Outcomes of non-operative management of penetrating abdominal trauma

BACKGROUND

Selective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is routinely practised in our trauma centre. This study aims to report the outcomes of patients who have failed SNOM.

METHODS

Patients presenting with PAT from 1 May 2015 - 31 January 2018 were reviewed. They were categorised into immediate laparotomy and delayed operative management (DOM) groups. Outcomes compared were postoperative complications, length of hospital stay and mortality.

RESULTS

A total of 944 patients with PAT were reviewed. After excluding 100 patients undergoing damage control surgery, 402 (47.6%) and 542 (52.4%) were managed non-operatively and operatively, respectively. In the SNOM cohort, 359 (89.3%) were managed successfully without laparotomy. Thirty-seven (86.0%) patients in the DOM group had a therapeutic laparotomy, and six (14.0%) had an unnecessary laparotomy. Nine (20.9%) patients in the DOM group developed complications. The DOM group had lesser complications. However, the two groups had no difference in hospital length of stay (LOS). There was no mortality in the non-operative management (NOM) group.

CONCLUSION

In this study, we demonstrated no mortality and less morbidity in the DOM group when appropriately selected compared to the immediate laparotomy group. This supports the selective NOM approach for PAT in high volume trauma centres.

Damage control laparotomy outcomes in a major urban trauma centre

BACKGROUND

Damage control laparotomy (DCL) is associated with high mortality. The purpose of this study was to review the outcomes of DCL.

METHODS

All patients undergoing DCL for penetrating trauma from May 2015 to July 2017 were reviewed. Data retrieved were demographics, mechanism of injury, vitals, and biochemical parameters. Injury severity was described by the revised trauma score (RTS), penetrating abdominal trauma index (PATI), injury severity score (ISS) and trauma and injury severity score (TRISS). Indications for DCL, length of ICU stay, number of procedures and primary abdominal closure rates, complications and mortality were recorded.

RESULTS

Fifty-one patients underwent DCL and 47 patients sustained gunshot injuries. Indications for laparotomy were haemodynamic instability (n = 27) and peritonism in stable patients (n = 22). The medians for the different severity scores were RTS 7.36, ISS 20, and PATI 30. The organs most commonly injured, in decreasing frequency, were small bowel (33), large bowel (25), abdominal vasculature (22), liver (18), stomach (14), kidney (10), diaphragm (10), spleen (9) and pancreas (8). DCL procedures performed were abdominal packing (36), temporary bowel ligation (30), vascular (5) and ureteric (1) shunting. The median number of laparotomies performed per patient was three, with a primary fascial closure rate of 69%. The mortality rate was 29%.

CONCLUSION

DCL in our centre is associated with a 29% mortality rate. Severe acidosis, massive blood transfusion in first 24 hours and median PATI score more than 47 are independent risk factors associated with increased mortality.

Damage control laparotomy outcomes in a major urban trauma centre

BACKGROUND: Damage control laparotomy (DCL) is associated with high mortality. The purpose of this study was to review the outcomes of DCL. METHODS: All patients undergoing DCL for penetrating trauma from May 2015 to July 2017 were reviewed. Data retrieved were demographics, mechanism of injury, vitals, and biochemical parameters. Injury severity was described by the revised trauma score (RTS), penetrating abdominal trauma index (PATI), injury severity score (ISS) and trauma and injury severity score (TRISS). Indications for DCL, length of ICU stay, number of procedures and primary abdominal closure rates, complications and mortality were recorded. RESULTS: Fifty-one patients underwent DCL and 47 patients sustained gunshot injuries. Indications for laparotomy were haemodynamic instability (n = 27) and peritonism in stable patients (n = 22). The medians for the different severity scores were RTS 7.36, ISS 20, and PATI 30. The organs most commonly injured, in decreasing frequency, were small bowel (33), large bowel (25), abdominal vasculature (22), liver (18), stomach (14), kidney (10), diaphragm (10), spleen (9) and pancreas (8). DCL procedures performed were abdominal packing (36), temporary bowel ligation (30), vascular (5) and ureteric (1) shunting. The median number of laparotomies performed per patient was three, with a primary fascial closure rate of 69%. The mortality rate was 29%. CONCLUSION: DCL in our centre is associated with a 29% mortality rate. Severe acidosis, massive blood transfusion in first 24 hours and median PATI score more than 47 are independent risk factors associated with increased mortality.

