Gunshot Wounds of Abdomen: Evaluation of Stable Patients with Triple-Contrast Helical CT

Role of preoperative CT imaging in penetrating thoraco-abdominal injuries: A multicenter study of urban trauma centers

INTRODUCTION

Management of penetrating thoracoabdominal (PTA) injuries with signs of hemorrhage have warranted operative intervention but improved imaging capabilities have redefined interventions required. We examined outcomes of hemodynamically stable patients undergoing preoperative CT imaging with the hypothesis that CT imaging would decrease OR time without delaying OR arrival.

METHODS

A retrospective multicenter study was performed amongst four urban trauma centers examining hemodynamically stable patients with PTA injuries requiring operative intervention from January 2017-December 2021. The primary outcome was OR time. Secondary outcomes included length of stay (LOS), ICU LOS, and mortality. A multivariable logistic regression with random intercept for trauma center was fit to assess whether preoperative CT affected time in the OR.

RESULTS

Of 534 hemodynamically stable patients with penetrating injuries, 322 (60.3 ​%) received preoperative CT. The median time in OR were 130 (IQR: 84,180) and 140 (IQR: 100, 180) minutes for patients with and without preoperative CT, respectively. Median time to OR was 68 (IQR: 47, 110) and 26 (IQR 17,38) minutes in patients with and without preop CT, respectively. Median ICU LOS were 0 vs 1 day, the median hospital LOS were 7 vs 8 days for patients with and without pre-op imaging respectively. The multivariable model showed that obtaining a pre-op CT scanning was not independently associated with time spent in OR. (Adjusted OR:0.94; 95 ​% CI: 0.85, 1.04).

CONCLUSION

In patients with PTA injuries and hemodynamic stability, preoperative CT scanning was not associated with decreased OR time, postoperative complications, or mortality.

Firearm injury to the left buttock with uterus penetrating trauma

A multispecialty trauma team must provide care for pelvic gunshot wounds (PGW) due to the high risk of associated morbidity and mortality, the high density of organs that might be wounded within the pelvis, and the potential consequences of these complicated injuries. We present a case of a 59-year-old woman hemodynamically stable with firearm injury to the left buttock. CT examination showed free air in the peritoneal cavity and in the retroperitoneum and a focal contrast extravasation within the uterine fundus. The patient underwent urgent laparotomy that revealed triple bowel perforation (sigmoid colon, medium rectum, ileum) and a laceration of the posterior and anterior uterine wall at level of the cervix with no signs of active bleeding. The bullet was lodged above the peritoneal reflection, in the right pelvis, and it was removed, and handed over to the judicial authority. The perforated bowel segments were resected with Hartmann's procedure and ileal anastomosis. The uterine laceration was repaired. Although all the viscera and the structures along the trajectory can be harmed, pelvic gunshot wounds have the potential to inflict serious injury. Nongravid uterine traumas are a unique occurrence, and proper care requires an understanding of lesion grading. Finding the gynecological lesion in female patients is essential to receiving the best care and protecting the reproductive system.

ACR Appropriateness Criteria® Penetrating Torso Trauma

This document assesses the appropriateness of various imaging studies for acute penetrating trauma to the torso. Penetrating trauma most commonly occurs from gunshots and stabbings, although any object can impale the patient. Anatomic location, type of penetrating trauma, and hemodynamic status are among the many important factors when deciding upon if, what, and when imaging is needed to further evaluate the patient. Imaging plays a critical role in the management of these patients. CT, in particular, aids in identifying and predicting internal injuries based upon trajectory of the object. Clinical variants are distinguished by ballistic versus nonballistic injuries, hemodynamic status, and compartment of the body injured. Ballistic trauma trajectory is less predictable, and imaging recommendations are adjusted for this unpredictability. Excluded from this document are penetrating traumatic injuries to pediatric patients and specific recommendations when the genitourinary system is clinically suspected to be injured, the latter of which is more specifically discussed in other Appropriateness Criteria documents. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are documented annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer documented journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer documented literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Outcomes of selective non-operative management in adults with abdominal gunshot wounds: a systematic review and meta-analysis

