Nontherapeutic Laparotomy Research Articles

The fallacy of a roadmap computed tomography after an abdominal gunshot wound: A road that leads to nowhere.

The 2019 Western Trauma Association guidelines recommend an abdominopelvic computed tomography (CTAP) in patients with a question of abdominal penetration after a gunshot wound. However, it is common practice to obtain a CTAP to provide a roadmap for an operation or to potentially alter management even in patients with classic indications for a laparotomy. The hypothesis for this study was that a CTAP for preoperative planning has no value in patients with an abdominal gunshot wound. This was a retrospective study from 2017 to 2022 of patients with an abdominal gunshot wound who had a preoperative CTAP. Data collection included clinical characteristics and CTAP and operative findings. Admission hypotension, abdominal pain and/or peritonitis, evisceration, and a transabdominal trajectory were considered clear indications for laparotomy. Computed tomography and operative findings were compared to determine concordance and if computed tomography altered management. There were 149 patients included in the study, of which 72.5% had a clear indication for laparotomy. The CTAP findings were concordant with operative findings in 57.0% of patients, while additional injuries were found at laparotomy in 36.2% of patients. Based on CTAP, a negative diagnostic angiogram was performed in three patients (2.0%). Three patients (2.0%) underwent a trial of nonoperative management based on CTAP findings. All underwent laparotomy after a clinical change. Six patients (4.0%) had a nontherapeutic operation; all patients had findings suspicious for either a hollow viscous injury or a vascular injury on preoperative imaging. While a CTAP scan may help to define an intra-abdominal trajectory when the trajectory is unclear, it does not alter management in those with indications for operation. In addition, CTAP missed injuries in a third of patients and contributed to all six nontherapeutic laparotomies. A preoperative CTAP has minimal value in patients who have indications for an operation. Diagnostic Test/Criteria; Level IV.

Non-therapeutic laparotomies in military trauma (2009-2014).

Combat casualties are frequently injured in austere settings where modern imaging modalities are unavailable. Exploratory laparotomies are often performed in these settings when there is suspicion for intra-abdominal injury. Prior studies of combat casualties reported non-therapeutic laparotomy (NTL) rates as high as 32%. Given improvements in combat casualty care over time, we evaluated NTLs performed during later years of the wars in Iraq and Afghanistan. Military personnel with combat-related injuries (6/1/2009-12/31/2014) who underwent exploratory laparotomy based on concern for abdominal injury (i.e. not performed for proximal vascular control or fecal diversion) and were evacuated to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals were assessed. An NTL was defined as a negative laparotomy without substantial intra-abdominal injuries requiring repair. Characteristics, indications for laparotomy, operative findings, and outcomes were examined. Among 244 patients who underwent laparotomies, 41 (16.8%) had NTLs and 203 (83.2%) had therapeutic laparotomies (i.e. positive findings). Patients with NTLs had more computed tomography scans concerning for injury (48.8% vs 27.1%; p = 0.006), less penetrating injury mechanisms (43.9% vs 71.9%; p < 0.001), and lower Injury Severity Scores (26 vs 33; p = 0.003) compared to patients with therapeutic laparotomies. Patients with NTLs were also less likely to be admitted to the intensive care unit (70.7 vs 89.2% for patients with therapeutic laparotomies; p = 0.007). No patients with NTLs developed abdominal surgical site infections (SSI) compared to 16.7% of patients with therapeutic laparotomies (p = 0.002). There was no significant difference in mortality between the groups (p = 0.198). Our proportion of NTLs was lower than reported from earlier years during the wars in Iraq and Afghanistan. No infectious complications from NTLs (i.e. abdominal SSIs) were identified. Nevertheless, surgeons should continue to have a low threshold for exploratory laparotomy in military patients in austere settings with concern for intra-abdominal injury.

A clinical observation algorithm for anterior abdominal stab wound is safe in an Australian setting.

