surg 2013; 37:1162-8. [PMID: 23400590 DOI: 10.1007/s00268-013-1931-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With the progressive use of new diagnostic techniques, the management of penetrating abdominal stab wounds is changing. Most studies have been conducted in well-equipped trauma centers in developed countries, and there is a paucity of reports from general teaching hospitals with limited resources. We reviewed the assessment of anterior abdominal stab wounds in patients presenting to our hospital hoping to establish an evidence-based algorithm for managing such patients in busy general hospitals. METHODS The medical records of all 393 patients treated at our hospital for anterior abdominal stab wounds over a 7-year period were reviewed. Information regarding age, gender, site of the stab wound, management, and complications were analyzed. RESULTS Twenty-six patients with hemodynamic instability at presentation underwent urgent laparotomy (LAP); 24 (92.3 %) of those procedures were therapeutic. Local wound exploration (LWE) proved that 114 (31 %) of all hemodynamically stable patients had no abdominal fascia penetration and consequently could be discharged home from the emergency department (ED). A total of 253 patients were found to have fascial penetration, and all were admitted for repeat clinical assessments (RCA) and imaging studies. A total of 121 (48 %) of the patients underwent abdominal exploration with 102 (84 %) therapeutic LAP procedures. CONCLUSIONS Hemodynamic instability and evisceration should continue to prompt urgent LAP. For stable patients, a sequence of LWE followed by focused abdominal sonography for trauma and computed tomography scanning for unclear cases primed by RCA was found to be efficient in limiting hospital admissions and reducing the rate of non-therapeutic LAP.
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Affiliation(s)
- Abdelkarim Omari
- Department of General Surgery, Faculty of Medicine Jordan University of Science and Technology (JUST), P.O. Box 3030, Irbid, Jordan.
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Ouedraogo R, Konsem T, Gyebre Y, Ouedraogo B, Sereme M, Bambara C, Ouattara M, Ouoba K. Experience with head and neck missile injuries at the yalgado university teaching hospital, ouagadougou, burkina faso. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2012; 2:1-9. [PMID: 25452999 PMCID: PMC4220480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND To report the diagnostic and therapeutic options of missile head and neck injuries. AIM AND OBJECTIVES To present our experience in the management of head and neck missile injuries as seen in our centre. METHODOLOGY All the patients with head and neck missile injuries who were managed in the ENT and Dental services of Yalgado University Teaching Hospital, in Ouagadougou, the capital of Burkina Faso between January 2003 and December 2012 were reviewed. The data obtained from medical records included demographic data, history, physical findings, and site of injury, diagnosis, type of treatment/surgery, complications and outcome. RESULTS Out of a total of 32 patients in this study, there were 26 males and 6 females with a sex ratio of 4.3:1. Their ages ranged from 18 to 63 years with a mean of 32 years ± 5.2. The age range of 20-40 accounted for 68.7% of the patients. The injury was accidental in 37.5%, assault in 56.3 and self inflicted/suicide in 6.3%. Most (59.4%) of the patients had multiple injuries while in 50 % of the cases, the injuries affected the face. Surgical intervention was done in 59.4% of the patients and conservative treatment in 40.6 % of the patients. Complications were noted in 52% of the patients. Seven patients died given a mortality rate of 21.9%. CONCLUSION The head and neck missile injuries are not uncommon in our environment with a high mortality and morbidity rates.
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Pereira BMT. Non-operative management of hepatic trauma and the interventional radiology: an update review. Indian J Surg 2012; 75:339-45. [PMID: 24426473 DOI: 10.1007/s12262-012-0712-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 07/18/2012] [Indexed: 12/22/2022] Open
Abstract
The growing trend to manage hepatic injuries nonoperatively has been increasing demand for advanced endovascular interventions. This brings up the necessity for general and trauma surgeons to update their knowledge in such matter. Effective treatment mandates a multispecialty team effort that is usually led by the trauma surgeon and includes vascular surgery, orthopedics, and, increasingly, interventional radiology. The focus on hemorrhage control and the angiographer's unique access to vascular structures gives interventional radiology (IR) an important and increasingly recognized role in the treatment of patients with hemodynamic instability. Our aim is to review the basic concepts of IR primarily in hepatic trauma and secondarily in some other special situations. A liver vascular anatomy review is also needed for better understanding the roles of IR. As a final point we propose a guideline for the operative/nonoperative management of traumatic hepatic injuries. The benefit of multidisciplinary approach (TAE) appears to be a powerful weapon in the medical arsenal against the high mortality of injured trauma liver patients.