BACKGROUND AND AIMS

Abdominal gunshot wounds (GSWs), a clinically devastating injury, can result in a variety of severe and lethal complications. Traditionally, exploratory laparotomy is the first-line approach for the management of abdominal GSWs, but it is associated with a considerable amount of unnecessary surgeries. At present, selective non-operative management (SNOM) of abdominal GSWs is becoming an effective and well-recognized approach, but it remains widely disputed since many surgeons are skeptical about the validity of SNOM in clinical practice. This meta-analysis aims to estimate the outcomes of SNOM and immediate laparotomy in patients with GSWs by collecting the currently available evidence.

METHODS

The PubMed , EMBASE , and Cochrane Library databases were searched. A random-effects model was employed. A pooled proportion with 95% confidence intervals (CIs) was calculated. Heterogeneity was evaluated using Cochran's Q test and I2 statistics.

RESULTS

Overall, 53 studies involving 60 291 participants were included. The pooled proportions of SNOM and SNOM failure were 27.0% (95% CI=24.0-30.0%) and 10.0% (95% CI=7.0-13.0%), respectively. The pooled mortality after SNOM and SNOM failure were 0.0% (95% CI=0.0-1.0%) and 0.0% (95% CI=0.0-0.0%), respectively. The pooled proportions of immediate laparotomy and unnecessary immediate laparotomy were 73.0% (95% CI=70.0-76.0%) and 10.0% (95% CI=8.0-13.0%), respectively. The pooled mortality after immediate laparotomy and unnecessary immediate laparotomy was 10.0% (95% CI=8.0-13.0%) and 0.0% (95% CI=0.0-1.0%), respectively. Heterogeneity was statistically significant in nearly all meta-analyses.

CONCLUSION

Immediate laparotomy is still the mainstay approach for the management of abdominal GSWs. Approximately one-third of patients with abdominal GSWs undergo SNOM. SNOM failure is not frequent, and its related mortality is also rare.

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.

CT after emergency surgery in penetrating trauma: a seven-year experience in a level I Nordic trauma center

BACKGROUND

Patients with severe penetrating trauma may require emergency surgery on arrival, and postoperative computed tomography (CT) can reveal significant additional injuries.

PURPOSE

To determine the utility of postoperative CT performed within 48 h of emergency surgery after penetrating trauma.

MATERIAL AND METHODS

Trauma registry data were retrieved over a seven-year period at a single level 1 trauma center. All patients aged ≥17 years, admitted with penetrating injury, who underwent urgent surgery and postoperative CT imaging within 48 h, were included. Pre- and intraoperative medical records were compared to CT findings. Age, sex, Injury Severity Score (ISS), New Injury Severity Score (NISS), 30-day mortality, injury mechanism, surgical intervention, and intensive care unit length of stay were extracted.

RESULTS

Out of 1262 patients, 38 fulfilled the study criteria (36 men [94.7%], 2 women [5.3%]; mean age = 31.5 years. Stab wound (SW) was the most common injury mechanism (26/38, 68.4%) followed by gunshot wound (GSW; 10/38, 26.3%). Patients with GSWs were more severely injured than SW victims (median NISS = 34 [range = 3-75]; for GSWs = 34; for SWs = 26; P = 0.045). Out of 38 patients, 20 (52.6%) had additional findings at postoperative CT. Six patients (15.8%) had unidentified or underestimated findings at CT that were severe enough to warrant additional surgery or angiography.

CONCLUSION

Postoperative CT imaging after emergency surgery in penetrating trauma is an important tool in evaluating the injury panorama. Out of 38 patients, 6 (15.8%) had findings at postoperative CT that warranted additional surgical or angiographic intervention.

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.

Trends in the Management of Abdominal Gunshot Wounds Over the Last Decade: A South African Experience

BACKGROUND

This study aimed to review our decade-long experience with the management of abdominal gunshot wounds (GSWs), to document trends in our approach and to develop an evidence base for our contemporary management algorithms in a major trauma in South Africa.

MATERIALS AND METHODS

This was a retrospective study that included all adult patients with abdominal GSWs between January 2013 and October 2020 managed at a major trauma centre in South Africa.

