Non-operative Management in Penetrating Abdominal Trauma
Non-operative Management in Penetrating Abdominal Trauma
Background The recent mandate for surgical exploration for all penetrating abdominal trauma has been questioned. High-volume centers report good outcomes for non-operative treatment in penetrating trauma for hemodynamically stable patients without peritonitis and with tangential wounds. The applicability of this strategy in smaller hospitals is unknown.
Study Objectives The purpose of this study was to evaluate non-operative management of penetrating abdominal trauma at a Level II trauma center.
Methods We retrospectively reviewed all patients with penetrating abdominal trauma from 2006 through 2008. Demographic information, treatments, and outcomes were analyzed using descriptive statistics.
Results Our sample consisted of 86 patients with penetrating abdominal trauma; 12 (14%) had documented peritoneal violation and were managed non-operatively. The average age was 30 years (range 21–39 years), with 50% African American, 33% Caucasian, and 17% Hispanic. Male patients accounted for 92%, and the average Injury Severity Score was 5.2 (range 1–13). Overall non-operative treatment failed in 3 patients (25%); one required drainage of a retrogastric abscess on hospital day 4, and another underwent gastric and diaphragm repair on hospital day 1. The third treatment failure did not require an operation but developed a biloma requiring percutaneous drainage. There were no other complications related to non-operative therapy and no mortalities. The average length of stay was 3.9 days; 83% of patients were discharged home.
Conclusions In hemodynamically stable patients without peritonitis and documented isolated injuries to solid organs, non-operative management of penetrating abdominal trauma seems safe; however, it can delay diagnosis of hollow viscus injuries. Until further data emerge, extreme caution should be used in employing non-operative management for penetrating abdominal injuries at small trauma centers.
Routine surgical exploration has been the standard practice for penetrating solid organ abdominal injuries. Conversely, non-operative therapy has become the standard of care for blunt solid organ abdominal injuries. With improvements in diagnostic strategies and with the hope of minimizing negative laparotomies, the mandate for surgical exploration for all penetrating abdominal injuries has been questioned, with several authors reporting acceptable outcomes in hemodynamically stable patients without peritonitis. The recent guidelines developed by the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee recommend selective non-operative management in penetrating abdominal trauma and that routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal pain and in patients suffering tangential gunshot wounds without peritonitis.
The majority of the reports on selective non-operative therapy for penetrating abdominal trauma have come from large, Level I trauma centers with high volumes and extensive experience with penetrating injuries, raising the question of applicability to smaller centers with perhaps fewer resources. The purpose of our study was to evaluate whether the strategy of selective non-operative therapy for penetrating abdominal trauma is feasible at a Level II trauma center.
Abstract and Introduction
Abstract
Background The recent mandate for surgical exploration for all penetrating abdominal trauma has been questioned. High-volume centers report good outcomes for non-operative treatment in penetrating trauma for hemodynamically stable patients without peritonitis and with tangential wounds. The applicability of this strategy in smaller hospitals is unknown.
Study Objectives The purpose of this study was to evaluate non-operative management of penetrating abdominal trauma at a Level II trauma center.
Methods We retrospectively reviewed all patients with penetrating abdominal trauma from 2006 through 2008. Demographic information, treatments, and outcomes were analyzed using descriptive statistics.
Results Our sample consisted of 86 patients with penetrating abdominal trauma; 12 (14%) had documented peritoneal violation and were managed non-operatively. The average age was 30 years (range 21–39 years), with 50% African American, 33% Caucasian, and 17% Hispanic. Male patients accounted for 92%, and the average Injury Severity Score was 5.2 (range 1–13). Overall non-operative treatment failed in 3 patients (25%); one required drainage of a retrogastric abscess on hospital day 4, and another underwent gastric and diaphragm repair on hospital day 1. The third treatment failure did not require an operation but developed a biloma requiring percutaneous drainage. There were no other complications related to non-operative therapy and no mortalities. The average length of stay was 3.9 days; 83% of patients were discharged home.
Conclusions In hemodynamically stable patients without peritonitis and documented isolated injuries to solid organs, non-operative management of penetrating abdominal trauma seems safe; however, it can delay diagnosis of hollow viscus injuries. Until further data emerge, extreme caution should be used in employing non-operative management for penetrating abdominal injuries at small trauma centers.
Introduction
Routine surgical exploration has been the standard practice for penetrating solid organ abdominal injuries. Conversely, non-operative therapy has become the standard of care for blunt solid organ abdominal injuries. With improvements in diagnostic strategies and with the hope of minimizing negative laparotomies, the mandate for surgical exploration for all penetrating abdominal injuries has been questioned, with several authors reporting acceptable outcomes in hemodynamically stable patients without peritonitis. The recent guidelines developed by the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee recommend selective non-operative management in penetrating abdominal trauma and that routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds without signs of peritonitis or diffuse abdominal pain and in patients suffering tangential gunshot wounds without peritonitis.
The majority of the reports on selective non-operative therapy for penetrating abdominal trauma have come from large, Level I trauma centers with high volumes and extensive experience with penetrating injuries, raising the question of applicability to smaller centers with perhaps fewer resources. The purpose of our study was to evaluate whether the strategy of selective non-operative therapy for penetrating abdominal trauma is feasible at a Level II trauma center.
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