Penetrating Abdominal Trauma Research Articles

English

4 ORIGINAL PROF-3079 ABSTRACT… Background: An intestinal stoma is an opening of intestine on the anterior abdominal wall made surgically. The commonly performed procedures include colostomy and ileostomy. The purpose of the present study was to identify indications for commonly performed intestinal stomas and to study complications related to it. Objective: To identify indications for commonly performed intestinal stomas and to study complications related to it. Study Design: Observational study. Setting: Department of General Surgery, Unit- B, Lady reading Hospital, Peshawar. Period: 1 st Jan 2013, to 31 st Dec 2013. Subjects and Method: A total of 106 patients who underwent surgery and ended up in intestinal stomas, ileostomy or colostomy, were included in the study. Indications, immediate and late complications of stomas were recorded. Results: A break up of 106 patients of different intestinal stomas. Majority (61.32%) of patients were males. There were 49 ileostomies and 57 cases of colostomy making a total of 106 patients. Main indications of Ileostomy were enteric perforation (55.10%), and intestinal tuberculosis (20.40%). Main indications of colostomy were penetrating injuries (50.88%), and intestinal obstruction. In a total of 106 stomas local complications appeared in 23 (21.69%). Skin excoriation, ulceration, lap and wound infection were the most common respectively. Seventy eight stomas including 36 ileostomies and 42 colostomies were closed on an average of 3 months after primary operation. There were 7 cases of wound infection, 2 anastamotic leak-ages and one mortality (1.3%) in the stoma reversal group. Conclusion: Common indications for intestinal stomas were abdominal penetrating trauma, enteric perforation, intestinal obstruction and intestinal tuberculosis. Main complications included local skin problems, wound infection and retraction.

Laparoscopy in Pediatric Abdominal Trauma: A 13-Year Experience.

Introduction Abdominal injuries are common, costly, deadly, and a source of considerable uncertainty in pediatric trauma. In some circumstances, laparoscopy offers a diagnostic and therapeutic alternative with less morbidity than standard exploration, and more certainty than most imaging. In this study, we review our experience with laparoscopic exploration for trauma. We hypothesized that laparoscopy could be employed effectively in stable blunt or penetrating trauma patients in whom diagnostic uncertainty was unresolved by imaging. Patients and Methods A retrospective review of the trauma database identified all children admitted to our Level I pediatric trauma center between January 1, 2000, and December 31, 2012, requiring surgical abdominal exploration. The utilization of laparoscopy and laparotomy was charted over the 13-year period. Negative laparoscopies and laparotomies and nontherapeutic laparoscopies and laparotomies were examined to investigate clinical scenarios in which laparotomy might have been avoided. Statistical analyses were performed using descriptive statistics, simple linear regression analysis, and Mann-Whitney U test (p < 0.05). Results Over the 13-year study period, there were 16,321 trauma admissions. Of these, 119 patients (0.7%) required surgical abdominal exploration: 81 patients underwent laparotomy and 38 patients underwent laparoscopy. In 13 patients (34.2%), laparoscopic exploration ruled out injuries. In nine patients (23.7%), laparoscopy identified an injury for which no surgical intervention was necessary. In nine patients (23.7%), an injury was repaired laparoscopically. In seven cases (18.4%), the identified injury required conversion to laparotomy. There were no missed injuries. In the laparotomy group, a less invasive approach could have yielded the same information in 8.7% of patients. Laparoscopy was more likely to be used after a qualitative change in institutional minimally invasive surgical capability. Conclusion Laparoscopy reliably resolves diagnostic uncertainty in selected cases of pediatric abdominal blunt and penetrating trauma. In a hemodynamically stable patient with a concerning exam and inconclusive imaging, laparoscopy provides sensitive diagnostic capability and opportunity for definitive repair with diminished surgical morbidity.

Experiences of Conflict Zone-Related Ballistic Renal Injury.

