A clinical observation algorithm for anterior abdominal stab wound is safe in an Australian setting

INTRODUCTION

We previously published the outcomes associated with the use of diagnostic laparoscopy to determine peritoneal breach for AASW patients without an immediate indication for laparotomy. Although this pathway was 100% sensitive there was a 54% non-therapeutic laparotomy rate. Another option that has been extensively reported is the clinical observation algorithm (COA) however, majority of the data originate from high-volume centres. We hypothesized that a COA would also be a safe option in an Australian setting, and reduce the rate of non-therapeutic operative intervention in managing AASW.

METHODS

This was a prospective cohort study examining patients with AASW admitted to a level 1 trauma centre in Sydney, Australia, between June 2021 and August 2023. Patient, injury, management and outcome data were collected from electronic medical records and the hospital trauma registry. Data were then analysed to determine the diagnostic accuracy of the COA, complication rates and median hospital length-of-stay (LOS).

RESULTS

A total of 48 patients presented with AASW. Of these patients, 11 (22.9%) proceeded to immediate laparotomy. Seven patients had a contraindication to COA and underwent diagnostic laparoscopy. Thirty patients were managed with the COA, with three (10%) patients subsequently requiring a laparotomy. Only one patient (3.3%) underwent a non-therapeutic laparotomy. There were no missed injuries. The COA sensitivity was 100%, specificity 92.7%, PPV 50% and NPV 100%. Patients managed with COA had no complications. Overall median hospital LOS was 1 day (1.0-2.3).

CONCLUSION

A COA is a safe approach for evaluating patients with AASW in an Australian setting with adequate resources. It reduces the rate of non-therapeutic operative intervention and has acceptable outcomes compared with a diagnostic laparoscopy pathway.

Penetrating Abdominal Trauma: Descriptive Analysis of a Case Series From an Indian Metropolitan City

Introduction Penetrating abdominal trauma (PAT) is a major injury that patients present to the emergency department in developed and developing countries. There are many modes and causes of injury. The aim of this study is to analyse the patterns of presentation and parameters at assessment, including investigations, interventions and outcomes of penetrating abdominal trauma at a major trauma centre in an Indian metropolitan city. Methods This is an observational descriptive study done over 18 months at a major trauma centre in a metropolitan city in India. The study was registered with the institutional ethics committee and the patients were recruited after obtaining consent on admission. The relevant details were collected from the patient's electronic records after admission and analysed. Results Stab wounds in the 21-40-year-old subset were the commonest. The small intestine was the most commonly injured organ. The mortality rates and the duration of the hospital stay were similar to other case series of the same condition. Conclusion The analysis of our case series has highlighted the patterns and outcomes of penetrating abdominal trauma in an urban demographic of a developing economy. Individuals in the prime of their lives, unfortunately, are victims of this mode of injury. Better implementation of standard management protocols can improve outcomes.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.

CT tractography in anterior abdominal stab wounds: a proposed algorithm

PURPOSE

This study evaluates the accuracy of IV contrast-enhanced computed tomography (CT) tractography in the detection of peritoneal violation in anterior abdominal stab wounds (AASW) and its impact on the management algorithm.

METHODS

This prospective study included 61 patients who presented to Kasr Alainy Hospital with AASW. According to the IV contrast-enhanced CT tractography, they were classified into penetrating, equivocal and non-penetrating injuries. The former two were subjected to diagnostic laparoscopy (DL), while the non-penetrating group was subjected to serial abdominal examination (SAE). The accuracy of CT tractography to detect peritoneal violation was assessed by correlating its findings with management outcome.

RESULTS

CT tractography stratified the injuries into non penetrating (54.1%), equivocal (14.8%) and penetrating (31.1%). All non-penetrating stabs were managed successfully by SAE. DL proved negative for peritoneal violation in all equivocal injuries and positive in all injuries designated as penetrating. Consequently, sensitivity, specificity, positive and negative predictive values and accuracy of CT tractography in detecting peritoneal violation was 100%. No missed injuries were encountered in this study.

CONCLUSION

IV contrast-enhanced CT tractography is an effective tool in the evaluation of patients with AASW. Patients with negative tractography can be safely managed by SAE. Positive tractography accurately indicates peritoneal violation which warrants further management. Patients with equivocal findings were all negative for peritoneal violation by laparoscopy, therefore, they might be reallocated for frequent SAE to reduce the rate of non-therapeutic interventions.

Evaluation and management of abdominal stab wounds: A Western Trauma Association critical decisions algorithm

This is a recommended management algorithm from the Western Trauma Association addressing the management of adult patients with abdominal stab wounds. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published observational studies and expert opinion of Western Trauma Association members. The algorithm and accompanying comments represent a safe and sensible approach that can be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this as a guideline to develop their own local protocols.

Comparison between isolated serial clinical examination and computed tomography for stab wounds in the anterior abdominal wall

OBJECTIVE

to compare abdominal computer tomography (CT) with isolated serial clinical exam (SCE) in the management of anterior abdominal stab wounds.

METHODS

randomized prospective study performed at Hospital de Pronto Socorro de Porto Alegre involving patients with anterior abdominal stab wounds without indication of immediate laparotomy; patients were divided in two groups: CT group and SCE group, In the SCE group, patients were followed up with serial clinical exam every 6 hours, Patients of CT group were submitted to abdominal computer tomography after initial evaluation.

RESULTS

66 patients were studied and 33 were included in each group, Of total, six were submitted to surgery, three of each group, In the SCE group, patients submitted to surgery in media waited 12 hours from arrival to diagnosis without any non-therapeutic surgeries, The remaining 30 patients of this group were discharged from hospital after 24 hours of observation, In the CT group, three patients showed alteration at CT and were submitted to laparotomy, one non-therapeutic, The others were discharged from hospital after 24 hours of observation, Abdominal computer tomography had a positive predictive value (PPV) of 67% and negative predictive value (NPV) of 100%, with 96% of accuracy, Isolated serial clinical exam showed PPV and NPV of 100% and 100% of accuracy.

CONCLUSION

selective management of anterior abdominal stabs is safe, when a rigorous selection of patients is observed, Isolated serial clinical exam may be performed without computer tomography, without increase of hospitalization time or morbidity, reducing costs, exposure to radiation, mortality and morbidity and non-therapeutic laparotomies.