Nonoperative management of renal stab wounds

A prospective clinical study of 54 patients with stab wounds and hematuria was conducted to evaluate the safety of selective nonoperative management compared to mandatory surgical exploration of these patients. In the absence of signs of severe blood loss, associated intra-abdominal injury or major abnormality on the excretory urogram patients were randomized to undergo mandatory surgery (group 1) or nonoperative management (group 2). Patients with signs of severe blood loss, associated intra-abdominal injury or gross abnormality on excretory urography were selected for an operation (group 3). The rate of probably needless operations (defined as minor renal injury without associated intra-abdominal lacerations) was 78 per cent in group 1 and 0 per cent in group 3. Pulmonary complications occurred in 33 per cent of the patients in group 1, 4 per cent in group 2 and 38 per cent in group 3. Despite an operation delayed renal hemorrhage occurred in 1 patient (5 per cent) in group 1 and 2 (15 per cent) in group 3, and resulted in nephrectomy in 2 of these patients. No instance of secondary hemorrhage occurred in group 2 patients. The mean length of hospitalization was 9, 5 and 11 days in groups 1 to 3, respectively. Our results indicate that the selective nonoperative management of patients with renal stab wounds can lead to a decrease in the rate of unnecessary operations, postoperative complications and length of hospitalization compared to a policy of mandatory surgical intervention.     

Prediction of injury caused by penetrating wounds to the abdomen, flank, and back

Controversy about the appropriate evaluation of penetrating abdominal, flank, and back injuries prompted this retrospective review of 311 patients at an urban level 1 trauma center over 5 years. Seventy-five (24%) patients sustained gunshot wounds to the abdomen. All patients with gunshot wounds underwent exploratory laparotomy; results of 67 laparotomies (89%) were positive. Of 236 patients sustaining stab wounds (140 abdominal wounds, 51 flank wounds, 26 back wounds, and 19 wounds to multiple sites), 147 were treated according to a selective protocol, based on results of physical examination, wound exploration, peritoneal lavage, and ancillary diagnostic studies. No injuries were found at celiotomy in three (2%) of these 147 patients. One false-negative result of evaluation of a flank wound occurred. Significant injuries were found in 13 patients (68%) with stab wounds to multiple sites, 61 patients (44%) with abdominal stab wounds, 15 patients (29%) with flank stab wounds, and four patients (15%) with back stab wounds. Mandatory exploration of gunshot wounds is justified. Physical findings of intra-abdominal injury or positive results of peritoneal lavage identify stab wound victims likely to benefit from surgical exploration. A policy of mandatory observation or routine celiotomy for treatment of stab wounds is not justified.     

Renal exploration after trauma. Indications and reconstructive techniques

Blunt traumatic renal injuries seldom (less than 10 per cent) require operation. Improved staging techniques such as CT have been responsible for the decrease in the number of renal explorations. Penetrating renal injuries from knife or gunshot wounds historically have mandated surgical exploration. This practice should be continued unless staging studies confirm that the degree of injury justifies expectant management. In the authors' experience, 42 per cent of stab wounds and 76 per cent of gunshot wounds have necessitated renal exploration.     

Diagnostic laparotomy for abdominal trauma. A university hospital experience

Following the experience of World War II, exploratory laparotomy in all patients with penetrating abdominal trauma was deemed mandatory until 1960 when Shaftan reported his experience with selective laparotomy. In 1973, Nance et al. reported on selective observation of abdominal stab wounds. There seems to be little controversy over mandatory laparotomy for abdominal gunshot wounds. Blunt trauma is generally managed expectantly with the adjunctive use of peritoneal lavage, CT scanning, and serial examinations of the abdomen. Despite the selective approach and the use of adjunctive diagnostic methods, exploratory laparotomy continues to be the most accurate method used to diagnose the presence of intra-abdominal injury. In order to examine our experience with diagnostic laparotomy for trauma, both blunt and penetrating, a retrospective study of 494 consecutive patients undergoing exploratory laparotomy over the past 4 years was undertaken. Abdominal stab wounds were explored under local anesthesia, and, if found to penetrate the posterior fascia, laparotomy was accomplished. All patients with abdominal gunshot wounds underwent exploration. Exploratory laparotomy in patients with blunt abdominal trauma was mandated by clinical signs, positive peritoneal lavage, or positive CT scan. All patients with unexplained shock and/or signs of peritoneal irritation underwent urgent laparotomy. In this series of 494 patients, 99 or 20 per cent of the entire group had a negative exploration (30% for stab wounds, 16% for gunshot wounds, and 19% for blunt abdominal trauma). The morbidity for the negative laparotomy group was limited to five patients with postoperative atelectasis. There were no anesthesia complications, iatrogenic intraoperative injuries, or wound infections. There were five deaths but none were laparotomy-related.(ABSTRACT TRUNCATED AT 250 WORDS)     

Penetrating renal injuries.

