A multi faceted quality improvement programme results in improved outcomes for the selective non-operative management of penetrating abdominal trauma in a developing world trauma centre.
BACKGROUND
The selective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is well established in our environment. As a quality-improvement initiative, we aimed to re-evaluate patient outcomes with PAT. This follows the application of new imaging and diagnostic modalities using protocolised management algorithms.


METHODS
A prospectively maintained digital registry was retrospectively interrogated and all patients with PAT treated by our service from January 2012 to March 2013 were included in this study.


RESULTS
A total of 325 patients sustained PAT during the fourteen-month study period. This included 238 SWs, 80 GSWs and 7 impalement injuries. 11 patients had eviscerated bowel, and 12 had eviscerated omentum. A total of 123 patients (38%) were selected for a trial of SNOM. This included 103 SWs, 15 GSWs and 5 impalement injuries. Emergency laparotomy was performed on 182 patients (115 SWs, 65 GSWs and 2 impalement injuries) and 21 patients with left sided thoraco-abdominal SWs underwent definitive diagnostic laparoscopy (DL). SNOM was successful in 122 cases (99%) and unsuccessful in one case (1%). In the laparotomy group 161 (88%) patients underwent a therapeutic procedure, in 12 cases (7%) the laparotomy was non-therapeutic and in 9 cases (5%) the laparotomy was negative. In the laparoscopy group (24), two patients required conversion for colonic injuries and one for equipment failure. Seven (33.3%) laparoscopies were therapeutic with the identification and intra-corporeal repair of seven left hemi-diaphragm injuries.


CONCLUSIONS
We have improved our results with the SNOM of PAT and have also managed to safely and successfully extend the role of SNOM to abdominal GSWs. We have selectively adopted newer modalities such as laparoscopy to assess stable patients with left thoraco-abdominal SWs and abdominal CT scan for the SNOM of abdominal GSWs.
Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg Metropolitan Hospital Complex, Department of General Surgery, University of KwaZulu-Natal Nelson R Mandela School of Medicine, South Africa.
G L
GL
Laing
D L
DL
Skinner
J L
JL
Bruce
W
W
Bekker
G V
GV
Oosthuizen
D L
DL
Clarke
D000007:Abdominal Injuries / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D015601:Injury Severity Score; D010535:Laparoscopy; D007813:Laparotomy; D008297:Male; D008875:Middle Aged; D009852:Omentum / Q000293:injuries; D018579:Patient Selection; D058996:Quality Improvement; D011859:Radiography; D012189:Retrospective Studies; D014193:Trauma Centers / Q000592:standards*; D016896:Treatment Outcome; D014948:Wounds, Gunshot / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D014951:Wounds, Stab / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy; D055815:Young Adult
Penetrating abdominal trauma; Selective non-operative management