Management of patients with anterior abdominal stab wounds: a Western Trauma Association multicenter trial.
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.
Biffl
Walter L
WL
Department of Surgery, Denver Health Medical Center/University of Colorado-Denver, Denver, Colorado 80204-4507, USA. walt@biffl.com
Kaups
Krista L
KL
Cothren
C Clay
CC
Brasel
Karen J
KJ
Dicker
Rochelle A
RA
Bullard
M Kelley
MK
Haan
James M
JM
Jurkovich
Gregory J
GJ
Harrison
Paul
P
Moore
Forrest O
FO
Schreiber
Martin
M
Knudson
M Margaret
MM
Moore
Ernest E
EE
D000007:Abdominal Injuries / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D000328:Adult; D005260:Female; D006801:Humans; D015994:Incidence; D015601:Injury Severity Score; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods*; D007902:Length of Stay / Q000639:trends*; D008297:Male; D010149:Postoperative Pain / Q000503:physiopathology; D010533:Peritoneal Lavage; D010538:Peritonitis / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014951:Wounds, Stab / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*