We previously published the outcomes associated with the use of diagnostic laparoscopy to determine peritoneal breach for AASW patients without an immediate indication for laparotomy. Although this pathway was 100% sensitive there was a 54% non-therapeutic laparotomy rate. Another option that has been extensively reported is the clinical observation algorithm (COA) however, majority of the data originate from high-volume centres. We hypothesized that a COA would also be a safe option in an Australian setting, and reduce the rate of non-therapeutic operative intervention in managing AASW. This was a prospective cohort study examining patients with AASW admitted to a level 1 trauma centre in Sydney, Australia, between June 2021 and August 2023. Patient, injury, management and outcome data were collected from electronic medical records and the hospital trauma registry. Data were then analysed to determine the diagnostic accuracy of the COA, complication rates and median hospital length-of-stay (LOS). A total of 48 patients presented with AASW. Of these patients, 11 (22.9%) proceeded to immediate laparotomy. Seven patients had a contraindication to COA and underwent diagnostic laparoscopy. Thirty patients were managed with the COA, with three (10%) patients subsequently requiring a laparotomy. Only one patient (3.3%) underwent a non-therapeutic laparotomy. There were no missed injuries. The COA sensitivity was 100%, specificity 92.7%, PPV 50% and NPV 100%. Patients managed with COA had no complications. Overall median hospital LOS was 1 day (1.0-2.3). A COA is a safe approach for evaluating patients with AASW in an Australian setting with adequate resources. It reduces the rate of non-therapeutic operative intervention and has acceptable outcomes compared with a diagnostic laparoscopy pathway.

CT evaluation of bowel wall enhancement in pneumatosis intestinalis: preventing non-therapeutic laparotomies.

To evaluate the diagnostic performance of bowel wall enhancement for diagnosing concomitant bowel ischemia in patients with parietal pneumatosis (PI) diagnosed at abdominal CT. From January 1, 2012 to December 31, 2021, 226 consecutive patients who presented with PI on abdominal CT from any bowel segment were included. Variables at the time of the CT were retrospectively extracted from medical charts. CT examinations were blindly analyzed by two independent radiologists. The third reader classified all disagreement of bowel enhancement in three categories: (1) normal bowel enhancement; (2) doubtful bowel wall enhancement; (3) absent bowel wall enhancement. Multivariable logistic regression analysis was performed. Concomitant bowel ischemia was defined as requirement of bowel resection specifically due to ischemic lesion in operated patients and death from bowel ischemia in non-operated patients. Overall, 78/226 (35%) patients had PI associated with concomitant bowel ischemia. At multivariate analysis, Only absence or doubtful bowel wall enhancement was associated with concomitant bowel ischemia (OR = 167.73 95%CI [23.39-4349.81], P < 0,001) and acute mesenteric ischemia associated with PP (OR = 67.94; 95%CI [5.18-3262.36], P < 0.009). Among the 82 patients who underwent a laparotomy for suspected bowel ischemia, rate of non-therapeutic laparotomy increased from 15/59 (25%), 2/6 (50%) and 16/17 (94%) when bowel wall enhancement was absent, doubtful and normal respectively. Absence of enhancement of the bowel wall is the primary feature associated with concomitant bowel ischemia. It should be carefully assessed when PI is detected to avoid non-therapeutic laparotomy.

Surgery for Locally Advanced Pancreatic Cancer Following Induction Chemotherapy: A Single-Center Experience