A contemporary prospective review of 205 consecutive patients with penetrating colon injuries

BACKGROUND

Management of colon injuries has significantly evolved in the recent decades resulting in considerably decreased morbidity and mortality. We set out to investigate penetrating colon injuries in a high-volume urban academic trauma center in South Africa.

METHODS

All patients with penetrating colon injuries admitted between 1/2015 and 1/2018 were prospectively enrolled. Data collection included demographics, injury profile and outcomes. Primary outcome was in-hospital mortality. Secondary outcome was morbidity.

RESULTS

Two-hundred and five patients were included in the analysis. Stab and gunshot wounds constituted 18% and 82% of the cases, respectively. Mean age was 28.9 (10.2) years and 96.1% were male. Median injury severity score (ISS) and penetrating abdominal trauma index (PATI) were 16 (9-25) and 19 (10-26), respectively. A total of 47.8% of the patients had a complication per Clavien-Dindo classification. Colon leak rate was 2.4%. Wound and abdominal organ/space infection rate was 15.1 and 6.3%, respectively. Overall in-hospital mortality was 9.3%. Risk factors for mortality were higher ISS and PATI, shock on admission, need for blood transfusion, intra-abdominal vascular injury, damage control surgery, and extra-abdominal severe injuries.

CONCLUSIONS

Contemporary overall complication rate remains high in penetrating colon injuries, however, anastomotic leak rate is decreasing. Colon injury associated mortality is related to overall injury burden and hemorrhage rather than to colon injuries.

Blunt Pharyngoesophageal Injuries: Current Management Strategies

BACKGROUND:

Blunt pharyngoesophageal injuries pose a management challenge to the trauma surgeon. The purpose of this study was to explore whether these injuries can be managed expectantly without neck exploration.

METHODS:

The National Trauma Databank datasets 2007-2011 were reviewed for blunt trauma patients who sustained a pharyngeal injury, including an injury to the cervical esophagus. Patients who survived over 24 h and were not transferred from other institutions were divided into two groups based on whether a neck exploration was performed. Outcomes included mortality and hospital stay.

RESULTS:

A total of 545 (0.02%) patients were identified. The median age was 18 years and 69% were male. Facial fractures were found in 16%, while 13% had an associated traumatic brain injury. Of the 284 patients who survived over 24 h and were not transferred from another institution, 65 (23%) underwent a neck exploration. The injury burden was significantly higher in this group as indicated by the higher median Injury Severity Score (17 vs 10, p < 0.01) and need for intensive care unit admission (75% vs 31%, p < 0.01). The overall mortality was 2%: 3.1% for neck explorations versus 1.6% for conservative management (adjusted p = 0.54). Neck exploration patients were more likely to remain longer in the hospital (median 13 vs 10 days, adjusted p = 0.03).

CONCLUSION:

Pharyngoesophageal injuries are rare following blunt trauma. Only a quarter require a neck exploration and this decision appears to be dictated by the injury burden. Selective non-operative management based on clinical status seems to be feasible and is not associated with increased mortality.

Laparoscopy or clinical follow-up to detect occult diaphragm injuries following left-sided thoracoabdominal stab wounds: A pilot randomized controlled trial

BACKGROUND

The purpose of this study was to determine whether patients with left-sided thoracoabdominal (TA) stab wounds can be safely treated with clinical and chest X-ray follow up.

METHOD

A prospective, randomized control study was conducted at Groote Schuur Hospital from September 2009 through to November 2014. Patients with asymptomatic left TA stab wounds included in the trial were randomized into two groups. Group A underwent diagnostic laparoscopy and Group B underwent clinical and radiological follow-up.

