Outcomes of Nonoperative Management of Penetrating Abdominal Trauma Injury: A Retrospective Study

BACKGROUND

The treatment of penetrating abdominal injuries has changed in recent years with more focus on "nonoperative management" (NOM) to avoid unnecessary laparotomies while identifying injuries early. Although the NOM approach is widely used for stab wounds, its effectiveness in managing abdominal gunshot wounds is controversial. NOM of penetrating abdominal injuries is becoming more dependent on hemodynamic stability and improved noninvasive radiological interventions. The role of NOM is significantly underreported and underestimated in developing countries, particularly in fragile and conflict-affected states such as Yemen. The present study aims to evaluate the clinical outcomes of NOM in penetrating abdominal trauma injury patients and identify factors associated with NOM failure in a low-resource setting.

METHODS

A retrospective study from January 2021 to December 2022 including patients diagnosed with penetrating abdominal trauma at the General Military Hospital, Sana'a, Yemen, was conducted. Hemodynamically stable patients without peritonitis or clear indications for immediate laparotomy were candidates for NOM and were included in the study. Patients with blunt abdominal injuries, penetrating wounds outside the abdomen, particularly head injury, eviscerated structures, and gastrointestinal hemorrhage, or those pronounced dead on arrival were excluded. The primary outcome was the success and failure rate of NOM necessitating laparotomy. The secondary outcome was the factors associated with NOM failure.

RESULTS

During the study, 256 patients with penetrating abdominal injury were admitted, with 222 (86.7%) undergoing immediate laparotomy and 34 (13.3%) treated with NOM. The mean age was 27.6±7.4 years. Bump explosions, mostly sharp objects (secondary blast injuries), were the main causes of injury (n=18, 52.9%). Other causes were low-velocity gunshot wounds, stab wound injuries, and shotgun injuries in 14 (41.2%), one (2.9%), and one (2.9%), respectively. The majority of patients (n=25, 55.9%) were admitted within 6-24 hours of the incident. The abdominal computed tomography (CT) scan revealed various injuries in all patients, including hemoperitoneum in 11 (32.4%), pneumoperitoneum in five (14.7%), liver injury in 15 (44.1%), foreign body attached to the wall colon in 23 (67.6%), kidney injury in two (5.9%), and splenic injury in one (2.9%). NOM was successful in 31 (91.2%) patients. NOM failed in three (8.8%). One patient was treated via the laparoscopic procedure, and two patients were treated with laparotomy procedures. Five (14.7%) cases required intensive care unit (ICU) admission, with no deaths or major complications. In univariate analysis, the presence of free intra-abdominal fluid (pneumoperitoneum) on the initial CT scan and the need for ICU admission were associated with NOM failure and were statistically significant (p<0.05).

CONCLUSION

Our findings support that some penetrating abdominal trauma patients can benefit from NOM. The goal of preventing unnecessary laparotomies should be aligned with a comprehensive comprehension of the clinical signs and symptoms of NOM failure and the necessity for surgical intervention. Serial abdominal examinations remain the foundation of selected NOM; nevertheless, radiological and laboratory tests can be important tools in decision-making. In this study, free intra-abdominal fluid on the initial CT scan and the need for ICU admission were associated with NOM failure.

Diagnostic performance of sonography in penetrating torso trauma: a systematic review and meta-analysis

BACKGROUND

This systematic review investigates the diagnostic value of ultrasound in the evaluation of torso injuries following a penetrating trauma.

METHODS

We searched PubMed, Scopus, and WOS databases for related original articles until May 7, 2023, and extracted data related to diagnostic performance. The bivariate model and hierarchic summary receiver operating characteristic (HSROC) approach were used to calculate pooled diagnostic values. Cochrane Q test and I-squared were performed to evaluate heterogeneity. We assessed heterogeneity with meta-regression.

RESULTS

Seventeen studies were included, which involved a total number of 1866 patients. According to meta-analysis, sonography demonstrated a pooled sensitivity of 56% (45-67%) and specificity of 96% (94-97%), positive likelihood ratio (LR +) of 13.66 (8.03-23.23), and negative likelihood ratio (LR-) of 0.45 (0.35-0.59) for detecting abdominal injuries. In pericardial penetrating trauma, pooled sensitivity was 100% (45-100%), pooled specificity was 99% (96-100%), LR + was 136.7 (24.8-752.3), and LR- was 0.00 (0.00-1.22). For thoracic penetrating trauma, pooled sensitivity was 99% (93-100%) and specificity was 100% (98-100%).

CONCLUSIONS

Sonography demonstrated promising diagnostic value in the initial assessment of torso penetrating trauma, particularly in the thoracic and pericardial regions. However, the sensitivity of sonography is limited in abdominal penetrating trauma and a combination with other imaging modalities should be considered in these cases.

Cesena guidelines: WSES consensus statement on laparoscopic-first approach to general surgery emergencies and abdominal trauma

BACKGROUND

Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma.

METHODS

This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement.

RESULTS

A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma.

CONCLUSIONS

The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

Concordance of CT imaging and surgical lesions in penetrating abdominal trauma

OBJECTIVE

The management of penetrating abdominal wounds has greatly benefited from the development of computed tomography (CT), particularly in stable patients. In this setting, the scanner is the reference examination. Our study aims to evaluate the performance of preoperative CT in the assessment of penetrating abdominal lesions.