BackgroundThe use of surgery in patients with locally advanced pancreatic cancer (LAPC) following induction chemotherapy is increasing. However, most series do not report on the total cohort of patients undergoing surgical exploration; therefore, this single-center study investigates outcomes among all consecutive patients with LAPC who underwent surgical exploration.MethodsWe conducted a retrospective, single-center analysis including all consecutive patients with LAPC (Dutch Pancreatic Cancer Group criteria) who underwent surgical exploration with curative intent (January 2014–June 2023) after induction therapy. Primary outcomes were resection rate and overall survival (OS) from the time of diagnosis.ResultsOverall, 127 patients underwent surgical exploration for LAPC, whereby 100 patients (78.7%) underwent resection and 27 patients (21.3%) underwent a non-therapeutic laparotomy due to the extent of vascular involvement (n = 11, 8.7%) or occult metastases (n = 16, 12.6%). The overall in-hospital/30-day mortality rate was 0.8% and major morbidity was 31.3% (in patients after resection: 1.0% and 33.3%, respectively). The overall 90-day mortality rate was 5.5%, which included 3.1% mortality due to disease progression. Resection was associated with longer median OS {29 months (95% confidence interval [CI] 26–43) vs. 17 months (95% CI 11–26); p < 0.001} compared with patients undergoing non-therapeutic laparotomy, with corresponding 5-year OS rates of 28.4% and 7.7%. In Cox proportional hazard regression analysis, only pancreatic body/tail tumors independently predicted OS (hazard ratio 1.788 [95% CI 1.042–3.068]).ConclusionThis single-center series found a resection rate of 78.7% in patients with LAPC selected for surgical exploration, with a low risk of mortality and morbidity in all explored patients and a 5-year OS rate after resection of 28.4%.

Clinical predictors of therapeutic laparotomy in anterior abdominal stab injuries: a multicenter study from low-income institutions in Ethiopia.

Despite the high incidence of abdominal stab injuries, the rate of nontherapeutic laparotomies and the predictors of therapeutic laparotomies have rarely been studied in low-income settings. This multicenter retrospective study involved three of the largest academic medical centers in central Ethiopia. All patients who sustained an anterior abdominal stab injury and underwent exploratory laparotomy, regardless of the intraoperative findings, were included over the 3-year course of the study. Of the 117 patients who underwent exploratory laparotomy, 35 patients (29.9%) underwent nontherapeutic laparotomies. Three factors predicted therapeutic laparotomy: hollow viscus evisceration (adjusted odds ratio [AOR], 5.77; 95% confidence interval [CI], 1.16-28.64; P=0.032), localized and generalized peritonitis (AOR, 4.77; 95% CI, 1.90-11.93; P=0.001), and white blood cell count ≥11,500/mm3 (AOR, 2.77; 95% CI, 1.002-7.650; P=0.049). The overall positive predictive value of the therapeutic predictors was 80.2%, while the negative predictive value of all predictor-negative patients was 58.1%. The predictors would have prevented 51.4% of the nontherapeutic laparotomies. Close to one-third of the patients had a nontherapeutic laparotomy. The clinical predictors of therapeutic laparotomy were shown to have a high positive predictive value despite a lower negative predictive value. Further prospective studies that involve all patients who sustain anterior abdominal stab injuries are needed to potentially improve on the negative predictive value of the predictors suggested by our study.

Penetrating abdominal stab and gunshot injuries: 10-year experience of a secondary public hospital located in a suburban area with solo surgeons.

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. 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. 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. 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.

Laparoscopic ultrasonography along with staging laparoscopy as a tool for staging in patients with hepatopancreaticobiliary malignancy - A prospective cohort study from a tertiary care centre.

Staging laparoscopy (SL) plays an important role in avoiding unnecessary non-therapeutic laparotomy in radiologically resectable hepatopancreaticobiliary (HPB) malignancy patients. The limitation of SL is to detect deep-seated malignancy. The addition of laparoscopic ultrasonography for identifying metastatic lesions or locally unresectable disease improves the diagnostic yield of SL. This prospective, observational study was conducted in a single unit of the tertiary care centre between 2017 and 2019. All the patients of HPB malignancy who were radiologically resectable underwent SL and laparoscopic intraoperative ultrasonography. Metastatic disease patients were either underwent palliative bypass procedures or abandoned depending on the condition of the patient. Patients who had resectable disease underwent standard surgical procedures. Forty patients of HPB malignancy with potentially resectable on radiological imaging underwent SL and diagnostic ultrasonography. Out of 40, 21 patients had periampullary, 14 had carcinoma gallbladder and 5 patients had distal cholangiocarcinoma. Metastatic lesions were identified on laparoscopy in eight patients and the diagnostic yield of SL is 20%. Addition of laparoscopic ultrasonography identified one haemangioma which was false positive on laparoscopy and underwent the radical standard procedure. Four patients were unresectable so the procedure was abandoned and another three patients underwent a bypass procedure. Laparoscopic ultrasonography during SL can detect deep-seated metastatic lesions and decide the management in resectable disease.