RESULTS

Twenty-seven patients were randomized to Group A (N=27) and thirty-one to Group B (N=31). All patients were young males with a median age of 26 years (range 18 to 48). The incidence of occult diaphragm injury in Group A was 29%. All diaphragm injuries found at laparoscopy were repaired. The mean hospital stay for the patients in Group A was 5 days (SD 1.3), compared to a mean hospital stay of 2.9 days (SD, 1.5), in Group B (p < 0.001). All patients in Group B had normal chest X-rays at their last visit. The mean follow-up time was 24 months (median: 24; interquartile range: 1-40). There was no morbidity or mortality in Group B.

CONCLUSION

Clinical and radiological follow-up are feasible and appear to be safe, in the short term, in patients who harbour occult diaphragm injuries after left TA stab wounds. Until studies showing the natural history of diaphragm injury in humans are available, laparoscopy should remain the gold standard in treatment.

The effect of emergency medical services response on outcome of trauma laparotomy at a Level 1 Trauma Centre in South Africa

BACKGROUND

Due to resource constrained pre-hospital emergency medical services (EMSs) there is a significant delay in injured patients arriving at Groote Schuur Hospital Trauma Centre (GSHTC). The aim of the study was to examine the effectiveness of EMSs in transferring trauma patients to GSHTC. The effect of any delay to laparotomy from injury was noted.

METHOD

A prospective audit of patients presented directly from the scene to GSHTC following abdominal trauma over a four-month period was performed. Time from contact to the arrival of EMS at scene - the response time (RT) - was used as an indicator of EMS performance. Postoperative complications were graded according to Clavien-Dindo classification of surgical complications.

RESULTS

A total of 118 patients were admitted to the trauma surgery ward following abdominal trauma. The mechanism was penetrating 101 (85.6%) [stab wounds in 67 (56.8%) and gunshot in 34 (28.8%)], and 17 (14.4%) with blunt injuries. EMSs transported 110 (93.2%) patients. A total of 48 index laparotomies were done during this period, of which 13 patients developed postoperative complications. The median RT of the EMS after contact was 53 min for patients who developed complications. It was significantly longer than for those without complications, 21 min (p < 0.01). The median delay to laparotomies from injury for patients with postoperative complications was 10.3 hours and for those without complications was 7.5 hours. The delay from injury to the theatre was also a significant factor in the development of complications (p = 0.02).

CONCLUSION

The response delay by EMS and delay from injury to the theatre increased complications. Therefore, rapid response by EMS in transferring trauma patients needs to be strengthened.

Enhanced recovery after surgery (ERAS) in penetrating abdominal trauma: A prospective single-center pilot study

BACKGROUND

Enhanced recovery after surgery (ERAS) programmes employed in elective surgery have provided strong evidence for decreased lengths of hospital stay without increase in postoperative complications. The aim of this study was to explore the role and benefits of ERAS implemented in patients undergoing emergency laparotomy for penetrating abdominal trauma.

METHOD

Institutional University of Cape Town Human Research Ethics Committee (UCT-HREC) approved study. A prospective cohort of 38 consecutive patients with isolated penetrating abdominal trauma undergoing emergency laparotomy were included in the study. The enhanced recovery protocols (ERPs) included: early urinary catheter removal, early nasogastric tube (NGT) removal, early feeding, early mobilisation/physiotherapy, early intravenous line removal and early optimal oral analgesia. This group was compared to a historical control group of 40 consecutive patients undergoing emergency laparotomy for penetrating abdominal trauma, prior to the introduction of the ERP. Demographics, mechanism of injury, injury severity scores (ISS) and penetrating abdominal trauma index (PATI) were determined for both groups. The primary end-points were length of hospital stay (LOS) and incidence of postoperative complications (Clavien-Dindo classification) in the 2 groups. The difference in means was tested using the t-test assuming unequal variances. Statistical significance was defined as p-value less than 0.05 (p < 0.05).