MATERIAL AND METHODS

Between January 1, 2015 and January 1, 2022, 81 patients were hospitalized following penetrating abdominal trauma at the Army Training Hospitals of Sainte-Anne and Laveran. Fifty-one stable patients who had an abdominopelvic CT scan and thereafter underwent abdominal surgery (laparotomy or laparoscopy) were included. Radiological and surgical data were collected from the electronic record and compared by a descriptive analysis (calculation of the sensitivity, specificity, positive and negative predictive value of the CT for the detection of lesions of the various organs) and by a correlation of the CT findings with surgical findings using Kripendorff's alpha coefficient.

RESULTS

The cohort was largely male (n=45; 88%), with injuries by knife wound in 62.7% of cases (n=32) and gunshot in 35.3% (n=18) of cases. The median age was 36years (25-47). The median index of severity score (ISS) was 17 (10-26). Excellent agreement between predicted and actual findings was obtained for solid organs (α=0.801) with high sensitivity and specificity (81.8% and 96.6%, respectively). The largest discrepancies were observed for the hollow organs (α=26.2%, sensitivity of 53.3% and specificity of 76.2%) and the diaphragm (α=67.3%, sensitivity 75%, specificity 92.3%). Surgical exploration was non-therapeutic for five patients (9.8%). The failure rate for non-operative treatment was 10% (n=1).

CONCLUSION

CT detection of solid organ lesions in patients with penetrating abdominal wounds is excellent. However, the detection of hollow organ and diaphragmatic wounds remains a challenge with a risk of over- and underdiagnosis. Laparoscopic exploration should be able to fill in the gaps in the CT findings.

Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds

BACKGROUND

Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW.

METHODS

This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed.

RESULTS

Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99).

CONCLUSION

While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria; Level II.

Comparison of the diagnostic accuracy of CT scan with oral and intravenous contrast versus CT scan with intravenous contrast alone in the diagnosis of blunt abdominal traumas

PURPOSE

Abdominal CT scan using oral and intravenous (IV) contrast is helpful in the diagnosis of intra-abdominal injuries. However, the use of oral and IV contrast delays the process of diagnosis and increases the risk of aspiration. It has also been shown that CT scan with IV contrast alone is as helpful as CT scan with oral and IV contrast and rectal CT scan in detecting abdominal injuries. Therefore, the present study aims to prospectively compare the diagnostic value of CT scan with oral and IV contrast versus CT scan with IV contrast alone in the diagnosis of blunt abdominal traumas (BATs).

METHODS

Altogether 123 BAT patients, 60 (48.8%) women and 63 (51.2%) men with the mean age of (40.4 ± 18.7) years who referred to the emergency department of Imam Khomeini Educational and Medical Center in Sari, Iran (a tertiary trauma center in north of Iran) from November 2014 to March 2017 and underwent abdominal CT scans + laparotomy were investigated. Those with penetrating traumas or hemodynamically unstable patients were excluded. The participants were randomly allocated to two groups: abdominal CT scan with oral and IV contrast (n = 63) and CT scan with IV contrast alone (n = 60). No statistically significant difference was found between two groups regarding the hemodynamic parameters, age, gender, injury mechanisms (all p > 0.05). The results of CT scan were compared with that of laparotomy results. The collected data were recorded in SPSS version 22.0 for Windows. Quantitative data were presented as mean and SD.

RESULTS

The sensitivity and specificity of CT scan using oral and IV contrast in the diagnosis of BATs were estimated at 96.48 (95% CI: 90.73-99.92) and 92.67 (95% CI: 89.65-94.88), respectively; while CT scan with IV contrast alone achieved a comparable sensitivity and specificity of 96.6 (95% CI: 87.45-99.42) and 92.84 (95% CI: 89.88-95.00), respectively.

CONCLUSION

CT scan with IV contrast alone can be used to assess visceral injuries in BAT patients with normal hemodynamics to avoid diagnostic delay.

Diagnostic performance of triple-contrast versus single-contrast multi-detector computed tomography for the evaluation of penetrating bowel injury

PURPOSE

Selecting groups of low-risk penetrating trauma patients to forego laparotomy can be challenging. The presence of bowel injury may prevent non-operative management. Optimal CT technique to detect bowel injury related to penetrating injury is controversial. Our goal is to compare the diagnostic performance of triple-contrast (oral, rectal, and IV) against IV contrast-only CT, for the detection of bowel injury from penetrating abdominopelvic trauma, using surgical diagnosis as the reference standard.

METHODS

Nine hundred ninety-seven patients who underwent CT for penetrating torso trauma at a single institution between 2009 and 2016 in our HIPPA-compliant and institutional review board-approved retrospective cohort study. A total of 143 patients, including 15 females and 123 males underwent a pre-operative CT, followed by exploratory laparotomy. Of these, 56 patients received triple-contrast CT. CT examinations were independently reviewed by two radiologists, blinded to surgical outcome and clinical presentation. Results were stratified by contrast type and injury mechanism and were compared based upon diagnostic performance indicators of sensitivity, specificity, negative predictive value, and positive predictive value. Area under the receiving operating characteristics curves were analyzed for determination of diagnostic accuracy.

RESULTS

Bowel injury was present in 45 out of 143 patients (10 on triple-contrast group and 35 on IV contrast-only group). Specificity and accuracy were higher with triple-contrast CT (98% specific, 97-99% accurate) compared to IV contrast-only CT (66% specific, 78-79% accurate). Sensitivity was highest with IV contrast-only CT (91% sensitive) compared with triple-contrast CT (75% sensitive), although this difference was not statistically significant. Triple-contrast technique increased diagnostic accuracy for both radiologists regardless of mechanism of injury.

CONCLUSION

In our retrospective single-institution cohort study, triple-contrast MDCT had greater accuracy, specificity, and positive predictive values when compared to IV contrast-only CT in evaluating for bowel injury from penetrating wounds.

