Penetrating abdominal trauma – clinical view

Ari Leppäniemi, MD Department of Abdominal Surgery

Meilahti hospital University of Helsinki

Finland

Meilahti hospital

- one of Helsinki University hospitals - general and GI-surgery - cardiothoracic and vascular surgery, transplantation

- 14.000 emergency surgical visits annually - 70% acute abdomen (including GI-bleeding) - 12% urology, 10% vascular, 5% thoracic - trauma: - blunt 60% (isolated torso injuries) - penetrating 40% (stab wounds > gunshot wounds)

- 4.000 emergency operations/year (50% of all)

Incidence of organ injuries and outcome in abdominal trauma

Frequency of Hospital organ injuries mortality

Stab wounds 7-50 % 0-4 % Gunshot wounds 40-90 % 10-13 % Blunt trauma 5-10 % 13-25 %

Frequency of organ injuries

Penetrating (1272) Blunt (539) Liver 28% 51% Spleen 7% 47% Colon 23% 5% Small bowel 29% 7% Stomach 13% 2% Duodenum 5% 4% Pancreas 6% 6%

Fabian & Croce 1996

Abdominal vascular injuries Pen Blunt Total %Blunt

Inferior vena cava 474 44 518 8.5 Iliac vein 267 9 276 3.3 Abdominal aorta 237 5 242 2.1 Iliac artery 213 11 224 4.9 Mesenteric artery 188 14 202 6.9 Portal venous 163 22 185 11.9 Renal vessel 123 32 155 20.6 Hepatic veins 43 8 51 15.7

Mattox 1989

Evolution in abdominal trauma care

- nonoperative management until 1890’s - 1881 Sims advocated formal laparotomy for

abdominal gunshot wounds to prevent death from shock, hemorrhage or septicemia

- 1887 American Surgical Association recommended exploration of civilian penetrating abdominal wounds

- routine exploration of abdominal war wounds from 1915

Evolution in abdominal trauma care

- mandatory explorative laparotomy until 1960’s - challenged in abdominal stab wounds by Shaftan in

1960 - selective nonoperative management

- abdominal stab wounds in from 1970’s - first randomized study in 1996

- blunt solid abdominal organ injuries from 1980’s - abdominal gunshot wounds from 1990’s

Critical observations and advances Consequences of mandatory laparotomy

High rate of unnecessary operations Associated short- and long-term morbidity Cost considerations

Improved diagnostics of abdominal trauma Diagnostic peritoneal lavage, Ultrasound (FAST) Computed tomography (multislice multidetector CT) Natural orifice and cavitary endoscopy

Nonsurgical interventions Percutanoeus, endoscopic, angiographic/endovascular

Therapeutic interventions required

- significant bleeding - hollow organ perforation - diaphragmatic perforation - abdominal wall (evisceration)

Source of major hemorrhage

n died % exsanguin. Aorta 36 17 (47%) 82% Inferior vena cava 23 9 (39%) 78% (33%) SMA/SMV/PV/HA 13 2 (15%) 0 Liver 229 21 (9%) 62% (38%) Spleen 213 15 (7%) 7% (0%) Kidney 83 5 (6%) 80% (0%) Pancreas 43 8 (19%) 25% (0%) Colon (SW) 38 0 0 Diaphragm (blunt) 20 3 (15%) 67% (0%)

Risk of death and average time to death by systolic blood pressure (penetrating torso)

(Pennsylvania Trauma Registry, patients aged 18-45 years)

SBP Risk of death Time to death 90+ 4% 419 minutes 76-89 8% 188 minutes 50-75 46% 161 minutes <50 95% 18 minutes

Champion et al. 2003

ED time does matter

- 243 hypotensive patients bleeding from abdominal injuries

- pre-laparotomy ED time and survival - in patients spending <90 minutes in the ED, the

probability of death increased 1% for each 3 minutes in the ED (overall mortality 40%) Clarke et al. 2002

Simple stab wounds vs. hara-kiri wounds

- self-inflicted wounds (n=84) - simple stab wounds (n=75) - mostly periumbilical and epigastric - organ injuries in 59% - mortality 1% - hara-kiri wounds (n=9) - middle abdomen - organ injuries in 67% - mortality 22% Morita et al. 2008

Studies from Meilahti hospital

- Complications of negative laparotomy for truncal stab wounds. J Trauma 1995; 38: 54

- Selective nonoperative management of abdominal stab wounds: prospective, randomized study. World J Surg 1996; 20: 1101

- Indications for early mandatory laparotomy in abdominal stab wounds. Br J Surg 1999; 86: 76

- Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma 2003; 55: 636

- Occult diaphragmatic injuries caused by stab wounds. J Trauma 2003; 55: 646

Should all patients be operated?

