Introduction: Screening of patients with anterior abdominal penetrating trauma in need for laparotomy is an important issue in management of these cases. This study aimed to compare the accuracy of abdominal wall ultrasonography (AWU) and local wound exploration (LWE) in this regard.Methods: This diagnostic accuracy study was conducted on ≥ 18 year-old patients presenting to emergency department with anterior abdominal stab wound and stable hemodynamics, to compare the characteristics of AWU and LWE in screening of patients in need of laparotomy.Results: 50 cases with the mean age of 28.44 ± 7.14 years were included (80% male). Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve of AWU were 70.58 (95% CI: 44.04 – 88.62), 93.33 (95% CI: 76.49 – 98.83), and 81.96 (95% CI: 69.91 – 94.01), respectively. These measures were 88.23 (62.25 – 97.93), 93.33 (76.49 – 98.83), and 90.78 (95% CI: 81.67 – 99.89) for LWE, respectively. The difference in overall accuracy of the two methods was not statistically significant (p = 0.0641).Conclusion: Based on the findings of the present study, AWU and LWE had the same specificity but different sensitivities in screening of anterior abdominal stab wound patients in need of laparotomy. The overall accuracy of LWE was slightly higher (91.48% versus 85.1%)

Heidari, Kamran

Saboorizadeh, Afshin

Shams Akhtari, Amin

Vafaei, Ali

English

PubMed

Introduction: Screening of patients with anterior abdominal penetrating trauma in need for laparotomy is an important issue in management of these cases. This study aimed to compare the accuracy of abdominal wall ultrasonography (AWU) and local wound exploration (LWE) in this regard.Methods: This diagnostic accuracy study was conducted on ≥ 18 year-old patients presenting to emergency department with anterior abdominal stab wound and stable hemodynamics, to compare the characteristics of AWU and LWE in screening of patients in need of laparotomy.Results: 50 cases with the mean age of 28.44 ± 7.14 years were included (80% male). Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve of AWU were 70.58 (95% CI: 44.04 – 88.62), 93.33 (95% CI: 76.49 – 98.83), and 81.96 (95% CI: 69.91 – 94.01), respectively. These measures were 88.23 (62.25 – 97.93), 93.33 (76.49 – 98.83), and 90.78 (95% CI: 81.67 – 99.89) for LWE, respectively. The difference in overall accuracy of the two methods was not statistically significant (p = 0.0641).Conclusion: Based on the findings of the present study, AWU and LWE had the same specificity but different sensitivities in screening of anterior abdominal stab wound patients in need of laparotomy. The overall accuracy of LWE was slightly higher (91.48% versus 85.1%).</p