A retrospective analysis of 81 penetrating renal injuries revealed a need for surgical exploration in only 39 per cent, and the following conclusions are made: (1) Criteria for classifying a traumatic renal injury as major and therefore requiring further evaluation (arteriography) or appropriate urgent surgery, include urographic nonfunction or extravasation, persistent or severe hematuria or retroperitoneal hemorrhage, and deteriorating clinical status. (2) Preoperative urologic assessment is mandatory to avoid needless renal exploration; 58 per cent of patients with minor injuries were in this series operated on. (3) It is doubtful that late sequelae of penetrating renal injury occur so frequently that immediate surgery to prevent them is advisable.     

Radiographic assessment of renal trauma: a 10-year prospective study of patient selection

To develop criteria to determine which patients require radiographic assessment after blunt renal trauma, we studied prospectively 1,146 consecutive patients with either blunt (1,007) or penetrating (139) renal trauma between 1977 and 1987. Based on our preliminary results from 1977 to 1983, in which none of the 221 patients with blunt trauma and microscopic hematuria without shock had significant renal injuries, we designed a prospective study to determine if such patients could be managed safely without radiographic staging. During the last 10 years significant renal injuries were found in 44 patients (4.4 per cent) with blunt trauma and gross hematuria or microscopic hematuria associated with shock, and in 88 patients (63 per cent) with penetrating trauma. No significant injuries occurred in the 812 patients with blunt trauma and microscopic hematuria without shock, 404 of whom had complete radiographic assessment and 408 of whom did not. There were no delayed operations or significant sequelae related to the renal injury in these patients. We conclude that complete radiographic staging is mandatory in patients with penetrating trauma to the flank or abdomen and in patients with blunt trauma associated with either gross hematuria or microscopic hematuria and shock. However, patients with blunt trauma, microscopic hematuria and no shock who do not have associated major intra-abdominal injuries can be managed safely without excretory urography.     

Gunshot wound of the abdomen: role of selective conservative management

This prospective study includes 146 patients with gunshot wounds of the abdomen. One hundred and five patients (72 per cent) had an acute abdomen on admission and were operated on immediately. The remaining 41 patients (28 per cent) had minimal or equivocal abdominal signs and were observed with serial clinical examinations. Seven of the observed patients needed subsequent laparotomy, but there was no mortality or serious morbidity. Had a policy of mandatory exploration for abdominal gunshot wound been applied the incidence of unnecessary or negative laparotomies would have been 27 per cent. By using a policy of selective conservatism this figure was only 5 per cent. We suggest that abdominal gunshot wounds should be assessed and managed exactly like knife wounds. Physical examination is reliable in detecting significant intra-abdominal injuries. Many carefully selected patients with abdominal gunshot wounds can safely be managed non-operatively.     

Penetrating trauma to the back and flank. A reassessment of mandatory celiotomy

The optimum management of penetrating wounds to the back and flank remains controversial. Since 1980 our institution has followed a policy of mandatory celiotomy for back and flank wounds with evidence of fascial penetration. Following this policy, 34 patients underwent celiotomy for back (8), flank (22), or combined (4) area penetrating injuries. Four patients sustained shotgun blasts, eight sustained handgun or rifle injuries, and 22 patients were stabbed. All shotgun blasts caused multiple intra-abdominal injuries and five (63%) of the eight gunshot victims had significant intra-abdominal injuries. Only one (5%) of the 22 stab victims had significant intra-abdominal injury. Four (12%) patients died, three of shotgun injuries. One patient had a small bowel obstruction 1 month after a noncontributory abdominal examination. Based on this review, the authors recommend selective management of stab wounds to the back and flank. Gunshot wounds continue to warrant mandatory exploration.     

Increasing role of angiography and segmental artery embolization in the management of renal stab wounds.

