UROGENITAL TRAUMA

Selective nonoperative management of penetrating abdominal solid organ injuries
Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, Salim A
Division of Trauma and Surgical Intensive Care, Department of Surgery, USC School of Medicine, Los Angeles, CA, USA
Ann Surg. 2006; 244: 620-8

• Objective: To assess the feasibility and safety of selective nonoperative management in penetrating abdominal solid organ injuries.
• Background: Nonoperative management of blunt abdominal solid organ injuries has become the standard of care. However, routine surgical exploration remains the standard practice for all penetrating solid organ injuries. The present study examines the role of nonoperative management in selected patients with penetrating injuries to abdominal solid organs.
• Patients and Methods: Prospective, protocol-driven study, which included all penetrating abdominal solid organ (liver, spleen, kidney) injuries admitted to a level I trauma center, over a 20-month period. Patients with hemodynamic instability, peritonitis, or an unevaluable abdomen underwent an immediate laparotomy. Patients who were hemodynamically stable and had no signs of peritonitis were selected for further CT scan evaluation. In the absence of CT scan findings suggestive of hollow viscus injury, the patients were observed with serial clinical examinations, hemoglobin levels, and white cell counts. Patients with left thoracoabdominal injuries underwent elective laparoscopy to rule out diaphragmatic injury. Outcome parameters included survival, complications, need for delayed laparotomy in observed patients, and length of hospital stay.
• Results: During the study period, there were 152 patients with 185 penetrating solid organ injuries. Gunshot wounds accounted for 70.4% and stab wounds for 29.6% of injuries. Ninety-one patients (59.9%) met the criteria for immediate operation. The remaining 61 (40.1%) patients were selected for CT scan evaluation. Forty-three patients (28.3% of all patients) with 47 solid organ injuries who had no CT scan findings suspicious of hollow viscus injury were selected for clinical observation and additional laparoscopy in 2. Four patients with a “blush” on CT scan underwent angiographic embolization of the liver. Overall, 41 patients (27.0%), including 18 cases with grade III to V injuries, were successfully managed without a laparotomy and without any abdominal complication. Overall, 28.4% of all liver, 14.9% of kidney, and 3.5% of splenic injuries were successfully managed nonoperatively. Patients with isolated solid organ injuries treated nonoperatively had a significantly shorter hospital stay than patients treated operatively, even though the former group had more severe injuries. In 3 patients with failed nonoperative management and delayed laparotomy, there were no complications.
• Conclusions: In the appropriate environment, selective nonoperative management of penetrating abdominal solid organ injuries has a high success rate and a low complication rate.
  
  
• Editorial Comment
  Most blunt solid organ injuries can successfully be managed nonoperatively. Stab wounds, in general can be managed nonoperatively about 50% of the time for anterior abdominal entrance wounds and 85% for retroperitoneal entrance. While traditionally teaching dictates that gunshot wounds of the abdomen were absolute indications for exploration, such concepts have been brought into question with multiple publications in the last few years, mostly championed by the trauma group from LA County Medical Center. In general the treatment algorithm for penetrating abdominal trauma is as follows: signs or symptoms of peritonitis, hemodynamic instability or an abdomen difficult to evaluate due to mental status change or body habitus, underwent intra-abdominal exploration. All other patients were imaged by CT with intravenous contrast. If the CT suggested a hollow organ viscus injury or a contrast “blush” with instability, the patient was explored. Contrast “bush” and stable patients underwent angiography. If there was no bowel injury and the penetrating wound was on the left and thoracoabdominal, a delayed diagnostic laparoscopy is performed to evaluate for a diaphragmatic injury. Any injury was repaired laparoscopically. The patient is then examined serially for the next 24 to 48 hours. Persistently asymptomatic patients were fed and discharged after 48 hours. 60% of penetrating injuries were explored immediately, 30% (27) of whom had with kidney injuries. Of the injured kidneys, 12 underwent renorrhaphy and 9 or (33%) nephrectomy. Of those kidney injuries managed conservatively, none of the Grade 1 and 2 injuries were explored while 1 of 3 of the Grade 3-5 injuries were explored. In conclusion, in the very select patient gunshot wound to the kidney patient, nonoperative management can be successful.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri,USA