Top

European Journal of Trauma and Emergency Surgery

Published in:

18-08-2022 | Computed Tomography | Original Article

Contrast-enhanced computed tomography abdomen versus diagnostic laparoscopy-based management in patients with penetrating abdominal trauma: a randomised controlled trial

Authors: Supreet Kaur, Dinesh Bagaria, Abhinav Kumar, Pratyusha Priyadarshini, Narendra Choudhary, Sushma Sagar, Amit Gupta, Biplap Mishra, Mohit Joshi, Atin Kumar, Shivanand Gamanagatti, Kapil Dev Soni, Richa Aggarwal, Sreenivas Vishnubhatla, Subodh Kumar

Published in: European Journal of Trauma and Emergency Surgery | Issue 1/2023

Abstract

Purpose

Penetrating abdominal trauma was traditionally managed by mandatory exploration, which led to high rates of non-therapeutic surgery and prolonged hospital stay. Diagnostic laparoscopy (DL) is a less-invasive alternative; however, it requires general anaesthesia and carries a potential risk of iatrogenic injuries. Contrast-enhanced computed tomography (CECT)-guided selective non-operative management (SNOM) may avoid surgery altogether, but there is apprehension of missed injury. Randomised trials comparing these two modalities are lacking. This study is aimed at comparing outcomes of these two management approaches.

Methods

Hemodynamically stable patients with penetrating trauma to anterior abdominal wall were randomised in 1:1 ratio to DL or CECT-based management. Primary outcome was length of hospital stay (LOS). Secondary outcomes were rate of non-therapeutic surgery, complications, and length of intensive care unit (ICU) stay.

Results

There were 52 patients in DL group and 54 patients in CECT group. Mean LOS was comparable (3 vs 3.5 days; p = 0.423). Rate of non-therapeutic surgery was significantly lower in CECT group (65.4 vs 17.4%, p = 0.0001). Rate of complications and length of ICU stay were similar. Selective non-operative management based on CECT findings was successful in 93.8% of patients; 2 patients had delayed surgery.

Conclusion

In patients with penetrating trauma to anterior abdominal wall, DL and CECT-based management led to comparable hospital stay. Significant reduction in non-therapeutic surgery could be achieved using a CECT-based approach.

Trial registration

Clinical trials registry-India (CTRI/2019/04/018721, REF/2019/01/023400).

Leppäniemi A. Nonoperative management of solid abdominal organ injuries: from past to present. Scand J Surg SJS Off Organ Finn Surg Soc Scand Surg Soc. 2019;108:95–100. https://doi.org/10.1177/1457496919833220.CrossRef

Ball CG. Current management of penetrating torso trauma: nontherapeutic is not good enough anymore. Can J Surg. 2014;57:E36-43. https://doi.org/10.1503/cjs.026012.CrossRefPubMedPubMedCentral

Fouda EY, Magdy A, Emile SH. Selective non-operative management of anterior abdominal stab wounds with emphasis on the value of follow-up abdominal CT scanning. Trauma. 2018;20:194–202. https://doi.org/10.1177/1460408617706389.CrossRef

Shaftan GW. Indications for operation in abdominal trauma. Am J Surg. 1960;99:657–64. https://doi.org/10.1016/0002-9610(60)90010-6.CrossRefPubMed

Clarke DL, Allorto NL, Thomson SR. An audit of failed non-operative management of abdominal stab wounds. Injury. 2010;41:488–91. https://doi.org/10.1016/j.injury.2009.10.022.CrossRefPubMed

Di Saverio S, Biscardi A, Tugnoli G, Coniglio C, Gordini G, Bendinelli C. The brave challenge of NOM for abdominal GSW trauma and the role of laparoscopy as an alternative to CT Scan. Ann Surg. 2017;265:e37–8. https://doi.org/10.1097/SLA.0000000000001301.CrossRefPubMed

Martin MJ, Brown CVR, Shatz DV, Alam HB, Brasel KJ, Hauser CJ, et al. Evaluation and management of abdominal stab wounds: a Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg. 2018;85:1007–15. https://doi.org/10.1097/TA.0000000000001930.CrossRefPubMed

Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010;68:721–33. https://doi.org/10.1097/TA.0b013e3181cf7d07.CrossRefPubMed

Lin H-F, Wu J-M, Tu C-C, Chen H-A, Shih H-C. Value of diagnostic and therapeutic laparoscopy for abdominal stab wounds. World J Surg. 2010;34:1653–62. https://doi.org/10.1007/s00268-010-0485-5.CrossRefPubMed

10.

Leppäniemi A, Haapiainen R. Diagnostic laparoscopy in abdominal stab wounds: a prospective, randomized study. J Trauma. 2003;55:636–45. https://doi.org/10.1097/01.TA.0000063000.05274.A4.CrossRefPubMed

11.

Sumislawski JJ, Zarzaur BL, Paulus EM, Sharpe JP, Savage SA, Nawaf CB, et al. Diagnostic laparoscopy after anterior abdominal stab wounds: worth another look? J Trauma Acute Care Surg. 2013;75:1013–7. https://doi.org/10.1097/TA.0b013e3182a1fde8 (discussion 1017-1018).CrossRefPubMed

12.

Salim A, Sangthong B, Martin M, Brown C, Plurad D, Inaba K, et al. Use of computed tomography in anterior abdominal stab wounds: results of a prospective study. Arch Surg Chic Ill. 1960;2006(141):742–5. https://doi.org/10.1001/archsurg.141.8.745.CrossRef

13.

