Role of laparoscopy in management of patients with anterior abdominal stab wounds.

BACKGROUND: In this retrospective cohort study, we assessed the utility of laparoscopic surgery for diagnostic and therapeutic purposes in patients with anterior abdominal stab wounds (AASWs). We also investigated patient characteristics that might suggest a greater suitability of laparoscopic interventions. METHODS: Over a 25-year span, we analyzed AASW patients who had operations, categorizing them based on the presence of significant intra-abdominal injuries and whether they received laparoscopic surgery or laparotomy. We compared variables such as preoperative conditions, surgical details, and postoperative outcomes. We further evaluated the criteria indicating the necessity of direct laparotomies and traits linked to overlooked injuries in laparoscopic surgeries. RESULTS: Of 142 AASWs surgical patients, laparoscopic surgery was conducted on 89 (62.7%) patients. Only 2 (2.2%) had overlooked injuries after the procedure. Among patients without significant injuries, those receiving laparoscopic surgery had less blood loss than those receiving laparotomy (30.0 vs. 150.0 ml, p = 0.004). Patients who underwent laparoscopic surgery also had shorter hospital stays (significant injuries: 6.0 vs. 11.0 days, p < 0.001; no significant injuries: 5.0 vs. 6.5 days, p = 0.014). Surgical complications and overlooked injury rates were comparable between both surgical methods. Bowel evisceration correlated with higher laparotomy odds (odds ratio = 16.224, p < 0.001), while omental evisceration did not (p = 0.107). CONCLUSIONS: Laparoscopy is a safe and effective method for patients with AASWs, fulfilling both diagnostic and therapeutic needs. For stable AASW patients, laparoscopy could be the preferred method, reducing superfluous nontherapeutic laparotomies.

Epidemiology, repair technique, and predictors of stroke and mortality in penetrating carotid artery injuries.

OBJECTIVE: Penetrating carotid artery injuries (PCAI) are significantly morbid and deadly, often presenting in extremis with associated injuries and central nervous system deficit. Repair may be challenging with arterial reconstruction vs ligation role poorly defined. This study evaluated contemporary outcomes and management of PCAI. METHODS: PCAI patients in the National Trauma Data Bank from 2007 to 2018 were analyzed. Outcomes were compared between repair and ligation groups after additionally excluding external carotid injuries, concomitant jugular vein injuries, and head/spine Abbreviated Injury Severity score of ≥3. Primary end points were in-hospital mortality and stroke. Secondary end points were associated injury frequency and operative management. RESULTS: There were 4723 PCAI (55.7% gunshot wounds, 44.1% stab wounds). Gunshot wounds more frequently had associated brain (73.8% vs 19.7%; P < .001) and spinal cord (7.6% vs 1.2%; P < .001) injuries; stab wounds more frequently had jugular vein injuries (19.7% vs 29.3%; P < .001). The overall in-hospital mortality was 21.9% and the stroke rate was 6.2%. After exclusion criteria, 239 patients underwent ligation and 483 surgical repair. Ligation patients had lower presenting Glasgow Coma Scale (GCS) than repair patients (13 vs 15; P = .010). Stroke rates were equivalent (10.9% vs 9.3%; P = .507); however, in-hospital mortality was higher after ligation (19.7% vs 8.7%; P < .001). In-hospital mortality was higher in ligated common carotid artery injuries (21.3% vs 11.6%; P = .028) and internal carotid artery injuries (24.5% vs 7.3%; P = .005) compared with repair. On multivariable analysis, ligation was associated with in-hospital mortality, but not with stroke. A history of neurological deficit before injury lower GCS, and higher Injury Severity Score (ISS) were associated with stroke; ligation, hypotension, higher ISS, lower GCS, and cardiac arrest were associated with in-hospital mortality. CONCLUSIONS: PCAI are associated with a 22% rate of in-hospital mortality and a 6% rate of stroke. In this study, carotid repair was not associated with a decreased stroke rate, but did have improved mortality outcomes compared with ligation. The only factors associated with postoperative stroke were low GCS, high ISS, and a history of neurological deficit before injury. Beside ligation, low GCS, high ISS, and postoperative cardiac arrest were associated with in-hospital mortality.

Prospective evaluation of the selective nonoperative management of abdominal stab wounds: When is it safe to discharge?

