الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
This study was conducted to compare between operative and conservative management of PAT as a trial to avoid non therapeutic laparotomies. Also by focusing on the art of making decision to minimize as much as possible both negative and delayed explorations.
The aim of our study was to assess the feasibility and safety of SNOM in PAT and to identify a protocol for selection of patients suitable for SNOM.
This comparative study was conducted at ED of Alexandria Main University Hospital. 40 patients with penetrating abdominal trauma were selected during six month period (from the 1st of April 2014 till the 30th of September 2014) of which 20 patients were explored and another 20 patients were treated conservatively according to specific selection criteria.
Of the 40 patients 39 were males (97.5 %) and 1 was female (2.5%). The age range from 15 to 70 years with mean age of 28.8. Thirty six patients presented by SWs (90%), 4 patients presented by GSWs (10%).
All the patients were initially assessed regarding vital signs, abdominal examination and then divided into 2 groups where 20 patients were explored and 20 were suitable for expectant (conservative) management.
Ten patients (25%) were considered vitally unstable at initial assessment. The remaining patients (30) were vitally stable at admission.
Those vitally unstable ten patients were resuscitated by receiving intravenous fluid replacement (one liter of crystalloid) after that they were divided into two groups:
Responders (including rapid and transient responders): 8 patients (80% of vitally unstable patients) who then continued the investigations and follow up.
Non-responders: 2 patients (20% of vitally unstable patients) who were rushed to operation room without any further delay where one patient had a grade V splenic injury and splenectomy was done, the other patient had jejunal tear with bleeding mesentery and presented by evisceration of small bowel loop.
During conservation 2 patients out of 20 (in the conservative group) became vitally unstable (within 12-24 hours) and underwent laparotomy where small bowel injury was detected in both.
All the patients that were operated on basis of vital instability either immediately (2 patients = non responders to resuscitation) after admission or during follow up (2 patients = who were stable at admission but became unstable during follow up) had therapeutic explorations, so exploration was mandatory with 100% sensitivity and specificity.
All patients had abdominal examination on admission, where 28 patients were considered clinically free on admission and 12 showed positive abdominal examination.
The 12 patients who had positive abdominal examination on admission were explored with ten therapeutic and two non therapeutic explorations.
On the other hand, 2 patients of the conservative group developed signs of peritonitis during conservation within 12-24 hours of admission and were explored and bowel injury was detected in both.
FAST was done for 38 patients (while the remaining two were rushed to the operating theatre). Collectively, six patients showed no evidence of free IP fluid collection, 32 patients showed evidence of free IP fluid collection.
CT scan was done in 33 patients and showed the following findings: Six patients had no evidence of IP collection five of them were conserved successfully and one was conserved initially but on follow up CT it showed mild IP collection and conservation was terminated, while 27 patients had some degree of IP collection (minimal, mild, or moderate) 13 of them were explored with five negative results and eight positive, the remaining 14 were conserved where 13 were completed successfully and one failure of conservation. Pneumnoperitoneum in six patients all in the operative group (and all were combined with IP fluid collection) on exploration five of which showed hollow viscus injury, and one negative exploration. Solid organ injury was detected in six patients. Two patients were explored and had therapeutic laparotomy. In the other four patients conservative management was completed successfully without any complications. Only one patient had a negative CT result who was planned for conservation but required exploration with a delay of 13 hours and was found to have bowel injury.
In our study 2 patients presented with evisceration of abdominal content. Both required laparotomy with small bowel injury identified and managed.
Four patients presented with gunshot wounds and all were explored. Three explorations were therapeutic. One exploration was negative and two pellets were found IP without any solid organ nor visceral injury.
The hospital stay in the operated group ranged between 4.0 – 30.0 days with a mean of 8.05 ± 6.81 days, while in the conservative group the hospital stay ranged between 2.0 – 6.0 days with a mean of 3.35 ± 0.99 days.