 
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Journal of the New Zealand Medical Association,
12-December-2008, Vol 121 No 1287
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Management of low-velocity, non-gunshot-wound
penetrating abdominal injury: have we moved with the times?
Li Hsee, Ian Civil
Traditionally in the Australasian context, penetrating
injuries to the abdomen have been surgically
explored.1 If there was evidence that there was
a breach of peritoneum, laparotomy was mandatory.
Over the past decade, the availability of various imaging
modalities, such as Focused Abdominal Sonography for Trauma (FAST), improved CT
imaging, and improvements in laparoscopic techniques have influenced overseas
practice in managing this population of patients.
While high volume penetrating trauma centres have generally
used observation liberally, low volume centres have tended to have an invasive
approach. Over recent years, a negative FAST/Diagnostic Peritoneal Lavage (DPL)
or lack of CT evidence of intra-abdominal injury has resulted in a non-operative
approach in many trauma centres.2
In Auckland, New Zealand, where the case volume of
penetrating abdominal wounds is small compared to other overseas trauma
centres,3 and the working hours of the surgical
residents are strictly controlled by safe working hour legislation, a more
aggressive surgical approach has usually been undertaken.
Increased usage of imaging modalities such as CT and
ultrasound scans and the acquisition of advanced laparoscopic
skills4 in training has also occurred in New
Zealand.
To determine whether the advances in surgical practice have
affected our management of patients with penetrating abdominal injuries we
undertook this retrospective study.
Patients and MethodsPatients were identified from the Auckland City
Hospital trauma registry5 over a 10-year period
(1996–2005). Patients with penetrating abdominal injury were identified
using the relevant mechanism of injury and abdominal AIS
codes.6 The anatomical description of the
abdomen was defined from the level of fourth intercostal space to the groin.
Gun shot wounds were excluded. The medical files of
these patients were retrospectively reviewed. Demographics including age,
gender, ISS score, LOS, ICU admission days, location of injury, and initial
vitals signs were recorded. All patients who had operative procedures had their
operative notes, especially their intraoperative findings reviewed in
detail.
The study population was subdivided into two groups for
comparison purposes: the earlier group (1996–2000) and the later group
(2001–2005). The number of patients who had observation only, laparoscopy
only, laparoscopy converted to laparotomy, and laparotomy were recorded. In
addition, the number patients who had negative laparotomy, and those who had
therapeutic/non therapeutic surgery were noted. Statistical comparisons were
performed using Fisher’s exact test.
ResultsThere were 13,366 trauma patients admitted to Auckland City
Hospital during this period. 123 patients were identified who had sustained
non-gunshot wound injuries to the abdomen. This represented of 0.9% of total
trauma admissions. The earlier and later group consists of 63 and 60 patients,
respectively. The characteristics of the two groups are listed in Table 1. There
were no statistically significant differences.
Table 1. Characteristics of the two injury
groups
ISS=Injury Severity Score; ICU=Intensive Care
Unit.
Treatment approaches are outlined in Table 2. Again, no
statistical differences were recorded between the two cohorts.
Table 2. Treatment approaches
Table 3. Abdominal location of penetrating
wound
Table 4. Associated injuries of study
groups
DiscussionAt Auckland City Hospital, clinical guidelines govern the
management of low-velocity, non-GSW penetrating abdominal injuries. The protocol
is outlined below (Figure 1). This is consistent with the protocol outlined by
Sugrue et al7 (A N Z J of Surgery.
2007:77:616).
Figure 1. Auckland City Hospital clinical
protocol for management of haemodynamically stable penetrating lower chest or
abdominal stab wounds
 *Chest tube in situ for all chest
injuries.
When a patient presented to the resuscitation room in the
emergency department with cardiovascular instability, peritonitis or obvious
evisceration of abdominal contents they are taken to the operating room for
laparotomy. The group of patients that present with stable abdominal penetrating
injuries are the group where investigation and management can be
controversial.8
In our two cohorts of patients, basic demographic data are
similar. All of the patients were discharged alive except for one patient in the
second group who died of chemical poisoning as a part of his suicide attempt.
