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Selective Nonoperative Management of Penetrating Torso Injury From Combat Fragmentation Wounds

Beekley, Alec C. MD; Blackbourne, Lorne H. MD; Sebesta, James A. MD; McMullin, Neil MD; Mullenix, Philip S. MD; Holcomb, John B. MCMembers of the 31st Combat Support Hospital Research Group

The Journal of Trauma: Injury, Infection, and Critical Care: February 2008 - Volume 64 - Issue 2 - p S108-S117
doi: 10.1097/TA.0b013e31816093d0
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Background: Historically, military surgical doctrine has mandated exploratory laparotomy for all penetrating fragmentation wounds. We hypothesized that stable patients with abdominal fragmentation injuries whose computerized tomography (CT) scans for intraperitoneal or retroperitoneal penetration disclosed nothing abnormal, can be safely observed without therapeutic laparotomy.

Methods: We retrospectively studied all hemodynamically stable patients with penetrating fragmentation wounds to the back, flank, lower chest, abdomen, and pelvis evaluated by abdominal physical examination (PE), CT, or ultrasound treated during a 6-month period at one combat support hospital. Sensitivity, specificity, and positive and negative predictive values were calculated comparing each positive test to laparotomy and each negative test to successful nonoperative management.

Results: One hundred forty-five patients met study criteria. Based on CT scans, 85 (59%) patients were managed nonoperatively; 60 (41%) underwent laparotomy. Forty-five of 60 (75%) of laparotomies were therapeutic. CT scan for intraperitoneal or retroperitoneal penetration that disclosed nothing abnormal was 99% predictive of successful nonoperative management. In detecting intra-abdominal injury requiring laparotomy, sensitivity for each method was 30.2% (PE), 11.7% (ultrasound), and 97.8% (CT) (p < 0.05). Specificity was 94.8% (PE), 100% (ultrasound), and 84.8% (CT). The areas under the receiver operating characteristic (ROC) curves were 0.565 (PE), 0.543 (ultrasound), and 0.929 (CT) (p < 0.0001). All patients with a positive ultrasound (n = 4) underwent therapeutic laparotomy.

Conclusion: PE alone was unreliable in stable patients with abdominal fragmentation injuries. The clinical value of ultrasound results was limited, likely because the majority of these stable patients did not have injuries associated with the large accumulation of peritoneal fluid. CT scan safely and effectively analyzed nonoperative management of penetrating abdominal fragmentation injuries and should be the diagnostic study of choice in all stable patients without peritonitis with abdominal, flank, back, or pelvic combat fragmentation wounds.

From the Department of General Surgery (A.C.B., J.A.S.), Madigan Army Medical Center, Tacoma, Washington; the Department of Trauma/Critical Care/Burns (L.H.B.), the Institute of Surgical Research (L.H.B., J.B.H.), the Department of General Surgery (N.M.), Brooke Army Medical Center, San Antonio, Texas; and the Walter Reed Army Medical Center (P.S.M.), Washington DC.

Submitted for publication October 30, 2007.

Accepted for publication October 30, 2007.

The opinions and assertions contained in this article are solely the authors' private ones and are not to be construed as official or reflecting the views of the United States Army or the Department of Defense. This manuscript was prepared by United States Government employees and therefore cannot be copyrighted and may be copied without restriction.

This paper was accepted for poster presentation at the American Association for the Surgery of Trauma (AAST) meeting, Atlanta, Georgia, September 2005, and was the 2006 Army State Winner (Clinical) and Region XIII (Military) Winner (Clinical), American College of Surgeons Committee on Trauma Resident Trauma Paper Competition.

Address for reprints: Alec C. Beekley, MD, FACS, Department of General Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Road, Fort Lewis, WA 98431-1100; email: alec.beekley@us.army.mil.

© 2008 Lippincott Williams & Wilkins, Inc.