Ali Vafaei

Kamran Heidari

Afshin Saboorizadeh

Amin Shams Akhtari

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Emergency. 2017; 5 (1): e34ORIGINAL RESEARCHDiagnostic Accuracy of Abdominal wall Ultrasonographyand Local Wound Exploration in Predicting the Need forLaparotomy following Stab WoundAli Vafaei1, Kamran Heidari1, Afshin Saboorizadeh1, Amin shams akhtari1∗1. Department of Emergency Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.Received: December 2016; Accepted: December 2016; Published online: 11 January 2017Abstract: Introduction: Screening of patients with anterior abdominal penetrating trauma in need for laparotomy is animportant issue in management of these cases. This study aimed to compare the accuracy of abdominal wallultrasonography (AWU) and local wound exploration (LWE) in this regard. Methods: This diagnostic accuracystudy was conducted on âL’ě 18 year-old patients presenting to emergency department with anterior abdominalstab wound and stable hemodynamics, to compare the characteristics of AWU and LWE in screening of patientsin need of laparotomy. Results: 50 cases with the mean age of 28.44 ± 7.14 years were included (80% male).Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve of AWU were 70.58 (95%CI: 44.04 – 88.62), 93.33 (95% CI: 76.49 – 98.83), and 81.96 (95% CI: 69.91 – 94.01), respectively. These measureswere 88.23 (62.25 – 97.93), 93.33 (76.49 – 98.83), and 90.78 (95% CI: 81.67 – 99.89) for LWE, respectively. Thedifference in overall accuracy of the two methods was not statistically significant (p = 0.0641). Conclusion:Based on the findings of the present study, AWU and LWE had the same specificity but different sensitivities inscreening of anterior abdominal stab wound patients in need of laparotomy. The overall accuracy of LWE wasslightly higher (91.48% versus 85.1%).Keywords: Abdominal injuries; wounds, penetrating; wounds, stab; ultrasonography; diagnostic techniques and proce-dures© Copyright (2017) Shahid Beheshti University of Medical SciencesCite this article as: Vafaei A, Heidari K, Saboorizadeh A, Shams akhtari A. Diagnostic Accuracy of Abdominal wall Ultrasonography and LocalWound Exploration in Predicting the Need for Laparotomy following Stab Wound. Emergency. 2017; 5(1): e34.1. IntroductionPenetrating abdominal trauma is known as one of therelatively frequent causes of emergency departmentvisits. There is a general agreement that patients withpenetrating abdominal trauma and hemodynamic instabil-ity must immediately be referred to operation room withoutadditional diagnostic measures (1). However, managementof hemodynamically stable patients is a controversial issue.At least 25% of anterior abdominal stab wounds are super-ficial and do not need laparotomy (2). Unnecessary laparo-tomy can increase the risk of morbidity and mortality of thesepatients (3). Sanei et al. showed that 82% of stab wound la-parotomies, which were done only based on anterior fascial∗Corresponding Author: Amin Shams Akhtari; Emergency Department,Loghman Hakim Hospital, Kamali Street, Karegar Avenue, Tehran, Iran. Tel:+989123788731 / Fax: +982155415539 / E-mail: amin.may1981@gmail.comimpairment, are negative (4). In recent years, most physi-cians have tried to change their diagnostic approaches frommandatory exploration to selective diagnostic approaches(5-7). Appropriate approach to these patients needs balancebetween invasiveness and accuracy of diagnostic measuresin this regard. Using ultrasonography, deep peritoneal lavage(DPL), serial clinical examination, local wound exploration(LWE), and abdominal computed tomography (CT) scan aresuggested by different studies to decrease the rate of unnec-essary laparotomies. LWE is a valid, yet invasive, screeningtool for selection of stab wound patients in need of laparo-tomy (2). However, abdominal wall ultrasonography (AWU)seems to be as a non-invasive, available, bedside, and safealternative for LWE in this regard (1, 3). Based on the above-mentioned point, this study aimed to assess the diagnosticaccuracy of AWU and LWE in detection of patients in need oflaparotomy following anterior abdominal stab wound.This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.comA. Vafaei et