Role of laparoscopy in management of patients with anterior abdominal stab wounds.

In this retrospective cohort study, we assessed the utility of laparoscopic surgery for diagnostic and therapeutic purposes in patients with anterior abdominal stab wounds (AASWs). We also investigated patient characteristics that might suggest a greater suitability of laparoscopic interventions. Over a 25-year span, we analyzed AASW patients who had operations, categorizing them based on the presence of significant intra-abdominal injuries and whether they received laparoscopic surgery or laparotomy. We compared variables such as preoperative conditions, surgical details, and postoperative outcomes. We further evaluated the criteria indicating the necessity of direct laparotomies and traits linked to overlooked injuries in laparoscopic surgeries. Of 142 AASWs surgical patients, laparoscopic surgery was conducted on 89 (62.7%) patients. Only 2 (2.2%) had overlooked injuries after the procedure. Among patients without significant injuries, those receiving laparoscopic surgery had less blood loss than those receiving laparotomy (30.0 vs. 150.0ml, p = 0.004). Patients who underwent laparoscopic surgery also had shorter hospital stays (significant injuries: 6.0 vs. 11.0days, p < 0.001; no significant injuries: 5.0 vs. 6.5days, p = 0.014). Surgical complications and overlooked injury rates were comparable between both surgical methods. Bowel evisceration correlated with higher laparotomy odds (odds ratio = 16.224, p < 0.001), while omental evisceration did not (p = 0.107). Laparoscopy is a safe and effective method for patients with AASWs, fulfilling both diagnostic and therapeutic needs. For stable AASW patients, laparoscopy could be the preferred method, reducing superfluous nontherapeutic laparotomies.

Role of diagnostic laparoscopy in comparison with CT scan finding of patients presenting with abdominal trauma-A cross-sectional study

Background: Trauma is a critical and urgent surgical condition that we encounter on a regular basis. Blunt trauma mechanisms account for 78.9–95.6% of all injuries, with the abdomen being affected in 6.0–14.9% of all traumatic injuries. Diagnostic laparoscopy (DL) for blunt abdominal trauma (BAT) is safe and feasible. Prerequisites are the hemodynamic stability of the patient and surgical expertise in advanced laparoscopy. Aims and Objectives: To find out the role of DL in the diagnosis and management of abdominal trauma patients. Effect on the length of hospital stay and rate of reduction of non-therapeutic laparotomy in the patients with trauma abdomen. Materials and Methods: This cross-sectional study was conducted with 50 patients of abdominal trauma with pre-structured pro forma and Written informed consent. A contrast-enhanced computed tomography (CECT) scan of the abdomen was done in hemodynamically stable patient and injury was noted. Patients meeting the inclusion criteria underwent DL. Results: The duration of hospital stay was lower in laparoscopically managed patients than in laparotomy patients. Most of the patients were managed conservatively 37 (74%) and thus by reducing non-therapeutic laparotomy. Overall recovery was 86% which signifies the reduction in mortality rate with the use of DL. In this study, clear diagnosis was obtained in 88% of the cases, so the efficacy is 88%. Conclusion: Laparoscopy and CECT abdomen has an effective diagnostic and management role in patients with BAT. The therapeutic value of DL is also accepted, well appreciated, and it cannot be underestimated.

Identifying Radiographic and Clinical Indicators to Reduce the Occurrence of Nontherapeutic Laparotomy for Blunt Bowel and Mesenteric Injury.