During a 5-year period 93 patients with stab wounds involving the upper urinary tract were treated. Of these patients 79 were treated initially at our department (group 1) and 14 were referred with complications after initial treatment elsewhere (group 2). In group 1, 26 patients (33%) were selected for surgery on the basis of signs of severe blood loss or associated intra-abdominal injury, or major abnormality on the excretory urogram. At operation a major renal injury and/or associated intra-abdominal laceration was found in 23 patients (88%) and nephrectomy was required in 7 (27%) of them. Nonoperative management was selected in 53 patients (67%) in group 1 and secondary hemorrhage occurred in 8 (15%). Of the patients in group 2, 4 had undergone an operation elsewhere and 10 had been managed nonoperatively. Renal arteriography was performed in 14 patients who had been managed nonoperatively (6 from group 1 and 8 from group 2) and demonstrated a traumatic pseudoaneurysm in 6, an arteriovenous fistula in 5 and no large vessel injury in 3. Selective embolization of the involved segmental artery was successful in 9 of 11 patients (82%) when angiography showed a vascular lesion. This study demonstrates the increasingly important role of renal angiography and selective embolization in the selective nonoperative management of patients with stab wounds of the kidney.     

Clinical study on stab wounds of chest--factors that may influence their mortality

Stab wounds of the chest occupy an important position in penetrating thoracic injuries in Japan. A retrospective review of 117 patients with stab wounds of the chest admitted to our hospital over the past 12 years (from 1975 to 1987) revealed some factors that might influence their mortality. Seven patients died from trans-diaphragmatic injuries of intra-abdominal organs. The management of intra-abdominal injuries was very important in thoracic stab wounds. Many of the patients with stab wounds of the precordial chest (danger zone) had cardiac or major vascular injuries, and the mortality rate of them was high. The mortality rate of the patients with stab wounds of the right lateral thorax was high, because many of them had trans-diaphragmatic liver injuries. We thought that right lateral thorax as well as precordial chest is the danger zone in thoracic stab wounds. Survival rate in the patients whose circulatory condition had been unstable when they admitted was very low. Five DOA (dead on arrival) patients with stab wounds of the chest required emergency room thoracotomy (ERT). One of them survived. Survival rate in the DOA patients with stab wounds of the chest was higher than that in the DOA patients with blunt thoracic injuries. ERT for cardiac insufficiency following stab wounds of the chest was thought an effective procedure for surviving. Survival rate of the patients with cardiac stab wounds was 63.6 per cent.     

Hepatic trauma: risk factors influencing outcome

This retrospective study analyses the fate and associated risk factors of 99 patients who underwent laparotomy for hepatic trauma from 1977 to 1986. Blunt trauma (88 patients) and stab wounds (7 patients) had mortality rates of 36 and 14 per cent respectively. The overall death rate was 35 per cent. Multiple trauma patients had a significantly higher mortality for each additional system that was seriously injured. Pre-operative shock raised the mortality from 20 to 58 per cent (P less than 0.001). For patients over 50 years of age, the mortality rate increased from 30 (younger patients) to 63 per cent (P = 0.028). Minor hepatic wounds required relatively simple surgical measures in 60 patients, yet 13 died (22 per cent) of other causes. More sophisticated surgical management was applied to 27 major hepatic lesions, with 10 deaths (37 per cent). Twelve patients (seven with minor and five with major hepatic wounds) died before surgical treatment of the liver injury could be undertaken. The overall mortality rate of major hepatic wounds was 47 per cent and for minor wounds 30 per cent. However, the difference was not significant (P = 0.152). Resection was resorted to in 15 patients, 5 of whom subsequently died (33 per cent). Classical hepatic lobectomy led to 4 deaths (50 per cent). Among the 35 deaths, 6 were due to the hepatic trauma itself (5 exsanguinations and 1 intra-abdominal sepsis). Isolated hepatic injury was fatal in three patients. We believe that conservative surgical measures should be used whenever possible in patients with hepatic trauma, especially when risk factors are encountered.     

Evaluation of anterior abdominal stab wounds: is local wound exploration beneficial?

Purpose: Local wound exploration (LWE) to assess penetrance when used as an indicator for mandatory laparotomy leads to a high rate of negative laparotomies. The aim of this study was to evaluate the need for LWE.Methods: An ongoing 5-year retrospective review of stab wounds to the anterior abdomen with LWE was performed. Patients with multiple stab wounds or associated injuries were excluded. Twenty-five cases of single stab wounds were identified, in all of which LWE was performed.Results: In 22 cases where fascial penetration was found, there were 17 (77%) negative laparotomies (5 nontherapeutic) and 5 with intra-abdominal injuries. Three of the LWEs were negative for penetrance, but all resulted in positive laparotomy. Cases that resulted in laparotomy presented with findings on clinical evaluation (tenderness, hemodynamic lability, etc.). When evisceration was used as an indicator for mandatory laparotomy, 4 of 6 (66%) resulted in negative explorations. No deaths occurred.Conclusions: Local wound exploration to assess penetrance, in the setting of hemodynamic stability and lack of clinical findings, results in a high rate of nontherapeutic laparotomies and may not be necessary. Evisceration as an indicator may also need further evaluation.     