RESULT

Five hundred and ninety-six cases were included (87% male, mean age: 32 years). The median Injury Severity Score (ISS) was 12. 52% (309/596) of cases had indications of immediate laparotomy and proceeded directly to the operating room without any CT imaging. Of this cohort, the laparotomy was positive in 292 and in the remainder (5%) was negative. Of the remaining 287 cases, 209 underwent a CT scan (35%). 78 were managed without any CT imaging. Of the 78 who did not undergo CT scan, all were managed without any operation and discharged home well. Of the 209 who underwent CT scan, 99 were observed and only one case in this group subsequently required a laparotomy. The remaining 110 cases underwent a laparotomy, which was negative in 7. There were correlations with increasing use of CT, as well as a decrease in those proceeding directly to laparotomy. The overall morbidity rate was 8% (47/596). 32% (190/596) require intensive care unit (ICU) admission. The overall mortality rate was 8% (67/596).

CONCLUSIONS

The management of abdominal GSWs has continued to evolve. There is now a well-defined role for selective non-operative management in this group of patients and relies on accurate CT assessment. CT scan is now an important component in the management of abdominal GSW even in our resource-constrained environment.

Expectant management in delayed presentation of war casualties with penetrating abdominal trauma

INTRODUCTION

While the management of acute civilian abdominal injuries is well established, The literature regarding the management of battle-related abdominal injuries presented in a delayed fashion is scarce. The objective of this study was to investigate the safety of non-operative management approach in delayed evacuation of battle-related abdominal injuries.

METHODS

Clinical records of thirty-seven hemodynamically normal patients with battle related injuries and Computed Tomography (CT) findings of penetrating abdominal trauma were retrospectively studied.

RESULTS

All 37 patients suffered penetrating abdominal injuries during the civil war in Syria. In this complex scenario, the casualties presented after a minimum 12-hour delay to our hospital. All patients had abnormal abdominal CT scans with no clinical peritoneal signs. Twenty-one [of the 37] patients exhibited 29 hard signs on CT scan. Of these, 17 patients were treated non-operatively and 4 underwent exploratory laparotomy (of which 2 were non-therapeutic). Sixteen patients exhibited a total of 75 soft signs on CT scan; 15 were treated non-operatively and one underwent non-therapeutic laparotomy. No complications were recorded in either the operative or non-operative groups. In total, 32 patients (86%) were treated non-operatively. Five patients (14%) underwent exploratory laparotomy (3 of which were non-therapeutic). Length of stay was dependent on the unique requirements of each individual patient as determined by the state department for returning across the border.

CONCLUSION

We propose that in battle related casualties, acute survivable penetrating abdominal trauma may be safely treated non-operatively in selected patients who are hemodynamically normal and in whom there is an absence of abdominal pain or tenderness on repeated clinical assessment.

A through-and-through abdominal gunshot wound without intra-abdominal damage: A case report

Abdominal gunshot trauma is the third leading cause of death and is responsible for more than 90% of deaths among people ages 15 to 24 years old. It can cause multi-system organ damage, shock, and infection. We present a case of a through-and-through abdominal bullet wound where laparotomy exploration has found nothing as damage inside the abdomen.

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.

Penetrating abdominal trauma in the era of selective conservatism: a prospective cohort study in a level 1 trauma center

BACKGROUND

Global trend has seen management shift towards selective conservatism in penetrating abdominal trauma (PAT). The purpose of this study is to compare the presentation; management; and outcomes of patients with PAT managed operatively versus non-operatively.

METHODS

Prospective cohort study of all patients Ùpresenting with PAT to Groote Schuur Hospital, Cape Town from 01 May 2015 to 30 April 2017. Presentation; management; and outcomes of patients were compared. Univariate predictors of delayed operative management (DOM) were explored.

