Article

Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma

Division of Trauma, Critical Care, and Burns, Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.
The Journal of trauma (Impact Factor: 2.96). 03/2010; 68(3):721-33. DOI: 10.1097/TA.0b013e3181cf7d07
Source: PubMed

ABSTRACT

: Although there is no debate that patients with peritonitis or hemodynamic instability should undergo urgent laparotomy after penetrating injury to the abdomen, it is also clear that certain stable patients without peritonitis may be managed without operation. The practice of deciding which patients may not need surgery after penetrating abdominal wounds has been termed selective management. This practice has been readily accepted during the past few decades with regard to abdominal stab wounds; however, controversy persists regarding gunshot wounds. Because of this, the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee set out to develop guidelines to analyze which patients may be managed safely without laparotomy after penetrating abdominal trauma. A secondary goal of this committee was to find which diagnostic adjuncts are useful in the determination of the need for surgical exploration.
: A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov).
: The search retrieved English language articles concerning selective management of penetrating abdominal trauma and related topics from the years 1960 to 2007. These articles were then used to construct this set of practice management guidelines.
: Although the rate of nontherapeutic laparotomies after penetrating wounds to the abdomen should be minimized, this should never be at the expense of a delay in the diagnosis and treatment of injury. With this in mind, a routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal tenderness. Likewise, it is also not routinely indicated in stable patients with abdominal gunshot wounds if the wounds are tangential and there are no peritoneal signs. Abdominopelvic computed tomography should be considered in patients selected for initial nonoperative management to facilitate initial management decisions. The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness. Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration in an effort to avoid unnecessary laparotomy.

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Available from: Michelle Holevar, Nov 17, 2014
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    • "Although a diagnostic laparoscopy is a minimally invasive procedure, general anesthesia and laparoscopy have their own potential complication risks. In several studies, it has been observed that routine laparoscopies are highly non-therapeutic [3] [10] [23] [24]. When the high sensitivity and specificity rates obtained with physical examination are taken into consideration, a diagnostic laparoscopic exploration as a component of selective conservative treatment would not be an appropriate approach. "
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    ABSTRACT: A selective conservative treatment for penetrating anterior abdominal stab injuries is an increasingly recognized approach. We analyzed patients who followed-up and treated for penetrating anterior abdominal stab injuries. The anterior region was defined as the area between the arcus costa at the top and the mid-axillary lines at the laterals and the inguinal ligaments and symphysis pubis at the bottom. An emergency laparotomy was performed on patients who were hemodynamically unstable or had symptoms of peritonitis or organ evisceration; the remaining patients were followed-up selectively and conservatively. A total of 175 patients with purely anterior abdominal injuries were included in the study. One hundred and sixty-five of the patients (94.29%) were males and 10 (5.71%) were females; the mean age of the cohort was 30.85 years (range: 14-69 years). While 16 patients (9%) were made an emergency laparotomy due to hemodynamic instability, peritonitis or evisceration, the remaining patients were hospitalized for observation. During the selective conservative follow-up, an early laparotomy was performed in 20 patients (12%), and a late laparotomy was performed in 13 patients (7%); the remaining 126 patients (72%) were discharged after non-operative follow-up. A laparotomy was performed on 49 patients (28%); the laparotomy was therapeutic for 42 patients (86%), non-therapeutic for 4 patients (8%), and negative for 3 patients (6%). A selective conservative approach based on physical examination and clinical follow-up in penetrating anterior abdominal stab injuries is an effective treatment approach.
    Full-text · Article · Sep 2015 · International Journal of Clinical and Experimental Medicine
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    • "The selective management of penetrating abdominal trauma has been widely accepted as a safe approach [1] [2]. Although most trauma surgeons working in high volume centres will be comfortable with using such an approach for injuries to the anterior abdomen, similar injuries to the posterior abdomen create a divergence of opinion [1] [2] [8]. It is often suggested that the thick paraspinal musculature causes difficulties in clinical evaluation, and the potential tamponading effect of retroperitoneal organ injuries may lead to morbidity from the delayed recognition of occult injuries [3] [4] [8]. "
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    ABSTRACT: The selective non-operative management (SNOM) of stab injuries of the anterior abdomen is well established, but its application to the posterior abdomen remains controversial. A retrospective review of 1013 patients was undertaken at a major trauma service in South Africa over a five-year period. Ninety per cent of patients were males, and the mean age was 25 years. The mean time from injury to presentation was 4h and 73% of all injuries were inflicted by knives. A total of 9% (93) of patients required a laparotomy [Group A] and 82% (833) were successfully observed without the need for operative intervention [Group B]. CT imaging was performed on 52 patients (5%) who had haematuria [Group C], 25 (3%) who had neurological deficits [Group D], and 10 (1%) with retained weapon injuries [Group E]. The accuracy of physical examination for identifying the presence of organ injury was 88%. All observed patients who required laparotomy declared themselves within 24h. There were no mortalities as direct result of our current management protocol. Selective management based on active clinical observation and serial physical examination is safe, and when coupled with the judicious use of advanced imaging, is a prudent and reliable approach in a resource constrained environment. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Jan 2015 · Injury
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    • "The selective management of penetrating abdominal trauma has been widely accepted as a safe approach [1] [2]. Although most trauma surgeons working in high volume centres will be comfortable with using such an approach for injuries to the anterior abdomen, similar injuries to the posterior abdomen create a divergence of opinion [1] [2] [8]. It is often suggested that the thick paraspinal musculature causes difficulties in clinical evaluation, and the potential tamponading effect of retroperitoneal organ injuries may lead to morbidity from the delayed recognition of occult injuries [3] [4] [8]. "
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    ABSTRACT: Introduction: The selective non-operative management (SNOM) of stab injuries of the anterior abdomen is well established, but its application to the posterior abdomen remains controversial. Materials and methods: A retrospective review of 1013 patients was undertaken at a major trauma service in South Africa over a five-year period. Results: Ninety per cent of patients were males, and the mean age was 25 years. The mean time from injury to presentation was 4 h and 73% of all injuries were inflicted by knives. A total of 9% (93) of patients required a laparotomy [Group A] and 82% (833) were successfully observed without the need for operative intervention [Group B]. CT imaging was performed on 52 patients (5%) who had haematuria [Group C], 25 (3%) who had neurological deficits [Group D], and 10 (1%) with retained weapon injuries [Group E]. The accuracy of physical examination for identifying the presence of organ injury was 88%. All observed patients who required laparotomy declared themselves within 24 h. There were no mortalities as direct result of our current management protocol. Conclusions: Selective management based on active clinical observation and serial physical examination is safe, and when coupled with the judicious use of advanced imaging, is a prudent and reliable approach in a resource constrained environment.
    Full-text · Article · Jan 2015 · Injury
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