Laparoscopy vs. Laparotomy for the Management of Abdominal Trauma: A Systematic Review and Meta-Analysis

Background

There is still no consensus regarding the role of laparoscopy in trauma cases. The purpose of this paper is to assess the value of diagnostic and therapeutic laparoscopy for patients with blunt or penetrating abdominal trauma by performing a systematic review and meta-analysis.

Methods

PubMed, Embase, and the Cochrane library were systemically searched for the randomized controlled trials (RCTs) and non-RCT comparative studies on effectiveness and safety of laparoscopy vs. laparotomy for the two authors independently performed the search, data extraction, and quality assessment.

Results

A total of 5,517 patients were enrolled in 23 eligible studies that were published in English. Meta-analysis results suggest that there is no significant difference in the incidence of missed injury and mortality between abdominal trauma patients receiving laparoscopy and those receiving laparotomy. Concerning postoperative complications, compared with patients in the open surgery group, those in the laparoscopy group are at a similar risk of intra-abdominal abscesses, thromboembolism, and ileus, while there is a decreased incidence of wound infection and pneumonia. Besides, patients in the laparoscopy group experience shorter hospitalization times and procedure times. For most outcomes, the sensitivity analysis yielded similar results to the primary analysis.

Conclusion

Laparoscopic surgery is a practical alternative to laparotomy for appropriate patients. The decision to perform laparoscopy should be based on the experience of the surgeon and the resources available.

Use of Enteric Contrast Material for Abdominopelvic CT in Penetrating Traumatic Injury in Adults: Comparison of Diagnostic Accuracy Systematic Review and Meta-Analysis

BACKGROUND. Scarce evidence exists on the diagnostic benefit of enteric contrast administration for abdominopelvic CT performed in the setting of penetrating trauma. OBJECTIVE. The purpose of this systematic review and meta-analysis is to compare the diagnostic accuracy of CT using enteric contrast material with that of CT not using enteric contrast material in penetrating traumatic abdominopelvic injury in adults. EVIDENCE ACQUISITION. A protocol was registered a priori (PROSPERO CRD42019139613). MEDLINE and EMBASE databases were searched until June 25, 2019. Studies were included that evaluated the diagnostic accuracy of abdominopelvic CT either with or without enteric (oral and/or rectal) contrast material in patients presenting with penetrating traumatic injury. Relevant study data metrics and risk of bias were assessed. Bivariate random-effects meta-analyses and meta-regression modeling were performed to assess and compare diagnostic accuracies. EVIDENCE SYNTHESIS. From an initial sample of 829 studies, 12 studies were included that reported on 1287 patients with penetrating injury (389 with confirmed bowel, mesenteric, or other abdominopelvic organ injury). The enteric contrast material group (seven studies; 506 patients; 124 patients with confirmed penetrating injury) showed a sensitivity of 83.8% (95% CI, 73.7-90.5%) and specificity of 93.8% (95% CI, 83.6-97.8%). The group without enteric contrast administration (six studies; 781 patients; 265 patients with confirmed penetrating injury) showed a sensitivity of 93.0% (95% CI, 86.8-96.4%) and a specificity of 90.3% (95% CI, 81.4-95.2%). No statistically significant difference was identified for sensitivity (p = .07) or specificity (p = .37) between the groups with and without enteric contrast material according to meta-regression. Nine of 12 studies showed risk of bias in at least one QUADAS-2 domain (most frequently limited reporting of blinding of radiologists or lack of blinding of radiologists, insufficient clinical follow-up for the reference standard, and limited reporting of sampling methods). CONCLUSION. The use of enteric contrast material for CT does not provide a significant diagnostic benefit for penetrating traumatic injury. CLINICAL IMPACT. Eliminating enteric contrast administration for CT in penetrating traumatic injury can prevent delays in imaging and surgery and reduce cost.

The role of diagnostic laparoscopy for trauma at a high-volume level one center

Background

The role of minimally invasive surgery in trauma has continued to evolve over the past 20 years. Diagnostic laparoscopy (DL) has become increasingly utilized for the diagnosis and management of both blunt and penetrating injuries.

Objective

While the safety and feasibility of laparoscopy has been established for penetrating thoracoabdominal trauma, it remains a controversial tool for other injury patterns due to the concern for complications and missed injuries. We sought to examine the role of laparoscopy for the initial management of traumatic injuries at our urban Level 1 trauma center.

Methods

All trauma patients who underwent DL for blunt or penetrating trauma between 2009 and 2018 were retrospectively reviewed. Demographic data, indications for DL, injuries identified, rate of conversion to open surgery, and outcomes were evaluated.

Results

A total of 316 patients were included in the cohort. The mean age was 34.9 years old (± 13.7), mean GCS 14 (± 3), and median ISS 10 (4–18). A total of 110/316 patients (35%) sustained blunt injury and 206/316 patients (65%) sustained penetrating injury. Indications for DL included evaluation for peritoneal violation (152/316, 48%), free fluid without evidence of solid organ injury (52/316, 16%), evaluation of bowel injury (42/316, 13%), and evaluation for diaphragmatic injury (35/316, 11%). Of all DLs, 178/316 (56%) were negative for injury requiring intervention, which was 58% of blunt cases and 55% of penetrating cases. There were no missed injuries noted. Average hospital length of stay was significantly shorter for patients that underwent DL vs conversion to open exploration (2.2 days vs. 4.5 days, p < 0.05).