To analyze our approaches and experiences in patients with renal injuries accompanying penetrating abdominal injuries admitted to the hospital due to high kinetic energy weapons. Patients including renal injuries associated with penetrating abdominal injuries due to gunshot wounds and fragments of shell treated at our institution between February 2002 and May 2013 were retrospectively analyzed. Total 21 patients were included in this study, 20 of whom (86.2%) were male and 1 (13.8%) female. Renal injury was scaled in 2 patients as grade 1, 4 patients as grade 2, 4 patients as grade 3, 8 patients as grade 4, and 3 patients as grade 5. While conservative treatment was applied to patients with grade 1 and 2 injuries, 2 patients with grade 3 injury underwent renal repair and the other 13 patients underwent nephrectomy. The amount of blood transfused in all cases was determined to be mean 8.28 (6-16) units for red blood cells (ES) and 9 (6-17) units for fresh frozen plasma. When patients were assessed according to the Penetrating Abdominal Trauma Index (PATI) scores, the median score and average PATI score were 35 and 37.6 (10-70), respectively. A physical examination along with a quick assessment of vital signs should be made, and unnecessary and time-consuming investigations such as abdominal tomography and angiographic intervention should be avoided. Conservative and organ preservation should be considered absolutely for appropriately selected patients, namely in stable patients in whom kinetic energy transfer is less and who have bullet path away from midline. However, the majority of these patients are considered to be hemodynamically unstable condition, possible complications of the procedure to be applied, and selection of patients should be carefully evaluated.

Imaging of abdominal and pelvic injuries from the Boston Marathon bombing.

The aim of this study is to describe the imaging findings of abdominal and pelvic injuries in victims of the Boston Marathon bombing. A retrospective review of 87 patients following the Boston Marathon bombing was performed to evaluate for abdominal and pelvic injuries on plain radiography or CT scans of the abdomen and pelvis. Imaging exams were evaluated for shrapnel, soft tissue injury, visceral damage, vascular disruption, and fractures. The injuries were classified as primary, secondary, tertiary, and quaternary blast injuries. Eleven of the 87 patients had positive findings in the abdomen or pelvis (M:F = 7:4, average age 34.6 years). There were 22 ball bearings, two nails, one screw, and two irregular metal fragments in the 11 patients with secondary blast (shrapnel) injuries. There was no peritoneal penetration or visceral injury seen in any of the patients. One patient had multiple transverse process fractures, representing tertiary blast injury. All but one patient had superficial penetrating abdominal or pelvic injuries secondary to shrapnel. There were no cases of bowel or solid visceral organ injuries due to the lack of peritoneal violation from the relatively low-powered explosions. Absence of peritoneal penetration by shrapnel indicates no need for laparotomy following low-powered explosions.

The Role of Laparoscopy in Penetrating Abdominal Trauma: Our Initial Experience.

Diagnostic and therapeutic laparoscopy is a known approach in managing patients with penetrating abdominal trauma (PAT). However, multiple controversies exist on indications, contraindications, and its appropriateness. The aim of this study was to evaluate the appropriateness of diagnostic and therapeutic laparoscopy in patients with PAT at Dr George Mukhari Academic Hospital, Pretoria, South Africa. This was a retrospective, observational study. All patients with PAT managed by diagnostic and therapeutic laparoscopy during 2012-2013 were included. Recorded indications and contraindications, the mechanism of injury, the anatomical location of injury, intraoperative findings, reasons for conversion, and adverse outcomes (complications, reoperations and mortality) were analyzed in every case. One hundred fourteen patients were included. Stab injuries were sustained by 81 (71%) patients, and 33 (29%) patients sustained gunshot wounds (GSW) to the abdomen. The conversion rate was 7%. The operation was completed laparoscopically in 106 patients: 79 with stab wounds (74.5%) and 27 with GSW (25.5%). Laparoscopy was diagnostic for 44 patients (41.5%) and therapeutic for 62 patients (58.5%). In total, 13 patients (12%) required re-intervention, and 2 patients died (1.9%). The complications were not specific to the laparoscopic approach. No missed injuries were reported in the study. Diagnostic and therapeutic laparoscopy in patients with PAT is an appropriate management in hemodynamically stable patients or those responsive to initial resuscitation. The location of injuries is not a limiting factor, although it affects placement of ports. The conversion is not a complication but rather the correct way of completing the operation in an appropriate situation. It should be considered in patients with extensive intraabdominal bleeding suggesting the possibility of major vessel injury, a significant deterioration of the patient, and the complexity of injuries requiring a prolonged laparoscopic procedure.

