8 Original article Penetrating abdominal injuries in children: a study of 33 cases Samuel Wabada, Auwal M. Abubakar, John Y. Chinda, Sani Adamu and Kefas J. Bwala Background Trauma is gradually becoming a major cause arrow injuries. Fourteen (42.4%) patients had abdominal of disability and it can be of any form, physical or organ evisceration; of them, nine were as a result of emotional. For the surgeon the physical form is of major gunshot injuries. Routine exploratory laparotomy was interest, especially its causes and incidence, which can be carried out in all 33 patients. Seven (21.2%) were operated influenced by environmental or social factors. on with simultaneous resuscitation in the immediate laparotomy group, and 26 (78.8%) underwent delayed Aim The aim of this work was to study the incidence, laparotomy. There was a negative laparotomy in four etiology, principles of management and outcome of (12.1%) patients, two of whom had only omental children with penetrating abdominal injuries. evisceration with no other accompanying visceral injuries, Materials and methods This was a 2-year prospective and two without evisceration. Three (9.1%) patients died study of 33 children aged 0–15 years with penetrating after developing enterocutaneous fistula, compartment abdominal injuries at the University of Maiduguri Teaching syndrome and sepsis. Hospital in northeast Nigeria. Information obtained Conclusion There were more cases of penetrating included the following: the patient’s biodata, mechanism of abdominal injuries among boys and children from the rural injury, time of presentation to the Accident and Emergency areas than in those from urban areas. Ann Pediatr Surg Department after the injury, haemodynamic status at 14:8–12 c 2018 Annals of Pediatric Surgery. presentation, presence or absence of abdominal organ evisceration, presence or absence of associated injuries, Annals of Pediatric Surgery 2018, 14:8–12 the timing of surgery, intraoperative findings, the type of Keywords: evisceration, exploratory laparotomy, penetrating abdominal surgical procedure and outcome. injury Results Thirty-three (31.4%) children [of whom 24 (i.e. Department of Surgery, Paediatric Surgery Unit, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria 72.7%) were from the rural areas] of 105 children with trauma-related injuries had penetrating abdominal injuries. Correspondence to Samuel Wabada, MBBS, FWACS, Department of Surgery, Paediatric Surgery Unit, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria The male : female ratio was 3 : 1, and the mean age ± SD E-mail: [email protected] was 2.30 ± 0.81 years. There were 15 (45.4%) children with Received 8 July 2016 accepted 11 April 2017 gunshot wounds, 11 (33.3%) with bomb blast wounds, three (9.1%) with impalement injuries and two (6.1%) with Introduction static [12]. Although in developing countries there is no In children, unintentional injury due to either road traffic unified data on the incidence of firearm-related injuries, accidents, sports and occupational and recreational it has been reported as one of the leading cause of activities are a frequent cause of abdominal trauma, and morbidity and mortality after malnutrition and commu- often result in blunt abdominal injury [1,2]. Never- nicable diseases in sub-Saharan Africa [13]; thus, it has theless, penetrating abdominal injury due to stab wound, gradually joined the rank of conditions that threaten the firearms, or impalement injuries can still occur, but often well-being of the child. As such, trauma has become the as isolated cases [3,4]. Blunt abdominal trauma may be disease of the 21st century and it is gradually taking its the common type of abdominal trauma in children [5–7], place as the leading threat to the health of children in but in times of civil or communal conflicts and insurgency Africa. There is, therefore, the need to consider this this pattern can change as firearms and other forms of threat in health budgeting and planning among the ranks missile injuries such as improvised explosive devices of others such as malnutrition and communicable diseases (IED) may be rampant, to the extent that penetrating in Africa [14]. This study aimed at determining the abdominal injury become common [8]. This could incidence, etiology, principles of management and out- account for the relative increase in the incidence of come of penetrating abdominal injuries in children. penetrating abdominal injuries recently seen in both developed and developing countries [9,10], because of Materials and methods the recent rise in communal conflicts and insurgent A prospective observational study was carried out on 33 attacks. This has obviously translated into increased children aged between 0 and 15 years with penetrating burden of firearm-related morbidity and mortality not abdominal injuries at the University of Maiduguri only in developing countries alone but across the Teaching Hospital in northeast Nigeria, from June 2013 globe [11]. In 2009, firearms accounted for 89% of to June 2015. Children with penetrating abdominal hospital admissions in