Conclusion

In this single institution, retrospective study, the high volume of cases appears to show that DL is a reliable tool for detecting injury and avoiding potential negative or non-therapeutic laparotomies. However, when injuries were present, the high rate of conversion to open exploration suggests that its utility for therapeutic intervention warrants further study.

The Evolution of Nonoperative Management of Abdominal Gunshot Wounds in the United States

BACKGROUND

Surgical exploration for gunshot wounds to the abdomen has been a surgical standard for the greater part of the past century. Recently, nonoperative management (NOM) has been deemed as a safe option for abdominal gunshot wounds (AGWs). The aim of this analysis was to review the utilization of NOM and mortality after AGWs.

METHODS

We performed a 2010-2014 retrospective analysis of the American College of Surgeons Trauma Quality and Improvement Program. We included all adult (aged 18 and older) patients with AGWs. NOM was defined as nonsurgical intervention within the first 6 h. Outcome measures were trends of utilization of NOM and mortality. Cochrane-Armitage trend analysis was performed.

RESULTS

A total of 808,272 trauma patients were identified, and 16,866 patients with AGWs were included. During the study period, the incidence of AGWs increased, whereas the proportion of bowel injury (P = 0.75) and solid organ injury (P = 0.44) did not change. The NOM rate of AGW increased (2010: 19.5% versus 2014: 27%, P < 0.001). This was accompanied by a decrease in mortality rate (11% versus 9.4%, P = 0.01). Likewise, there was an increase in the use of angiography (7.5% versus 27%, P < 0.001) and laparoscopy (0.9% versus 2.6%, P < 0.001). Overall, 9.8% of the patients had failed NOM. There was no difference in mortality in patients who were managed successfully or failed NOM (5% versus 4.6%, P = 0.45).

CONCLUSIONS

NOM of AGW is more prevalent and is associated with a decrease in mortality rate. Selective NOM may be practiced safely after AGWs.

Selective non-operative management for penetrating abdominal injury in a Dutch trauma centre

INTRODUCTION

Selective non-operative management (SNOM) for penetrating abdominal injury (PAI) is accepted in trauma centres in South Africa and the US. Owing to the low incidence of gunshot wounds (GSWs) in Western Europe, few are inclined to practise SNOM for such injuries although it is considered for stab wounds (SWs). This study evaluated the outcome of patients admitted to a Dutch level 1 trauma centre with PAI.

METHODS

A retrospective study was undertaken of all PAI patients treated over 15 years. In order to prevent bias, patients admitted six months prior to and six months following implementation of a treatment algorithm were excluded. Data concerning type of injury, injury severity score and treatment were compared.

RESULTS

A total of 393 patients were included in the study: 278 (71%) with SWs and 115 (29%) with GSWs. Of the 178 SW patients in the SNOM group, 111 were treated before and 59 after introduction of the protocol. The SNOM success rates were 90% and 88% respectively (p=0.794). There were 43 patients with GSWs in the SNOM cohort. Of these, 32 were treated before and 11 after implementation of the algorithm, with respective success rates of 94% and 100% (p=0.304).The protocol did not bring about any significant change in the rate of non-therapeutic laparotomies for SWs or GSWs. However, the rate of admission for observation for SWs increased from 83% to 100% (p<0.001). There was a decrease in ultrasonography for SWs (from 84% to 32%, p<0.001) as well as for GSWs (from 87% to 43%, p<0.001). X-ray was also used less for GSWs after the protocol was introduced (44% vs 11%, p=0.001).

CONCLUSIONS

SNOM for PAI resulting from either SWs or GSWs can be safely practised in Western European trauma centres. Results are comparable with those in trauma centres that treat high volumes of PAI cases.

The medical and operational impact of the deployment of a scanner within Role 2 in Mali for the French army

INTRODUCTION

According to the NATO classification, the difference between Role 2 and Role 2+ is the presence of extra diagnostic and therapeutic means, including the deployment of a scanner. The aim of this study is to analyze the impact of this deployment at the front, in the Gao French Role 2 (Mali). Our main hypothesis is that the presence of a scanner at the front improves the servicemen's diagnostic and therapeutic management abilities. Secondly that scanner holds strategic relevance by limiting the repatriation of servicemen on medical grounds.

MATERIALS AND METHODS

A prospective analytical observational study was conducted over 6 months within Gao's Role 2. All the French military patients who received a scanner were involved. The collected data was epidemiological, clinical and radiological in nature, and included the results from the scanner and data regarding the operational impact (repatriation). The principal judgment criterion was the rate of modification of the therapeutic decision. The secondary criterion was the modification of the repatriation decision on medical grounds.

RESULTS

Of the 45 patients examined, in 14 cases (31.1%), performing a scanner changed patients' therapeutic management in relation to the management, which would have been conducted in the scanner's absence. For 12 of these patients (85.7%), the indication of the scanner concerned visceral or cranium-spine pathologies. For 33 patients (73.3%), the scanner enabled diagnosis via the elimination of an organic injury or a severity criterion. The repatriation decision remained unchanged for many patients.

DISCUSSION

The scanner appears to be a significant factor in the initial therapeutic decision. Scanning made it possible to clarify the diagnosis and to better adapt the initial therapeutic decision. In contrast, the operational impact was null. The literature highlights the relevance of scanner in surgical abstention (limiting unnecessary operative procedures), and for the visceral, cranium-cerebral and spine pathologies in an emergency.

CONCLUSION

The scanner, a heavy logistic unit deployed within a forward surgical unit, holds therapeutic relevance for French servicemen's management with an important medical service provided for the therapeutic choices, although its operational impact has yet to be demonstrated.

Traumatic rectal injuries: Is the combination of computed tomography and rigid proctoscopy sufficient?

