Transcript ABDOMINAL PENETRATING INJURY

Dr. Andriana Purnama, SpB-KBD
Alamat Kantor
: Divisi Bedah Digestif FK UNPAD/RSHS
Jl. Pasteur No. 38 Bandung 40161
Telp/Fax Kantor : 022-2034574
Alamat Rumah : Jl. Babakan Jeruk III No. 23 Bandung
Telp/Fax rumah : No.HP
: 08122025557
Tempat/Tgl Lahir: Bandung, 09 Juni 1972
Email
:Profesi
: Dokter Konsultan Bedah Digestif
Jabatan
:
1. Staf Divisi Bedah Digestif RSHS
2. -
Andriana Purnama
Department of Surgery
Hasan Sadikin Hospital
Faculty of Medicine Padjadjaran University
Bandung
HOT TOPICS
 Interest in selective non-operative management
(SNOM) of PAI began to increase.
 SNOM for stab wounds is now common
 SNOM for gunshot wounds remains controversial
 The doctor should answer 2 questions :
1. Is there intra abdominal injury ?
2. Does this injury require operative
repair ?
DO It or not???
Risks of Operative Management of
Abdominal Trauma
Higer Unnecessary Laparatomy Rate
Morbidity
Mortality
Longer Hospital Stays
Increased Hospital Costs
Mc.Connell DB & Trunkey .DD : Nonoperative Management of Abdominal
Trauma, in Surg.Clin.North Am, 1990 (70) :3, 679.
Risks of NOM of Abdominal Trauma
 Missed injury
 Morbidity
 Mortality
 Continued bleeding
 Transfusion risk
 Abdominal Compartment Syndrome
Mc.Connell DB & Trunkey .DD : Nonoperative Management of Abdominal Trauma, in Surg.Clin.North
Am, 1990 (70) :3, 678.
History
 Until the early 1900s, PAI was managed conservatively.
 World War I :
patients who underwent mandatory operative exploration
had a better chance of survival,
 Laparotomy became the standard of care.
 World War II : early laparotomy improved survival.
 1950, laparotomy was the standard treatment of PAI pts
 1960, Shaftan : high rate of negative laparotomies
 published a report on the Non Operative
Management of abdominal injury
 He had managed 125 of 180 PAI patients without surgery,
with a mortality rate < 1 %
Introduction
 Recent guidelines have recommended :
* Observation for haemodynamically stable patients
with no evidence of peritonitis
for stab wounds and tangential GSW
* Up to 30 % of anterior abdominal GSW &
67 % of gunshot injuries to the back,
can be managed safely without operative
intervention
Zafar NS, Rushing A, Haut ER, Kisat MT, Villegas CV, Chi A et al, Outcome of selective
non-operative management of penetrating abdominal injuries from the North American
National Trauma Database, British Journal of Surgery 2011; 99(Suppl 1): 155–165
Mechanism of injury
Low velocity
 Knife wound/stab wounds
 Disrupts only structures penetrated
Medium velocity
 Handguns and pellet guns
High velocity
 Military weapons and rifles
Gunshot Wound VS Stab Wound
GSW
 The most commonly
injured organs
Small bowel (50%)
2. Colon (40%)
3. Liver (30%)
4. Abdominal vascular
structures (25%)
1.
SW
 The most commonly
injured organs
1. Liver (40%)
2. Small bowel (30%)
3. Diaphragm (20%)
4. Colon (15%)
Stab Wound
 Demetriades and Rabinowitz 1987 :
 Prospective study of 651 patients with stab wounds to
the anterior abdomen treated with SNOM
 Based mainly on serial physical examinations.


Half cases were successfully managed without laparotomy.
Eleven (1.6%) patients who were initially observed,
required a laparotomy later,
 No mortality among them.
 The accuracy of the initial physical examination was
93.9% (false negative initial exam 3.2%, false negative
exam 2.9%).
Demetriades D, Velmahos GC, Indications for & Techniques of Laparotomy, in
Feliciano DV, Mattox KL, Moore EE, Trauma, 7th ed, 2013
Stab Wound
 Shorr et al 1988 :
 330 patients with abdominal stab wounds :
 32% of had a therapeutic laparotomy
 14% a non therapeutic laparotomy.
 53% were discharged without an operation.
Demetriades D, Velmahos GC, Indications for & Techniques of Laparotomy,
in Feliciano DV, Mattox KL, Moore EE, Trauma, 7th ed, 2013
Stab Wound
 Indications for laparotomy such as :
peritoneal penetration,
omental evisceration,
free air on abdominal radiographs,
blood on abdominal paracentesis
 are debated.
1. 69% associated with significant intra-abdominal injuries,
even in the absence of generalized abdominal tenderness
2. Others have found no such association :
 continue to use SNOM
 avoid routine operation
 SNOM should be considered only in centers with
experience & appropriate in-house staffing by trauma surgeons.




Stab Wound
 In most patients :
Decision to operate or not, should be based
on
1. serial physical exams and
2. close hemodynamic monitoring.