BACKGROUND: The optimal observation time required to exclude hollow viscus injury in patients undergoing selective nonoperative management (SNOM) for abdominal stab wounds (SWs) remains unclear. The aim of this study was to determine the safe period of observation required before discharge. METHODS: In this prospective observational study, all patients who sustained an abdominal SW were screened for study inclusion (July 2018 to May 2021). The primary study outcome was time to SNOM failure, defined as the need for surgical intervention after an initial period of observation. RESULTS: During the study period, 256 consecutive patients with an abdominal SW met the study criteria. The mean age was 33 (26-46) years, and 89% were male. Of all patients, 77% had single SW, and 154 (60%) had an anterior abdominal SW (most common site right upper quadrant, 31%). Forty-six (18%) underwent immediate laparotomy because of evisceration (59%), hemodynamic instability (33%), or peritonitis (24%). The remaining 210 patients (82%) were taken for computed tomography scan (n = 208 [99%]) or underwent clinical observation only (n = 2 [<1%]). Of the patients undergoing computed tomography scan, 27 (13%) triggered operative intervention, and 9 (4%) triggered angioembolization. The remaining 174 patients (83%) underwent SNOM. Of these, three patients (2%) failed SNOM and underwent laparotomy: two developed peritonitis at 10 and 20 hours after arrival, respectively, and at laparotomy had small bowel and gastric injuries. The third patient developed increasing leukocytosis but had nontherapeutic laparotomy. CONCLUSION: Selective nonoperative management of stab wounds to the abdomen commonly avoids nontherapeutic operative intervention and its resultant complications. A small percentage of patients will fail SNOM, and therefore, close clinical observation of these patients in hospital is critical. All patients in this series who failed SNOM did so within 24 hours of presentation. Therefore, we recommend a period of 24 hours of close clinical monitoring to exclude a hollow viscus injury before discharge of patients with abdominal stab wounds who do not meet the criteria for immediate operative intervention. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level III.

A Prospective Audit of 805 Consecutive Patients With Penetrating Abdominal Trauma: Evolving Beyond Injury Mechanism Dictating Management.

BACKGROUND: Global trends of penetrating abdominal trauma (PAT) have seen a shift toward a selectively conservative management strategy. However, its widespread adoption for gunshot injuries has been sluggish. The purpose of this study is to compare the injury mechanisms of gunshot (GSW) and stab wounds (SW) to the abdomen in presentation, management, and outcomes. METHODS: Prospective cohort study, set in Cape Town, South Africa, over 2 years. All patients presenting to the center with PAT during this time were included. Presentation, management, and outcomes were compared by injury mechanism, with a focus on the operative strategy (operative vs nonoperative). RESULTS: During the study period, 805 patients (SW 37.6%; GSW 62.4%) with PAT were managed. Immediate laparotomies were performed in 119 (39.3%) SW and 355 (70.7%) GSW, with a therapeutic laparotomy rate of 85.7% and 91.8% for SW and GSW, respectively. Nonoperative management (NOM) was implemented in 184 SW (60.7%) and 147 GSW (29.3%) (P < 0.001), with a 92.9% and 92.5% success rate for SW and GSW, respectively. The therapeutic laparotomy rate for the delayed laparotomies (DOM) was 69.2% for SW, and 90.9% for GSW. The accuracy of clinical assessment (with adjuncts) in determining the need for laparotomy was: GSW-92% and SW-91%. Univariate analysis revealed the mechanism not to be associated with DOM. The overall mortality rate was 7.2%, and nonfatal morbidities 22.2%. CONCLUSION: Although GSW is a more morbid and often fatal injury, the general principles of selective conservatism hold true for both GSW and SW, equally.

Evaluation of diagnostic laparoscopy for penetrating abdominal injuries: About 131 anterior abdominal stab wound.

