dr. andriana purnama, spb-kbd alamat kantor : divisi bedah digestif fk unpad/rshs jl. pasteur no. 38...

Dr. Andriana Purnama, SpB-KBDAlamat Kantor : Divisi Bedah Digestif FK UNPAD/RSHS

Jl. Pasteur No. 38 Bandung 40161Telp/Fax Kantor : 022-2034574Alamat Rumah : Jl. Babakan Jeruk III No. 23 BandungTelp/Fax rumah : -No.HP : 08122025557Tempat/Tgl Lahir: Bandung, 09 Juni 1972Email : -Profesi : Dokter Konsultan Bedah DigestifJabatan :

1. Staf Divisi Bedah Digestif RSHS 2. -

Penetrating Abdominal Trauma: Guidelines For

Evaluation

Andriana PurnamaDepartment of SurgeryHasan Sadikin Hospital

Faculty of Medicine Padjadjaran UniversityBandung

HOT TOPICS

Interest in selective non-operative management(SNOM) of PAI began to increase.

SNOM for stab wounds is now common

SNOM for gunshot wounds remains controversial

The doctor should answer 2 questions :

1. Is there intra abdominal injury ?2. Does this injury require operative

repair ?

DO It or not???

Risks of Operative Management of Abdominal Trauma

Higer Unnecessary Laparatomy RateMorbidityMortalityLonger Hospital StaysIncreased Hospital Costs

Mc.Connell DB & Trunkey .DD : Nonoperative Management of Abdominal Trauma, in Surg.Clin.North Am, 1990 (70) :3, 679.

Risks of NOM of Abdominal Trauma

Missed injuryMorbidityMortalityContinued bleedingTransfusion riskAbdominal Compartment Syndrome

Mc.Connell DB & Trunkey .DD : Nonoperative Management of Abdominal Trauma, in Surg.Clin.North Am, 1990 (70) :3, 678.

History Until the early 1900s, PAI was managed

conservatively.World War I :

patients who underwent mandatory operative exploration had a better chance of survival, Laparotomy became the standard of care.

World War II : early laparotomy improved survival.

1950, laparotomy was the standard treatment of PAI pts

1960, Shaftan : high rate of negative laparotomies published a report on the Non Operative Management of abdominal injury He had managed 125 of 180 PAI patients

without surgery, with a mortality rate < 1 %

Introduction

Recent guidelines have recommended :

* Observation for haemodynamically stable patients

with no evidence of peritonitis for stab wounds and tangential GSW

* Up to 30 % of anterior abdominal GSW & 67 % of gunshot injuries to the back, can be managed safely without operative

interventionZafar NS, Rushing A, Haut ER, Kisat MT, Villegas CV, Chi A et al, Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database, British Journal of Surgery 2011; 99(Suppl 1): 155–165

Mechanism of injury

Low velocityKnife wound/stab woundsDisrupts only structures penetrated

Medium velocityHandguns and pellet guns

High velocityMilitary weapons and rifles

Gunshot Wound VS Stab Wound

GSW SW

The most commonly injured organs

1. Small bowel (50%)2. Colon (40%)3. Liver (30%)4. Abdominal vascular

structures (25%)

The most commonly injured organs

1. Liver (40%)2. Small bowel (30%)3. Diaphragm (20%)4. Colon (15%)

Stab WoundDemetriades and Rabinowitz 1987 :

Prospective study of 651 patients with stab wounds to the anterior abdomen treated with SNOM

Based mainly on serial physical examinations. Half cases were successfully managed without laparotomy. Eleven (1.6%) patients who were initially observed,

required a laparotomy later, No mortality among them. The accuracy of the initial physical examination was

93.9% (false negative initial exam 3.2%, false negative exam 2.9%).

Demetriades D, Velmahos GC, Indications for & Techniques of Laparotomy, in Feliciano DV, Mattox KL, Moore EE, Trauma, 7th ed, 2013

Stab Wound

Shorr et al 1988 :330 patients with abdominal stab

wounds :32% of had a therapeutic laparotomy 14% a non therapeutic laparotomy. 53% were discharged without an

operation.Demetriades D, Velmahos GC, Indications for & Techniques of Laparotomy, in Feliciano DV, Mattox KL, Moore EE, Trauma, 7th ed, 2013

Stab WoundIndications for laparotomy such as :

peritoneal penetration, omental evisceration, free air on abdominal radiographs, blood on abdominal paracentesis are debated.1. 69% associated with significant intra-abdominal

injuries, even in the absence of generalized abdominal tenderness

2. Others have found no such association : continue to use SNOM avoid routine operation

SNOM should be considered only in centers with experience & appropriate in-house staffing by trauma surgeons.