Selective surgical management of renal stab wounds.

Patients with stab wounds and haematuria were selected for surgical exploration if they had signs of severe blood loss, an associated intra-abdominal laceration or major abnormality on the intravenous urogram (IVU). Patients without these signs were selected for non-operative management, consisting of bed rest, an intravenous antibiotic for 24 h and regular observation. Of 95 patients, 60 (63%) were selected for non-operative management (Group 1) and 35 (37%) were selected for primary surgical exploration (Group 2). At surgery in Group 2, a major renal injury and/or associated intra-abdominal laceration was found in 31 patients. Thus a probably unnecessary operation was performed in only 4 patients (4% of the whole group of 95 patients). Renal complications occurred in 12 of the 60 patients (20%) in Group 1 and consisted mainly of secondary haemorrhage caused by an arteriovenous fistula (AVF) or pseudo-aneurysm. Management of the renal complications included segmental artery embolisation in 6, nephrectomy in 2, heminephrectomy in 1, open surgical ligation of an AVF in 1 and spontaneous resolution in 2 patients. The mean period of hospitalisation was significantly shorter in Group 1 (6.1 days) than in Group 2 patients (9.9 days). Comparing the Group 1 patients who developed renal complications with those who did not, we would recommend more aggressive selection for surgery of those patients exhibiting clinical signs of shock, a fall in haemoglobin during observation, a palpable abdominal mass, a haemothorax and/or pneumothorax ipsilateral to the renal injury, and IVU signs of extravasation, non-function, delayed excretion or hydroureteronephrosis due to blood clots.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnostic and treatment problems in renal injuries

The case records of 112 patients with 116 renal injuries seen at Detroit Receiving Hospital (July 1980 to June 1985) were reviewed. Eighty-three (74%) of the injuries were caused by gunshot wounds, 18 (16%) by stab wounds, and 11 (10%) by blunt trauma. Of 102 patients who had a urinalysis (U/A) in the Emergency Department (ED), 12 had a normal U/A. Five of these 12 patients had severe renal pedicle injuries. Of 75 excretory urograms (IVPs) performed preoperatively, 21 (28%) were normal including seven in patients with major renal injuries requiring surgical treatment. The incidence of shock was 38 per cent in patients with injuries not requiring renal explorations, 69 per cent in patients with renal parenchymal injuries requiring surgery, and 93 per cent in patients with pedicle injuries requiring repair or nephrectomy. Although it is generally believed that traumatic perirenal hematomas should not be explored, there was an increased incidence of complications with this approach in this series. Of 65 stable renal injuries treated conservatively (without exploration of the renal parenchyma), there were nine (14%) complications including three reoperation for missed injuries and three perinephric abscesses. In 46 injuries that were explored (38 for bleeding and eight without bleeding), there were only two complications (5%), including a perinephric abscess.     

Surgery for liver trauma

Hepatic injuries are found in 30 per cent of patients undergoing operation after penetrating abdominal wounds and in 15 to 20 per cent of patients undergoing operation after blunt trauma. Signs of blood loss, peritonitis, or peritoneal traverse by a missile prompt early operation in many patients. Stable patients who have suffered stab wounds in proximity to the liver may be safely evaluated by diagnostic peritoneal lavage, whereas CT evaluation is now used in stable patients suffering blunt trauma that may involve the liver. "Simple" techniques of repair such as suture hepatorrhaphy, application of topical agents, or application of fibrin glue suffice in 60 per cent (blunt trauma) to 90 per cent (penetrating trauma) of patients with hepatic injuries. The remainder require "advanced" techniques of repair such as extensive hepatorrhaphy, hepatotomy with selective vascular ligation, resectional debridement with selective vascular ligation, lobectomy or segmentectomy, selective hepatic artery ligation, or perihepatic packing. Using the techniques described, the mortality rate for all patients with hepatic injuries will be approximately 10 per cent, with 75 to 80 per cent of all deaths occurring in the perioperative period from shock or transfusion-related coagulopathies. The most common major complications in survivors are perihepatic abscesses and postoperative hemorrhage, both of which are frequently treated by the interventional radiologist.     

Laparoscopic cholecystectomy: the Dundee technique.