Nontherapeutic laparotomy for abdominal stab wounds

- 459 (mandatory) laparotomies for abdominal and thoracoabdominal stab wounds (1967-91)

- nontherapeutic in 172 (37%) - mortality 0.6% (thoracic vascular injury) - hospital morbidity 21% - mostly wound complications - prolonged hospital stay by 4.6 days Leppäniemi et al. J Trauma 1995

What happens if some patients are treated nonoperatively?

- mandatory laparotomy vs. selective nonoperative management (1992-4, n = 127) - immediate oper. 46%, superficial 12%, drop outs 2% - randomized: laparotomy (n=27) or observation (n=24) - therapeutic laparotomy rate 6/27 (22%) - delayed recognition of injuries 4/20 (17%) - no early mortality, morbidity: 19% vs. 8% (p=0.26) - median hospital stay: 5 vs. 2 days (p=0.002) - costs saved/observed patient: USD 2.800 Leppäniemi and Haapiainen 1996

Who needs early operative exploration?

Predicting the presence of a significant organ injury after abdominal stab wound PPV NPV p

Shock on admission 0.83 0.64 0.00 Continuing hemorrhage 0.86 0.64 0.02 Generalized tenderness 0.81 0.74 0.00 GI bleeding or fistula 1.00 0.58 0.15 Omental evisceration 0.65 0.60 0.06 Peritoneal penetration on LWE 0.61 1.00 0.00 Fluid on ultrasonography 0.54 0.70 0.08 Extraluminal air on radiography 0.72 0.68 0.08 Male sex 0.45 0.71 0.13

Leppäniemi et al. 1999

Evaluating peritoneal penetration

- local wound exploration (local anesthesia, ED) - always available, inexpensive, rapid - unreliable in patients with - obesity, thick abdominal musculature - thoracoabdominal stab wounds - intact anterior fascia (rather than peritoneum) - reliable in identifying superficial injuries

- laparoscopy (local/general anesthesia, ED/OR) - sensitive and specific for peritoneal penetration

CT in the evaluation abdominal stab wounds

- stable patients, requires interpretation

- serial US and CT guided management safe (Soto et al. 2001) - triple-contrast helical CT in the diagnosis and

exclusion of peritoneal violation and visceral injury - for peritoneal violation: - sensitivity 97%, specificity 98%, accuracy 98% Shanmuganathan et al. 2004

- can be used to exclude visceral injuries (NPV 100%) identifying patients who can be discharged early Salim et al. 2006

Explorative laparotomy (EL) vs. diagnostic laparoscopy (DL) in abdominal stab wounds

Nontherapeutic Laparotomies laparotomy rate prevented EL DL

Dalton 1994 54% 19% 54% Mutter 1997 not stated 76% Hallfeldt 1998 65% 50% 87% DeMaria 2000 57% 19% 55% Leppäniemi 2003 65% 11% 55% Cherry 2005 35% 17% 61%

Explorative laparotomy (EL) vs. diagnostic laparoscopy (DL) in abdominal stab wounds

Morbidity % LOS (days) Costs (1000$) EL DL EL DL EL DL

Dalton 1994 not stated 5.0 2.9 7.9 6.6 Mutter 1997 22 0 10.2 5.6 not stated Hallfeldt 1998 18 0 6.4 2.4 not stated DeMaria 2000 ? 0 5.9 4.1 8.3 6.1 Leppäniemi 2003 13 10 5.7 5.1 4.5 4.7

Conclusions

Diagnostic laparoscopy can not be recommended as a routine diagnostic procedure in anterolateral abdominal or lower thoracic stab wounds.

Whether a subgroup of patients with left-sided thoracoabdominal or epigastric stab wounds would benefit from laparoscopy solely to exclude diaphragmatic perforation is possible but not confirmed in this study.

Retrospective analysis of epigastric and thoracoabdominal stab wounds, n=97

Incidence of diaphragmatic injuries - overall in the exploration group: 4/47 (9%) - occult (excluding patients with associated injuries

requiring surgical repair): 3/43 (7%) - delayed presentation of diaphragmatic injuries

(observation group): 2/50 (4%) - occult diaphragmatic injuries following left-sided

thoracoabdominal stab wounds: 4/24 (17%) Leppäniemi and Haapiainen 2003b

Summary: Risk of significant organ injury in abdominal stab wounds

- anterior stab wound 40-50% - if peritoneal violation 60-70% - equivocal peritoneal violation 7% - peritoneum intact on LWE 0%

- stab wound of the flank 20-30% - posterior stab wound 7-15% - thoracoabdominal stab wound 15%