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Affiliation(s)
- Bruno Monteiro Tavares Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences (FCM), University of Campinas (UNICAMP), Campinas, SP Brazil ; Faculty of the Division of Trauma Surgery, School of Medicine-University of Campinas-UNICAMP, Campinas, Brazil ; UNICAMP, 181 Rua Alexander Fleming, 13.083-970 Campinas, SP Brazil
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Jiang H, Wang J. Emergency strategies and trends in the management of liver trauma. Front Med 2012; 6:225-33. [PMID: 22673827 DOI: 10.1007/s11684-012-0186-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 01/10/2012] [Indexed: 12/14/2022]
Abstract
The liver is the most frequently injured organ during abdominal trauma. The management of hepatic trauma has undergone a paradigm shift over the past several decades, with mandatory operation giving way to nonoperative treatment. Better understanding of the mechanisms and grade of liver injury aids in the initial assessment and establishment of a management strategy. Hemodynamically unstable patients should undergo focused abdominal sonography for trauma, whereas stable patients may undergo computed tomography, the standard examination protocol. The grade of liver injury alone does not accurately predict the need for operation, and nonoperative management is rapidly becoming popular for high-grade injuries. Hemodynamic instability with positive focused abdominal sonography for trauma and peritonitis is an indicator of the need for emergent operative intervention. The damage control concept is appropriate for the treatment of major liver injuries and is associated with significant survival advantages compared with traditional prolonged surgical techniques. Although surgical intervention for hepatic trauma is not as common now as it was in the past, current trauma surgeons should be familiar with the emergency surgical skills necessary to manage complex hepatic injuries, such as packing, Pringle maneuver, selective vessel ligation, resectional debridement, and parenchymal sutures. The present review presents emergency strategies and trends in the management of liver trauma.
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Affiliation(s)
- Hongchi Jiang
- Department of Hepatic Surgery, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
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Böyük A, Gümüş M, Önder A, Kapan M, Aliosmanoğlu I, Taşkesen F, Arıkanoğlu Z, Gedik E. Splenic injuries: factors affecting the outcome of non-operative management. Eur J Trauma Emerg Surg 2012; 38:269-74. [PMID: 26815958 DOI: 10.1007/s00068-011-0156-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 09/23/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the outcome of non-operative management (NOM) in patients with splenic injuries and to determine the predictive factors of NOM failure. METHODS Two hundred and six patients with splenic injury were admitted between January 2005 and April 2011. Of the 206 patients with splenic injury, 47 patients met the inclusion criteria of NOM. The mechanism of injury, grade of splenic injury, other intra- and extra-abdominal injuries, systolic blood pressure on admission, hemoglobin levels, number of transfusions, Injury Severity Score (ISS), Glasgow Coma Scale score, and hospitalization period were recorded. The patients were divided into two groups: those with NOM and those in whom the failure of NOM led to laparotomy. The patients were monitored for vital signs, abdominal findings, and laboratory data. NOM was abandoned in cases of hemodynamic instability, ongoing bleeding, or development of peritonitis. Independent predictive factors of NOM failure were identified. The patients managed non-operatively were compared with the patients for whom NOM failed. RESULTS NOM was successful in 40 of 47 patients. There were differences between the two groups for ISS, hemoglobin levels, need for blood transfusion, and the number of associated extra-abdominal injuries. The grade of splenic injury was determined to be an important and significant independent predictive factor for the success of NOM of splenic injuries. CONCLUSIONS The grade of splenic injury is an important and significant independent predictor factor for the success of NOM. NOM is not recommended in patients with high-grade splenic injury.
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Affiliation(s)
- A Böyük
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey.
| | - M Gümüş
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - A Önder
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - M Kapan
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - I Aliosmanoğlu
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - F Taşkesen
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - Z Arıkanoğlu
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
| | - E Gedik
- Department of General Surgery, Medical Faculty, Dicle University, Yenişehir, 21280, Diyarbakır, Turkey
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Evolution-based algorithm for the management of penetrating abdominal stab injury. Eur J Trauma Emerg Surg 2012; 38:531-6. [PMID: 26816256 DOI: 10.1007/s00068-012-0188-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Accepted: 03/26/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE As an increasing amount of penetrating abdominal stab injuries has been observed in the last few decades, it is important to evaluate the adequacy of the medical systems and surgical education and training to handle this type of injury. The aim of this study was to analyze the outcome of patients with penetrating abdominal stab injuries admitted to the Emergency Unit and to evaluate the effects of using a new treatment algorithm. METHODS From January 2009 to April 2009, a standardized education and training system for the surgical team was implemented in order to improve the emergency medical care system. From April 2009 to April 2011, 106 patients with the diagnosis of a penetrating abdominal stab injury were prospectively included in the study. RESULTS The cohort included 98 males and the mean age was 29.40 ± 10.9 years. Eighty-two percent of the patients were managed conservatively, whereas 18 % underwent surgery. Based on the surgical outcomes of the patients, the rate of negative, non-therapeutic, and therapeutic laparotomies was 5, 11, and 84 %, respectively. No statistically significant difference between patients who did and did not receive surgery was observed with regards to blood pressure, temperature, hematocrit, hemoglobin, and C-reactive protein (CRP) values. However, a statistically significant difference was observed in the pulse rate, leukocyte, and neutrophil counts. The mortality and morbidity rates were 0.94 and 3.77 %, respectively. CONCLUSIONS Selective non-operative management, which has been standardized in trauma centers, may be carefully utilized in order to treat penetrating abdominal stab wounds with caution in well-equipped medical centers with well-trained staff.
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