Roughly 5% of patients with blunt abdominal trauma (BAT) have a blunt bowel and/or mesenteric injury (BBMI). Determining the need for operative management in these patients can be challenging when hemodynamically stable. Single center studies have proposed scoring systems based on CT findings to guide management. Our study aimed to determine the predictability of abdominopelvic CT scan (CT A/P) findings in conjunction with clinical exam to determine the necessity of operative intervention for BBMI. Patients presenting from 2017 to 2022 to the University of South Alabama Level 1 Trauma Center after motor vehicle collision were retrospectively reviewed. Patients with CT findings suggestive of BBMI were further analyzed, noting CT findings, Glasgow coma scale (GCS), shock index, abdominal exam, operative or nonoperative management, and intraoperative intervention. 1098 patients with BAT underwent CT A/P. 139 patients had ≥1 finding suggestive of BBMI. 38 patients underwent surgical exploration and 30 had surgically confirmed BBMI. 27 patients required intervention for BBMI. Univariate analysis indicated that pneumoperitoneum (p < 0.0001), active extravasation of contrast (p = 0.0001), hemoperitoneum without solid organ injury (SOI) (p < 0.0001), peritonitis (p < 0.0001), and mesenteric stranding(p < 0.05) were significantly associated with intervention. In total, 30 patients had surgically confirmed BBMI. Active extravasation, pneumoperitoneum, hemoperitoneum without SOI, mesenteric stranding, and peritonitis were significant indicators of BBMI requiring intervention. CT and clinical findings cannot reliably predict the need for surgical intervention without ≥1 of these findings. Initial nonoperative management with serial clinical exams should be strongly considered to reduce incidence of nontherapeutic laparotomies.

Role of laparoscopy in patients with abdominal trauma: Rashid Hospital Trauma Center experience

Background: Exploratory laparotomy has been the standard intervention for surgical evaluation or treatment of abdominal trauma. Laparoscopic surgery with its proposed favorable surgical outcome may provide a reliable and accurate diagnosis of the injury. In this study, we aim to define the diagnostic role of laparoscopy in abdominal trauma and define the proposed advantages of reducing nontherapeutic laparotomies. Methodology: The study is a cohort retrospective study conducted at a level I trauma center – Rashid Hospital, United Arab Emirates. All patients from January 2016 to May 2019 with a history of abdominal trauma requiring surgical intervention fulfilling the inclusion criteria were included. The outcome of this study was to look at the rate of reduction of nontherapeutic laparotomies and the rate of missed injury. Results: The rate of reduction of nontherapeutic laparotomy in patients with abdominal trauma using diagnostic laparoscopy was 19.4%. Post-operative complications were higher in the open exploration group (p-value = 0.04). No missed injury was reported among the laparoscopy group. The mean hospital stay was higher in the laparotomy group compared to the laparoscopy group (13.6 vs 17.1). Laparoscopy was successful in 68.4% of the patients and the conversion rate was 31.6%. Conclusions: Laparoscopy has a role in the diagnosis of intra-abdominal injuries of hemodynamically stable patients with suspected abdominal injury to reduce unnecessary laparotomies, thereby decreasing postoperative complications.

Preoperative Management of Perihilar Cholangiocarcinoma.

