Abdominal Stab Wounds in Children: an 18-Year Experience

European Journal of Trauma Original Article

1 1 1 · 1 2 Hayrettin Öztürk , Abdurrahman Onen , Selcuk Otçu , Ali Ihsan Dokucu , Yusuf Yaˇgmur , Senol Gedik1

Abstract Signs of major internal hemorrhage or generalized Objective: Evaluation of the diagnosis, management, peritonitis are an absolute indication for emergency and the role of selective treatment in children with operation for abdominal stab wounds. Peritoneal pene- abdominal stab wounds. trations, free air on the abdominal X-ray, and omental Patients and Methods: 59 children (56 male and three or intestinal evisceration are poor indicators of signifi- female) were included in the study. The patients’ medi- cant organ injuries, and patients presenting these signs an age was 11.8 years (range, 5–14 years). Time between should be closely followed up for developing acute injury and admission was about 3 h. Laparotomy was abdominal symptoms. performed in 44 patients (74%). Solid organ injury was detected in 32 of these patients (73%) and could not be Key Words observed in twelve (27%). 15 patients (26%) were treat- Trauma · Abdominal stab wounds · Laparotomy · ed conservatively, and only one (6.6%) underwent Child laparotomy during the follow-up. The stomach was the most frequently injured organ (ten patients), followed Eur J Trauma 2002;27:85–9 by the intestines (nine patients). Types of surgical treat- DOI 10.1007/s00068-002-1186-z ment were as follows: primary suture in 28 patients, resection-anastomosis in three, and osteotomy in two. Results: Some prognostic factors such as presence of abdominal organ evisceration and pneumoperi- Introduction toneum were not significantly correlated with Abdominal stab wounds amount to approximately intraabdominal organ injury, whereas some other risk 5–10% of total abdominal childhood traumas [1, 2]. The factors such as acute abdomen on admission (p < management of penetrating abdominal injuries varies 0.002) or abnormal clinical and hemodynamic find- widely in different trauma centers. Negative laparotomy ings (p < 0.001) showed significant correlation with for penetrating abdominal trauma is associated with sig- intraabdominal organ injury. The relative risk (odds nificant morbidity and mortality [3, 4]. Some surgeons ratio) of developing an intraabdominal organ injury advocate routine exploration of potentially penetrating was > 2 for patients with signs of an acute abdomen abdominal wounds [5]. Others, however, prefer selec- on admission. Postoperative complications were tive laparotomy which repeatedly has been shown to be observed in five patients with organ injuries. None of a safe and reliable treatment method [6–9]. our patients died. The aim of this report is to evaluate the diagnosis, Conclusions: Conservative treatment can be safely per- management, and the role of selective treatment in chil- formed in most children with abdominal stab injuries. dren with abdominal stab wounds.

1 Department of Pediatric Surgery, and 2 Department of General Surgery, Dicle University, Medical School, Diyarbakır, Turkey. Received: November 2, 2001; revision accepted: February 15, 2002

European Journal of Trauma 2002 · No. 2 © Urban & Vogel 85 Öztürk H, et al. Abdominal Stab Wounds in Children

