Faculty Collaboration Database

Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial. J Trauma 2009 May;66(5):1294-301

Date

05/12/2009

Pubmed ID

19430229

DOI

10.1097/TA.0b013e31819dc688

Scopus ID

2-s2.0-67649660017 (requires institutional sign-in at Scopus site)   94 Citations

Abstract

BACKGROUND: The optimal management of hemodynamically stable, asymptomatic patients with anterior abdominal stab wounds (AASWs) remains controversial. The goal is to identify and treat injuries in a safe, cost-effective manner. Common evaluation strategies include local wound exploration (LWE)/diagnostic peritoneal lavage (DPL), serial clinical assessments (SCAs), and computed tomography (CT) imaging. The purpose of this multicenter study was to evaluate the clinical course of patients managed by the various strategies, to determine whether there are differences in associated nontherapeutic laparotomy (NONTHER LAP), emergency department (ED) discharge, or complication rates.

METHODS: A multicenter, Institutional Review Board-approved study enrolled patients with AASWs. Management was individualized according to surgeon/institutional protocols. Data on the presentation, evaluation, and clinical course were recorded prospectively.

RESULTS: Three hundred fifty-nine patients were studied. Eighty-one had indications for immediate LAP, of which 84% were therapeutic. ED D/C was facilitated by LWE, CT, and DPL in 23%, 21%, and 16% of patients, respectively. On the other hand, LAP based on abnormalities on LWE, CT, and DPL were NONTHER in 57%, 24%, and 31% of patients, respectively. Twelve percent of patients selected for SCA ultimately had LAP (33% were NONTHER); there was no apparent morbidity due to delay in intervention.

CONCLUSIONS: Shock, evisceration, and peritonitis warrant immediate LAP after AASW. Patients without these findings can be safely observed for signs or symptoms of bleeding or hollow viscus injury. To limit the number of hospital admissions, we propose a uniform strategy using LWE to ascertain the depth of penetration; the patient may be safely discharged in the absence of peritoneal violation. Peritoneal penetration, absent evidence of ongoing hemorrhage or hollow viscus injury, should not be considered an indication for LAP, but rather an indication for admission for SCAs. We suggest that a prospective multicenter trial be performed to document the safety and cost-effectiveness of such an approach.

Author List

Biffl WL, Kaups KL, Cothren CC, Brasel KJ, Dicker RA, Bullard MK, Haan JM, Jurkovich GJ, Harrison P, Moore FO, Schreiber M, Knudson MM, Moore EE

MESH terms used to index this publication - Major topics in bold

Abdominal Injuries
Adult
Female
Humans
Incidence
Injury Severity Score
Laparotomy
Length of Stay
Male
Pain, Postoperative
Peritoneal Lavage
Peritonitis
Postoperative Complications
Prognosis
Prospective Studies
Risk Assessment
Survival Rate
Tomography, X-Ray Computed
Treatment Outcome
Wounds, Stab