Simple SummaryIn patients diagnosed with potentially resectable perihilar cholangiocarcinoma, deliberate and coordinated preoperative workup and optimization of the patient and future liver remnant are crucial. Strategic optimization and multidisciplinary evaluation may reduce the rate of unnecessary procedures, perioperative complications, and non-therapeutic laparotomy for unresectable disease. In this review, we describe preoperative assessment and optimization of patients with perihilar cholangiocarcinoma, including imaging workup, evaluation of resectability, preoperative drainage and hypertrophy-inducing procedures, and the role of diagnostic laparoscopy.Perihilar cholangiocarcinoma is a rare hepatobiliary malignancy that requires thoughtful, multidisciplinary evaluation in the preoperative setting to ensure optimal patient outcomes. Comprehensive preoperative imaging, including multiphase CT angiography and some form of cholangiographic assessment, is key to assessing resectability. While many staging systems exist, the Blumgart staging system provides the most useful combination of resectability assessment and prognostic information for use in the preoperative setting. Once resectability is confirmed, volumetric analysis should be performed. Upfront resection without biliary drainage or portal venous embolization may be considered in patients without cholangitis and an estimated functional liver remnant (FLR) > 40%. In patients with FLR < 40%, judicious use of biliary drainage is advised, with the goal of selective biliary drainage of the functional liver remnant. Percutaneous biliary drainage may avoid inadvertent contamination of the contralateral biliary tree and associated infectious complications, though the relative effectiveness of percutaneous and endoscopic techniques is an ongoing area of study and debate. Patients with low FLR also require intervention to induce hypertrophy, most commonly portal venous embolization, in an effort to reduce the rate of postoperative liver failure. Even with extensive preoperative workup, many patients will be found to have metastatic disease at exploration and diagnostic laparoscopy may reduce the rate of non-therapeutic laparotomy. Management of perihilar cholangiocarcinoma continues to evolve, with ongoing efforts to improve preoperative liver hypertrophy and to further define the role of transplantation in disease management.

Work-Up and Outcome of Hepatic Resection for Peri-Hilar Cholangiocarcinoma (PH-CCA) without Staging Laparoscopy.

Simple SummaryThis is a single centre cohort of patients undergoing surgery for PH-CCA suggests that routine staging laparoscopy may not be necessary in the pre-operative work-up.Background: This study reports the outcome of a work-up programme for resection of peri-hilar cholangiocarcinoma (PH-CCA) without the use of staging laparoscopy. Methods: This is a clinical case cohort series of patients undergoing surgical resection of PH-CCA without the use of staging laparoscopy in the work-up algorithm. During the 13 years from 1 January 2009 to 1 January 2022, 32 patients underwent laparotomy for planned surgical resection of PH-CCA. Data were collected on demographic profile, admission biochemistry, radiology, pre-operative intervention, operation and outcome, together with post-operative complications and disease-free and overall survival. Results: All patients underwent pre-operative contrast-enhanced CT. Twenty-four (75%) underwent pre-operative MR. Twenty-three (72%) underwent pre-operative biliary drainage. Twenty-nine patients (91%) had either type III or IV peri-hilar cholangiocarcinoma. One patient (3%) in this series underwent a non-resectional laparotomy. Twenty-nine (91%) had a final histopathological diagnosis of PH-CCA. One further patient had a final diagnosis of an intraductal papillary neoplasm of the biliary tree (IPNB) with high-grade dysplasia but no invasive cancer. Eleven patients (36%) received chemotherapy after surgery. The median (95% CI) time to recurrence was 14 (7–31) months. The median survival was 25 (18-upper limit not reached) months. Conclusion: This cohort of 32 patients undergoing attempted resection for PH-CCA without the use of staging laparoscopy in the work-up algorithm indicates that with careful attention to patient fitness and cross-sectional and interventional radiologic/endoscopic imaging, a very low non-therapeutic laparotomy rate of 3% can be achieved and sustained.

Outcome of laparotomy and conservative treatment of patients with acute mesenteric venous ischemia with viable bowel