RESULTS

Over the 2-year study period, 805 patients with PAT were managed. There were 502 (62.4%); and 303 (37.6%) patients with gunshot (GSW) and stab wounds (SW), respectively. The majority were young men (94.7%), with a mean age of 28.3 years (95% CI 27.7-28.9) and median ISS of 13 (IQR 9-22). Successful non-operative management was achieved in 304 (37.7%) patients, and 501 (62.5%) were managed operatively. Of the operative cases, 477 (59.3%) underwent immediate laparotomy and 24 (3.0%) DOM. On univariate analysis, number; location; and mechanism of injuries were not associated with DOM. Rates of therapeutic laparotomy were achieved in 90.3% in the immediate, and 80.3% in the DOM cohorts. The mortality rate was 1.3, 11.3 and 0% in the in the NOM, immediate laparotomy and DOM subgroups, respectively. The rate of complications was no different in the immediate and DOM cohorts (p > 0.05).

CONCLUSION

Patients with PAT in the absence of haemodynamic instability; peritonism; organ evisceration; positive radiological findings, or an unreliable clinical examination, can be managed expectantly without increased morbidity or mortality.

Selective conservative treatment for anterior abdominal gunshot: a literature narrative review

The nonoperative treatment of anterior abdominal gunshot wounds remains controversial. This article presents a narrative review of the literature after the selection of studies in electronic databases (PubMed, Cochrane Library and Lilacs), with the intention of evaluating the clinical and diagnostic tools that should be part of conservative selective approach of these lesions. It was observed that a nonoperative selective treatment can be effectively and safely used, when performed by a trained interdisciplinary team, working in adequate trauma centers. The selective nonoperative treatment is associated with a decrease in negative and nontherapeutic laparotomies, reducing the incidence of complications. It also contributes to the reduction of hospital costs.

Imaging Ballistic Injuries

Here in Canada, we often think of gun violence as confined to conflict zones, terrorism, and more of a problem for our southern neighbor. However, in recent years, it has also become a Canadian problem with increased gun violence related to criminal activity presenting in daily practice. Radiologists play a critical role in the evaluation of ballistic trauma and must therefore be familiar with both the common and uncommon patterns of ballistic injury. In this article, we review the mechanisms of ballistic trauma as well as their resultant injury patterns in order to guide image interpretation.

Accuracy of Preoperative MDCT in Patients With Penetrating Abdominal and Pelvic Trauma

Purpose:

This study aims to evaluate the overall diagnostic accuracy of preoperative multidetector computed tomography (MDCT) in penetrating abdominal and pelvic injuries (PAPI).

Method and Materials:

We used our hospitals’ trauma registry to retrospectively identify patients with PAPI from January 1, 2006, to December 31, 2016. Only patients who had a 64-MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in our study cohort. Each finding noted on MDCT was rated using a 5-point scale to indicate certainty of injury, with a score of 0 being definitive. Using surgical findings as the gold standard, the accuracy of radiology reports was analyzed in 2 ways. A κ statistic was calculated to evaluate each pair of values for absolute agreement, and ratings for all organ systems were analyzed using a repeated measures analysis of variance (ANOVA) to determine whether radiology and surgical findings were similar enough to be clinically meaningful. Qualitative review of the radiology and surgical reports focused on the gastrointestinal (GI) tract was conducted.

Results:

Our cohort consisted of 38 males and 4 females with a median age of 29 years and a median injury severity score of 15.6. For this study, 12 different organ groups were categorized and analyzed. Of those organ groups, absolute agreement between MDCT and surgical findings was found only for liver and spleen (κ values ranging from 0.2 to 0.5). Additionally, the ANOVA revealed an interaction between finding type and organ system ( F 1, 33 = 7.4, P < .001). The most clinically significant discrepancies between MDCT and surgical findings were for gallbladder, bowel, mesenteric, and diaphragmatic injuries. Qualitative review of the GI tract revealed that radiologists can detect significant findings such as presence of injury, however, localization and extent of injury pose a challenge.

Conclusion:

The detection of clinically significant injuries to solid organs in trauma patients with PAPI on 64-MDCT is adequate. However, detection of injury to the remaining organ groups on MDCT, especially bowel, mesentery, and diaphragm, remains a challenge.

