PDF(Pubmed)
Abstract：
BACKGROUND: The treatment of penetrating abdominal injuries has changed in recent years with more focus on \"nonoperative management\" (NOM) to avoid unnecessary laparotomies while identifying injuries early. Although the NOM approach is widely used for stab wounds, its effectiveness in managing abdominal gunshot wounds is controversial. NOM of penetrating abdominal injuries is becoming more dependent on hemodynamic stability and improved noninvasive radiological interventions. The role of NOM is significantly underreported and underestimated in developing countries, particularly in fragile and conflict-affected states such as Yemen. The present study aims to evaluate the clinical outcomes of NOM in penetrating abdominal trauma injury patients and identify factors associated with NOM failure in a low-resource setting.
METHODS: A retrospective study from January 2021 to December 2022 including patients diagnosed with penetrating abdominal trauma at the General Military Hospital, Sana\'a, Yemen, was conducted. Hemodynamically stable patients without peritonitis or clear indications for immediate laparotomy were candidates for NOM and were included in the study. Patients with blunt abdominal injuries, penetrating wounds outside the abdomen, particularly head injury, eviscerated structures, and gastrointestinal hemorrhage, or those pronounced dead on arrival were excluded. The primary outcome was the success and failure rate of NOM necessitating laparotomy. The secondary outcome was the factors associated with NOM failure.
RESULTS: During the study, 256 patients with penetrating abdominal injury were admitted, with 222 (86.7%) undergoing immediate laparotomy and 34 (13.3%) treated with NOM. The mean age was 27.6±7.4 years. Bump explosions, mostly sharp objects (secondary blast injuries), were the main causes of injury (n=18, 52.9%). Other causes were low-velocity gunshot wounds, stab wound injuries, and shotgun injuries in 14 (41.2%), one (2.9%), and one (2.9%), respectively. The majority of patients (n=25, 55.9%) were admitted within 6-24 hours of the incident. The abdominal computed tomography (CT) scan revealed various injuries in all patients, including hemoperitoneum in 11 (32.4%), pneumoperitoneum in five (14.7%), liver injury in 15 (44.1%), foreign body attached to the wall colon in 23 (67.6%), kidney injury in two (5.9%), and splenic injury in one (2.9%). NOM was successful in 31 (91.2%) patients. NOM failed in three (8.8%). One patient was treated via the laparoscopic procedure, and two patients were treated with laparotomy procedures. Five (14.7%) cases required intensive care unit (ICU) admission, with no deaths or major complications. In univariate analysis, the presence of free intra-abdominal fluid (pneumoperitoneum) on the initial CT scan and the need for ICU admission were associated with NOM failure and were statistically significant (p<0.05).
CONCLUSIONS: Our findings support that some penetrating abdominal trauma patients can benefit from NOM. The goal of preventing unnecessary laparotomies should be aligned with a comprehensive comprehension of the clinical signs and symptoms of NOM failure and the necessity for surgical intervention. Serial abdominal examinations remain the foundation of selected NOM; nevertheless, radiological and laboratory tests can be important tools in decision-making. In this study, free intra-abdominal fluid on the initial CT scan and the need for ICU admission were associated with NOM failure.
METHODS: A retrospective study from January 2021 to December 2022 including patients diagnosed with penetrating abdominal trauma at the General Military Hospital, Sana\'a, Yemen, was conducted. Hemodynamically stable patients without peritonitis or clear indications for immediate laparotomy were candidates for NOM and were included in the study. Patients with blunt abdominal injuries, penetrating wounds outside the abdomen, particularly head injury, eviscerated structures, and gastrointestinal hemorrhage, or those pronounced dead on arrival were excluded. The primary outcome was the success and failure rate of NOM necessitating laparotomy. The secondary outcome was the factors associated with NOM failure.
RESULTS: During the study, 256 patients with penetrating abdominal injury were admitted, with 222 (86.7%) undergoing immediate laparotomy and 34 (13.3%) treated with NOM. The mean age was 27.6±7.4 years. Bump explosions, mostly sharp objects (secondary blast injuries), were the main causes of injury (n=18, 52.9%). Other causes were low-velocity gunshot wounds, stab wound injuries, and shotgun injuries in 14 (41.2%), one (2.9%), and one (2.9%), respectively. The majority of patients (n=25, 55.9%) were admitted within 6-24 hours of the incident. The abdominal computed tomography (CT) scan revealed various injuries in all patients, including hemoperitoneum in 11 (32.4%), pneumoperitoneum in five (14.7%), liver injury in 15 (44.1%), foreign body attached to the wall colon in 23 (67.6%), kidney injury in two (5.9%), and splenic injury in one (2.9%). NOM was successful in 31 (91.2%) patients. NOM failed in three (8.8%). One patient was treated via the laparoscopic procedure, and two patients were treated with laparotomy procedures. Five (14.7%) cases required intensive care unit (ICU) admission, with no deaths or major complications. In univariate analysis, the presence of free intra-abdominal fluid (pneumoperitoneum) on the initial CT scan and the need for ICU admission were associated with NOM failure and were statistically significant (p<0.05).
CONCLUSIONS: Our findings support that some penetrating abdominal trauma patients can benefit from NOM. The goal of preventing unnecessary laparotomies should be aligned with a comprehensive comprehension of the clinical signs and symptoms of NOM failure and the necessity for surgical intervention. Serial abdominal examinations remain the foundation of selected NOM; nevertheless, radiological and laboratory tests can be important tools in decision-making. In this study, free intra-abdominal fluid on the initial CT scan and the need for ICU admission were associated with NOM failure.