Patients and Methods Table 1. Comparison of laparotomy to conservative treatment in In this study, children with abdominal stab wounds abdominal stab injury. admitted to the Dicle University Faculty of Medicine Number of Laparotomy Conservative treatment between March 1983 and May 2001 were investigated patients Organ Organ Organ Organ retrospectively. 59 patients with peritoneal penetration injury (+) injury (–) injury (+) injury (–) were evaluated for age, sex, admission time, mechanism First 5 years 19/14 19/5 0/0 0/0 of injury, symptoms during admission, diagnostic tech- (n = 19) niques, localization of perforation, associated injury, Second 5 years 14/8 14/6 3/0 3/3 treatment modalities, morbidity and mortality rate. (n = 17) a Univariate analysis was done to identify those vari- Last 8 years 11/10 11/1 12/1a 12/11 (n = 23) ables, which might serve as interdependent predictors of intraabdominal organ injury. The following risk factors a Conservative treatment has increased during the last 8 years. There is statistical significance between conservative treatment in the last 8 years and the first and were analyzed: presence of acute abdomen, eviscera- second 5 years (p < 0.001 and p < 0.0001) tion of intraabdominal organ, pneumoperitoneum, patients with abdominal organ evisceration and pneu- abdomen and omental or intestinal evisceration under- moperitoneum developing an acute abdomen, and nor- went surgery. Organ injuries were detected in 20 (77%) mal clinical and hemodynamic findings (NCHF). of 26 patients presenting with an acute abdomen and in Patients were investigated in three terms: first 5 ten (63%) of 16 patients presenting with eviscerations. years, second 5 years, and last 8 years. The laparoto- Laparoscopy was performed in five patients and my/conservative treatment ratio was defined for each of revealed liver laceration and intestinal perforation in these terms. The presence of organ injuries in patients one patient each. These two patients underwent laparo- treated conservatively and in patients undergoing tomy, and another three patients with normal laparo- laparotomy was pointed out and patients were com- scopic findings were treated conservatively. pared for morbidity rate. 15 patients with normal clinical and hemodynamic findings were treated conservatively although abdomi- Statistical Analysis nal paracentesis was positive for blood in six. In the Data were entered into and analyzed on a personal remaining nine patients, peritoneal penetration was computer using SPSS version 10.0. The 2 test was used determined by local exploration of the wound in six and for statistical analysis. A p-value < 0.05 was considered by stabogram in three. One of these patients had devel- statistically significant. oped signs of an acute abdomen at follow-up and was operated on. 16 patients with pneumoperitoneum Results underwent surgery. However, organ injuries were Of the children in the study, 56 (94%) were male and detected in only six (37%) of them. three female (6%). The patients’ median age was 11.8 The most frequently injured organs were the stom- years (range, 5–14 years). The median duration of time ach in ten patients, the intestines in nine, the liver in five, until admission was 3 h (range, 1–8 h). The mean was 4 h the diaphragm in five, the spleen in two, and the colon in (3–8 h) in patients with acute abdomen on admission. three. Four of seven patients with intestinal injuries had Laparotomy was performed in 44 patients (74%). Solid multiple injuries. Pancreatic injury was detected in two organ injury was detected in 32 of these patients (73%) patients, ureteric injury in one, and vena cava inferior and could not be observed in twelve (27%). 15 patients injury in one. Pneumohemothorax was seen in two (26%) did not undergo laparotomy on admission, which patients. was performed later in only one patient (6.6%). Laparo- Types of surgical treatment were as follows: primary tomy represented the main procedure in the first 10 suture in 28 patients, resection-anastomosis in three, years; during the last 8 years, however, most of the and ostomy in two. Laparotomy was negative in twelve patients were treated conservatively (Table 1). patients. During initial examination of the 59 patients, 26 Postoperative complications were observed in five (44%) showed signs of an acute abdomen. 16 patients patients with organ injuries, namely adhesive obstruc- (27%) presented with evisceration of the omentum (n = tion (n = 3) and wound infection (n = 2). Yet as far as 14) or small bowel (n = 2). All patients with acute complications are concerned, no statistical significance

86 European Journal of Trauma 2002 · No. 2 © Urban & Vogel Öztürk H, et al. Abdominal Stab Wounds in Children

Table 2. Presence of abdominal organ injury in relation to the patients’ clinical status. AOE: various diagnostic techniques such abdominal organ evisceration; (L–U): lower–upper; NCHF: normal clinical and hemodynamic as local exploration of the wound or findings; n.s.: not significant. stabogram have been used to assess Parameter Abdominal p-value Odds ratioEstimated 95% the integrity of the peritoneum [5]. organ injury confidence Presence of an acute abdomen and n (%) interval (L–U) major internal hemorrhage, evis- Acute abdomen Yes (n = 26) 20 (77) ceration of intraabdominal organ, No (n = 33) 12 (36) 0.002* 2.115 1.286–3.481 pneumoperitoneum, and normal AOE Yes (n = 16) 10 (62) clinical and hemodynamic findings No (n = 43) 22 (55) n.s. 1.344 0.818–2.208 are important to decide on the type Pneumoperitoneum Yes (n = 16) 6 (37) No (n = 43) 26 (60) n.s. 0.620 0.315–1.221 of treatment in abdominal stab AOE + acute abdomen Yes (n = 6) 3 (50) injuries. For 8 years, we have been No (n = 53) 29 (55) n.s. 1.208 0.223–2.543 using an algorithm in the manage- Pneumoperitoneum + Yes (n = 8) 6 (75) ment of abdominal stab injuries acute abdomen No (n = 52) 26 (50) n.s. 1.825 0.543–3.134 (Figure 1). In our clinic, all patients NCHF Yes (n = 15) 1 (7) No (n = 44) 31 (70) 0.001* 2.534 1.671–3.843 with abdominal stab wounds had undergone laparotomy in the first 5 *significant value (p < 0.05) years, however, the percentage of laparotomy decreased to 72% in the was found between patients with solid organ injuries, second 5 years and to 52% in the last 8 years. So in the with negative laparotomy, and patients treated conserv- last 8 years, almost half of the patients with abdominal atively. stab injuries were treated conservatively. The univariate statistical analysis is outlined in Many authors have reported an incidence of false- Table 2. Some prognostic factors such as abdominal stab normal initial abdominal assessments of 14–35% and a wounds, pneumoperitoneum, and patients with abdom- false “acute” abdomen of 15–28% [13]. In the prospec- inal organ evisceration or pneumoperitoneum develop- tive study of Demetriades & Rabinowitz, the false-nor- ing an acute abdomen were not significantly correlated mal initial examination rate amounted to 2.9% and the with intraabdominal organ injury, whereas some other false acute abdomen rate to 3.2% [5]. Our false acute risk factors such as acute abdomen on admission (p < abdomen rate was 23%. However, we accept acute 0.002) or abnormal clinical and hemodynamic findings abdomen as a predictor of the intraabdominal organ (p < 0.001) were significant in their relation to intraab- injury. Acute abdomen on admission was a significant dominal organ injury. The relative risk (odds ratio) of predictor in its relation to intraabdominal organ injury, developing an intraabdominal organ injury was > 2 for and the relative risk (odds ratio) of developing an patients with signs of an acute abdomen on admission. intraabdominal organ injury in patients with signs of Overall mean hospitalization time for all patients acute abdomen was > 2. amounted to 4.1 days, and was 5.6 days in group 1, 2 days It is generally accepted that evisceration of omen- in group 2, and 1.9 days in group 3. None of our patients tum or bowel is an absolute indication for an emergency died. operation [14, 15]. According to McFarlane [16], omental evisceration through an abdominal stab wound in a Discussion patient with stable clinical signs and without evidence of Laparotomy is not necessary in 5–40% of patients who peritonitis is not an absolute indication for exploratory suffer penetrating abdominal traumas [10, 11]. Manage- laparotomy. In our study, all patients with omental or ment strategies for abdominal stab wounds in initially bowel evisceration underwent laparotomy, and an asymptomatic patients range from mandatory explo- abdominal organ injury was found in 63% of them. Uni- rative laparotomy to conservative treatment [12]. In the variate statistical analysis showed that patients with past 30 years, some studies were planned to decrease the omental or bowel evisceration who underwent laparo- incidence of negative laparotomy and the complication tomy had a 1.34-fold higher risk of abdominal organ rate associated with this procedure and to define injury than patients without abdominal organ eviscera- absolute indications for laparotomy. For this reason, tion. This relation was almost statistically significant.

