a b s t r a c t

Introduction: The study aimed to identify the presence of peritoneal penetration in management of anterior abdominal Stab wound by using computed tomography (CT) tractography.

Material and methods: Hemodynamically stabile, CT tractography-performed patients who were admitted to our emergency clinic with anterior Abdominal stab wounds between the years 2012 and 2014 were included in this study, and all images were evaluated in terms of peritoneal penetration and possible intra-Abdominal injury. Results: In the study CT tractography identified necessity of laparotomy accurately in 90% of the patients, and none of the patients without peritoneal penetration needed surgical treatment in their follow-up.

Conclusion: The procedure may be used for some selected cases of hemodynamically stable patient with anterior abdominal Stab wounds to abstain from local wound exploration.

(C) 2015

Introduction

Penetrating abdominal wounds were managed nonoperatively in 19th century resulted with high mortality and morbidity. During the world wars and the Korean conflicts, penetrating wounds were started to manage operatively. After that, conservative treatment for penetrating wounds was suggested in selective cases at mid-20th century.

Although there is considerable regional variability in the type of abdominal trauma, blunt abdominal traumas are more common than abdominal stab wounds and among civilian people, and the vast of penetrating traumas are stab wounds [1-3].

Patients without hemodynamic instability; evisceration; and sign of peritonitis, impalement, blood from a nasogastric tube, or on rectal examination may not require surgical management immediately. These patients may be evaluated by serial physical examination, local wound exploration, imaging procedures, Diagnostic peritoneal lavage, and laparoscopy. Computed tomography (CT) is one of the most used noninvasive imaging procedures with the advantages in detecting solid Organ injuries, peritoneal penetration, and visceral injury. We aimed in this study to identify the presence of peritoneal penetration by a stab injury with tractography during CT scan for anterior abdominal stab wounds to abstain from local wound exploration.

? Disclosure statement: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

* Corresponding author at: Kayseri Egitim ve Arastirma Hastanesi, Genel Cerrahi Klinigi, Sanayi Mah. Ataturk Bulvari Hastane Cad No. 78, 38010 Kocasinan/Kayseri, 002F Turkey. Tel.: +90 352 336 88 88; fax: +90 352 320 73 13.

E-mail addresses: [email protected] (T. Ertan), [email protected] (Y. Sevim), [email protected] (T. Sarigoz), [email protected] (O. Topuz), [email protected] (B. Tastan).

Material and methods

Hemodynamically stabile, CT tractography-performed patients who were admitted to our emergency clinic with anterior abdominal stab wounds between the years 2012 and 2014 were included in this study. Anterior abdomen encompasses the space between the costal margins to the groin creases and laterally to the anterior axillary lines. Our exclusion criteria were gunshot wounds, hemodynamic instability (systolic blood pressure b 90 mm Hg, hearth rate N 100 beats per minute, and hemoglobin level b 10 g/dL) and unconsciousness, presence of evisceration, acute hemorrhage, and signs of peritonitis.

The CT examinations were based on dual-section spiral CT scanner (SOMATOM Emotion; Siemens Medical Solutions). This CT scanner can acquire images with slice thickness from 1 to 10 mm, and images with 1.5-mm slice thickness were used in this study. Intravenous nonionic 60-mL contrast (iopromide, Ultravist; Bayer Schering Pharma AG, Berlin, Germany) was injected within a 45- to 60-second acquisition period. The site of stab wound was disinfected with 10% povidone iodine solution (Batticon, Adeka Co, Samsun, Turkey), and injection of 50- to 75-mL contrast was performed through the wound compressively to prevent overlapping of the surrounding tissues. All images were evaluated with a radiologist and 2 surgeons together in terms of perito- neal penetration and possible intra-abdominal injury.

Results

computed tomography tractography-performed 20 patients with anterior abdominal stab wounds were included in our study. The mean age of the study subjects was 32.40 +- 12.22 years. Eighteen of the patients (90%) were male. All of the stab wounds were caused by

http://dx.doi.org/10.1016/j.ajem.2015.05.018

0735-6757/(C) 2015

T. Ertan et al. / American Journal of Emergency Medicine 33 (2015) 1188-1190 1189

Table

Some features of the study groups

other hand, a significant part of the patients who are hemodynamically stable should be managed conservatively. From the beginning of the last

Localizations

Sex Male	18 (90%)	century, management of anterior abdominal stab wounds is in evolu- tion. Until the 20th century, penetrating abdominal traumas (PAT)
Female	2 (10%)	were managed conservatively with high mortality [5]. During the
Age (mean +- SD) CT tractography Positive penetration	32.40 +- 12.22 10 (50%)	world wars, early laparotomy was realized as lifesaving, and laparotomy was performed routinely for the treatment of PAT until 1960 [6]. Shaftan
Negative penetration	10 (50%)	[5] published his article that included 180 patients with abdominal trau-

RUQ 6 (30%)

LUQ 6 (30%)

RLQ 3 (15%)

LLQ 3 (15%)

Right flank 1 (5%)

Left flank 1 (5%)

Epigastrium^a 1 (5%)

No. of wounds

Single 16 (80%)

Multiple 4 (20%)

Effected organs

Mesentery 3 (23.08%)

Descending colon 2 (15.39%)

EpiGastric artery 2 (15.39%)

Liver laceration 2 (15.39%)

Others^b 4 (30.77%)

Abbreviations: RUQ, right upper quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; LLQ, left lower quadrant.

^a Epigastric localization addition to left upper quadrant.

^b Transverse colon, stomach, pancreas, and rectus.

knife, and the most identified localizations for wounds were right and left upper quadrants (each of them for 6 patients, 30%), and there was only 1 patient who had stab wounds at multiple quadrants, left upper and epigastrium together (Table).