Successful management of severe penetrating abdominal aortic injury by the Pringle maneuver and thoracic aortic cross-clamping

Successful management of severe penetrating abdominal aortic injury by the Pringle maneuver and thoracic aortic cross-clamping

Major chemical burn injury combined with a penetrating injury of the abdomen leading to hypovolemic shock

Summary A chemical burn is a specific type of lesion and represents a small proportion of all cutaneous burns. The incidence of such burns can be as high as 10.7%, and they account for up to 30% of all burn deaths. They require individualized treatment and management depending on the causative agent. Sometimes, a chemical burn might be complicated with other major forms of trauma, making it more difficult to manage. This report details the successful treatment of a major sulfuric acid burn complicated with an abdominal penetrating injury leading to hypovolemic shock. A 38-year-old woman presented with major second- and third-degree chemical burn injuries over her chin, anterior chest, and both upper limbs. The burns covered approximately 15% of her total body surface area and were combined with an abdominal penetrating injury and hypovolemic shock. Emergency damage control surgery was performed to stabilize the patient's vital signs. Second-stage reconstruction and debridement with skin grafting was performed when the patient had reached a relatively stable condition. At a 1-year follow-up, the patient had recovered well, capable of full-range motion over her neck and in both upper limbs and exhibiting no scar contracture. The combination of a chemical burn and trauma has a high potential morbidity and mortality rate. The initial management of this condition involves stabilization and resuscitation, as in the management of traumas without burn injuries. Damage control surgery with intensive care is the most urgent, followed by management of the burn wounds. After immediate treatment, management strategies are considerably similar for chemical and thermal burns.

Spontaneous regeneration capacity of controlled small bowel perforations: an experimental study in rats.

Selective observation method has started to replace routine laparotomy application for abdominal penetrating trauma patients after Shaftan's selective observation method applied in the 1960s. In this respect, there is a possibility of bowel perforations healing without operations. An experimental model was established in this study in order to clarify this possibility. Fifty Wistar-Albino rats were divided into five groups, ten in each. While one group served as the control, distal part of the small bowel of the rats in the other four groups was perforated 1, 2, 3, and 4 mm in diameter with appropriate cutters. After a week of observation, test rats were sacrificed and relaparotomy was applied. The test material consisting of the perforated bowel, covering 1 cm of proximal and distal margins, and some peritoneal tissue was taken for histopathological examination. Small bowel perforations with a diameter of 2 mm or below healed spontaneously without any operation. Peritonitis intensity increased in direct ratio with perforation diameters. Wall repair capacity of the bowel diminished with increasing perforation diameters. It was observed that small perforations in the small bowel of rats could be limited by the organism itself without a necessity of any surgical intervention.

Conservative Management of Anterior Abdominal Penetrating Trauma

Background Selective conservative management of abdominal penetrating trauma can significantly minimize the morbidity and length of hospitalization by decreasing the rate of unnecessary laparotomies. Objectives In the present study, we reported the outcome of newest guidelines of our trauma center in one year. Patients and Methods All patients with anterior abdominal stab wounds who were referred to Rajaiee trauma center between September 2012 and September 2013 were enrolled. Patients without shock, peritonitis, and evisceration who did not require emergency operation were planned for nonoperative management with serial physical examinations, blood cells count, and radiographic investigations. Outcome of nonoperative management was described in order to reveal the advantages and disadvantages of our current guideline. Results Among 45 patients who underwent nonoperative management, 27 cases (60%) required laparotomy due to peritonitis or shock. Rate of unnecessary nontherapeutic operations was 49.2%. Conclusions Minimizing diagnostic procedures such as diagnostic peritoneal lavage and computed tomography can significantly increase the rate of unnecessary operations leading to longer hospitalizations and operation-related morbidity. To reduce the failure rate of nonoperative management and nontherapeutic surgeries, modifications in current guidelines should be made.