Stab Wound

In most patients :Decision to operate or not, should be based on1. serial physical exams and 2. close hemodynamic monitoring.


Gunshot Wound

Abdominal GSW are treated by routine laparotomy in most trauma center

GSWs to the abdomen are still commonly treated with mandatory exploration because of multiple reports emphasizing a high incidence of intra-abdominal injuries

GSWs1. Demetriades D, Velmahos GC, Cornwell EE III

1997 : ⅓ GSW to anterior abdomen ⅔ GSW to the back No significant intra abdominal injury safe to SNOM

2. Velmahos GC, Demetriades D, Toutouzas KG 2001 : 1856 GSW pts : 1405 anterior / 451 posterior –

8 yr period 47% : no significant abdominal injury

39% anterior / 74% posterior GSW 80 pts ( 4% ) developed signs delayed

laparotomy 5 pts (0.3%) : complications managed

successfully


G S WsBased on these observations

Selected patients with : isolated gunshot wounds to solid organs (liver, spleen,

kidney) hemodynamically stable no peritoneal signs,

may be managed nonoperatively

In a study of 152 patients with gunshot injuries to the liver, 21% of cases with isolated liver injury were successfully managed non operatively


Serial Physical Examination

A careful initial physical examination followed by serial examinations :Are the most

important tool to set the indications for laparotomy after abdominal stab wounds.

Realible in detecting significant Injuries

after PAI, if performed by experienced

clinicans and preferably by the same team

The Journal of TRAUMA Injury, Infection, and Critical Care. Vol 71, Number 6, 2011

Serial Physical Examination

Diagnostic Peritoneal Lavage

DPL has been used to identify significant peritoneal injury after PAI for at least 30 years and still has arole in Trauma Care

DPL reduced unnecessary LAP, Rapid, Safe and Highly cost-effective

Diagnostic Peritoneal Lavage

When the Concept of Selective Management rather than Mandatory LAP began to receive more attention, The Non Invasive Tools become more popular adjuncts

The more recent literatur Suggest that DPL now seems to be Increasingly replaced by the use of other diagnostic modalities


Diagnostic Peritoneal Lavage - DPL

For hemodynamically stable patients CT scan For hemodynamically unstable patients FAST DPL is used predominantly when :

1. CT or FAST are not available, 2. No sufficient expertise to make decisions based

on the FAST results, 3. FAST results are negative, but there is no other

source to account for the hemodynamic instability.

Local Wound Exploration

LWE has been used in a number of series to rule out penetration of the Anterior Fascia

If the patient has no penetration of the anterior Fascia, the patient may be safely discharged from the ED

When LWE is used alone to determine Laparatomy there will be a high unnecessary Laparatomy Rate

Even the peritoneum is penetrated were used as a Cutt- Off, many patients will have no intra peritoneal Injury, or an Injury that does not require surgical Intervention

Most Commonly: Omental Laceration, Mesenteric Laceration or Liver tears that have stopped Bleeding

Most Authors have Investigated; LWE (+), Laparatomy Negative almost 50%

Management Guidelines for Penetrating Abdominal Trauma. Current Opinion in Critical Care 2010, 16:609-617

Local Wound Exploration

Ultrasonography - FASTExcellent sensitivity in identifying intra-

abdominal fluidEase of use, repeatability, and avoidance of

radiationThe most significant contribution of the

FAST is : detection of intra-abdominal fluid in the : hemodynamically unstable and clinically unevaluable blunt trauma victim. immediate exploratory laparotomy

Negative FAST further evaluation - most commonly CT

Abdominal Computed Tomography

Show accurate imaging of solid parenchymal injury

Major role in decision to manage the injured spleen, liver & kidney nonoperatively

Increase use in blunt traumaUse in evaluation of abdominal GSW,

selected for nonoperative management ( SNOM )

Abdominal CT has become an indispensable tool in the evaluation of abdominal trauma.