BackgroundAcute mesenteric ischemia (AMI) is one of the most serious abdominal emergencies. Predicting the onset of bowel necrosis that warrants surgical intervention is of paramount importance in AMI. The present study aimed to investigate the outcome of patients with AMI secondary to mesenteric venous occlusion (MVO) and the consequence of non-therapeutic exploratory laparotomy.MethodsThe records of 132 patients with AMI were retrospectively reviewed. The outcome of patients with acute mesenteric venous ischemia (AMVI) and viable bowel was analyzed based on the method of treatment: conservative versus surgical. The impact of non-therapeutic laparotomy on the outcome of patients with AMVI in terms of morbidity, readmission, and mortality was analyzed.ResultsForty-seven patients (34 male) with AMVI had viable bowel. Of the 47 patients with viable bowel, 8 (17%) had an exploratory non-therapeutic laparotomy, whereas 39 patients were treated conservatively. Patients who had non-therapeutic laparotomy had significantly higher complication (50 vs 5.1%, p = 0.005) and readmission rates (37.5 vs 5.1%, p = 0.03) and longer hospital stay (8.5 vs 7 days, p = 0.02) than those treated conservatively. Patients with bowel necrosis who had a therapeutic laparotomy had slightly lower rates of morbidity and mortality as compared to patients with viable bowel who underwent a non-therapeutic laparotomy.ConclusionCareful assessment and informed decision-making in patients with AMVI are crucial to avoid unnecessary surgical intervention that can result in higher rates of complications and readmission and extended hospital stay.

Limitations of laparoscopy to assess the peritoneal cancer index and eligibility for cytoreductive surgery with HIPEC in peritoneal metastasis

PurposeWe aimed to determine the value of laparoscopy to assess the intra-abdominal tumor extent and predict complete cytoreduction.MethodsAll patients at our department in the period from 2017 to 2021 that underwent laparoscopy to assess peritoneal metastasis and subsequent open exploration with the intention to perform cytoreductive surgery (CRS) with HIPEC were retrospectively identified in a continuously maintained database.ResultsForty-three patients were analyzed. Peritoneal cancer index (PCI) determination by laparoscopy compared to open surgery was overestimated in five patients (11.6%), identical in eleven patients (25.6%), and underestimated in 27 patients (62.8%). PCI differences were independent of surgeons, tumor entities, and prior chemotherapy. Thirty-four patients (79.1%) were determined eligible for CRS with HIPEC during open exploration, whereas nine patients (20.9%) underwent a non-therapeutic laparotomy. Complete or almost complete cytoreduction was achieved in 33 patients (76.7%). In one patient, completeness of cytoreduction was not documented.ConclusionsWe demonstrate a moderate agreement according to weighted Cohen’s kappa analysis of PCI values calculated during laparoscopy and subsequent open exploration for CRS with HIPEC. Uncertainty of PCI assessment should therefore be kept in mind when performing laparoscopy in patients with peritoneal metastasis.

The Management of Pancreatic Trauma - A Continuous Challenge.

Background: The aim of this analysis was to assess the factors that influence the severity of pancreatic trauma cases, also underlining the importance of early and accurate diagnosis and proper management of each case. Methods: This study is a retrospective analysis of patients that were presented to the Clinical Emergency Hospital of Bucharest, Romania, in several periods of time: 1985-1990 (50 patients); 1990-1999 (102 patients); 2000-2005 (56 patients); 2012-2019 (48 patients). Results: The mean age was around 40 years old, with predominance of male incidence in all the groups and traffic accidents (blunt trauma) as the main cause of injury. Most patients (almost 50% in each group) were operated on within the first 24 hours from hospital presentation. The general mortality rate varied: 42% (1985-1990), 23.5% (1990-1999), 12.7% (2000-2005) and 33% (2012-2015). Pancreatic mortality rate was 6% (1985-1990 and 1990-1999), 3.5% (2000-2005) and 8% (2012-2019). Conclusions: During the last 35 years, the preoperative diagnosis in patients with trauma of the pancreas remained a challenge and the treatment of the pancreatic trauma suffered a very interesting evolution- from the very frequent laparotomy to the nonoperative management and the damage control. These procedures produced a significant decreasing of the negative or nontherapeutic laparotomies. For the effectiveness of treatment, methods must be correlated with the lesion score.