BACKGROUND

There are no clear guidelines for the best test or combination of tests to identify traumatic rectal injuries. We hypothesize that computed tomography (CT) and rigid proctoscopy (RP) will identify all injuries.

METHODS

American Association for the Surgery of Trauma multi-institutional retrospective study (2004-2015) of patients who sustained a traumatic rectal injury. Patients with known rectal injuries who underwent both CT and RP as part of their diagnostic workup were included. Only patients with full thickness injuries (American Association for the Surgery of Trauma grade II-V) were included. Computed tomography findings of rectal injury, perirectal stranding, or rectal wall thickening and RP findings of blood, mucosal abnormalities, or laceration were considered positive.

RESULTS

One hundred six patients were identified. Mean age was 32 years, 85(79%) were male, and 67(63%) involved penetrating mechanisms. A total of 36 (34%) and 100 (94%) patients had positive CT and RP findings, respectively. Only 3 (3%) patients had both a negative CT and negative RP. On further review, each of these three patients had intraperitoneal injuries and had indirect evidence of rectal injury on CT scan including pneumoperitoneum or sacral fracture.

CONCLUSION

As stand-alone tests, neither CT nor RP can adequately identify traumatic rectal injuries. However, the combination of both test demonstrates a sensitivity of 97%. Intraperitoneal injuries may be missed by both CT and RP, so patients with a high index of suspicion and/or indirect evidence of rectal injury on CT scan may necessitate laparotomy for definitive diagnosis.

LEVEL OF EVIDENCE

Diagnostic, level IV.

A study on initial outcome of selective non-operative management in penetrating abdominal injury in a tertiary care hospital in Bangladesh

Objectives

The aim of this study was to assess the initial outcome of non-operative, conservative management in selective penetrating abdominal injury in a tertiary care hospital.

Material and Methods

This was a cross sectional study done on purposively selected 36 patients with penetrating abdominal injuries of all ages admitted within 6 hours of the incident. All patients confirmed peritoneal breach and standard algorithm of management was followed. Closed monitoring was ensured with repeated investigations at regular intervals. Outcome parameters included surgical site infection (SSI), fever, hypothermia, wound dehiscence, fecal fistula, length of stay, pulmonary complication and death.

Results

A total of 36 patients with a mean age of 30 years (SD= 6.7), consisting all males, mostly (58%) from rural areas and 73% from low socioeconomic condition. Site of injury was noted in the epigastrium (42%) and right iliac region (22%). Among them, 33 (92%) patients were successfully managed with non-operative management and 3 (8%) patients needed laparotomy. Routine imaging and clinical observation could detect hollow viscus injury within 36 hours in 3 patients. Hospital stay was significantly lower ( <7 days) in conservative management.

Conclusion

Clinical examination alone and/or together with different diagnostic methods could reduce the number of negative laparotomies and associated morbidities. Single surgeon must closely monitor a patient of penetrating abdominal injury and take vital decisions from the time of admission until discharge.

Determining Trajectory to Predict Injury: The Use of X-Ray During Resuscitation in Gunshot Wounds

BACKGROUND

The practice of marking gunshot wounds and obtaining X-rays (XRs) has been performed to determine the trajectory of missiles to help identify internal injuries. We hypothesized that surgeons would have poor accuracy in predicting injuries and that X-rays do not alter the clinical decision.

METHODS

We developed a 50-patient (89 injury sites) PowerPoint survey based on cases seen at our level 1 trauma center from 2012 to 2014. Images of a silhouetted BodyMan (BM) with wounds marked, XRs, and vital signs (VSs) were shown in series for 20 s each. Surgeons were asked to record which organs they thought could be injured and to document their clinical decision. Data were analyzed to determine the inter-rater reliability (agreement, intraclass correlation coefficient [ICC]) for each mode of clinical information (BM, XR, VS). Predicted versus actual injuries were compared using absolute agreements.

RESULTS

Ten surgeons completed the survey. We found that no single piece of information was helpful in allowing the surgeon to accurately predict injuries. Pulmonary injury had the highest agreement among all injuries (ICC = 0.727). VSs had the highest ICC in determining the clinical plan for the patient (ICC = 0.342), whereas both BM and XR had low ICCs (0.162 and 0.183, respectively).

CONCLUSIONS

We found that marking wounds and obtaining X-rays, other than a chest X-ray, did not result in accuracy in predicting injury nor alter the clinical decision. VSs were the only piece of information found significant in determining clinical management. We conclude that marking wounds for X-rays is an unnecessary step during the initial resuscitation of patients with gunshot wounds.

Penetrating stab injuries in Iceland: a whole-nation study on incidence and outcome in patients hospitalized for penetrating stab injuries

Background

Studies on penetrating injuries in Europe are scarce and often represent data from single institutions. The aim of this study was to describe the incidence and demographic features of patients hospitalized for stab injury in a whole nation.

Materials and methods

This was a retrospective nationwide population-based study on all consecutive adult patients who were hospitalized in Iceland following knife and machete-related injuries, 2000–2015. Age-standardized incidence was calculated and Injury Severity Score (ISS) was used to assess severity of injury.

Results

Altogether, 73 patients (mean age 32.6 years, 90.4% males) were admitted during the 16-year study period, giving an age-standardized incidence of 1.54/100,000 inhabitants. The incidence did not vary significantly during the study period (P = 0.826). Most cases were assaults (95.9%) occurring at home or in public streets, and involved the chest (n = 32), abdomen (n = 26), upper limbs (n = 26), head/neck/face (n = 21), lower limbs (n = 10), and the back (n = 6). Median ISS was 9, with 14 patients (19.2%) having severe injuries (defined as ISS > 15). The median length of hospital stay was 2 days (range 0–53). Forty-seven patients (64.4%) underwent surgery and 26 of them (35.6%) required admission to an intensive care unit (ICU), all with ISS scores above 15. Three patients did not survive for 30 days (4.1%); all of them had severe injuries (ISS 17, 25, and 75).