al. 22. Methods2.1. Study design and settingThis cross sectional study was conducted on patients pre-senting to emergency departments of Loghman Hakim,Imam Hossein, and Hafte-tir Hospitals, Tehran, Iran, follow-ing anterior abdominal stab wound, during March 2013 toMarch 2015, to compare the diagnostic accuracy of AWU andLWE in prediction of need for laparotomy. The study protocolwas approved by ethics committee of Shahid Beheshti Uni-versity of Medical Sciences and informed consent form wassigned by all participants. Authors adhered to all Helsinkirecommendations and confidentiality of patients’ informa-tion during the study period.2.2. ParticipantsPatients older than 18 years old with anterior abdominal stabwound were included. Hemodynamic instability, presentingperitoneal signs, protrusion of abdominal organs, gastroin-testinal bleeding, pregnancy, instrument in situ, presence ofabdominal free fluid on focused abdominal ultrasonographyfor trauma patients (FAST), peritoneal evisceration, multi-ple wounds, and need for emergent laparotomy were amongthe exclusion criteria. Anterior abdominal wall was definedas the area superior to the inguinal ligaments, medial to theanterior axillary line, and two fingerbreadths inferior to thecostal margins.2.3. Data gatheringA predesign check list, consisting of demographic informa-tion (age, sex), trauma mechanism, vital signs (blood pres-sure, heart rate, respiratory rate, and oxygen saturation),findings of AWU and LWE regarding need for laparotomy, aswell as final outcome (decision of in charge surgeons regard-ing performing laparotomy), was used for data gathering.Without interfering in the routine approach, eligible patientsunderwent AWU by a trained senior emergency medicineresident (under supervision of an emergency medicine spe-cialist) at the time of admission to emergency department.The emergency medicine resident was trained and certi-fied by an expert radiologist, performing tract ultrasonogra-phy on ten sheep cadaver models under his direct supervi-sion. After doing AWU, all patients underwent LWE by se-nior surgery residents and were followed until discharge fromhospital. Patients that underwent laparotomy based on fi-nal decision of in charge surgeon, considering all clinicaland imaging findings (serial clinical examination, abdominalCT scan, serial FAST, and etc.) during the period of hospi-tal admission were considered as reference group. SamsungHM70A ultrasonography machine with 8 MHZ linear probewas used for ultrasonography of the abdominal wall and its10 × 10 cm surrounding area (figure 1).Figure 1: Abdominal wall ultrasonography view.2.4. Statistical AnalysisConsidering 25% prevalence of penetrating abdominaltrauma in need for laparotomy (2), d = 0.05, and 95% confi-dence interval (CI), the minimum required sample size wascalculated to be 35 cases. Data were analyzed using SPSSversion 21 and STATA 11. Qualitative and quantitative vari-ables were presented with frequency and percentage, andmean ± standard deviation, respectively. For evaluating thescreening performance characteristics of AWU and LWE inprediction of need for laparotomy sensitivity, specificity, pos-This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.com3 Emergency. 2017; 5 (1): e34Table 1: Baseline characteristics of studied patients (n = 50)Variable Number (%)Age (year)18 -24.9 12 (24)25- 34.9 23 (46)≥ 35 15 (30)SexMale 40 (80)Female 10 (20)Marital statusMarried 18 (38.3)Single 29 (61.7)Trauma mechanismKnife 41 (82)Other 9 (18)EmploymentEmployed 36 (72)Non-employed 14 (28)Vital SignSystolic blood pressure (mmHg) 117.10 ± 10.79Diastolic blood pressure (mmHg) 71.30 ± 9.36Heart rate (/minute) 87.62 ± 6.97Respiratory rate (/minute) 19.20 ± 1.84Oxygen saturation (%) 96.52 ± 1.50Data are presented as mean ± standard deviation orfrequency and percentage.Figure 2: Area under the receiver operating characteristic (ROC)curve of abdominal wall ultrasonography and local wound explo-ration in prediction of need for laparotomy following anterior ab-dominal stab wound (p = 0.0641).itive predictive value (PPV), negative predictive value (NPV),positive likelihood ratio (PLR), and negative likelihood ratio(NLR) with 95% CI were calculated. The area under the re-ceiver operating characteristic (ROC) curve of the two testswas compared. Need for laparotomy based on final decisionof in charge surgeon was considered as the reference test. P-values less than 0.05 were assumed significant results.3. Results3.1. Baseline characteristics50 cases with the mean age of 28.44± 7.14 years (18 – 47) wereincluded (80% male). Table 1 shows the baseline character-istics of studied patients. 