To Scan or Not to Scan, That is the Question

Background Selective conservative management of abdominal penetrating trauma can significantly minimize the morbidity and length of hospitalization by decreasing the rate of unnecessary laparotomies. Objectives In the present study, we reported the outcome of newest guidelines of our trauma center in one year. Patients and Methods All patients with anterior abdominal stab wounds who were referred to Rajaiee trauma center between September 2012 and September 2013 were enrolled. Patients without shock, peritonitis, and evisceration who did not require emergency operation were planned for nonoperative management with serial physical examinations, blood cells count, and radiographic investigations. Outcome of nonoperative management was described in order to reveal the advantages and disadvantages of our current guideline. Results Among 45 patients who underwent nonoperative management, 27 cases (60%) required laparotomy due to peritonitis or shock. Rate of unnecessary nontherapeutic operations was 49.2%. Conclusions Minimizing diagnostic procedures such as diagnostic peritoneal lavage and computed tomography can significantly increase the rate of unnecessary operations leading to longer hospitalizations and operation-related morbidity. To reduce the failure rate of nonoperative management and nontherapeutic surgeries, modifications in current guidelines should be made.

Selective Nonoperative Management of Pediatric Penetrating Abdominal Trauma

Penetrating abdominal trauma from gunshot or stab wounds accounts for just 10% of all abdominal injuries in children. Exploratory laparotomy has been the surgical dictum for the evaluation penetrating abdominal injuries; however, accumulating data in the adult and pediatric literature indicate that selective nonoperative management may be safely considered in hemodynamically stable children after careful clinical examination and appropriate radiographic evaluation. We describe 2 children with penetrating abdominal injury who were managed successfully nonoperatively and briefly review the literature on this approach in children.

Successful selective angiographic embolisation of a gastroduodenal pseudoaneurysm following penetrating abdominal trauma.

New endoscopic and endovascular therapies have revolutionised the management of complex traumatic visceral aneurysms. A pseudoaneurysm of the gastroduodenal artery following penetrating abdominal trauma was successfully managed by selective angiographic embolisation.

Right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literature review.

IntroductionDiaphragmatic injuries are rare consequences of thoracoabdominal trauma and they often occur in association with multiorgan injuries. The diaphragm is a difficult anatomical structure to study with common imaging instruments due to its physiological movement. Thus, diaphragmatic injuries can often be misunderstood and diagnosed only during surgical procedures. Diagnostic delay results in a high rate of mortality.MethodsWe report the management of a clinical case of a 45-old man who came to our observation with a stab wound in the right upper abdomen. The type or length of the knife used as it was extracted from the victim after the fight. CT imaging demonstrated a right hemothorax without pulmonary lesions and parenchymal laceration of the liver with active bleeding. It is observed hemoperitoneum and subdiaphragmatic air in the abdomen, as a bowel perforation. A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy.ConclusionIn countries with a low incidence of inter-personal violence, stab wound diaphragmatic injury is particularly rare, in particular involving the right hemidiaphragm. Diaphragmatic injury may be underestimated due to the presence of concomitant lesions of other organs, to a state of shock and respiratory failure, and to the difficulty of identifying diaphragmatic injuries in the absence of high sensitivity and specific diagnostic instruments. Diagnostic delay causes high mortality with these traumas with insidious symptoms. A diaphragmatic injury should be suspected in the presence of a clinical picture which includes hemothorax, hemoperitoneum, anemia and the presence of subdiaphragmatic air in the abdomen.