Parajuli P, Kumar S, Gupta A, Bansal VK, Sagar S, Mishra B, et al. Role of laparoscopy in patients with abdominal trauma at level-I trauma center. Surg Laparosc Endosc Percutan Tech. 2018;28:20–5. https://doi.org/10.1097/SLE.0000000000000379.CrossRefPubMed

14.

Matsevych OY, Koto MZ, Balabyeki M, Mashego LD, Aldous C. Diagnostic laparoscopy or selective non-operative management for stable patients with penetrating abdominal trauma: what to choose? J Minimal Access Surg. 2018. https://doi.org/10.4103/jmas.JMAS_72_18.CrossRef

15.

van den Hout WJ, van der Wilden GM, Boot F, Idenburg FJ, Rhemrev SJ, Hoencamp R. Early CT scanning in the emergency department in patients with penetrating injuries: does it affect outcome? Eur J Trauma Emerg Surg. 2018;44:607–14. https://doi.org/10.1007/s00068-017-0831-5.CrossRefPubMed

16.

Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJF, Scalea TM. Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury—a prospective study in 200 patients. Radiology. 2004;231:775–84. https://doi.org/10.1148/radiol.2313030126.CrossRefPubMed

17.

Akkoca M, Balas S, Yilmaz KB, Tatar IG, Akinci M, Tokgoz S, et al. CT-guided tractography is a safe and complementary diagnostic tool in the management of penetrating abdominal trauma. Asian J Surg. 2019;42:148–54. https://doi.org/10.1016/j.asjsur.2018.05.007.CrossRefPubMed

18.

Sarici İS, Kalayci MU. Is computed tomography tractography reliable in patients with anterior abdominal stab wounds? Am J Emerg Med. 2018;36:1405–9. https://doi.org/10.1016/j.ajem.2017.12.065.CrossRefPubMed

19.

Thorisdottir S, Oladottir GL, Nummela MT, Koskinen SK. Diagnostic performance of CT and the use of GI contrast material for detection of hollow viscus injury after penetrating abdominal trauma. Experience from a level 1 Nordic trauma center. Acta Radiol n.d.:7.

20.

Kong V, Cheung C, Elsabagh A, Rajaretnam N, Varghese C, Bruce J, et al. Radiographic pneumoperitoneum following abdominal stab wound is not an absolute indication for mandatory laparotomy—a South African experience. Injury. 2021;52:253–5. https://doi.org/10.1016/j.injury.2020.12.018.CrossRefPubMed

21.

Biffl WL, Leppaniemi A. Management guidelines for penetrating abdominal trauma. World J Surg. 2015;39:1373–80. https://doi.org/10.1007/s00268-014-2793-7.CrossRefPubMed

22.

Cocco AM, Bhagvan S, Bouffler C, Hsu J. Diagnostic laparoscopy in penetrating abdominal trauma. ANZ J Surg. 2019;89:353–6. https://doi.org/10.1111/ans.15140.CrossRefPubMed

23.

Bain K, Meytes V, Chang GC, Timoney MF. Laparoscopy in penetrating abdominal trauma is a safe and effective alternative to laparotomy. Surg Endosc. 2019;33:1618–25. https://doi.org/10.1007/s00464-018-6436-1.CrossRefPubMed

24.

O’Malley E, Boyle E, O’Callaghan A, Coffey JC, Walsh SR. Role of laparoscopy in penetrating abdominal trauma: a systematic review. World J Surg. 2013;37:113–22. https://doi.org/10.1007/s00268-012-1790-y.CrossRefPubMed

Title: Contrast-enhanced computed tomography abdomen versus diagnostic laparoscopy-based management in patients with penetrating abdominal trauma: a randomised controlled trial
Authors: Supreet Kaur
Dinesh Bagaria
Abhinav Kumar
Pratyusha Priyadarshini
Narendra Choudhary
Sushma Sagar
Amit Gupta
Biplap Mishra
Mohit Joshi
Atin Kumar
Shivanand Gamanagatti
Kapil Dev Soni
Richa Aggarwal
Sreenivas Vishnubhatla
Subodh Kumar
Publication date: 18-08-2022
Publisher: Springer Berlin Heidelberg
Keywords: Computed Tomography
Laparoscopy
Computed Tomography
Perforated Abdominal Trauma
Laparotomy
Laparotomy
Published in: European Journal of Trauma and Emergency Surgery / Issue 1/2023
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-022-02089-5

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Contrast-enhanced computed tomography abdomen versus diagnostic laparoscopy-based management in patients with penetrating abdominal trauma: a randomised controlled trial

Abstract

Purpose

Methods

Results

Conclusion

Trial registration

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Trial registration

Please log in to get access to this content

Other articles of this Issue 1/2023

Emergency physician and nurse discretion accurately triage high-risk trauma patients

Graded operative autonomy in emergency appendectomy mirrors case-complexity: surgical training insights from the SnapAppy prospective observational study

Associations between elevated high-sensitive cardiac troponin t and outcomes in patients with acute abdominal pain

Role of DOAC plasma concentration on perioperative blood loss and transfusion requirements in patients with hip fractures

COVID-19 rapid molecular point-of-care testing is effective and cost-beneficial for the acute care of trauma patients

The symmetry of the left and right tibial plateau: a comparison of 200 tibial plateaus