Managing post-traumatic gunshot thoraco-abdominal bleeding by intervention embolisation: A case report

We report an interesting life-threating case of post-traumatic severe bleeding in the thoraco-abdominal region. The patient was initially treated by open surgery, which failed to control bleeding in the intrahepatic and sub-diaphragmatic regions of the liver with associated haematoma collection. As bleeding continued, on the 2nd post-operative day, the patient underwent super-selective embolisation of the bleeding vessels to cease serious bleeding. The pre-embolisation arterial feeders with active bleeding and post-embolisation images by computed tomography subtraction angiography showed complete cessation of haemorrhage. Torrential haemorrhage in the thoraco-abdominal regions can be successfully managed by trained interventional radiologists in highly specialised centres.

Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis

Background

Although mandatory laparotomy has been standard of care for patients with abdominal gunshot wounds (GSWs) for decades, this approach is associated with non-therapeutic operations, morbidity, and long hospital stays. This systematic review and meta-analysis sought to summarize outcomes of selective nonoperative management (SNOM) of civilian abdominal GSWs.

Methods

We searched electronic databases (March 1966-April 1, 2017) and reference lists of articles included in the systematic review for studies reporting outcomes of SNOM of civilian abdominal GSWs. We meta-analyzed the associated risks of SNOM-related failure (defined as laparotomy during hospital admission), mortality, and morbidity across included studies using DerSimonian and Laird random-effects models. Between-study heterogeneity was assessed by calculating I2 statistics and conducting tests of homogeneity.

Results

Of 7155 citations identified, we included 41 studies [n = 22,847 patients with abdominal GSWs, of whom 6777 (29.7%) underwent SNOM]. The pooled risk of failure of SNOM in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis was 7.0% [95% confidence interval (CI) = 3.9-10.1%; I2 = 92.6%, homogeneity p < 0.001] while the pooled mortality associated with use of SNOM in this patient population was 0.4% (95% CI = 0.2-0.6%; I2 = 0%, homogeneity p > 0.99). In patients who failed SNOM, the pooled estimate of the risk of therapeutic laparotomy was 68.0% (95% CI = 58.3-77.7%; I2 = 91.5%; homogeneity p < 0.001). Risks of failure of SNOM were lowest in studies that evaluated patients with right thoracoabdomen (3.4%; 95% CI = 0-7.0%; I2 = 0%; homogeneity p = 0.45), flank (7.0%; 95% CI = 3.9-10.1%), and back (3.1%; 95% CI = 0-6.5%) GSWs and highest in those that evaluated patients with anterior abdomen (13.2%; 95% CI = 6.3-20.1%) GSWs. In patients who underwent mandatory abdominopelvic computed tomography (CT), the pooled risk of failure was 4.1% versus 8.3% in those who underwent selective CT (p = 0.08). The overall sample-size-weighted mean hospital length of stay among patients who underwent SNOM was 6 days versus 10 days if they failed SNOM or developed an in-hospital complication.

Conclusions

SNOM of abdominal GSWs is safe when conducted in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis. Failure of SNOM may be lower in patients with GSWs to the back, flank, or right thoracoabdomen and be decreased by mandatory use of abdominopelvic CT scans.

Endovascular Approach for Management of Bullet Embolization to the Heart

Bullet embolization to the right heart through the vasculature is seen infrequently in cases presenting with penetrating trauma. Patients with unstable hemodynamic status are managed operatively. For a patient with stable hemodynamic parameters, diagnostic evaluation such as computed tomography angiogram, echocardiogram, or angiography could be performed to select the best treatment option. Endovascular treatment is employed infrequently in these cases but can be a viable option for select patients. We present a case of a bullet embolus to the right ventricle treated successfully with endovascular approach and discuss the technical aspects of this approach.

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.

Surgical Management of Abdominal Trauma: Hollow Viscus Injury

Hollow viscus injury is common with penetrating trauma to the torso and infrequent with a blunt traumatic mechanism of injury. The diagnosis in hemodynamically unstable patients is often made in the operating room. In hemodynamically stable patients, the diagnosis can be difficult due to additional injuries. Although computed tomography remains the diagnostic tool of choice in hemodynamically stable patients, it has lower reported sensitivity and specificity with hollow viscus injury. However, even short delays in diagnosis increase morbidity and mortality significantly. Operative management of stomach, duodenal, small bowel, and colon injuries is reviewed.