BACKGROUND: The management of hemodynamically stable patients with anterior abdominal stab wounds (AASW) is debated. Mini-invasive techniques using laparoscopy and non-operative management (NOM) have reduced the rate of nontherapeutic laparotomies after AASW leading to unnecessary morbidity. The aim of this study was to determine with a systematic diagnostic laparoscopy of peritoneal penetration (PP), patients who do not require abdominal exploration in the management of stable patient with an AASW. METHODS: All patients with AASW were retrospectively recorded from 2006 to 2018. Criteria of inclusion were AASW patients who underwent a systematic diagnostic laparoscopy. Criteria of exclusion were patients with an evisceration, impaling, clinical peritonitis, and hemodynamic instability. If no PP was detected, laparoscopy was terminated. If defects of peritoneum were found, a laparotomy was performed looking for diagnosis and treatment of intra-abdominal injuries. RESULTS: On 131 AASW patients, 35 underwent immediate emergency laparotomy, 96 underwent diagnostic laparoscopy, 47 were positive (PP) and had an intra-abdominal exploration by laparotomy, 32 (68.1%) had intra-abdominal injuries which required treatment. All patients with an intra-abdominal injury had a positive diagnostic laparoscopy. For the 49 patients with a negative laparoscopy, the mean hospital stay was 1.6 days with ambulatory care for some patients. No patient presented a delayed injury. Non-therapeutic laparotomy rate was 15.6%. For patients who did not have an intra-abdominal injury the morbidity rate was low (3%). CONCLUSION: Our study shows that diagnostic laparoscopy was safe, with a low duration of hospitalization, a possible ambulatory care and had an excellent ability to screen the patients who did not need a abdominal exploration. This management can avoid many unnecessary laparotomies with an acceptable rate of negative laparotomy, without any delayed diagnosis of intra-abdominal injuries and with a low morbidity rate.

The role of leukocytes in predicting whether laparotomy is required in patients with penetrating abdominal stab wound.

BACKGROUND: This study aimed to determine the importance of leukocytes, leukocyte subgroups, platelets, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio in deciding whether laparotomy is required during observation in patients with penetrating abdominal stab wounds who were followed up because there was no indication for an emergency laparotomy. METHODS: Patients who did not indicate an emergency laparotomy were monitored. After 48 hours from initial hospitalization, patients who did not require laparotomy were discharged nonoperatively. The total leukocytes, leukocyte subsets, platelets, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio of patients who underwent laparotomy during the follow-up compared with those who were discharged nonoperatively. The sensitivity and specificity of these laboratory values in predicting the necessity of laparotomy were calculated. RESULTS: In the operated group (n = 71), leukocytes, neutrophils, monocytes, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio examined during observation were significantly higher (P < .001). Eosinophils and lymphocytes were significantly lower (P < .001) than in nonoperated (n = 476). Based on the deviation in the reference ranges of leukocyte and its subgroups, we report the sensitivity and specificity for predicting the necessity of laparotomy as 86% and 72% for leukocyte, 88% and 75% for neutrophil, 92% and 83% for neutrophil-to-lymphocyte ratio, and 72% and 77% for platelet-to-lymphocyte ratio, respectively. In receiver operating characteristic curve analysis, the cut-off value was found to be 4 for neutrophil-to-lymphocyte ratio and 125 for platelet-to-lymphocyte ratio (area under the curve/receiver operating characteristic curve of 0.929 and 0.808, respectively). CONCLUSION: Leukocyte, leukocyte subgroups, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio may be useful to determine if a laparotomy is necessary in patients in whom the necessity of laparotomy is undetermined owing to unclear examination findings.

Leukocytes are not Reliable in Predicting Possible Diaphragmatic Injury in Patients with Penetrating Left Thoracoabdominal Stab Wounds.