Abdominal stab wound six patients (10%), and all of them had penetrating liver or spleen injuries but without any signs of Stable Major internal hemorrhage acute abdominal injury. All patients Generalized peritonitis were treated conservatively, and no morbidity nor mortality occurred at Local wound Abdominal organ evisceration follow-up. Although we had a few exploration and/or Pneumoperitoneum stabogram patients with positive abdominal paracentesis for blood, we believe conservative treatment to be reason- Posterior fascia intact Suspected peritoneal able in the absence of acute abdomi- violation nal signs. Laparoscopy was recently used in the diagnosis and management of Peritoneal lavage, laparoscopy or patients with abdominal stab clinical follow-up wounds. Brefort et al [10] and Fer- nando et al [18] suggested neither Negativ Positiv mortality nor morbidity with the use of laparoscopy in the management

Observation of abdominal stab wounds and accepted laparoscopy as a reliable BenignBenign Peritoneal method allowing a very sensitive and courde signs course specific diagnosis of penetrating and visceral injuries. Our experience Discharge Laparotomy with laparoscopy is quite new. We Figure 1. Algorithm of abdominal stab wounds used in our clinic. recently performed diagnostic laparoscopy in five patients; two of them underwent laparotomy, and The radiologic presence of free air under the three were followed up conservatively. There was no diaphragm was considered an absolute indication for mortality nor morbidity in our patients. Due to the lim- surgery [4, 8, 17]. However, air may enter the peritoneal ited number of laparoscopically managed patients, we cavity from outside through the abdominal wall wound did no statistical analysis on this subject and avoided or from a right pneumothorax associated with perfora- giving any kind of experience. tion of the right hemidiaphragm. In this study, the inci- The mortality rate in patients with abdominal stab dence of solid organ injury was 38% of all patients with wounds was 1.6% and 6.3% in different series [19, 20]. free air on abdominal X-rays. We found no significant Lowe et al. also reported a mortality rate of 1.6% and a relation between the presence of pneumoperitoneum morbidity rate of 19% [19]. The morbidity rate was on admission and intraabdominal organ injury. 8.7% and 19% [19, 20]. In out study, it amounted to An abdominal paracentesis positive for blood was 8.9%, and all of these patients had laparotomy and sol- generally considered an indication for surgery [4, 8]. id organ injuries. None of our patients died. Demetriades & Rabinowitz speculated upon the neces- sity of abdominal exploration in the presence of positive Conclusions abdominal paracentesis for blood. In their opinion, this Conservative treatment may be safely performed in alone should not be an absolute indication for explo- selected children with abdominal stab injuries. Signs of ration. Of their 306 adult patients treated conservative- major internal hemorrhage or generalized peritonitis ly, twelve (4%) with positive abdominal paracentesis for are an absolute indication for emergency operation for blood were followed up. None of them required subse- abdominal stab wounds. However, peritoneal penetra- quent surgery, and no complications occurred [5]. In our tions, free air on the abdominal X-ray, and omental or study, abdominal paracentesis was positive for blood in intestinal evisceration are poor indicators of significant

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