摘要：
背景：近年来，腹部穿透性损伤的治疗方法发生了变化，更侧重于“非手术治疗”（NOM），以避免不必要的开腹手术，同时及早发现损伤。尽管NOM方法广泛用于刺伤，它在处理腹部枪伤方面的有效性是有争议的。穿透性腹部损伤的NOM越来越依赖于血液动力学稳定性和改进的无创放射学干预措施。在发展中国家，NOM的作用被严重低估和低估，特别是在也门等脆弱和受冲突影响的国家。本研究旨在评估NOM在穿透性腹部创伤损伤患者中的临床结果，并确定在低资源环境中与NOM失败相关的因素。
方法：2021年1月至2022年12月的回顾性研究，包括在总军医院诊断为穿透性腹部创伤的患者，Sana\'a,也门,进行了。没有腹膜炎或明确的立即剖腹手术指征的血流动力学稳定的患者是NOM的候选人，并被纳入研究。腹部钝性损伤患者,腹部外的穿透伤口，尤其是头部受伤,内脏结构，胃肠道出血,或者那些在抵达时宣布死亡的人被排除在外。主要结果是需要剖腹手术的NOM成功率和失败率。次要结果是与NOM失败相关的因素。
结果：在研究期间，收治了256例腹部穿透性损伤患者，222例（86.7％）立即进行剖腹手术，34例（13.3％）接受NOM治疗。平均年龄为27.6±7.4岁。碰撞爆炸，主要是尖锐物体(二次爆炸伤害)，是伤害的主要原因(n=18，52.9%)。其他原因是低速枪伤，刺伤,14人中有猎枪受伤(41.2%)，一个（2.9%），和一个(2.9%)，分别。大多数患者（n=25，55.9％）在事件发生后6-24小时内入院。腹部计算机断层扫描（CT）扫描显示所有患者均受到各种伤害，包括11例（32.4％）的腹膜，气腹五人(14.7%)，肝损伤15例（44.1%），23例(67.6%)附壁结肠异物,两个肾损伤（5.9％），和脾损伤中的一个(2.9%)。31例（91.2%）患者NOM成功。NOM在三个（8.8％）中失败。一名患者接受了腹腔镜手术治疗，两名患者接受了剖腹手术治疗。5例(14.7%)需要入住重症监护病房(ICU),无死亡或严重并发症。在单变量分析中，初次CT扫描时游离腹腔积液(气腹)的存在和ICU入住的需要与NOM失败相关,且有统计学意义(p<0.05).
结论：我们的发现支持一些腹部穿透性创伤患者可以从NOM中获益。预防不必要的开腹手术的目标应与全面了解NOM失败的临床体征和症状以及手术干预的必要性相一致。连续的腹部检查仍然是选定的NOM的基础；然而，放射学和实验室测试可能是决策的重要工具。在这项研究中,初次CT扫描时的腹腔内游离积液和需要入住ICU与NOM失败相关.
方法：2021年1月至2022年12月的回顾性研究，包括在总军医院诊断为穿透性腹部创伤的患者，Sana\'a,也门,进行了。没有腹膜炎或明确的立即剖腹手术指征的血流动力学稳定的患者是NOM的候选人，并被纳入研究。腹部钝性损伤患者,腹部外的穿透伤口，尤其是头部受伤,内脏结构，胃肠道出血,或者那些在抵达时宣布死亡的人被排除在外。主要结果是需要剖腹手术的NOM成功率和失败率。次要结果是与NOM失败相关的因素。
结果：在研究期间，收治了256例腹部穿透性损伤患者，222例（86.7％）立即进行剖腹手术，34例（13.3％）接受NOM治疗。平均年龄为27.6±7.4岁。碰撞爆炸，主要是尖锐物体(二次爆炸伤害)，是伤害的主要原因(n=18，52.9%)。其他原因是低速枪伤，刺伤,14人中有猎枪受伤(41.2%)，一个（2.9%），和一个(2.9%)，分别。大多数患者（n=25，55.9％）在事件发生后6-24小时内入院。腹部计算机断层扫描（CT）扫描显示所有患者均受到各种伤害，包括11例（32.4％）的腹膜，气腹五人(14.7%)，肝损伤15例（44.1%），23例(67.6%)附壁结肠异物,两个肾损伤（5.9％），和脾损伤中的一个(2.9%)。31例（91.2%）患者NOM成功。NOM在三个（8.8％）中失败。一名患者接受了腹腔镜手术治疗，两名患者接受了剖腹手术治疗。5例(14.7%)需要入住重症监护病房(ICU),无死亡或严重并发症。在单变量分析中，初次CT扫描时游离腹腔积液(气腹)的存在和ICU入住的需要与NOM失败相关,且有统计学意义(p<0.05).
结论：我们的发现支持一些腹部穿透性创伤患者可以从NOM中获益。预防不必要的开腹手术的目标应与全面了解NOM失败的临床体征和症状以及手术干预的必要性相一致。连续的腹部检查仍然是选定的NOM的基础；然而，放射学和实验室测试可能是决策的重要工具。在这项研究中,初次CT扫描时的腹腔内游离积液和需要入住ICU与NOM失败相关.
