UROLOGICAL SURVEY
Urogenital Trauma
Selective nonoperative management of penetrating abdominal solid organ injuries
Demetriades D; Hadjizacharia P; Constantinou C; Brown C; Inaba K; Rhee P; Salim A
Division of Trauma and Surgical Intensive Care, Department of Surgery, USC School of Medicine, Los Angeles, CA, USA
Ann Surg. 2006; 244: 620-8
OBJECTIVE: To assess the feasibility and safety of selective nonoperative management in penetrating abdominal solid organ injuries.
BACKGROUND: Nonoperative management of blunt abdominal solid organ injuries has become the standard of care. However, routine surgical exploration remains the standard practice for all penetrating solid organ injuries. The present study examines the role of nonoperative management in selected patients with penetrating injuries to abdominal solid organs.
PATIENTS AND METHODS: Prospective, protocol-driven study, which included all penetrating abdominal solid organ (liver, spleen, kidney) injuries admitted to a level I trauma center, over a 20-month period. Patients with hemodynamic instability, peritonitis, or an unevaluable abdomen underwent an immediate laparotomy. Patients who were hemodynamically stable and had no signs of peritonitis were selected for further CT scan evaluation. In the absence of CT scan findings suggestive of hollow viscus injury, the patients were observed with serial clinical examinations, hemoglobin levels, and white cell counts. Patients with left thoracoabdominal injuries underwent elective laparoscopy to rule out diaphragmatic injury. Outcome parameters included survival, complications, need for delayed laparotomy in observed patients, and length of hospital stay.
RESULTS: During the study period, there were 152 patients with 185 penetrating solid organ injuries. Gunshot wounds accounted for 70.4% and stab wounds for 29.6% of injuries. Ninety-one patients (59.9%) met the criteria for immediate operation. The remaining 61 (40.1%) patients were selected for CT scan evaluation. Forty-three patients (28.3% of all patients) with 47 solid organ injuries who had no CT scan findings suspicious of hollow viscus injury were selected for clinical observation and additional laparoscopy in 2. Four patients with a "blush" on CT scan underwent angiographic embolization of the liver. Overall, 41 patients (27.0%), including 18 cases with grade III to V injuries, were successfully managed without a laparotomy and without any abdominal complication. Overall, 28.4% of all liver, 14.9% of kidney, and 3.5% of splenic injuries were successfully managed nonoperatively. Patients with isolated solid organ injuries treated nonoperatively had a significantly shorter hospital stay than patients treated operatively, even though the former group had more severe injuries. In 3 patients with failed nonoperative management and delayed laparotomy, there were no complications.
CONCLUSIONS: In the appropriate environment, selective nonoperative management of penetrating abdominal solid organ injuries has a high success rate and a low complication rate.
Editorial Comment
Most blunt solid organ injuries can successfully be managed nonoperatively. Stab wounds, in general can be managed nonoperatively about 50% of the time for anterior abdominal entrance wounds and 85% for retroperitoneal entrance. While traditionally teaching dictates that gunshot wounds of the abdomen were absolute indications for exploration, such concepts have been brought into question with multiple publications in the last few years, mostly championed by the trauma group from LA County Medical Center. In general the treatment algorithm for penetrating abdominal trauma is as follows: signs or symptoms of peritonitis, hemodynamic instability or an abdomen difficult to evaluate due to mental status change or body habitus, underwent intra-abdominal exploration. All other patients were imaged by CT with intravenous contrast. If the CT suggested a hollow organ viscus injury or a contrast "blush" with instability, the patient was explored. Contrast "bush" and stable patients underwent angiography. If there was no bowel injury and the penetrating wound was on the left and thoracoabdominal, a delayed diagnostic laparoscopy is performed to evaluate for a diaphragmatic injury. Any injury was repaired laparoscopically. The patient is then examined serially for the next 24 to 48 hours. Persistently asymptomatic patients were fed and discharged after 48 hours. 60% of penetrating injuries were explored immediately, 30% (27) of whom had with kidney injuries. Of the injured kidneys, 12 underwent renorrhaphy and 9 or (33%) nephrectomy. Of those kidney injuries managed conservatively, none of the Grade 1 and 2 injuries were explored while 1 of 3 of the Grade 3-5 injuries were explored. In conclusion, in the very select patient gunshot wound to the kidney patient, nonoperative management can be successful.
Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri,USA
Proposed mechanisms of lower urinary tract injury in fractures of the pelvic ring
Andrich DE; Day AC; Mundy AR
Institute of Urology, UCL, London, UK
BJU Int. 2007; 100: 567-73
OBJECTIVE: To investigate whether the observation of particular pelvic fracture patterns enables the clinician to predict the presence and type of injuries to the lower urinary tract, as the mechanisms of injury to the lower urinary tract in association with fractures of the pelvic ring are unclear.
PATIENTS AND METHODS: The case-notes and radiographs of 168 patients with either pelvic ring or acetabular fractures were reviewed; 108 pelvic ring fractures (81 men, 27 women) and 60 acetabular fractures (46 men, 14 women). The pelvic fractures were classified according to the system described by Tile and were correlated with the incidence and type of lower urinary tract injury (LUTI).
RESULTS: Overall, of the 108 men and women with pelvic ring fractures, 27 (25%) had a LUTI documented either radiologically or as an intraoperative finding. Of the 81 men with pelvic ring fractures, 24 (30%) had a LUTI, of whom six (7%) had an isolated bladder laceration, 14 (17%) a partial urethral injury (PUI) and four (5%) a complete urethral disruption (CUD). Five of the 18 men with urethral injuries also had bladder injuries and in three of these, the bladder neck was also injured. Three of 27 women (11%) had a LUTI, all of whom had isolated bladder lacerations. Of the 46 men with an acetabular fracture, one (2%) had a CUD, and three (7%) had a PUI. One of 14 of women with an acetabular fracture sustained a bladder laceration. None of the three men with a Tile Type-A pelvic ring fracture sustained a LUTI. Of the 28 men with 'open-book' (Tile Type-B1) fractures, 21 (75%) had no associated LUTI and seven (25%) had a LUTI (five partial urethral injuries and two bladder lacerations). Of the 10 men with 'lateral compression' (Tile Type-B2) fractures, six had no LUTI and four had a LUTI (two partial urethral injuries and two bladder lacerations). Of the 40 men with 'vertical shear' (Tile Type-C) fractures, 27 (68%) had no LUTI and 13 (32%) a LUTI (four complete urethral disruptions, seven partial urethral injuries, and two bladder lacerations) including all of the combined bladder and urethral injuries and all of the bladder neck injuries.
CONCLUSION: The pelvic fracture pattern alone does not predict the presence of a LUTI. When it occurs, the type of LUTI appears to be related to the fracture mechanism. The pattern of injury to the soft tissue envelope and specifically to the ligaments supporting the lower urinary tract offers the best correlation with the observed LUTI. We propose a mechanism for this.
Editorial Comment
The above article by Mundy clearly deserves a closer look, particularly at the illustrative images and figures. Pelvic fractures are typically classified by fracture pattern and mechanism of injury. The two most commonly used schemas are the Young-Burgess and the Tile classifications. They divide the fracture patterns more by mechanism into Type A, anterior compression (AP) injury, Type B, lateral compression (LC) and Type C vertical shear and conformationally unstable. Bladder injuries in the male with pelvic fractures are primarily due to shearing forces and not to bladder penetration from a bony spicule. This is illustrated by publications from the SF General Group where half of bladder injuries occurred on the opposite side of the bony fracture. Intuitively, a pelvic fracture that results in the most shearing forces, then should also give the highest likelihood for bladder injury. Urethral injuries have been classically described by Turner Warwick as prostato-membranous disruption injuries. It is my observation, and that of others, most injuries to the urethra from pelvic fracture are at the bulbomembranous junction and not at the level of the prostate. Again, in the male, it appears that shearing forces are the cause of urethral injury and not direct compression or penetration. In other words, the injury that causes the most shearing forces to the urethra should cause an injury.
Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, US
Publication Dates
-
Publication in this collection
29 Feb 2008 -
Date of issue
Oct 2007