46% of cases were in 25 – 35 yearsage group, 61.7% single, 72% employee, and 82% with knife. 3(6%) cases were discharged against medical advice and wereomitted from final analysis.3.2. Screening characteristicsBased on AWU and LWE 14 (28%) and 17 (34%) cases weredetected as peritoneal penetration and needed laparotomy.According to the final decision of surgery service based on allclinical and imaging findings, 17 (34%) cases underwent la-parotomy during the hospitalization period. Table 2 and fig-ure 2 summarize the screening performance characteristicsof AWU and LWE in prediction of need for laparotomy follow-ing anterior abdominal stab wound. The area under the ROCcurve of AWU and LWE were 81.96 (95% CI: 69.91 – 94.01) and90.78 (95% CI: 81.67 – 99.89), respectively (p = 0.0641).4. DiscussionBased on the findings of the present study, AWU and LWEhave the same specificity (93.3%) but different sensitivities(70.58% versus 88.23%) in screening of anterior abdominalstab wound patients in need of laparotomy. The overall ac-curacy of LWE in this regard is slightly higher (91.48% ver-sus 85.1%) without statistical significance. Rapid assessmentand decision making plays a main role in improving the out-come of severely injured trauma patients (8-11). Althoughusing LWE could be helpful in eliminating hospitalizationof more than 30% of patients with anterior abdominal stabwound (2), it is invasive, uncomfortable for the patient, anddifficult in obese and uncooperative patients as well as thosewith thick abdominal musculature. Finding noninvasive al-ternatives for LWE is an interesting area in management ofthese patients in emergency and surgery departments. Ultra-sonography is known as an available diagnostic measure forfocused assessment of blunt and penetrating trauma patientsin emergency department (12-17). Omari et al. showed thatultrasonography is a good guide for selecting patients in needfor laparotomy following penetrating abdominal trauma (1).Murphy et al. reported that tract ultrasonography in patientswith anterior abdominal penetrating trauma had 59% sen-sitivity and 100% specificity (18). Soffer et al. reported thatsonography had 48% sensitivity and 98% specificity in di-agnosis of intra-abdominal lesions and Fray et al. reported100% positive and negative predictive value of ultrasonogra-phy in this regard (19, 20). Ku et al. presented a 76 year-oldstab wound case with negative abdominal CT scan findings,This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.comA. Vafaei et al. 4Table 2: Screening performance characteristics of abdominal wall ultrasonography (AWU) and local wound exploration (LWE) in predictionof need for laparotomy following anterior abdominal stab wound (n = 47)Characteristics AWU LWETrue positive 12 (25.5) 15 (31.9)True negative 28 (59.6) 28 (59.6)False positive 2 (4.2) 2 (4.2)False negative 5 (10.6) 2 (4.2)Sensitivity 70.58 (44.04 – 88.62) 88.23 (62.25 – 97.93)Specificity 93.33 (76.49 – 98.83) 93.33 (76.49 – 98.83)Positive predictive value 85.71 (56.15 – 97.48) 88.23 (62.25 – 97.93)Negative predictive value 84.84 (67.33 – 94.28) 93.33 (76.49 – 98.83)Positive likelihood ratio 6.00 (1.63 – 22.03) 7.50 (2.01 – 27.88)Negative likelihood ratio 0.17 (0.07 –0.40) 0.07 (0.01 – 0.27)Data are presented with 95% confidence interval.which underwent laparoscopy based on positive tract ultra-sonography finding regarding peritoneal impairment (21). Inour study, need for laparotomy was confirmed in 85.7% of pa-tients with positive AWU and 88.2 % of positive LWE results.There were 5 (10.6%) cases with false negative ultrasonogra-phy reports and 2 (4.2%) cases with false negative explorationreports. Although the difference in total accuracy of the twomodels is not statistically significant, accuracy of explorationis in