Selective nonoperative management of penetrating abdominal solid organ injuries

The need for early angiography in patients with penetrating renal injuries

BACKGROUND

Renal injuries occur in as many as 10% of penetrating abdominal wounds. Today, these wounds are often managed selectively, but there is little contemporary information on the natural history of kidney injuries after penetrating trauma. The purpose of this study was to examine the clinical outcomes of penetrating injuries to the kidney, and to determine if these patients may benefit from routine early angiography.

METHODS

All trauma patients admitted to three Level I Trauma Centers with penetrating renal injuries over a 10 year study period were retrospectively reviewed.

RESULTS

We identified 237 patients with a penetrating renal injury, of whom 39 died within the first 24 h and were excluded from analysis. Among the remaining 198 individuals, 130 (66%) underwent immediate exploratory laparotomy. Of the 68 subjects not undergoing immediate surgery, seven had early angiography. The remaining 61 patients (31%) were observed, with 12 (20%) ultimately requiring an intervention to treat the renal injury. Those subjects who failed nonoperative management had significantly fewer hospital-free days compared to those who did not need a procedure (19.2 ± 8.1 vs. 25.7 ± 4.5, p = 0.002).

CONCLUSIONS

Nearly one in three patients with penetrating renal injuries are currently managed with serial observation, although one in five of these subjects ultimately require either angiographic or surgical treatment. We feel that routine use of early angiography may reduce the failure rate and improve outcomes for patients whose penetrating renal injuries are managed nonoperatively.

Current practice and the role of the CT in the management of penetrating liver injuries at a Level I trauma center

Background:

The liberal utilization of computed tomography (CT) has significantly contributed to overall improvements in trauma care. However, the role and the current practice of the CT examinations in the management of patients with penetrating liver injuries are scantily documented.

Aims:

This study was aimed to assess the current practice and the role of the admission and follow-up CT in patients with penetrating liver injuries.

Setting and Design:

This is a retrospective study at a Level I trauma center. Study period is from 01/2005 to 12/2007.

Methods:

All patients with penetrating liver injuries were analyzed.

Results:

Overall, 178 patients with penetrating liver injuries were assessed. A total of 123 (69.1%) patients underwent emergent laparotomy without preoperative CT due to signs of peritonitis (47.8%), hypotension (16.3%), or a GCS of ≤8 (5.1%). In this group of patients, no nontherapeutic laparotomy occurred. The remaining 55 (30.9%) patients underwent CT scan evaluation on admission. Of these, 54.5% were selected for nonoperative management (NOM). Sensitivity and specificity of the admission CT to predict a positive laparotomy was 95.7% and 90.6%, respectively. Overall, 80.6% of isolated liver injuries were successfully managed nonoperatively. Thirty-three (18.5%) patients died within 72 h. In the remaining 145 patients, 33 liver-related complications occurred in 17.2% (25 of 145) of patients.

Conclusion:

Two-thirds of patients with penetrating liver injuries require emergent laparotomy, mainly due to associated injuries. The remaining one-third of patients, however, is amenable for an admission CT, which reliably predicts successful NOM. Moderate or severe injuries require follow-up CT because of the high incidence of asymptomatic liver-related complications.

Management of liver trauma in adults

The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of the liver and use of atriocaval shunt are rarely indicated.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Penetrating abdominal injuries: management controversies

Penetrating abdominal injuries have been traditionally managed by routine laparotomy. New understanding of trajectories, potential for organ injury, and correlation with advanced radiographic imaging has allowed a shift towards non-operative management of appropriate cases. Although a selective approach has been established for stab wounds, the management of abdominal gunshot wounds remains a matter of controversy. In this chapter we describe the rationale and methodology of selecting patients for non-operative management. We also discuss additional controversial issues, as related to antibiotic prophylaxis, management of asymptomatic thoracoabdominal injuries, and the use of colostomy vs. primary repair for colon injuries.