- occult diaphragmatic injury 7% - right side 3% - left side 17%

IMMEDIATEOPERATION

SURGICAL ABDOMENOR

PERICARDIALTAMPONADE

LAPAROTOMY

PERITONEALVIOLATION

CONFIRMED

OBSERVE24-48 HOURS

PERITONEALVIOLATIONEQUIVOCAL

DIAGNOSTICLAPAROSCOPY

LEFTTHORACOABDOMINAL

WOUND

DISCHARGE

SUPERFICIALWOUND

LOCALWOUND

EXPLORATION

NO INDICATIONSFOR IMMEDIATE

SURGERY

STAB WOUND OF THEANTERIOR ABDOMEN

OR FLANK

Stab wounds of the back

LAPAROTOMY

WOUND EXTENDS TO

RETROPERITONEUM

FOLLOW UP24-48 HOURS

WOUND LENGTHUNDETERMINED

DISCHARGE

WOUND LIMITEDTO

MUSCULAR LAYER

CT SCAN

STABLE PATIENT

IMMEDIATEOPERATION

UNSTABLE PATIENTOR

SURGICAL ABDOMEN

STAB WOUNDOF THE

LOWER BACK

Abdominal gunshot wounds

Laparoscopy in abdominal gunshot wounds

- prospective, abdominal gunshot wounds (n=672) - DL for 121 consecutive (18% of all) patients, stable - 42 (35%) positive laparoscopies

- 39 (93%) explorative laparotomies, 3 NOM (liver) - 32 (82%) therapeutic (21 solid, 13 dia, 11 hollow) - 7 non-therapeutic - 79 (65%) negative laparoscopies - no false negatives, no delayed laparotomies

- sensitivity 83%, specificity 100% Sosa et al. 1995

Abdominal computed tomography CT in abdominal gunshot wounds

n=100 nontangential, no shock or peritonitis Laparotomy in 26 (5 nontherapeutic; CT 3, clinical 2) False negative in 2 (operated 2 and 3.5 hours later)

Hollow viscus injuries, no complications Sens 91%, spec 96%, change in management in 40 patients CT is safe and useful in selecting patients for NOM Routine vs. clinical examination and selective CT ?

Velmahos et al. J Trauma 2005

Radiation exposure in trauma patients Mean 22.7 mSv; 190/100.000 additional cancer deaths

Tien et al. J Trauma 2007

Selective nonoperative management

”Selective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.” (Velmahos et al. 2001)

LAPAROTOMY

OBVIOUSPERITONEAL

PENETRATION

LAPAROTOMY

SHOCKPERITONITIS

GI-BLEEDING/FISTULAEVISCERATION

LAPAROTOMY

PERITONEALPENETRATION OR

HIGH ENERGYBULLET

DEBRIDEMENT ANDDELAYED PRIMARY

CLOSURE

EXTRA-PERITONEAL

WOUND

WOUNDEXPLORATION

SUPERFICIAL ORTANGENTIAL

WOUND CHANNEL

ABDOMINALGUNSHOT WOUND

Nonoperative management

- abdominal vascular injuries - liver injuries - splenic injuries - 85% of adult hepatic and splenic injuries are

managed nonoperatively - organ injury grading is important! - interventional radiology

Liver Injury Scale

I - subcapsular (<10%) hematoma, <1cm laceration II - subcapsular (10-50%), intraparenchymal (<10 cm) hematoma

- 1-3 cm deep laceration (<10 cm long) III - subcapsular (>50% or exp.), intraparenchymal

(>10 cm or exp.) or ruptured hematoma - >3cm deep laceration

IV - parenchymal disruption (25-75% of lobe or 1-3 segments in one lobe)

V - parenchymal disruption (>75% of lobe, >3 segments) - juxtahepatic venous injury, hepatic avulsion Moore et al. 1995

Pancreatic injury - severity classification (AAST 1990)

- Grade I and II: hematoma or laceration, main duct intact

- Grade III: distal transection or parenchymal injury with duct injury at or to the left of the SMV

- Grade IV: proximal transection or parenchymal injury not involving ampulla

- Grade V: massive disruption of the pancreatic head with ampullary injury

Nonsurgical interventions

Angioembolization Splenic, hepatic and renal injuries Retroperitoneal and pelvic arteries Pseudoaneurysms, and AV-fistulas

Endovascular treatment (stent grafts) Endoscopy

ERCP: partial injuries to biliary and pancreatic ducts Percutanous drainage

Replacing surgical drainage Postoperative for complications

Summary Abdominal stab wounds Majority of stab wounds of the anterior abdomen, flanks

and the back can be managed nonoperatively Peritoneal penetration, when reliably detected, is

associated with moderate risk of significant organ injury and requires further diagnostic studies or exploration (low volume centers?)

Laparoscopy detects diaphragmatic perforations in left-sided thoracoabdominal stab wounds

Abdominal gunshot wounds Majority need operative exploration but nonoperative

management can be used in selected cases

Thank you!