Correspondence / American Journal of Emergency Medicine 36 (2018) 2103-2128

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Talha Sarigoz

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The use of computed tomography tractography in anterior abdominal Stab wounds

Dear Editor,

Clinical approach to penetrating abdominal trauma has changed considerably over the years. With the aid of new diagnostic tech- niques, reduced number of negative laparotomies and shortened du- ration of hospital stay were reported. In the same group of patients, role of computed tomography tractography has been the topic of recent debate. In this regard, we read the article “Is computed to- mography tractography reliable in patients with anterior abdominal stab wounds?” published in your journal with great interest and we want to share our opinions on this subject [1]. Despite quite impres- sive study results, we have thought several points need clarification before disapproving CT tractography in anterior abdominal Stab wounds.

local wound exploration (LWE) is an effective method in evaluat- ing the peritoneal penetration but the method has some limitations especially for patients with obesity or heavy muscle. And also it is difficult to explore the oblique wound tracts. The mean body mass index of the related study was 25.2 +- 4.9, and this might be the rea- son why LWE was so successful. Theoretically tractography may have a better role in obese patients rather than LWE but the litera- ture lacks research in this setting [2,3]. Also, we are wondering why the authors applied all 3 methods -LWE, CT, and CT tractography- in the LWE positive patients. Their method puts pa- tient at risk for excessive radiation and additional trauma. In the work of Ertan et al., all patients were evaluated by CT tractography and they pointed out that this procedure helped abstain from LWE [4]. In a later study, again highly successful results were reported for CT tractography in determination of peritoneal violation [5]. Also performing LWE in prior to tractography may have disrupted trajectory and can be blamed for final results, and we are wondering the authors’ opinion about this subject. Furthermore, the main pur- pose of a CT tractography in patients with anterior stab wound should be to differ cases that need surgical exploration from can be followed as outpatient and treated with simple intervention. But the authors preferred to hospitalize patients with negative perito- neal penetration. We think this is not cost-effective, and need to know the rationale for their preference.

Finally, due to technical variety and lack of randomized study, it is too early to make a judgment on CT tractography. We believe continued pursuit of research will clarify appropriate approach to this group of patients.

Financial disclosure

We declare that this study has received no financial support.

Conflict of interest disclosure

We declare that we do not have any commercial or associative inter- est that represents a conflict of interest in connection with the work submitted.

Batman Sason State Hospital, General Surgery, Batman, Turkey

Corresponding author at: Asagi Mahalle, Eski Tekel Caddesi, Sason

Devlet Hastanesi, 72500 Batman, Turkey.

E-mail address: [email protected].

Yusuf Sevim Ankara Numune Training and Research Hospital, Department of General Surgery, Division of Colorectal Surgery, Ankara, Turkey

9 March 2018

https://doi.org/10.1016/j.ajem.2018.03.028

References

1. Sarici IS, Kalayci MU. Is computed tomography tractography reliable in patients with anterior abdominal stab wounds? Am J Emerg Med 2018. https://doi.org/10.1016/j. ajem.2017.12.065 [in press].
2. Henneman PL. Penetrating abdominal trauma. Emerg Med Clin North Am 1989;7(3): 647-66.
3. Tsikitis V, Biffl WL, Majercik S, Harrington DT, Cioffi WG. Selective clinical manage- ment of anterior abdominal stab wounds. Am J Surg 2004;188(6):807-12.
4. Ertan T, Sevim Y, Sarigoz T, Topuz O, Tastan B. Benefits of CT tractography in evalua- tion of anterior abdominal stab wounds. Am J Emerg Med 2015;33(9):1188-90.
5. Uzunosmanoglu H, Corbacioglu SK, Cevik Y, Akinci E, Hacifazlioglu C, Yavuz A, et al. What is the diagnostic value of computed tomography tractography in patients with abdominal stab wounds? Eur J Trauma Emerg Surg 2017;43(2):273-7.

   Is computed tomography tractography reliable in patients with anterior abdominal stab wounds?

   Dear Editor,

   Penetrating traumas are still common traumas encountered in trauma and emergency departments. Determination peritoneal violation is to be done first with local wound exploration in cases of anterior abdomi- nal stab wounds [1]. According to the current literature and guidelines recommendations, local wound exploration is the method with the highest accuracy to determine peritoneal violation [1,2]. Advances in ra- diologic imaging have shown that high-resolution CTs and CT tractography in the recent period are used for the evaluation of these patients and this imaging is preferred by Emergency doctors. In our study protocol, tomography performed a low-dose radiation even lower than the dosing routinely the patient received. The maximum dose that an adult person can receive per year is 0.1 Sv. We calculate our computed tomography scan protocol with the effective dose esti- mate for abdominal tomography (dose-length product (251 mGy-cm)

   * k (0.015): 3.7 mSV).

   CT tractography is reported in two ways that peritoneal violation positive or negative. In the presence of positive peritoneal penetration, the emergency physician consults the patient to general surgeon. How- ever, there are different situations that need to be addressed by the gen- eral surgeon, who responsible the patient after this stage. Are there any intraabdominal Organ injuries in the patient? Should the patient followed conservatively or surgery be performed? The surgeon will have to give the decision to do it. As it is known, 55% of the positive peri- toneal violation with anterior abdominal stab wounds doesn’t cause organ injury [1,2]. How the CT tractography may affect the surgeon in making these decisions at this stage is discussed in detail in the last two paragraphs in the Discussion section and in Table 5 of the article [5]. The second result of CT tractography is negative peritoneal violation. What should be done when peritoneal penetration is not detected? Can we discharge the patient safely when CT tractography is negative? There are two papers on CT tractography in anterior abdominal stab wounds patients. In the study performed by Ertan et al., 20 patients