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.

Highlights from the scientific and educational abstracts presented at the ASER 2016 annual scientific meeting and postgraduate course

The annual meeting of the American Society of Radiology (ASER) took place in San Francisco, California on September 14 through September 17, 2016. Attendees represented the USA as well as international emergency radiology communities, including those from academic, private practice, and teleradiology settings. There were several "members in training" in attendance as well. The meeting again featured the "Trauma Head to Toe" 2-day didactic course, highlighting various important topics on imaging of traumatic injuries. Scattered throughout the 4 days were several poster and case of the day presentations, scientific sessions, and self-assessment modules. The following is a summary of the educational posters and scientific papers.

The early management of gunshot wounds Part II: the abdomen, extremities and special situations

The management of gunshot wounds of the abdomen and extremities is evolving with centres who treat large volumes of such injuries tending to the application of a policy of selective non-operative management. This article discusses the management of gunshot wounds to the abdomen and extremities and reviews the evidence supporting these changing practices. Special situations such as wounding by shotguns or air rifles are also examined as are the special considerations needed when dealing with the gunshot injured pregnant women or in a child.

Diagnostic accuracy of triple-contrast multi-detector computed tomography for detection of penetrating gastrointestinal injury: a prospective study

PURPOSE

Neither the performance of CT in diagnosing penetrating gastrointestinal injury nor its ability to discriminate patients requiring either observation or surgery has been determined.

MATERIALS AND METHODS

This was a prospective, single-institutional observational study of patients with penetrating injury to the torso who underwent CT. Based on CT signs, reviewers determined the presence of a gastrointestinal injury and the need for surgery or observation. The primary outcome measures were operative findings and clinical follow-up. CT results were compared with the primary outcome measures.

RESULTS

Of one hundred and seventy-one patients (72 gunshot wounds, 99 stab wounds; age range, 18-57 years; median age, 28 years) with penetrating torso trauma who underwent CT, 45 % were followed by an operation and 55 % by clinical follow up. Thirty-five patients had a gastrointestinal injury at surgery. The sensitivity, specificity, and accuracy of CT for diagnosing a gastrointestinal injury for all patients were each 91 %, and for predicting the need for surgery, they were 94 %, 93 %, 93 %, respectively. Among the 3 % of patients who failed observation, 1 % had a gastrointestinal injury.

CONCLUSION

CT is a useful technique to diagnose gastrointestinal injury following penetrating torso injury. CT can help discriminate patients requiring observation or surgery.

KEY POINTS

• The most sensitive sign is wound tract extending up to gastrointestinal wall. • The most accurate sign is gastrointestinal wall thickening. • Triple-contrast CT is a useful technique to diagnose gastrointestinal injury. • Triple-contrast CT helps to discriminate patients requiring observation and surgery.

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.

MDCT of complications and common postoperative findings following penetrating torso trauma

Victims of penetrating torso trauma often present with findings that necessitate emergent exploratory laparotomy, precluding scanning with multidetector computed tomography (MDCT) until the postoperative period. This article reviews the wide range of complications as well as expected findings that may be encountered at MDCT performed postoperatively. Little has been written to guide the radiologist in interpreting these often complex and potentially confusing studies.

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.

Selective non-operative management of civilian gunshot wounds to the abdomen: a systematic review of the evidence

BACKGROUND

Selective non-operative management (SNOM) of penetrating abdominal wounds has become increasingly common in the past two or three decades and is now accepted as routine management for stab wounds. Gunshot wounds are more frequently managed with mandatory laparotomy but recently SNOM has been successfully applied. This review systematically appraises the evidence behind SNOM for civilian abdominal gunshot wounds.

METHODS

A Medline search from 1990 to present identified civilian studies examining success rates for SNOM of abdominal gunshot wounds. Case reports, editorials and abstracts were excluded. All other studies meeting the inclusion criteria of reporting the success rate of non-operative management of abdominal gunshot wounds were analysed.