RESULTS

The two groups were comparable with regards to age, gender, mechanism of injury, ISS and PATI scores. The mean time to solid diet, urinary catheter and nasogastric tube (NGT) removal was 3.6 (non-ERAS) and 2.8 (ERAS) days [p < 0.035], 3.3 (non-ERAS) and 1.9 (ERAS) days [p < 0.00003], 2.1 (non-ERAS) and 1.2 (ERAS) days [p < 0.0042], respectively. There was no difference in time from admission to time of laparotomy 313 (non-ERAS) vs 358 (ERAS) minutes [p < 0.07]. There were 11 and 12 complications in the non-ERAS and ERAS groups, respectively. When graded as per the Clavien-Dindo classification, there was no significant difference in the 2 groups (p < 0.59). Hospital stay was significantly shorter in the ERAS group: 5.5 (SD 1.8) days vs. 8.4 (SD 4.2) days [p < 0.00021].

CONCLUSION

This pilot study shows that ERPs can be successfully implemented with significant shorter hospital stays without any increase in postoperative complications in trauma patients undergoing emergency laparotomy for penetrating abdominal trauma.

Trauma unit attendance: Is there a relationship with weather, sporting events and week/ month-end times? An audit at an urban tertiary trauma unit in Cape Town

BACKGROUND

The Groote Schuur Hospital Trauma Unit is a high-volume referral center where patient volumes may be related to temporal and environmental factors.

OBJECTIVE

This audit aimed to determine if numbers of patients presenting after motor vehicle collisions (MVCs) and interpersonal violence (IPV) were related to temporal factors, weather variables and important soccer matches.

METHOD

Numbers of patients presenting to the unit per shift over 17 months were obtained from unit logs. Weather data, local soccer match locations and results, and information regarding public holidays and long weekends were obtained for the relevant shifts. Average daily attendances for IPV-related injuries and MVCs were compared across the various external factors described. Poisson regression models were fitted and used to express the relative incidence of attendances. These results are expressed using incidence rate ratios (IRRs).

RESULTS

For the study period, 7 350 attendances due to IPV-related injuries, and 3 188 injuries due to MVCs were recorded. Weekdays, long-weekend nights and month-end weekends had increased MVC-related attendance. Precipitation also increased attendances related to MVCs. Public holidays had less MVC-related attendance. IPV-related attendances were increased at night, on long weekends, and on month-end weekends. Weekend shifts were busier than weekday shifts, particularly at month-end. Long weekends showed similar trends to ordinary weekends, and public holidays showed similar trends to ordinary weekdays. Increasing temperatures are associated with increased attendances. Soccer matches and their outcomes have no significant effect on IPV-related attendances.

CONCLUSION

Temporal and weather factors can help predict which trauma unit shifts will be busiest.

An urban trauma centre experience with abdominal vena cava injuries

BACKGROUND

The aim of the study was to present the surgical management of injuries to the abdominal vena cava (AVC) and to identify clinical and physiological factors and management strategies which affect the outcome.

METHOD

A retrospective review was conducted of AVC injuries in patients attending the trauma centre at Groote Schuur Hospital, Cape Town, from January 2003 to December 2011. Demographic data, mechanism and agent of injury, level of injury, physiological parameters, associated injuries, trauma scores, management strategy, morbidity and mortality, and length of hospital stay were taken from the trauma centre's operative databank at Groote Schuur Hospital.

RESULTS

Thirty-fi ve patients with AVC injuries were identifi ed. There were 33 penetrating injuries (94%). Gunshot wounds accounted for 28 of them (85%). There were 19 (54%) infrarenal, 9 (26%) juxtarenal, 3 (7%) suprarenal and 4 (11%) retrohepatic AVC injuries. Most patients were treated with ligation (66%). There were 17 (49%) deaths. There were signifi cant differences in the preoperative systolic blood pressure (p = 0.044), number of red cell units transfused (p = 0.001), serum lactate (p = 0.007), arterial pH (p = 0.002) and preoperative temperature (p = 0.000) between the survivors and non-survivors. There was also a signifi cant difference in ligation versus repair between the two groups (p = ≤ 0.000). There was no difference in the injury severity, level of injury and the number of associated injuries between survivors and non-survivors.

CONCLUSION

AVC injuries are associated with high mortality. Patients presenting with clinical and physiological evidence of shock and who require "damage control" surgery are more likely to suffer a worse outcome, particularly when multiple physiological deragements are present. Patients who died often have severe associated injuries.