the USA among children less than injuries, which had not breached the peritoneum, were 15 years of age and this figure has not remained excluded from the study. After obtaining ethical approval 1687-4137 c 2018 Annals of Pediatric Surgery DOI: 10.1097/01.XPS.0000516205.41923.be Copyright r 2018 Annals of Pediatric Surgery. Unauthorized reproduction of this article is prohibited. Penetrating abdominal injuries in children Wabada et al.9 from the hospital ethics and research committee. Data followed by IED in 11 (33.3%) children. Other causes of collected from patients included either rural or urban penetrating abdominal injuries are shown in Table 2. dwellers, cause of the penetrating abdominal injury There were 14 (42.4%) children with evisceration of (gunshot, bomb blast/IED, arrow shot, stab wounds, abdominal organs and 19 (57.6%) without evisceration. impalement injuries), and the presence or absence of visceral evisceration. For those with evisceration the type The eviscerated organs were the omentum with jejunum of the eviscerated organ and the assault device were in four, jejunum alone in two, ileum in two, stomach with ascertained. The time that the patient’s presented to the omentum in two, the omentum only in three and the the Accident and Emergency Department was noted as stomach alone in one child. Gunshot injuries were a follows: less than 6 h; 6–12 h, and more than 12 h after common cause of evisceration (64.3%), followed by IED injury. Those patients who presented less than 6 h are (28.6%) (Table 2). As regards duration of presentation to classified as the immediate presentation group, whereas the Accident and Emergency Department, most of the those who presented between 6 and 12 h and those who patients (19, 57.6%) presented less than 6 h of injury, presented more than 12 h of injury are the delayed and eight (24.2%) and six (18.2%) children presented late presentation groups, respectively. In terms of their between 6 and 12 h and more than 12 h, respectively, haemodynamic status at presentation, patients who had after the injuries had occurred. A child with evisceration tachypnoea, pulse rate above 90 beats/min, pallor, dehy- due to IED injuries presented after 6 days. Of those who dration and abdominal distension with peritonitis were presented less than 6 h of injury, nine (47.4%) had considered haemodynamically unstable; patients without abdominal organ evisceration. Among the eight (24.2%) dehydration and pallor, with respiratory rate less than patients who presented between 6 and 12 h of injury, 20 cycles/min, pulse rate less than 90 beats/min, absent three (37.5%) were with eviscerations. Two children abdominal distension, and also without peritonitis were (33.3%) out of the six (18.2%) patients who were considered haemodynamically stable. Patients who admitted more than 12 h and beyond had eviscerated were operated less than 6 h of presentation constituted abdominal organs. those who had immediate reaction time (immediate Concerning haemodynamic status, 21 (63.6%) haemodyna- laparotomy); those who were operated after stabilization mically unstable patients were admitted; 12 (57.1%) of of hemodynamic status in more than 6 h of presentation them were with evisceration. Plane abdominal radiography had delayed reaction time (delayed laparotomy). The performed on 12 (36.4%) haemodynamically stable patients intraoperative findings determined the type of surgery showed pneumoperitoneum in 10 of them; a radioopaque performed; however, the surgical procedure was categor- shadow, extending covering about one-third of the abdo- ized into one-stage, two-stage, or three-stage procedures men was observed in the other two on an oblique view. based on intraoperative findings. If a definitive procedure was performed at the first laparotomy it is attributed as Associated injuries in eight (24.2%) children included the one-stage procedure. Two-stage procedures are attributed following: grade IV scrotal injury, two severe head injuries, to damage control or any form of enterostomy only at the closed fracture of the mid-shaft of the left radial bone, initial laparotomy (i.e. a second surgery will be required mangled left upper limb, open fracture of the right radial to return the , a patient that will have anastomosis/closure and ulnar bones, closed segmental fracture of the right of a rectal perforation with a protective proximal diverting femur, and open fracture of the tarsus of the left foot. stoma at the initial laparotomy, and subsequent revision These associated injuries were all in children with missile of the stoma later is qualified as three-stage procedure. injuries. The outcome of the procedures was recorded. Patients were resuscitated according to the advanced Results trauma live support protocol. Seven (21.2%) patients underwent exploratory laparotomy in less than 6 h of There were 33 (31.4%) children with penetrating presentation (immediate laparotomy); of them, three abdominal injuries of the 105 children with trauma- patients underwent two-stage surgeries and four under- related injuries admitted during the study period.