Selective Nonoperative Management of Abdominal Stab Wounds: Prospective, Randomized Study

Stab wounds (SW) to the abdomen traditionally require urgent exploration when associated with shock, evisceration, or peritonitis. Hemodynamically stable patients without evisceration may benefit from serial exams even with peritonitis. We compared patients taken directly to the operating room with abdominal SWs (ED-OR) to those admitted for serial exams (ADMIT). We retrospectively reviewed hemodynamically stable patients presenting with any abdominal SW between January 2000 and December 2012. Exclusions included evidence of evisceration, systolic blood pressure ≤110 mm Hg, or blood transfusion. NON-THER was defined as abdominal exploration without identification of intra-abdominal injury requiring repair. Of 142 patients included, 104 were ED-OR and 38 were ADMIT. When ED-OR was compared with ADMIT, abdominal Abbreviated Injury Score was higher (2.4 vs 2.1; P = 0.01) and hospital length of stay was longer (4.8 vs 3.3 days; P = 0.04). Incidence of NON-THER was higher in ED-OR cohort (71% vs 13%; P ≤ 0.001). In a regression model, ED-OR was a predictor of NON-THER (adjusted odds ratio 16.6; P < 0.001). One patient from ED-OR expired after complications from NON-THER. There were no deaths in the ADMIT group. For those patients with abdominal SWs who present with systolic blood pressure ≥110 mm Hg, no blood product transfusion in the emergency department and lacking evisceration, admission for serial abdominal exams may be preferred regardless of abdominal exam.

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Selective Nonoperative Management of Abdominal Stab Wounds with Isolated Omental Evisceration is Safe: A South African Experience

Scandinavian Journal of Surgery ◽

10.1177/1457496920903982 ◽

2020 ◽

pp. 145749692090398

Author(s):

V. Y. Kong ◽

R. D. Weale ◽

J. M. Blodgett ◽

A. Madsen ◽

G. L. Laing ◽

...

Keyword(s):

South African ◽

Nonoperative Management ◽

Stab Wound ◽

African Experience ◽

Significant Difference ◽

Selective Nonoperative Management ◽

Laparotomy Group ◽

Abdominal Stab Wounds ◽

Mean Time

Background and Aims: Selective nonoperative management of abdominal stab wound is well established, but its application in the setting of isolated omental evisceration remains controversial. The aim of the study is to establish the role of selective nonoperative management in the setting of isolated omental evisceration. Materials and Methods: A retrospective study was conducted over an 8-year period from January 2010 to December 2017 at a major trauma center in South Africa to determine the outcome of selective nonoperative management. Results: A total of 405 consecutive cases were reviewed (91% male, mean age: 27 years), of which 224 (55%) cases required immediate laparotomy. The remaining 181 cases were observed clinically, of which 20 (11%) cases eventually required a delayed laparotomy. The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), 3–6 h in 6% (14/244), 6–12 h 2% (4/244), and 12–18 h in 1% (2/244). There was no significant difference between the immediate laparotomy and the delayed laparotomy group in terms of length of stay, morbidity, or mortality. Ninety-eight percent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic. Conclusion: Selective nonoperative management for abdominal stab wound in the setting of isolated omental evisceration is safe and does not result in increased morbidity or mortality. Clinical assessment remains valid and accurate in determining the need for laparotomy but must be performed by experienced surgeons in a controlled environment.

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A selective non-operative approach to thoracic stab wounds is safe and cost effective – a South African experience

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2018.0118 ◽

2018 ◽

Vol 100 (8) ◽

pp. 641-649

Author(s):

KSS Dayananda ◽

VY Kong ◽

JL Bruce ◽

GV Oosthuizen ◽

GL Laing ◽

...

Keyword(s):

Computed Tomography ◽

Thoracic Trauma ◽

Nonoperative Management ◽

Tube Thoracostomy ◽

Stab Wounds ◽

Penetrating Thoracic Trauma ◽

Thoracic Computed Tomography ◽

Active Observation ◽

Selective Nonoperative Management ◽

Clinical Algorithms

Introduction Penetrating thoracic trauma is common and costly. Injuries are frequently and selectively amenable to non-operative management. Our selective approach to penetrating thoracic trauma is reviewed and the effectiveness of our clinical algorithms confirmed. Additionally, a basic cost analysis was undertaken to evaluate the financial impact of a selective nonoperative management approach to penetrating thoracic trauma. Materials and methods The Pietermaritzburg Metropolitan Trauma Services electronic regional trauma registry hybrid electronic medical records were reviewed, highlighted all penetrating thoracic traumas. A micro-cost analysis estimated expenses for active observation, tube thoracostomy for isolated pneumothorax greater than 2 cm and tube thoracostomy for haemothorax. Routine thoracic computed tomography does not form part of these algorithms. Results Isolated thoracic stab wounds occurred in 589 patients. Eighty per cent (472 cases) were successfully managed nonoperatively. Micro-costing shows that active observation costs 4,370 ZAR (£270), tube thoracostomy for isolated pneumothorax costs 6,630 ZAR (£400) and tube thoracostomy for haemothorax costs 21,850 ZAR (£1,310). Discussion Penetrating thoracic trauma places a striking financial burden on our limited resources. Diligent and serial clinical assessments, alongside basic radiology and stringent management criteria, can accurately stratify patients to correct clinical algorithms. Conclusion Selective nonoperative management for penetrating thoracic trauma is safe and effective. Routine thoracic computed tomography is unnecessary in all patients with isolated thoracic stab wounds, which can be reserved for a select group who are identifiable clinically. Routine thoracic computed tomography would not be financially prudent across Pietermaritzburg Metropolitan Trauma Services. Government action is required to reduce the overall incidence of such trauma to save resources and patients.

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Management of Patients with Evisceration after Abdominal Stab Wounds

The American Surgeon ◽

10.1177/000313481408001016 ◽

2014 ◽

Vol 80 (10) ◽

pp. 984-988 ◽

Cited By ~ 3

Author(s):

Kristina Nicholson ◽

Kenji Inaba ◽

Dimitra Skiada ◽

Obi Okoye ◽

Lydia Lam ◽

...

Keyword(s):

Nonoperative Management ◽

Diagnostic Yield ◽

Descriptive Analysis ◽

Vital Signs ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Stab Wounds ◽

Level I ◽

Operative Findings ◽

Abdominal Stab Wounds

In the era of nonoperative management of abdominal stab wounds, the optimal management of patients with evisceration remains unclear. Furthermore, the role of imaging in guiding management of these patients has not been defined. Patients admitted to a Level I trauma center (2005 to 2012) with evisceration after an abdominal stab wound were retrospectively identified. Demographics, admission vital signs, topography and contents of evisceration, Glasgow Coma Score, indications for exploration, and imaging and operative reports were abstracted. Clinical outcomes measured were: injuries identified on exploration, hospital length of stay, and mortality. Descriptive analysis was performed. Ninety-three patients with evisceration were identified. Ninety-two (98.9%) were male and 60 (64.5%) were Hispanic. Mean age was 31.9 ± 13 years. Forty-seven (50.5%) had evisceration of the omentum, 41 (44.1%) had evisceration of abdominal organs, and two (2.2%) had both. Seventy-four (80.4%) had positive laparotomies. Ten (10.8%) underwent computed tomography (CT) preoperatively. Sixty per cent of CT findings were congruent with operative findings. CT did not impact clinical management. In conclusion, the rate of intra-abdominal injury in patients with evisceration remains high. Even in the age of nonoperative management, evisceration continues to be an indication for immediate laparotomy. The diagnostic yield of CT is low and CT should not impact management of these patients.

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