RESULTS

Sixteen prospective and six retrospective studies met the inclusion criteria, including 18,602 patients with abdominal gunshot wounds. 32.2% (n=6072) of patients were initially managed non-operatively and 15.5% (n=943) required a delayed laparotomy. The presence of haemodynamic instability, peritonitis, GI bleeding or any co-existing pathology that prevented frequent serial examination of the abdomen from being performed were indications for immediate laparotomy in all studies. Delayed laparotomy results in similar outcomes to those in patients subjected to immediate laparotomy. Implementation of SNOM reduces the rates of negative and non-therapeutic laparotomies and reduces overall length of stay.

CONCLUSIONS

SNOM can be safely applied to some civilian patients with abdominal gunshot wounds and reduces the rates of negative or non-therapeutic laparotomy. Patients who require delayed laparotomy have similar rates of morbidity and mortality and similar length of stay to those patients who undergo immediate laparotomy.

The principles of non-operative management of penetrating abdominal injury

The selective non-operative management of penetrating abdominal injury is gaining increasing acceptance. Recognition of the morbidity, mortality, and cost associated with non-therapeutic exploration has provided the impetus for selective management. This review describes the principles of, and evidence for, this strategy. Selective management is widely accepted for the treatment of stab wounds, but the selective management of ballistic injuries, particularly in the military setting, remains contentious. As a result, there are marked variations in the application of this practice. Computed tomography is a prerequisite for the selective management of ballistic injuries, and possibly also stab wounds. Failure of non-operative management, following stab wounds or gunshot wounds, is invariably apparent within 24 hours.

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.

Non operative management of gunshot wounds on the right thoracoabdomen

OBJECTIVE

To analyze the results after the implementation of the non-operative management (NOM) of the right upper thoracoabdominal gunshot injuries protocol.

METHODS

Prospective study. From January 2005 to December 2011, 115 patients were included into this study. Criteria for inclusion were gunshot wound to the right thoracoabdominal region, haemodynamic stability, no signs of peritonitis, and realized CT scan. The data collected were analysed by the software EXCEL.

RESULTS

Among the 115 patients included in our study, the mean age was 25.8 years old (range, 14-78 years old), of whom 95.6% were male, 62.6% had thoracoabdominal injuries and 37.4% had exclusively abdominal injuries. The averages of trauma scores were RTS 7.7, ISS 14.8 and TRISS 97%. One hundred and nine patients (94.8%) had liver injury, 72 (62.6%) had diaphragm and lung injury, 28 (24.4%) had renal injury. Complications were present in 12 (10.5%) patients, 7 of these related to the thorax. The NOM failure happened in 4 (3.5%) patients, 2 of them due to bile peritonitis, 1 related to bleeding and 1 the laparotomy was unnecessary. The mean hospital stay was 9.4 days. There were 2 deaths due to associated gunshot brain injury. Sixty seven patients (58.3%) were presented in the follow-up after 2 months of trauma. The CT scan showed injury scar in 58 patients (86.5%).

CONCLUSION

NOM of the penetrating right thoracoabdominal injuries must be seen with caution. The NOM of right thoracoabdominal gunshot injuries is safe only in selected cases, followed by well-defined protocols and when performed in places that have adequate infrastructure.

Non-operative management of liver trauma

The liver is one of the commonest intra-abdominal organs injured worldwide in blunt and penetrating trauma and its management has evolved significantly in the last 30 years. Mandatory laparotomy has been replaced by an acceptance that for most blunt hepatic trauma, a selective non-operative approach is safe and effective with a failure rate ie the need to proceed to delayed laparotomy of approximately 10%. There is a markedly lower rate of complications in those that are managed non-operatively. Adjuncts to this conservative regimen such as angioembolisation and delayed laparoscopy to treat biliary peritonitis increase the chances of avoiding laparotomy. This belief in non-operative management has also been transferred to some degree to penetrating liver trauma, where there is a gradual accumulation of evidence to support this non-operative approach in a carefully selected group of patients. This article examines the evidence supporting the selective non-operative management of both blunt and penetrating liver trauma and describes the outcomes and complications.