Penetration was detected for 10 patients (50%), and those patients underwent surgery (Figure A). The most effected organ was mesentery (3 patients, 23.08%; shown in Table). One of the patients (7.69%) had only injury on Rectus abdominis muscle. Furthermore, 10 patients were defined negative for peritoneal penetration by CT tractography (Figure B and C), and all of the patients in this group were discharged from emergency service.

In our study, CT tractography identified necessity of laparotomy accurately in 90% of the patients, and none of the patients without peri- toneal penetration needed surgical treatment in their follow-up.

Discussion

Nonresponding or transiently responding hypotension, overt perito- nitis, significant evisceration, and obvious signs of visceral injury such as hematemesis, significant bleeding from nasogastric tube, and proctorrhagia are the indications of emergent laparotomy [4]. On the

ma and 125 of the patients were managed nonoperatively without mor- bidity and mortality leading to an approach that was later called “selective conservatism.” In addition, diagnostic peritoneal lavage was described by Root et al [7] in 1965 for evaluating severe blunt abdomi- nal trauma. After that, selective nonoperative treatment of stab wounds has become standard in many trauma centers. It was reported that ap- proximately 50% of anterior stab wounds and 85% of posterior stab wounds had been managed nonoperatively [8,9]. In 1989, Robin et al

[10] published their study about anterior abdominal stab wounds, and they operated nearly half of the patients, and 28 (16.7%) of the laparot- omies were identified as negative. The surgeons should be selective for operation because the negative laparotomy has significant associated morbidity. In a study, the incidence of negative or nontherapeutic lapa- rotomy was mentioned from 15% to 30%, with 41% complication rate [11]. The surgical exploration for all penetrating abdominal injuries has been questioned in Hemodynamically stable patients, with im- provements in Diagnostic strategies and the hope of minimizing nega- tive laparotomies [4,12,13].

Local wound exploration has been used to rule out penetration of anterior fascia. In this technique for anterior stab wounds, if the deepest extend of the wound demonstrates the anterior fascia not violated, the patients without additional or extra-abdominal injuries may be discharged after appropriate wound care [14,15]. Thompson and Moore [16] identified that local wound exploration followed by diag- nostic peritoneal lavage when peritoneal violation was thought likely after stab wounds resulted in 8% negative laparotomy rate. Laparotomy after positive local wound exploration with anterior facial penetration has been reported as negative nearly 50% of the case [17]. As in our study, tractography provides an advantage to the clinicians in evalua- tion of the penetration depth, and CT tractography may identify the penetration of peritoneum clearly (penetration of anterior and posterior fascia of rectus abdominis with continuity of peritoneum shown in Figure B). We could identify the peritoneum nonviolated in this case, al- though we used CT images with 1.5-mm slice thickness. Administration of the contrast may help the clinician evaluate the presence of penetra- tion more accurately but not exactly. Local wound exploration carries higher morbidity then less invasive methods [18,19]. Local wound ex- ploration should be possible only subdiaphragmatic injuries and often proves difficult in patients with obesity or heavy muscle [20,21]. Explo- ration of oblique tracts is hard to evaluate, and, after the exploration, hemorrhage and local Wound infection may be occurred.

Figure. Computed tomographic tractography scan. A, Penetration of peritoneum and presence of intra-abdominal contrast. B, Penetration of anterior and posterior fascia of rectus abdominis with continuity of peritoneum. C, Penetration of subcutaneous tissues.

1190 T. Ertan et al. / American Journal of Emergency Medicine 33 (2015) 1188-1190

Computed tomography should be used in some selected abdominal stab wounds. In addition, CT is the most sensitive and specific imaging procedure in assessing the injury severity to the liver and spleen [22]. Triple-contrast CT has been evaluated as a Diagnostic modality in hemo- dynamically stable patients in PAT. Oral, intravenous, and rectal con- trasts are administered, and the hollow viscus should be well evaluated with high accuracy [23]. In the past decade, triple-contrast CT has become standard for evaluation of Penetrating injuries.

In our study, we determined the necessity of laparotomy with high accuracy by using CT tractography. We think that this procedure may be used in the management of PAT instead of local wound exploration in selective hemodynamically stable patients. By this way, we may eval- uate the presence of violation of posterior fascia and peritoneum and intra-abdominal structures together.

There are limited studies about stab wounds examined with CT tractography. Bansal et al [24] reported that their study included 41 patients sustaining posterior and flank stab wound injuries and underwent CT tractography. They mentioned the CT tractography as a safe and effective strategy to evaluate posterior torso stab wounds. Furthermore, Bruckner et al [25] reported their experience of CT tractography applied 7 bullet wounded patients. All of those patients who had negative for peritoneal penetration detected with tractography were managed nonoperatively. The authors em- phasized that the addition of tractography to the triple contrast CT was a useful adjunct to simplify the management of the patient with a tangential gunshot wound. In our study, as the other CT tractography studies mentioned before, CT tractography helped us avoid negative laparotomy.

Conclusions

The fascia of the rectus abdominis, the transversalis fascia, and the peritoneum cannot be identified with CT directly. So, using of contrast administered through the stab wound before CT scans seems logical to abstain from this limitation. Furthermore, low number of patients was a limitative factor to demonstrate statistical significance on the tech- nique. However, this study showed us that tractography-added CT may prevent the clinicians from negative laparotomy. Tractography should be performed before CT scan practically without time losing. The procedure may be used for some selected cases of hemodynamical- ly stable patient with anterior abdominal stab wounds instead of local wound exploration.

Acknowledgments

The authors thank Duygu Gulmez Sevim for her assistance in editing of the language of this article.

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