Candida albicans spondylodiscitis following an abdominal stab wound: Forensic considerations

Candida albicans spondylodiscitis is a fungal infection of the spine which is still unusual in spite of the increasing frequency of predisposing factors. A 22-year-old man received an abdominal stab wound during a physical assault. Initial medical care included surgery, prolonged use of indwelling vascular catheters with administration of broad-spectrum antibiotics, and hospitalization in intensive care. Two months after the event, the victim experienced back pain in the right lumbar region and septic spondylodiscitis secondary to C. albicans was diagnosed three weeks later. This case is noteworthy because of its clinical forensic context. In France, the public prosecutor orders a medico-legal assessment after an assault for all living victims in order to establish a causal relationship between the assault and its complications. In our case, the patient presented numerous risk factors for candidemia and the forensic specialist reasonably accepted that the causal relationship was certain but indirect. We have only found one published case of spondylodiscitis after an abdominal penetrating injury and the pathogenic agent was not mentioned. We have found no case reported in a forensic context. This unusual observation shows that it may be genuinely difficult to prove the causal relationship between an abdominal penetrating injury and an unusual infectious complication such as fungal spondylodiscitis.

Pyogenic vertebral osteomyelitis complicating abdominal penetrating injury: case report and review of the literature

Pyogenic vertebral osteomyelitis is a rare condition usually associated with endocarditis or spinal surgery. However, it may also occur following abdominal penetrating trauma with associated gastrointestinal perforation. Diagnosis might be challenging and appropriate treatment is essential to ensure a positive outcome. In trans-abdominal trauma, 48 hours of broad-spectrum antibiotics is generally recommended for prophylaxis of secondary infections. A case report of vertebral osteomyelitis complicating trans-colonic injury to the retroperitoneum is presented and clinical management is discussed in the light of literature review.

Laparoscopic removal of an occult foreign body causing penetrating abdominal trauma in a child

An otherwise healthy four-year-old boy was brought to the emergency department by his mother several hours after he had an unwitnessed fall at home. He had been playing with his friends, when they found him bleeding through his shirt. He had no relevant past medical or surgical history, medication

Prophylactic antibiotics for penetrating abdominal trauma

Penetrating abdominal trauma occurs when the peritoneal cavity is breached. Routine laparotomy for penetrating abdominal injuries began in the 1800s, with antibiotics first being used in World War II to combat septic complications associated with these injuries. This practice was marked with a reduction in sepsis-related mortality and morbidity. Whether prophylactic antibiotics are required in the prevention of infective complications following penetrating abdominal trauma is controversial, however, as no randomised placebo controlled trials have been published to date. There has also been debate about the timing of antibiotic prophylaxis. In 1972 Fullen noted a 7% to 11% post-surgical infection rate with pre-operative antibiotics, a 33% to 57% infection rate with intra-operative antibiotic administration and 30% to 70% infection rate with only post-operative antibiotic administration. Current guidelines state there is sufficient class I evidence to support the use of a single pre-operative broad spectrum antibiotic dose, with aerobic and anaerobic cover, and continuation (up to 24 hours) only in the event of a hollow viscus perforation found at exploratory laparotomy. To assess the benefits and harms of prophylactic antibiotics administered for penetrating abdominal injuries for the reduction of the incidence of septic complications, such as septicaemia, intra-abdominal abscesses and wound infections. Searches were not restricted by date, language or publication status. We searched the following electronic databases: the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2013, issue 12 of 12), MEDLINE (OvidSP), Embase (OvidSP), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Conference Proceedings Citation Index- Science (CPCI-S) and PubMed. Searches were last conducted in January 2013. All randomised controlled trials of antibiotic prophylaxis in patients with penetrating abdominal trauma versus no antibiotics or placebo. Two authors screened the literature search results independently. We identified no trials meeting the inclusion criteria. There is currently no information from randomised controlled trials to support or refute the use of antibiotics for patients with penetrating abdominal trauma.

Is Extended Antibiotic Prophylaxis Necessary after Penetrating Trauma to the Thoracolumbar Spine with Concomitant Intraperitoneal Injuries?