Conclusion

Stab injuries that require hospital admission are rare in Iceland, and their incidence has remained relatively stable. One in every five patients sustained severe injuries, two-thirds of whom were treated with surgical interventions, and roughly one-third required ICU care. Although some patients were severely injured with high injury scores, their 30-day mortality was still low in comparison to other studies.

An international survey to assess use of oral and rectal contrast in CT protocols for penetrating torso trauma

PURPOSE

There is controversy regarding the administration of oral and rectal contrast for CT performed to detect bowel injury in the context of penetrating torso trauma. Given the lack of published societal guidelines, our goal was to survey radiologists from the American Society of Emergency Radiology membership database to determine consensus on CT protocols for penetrating trauma.

METHODS

With ethics board approval, an anonymous ten-question online survey was distributed via email to 589 radiologists in the American Society of Emergency Radiology (ASER) member database. The survey was open for a 4-week period in February 2018. A commercially available website that allows subscribers to create and analyze survey results was used for analysis.

RESULTS

We received 124 responses (21% response rate) with a majority from U.S. institutions (82%). Seventy-four percent of respondents indicated they do not routinely administer oral contrast in penetrating trauma, 68% do not administer rectal contrast, and 90% do not use commercially available software to assess penetrating injury trajectory. Results from U.S. and non-U.S. practices were comparable. The decision to administer intraluminal contrast is made by the referring physician at 52% of institutions. There is in-house attending level radiology coverage at 54% of institutions and when asked if trauma scans are reviewed before removing the patient from the table, 41% of respondents answered "No."

CONCLUSION

Enteric contrast is used in a minority of respondents' centers for penetrating trauma cases, which is likely driven by a perceived lack of added benefit and delays in patient care.

Diagnostic laparoscopy or selective non-operative management for stable patients with penetrating abdominal trauma: What to choose?

Background

Selective non-operative management (NOM) and diagnostic laparoscopy (DL) are well-accepted approaches in the management of stable patients with penetrating abdominal trauma (PAT). The aim of this pilot study was to investigate the advantages and disadvantages of early DL in stable asymptomatic or minimally symptomatic patients with PAT as opposed to NOM, a standard of care in this scenario. The secondary aim was to suggest possible indications for DL.

Methods

Patients managed with DL or NOM over a 12-month period were included in this study. The age, gender, mechanism and location of injuries, trauma scores, haemodynamic and metabolic parameters, intraoperative findings and length of hospital stay (LOS) were recorded and correlated with outcomes.

Results

Thirty-six patients were in the NOM group and 35 in the DL group. Stab wounds were more common. The most common location of injury was the anterior abdominal wall in the NOM group and the lower chest in the DL group. Computed tomography (CT) scan was performed more often in the NOM group (75% vs. 17.1%). The injury severity score (ISS), New ISS and PAT Index were higher in the DL group. Nearly 23 (66%) patients in the DL group had a penetration of the peritoneum, but no significant abdominal injuries. LOS in the NOM group was 2 days versus 3.1 days in the DL group. There were no missed injuries, complications or mortality.

Conclusion

NOM is a preferred modality for minimally symptomatic stable patients. However, there is a risk of missed injuries and delayed treatment. DL accurately visualizes injuries, decreases unnecessary CT scans and avoids nontherapeutic laparotomies.

FAST in the deployed military setting

INTRODUCTION

Focused assessment with sonography in trauma (FAST) is historically an effective method of assessing the patient in the trauma bay in order to aid decision-making and optimise patient outcomes. However, in the UK civilian practice, the use of FAST may decline given a recent change in National Institute for Health and Care Excellence guidance as a result of improvement in CT availability and resuscitation techniques.

METHOD

In the Role 3 Medical Treatment Facility, Camp Bastion, 187 patients with trauma who received FAST in the trauma bay in 2014 were reviewed to determine the accuracy of FAST in the deployed environment.

RESULTS

The data demonstrates the sensitivity and specificity of FAST to be 75% and 99.3%, respectively.

CONCLUSIONS

This study demonstrates that FAST is accurate on operations. FAST is provided by the integrated radiologist as part of damage control radiology, which gives the team leader rapid diagnostic information to improve decision-making and ultimately patient outcomes. CT is heavily utilised in civilian practice; however, the military operates in a different environment often with multiple casualties and limited access to CT, as a result, portable ultrasound will continue to be a valuable tool on operations if used properly. The next challenge is to develop and maintain this high diagnostic accuracy in future deployments where the memories of our prior success may fade.

Single-Contrast CT for Detecting Bowel Injuries in Penetrating Abdominopelvic Trauma

OBJECTIVE

Many centers advocate use of triple-contrast (IV, oral, and rectal) CT for assessing hemodynamically stable patients with penetrating abdominopelvic trauma. Enteric contrast material has several disadvantages, leading our practice to pursue use of single-contrast (IV) CT. We conducted a retrospective review of electronic medical records at our institution to assess the accuracy of single-contrast CT for diagnosing bowel injuries in cases of penetrating abdominopelvic trauma.

