Diagnostic peritoneal lavage in abdominal injuries. Our experience

Personal experience is reported in the use of peritoneal lavage in closed abdominal trauma to provide rapid, definitive diagnosis of haemoperitoneum. The techniques to be employed in order to obtain accurate diagnosis without any of the complications reported in the literature are specified and the advantages of the technique in resolving diagnostic uncertainties are analysed.     

Diagnostic peritoneal lavage through an abdominal stab wound

Diagnostic peritoneal lavage (DPL) is one of the most useful tools in the diagnosis of intraperitoneal injuries secondary to stab wounds. The lavage catheter is inserted into the peritoneal cavity through a surgical incision or a blind puncture. Complications related to the catheter insertion were previously reported in both techniques. We describe 2 cases in which the lavage catheter was inserted through the stab wound itself after local wound exploration clearly demonstrated violation of the peritoneum. We suggest that in anterior abdominal stab wounds, the DPL can be safely and effectively performed through the stab wound if penetration to the peritoneum is diagnosed.     

Diagnostic peritoneal lavage. Questions and answers

Peritoneal lavage is a useful adjunct to physical examination and to other traditional means of assessing the patient with potential intraabdominal injury. The procedure is safe in experienced hands and may be easily and rapidly performed with a minimum of equipment. The information that lavage provides may spare some patients an exploratory laparotomy and, more important, may identify those patients who appear to be in stable condition but who, in fact, need immediate lifesaving intervention.     

Diagnostic peritoneal lavage in blunt trauma

We reviewed the records of 274 trauma patients who had 275 diagnostic peritoneal lavages from Feb 1, 1983 through Jan 31, 1986. Lavage was done in 271 of 560 (48%) cases of blunt trauma and three of 245 (1%) penetrating injuries (gunshot wounds to the chest). The open lavage technique was used, and results were considered grossly positive if there was 10 ml of gross blood. Results were considered microscopically positive if there were more than 100,000 RBCs or 500 WBCs/cu mm, an elevated amylase or bilirubin value, or bacteria or vegetable fibers. Lavage was negative in 193 cases, including false-negative results (1%), and positive in 78, with three false-positive results (3.8%). Open peritoneal lavage is safe, rapid, readily available, and accurate in the evaluation of blunt abdominal trauma.     

A comparison of open peritoneal lavage with modified closed peritoneal lavage in blunt abdominal trauma

A randomized prospective study compared open peritoneal lavage using a peritoneal dialysis catheter with modified closed lavage using either the Lazarus-Nelson or Cook lavage catheter. The time required to perform the lavage, technical difficulties, complications, and accuracy were assessed in 63 adult victims of blunt abdominal trauma. The average time to perform lavage was 21.1 minutes for open lavage, 14.7 minutes for Lazarus-Nelson closed lavage, and 9.8 minutes for Cook closed lavage. The closed technique using the Cook catheter was significantly faster than open lavage. Technical difficulties were significantly less frequent with Cook catheter closed lavage than with Lazarus-Nelson catheter closed lavage. The overall complication rate was 1.8%, and the overall accuracy was 98.1%, without apparent difference among techniques. It is concluded that, when no contraindications to closed lavage exist, and when time is of importance, closed lavage with the Cook catheter is the preferred technique.     

Ultrasound in abdominal trauma: an alternative to peritoneal lavage.

Ultrasonography has been used as an investigation in patients with abdominal signs after blunt injury. Thirty-two patients were examined, of whom 11 had abnormal findings. Free intraperitoneal fluid was demonstrated in eight cases, seven of whom had this confirmed at subsequent laparotomy. The 21 patients with normal scans did not require abdominal intervention. It is suggested that ultrasonography is a reliable method of detecting haemoperitoneum and offers a valuable non-invasive method of investigating blunt abdominal injuries. The hepatorenal pouch is the site where free intraperitoneal fluid can be most easily demonstrated.     

Diagnostic peritoneal lavage and ultrasonography for blunt abdominal trauma: attitudes and training of current general surgical trainees.