Expectant management in delayed presentation of war casualties with penetrating abdominal trauma

IntroductionWhile the management of acute civilian abdominal injuries is well established, The literature regarding the management of battle-related abdominal injuries presented in a delayed fashion is scarce. The objective of this study was to investigate the safety of non-operative management approach in delayed evacuation of battle-related abdominal injuries. MethodsClinical records of thirty-seven hemodynamically normal patients with battle related injuries and Computed Tomography (CT) findings of penetrating abdominal trauma were retrospectively studied. ResultsAll 37 patients suffered penetrating abdominal injuries during the civil war in Syria. In this complex scenario, the casualties presented after a minimum 12-hour delay to our hospital. All patients had abnormal abdominal CT scans with no clinical peritoneal signs. Twenty-one [of the 37] patients exhibited 29 hard signs on CT scan. Of these, 17 patients were treated non-operatively and 4 underwent exploratory laparotomy (of which 2 were non-therapeutic). Sixteen patients exhibited a total of 75 soft signs on CT scan; 15 were treated non-operatively and one underwent non-therapeutic laparotomy. No complications were recorded in either the operative or non-operative groups. In total, 32 patients (86%) were treated non-operatively. Five patients (14%) underwent exploratory laparotomy (3 of which were non-therapeutic). Length of stay was dependent on the unique requirements of each individual patient as determined by the state department for returning across the border. ConclusionWe propose that in battle related casualties, acute survivable penetrating abdominal trauma may be safely treated non-operatively in selected patients who are hemodynamically normal and in whom there is an absence of abdominal pain or tenderness on repeated clinical assessment.

EP.FRI.99 Penetrating Abdominal Trauma: Comperative Study Between Operative and Conservative Management

Abstract Aim to Assess the feasibility and safety of selective non-operative management in penetrating abdominal injuries and to identify a protocol for selection of patient candidates for non-operative management. Methods In this comparative study 40 abdominal stab victims (admitted to Emergency Department) were selected during a 6 months period where 20 patients were suitable for non-operative management according to strict selection criteria whereas the other 20 patients were operated according to clinical and/or radiological indications or on basis of department protocol, the results were compared in view of final outcome. Results In our study, 15 patients were assigned for operative management according to selected clinical and/or radiological indications only 3 of them (20%) had non-therapeutic laparotomies, On the other hand, five patients were explored on basis of department protocol in violation of our indications for exploration; four of them (80%) were non-therapeutic. So, the rate of non-therapeutic laparotomies was significantly higher when done mandatory without selected clinical and radiological indications. Conclusion Assessment of vital signs together with abdominal examination are the most important and dependable tools in decision making in penetrating abdominal trauma patients. Patients with shock on admission (but responding to resuscitation), proved low grade solid organ injury (by CT), and proved intraperitoneal collection (by US or CT) could be managed conservatively regarding that they remain vitally and clinically stable. If failure of conservation occurs, it is usually during the 1st 24 hours after admission.

90 Penetrating Abdominal Trauma: Comperative Study Between Operative and Conservative Management

Abstract Aim to Assess the feasibility and safety of selective non-operative management in penetrating abdominal injuries and to identify a protocol for selection of patient’s candidates for non-operative management. Method In this comparative study 40 abdominal stab victims (admitted to Emergency Department of Alexandria Main University Hospital) were selected during 6 months period where 20 patients were suitable for non-operative management according to strict selection criteria whereas the other 20 patients were operated according to clinical and/or radiological indications or on basis of department protocol, the results were compared in view of final outcome. Results In our study, 15 patients were assigned for operative management according to selected clinical and/or radiological indications only 3 of them (20%) had non-therapeutic laparotomies, On the other hand, five patients were explored on basis of department protocol in violation of our indications for exploration; four of them (80%) were non-therapeutic. So, the rate of non-therapeutic laparotomies was significantly higher when done mandatory without selected clinical and radiological indications. Conclusions Assessment of vital signs together with abdominal examination are the most important and dependable tools in decision making in penetrating abdominal trauma patients. Patients with shock on admission (but responding to resuscitation), proved low grade solid organ injury (by CT), and proved intraperitoneal collection (by US or CT) could be managed conservatively regarding that they remain vitally and clinically stable. If failure of conservation occurs, it is usually during the 1st 24 hours after admission.