MATERIALS AND METHODS

We retrospectively reviewed patients who presented to our emergency department between January 1, 2004, and March 1, 2014, with penetrating abdominopelvic trauma, underwent an abdominopelvic CT, and had surgery performed thereafter. We reviewed pertinent emergency department records for details regarding the site of injury, the number of injuries per patient, and the type of weapon used. We correlated CT reports with operative notes for presence and sites of bowel injury.

RESULTS

A total of 274 patients (median age, 27 years old) met our inclusion criteria; 77% had sustained gunshot wounds (GSWs). CT showed bowel injury in 173 cases; surgery revealed bowel injury in 162 cases. CT had 142 true-positive, 31 false-positive, 81 true-negative, and 20 false-negative cases, resulting in sensitivity of 88%, specificity of 72%, positive predictive value of 82%, and negative predictive value of 80% for detecting bowel injuries. CT had the highest sensitivity and specificity in patients with multiple GSWs (94% and 79%, respectively) and those with injuries to the stomach and rectum.

CONCLUSION

Single-contrast CT can show bowel injuries in patients with penetrating abdominopelvic trauma with accuracy comparable with that reported for triple-contrast CT.

Early CT scanning in the emergency department in patients with penetrating injuries: does it affect outcome?

Background

To be a level I trauma center in the Netherlands a computed tomography (CT) scanner in the emergency department (ED) is considered desirable, as it is presumed that this optimizes the diagnostic process and that therapy can be directed based on these findings. Aim of this study was to assess the effects of implementing a CT scanner in the ED on outcomes in patients with penetrating injuries.

Methods

In this retrospective descriptive study, patients with penetrating injuries (shot and/or stab wounds), presented between 2000 and 2014 were analysed using the hospital’s electronic database, and data from the West Netherlands trauma registry and the financial department.

Results

405 patients were included: performing a CT scan upon arrival increased significantly from 26.7 to 67.0% (p = 0.00) after implementation of a CT scanner in the ED, with the mean cost of a CT being 96.85 euros. Overall mortality decreased from 6.9 to 3.7%, although not statistically significant. Intensive care unit admission (ICU-admission) and median hospital length of stay (H-LOS) decreased from 30.9 to 24.5% resp. 3.2 to 1.8 days (p ≤ 0.05). Overall mortality, adjusted for injury severity score (ISS), revised trauma score (RTS), and types of injuries, did not change significantly.

Conclusion

Patients with penetrating injuries more often received a CT scan on admission after implementation of a CT scanner in the ED. Early CT scanning is useful since it significantly reduces ICU-admissions and decreases H-LOS. It is a cheap and non-invasive diagnostic tool with significant clinical impact, resulting in directed treatment, and improvement of outcomes.

Multidetector CT for Penetrating Torso Trauma: State of the Art

The use of computed tomography (CT) for hemodynamically stable victims of penetrating torso trauma continues to increase but remains less singular to the work-up than in blunt trauma. Research in this area has focused on the incremental benefits of CT within the context of evolving diagnostic algorithms and in conjunction with techniques such as laparoscopy, endoscopy, and angiographic intervention. This review centers on the current state of multidetector CT as a triage tool for penetrating torso trauma and the primacy of trajectory evaluation in diagnosis, while emphasizing diagnostic challenges that have lingered despite tremendous technological advances since CT was first used in this setting 3 decades ago. As treatment strategies have also changed considerably over the years in parallel with advances in CT, current management implications of organ-specific injuries depicted at multidetector CT are also discussed.

Is quality and completeness of reporting of systematic reviews and meta-analyses published in high impact radiology journals associated with citation rates?

Purpose

The purpose of this study is to determine whether study quality and completeness of reporting of systematic reviews (SR) and meta-analyses (MA) published in high impact factor (IF) radiology journals is associated with citation rates.

Methods

All SR and MA published in English between Jan 2007–Dec 2011, in radiology journals with an IF >2.75, were identified on Ovid MEDLINE. The Assessing the Methodologic Quality of Systematic Reviews (AMSTAR) checklist for study quality, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for study completeness, was applied to each SR & MA. Each SR & MA was then searched in Google Scholar to yield a citation rate. Spearman correlation coefficients were used to assess the relationship between AMSTAR and PRISMA results with citation rate. Multivariate analyses were performed to account for the effect of journal IF and journal 5-year IF on correlation with citation rate. Values were reported as medians with interquartile range (IQR) provided.

Results

129 studies from 11 journals were included (50 SR and 79 MA). Median AMSTAR result was 8.0/11 (IQR: 5–9) and median PRISMA result was 23.0/27 (IQR: 21–25). The median citation rate for SR & MA was 0.73 citations/month post-publication (IQR: 0.40–1.17). There was a positive correlation between both AMSTAR and PRISMA results and SR & MA citation rate; ρ=0.323 (P=0.0002) and ρ=0.327 (P=0.0002) respectively. Positive correlation persisted for AMSTAR and PRISMA results after journal IF was partialed out; ρ=0.243 (P=0.006) and ρ=0.256 (P=0.004), and after journal 5-year IF was partialed out; ρ=0.235 (P=0.008) and ρ=0.243 (P=0.006) respectively.

Conclusion

There is a positive correlation between the quality and the completeness of a reported SR or MA with citation rate which persists when adjusted for journal IF and journal 5-year IF.

Assessment and treatment of the trauma patient in shock

High-volume crystalloid resuscitation is associated with increased length of stay, ICU and ventilator days, and organ failure and infection rates. Rapid evaluation of a hemodynamically unstable trauma patient is vital to diagnosis and treatment of the cause of shock. CT scanning should be used liberally in trauma patients to effect decreased mortality. Nonoperative management and catheter-based interventions are becoming the standard of care in appropriately selected patients with solid organ injuries.