OBJECTIVE: It has been suggested that diagnostic peritoneal lavage is now obsolete in UK hospitals with access to either skilled ultrasonography or emergency physician or surgeon-performed focused abdominal sonography in trauma. Diagnostic peritoneal lavage continues to be advocated and taught on Advanced Trauma Life Support courses. The aim of this study was to evaluate the experiences and attitudes of general-surgery trainees in one UK training region towards diagnostic peritoneal lavage and focused abdominal sonography in trauma in managing blunt abdominal trauma. METHODS: An anonymous postal piloted questionnaire was sent to all 66 general surgery specialist trainees in one UK training region between January and March 2005. RESULTS: Out of 40 replies to the questionnaire (response rate 61%), 53% and 38% of surgical trainees had either never performed or never observed a diagnostic peritoneal lavage during their training. Thirteen trainees (33%) felt diagnostic peritoneal lavage to be obsolete and would never contemplate using it; 15 trainees (37%) might consider using diagnostic peritoneal lavage if computed tomography or ultrasonography were unavailable. Ten trainees (25%) felt that diagnostic peritoneal lavage had been superseded by computed tomography. Only 12 trainees (30%) had worked in a UK hospital with access to facilities for focused abdominal sonography in trauma and only seven trainees (18%) had received any training or experience in focused abdominal sonography in trauma. CONCLUSIONS: Surgical trainees in one UK training region lack skills in both diagnostic peritoneal lavage and focused abdominal sonography in trauma for managing blunt abdominal trauma and are therefore reliant upon the availability of prompt, skilled radiological assistance or emergency physician-provided focused abdominal sonography in trauma.     

Incremental analysis of diagnostic peritoneal lavage fluid in adult abdominal trauma

It is uncertain how much diagnostic peritoneal lavage (DPL) fluid must be recovered from abdominal trauma patients to avoid falsely low red blood cell (RBC) counts. A study was carried out to investigate this controversy. A convenience sample of adult abdominal trauma patients in a Level 1 university trauma center who were undergoing DPL with 1 L crystalloid was enrolled. Subjects with grossly positive or colorless effluent were excluded. A blinded prospective experimental design was used. Differences were evaluated among RBC counts collected at 200, 400, 600, and 800 mL of returned fluid using repeated-measures analysis of variance. In 11 patients, mean RBC counts collected at 200 and 400 mL were 24,600 (95% confidence interval [Cl], 20,700 to 29,100) and 39,700 (95% Cl, 33,200 to 47,100) cells/μL. These were substantially lower than the final mean count of 95,800 (95% Cl, 80,000 to 115,800), measured at 800 mL (F = 23.7, P < .0001). Mean counts at 600 mL were less than those obtained at 800 mL but were not statistically different (P = .08). Two of the 11 subjects would have been misclassified (as not requiring surgery) had “early” sampling been used. In abdominal trauma patients, the RBC count of DPL fluid regularly increases as more fluid is recovered. It is important to collect >600 mL of effluent to avoid misleading, low RBC counts and misclassification of patients.     

Indications for and efficiency of peritoneal lavage in severe acute pancreatitis

Peritoneal lavage was developed as a simple method to evacuate the ascitic fluid associated with pancreatitis. Although a number of studies demonstrated its efficacy in improvement of clinical manifestations, a meta-analysis of randomized control studies could not reveal its effectiveness on mortality or morbidity in severe acute pancreatitis. However, it has been well established that the ascitic fluid with pancreatitis is extremely toxic and to induce organ damage due to apoptotic cell death. Particularly, we have recently found that the ascitic fluid with pancreatitis can induce bacterial translocation due to the increase of gut permeability. Therapeutic strategy of peritoneal lavage, i.e. evacuation of toxic substances from peritoneal cavity, should be reevaluated to achieve further improvement of treatment result of severe acute pancreatitis.     

Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage

Background

With recent advances in radiologic diagnostic procedures, the use of diagnostic peritoneal lavage (DPL) has markedly declined. In this study, we reviewed data to reevaluate the role of DPL in the diagnosis of hollow organ perforation in patients with blunt abdominal trauma.