A total of 61 patients was subjected to laparoscopic cholecystectomy. The procedure was completed in 60 cases and converted to open operation in one (2 per cent). The morbidity rate was low (total 7 per cent, major 2 per cent, blood transfusion rate 5 per cent). The median duration of the laparoscopic cholecystectomy with cholangiography was 135 min (range 65-270 min). The operation took less time to complete in patients with functioning gallbladders than in those with non-functioning fibrotic organs (median 120 versus 175 min). The majority of patients required opiate analgesia despite infiltration of the stab wounds with bupivacaine. The mean (s.d.) hospital stay was 2.9 (1.5) days. The median time to resume work or full activity after discharge was 11 days.     

Laparoscopy in the evaluation of penetrating thoracoabdominal trauma

The evaluation of penetrating thoracoabdominal trauma for the presence of a diaphragmatic injury presents a diagnostic challenge to the trauma surgeon. The use of diagnostic laparoscopy (DL) in this setting was reviewed at a level-one trauma institution. Eighty patients (71 males, 9 females) with penetrating injuries to the thoracoabdominal region underwent DL to rule out injury to the diaphragm. Fifty-eight patients (72.5%) had a negative study and were spared a celiotomy. In the remaining 22 patients (27.5%), injury to the diaphragm was identified. This subset of patients underwent a mandatory celiotomy to rule out an associated intra-abdominal injury. Seventeen out of 22 (77.2%) patients had a positive exploration requiring surgical intervention, representing an associated intra-abdominal injury rate of 21.2 per cent. Intra-abdominal injuries requiring repair included small bowel, colon, spleen, liver, and stomach, in descending order. There were no missed injuries or deaths. One patient with a left diaphragmatic injury secondary to a stab wound developed a subdiaphragmatic abscess. Respiratory insufficiency secondary to atelectasis was the most common complication. Diagnostic laparoscopy is an essential and safe modality for the evaluation of diaphragmatic injuries in penetrating thoracoabdominal trauma.     

Blunt bladder trauma: manifestation of severe injury

Twenty-nine patients with bladder injuries requiring operative treatment as a result of blunt trauma are presented. Motor vehicle accidents accounted for 86 per cent of the injuries. Hypotension and gross hematuria were the most prevalent clinical features, 68 per cent and 97 per cent, respectively. All patients had multiple associated injuries requiring operative treatment, average 2.9 per patient. Pelvic fractures occurred in 93 per cent and intra-abdominal injuries in 48 per cent of patients. The majority of ruptures (72%) were intraperitoneal. Mortality, related to associated injuries, was high (34%), attesting to the magnitude of injury sustained by the victim.     

Angiomyolipoma: clinical metamorphosis and concepts for management

In 10 years the diagnosis of renal angiomyolipoma was made in 44 patients (female-to-male ratio 8:1) at our institution; 4 cases were associated with tuberous sclerosis. Of these patients 29 underwent surgical exploration because of a renal mass; 11 patients with renal masses that were consistent with angiomyolipoma radiologically have not undergone exploration. Of the 4 patients with and the 29 patients without tuberous sclerosis 1 (25 per cent) and 2 (7 per cent), respectively, had renal cell cancer in association with angiomyolipoma. Metachronous involvement of the contralateral kidney has not been noted in any of our patients who underwent nephrectomy for unilateral involvement, nor has there been progression of the contralateral lesion in 3 patients with bilateral disease without tuberous sclerosis during a followup of about 6 years. Furthermore, we have not noted progression of lesions in the 11 patients under observation for a mean followup of almost 3 years. We recommend elective exploration and a renal preserving operation when possible, not only for patients with pain and hemorrhage but also for the complex multiple lesions occasionally seen in patients who do not have tuberous sclerosis. Lesions associated with tuberous sclerosis require surgical intervention only when they become symptomatic or enlarge silently.     

Is exploratory celiotomy necessary for all patients with truncal stab wounds?

Mandatory exploratory celiotomy was carried out in 1241 consecutive patients with truncal stab wounds. Four hundred seventy-one (38%) patients who had no intra-abdominal injury identified at operation developed 16 complications (3%), with one patient (0.2%) dying postoperatively. The average length of hospitalization (5 days) was increased if the patient: (1) required a simultaneous operation for associated site injuries (9 days), (2) developed postoperative complications (16 days), or (3) required reoperation (27 days). The 1990 projected cost per patient for routine celiotomy has increased 92% over that seen 10 years ago. Selective management protocols using observation, repeated physical examination, and special diagnostic procedures could be instituted for asymptomatic hemodynamically stable patients with truncal stab wounds if appropriate facilities and personnel are available. Successful implementation should preserve medical resources for those patients with trauma requiring a life-saving operation.