Demetriades D, Velmahos GC, Indications for & Techniques of
Laparotomy, in Feliciano DV, Mattox KL, Moore EE, Trauma, 7th ed, 2013
Gunshot Wound
 Abdominal GSW are treated by routine
laparotomy in most trauma center
 GSWs to the abdomen are still commonly
treated with mandatory exploration because
of multiple reports emphasizing a high
incidence of intra-abdominal injuries
GSWs
1. Demetriades D, Velmahos GC, Cornwell EE III 1997 :
 ⅓ GSW to anterior abdomen
 ⅔ GSW to the back
 No significant intra abdominal injury  safe to SNOM
2. Velmahos GC, Demetriades D, Toutouzas KG 2001 :
 1856 GSW pts : 1405 anterior / 451 posterior – 8 yr period
 47% : no significant abdominal injury
39% anterior / 74% posterior GSW
 80 pts ( 4% ) developed signs  delayed laparotomy
5 pts (0.3%) : complications  managed successfully
Demetriades D, Velmahos GC, Indications for & Techniques of Laparotomy, in Feliciano DV,
Mattox KL, Moore EE, Trauma, 7th ed, 2013
G S Ws
 Based on these observations
 Selected patients with :



isolated gunshot wounds to solid organs (liver, spleen, kidney)
hemodynamically stable
no peritoneal signs,
 may be managed nonoperatively
 In a study of 152 patients with gunshot injuries to the liver,
21% of cases with isolated liver injury were successfully
managed non operatively
Demetriades D, Velmahos GC, Indications for & Techniques of Laparotomy, in Feliciano DV,
Mattox KL, Moore EE, Trauma, 7th ed, 2013
Serial Physical Examination
 A careful initial
physical examination
followed by serial
examinations :
 Are the most important
tool to set the indications
for laparotomy after
abdominal stab wounds.
Serial Physical Examination
Realible in detecting significant Injuries after
PAI, if performed by experienced clinicans and
preferably by the same team
The Journal of TRAUMA Injury, Infection, and Critical Care. Vol 71, Number 6, 2011
Diagnostic Peritoneal Lavage
 DPL has been used to identify significant
peritoneal injury after PAI for at least 30
years and still has arole in Trauma Care
 DPL reduced unnecessary LAP, Rapid, Safe
and Highly cost-effective
Diagnostic Peritoneal Lavage
 When the Concept of Selective Management
rather than Mandatory LAP began to receive more
attention, The Non Invasive Tools become more
popular adjuncts
 The more recent literatur Suggest that DPL now
seems to be Increasingly replaced by the use of
other diagnostic modalities
 The Journal of TRAUMA Injury, Infection, and Critical Care. Vol 71, Number 6, 2011
Diagnostic Peritoneal Lavage - DPL
 For hemodynamically stable patients  CT scan
 For hemodynamically unstable patients  FAST
 DPL is used predominantly when :
1. CT or FAST are not available,
2. No sufficient expertise to make decisions based on the
FAST results,
3. FAST results are negative, but there is no other source
to account for the hemodynamic instability.
Local Wound Exploration
 LWE has been used in a number of series to rule
out penetration of the Anterior Fascia
 If the patient has no penetration of the anterior
Fascia, the patient may be safely discharged from
the ED
 When LWE is used alone to determine Laparatomy
there will be a high unnecessary Laparatomy Rate
Local Wound Exploration
 Even the peritoneum is penetrated were used as a
Cutt- Off, many patients will have no intra
peritoneal Injury, or an Injury that does not
require surgical Intervention
 Most Commonly: Omental Laceration, Mesenteric
Laceration or Liver tears that have stopped
Bleeding
 Most Authors have Investigated; LWE (+),
Laparatomy Negative almost 50%
Management Guidelines for Penetrating Abdominal Trauma. Current
Opinion in Critical Care 2010, 16:609-617
Ultrasonography - FAST
 Excellent sensitivity in identifying intra-abdominal
fluid
 Ease of use, repeatability, and avoidance of radiation
 The most significant contribution of the FAST is :
 detection of intra-abdominal fluid in the :
hemodynamically unstable and
clinically unevaluable blunt trauma victim.
 immediate exploratory laparotomy
 Negative FAST  further evaluation
- most commonly CT
Abdominal Computed Tomography
 Show accurate imaging of solid parenchymal
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injury
Major role in decision to manage the injured
spleen, liver & kidney nonoperatively
Increase use in blunt trauma
Use in evaluation of abdominal GSW, selected
for nonoperative management ( SNOM )
Abdominal CT has become an indispensable
tool in the evaluation of abdominal trauma.