Methods

Adult patients who had sustained blunt abdominal trauma and who were hemodynamically stable after initial resuscitation underwent an abdominal computed tomographic (CT) scan. Diagnostic peritoneal lavage was performed for patients who were indicated to receive nonoperative management and where hollow organ perforation could not be ruled out.

Results

During a 60-month period, 64 patients who had received abdominal CT scanning underwent DPL. Nineteen patients were diagnosed as having a positive DPL based on cell count ratio of 1 or higher. There were 4 patients who sustained small bowel perforation. The sensitivity and specificity of the cell count ratio for a hollow organ perforation in this study were 100% and 75%, respectively. No missed hollow organ perforations were detected.

Conclusion

For patients with blunt abdominal trauma and hemoperitoneum who plan to receive nonoperative management, DPL is still a useful tool to exclude hollow organ perforation that is undetected by CT.     

A comparison of diagnostic peritoneal lavage and computed tomography (CT scan) in evaluation of the hemodynamically stable patient with blunt abdominal trauma.

The diagnosis of intraabdominal injury in the patient who is victim of blunt trauma is often problematic. Currently, two procedures, diagnostic peritoneal lavage (DPL) and computed tomography (CT scan) are used to evaluate patients with possible intraabdominal injuries after blunt trauma. Controversy exists as to which of these modalities is more efficacious in this setting. There are advantages and disadvantages of both procedures, however, present evidence suggests that the clinician should not rely on the results of the CT scan. The DPL, on the other hand is a sensitive and specific modality in evaluating the patient with blunt abdominal trauma.     

Objective determination of the optimal red blood cell count in diagnostic peritoneal lavage done for abdominal stab wounds.

The purpose of this study was to determine objectively the optimal value or positivity criterion for red blood cell counts in diagnostic peritoneal lavage in stab wounds to the anterior abdomen. Our study group consisted of 91 consecutive adults with abdominal stab wounds who underwent peritoneal lavage. We excluded those patients who met criteria for immediate laparotomy and those with negative stab wound exploration. We divided the patients into two groups based on outcome. Group 1 consisted of those who had undergone laparotomy and had findings that required surgical intervention. Group 2 patients had either undergone laparotomy but had no injury requiring surgical intervention or had no surgery and a benign hospital course and follow-up. Receiver operator characteristic analysis was done on the diagnostic peritoneal lavage RBC counts for both groups. The overlap between the groups was minimal, with 75% of patients in Group 1 having > 120,000 RBC/mm3 and 75% of patients in Group 2 having < 486 RBC/mm3 in the lavage effluent. Using the observed probability of 23.1% of patients with abdominal stab wounds requiring surgery, a RBC count of 50,000/mm3 discriminated best those patients who required surgery from those who did not.     

腹腔镜下腹腔灌洗术对重症急性胰腺炎的疗效分析

目的 探讨腹腔镜下腹腔灌洗术对重症急性胰腺炎(SAP)治疗的疗效.方法 将60例SAP患者按人院先后顺序随机分为腹腔灌洗组和传统治疗组,每组30例.观察两组治疗前后血清TNF-α和IL-8水平的变化,比较两组腹内高压持续时间、住院时间、腹腔感染和血性感染的发生率及死亡率.结果 两组患者治疗后血清TNF-α和IL-8水平均显著下降,且腹腔灌洗组较传统治疗组下降更为明显.腹腔灌洗组腹内高压持续时间和住院时间明显缩短,腹腔感染显著减少,血性感染和死亡率也有所下降.结论 腹腔镜下腹腔灌洗术能够降低SAP患者炎症介质,缓解腹内高压,减少腹腔感染,缩短住院时间,对预后有益.     