BACKGROUND: The diaphragm is injured in approximately one-third of penetrating left thoracoabdominal stab wounds. Diagnostic laparoscopy or thoracoscopy is performed to reveal the diaphragmatic injury. This study investigated whether leukocytes, leukocyte subgroups, platelets, the neutrophil-to-lymphocyte ratio (NLR), and the thrombocyte-to-lymphocyte ratio (PLR) can be used to detect diaphragm injury without the need for diagnostic laparoscopy. METHODS: Patients hospitalized between January 2010 and January 2020 due to penetrating left thoracoabdominal stab wounds were examined. Laparotomy was performed in patients who had indications for laparotomy, such as hemodynamic instability and peritonitis. Diagnostic laparoscopy was performed to reveal possible diaphragmatic injury in patients who did not require laparotomy after 48h of follow-up. Leukocytes, leukocyte subgroups, platelets, NLR, and PLR were measured both at admission and during follow-up, and the results were compared between patients with and without diaphragm injury during diagnostic laparoscopy. RESULTS: The study included 108 patients with penetrating left thoracoabdominal stab wounds that did not require laparotomy after 48h of follow-up. Of these, 102 patients were male (94.44%), and the average age was 27.68 years (range 15-66 years). Diaphragm injury was detected in 31 patients (28.70%) in diagnostic laparoscopy, and the diaphragm was intact in 77 patients (71.30%). In the comparison of patients with and without diaphragmatic injury, no statistically significant difference was found in terms of age, gender, platelets, leukocyte values, NLR, and PLR both at admission and during follow-up. CONCLUSIONS: Leukocytes, leukocyte subsets, platelets, NLR, and PLR were insufficient in the detection of asymptomatic diaphragmatic injuries caused by penetrating left thoracoabdominal stab wounds.

Injuries Sustained During Incarceration Among Prisoners.

BACKGROUND: The U.S. prison population has increased substantially in recent years, and violent injury is common among prisoners. We sought to describe injury patterns and other characteristics of prisoners who presented to a trauma center after injury. Because penetrating trauma from an improvised weapon (e.g., shank) is frequent, we also sought to compare characteristics and outcomes of prisoners and non-prisoners who sustained an anterior abdominal stab or shank wound (AASW). METHODS: We analyzed injured adult prisoners who presented to a Level 1 trauma center between February, 2011, and April, 2017. We described characteristics of the injured prisoners and their hospitalizations. We compared prisoners who sustained an AASW to a random sample of non-prisoners with the same mechanism of injury using the chi-square test, Student's t-test, and logistic and Poisson regression. RESULTS: Of 14,461 hospitalized injured adults, 299 (2.0%) were injured while incarcerated. 185 (62%) encounters involved interpersonal violence and 36 prisoners (12%) presented with self-inflicted injuries. 98 (33%) had a psychiatric disorder. Among 33 prisoners and 66 non-prisoners who sustained an AASW, prisoners were less likely to have undergone a laparotomy [14/33 (42%) vs 44/66 (67%); RR 0.64 (95% CI 0.41-0.98)] or sustained an injury requiring operative intervention [2/33 (6%) vs 23/66 (35%); RR 0.17 (95% CI 0.04-0.69)]. CONCLUSIONS: Many injured prisoners have psychiatric illness, are involved in interpersonal violence, or harm themselves. Among hospitalized patients, abdominal stab/shank wounds sustained in prison are less likely to result in significant injuries or operative intervention than similar wounds in non-prisoners.

The scourge of knife crime: trends in knife-related assault managed at a major centre in South Africa.

BACKGROUND: Knife wounds are common and represent a major burden to the South African healthcare system. This study reviews trends in spectrum, management and outcome of these injuries at a single trauma centre in KwaZulu-Natal(KZN). METHOD: The regional hybrid electronic registry (HEMR) was reviewed for the period January 2013 - December 2018, and all patients who suffered a knife-related assault were identified and reviewed. RESULTS: During the period under review, a total of 2117 patients suffered a knife-related assault. Regions injured were as follows: head 445, neck 572, face 258, chest 939, abdomen 649, pelvic/urogenital 49, upper limb 418, and lower limb 105. The median ISS was 9 (4-10). Imaging comprised 1242 chest X-rays, 315 abdominal X-rays, 162 abdominal ultrasounds/ FAST, and 929 CT scans of which 634 were CT angiograms. A total of 783 (37%) patients required an operation. The rate of laparotomy was 447/649 (69%) and of thoracotomy/sternotomy/thoracoscopy 95/939 (10%). The rate of vascular exploration for upper and lower limb vascular injury was 101/523 (19%). Mortality was 49/2117 (2.3%).. CONCLUSION: Although our clinical outcomes over this period appear to be consistent, suggesting a familiarity with managing knife-related trauma, the persistently high rate of knife-related injury suggests that we have failed to develop a preventative strategy to try and reduce this scourge.

Penetrating cardiac trauma in stab wounds: A study of diagnostic accuracy of the cardiac area.

