Is non-operative approach applicable for penetrating injuries of the left thoraco-abdominal region?

Osman Kones; Cevher Akarsu; Halil Dogan; Yildiz Okuturlar; Ahmet Cem Dural; Mehmet Karabulut; Eyup Gemici; Halil Alis

doi:10.1016/j.tjem.2016.02.005

Osman Kones¹, Cevher Akarsu¹, Halil Dogan², Yildiz Okuturlar³, Ahmet Cem Dural¹, Mehmet Karabulut¹, Eyup Gemici¹, Halil Alis¹

¹Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
²Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
³Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Internal Medicine, Istanbul, Turkey

Keywords: Wounds penetrating; Physical examination; Diagnostic imaging; Treatment outcome

Abstract

Objectives: Currently, diagnostic laparoscopy (DL) is recommended for the left thoraco-abdominal region penetrating injuries (LTARP). However, organ and diaphragmatic injury may not be detected in all of these patients. Our aim is to focus on this LTARP patient group without any operative findings and to highlight the evaluation of diagnostic tools in the high-tech era for a possible selected conservative treatment.

Material and methods: The patients who were admitted to ED due to LTARP, and who underwent routine DL were evaluated retrospectively in terms of demographic, clinical, radiological, and operative findings of the patients.

Results: The current study included 79 patients with LTARP. In 44 of 79 patients, abdominal injury was not detected. In 30 patients an isolated diaphragmatic injury was revealed and in 4 patients a visceral injury was accompanying to diaphragmatic injury. Surgical findings revealed that the diaphragm was the organ most likely to sustain injury. In patients with more than one positive diagnostic findings need for surgery rate was 61.5%, however; in patients with one positive diagnostic finding (n = 53), positive surgical finding rate was only 35.8%, (p = 0.03). Regarding the combined use of all diagnostic tools in these patients; such as physical examination, plain chest X-ray, and computed tomography, when this method was used for pre-operative diagnosis, sensitivity was measured as 82.7%, specificity 84.1%, PPV 77.4% and NPV 88.1%.

Conclusion: Although DL is reliable for diagnosis of diaphragmatic and visceral injury in patients with LTARP. However, individual decision making for laparoscopic intervention is needed to prevent morbidity of an unnecessary operation under emergent setting due to high rates of negative intraabdominal findings.