Prospective Evaluation of the Selective Nonoperative Management of Abdominal Stab Wounds: When is it Safe to Discharge?

J Trauma Acute Care Surg. 2022 Jul 5. doi: 10.1097/TA.0000000000003733. Online ahead of print.

Abstract

Background: The optimal observation time required to exclude hollow viscus injury in patients undergoing selective nonoperative management (SNOM) for abdominal stab wounds (SW) remains unclear. The aim of this study was to determine the safe period of observation required prior to discharge.

Methods: In this prospective observational study, all patients who sustained an abdominal SW were screened for study inclusion (07/2018-05/2021). The primary study outcome was time to SNOM failure, defined as the need for surgical intervention after an initial period of observation.

Results: During the study period, 256 consecutive patients with an abdominal SW met study criteria. Mean age 33[26-46], 89% male. 77% with single SW, 154(60%) had an anterior abdominal SW (most common site RUQ, 31%). 46(18%) underwent immediate laparotomy due to evisceration (59%), hemodynamic instability (33%), or peritonitis (24%). The remaining 210(82%) patients were taken for computed tomography (CT) scan (n = 208, 99%) or underwent clinical observation only (n = 2, <1%). Of the patients undergoing CT scan, 27(13%) triggered operative intervention and 9(4%) triggered angioembolization. The remaining 174(83%) patients underwent SNOM. Of these, 3(2%) failed SNOM and underwent laparotomy: two developed peritonitis at 10 and 20 hours after arrival, respectively, and at laparotomy had small bowel and gastric injuries. The third patient developed increasing leukocytosis but had nontherapeutic laparotomy.

Conclusions: Selective nonoperative management of stab wounds to the abdomen commonly avoids nontherapeutic operative intervention and its resultant complications. A small percentage of patients will fail SNOM and therefore close clinical observation of these patients in hospital is critical. All patients in this series who failed SNOM did so within 24 hours of presentation. Therefore, we recommend a period of 24 hours of close clinical monitoring to exclude a hollow viscus injury prior to discharge of patients with abdominal stab wounds who do not meet criteria for immediate operative intervention.

Level of evidence: Prognostic and epidemiologic study, level III.