Liver transplantation for severe hepatic trauma: Experience from a single center

Liver transplantation has been reported in the literature as an extreme intervention in cases of severe and complicated hepatic trauma. The main indications for liver transplant in such cases were uncontrollable bleeding and postoperative hepatic insufficiency. We here describe four cases of orthotopic liver transplantation after penetrating or blunt liver trauma. The indications were liver failure, extended liver necrosis, liver gangrene and multiple episodes of gastrointestinal bleeding related to portal hypertension, respectively. One patient died due to postoperative cerebral edema. The other three patients recovered well and remain on immunosuppression. Liver transplantation should be considered as a saving procedure in severe hepatic trauma, when all other treatment modalities fail.

MDCT diagnosis of penetrating diaphragm injury

The purpose of the study was to determine the diagnostic sensitivity and specificity of multidetector CT (MDCT) in detection of diaphragmatic injury following penetrating trauma. Chest and abdominal CT examinations performed preoperatively in 136 patients after penetrating trauma to the torso with injury trajectory in close proximity to the diaphragm were reviewed by radiologists unaware of surgical findings. Signs associated with diaphragmatic injuries in penetrating trauma were noted. These signs were correlated with surgical diagnoses, and their sensitivity and specificity in assisting the diagnosis were calculated. CT confirmed diaphragmatic injury in 41 of 47 injuries (sensitivity, 87.2%), and an intact diaphragm in 71 of 98 patients (specificity, 72.4%). The overall accuracy of MDCT was 77%. The most accurate sign helping the diagnosis was contiguous injury on either side of the diaphragm in single-entry penetrating trauma (sensitivity, 88%; specificity, 82%). Thus MDCT has high sensitivity and good specificity in detecting penetrating diaphragmatic injuries.

The accuracy of FAST in relation to grade of solid organ injuries: a retrospective analysis of 226 trauma patients with liver or splenic lesion

Background

This study investigated the role of a negative FAST in the diagnostic and therapeutic algorithm of multiply injured patients with liver or splenic lesions.

Methods

A retrospective analysis of 226 multiply injured patients with liver or splenic lesions treated at Bern University Hospital, Switzerland.

Results

FAST failed to detect free fluid or organ lesions in 45 of 226 patients with spleen or liver injuries (sensitivity 80.1%). Overall specificity was 99.5%. The positive and negative predictive values were 99.4% and 83.3%. The overall likelihood ratios for a positive and negative FAST were 160.2 and 0.2. Grade III-V organ lesions were detected more frequently than grade I and II lesions. Without the additional diagnostic accuracy of a CT scan, the mean ISS of the FAST-false-negative patients would be significantly underestimated and 7 previously unsuspected intra-abdominal injuries would have been missed.

Conclusion

FAST is an expedient tool for the primary assessment of polytraumatized patients to rule out high grade intra-abdominal injuries. However, the low overall diagnostic sensitivity of FAST may lead to underestimated injury patterns and delayed complications may occur. Hence, in hemodynamically stable patients with abdominal trauma, an early CT scan should be considered and one must be aware of the potential shortcomings of a "negative FAST".

Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents

Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting.

Abdominal perforation after rupture of a diamond-studded wire: a case report

Introduction

There are numerous cases of abdominal injuries due to bullets. Abdominal injuries due to bullets are a diagnostic and therapeutic challenge. Here, an unusual case of an abdominal perforation caused by a metal projectile, lead to confusion in the interpretation of the preoperative computer tomography.

Case presentation

We present an unusual case of a 32-year-old male worker who sustained a "shot" to the left upper abdominal quadrant, as a result of a work-related accident. The projectile derived from a special wire that tore during operation. One chain element happened to accelerate towards the patients belly and perforated the abdominal wall. Computer tomography located the radiopaque projectile to the cortex of the left kidney and showed a lesion of the tail of the pancreas. The presence of intraperitoneal free air suggested a gastrointestinal perforation. Immediate open exploration of the peritoneal cavity and the retroperitoneal space revealed perforating lesions of the anterior and posterior gastric wall, as well as the pancreatic tail. The projectile was finally retrieved in the upper pole of the left kidney. The patient had a good clinical course subsequent to surgery and was discharged in good general condition.

Conclusion

This case represents a rare form of a retained bullet injury and corroborates the need of sufficient measures of worker-protection in area of diamond-studded wire cutting devices.

Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds

The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.