BACKGROUND: Stab wounds (SW) to the thorax raises suspicion for cardiac injuries; however, the topographic description is variable. The present study aims to evaluate different topographical descriptions within the thorax and establish their diagnostic value in penetrating cardiac trauma by SW. METHODS: Medical records of all patients admitted to our center with thoracic SW from January 2013 to June 2016 were included in this study. Diagnostic value potential was measured using different areas of the thorax described in the literature. RESULTS: In this study, we analyzed 306 cases. Thirty-eight (12.4%) patients had a cardiac injury managed surgically. Death by cardiac injury occurred in seven (18.4%) patients. The cardiac area defined between the right mid-clavicle line until the left anterior axillary line, and between 2nd and 6th intercostal spaces was the more accurate. It has sensitivity of 97.3%, specificity 72%, positive predictive value 33%, negative predictive value 99.4% and accuracy 75.1% for penetrating cardiac trauma. ROC was 0.894 IC 95% (0.760-0.901). CONCLUSION: Among the thoracic areas, topographical limits between the right mid-clavicle line and the left anterior axillary line, and between 2nd and 6th intercostal spaces are the more accurate and are highly indicative of cardiac injury in patients with SW to the thorax.

Performance of pre-hospital evaluations in ruling out invasive chest stab wounds.

BACKGROUND: Some guidelines advocate for managing patients with penetrating thoracic wounds in trauma centres with cardiothoracic surgery. This systematic approach is questionable. Only 15% of these patients require surgery. It is known that clinical examination fails to detect hemopneumothorax in penetrating trauma. However, no studies have evaluated the combined diagnostic performance of vital signs and the clinical evaluation of wounds. The clinical characteristics of wounds have not been investigated. We aimed to evaluate the ability of combinations of pre-hospital signs to rule out invasive chest stab trauma. METHODS: This was a prospective observational study. All consecutive adult patients hospitalized in the perioperative acute care unit of a tertiary university hospital were included. Injury diagnoses were provided by exploratory surgery and imaging tests. Patients with a final diagnosis of invasive wounds (IWs) and patients with only superficial wounds were compared. Data regarding management and outcome were analysed. RESULTS: A total of 153 patients were included. After imaging or surgery, 58 (38%) patients were diagnosed with only superficial wounds, and 95 (62%) were diagnosed with thoracic or abdominal IWs. The false-negative rate of pre-hospital evaluations in the diagnosis of IWs was 42% [31-51]IQR25-75. In stable patients, pre-hospital data could not rule out IWs, with a negative predictive value of 58% and a positive predictive value of 70%. Twenty-nine (19%) patients required early emergent cardiothoracic surgery. Among these patients, 8 (28%) had no evidence of IWs in the pre-hospital period. Among the 59 patients without pre-hospital signs of IWs, 19 (33%) underwent at least one emergent procedure. CONCLUSIONS: The combination of pre-hospital vital signs, visual evaluation of wounds, and physical examination failed to rule out IWs in patients with chest stab wounds. This implies that caution is needed in triage decision-making.

Does computed tomography scan add any diagnostic value to the evaluation of stab wounds of the anterior abdominal wall? A systematic review and meta-analysis.

BACKGROUND: The aim of this systematic review and meta-analysis was to evaluate whether computed tomography (CT) scan adds any diagnostic value in the evaluation of stab wounds of the anterior abdominal wall as compared with serial clinical examination (SCE). METHODS: PubMed, EMBASE, Cochrane Library, and MEDLINE via Ovid were systematically searched for records published from 1980 to 2018 by two independent researchers (M.G., R.L.). Quality assessment, data extraction, and analysis were performed according to the Cochrane Handbook for Systematic Reviews of Interventions. Mantel-Haenszel method with odds ratio (OR) and 95% confidence interval (95% CI) as the measure of effect size was used for meta-analysis. RESULTS: Three studies (1 randomized controlled trial and 2 observational studies) totaling 319 patients were included in the meta-analysis. Overall laparotomy rate was 12.8% (22 of 172 patients) in SCE versus 19% (28 of 147 patients) in CT. This difference was not significant (OR [95% CI], 0.63 [0.34-1.16]; p = 0.14). Negative laparotomy rate was 3.5% (6 of 172 patients) in SCE versus 5.4% (8 of 147 patients) in CT. The difference was not significant (OR [95% CI], 0.61 [0.20-1.83]; p = 0.37). CONCLUSION: This meta-analysis compared SCE with CT scan in patients presenting with stab wounds of the anterior abdominal wall and provided level II evidence showing no additional benefit in CT scan. Further observational and experimental clinical studies are needed to confirm the findings of this meta-analysis. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level II.

