Is computed tomography tractography reliable in patients with anterior abdominal stab wounds?

Contrast-enhanced computed tomography abdomen versus diagnostic laparoscopy-based management in patients with penetrating abdominal trauma: a randomised controlled trial

PURPOSE

Penetrating abdominal trauma was traditionally managed by mandatory exploration, which led to high rates of non-therapeutic surgery and prolonged hospital stay. Diagnostic laparoscopy (DL) is a less-invasive alternative; however, it requires general anaesthesia and carries a potential risk of iatrogenic injuries. Contrast-enhanced computed tomography (CECT)-guided selective non-operative management (SNOM) may avoid surgery altogether, but there is apprehension of missed injury. Randomised trials comparing these two modalities are lacking. This study is aimed at comparing outcomes of these two management approaches.

METHODS

Hemodynamically stable patients with penetrating trauma to anterior abdominal wall were randomised in 1:1 ratio to DL or CECT-based management. Primary outcome was length of hospital stay (LOS). Secondary outcomes were rate of non-therapeutic surgery, complications, and length of intensive care unit (ICU) stay.

RESULTS

There were 52 patients in DL group and 54 patients in CECT group. Mean LOS was comparable (3 vs 3.5 days; p = 0.423). Rate of non-therapeutic surgery was significantly lower in CECT group (65.4 vs 17.4%, p = 0.0001). Rate of complications and length of ICU stay were similar. Selective non-operative management based on CECT findings was successful in 93.8% of patients; 2 patients had delayed surgery.

CONCLUSION

In patients with penetrating trauma to anterior abdominal wall, DL and CECT-based management led to comparable hospital stay. Significant reduction in non-therapeutic surgery could be achieved using a CECT-based approach.

TRIAL REGISTRATION

Clinical trials registry-India (CTRI/2019/04/018721, REF/2019/01/023400).

Should the management approach to the anterior abdominal stab wound be different in patients with self-inflicted abdominal injury?

BACKGROUND

Self-inflicted injury is a leading cause of death worldwide. It is hypothesized that due to instincts for self-preservation, the severity of abdominal injury would be decreased following suicidal self-stabbing in comparison to stab wounds from assault, and therefore a more conservative management might be considered.

METHODS

All patients with isolated abdominal stab wound (SW) admitted to 19 Trauma Centers in Israel between the years 1997 and 2018 were included in the study. Patients with self-inflicted abdominal SW (Group I) were compared to victims with abdominal SW following assault (Group II).

RESULTS

Group I included 9.4% (314/3324) of patients eligible for this study. Compared to Group II, Group I patients were older (median: 39 years, IQR 28,52 vs. 24 years, IQR 19,33; p<0.001), had more females (28.7% vs 4.9%, p <0.001), had longer length of hospitalization (median: 3 days vs. 2 days; p<0.001), underwent surgery more frequently (55.4% vs. 37.4%; p<0.001), and had higher mortality (2.9% vs. 0.7%; p=0.003). Possible covariates for mortality were examined and following logistic regression, self-inflicted injury remained associated with higher death rates compared to assault (OR 4.027, CI95% 1.380, 11.749; p=0.011).

CONCLUSION

In this study, patients with isolated self-inflicted abdominal injuries had higher mortality and more frequently underwent abdominal surgery.

Role of hydrogen peroxide injection for penetrating abdominal injury in creating CT Tractogram

Penetrating abdominal trauma is responsible for approximately 35% of patients admitted to urban trauma centers, and up to 12% of those admitted in suburban or rural centers in the United States. Current protocol relies heavily on CT imaging as the diagnostic tool in evaluating for peritoneal violation in hemodynamically stable patients, however it is associated with false negative rates. In addition, visualization of the fascia of the rectus abdominis, the transversalis fascia, and the peritoneum cannot be reliably identified with CT. Studies have probed into the use of injecting IV contrast dyes prior to imaging to establish a CT tractography. We present a case of a 31-year-old male presenting to the emergency department for evaluation of stab wounds following an altercation. On exam, a 1 cm penetrating wound to the LUQ of his abdomen was noted. A CT scan of the abdomen and pelvis was performed with 91 mL of Omnipaque-350 intravenous contrast. Prior to imaging, 30 mL of hydrogen peroxide was injected directly into the opening site of the stab wound to amplify the wound tract. The result was a well-visualized intact peritoneum. We propose hydrogen peroxide as an alternative method to liquid contrast in reestablishing the stab wound tract. This method creates a negative contrast level to augment the ability of CT imaging to determine peritoneal penetration. Key Words: Penetrating Abdominal Injury, CT Tractography, Abdominal Trauma, Hydrogen Peroxide, Trauma Management.

Suprapubic penetrating abdominal trauma - defining peritoneal breach and choices in operative intervention

Penetrating abdominal trauma is an uncommon cause of presentation to emergency departments in Australia and is frequently associated with the clinical need for emergent operative intervention. Advances in imaging modalities, improved laparoscopic techniques and structured approaches to resuscitation in trauma have now allowed potential minimally invasive management of such injuries, avoiding laparotomy and therefore defining peritoneal breach; the major determinant of intra-abdominal organ injury in this setting is critical. We present the case of a self-inflicted stab injury to the suprapubic region in an otherwise healthy man and describe the combination of imaging and operative modalities used to define peritoneal breach in this case which successfully reduced the patient’s morbidity by avoiding non-therapeutic laparotomy.