Prolonged courses of broad-spectrum antibiotics are often cited as standard care for the prevention of infectious complications in thoracolumbar or sacral (TLS) fractures following penetrating abdominal trauma. Perforation of a hollow viscus in addition to a TLS fracture is believed to be associated with a high incidence of spine infection. Because over use of antibiotics is associated with an increasing prevalence of multi-drug-resistant organisms, this study seeks to define the actual risk of infection of the spine and need for antibiotics in patients with TLS fractures and intraperitoneal injuries following penetrating trauma. A retrospective review of 67 patients with penetrating abdominal trauma and concomitant TLS fracture was performed. Demographics, level of TLS fracture, associated spinal cord injury (SCI), need for operative intervention, presence of concomitant hollow viscus injury, and type and duration of antibiotic coverage were collected. In addition, associated infectious complications were reviewed. Spine infections were defined as spinal or paraspinal abscess, osteomyelitis of the spine, or meningitis. Intraabdominal infections were defined with imaging studies or positive peritoneal cultures. Sixty-seven patients (mean age of 27 ± 9 years) had an exploratory laparotomy and one or more TLS fractures. Four patients died within 24 h and were excluded from further study. Thirty-eight patients (60%) had one or more hollow viscus injuries, 13 (21%) had solid organ injuries alone and 12 (19%) had a non-therapeutic laparotomy. All patients received perioperative antibiotics; 92% received 48 h or less of antibiotic prophylaxis and 62% received only 24 h of antibiotics. In one patient with an isolated solid organ injury there was a spine infection (1%). In this study, 92% of patients received antibiotics for 48 h or less with no increased incidence of spine infections. Bacterial colonization of the vertebrae was not higher in patients with penetrating gastrointestinal injury. There is insufficient evidence to support the use of prolonged antibiotic prophylaxis to prevent spine infection in patients with penetrating abdominal trauma and TLS fracture.

An evaluation of embolisation in the management of haemorrhage from traumatic solid organ injury at a level 1 major trauma centre

An evaluation of embolisation in the management of haemorrhage from traumatic solid organ injury at a level 1 major trauma centre

A multi faceted quality improvement programme results in improved outcomes for the selective non-operative management of penetrating abdominal trauma in a developing world trauma centre

IntroductionThe selective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is well established in our environment. As a quality-improvement initiative, we aimed to re-evaluate patient outcomes with PAT. This follows the application of new imaging and diagnostic modalities using protocolised management algorithms. MethodologyA prospectively maintained digital registry was retrospectively interrogated and all patients with PAT treated by our service from January 2012 to March 2013 were included in this study. ResultsA total of 325 patients sustained PAT during the fourteen-month study period. This included 238 SWs, 80 GSWs and 7 impalement injuries. 11 patients had eviscerated bowel, and 12 had eviscerated omentum. A total of 123 patients (38%) were selected for a trial of SNOM. This included 103 SWs, 15 GSWs and 5 impalement injuries. Emergency laparotomy was performed on 182 patients (115 SWs, 65 GSWs and 2 impalement injuries) and 21 patients with left sided thoraco-abdominal SWs underwent definitive diagnostic laparoscopy (DL). SNOM was successful in 122 cases (99%) and unsuccessful in one case (1%). In the laparotomy group 161 (88%) patients underwent a therapeutic procedure, in 12 cases (7%) the laparotomy was non-therapeutic and in 9 cases (5%) the laparotomy was negative. In the laparoscopy group (24), two patients required conversion for colonic injuries and one for equipment failure. Seven (33.3%) laparoscopies were therapeutic with the identification and intra-corporeal repair of seven left hemi-diaphragm injuries. ConclusionWe have improved our results with the SNOM of PAT and have also managed to safely and successfully extend the role of SNOM to abdominal GSWs. We have selectively adopted newer modalities such as laparoscopy to assess stable patients with left thoraco-abdominal SWs and abdominal CT scan for the SNOM of abdominal GSWs.