Pictorial review on the endovascular management of paediatric aortic injuries.

Paediatric aortic trauma is a rare injury which can be fatal if not identified and managed appropriately. Surgical repair remains the gold-standard in moderate to severe aortic injuries. In the last decade however, endovascular treatment has gained popularity in children who have suitable vascular anatomy for intervention and are either not fit for surgery or in whom, endovascular intervention is the only alternative that will make a difference in the clinical outcome. Children pose a unique set of challenges to endovascular therapy. In this article, we aim to illustrate the different endovascular options that are available for the treatment of acute traumatic aortic injury and visceral thromboembolisation through pictorial representation. We will also demonstrate the feasibility and the limitation of this technique.

"Pop in a scope": attempt to decrease the rate of unnecessary nontherapeutic laparotomies in hemodynamically stable patients with thoracoabdominal penetrating injuries.

BACKGROUND: Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of the present study is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries. METHODS: Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy. We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy. RESULTS: Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32 years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were no missed injuries and no conversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively. CONCLUSION: Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate, and may avoid unnecessary laparotomies. The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.

Endovascular Treatment of an Anterior Tibial Artery Pseudoaneurysm Secondary to Penetrating Trauma in a Young Patient: Case Report and Literature Review.

We report a case of an 18-year-old woman who developed a delayed pseudoaneurysm of the right anterior tibial artery (ATA), 14 days after a knife accidental trauma. The patient was admitted to our emergency department for acute onset of pain in the right limb after a domestic trauma. At a physical examination, the limb was tense and tender, with a pulsatile mass in the anterior compartment. Femoral, popliteal, and distal pulses were palpable on both limbs. Duplex ultrasound scan (DUS) and computed tomography angiography showed the presence of an ATA pseudoaneurysm. An urgent endovascular treatment was performed under local anesthesia via percutaneous access. Pseudoaneurysm was excluded implanting 2 coronary covered balloon-expandable stents (BeGraft; Bentley Innomed GmbH, Hechingen, Germany). Postoperative course was uneventful and the patient was discharged on the second postoperative day under dual antiplatelet therapy. One- and 13-month scheduled follow-up visits and DUS revealed the presence of a normal pedal pulse, complete pseudoaneurysm exclusion, and patency of the stent grafts and the entire ATA with triphasic waveforms. In conclusion, endovascular treatment of an ATA pseudoaneurysm seems to be a feasible option. Further experience with this technique is needed to validate its safety and long-term patency, especially in young and healthy subjects.

Selective Management of Multiple Anterior Abdominal Stab Wounds: Is it Safe?

BACKGROUND: Selective management of stable patients with anterior abdomen stab wounds (AASWs) has become a gold standard management approach throughout the world. Evidenced-based options for supporting selective management include clinical follow-up, local wound exploration with or without diagnostic peritoneal lavage, diagnostic laparoscopy, and abdominal computerized tomography. The presence of multiple AASWs might signify a more aggressive attack and limit the safety of a selective management approach. OBJECTIVES: To evaluate whether multiple AASWs are associated with an increased risk of intra-abdominal injury requiring emergency surgery. METHODS: We retrospectively reviewed all AASW patients admitted to Assaf Harofeh Medical Center, Zerifin, Israel, and Hillel Yaffe Medical Center in Hadera, Israel, from 2007 to 2015. Patients were divided into two groups based on the number of stab wounds: single or multiple. Data were coded for demographics, severity of injury, presence of intra-abdominal injury, laparotomy rate, length of hospital stay (LOS), length of stay in the intensive care unit (LICU), and survival. RESULTS: The study included 169 patients. Of these, 143 patients had a single AASW and 26 had multiple AASWs. There were no differences between the groups regarding demographics, severity of injury, intra-abdominal penetration, specific organ injury, LOS, or LICU. There was no difference in the percentage of patients requiring laparotomy. The overall mortality was 2.36% (4/169). There was no significant difference in the mortality rate between the groups (P = 0.11). CONCLUSIONS: The presence of multiple AASWs is not a risk factor for increased frequency and severity of intra-abdominal injury.