excellent range and ultrasonography in good range.As we know, ultrasonography is very operator dependent andthis slight inferiority of ultrasonography could be eliminatedby more practice. It seems that tract ultrasonography as abedside, noninvasive, non-expensive, available, and safe di-agnostic approach could be considered for screening of pen-etrating abdominal trauma patients in need of laparotomy.5. LimitationAmong the limitations of the present study is not evaluat-ing the cases with multiple penetrating traumas and thosewith trauma of other parts of the abdominal area. In addi-tion, in most cases trauma was caused by knife, which affectsthe diversity of trauma type and might limit the generaliz-ability of the results for cases such as wounds caused by bul-lets. Patient selection for laparotomy was done by surgeonswho were aware of the results of LWE, which might have ledto some type of selection bias.6. ConclusionBased on the findings of the present study, AWU and LWEhave the same specificity (93.3%) but different sensitivities(70.58% versus 88.23%) in screening of anterior abdominalstab wound patients in need of laparotomy. The overall accu-racy of LWE is slightly higher (91.48% versus 85.1%) withoutstatistical significance.7. Appendix7.1. AcknowledgementsThe authors would like to thank all the staff of LoghmanHakim, hafte tir, and Imam Hossein Hospitals and ClinicalResearch Development Center of Loghman Hakim Hospital,for their cooperation.7.2. Author contributionAll authors passed four criteria for authorship contributionbased on recommendations of the International Committeeof Medical Journal Editors.7.3. Funding/SupportNone.7.4. Conflict of interestNone.References1. Omari A, Bani-Yaseen M, Khammash M, Qasaimeh G,Eqab F, Jaddou H. Patterns of anterior abdominal stabwounds and their management at Princess Basma teach-ing hospital, North of Jordan. World journal of surgery.2013;37(5):1162-8.2. Cothren CC, Moore EE, Warren FA, Kashuk JL, Biffl WL,Johnson JL. Local wound exploration remains a valu-able triage tool for the evaluation of anterior abdom-inal stab wounds. The American Journal of Surgery.2009;198(2):223-6.3. Ku C-Y, Chang C-J, Huang C-Y, Sun J-T, Lin H-F, Lin M-S, et al. A novel role of ultrasonography in identificationof the tract of abdominal stab injury. Critical UltrasoundJournal. 2014;6(1):1.4. Sanei B, Mahmoudieh M, Talebzadeh H, Shahabi Shah-miri S, Aghaei Z. Do Patients with Penetrating Abdomi-This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.com5 Emergency. 2017; 5 (1): e34nal Stab Wounds Require Laparotomy? Arch Trauma Res.2013;2(1):21-5.5. Tsikitis V, Biffl WL, Majercik S, Harrington DT, CioffiWG. Selective clinical management of anterior ab-dominal stab wounds. American journal of surgery.2004;188(6):807-12.6. Shaftan G. Indications for operations in abdominaltrauma. American journal of surgery. 1960;99:657-64.7. Demetriades D, Rabinowitz B. Indications for operationin abdominal stab wounds. A prospective study of 651patients. Annals of surgery. 1987;205(2):129-32.8. Walcher F, Kortum S, Kirschning T, Weihgold N, MarziI. [Optimized management of polytraumatized pa-tients by prehospital ultrasound]. Der Unfallchirurg.2002;105(11):986-94.9. 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Archives of surgery.1995;130(6):605-7; discussion 8.20. Soffer D, McKenney MG, Cohn S, Garcia-Roca R, NamiasN, Schulman C, et al. A prospective evaluation of ultra-sonography for the diagnosis of penetrating torso injury.The Journal of trauma. 2004;56(5):953-7; discussion 7-9.21. Ku C-Y, Chang C-J, Huang C-Y, Sun J-T, Lin H-F, Lin M-S. A novel role of ultrasonography in identification of thetract of abdominal stab injury. Critical Ultrasound Jour-nal. 2014;6:30.This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0).Downloaded from: www.jemerg.com

Diagnostic Accuracy of Abdominal wall Ultrasonography and Local Wound Exploration in Predicting the Need for Laparotomy following Stab Wound

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Diagnostic Accuracy of Abdominal wall Ultrasonography and Local Wound Exploration in Predicting the Need for Laparotomy following Stab Wound

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