Selective non operative management of gunshot wounds to the abdomen: a collective review

BACKGROUND

Over the past four decades there has been a shift from operative to selective conservatism in trauma. Selective nonoperative management (SNOM) of stab wounds to the abdomen is widely accepted in trauma centres. However, selective conservatism with gunshot wounds to the abdomen is controversial. This collective review assesses the evidence of SNOM of gunshot wounds to the abdomen.

METHODS

A Medline search between 1 January 1960 and 31 July 2013 was conducted identifying studies that investigated SNOM of gunshot wounds to the abdomen. Case reports, review articles and editorials were excluded. All other studies that investigated SNOM of gunshot wounds to the abdomen and its outcomes were included.

RESULTS

A total of 37 studies were included of which 22 were prospective, 14 were retrospective and 1 case series. A total of 21330 patients with gunshot wounds to the abdomen were included, of which 6468 (30.3%) were managed nonoperatively. Successful SNOM was possible in 5510 (85.18%) patients and 958 (14.8%) failed SNOM and underwent delayed laparotomies. SNOM reduces rates of non-therapeutic laparotomies and the associated morbidity. Special aspects reviewed include the prehospital and nursing involvement in this modality of care.

CONCLUSIONS

Current evidence supports SNOM of gunshot wounds to the abdomen. It is associated with a decreased rate of non therapeutic laparotomy. Careful patient selection and specially designed protocols should be established and adhered to.

Mechanisms of injury and CT findings in bowel and mesenteric trauma

Bowel and mesenteric injuries are relatively uncommon but associated with significant morbidity and mortality. Early recognition is crucial, and multidetector computed tomography (MDCT) now has a central role in the evaluation of patients with a history of trauma. In this review, we describe the MDCT appearances of bowel and mesenteric injuries with reference to findings at surgery. Emphasis is placed on the importance of an understanding of mechanism of injury when interpreting CT findings following abdominal trauma.

Penetrating wounds to the torso: evaluation with triple-contrast multidetector CT

Penetrating injuries account for a large percentage of visits to emergency departments and trauma centers worldwide. Emergency laparotomy is the accepted standard of care in patients with a penetrating torso injury who are not hemodynamically stable and have a clinical indication for exploratory laparotomy, such as evisceration or gastrointestinal bleeding. Continuous advances in technology have made computed tomography (CT) an indispensable tool in the evaluation of many patients who are hemodynamically stable, have no clinical indication for exploratory laparotomy, and are candidates for conservative treatment. Multidetector CT may depict the trajectory of a penetrating injury and help determine what type of intervention is necessary on the basis of findings such as active arterial extravasation and major vascular, hollow viscus, or diaphragmatic injuries. Because multidetector CT plays an increasing role in the evaluation of patients with penetrating wounds to the torso, the radiologists who interpret these studies should be familiar with the CT findings that mandate intervention.

Focused Assessment with Sonography in Trauma and Abdominal Computed Tomography Utilization in Adult Trauma Patients: Trends over the Last Decade

Objective. We sought to describe the trend in abdominal CT use in adult trauma patients after a point-of-care emergency ultrasound program was introduced. We hypothesized that abdominal CT use would decrease as FAST use increased. Methods. We performed a retrospective study of 19940 consecutive trauma patients over the age of 18 admitted to our level one trauma center from 2002 through 2011. Data was collected retrospectively and recorded in a trauma registry. We plotted the rate of FAST and abdominal CT utilization over time. Head CT was used as a surrogate for overall CT utilization rates during the study period. Results. Use of FAST increased by an average of 2.3% (95% CI 2.1 to 2.5, P < 0.01) while abdominal CT use decreased by the same rate annually. The percentage of patients who received FAST as the sole imaging modality for the abdomen rose from 2.0% to 21.9% while those who only received an abdominal CT dropped from 21.7% to 2.3%. Conclusions. Abdominal CT use in our cohort declined while FAST utilization grew in the last decade. The rising use of FAST may have played a role in the reduction of abdominal CT performed as decline in CT utilization appears contrary to overall trends.

Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database

BACKGROUND

The aim of this study was to investigate trends in the practice of selective non-operative management (SNOM) for penetrating abdominal injury (PAI) and to determine factors associated with its failure.

METHODS

The National Trauma Data Bank for 2002-2008 was reviewed. Patients with PAI were categorized as those who underwent successful SNOM (operative management not required) and those who failed SNOM (surgery required more than 4 h after admission). Yearly rates of SNOM versus non-therapeutic laparotomy (NTL) were plotted. Multivariable regression analysis was performed to identify factors associated with failed SNOM and mortality.

RESULTS

A total of 12 707 patients with abdominal gunshot and 13 030 with stab wounds were identified. Rates of SNOM were 22.2 per cent for gunshot and 33.9 per cent for stab wounds, and increased with time (P < 0.001). There was a strong correlation between the rise in SNOM and the decline in NTL (r = - 0.70). SNOM failed in 20.8 and 15.2 per cent of patients with gunshot and stab wounds respectively. Factors predicting failure included the need for blood transfusion (odds ratio (OR) 1.96, 95 per cent confidence interval 1.11 to 3.46) and a higher injury score. Failed SNOM was independently associated with mortality in both the gunshot (OR 4.48, 2.07 to 9.70) and stab (OR 9.83, 3.44 to 28.00) wound groups.

CONCLUSION

The practice of SNOM is increasing, with an associated decrease in the rate of NTL for PAI. In most instances SNOM is successful; however, its failure is associated with increased mortality. Careful patient selection and adherence to protocols designed to decrease the failure rate of SNOM are recommended.