Portopulmonary Hypertension: A Complex Case Derived from Multiple Penetrating Trauma-Induced Mesenteric Arteriovenous Fistulae.

Portopulmonary hypertension (PoPH) is a well-recognized complication of portal hypertension. This study reports a case of PoPH that was secondarily caused by post-traumatic mesenteric arteriovenous fistula. A 38-year-old man with a history of knife stabbing wounds in the abdomen in 2003 was admitted to the hospital with exertional shortness of breath and a mechanic murmur over the umbilical region. Computed tomography indicated signs of PoPH and mesenteric arteriovenous fistula. Percutaneous catheter-directed embolization was first performed but failed. Subsequently, the patient was successfully treated with fistula resection and partial enterectomy. The patient had been postoperatively followed regularly, and chief symptoms had been alleviated significantly and pulmonary pressure had successfully decreased to normal range. We believe that this is the first case of PoPH caused by mesenteric arteriovenous fistula.

Penetrating stab injuries in Iceland: a whole-nation study on incidence and outcome in patients hospitalized for penetrating stab injuries.

BACKGROUND: Studies on penetrating injuries in Europe are scarce and often represent data from single institutions. The aim of this study was to describe the incidence and demographic features of patients hospitalized for stab injury in a whole nation. MATERIALS AND METHODS: This was a retrospective nationwide population-based study on all consecutive adult patients who were hospitalized in Iceland following knife and machete-related injuries, 2000-2015. Age-standardized incidence was calculated and Injury Severity Score (ISS) was used to assess severity of injury. RESULTS: Altogether, 73 patients (mean age 32.6 years, 90.4% males) were admitted during the 16-year study period, giving an age-standardized incidence of 1.54/100,000 inhabitants. The incidence did not vary significantly during the study period (P = 0.826). Most cases were assaults (95.9%) occurring at home or in public streets, and involved the chest (n = 32), abdomen (n = 26), upper limbs (n = 26), head/neck/face (n = 21), lower limbs (n = 10), and the back (n = 6). Median ISS was 9, with 14 patients (19.2%) having severe injuries (defined as ISS > 15). The median length of hospital stay was 2 days (range 0-53). Forty-seven patients (64.4%) underwent surgery and 26 of them (35.6%) required admission to an intensive care unit (ICU), all with ISS scores above 15. Three patients did not survive for 30 days (4.1%); all of them had severe injuries (ISS 17, 25, and 75). CONCLUSION: Stab injuries that require hospital admission are rare in Iceland, and their incidence has remained relatively stable. One in every five patients sustained severe injuries, two-thirds of whom were treated with surgical interventions, and roughly one-third required ICU care. Although some patients were severely injured with high injury scores, their 30-day mortality was still low in comparison to other studies.

Abdominal stab wound injury in children: Do we need a different approach?

BACKGROUND: Penetrating stab wounds in children are relatively rare and no clear recommendations for the optimal evaluation have been devised. An acceptable traditional approach to the patient with an abdominal stab wound who does not require urgent surgery is selective nonoperative management and serial exams. The use of routine computed tomography remains an actively utilized investigation for these patients at many institutions. PURPOSE: We hypothesize that the approach to pediatric stab wound victims should be distinctly different than that of adult counterparts in order to minimize radiation exposure. METHODS: A retrospective cohort study involving abdominal stab wounds among pediatric trauma patients (age < 14) compared with adults between the years 1997 and 2016 was conducted utilizing the Israeli National Trauma Registry. RESULTS: A total of 92 children and 4444 adults were identified from the registry for inclusion. Among the children 20 (21.7%) patients had intraabdominal injury compared to 1730 (38.9%) among adult counterparts. Four children were hemodynamically unstable, two of them were referred directly to operating room and two others were treated without surgery. Among the remaining 88 children there was no observed mortality. CONCLUSIONS: The majority of pediatric stab wounds trauma victims have minor abdominal injuries. We do not recommend the routine utilization of abdominal CT scan in the evaluation of abdominal stab wounds. Observation with serial exams and minimization of radiation exposure from CT are warranted in this unique population. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: 3.