腹腔镜下置管灌洗引流在重症急性胰腺炎早期治疗中的应用

目的探讨腹腔镜下置管灌洗引流(LPLD)在重症急性胰腺炎(SAP)早期治疗中的效果。方法采用LPLD法治疗早期SAP患者22例,对其临床资料进行回顾性分析。结果LPLD手术时间(65.4±27.6)min,术后灌洗引流时间(11.3±8.6)d,术后住院时间(32.5±14.6)d。LPLD同期完成腹腔镜胆囊切除术5例,腹腔镜经胆囊管、胆总管取石1例,胆总管切开取石、T管引流术2例。1例术后4d死于多器官功能衰竭,余21例治愈。出院随访6~24个月,发现假性胰腺囊肿1例,行内引流手术治愈。结论LPLD是SAP早期治疗中一种安全可行的方法,采用微创方法即可达到开腹手术全面探查、充分灌洗引流治疗SAP的目的。     

The effect of peritoneal lavage and aprotinin in the treatment of severe acute pancreatitis

Fifty-five patients with severe acute pancreatitis were treated with peritoneal lavage at the Dept. of Surgery at Malm? General Hospital. In a randomized study 26 of the 55 patients received in addition 500,000 KIU aprotinin in the lavage fluid every 2 h. There were no significant differences between the aprotinin- and non-aprotinin-treated groups as to mortality and clinical results. The initial concentration of alpha 1-antitrypsin in plasma was mainly within normal range with increasing values during the treatment. No differences were seen between the two groups. The initial mean level of alpha 2-macroglobulin in plasma was slightly decreased, but 17 patients showed values below normal range. The alpha 2-macroglobulin level during the lavage showed a similar course in the two groups. alpha 1-Antitrypsin and alpha 2-macroglobulin in the lavage fluids showed signs of complexation but in plasma these inhibitors did not show any signs of complexation. On admission to the hospital the mean levels of C3 and kininogen in the plasma were slightly below normal. During the lavage treatment no differences were seen between the two groups. Degradation products of C3 and kininogen were seen in both serum and peritoneal fluids. The electrophoretic patterns of C3 and kininogen normalized in serum as well as in lavage fluids during the lavage treatment without any significant differences in the two groups. High levels of immunoreactive trypsin, pancreatic elastase, PSTI, and leukocyte elastase in serum were seen equally in both groups of patients.     

腹腔镜下置管灌洗引流对重症急性胰腺炎猪的治疗作用

目的探讨腹腔镜下腹腔置管灌洗引流对重症急性胰腺炎猪的治疗作用。方法采用腹腔镜下主胰管内加压注射牛磺胆酸钠和胰蛋白酶的方法制作猪重症急性胰腺炎模型。将模型动物随机分为两组,每组5只:对照组造模后仅行基础支持治疗,治疗组造模后行腹腔镜下胰周置管灌洗引流和基础支持治疗。于造模前和造模成功后6、24、48和72h测定血清淀粉酶及血浆TNF-!和IL-6的含量,同时观察模型动物的生命体征和存活情况。结果72h内对照组1只家猪死亡,死亡率20%,治疗组无死亡。对照组造模后血清淀粉酶及血浆TNF-“和IL-6的含量明显升高,血清淀粉酶24h时达到高峰为(4901.3&#177;512.4)u/L,6h时血浆TNF-а达到高峰为(1476.7&#177;206.2)ng/L,24h时血浆IL-6达到高峰为(542.5&#177;112.5)ng/L。治疗组造模后各时间点血清淀粉酶及TNF-а和IL-6的含量均显著性低于对照组(P&lt;0.05)。结论腹腔镜下腹腔置管引流能够有效减轻重症急性胰腺炎家猪过度的炎症反应,降低死亡率,改善预后。     

造血干细胞移植后急性移植物抗宿主病的超声改变

目的阐述血液病患者造血干细胞移植(HSCT)治疗后并发急性移植物抗宿主病(aGVHD)的腹部超声改变,探讨其在aGVHD诊断中的临床意义。方法对73例HSCT患者进行常规腹部超声检查,比较分析aGVHD患者(43例)及无aGVHD患者(30例)的肝脏、胆囊、胰腺、脾脏、肾脏及肠道声像图变化特征。结果aGVHD患者出现弥漫性肝实质损害、胆囊壁增厚、胆汁淤积、脾脏体积增大及肠蠕动异常等一系列超声变化,与无aGVHD患者比较存在明显差异(P<0.05)。结论HSCT治疗后并发aGVHD患者的腹部超声改变有特异性,能够为aGVHD的临床诊断提供较为可靠的影像学依据。