Diagnostic Laparoscopy
 Major limitation :  Inability to :
1. “ Run “ the bowel
2. Diagnose retroperitoneal injuries
3. Expose adequately deep lying organs
4. Estimate accurately the quantity of hemoperitoneum
 ≈ ½ existing injuries can be missed by laparoscopy
Vilavicencio RT, Aucar JA, Analysis of laparoscopy in trauma, J Am Coll Surg
189:11, 1999
Diagnostic Laparoscopy
Advantages :
 Excellent ( > 95% ) Sensitivity & Specifity to
establish :
1. Peritoneal violation
2. Hemoperitoneum
3. Enteric content spillage
 Peritoneal penetration or hemoperitoneum :
not always associated with therapeutic laparotomy
 the information provided by laparoscopy ???
Diagnostic Laparoscopy
 It does not appear that laparoscopy has a
role in the management of patients with PAI
 The procedure does not appear to be cost
effective, because it is rarely theurapeutic
(only 1 of 24 patients in WTA trials)
CURRENT MANAGEMENT OF
PENETRATING ABDOMINAL INJURY (PAI)
Review of published literatures
Validating the Western Trauma
Association Algorithm For Managing
Patients With Anterior Abdominal Stab
Wounds: A Western Trauma Association
Multicenter Trial
The Journal of TRAUMA Injury, Infection, and Critical
Care. Vol 71, Number 6, 2011
Western Trauma Association
 Six Center of Trauma
 May 2008-Nov 2010
 222 Pts PAI
 62 Pts had immediate LAP
 160 Pts Stable and Asymptomatic
 20 Pts D/C form ED after LWE (-)
 11 Pts Lap, When their clinical condition changed
The Journal of TRAUMA Injury, Infection, and Critical Care. Vol 71,
Number 6, 2011
The WTA proposed algorithm is
designed for cost-effectiveness. Serial
Clinical Assessments can be performed
without the added expense of CT, DPL or
Laparoscopy
• Biffel WL, Kaups KL, Cothren CC
et al : Management of patients
with anterior abdominal stab
wounds; Western Trauma
Association, Multicenter Trial. J
Trauma 2011, 71 (6); 1294-1301
MANAGEMENT OF
PENETRATING ABDOMINAL
TRAUMA
Feliciano, Mattox and Moore,
Trauma 7th edit, 2013
Conditions for SNOM of PAI
How about practicing SNOM in trauma centers with a :
Low volume of penetrating trauma
2. Inadequate resources to provide 24-hour in-house
coverage.
3. The inability to do serial physical examinations by
physicians with reasonable experience
1.
 prohibits the practice of SNOM
 It may be safer for small trauma centers with limited
exposure to GSW victims to retain a policy of routine
laparotomy.
Conditions for SNOM of PAI
SNOM of PAI is recommended in :
1. Facilities with the resources and experience to
select and monitor patients with PAI carefully,
2. Capability to provide immediate surgical
intervention to those who need it.
Zafar SN, et al, Outcome of selective non-operative management of penetrating abdominal
injuries from the North American National Trauma Database, BJS 2011; 99(Suppl 1): 155–165
SNOM : Success & Failure
 Success rate is 75–80 %
and improved over the time interval
 Failure rate 10–20 %
 Failed SNOM is associated with :
- longer hospital stays & costs
 Failed SNOM ≈ mortality has not been
documented
Como J.J et al J Trauma, 2010, 68:721-733
RECOMMENDATIONS
a. Pts who are hemodynamically unstable or who have
diffuse abdominal tenderness should be taken
emergently for laparotomy (level 1)
b. Pts who are hemodynamically stable with an
unrealable clinical examination ( i.e. brain injury,
spinal cord injury, intoxication, or need for sedation
or anesthesia). Should have further diagnostic
investigation performed for intra peritoneal injury
or undergo exploratory laparotomy (level 1)
RECOMMENDATIONS
c. A routine laparotomy is not indicated is
hemodynamically stable pts with abdominal
SWs without signs of peritonitis or diffuse
abdominal tenderness (away from the wounding
site) in centers with expertise (level 2).
d. A routine laparotomy is not indicated in
hemodynamically stable pts with abdominal
GSWs if the wounds are tangential and there
are no peritoneal signs (level 2)
RECOMMENDATIONS
e.
Serial physical examination is reliable in detecting
significant injuries after penetrating trauma to the
abdomen, if performed by experienced clinicians and
preferable by the same team (level 2)
f.
In pts selected for initial NOM, abdomino pelvic CT
should be strongly considered as a diagnostic tool to
fasicilitate initial management decision (level2)
RECOMMENDATIONS
Pts with penetrating injury isolated to the right upper
quadrant of the abdomen may be managed without
laparotomy in the presence of stable vital signs, reliable
examination, and minimal to no abdominal tenderness
(level 3)
h. The majority of pts with penetrating abdominal trauma
managed non operatively may be discharged after 24
hours of observation in the presence of a reliable
abdominal examination and minimal to no abdominal
tenderness (level 3)
i. Diagnostic laparoscopic may be considered as a tool to
evaluate diaphragmatic lacerations and peritoneal
penetration (level 2)
g.
Conclusion
 The rate of Unnecessary Laparatomy should be
minimized
 NOM should never be at the expense of a delay in
the diagnosis and tratment of Injury
 A part of anterior stab wound and GSW victims
can be managed non operatively safely