They have similar ISS, pulse rate and systolic blood pressures on initial
admission.
The types of injuries (intentional vs unintentional) and the
anatomical locations of the penetrating wounds were also similar in the two
groups. The length of hospital stay and ICU admission days tended to be shorter
in the later group.
In the operative management of the two cohorts of patients,
we have not identified any differences in terms of rate of laparoscopy and
laparotomy. Despite the passage of time, increasing laparoscopic skills, and
increasing non-operative management of trauma patients generally, laparotomy is
still used frequently in the two cohorts of patients in our institution.
In the earlier and later groups 65% and 70% respectively of
patients went straight to a laparotomy. Despite the increasing availability of
laparoscopic instruments and expertise, we have not found a substantial increase
in the utilisation of such procedures in these patients.
Three percent and 5% of patients had laparoscopy only to
determine whether there was a breach of abdominal fascia. Eight and 12% of
patients had laparoscopy converted to laparotomy in the early and late groups,
respectively.
Despite the safety of laparoscopy in
trauma,9,10 its use at the Auckland City
Hospital has been limited. It has been suggested appropriate use of laparoscopy
may avoid non-therapeutic laparotomy in up to 75% of patients rendering it
cost-effective for the health organisation.11
In our two cohorts of patients, there were 17.3% and 20% of
patients who had negative laparotomy and a further 23.9% and 30% who had a
non-therapeutic laparotomy. These numbers are high compared to other trauma
centres.12
We believe that this number of negative laparotomies and non
therapeutic laparotomies can be reduced if laparoscopic procedures were being
utilised more frequently.13 Although all
consultant general surgeons have acquired expertise in advanced laparoscopic
techniques, most of these acute operations are performed by duty surgical
registrars.
Auckland City Hospital provides an active educational
programme for trainees and consultants. Monthly trauma rounds and fora, and an
annual trauma conference, have been run for more than 10 years. A Definitive
Surgical Trauma Care (DSTC) course has also been run annually during the second
5-year period. However, the laparoscopic abilities of surgical registrars vary
and acute cases are often dealt with out of hours.
The educational efforts maybe targeting a more senior group
than those who actual treat the patients. The result may be more laparotomies
rather than laparoscopies in the management of these patients.
The usage of CT scans to diagnose hollow viscous injuries
has its limitations.14,15 These diagnoses often
rely on a high index of suspicion, presence of free gas and/or fluids on the
scan. Because of the potential of such injuries being missed, operative
exploration is the gold standard. However, in selected cases such as a right
upper quadrant stab wound, a CT scan prior to theatre for operative planning is
often useful especially when liver injury is considered likely.
In stable posterior and flank wound patients, CT imaging may
also be helpful in determining the extent of
injuries.15 While the “selective
conservatism”2,16 approach makes good
sense in theoretical practice, this concept is clinically challenging in
Australasia. This is due to the shorter surgical resident shifts, lack of
clinical consistency in doing serial examinations, and the fear of potential
missed serious injuries when the abdomen is unexplored.
In conclusion, our study has shown two remarkably similar
cohorts of patients. Their surgical management has also been remained similar.
Despite the availability of laparoscopic procedures and advanced imaging
techniques, we have not seen a change of practice in our surgical unit.
Reasons for lack of change maybe the generally small numbers
of such patients, lack of relevant skills amongst junior staff, failure of
supervision, or failure of educational process within the hospital. Although
overall outcomes were satisfactory, additional costs and patient morbidity may
have been incurred.
Competing interests: None known.
Author information: Li Hsee, Trauma Fellow;
Ian Civil, Director; Trauma Services, Auckland City Hospital, Auckland
Correspondence: Dr Li Hsee, Trauma
Services, Auckland City Hospital, PO Box 92024, Auckland, New Zealand. Fax: +64
(0)9 3078931; email: lchsee@gmail.com
References:
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|