Background: Patients with penetrating thoracoabdominal trauma (PTAT) by gunshot wounds (GSW) or by stab wounds (SW) pose the challenge of deciding which cavity to operate first. Initiating surgery in the cavity with less severe injuries may delay the management of a fatal hemorrhage or cardiac tamponade.
Aim and objective: The objective of this work was the analysis of:
• Characteristics of patients with PTAT with a sequence of combined surgical interventions.
• Characteristics of the error due to inappropriate sequence of said operative procedures.
• Relationship of these previous factors with mortality.
Design: Observational retrospective.
Materials and methods: Review of the medical records of the patients assisted in our institution between January 2005 and December 2018, with PTAT that required operative procedures both in the chest (pleural drainage or thoracotomy) and in the abdomen (laparotomy or laparoscopy).
Results: Seventy-nine patients with PTAT, 48 with normal hemodynamics (group I) and 31 with hypovolemic shock (group II) were assisted. In group I, SW (40) predominated over GSW (8), and lesions on the left side (42) (87.5%). In this group, there were no errors in sequential surgical management and no mortality was recorded. In group II, transfixing GSW of the midline predominated. In eight cases, an error was recorded when first approaching the cavity with less serious injuries (in four cases the thorax and in four cases the abdomen), seven of them died and determining mortality of 25.8% for group II. The analysis of the error in these eight cases found that in five it was potentially preventable and that it was related to erroneous results of the ultrasound and/or underestimation of the output of the pleural drainage and of the post-pleural drainage chest radiograph.
Conclusion: Patients with PTAT and hemodynamically compensated presented a predominance of left-sided SW and had no errors in the sequential management of cavities or mortality. On the other hand, in those with PTAT and shock, GSW and transfixing paths of the midline predominated, and this group was the one that had exclusively the handling errors and mortality. Most of the errors in management were considered potentially preventable since they were related to false results of the ultrasound and underestimation of the output of the pleural drainage and of the post-pleural drainage chest radiograph.
Clarke DL, Gall TMH, Thomson SR. Double jeopardy revisited: clinical decision making in unstable patients with, thoraco-abdominal stab woundsand, potential injuries in multiple body cavities. Injury 2011;42(5):478–481. DOI: 10.1016/j.injury.2010.06.027.
Asensio JA, Arroyo H, Veloz W, et al. Penetrating thoracoabdominal injuries: ongoing dilemma-which cavity and when? World J Surg 2002;26(5):539–543. DOI: 10.1007/s00268-001-0147-8.
Menegozzo CAM, Damous SHB, Alves PHF, et al. “Pop in a scope”: attempt to decrease the rate of unnecessary nontherapeutic laparotomies in hemodynamically stable patients with thoracoabdominal penetrating injuries. Surg Endosc 2020;34(1):261–267. DOI: 10.1007/s00464-019-06761-7.
Koto ZM, Mosai F, Matsevych OY. The use of laparoscopy in managing penetrating thoracoabdominal injuries in Africa: 83 cases reviewed. World J Emerg Surg 2017;12(1):27. DOI: 10.1186/s13017-017-0137-2.
Uhlich R, Kerby JD, Bosarge P, et al. Diagnosis of diaphragm injuries using modern 256-slice CT scanners: too early to abandon operative exploration. Trauma Surg Acute Care Open 2018;3(1):e000251. DOI: 10.1136/tsaco-2018-000251.
Mjoli M, Oosthuizen G, Clarke D, et al. Laparoscopy in the diagnosis and repair of diaphragmatic injuries in left-sided penetrating thoracoabdominal trauma: laparoscopy in trauma. Surg Endosc 2015;29(3):747–752. DOI: 10.1007/s00464-014-3710-8.
Yücel M, Özpek A, Tolan HK, et al. Importance of diagnostic laparoscopy in the assessment of the diaphragm after left thoracoabdominal stab wound: a prospective cohort study. Ulus Travma Acil Cerrahi Derg 2017;23(2):107–111. DOI: 10.5505/tjtes.2016.91043.
Furák J, Athanassiadi K. Diaphragm and transdiaphragmatic injuries. J Thorac Dis 2019;11(Suppl 2):S152–S157. DOI: 10.21037/jtd.2018.10.76.
Gao J, Du D, Li H, et al. Traumatic diaphragmatic rupture with combined thoracoabdominal injuries: difference between penetrating and blunt injuries. Chin J Traumatol 2015;18(1):21–26. DOI: 10.1016/j.cjtee.2014.07.001.
Gomez AC. Lesiones de diafragma. en de Torax Trauma. Vision Integral Para su Diagnostico y Tratamiento. Bogota: Editorial Medica Internacional; 2016. pp. 415–426.
Biffl WL, Cioffi WG. Diafragma. en Feliciano D, Mattox K, Moore E. ., Trauma. 9na ed., Mc Graw Hill; 2021.
Mattox KL, Hirshberg A. Top Knife Allen MK, ed. 2005. pp. 149–151.
Hirshberg A, Wall MJ, Allen MK, et al. Double jeopardy: thoracoabdominal injuries requiring surgical intervention in both chest and abdomen. J Trauma 1995;39(2):225–231. DOI: 10.1097/00005373-199508000-00007.
Juan A, Traumatismo toracoabdominal. En: Trauma Prioridades. Cap 11-1.SAMCT. 2002. Ed Panamericana.
Matsushima K, Khor D, Berona K, et al. Double jeopardy in penetrating trauma: get FAST, get it right. World J Surg 2018;42(1):99–106. DOI: 10.1007/s00268-017-4162-9.
Quinn AC, Gibbons RC. What is the utility of the focused assessment with sonography in trauma (FAST) exam in penetrating torso trauma? Injury 2011;42(5):482–487. DOI: 10.1016/j.injury.2010.07.249.
Netherton S, Milenkovic V, Taylor M, et al. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM 2019;21(6):727–738. DOI: 10.1017/cem.2019.381.
Adolfo G, Alberto G, Sizenando VS. Trauma abdominal penetrante. en Trauma: Sociedad Panamericana de Trauma Ferrada R, Rodriguez A, ed. 2da ed., Distribuna LTDA; 2009. pp. 338–347.
Wayne J. Meredith: traumatismo torácico: cuando y como intervenir. Surg Clin N Am 2007;87(1):95–118. DOI: 10.1016/j.suc.2006.09.014.
Carrillo E. Penetrating chest trauma. in: Initial management of injuries Sing R, Reilly P, ed. BMJ Books; 2001. pp. 87–95.