Diagnostic Laparoscopy

Major limitation : Inability to :1. “ Run “ the bowel2. Diagnose retroperitoneal injuries3. Expose adequately deep lying organs4. Estimate accurately the quantity of

hemoperitoneum

≈ ½ existing injuries can be missed by laparoscopy

Vilavicencio RT, Aucar JA, Analysis of laparoscopy in trauma, J Am Coll Surg 189:11, 1999

Diagnostic LaparoscopyAdvantages :Excellent ( > 95% ) Sensitivity &

Specifity to establish :1. Peritoneal violation2. Hemoperitoneum3. Enteric content spillage

Peritoneal penetration or hemoperitoneum :not always associated with therapeutic laparotomy the information provided by laparoscopy ???

Diagnostic Laparoscopy

It does not appear that laparoscopy has a role in the management of patients with PAI

The procedure does not appear to be cost effective, because it is rarely theurapeutic

(only 1 of 24 patients in WTA trials)

CURRENT MANAGEMENT OF PENETRATING ABDOMINAL INJURY (PAI)

Review of published literatures

Validating the Western Trauma Association Algorithm For Managing Patients With Anterior Abdominal Stab Wounds: A Western Trauma Association Multicenter Trial


Western Trauma Association

Six Center of TraumaMay 2008-Nov 2010222 Pts PAI62 Pts had immediate LAP160 Pts Stable and Asymptomatic20 Pts D/C form ED after LWE (-)11 Pts Lap, When their clinical condition

changed

The WTA proposed algorithm is designed for cost-effectiveness. Serial Clinical Assessments can be performed without the added

expense of CT, DPL or Laparoscopy

• Biffel WL, Kaups KL, Cothren CC et al : Management of patients with anterior abdominal stab wounds; Western Trauma Association, Multicenter Trial. J Trauma 2011, 71 (6); 1294-1301

Feliciano, Mattox and Moore, Trauma 7th edit, 2013

MANAGEMENT OF PENETRATING

ABDOMINAL TRAUMA

Conditions for SNOM of PAI

How about practicing SNOM in trauma centers with a :1. Low volume of penetrating trauma 2. Inadequate resources to provide 24-hour in-house

coverage. 3. The inability to do serial physical examinations by

physicians with reasonable experience

prohibits the practice of SNOM

It may be safer for small trauma centers with limited exposure to GSW victims to retain a policy of routine laparotomy.

Conditions for SNOM of PAI

SNOM of PAI is recommended in :1. Facilities with the resources and experience to

select and monitor patients with PAI carefully,

2. Capability to provide immediate surgical intervention to those who need it.

Zafar SN, et al, Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database, BJS 2011; 99(Suppl 1): 155–165

SNOM : Success & FailureSuccess rate is 75–80 %

and improved over the time interval

Failure rate 10–20 % Failed SNOM is associated with :

- longer hospital stays & costs Failed SNOM ≈ mortality has not been

documented

Como J.J et al J Trauma, 2010, 68:721-733

RECOMMENDATIONS

a. Pts who are hemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy (level 1)

b. Pts who are hemodynamically stable with an unrealable clinical examination ( i.e. brain injury, spinal cord injury, intoxication, or need for sedation or anesthesia). Should have further diagnostic investigation performed for intra peritoneal injury or undergo exploratory laparotomy (level 1)

c. A routine laparotomy is not indicated is hemodynamically stable pts with abdominal SWs without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with expertise (level 2).

d. A routine laparotomy is not indicated in hemodynamically stable pts with abdominal GSWs if the wounds are tangential and there are no peritoneal signs (level 2)

RECOMMENDATIONS

e. Serial physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferable by the same team (level 2)

f. In pts selected for initial NOM, abdomino pelvic CT should be strongly considered as a diagnostic tool to fasicilitate initial management decision (level2)

RECOMMENDATIONS

g. Pts with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination, and minimal to no abdominal tenderness (level 3)

h. The majority of pts with penetrating abdominal trauma managed non operatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness (level 3)

i. Diagnostic laparoscopic may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration (level 2)

RECOMMENDATIONS

Conclusion

The rate of Unnecessary Laparatomy should be minimized

NOM should never be at the expense of a delay in the diagnosis and tratment of Injury

A part of anterior stab wound and GSW victims can be managed non operatively safely

dr. andriana purnama, spb-kbd alamat kantor : divisi bedah digestif fk unpad/rshs jl. pasteur no. 38...

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