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Factors related to the occurrence of postoperative complications following penetrating gastric injuries

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Factors related to the occurrence of postoperative complications following penetrating gastric injuries
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  Injury Vol. 26. No. 7, pp.463-466, 1995 Copyright 0 19% Elsevier Science Ltd Printed in Great Britain, All rights reserved 002&1383/95 lO.OO+O.OO 0020-1383 95)00070-4 Factors related to the occurrence of postoperative complications following penetrating gastric injuries R. Coimbra, M. C. C. Pinto, J. R. Aguiar and S. Rasslan Emergency Service, Department of Surgery, Santa Casa School of Medicine, S5o Paulo, Brazil The aim of fhis sfudy was to determine fhe relationship between diaphragmafic injury andgross contamination of the peritoneal cauify caused by gastric injuries and the occurrence of postoperative complications, especially those related to the pleural cavity. Charts of 73 pafients sustuininggustric injuries due to penetrating trauma were refrospecfively eviewed. There were 66 males and mean age was 28 years. Sfab wounds were fhe most requent mechanism of injury, occurring in 46 cases. Most of the injuries were treated using simple suture and minor debridement. ostoperative orbidity ate was 30 per cent nd fhoracic omplications ccurred in f I patients. Twenfy-six patients ad diaphragmatic njuries; 54 per cent of them developed postoperative complicufions. Of the remaining 47 patients without diaphragmatic injuries, only eighf developed complications. Of the 26 pafienfs with diaphrugmatic injuries, seven developed pleuropul- monay complications compared with 4 of 47 without diaphragmatic injury. Of sixteen patients who had gross contamination secondary fo gastric injury, characterized by the presence of food or great amounfs of gasfric contents in the perifoneal cavity, 10 developed postoperafive complications compared wifh 12 of 57 without gross confaminafion. Overall mortality rafe was 11 per cent mostly due to sepsis. In conclusion, fhe presence of a diaphragmatic injury as well as gross contamination of the abdominal cavify are imporfanf factors related to the development f postoperative infections particularly in the pleural space. Injury, Vol. 26. No. 7. 463-466, 1995 Introduction Gastric injuries usually result from penetrating traumar,‘. Less than 1 per cent of such wounds are due to blunt trauma secondary to motor accidents, falls, cardiopul- monary resuscitation or interpersonal violence3-7. Morbidity and mortality rates after penetrating abdom- inal injuries associated with gastric wounds have been reported at about 27 per cent and 14 per cent respectively, due in most cases o the associated njuries, although the risk of morbidity from gastric injury itself is nearly 6 per cent’,‘. It has been reported that patients with thoracoabdom- inal wounds develop higher rates of pleuropulmonary complications than those with thoracic and abdominal injuries, without a diaphragmatic wound. This has also been observed when the stomach was the only injured organ in the abdomen, suggesting the importance of gastric contents in the genesis of postoperative com- plications’-r4. The aim of this study was to evaluate the influence of the diaphragmatic injury and the gross contamination of the peritoneal cavity caused by gastric injuries in the development of postoperative complications, especially those related to the pleural cavity. Methods The study method was a retrospective chart review of all patients sustaining penetrating trauma referred to the Emergency Service, Dept of Surgery, Santa Casa School of Medicine in SZo Paulo, Brazil, from February 1990 to January 1993. Inclusion criteria included patients with gastric injuries who survived for more than 48 hours after the initial operation. From 77 patients with gastric injuries, 73 fulfilled the inclusion criteria. Four patients died before 48 hours due to haemorrhagic shock and were excluded from the analysis. Data including age, sex, cause of injury, haemodynamic status on admission, site of external injury, operative findings, anatomic site of the injury in the stomach, gastric injury classification, Penetrating Abdominal Trauma Index (PATI)“, Penetrating Thoracic Trauma Index (PTTI) and Penetrating Trauma Index (PTI)i6, pleural or peritoneal gross contamination with gastric contents, complications and deaths were tabulated and analyzed using dBase II + and Primer statistical software packages. Injuries in the thoracoabdominal transition were defined as those with an entrance wound below the fourth intercostal space (ICS) anteriorly, sixth ICS laterally, and the eighth ICS posteriorly. A diaphragmatic wound char- acterized a thoracoabdominal injury. Gross contamination was defined as extravasation of food or large amounts of gastric contents through the gastric wound. Although evaluation of contamination is subjective and can induce misinterpretations, contamination was considered for fur- ther analysis when found in the operative report of the patients’ charts under the surgeon’s discretion. Two hypotheses were considered. First, patients with gastric injuries due to thorocoabdominal penetrating trauma develop a higher number of pleuropulmonary complications than those without a diaphragmatic injury.  464 Injury: International Journal of the Care of the Injured Vol. 26, No. 7, 1995 Second, gross contamination of the peritoneal cavity due to extravasation of large amounts of gastric contents results n a higher number of postoperative complications. Both hypotheses were evaluated using a ~2 contingency table. A P value < 0.05 was considered significant. Results The demographic profile was similar to that of other penetrating trauma series. Sixty-six patients (90.4 per cent) were male, and the mean age was 28 years (range 17-49 years). Stab wounds were the most frequent aetiological factor, occurring in 46 cases Table 1). The average time from the scene o the admission at the emergency department was approximately 1 hour. Fifty- nine (80.8 per cent) patients were considered haemody- namically stable on admission based on systolic blood pressure (SBP) > 80 mmHg (Table II). In all patients, at least one venous line was obtained for volume replacement with crystalloid, a Foley catheter and a nasogastric tube were positioned and broad spectrum antibiotics were initiated in the preoperative period. Forty-two patients had their external wounds in the thoracoabdominal transition 5 7.5 per cent) (Table II). Patients were submitted to a Iaparotomy through a midline incision in all cases but one, in whom a thoraco- laparotomy was performed due to massive bleeding through the chest tube. Associated injuries occurred in 61 patients, and the liver was the most frequently injured organ in association with gastric injuries, followed by the diaphragm and the colon (Table V). There were 123 gastric injuries, and most of them were located at the corpus (Table V). Isolated gastric injuries occurred in 16 patients. Classification of gastric injury is outlined in Table VI. Simple suture of the gastric wound was performed in 68 patients..Due to the severity of the gastric injury, a gastrectomy was necessary in two patients, and the remaining three patients had only Table I. Demographic ata Sex Male Female Aetiology Gunshot Stab N 66 90.4 7 9.6 27 37 46 63 Table II. Haemodynamic tatus on admission N Stable (SBP>80mmHg) 59 Unstable (SBP>80mmHg) 14 SBP = systolic blood pressure 56 80.8 19.2 Table III. Site of parietal njury Location N % Thoracoabdominal transition 42 57.5 Abdominal 27 37.0 Lumbar 4 5.5 superficial njuries to the serosa and no surgical procedure was necessary. Intraoperative approach in patients with diaphragmatic injuries and gross contamination of the peritoneal cavity consisted of irrigation of the chest through the diaphragmatic defect and placement of a chest tube. Of the I4 patients with haemodynamic nstability on admission, only seven required blood transfusion. The average volume transfused was 2.4 units of packed red blood cells per patient (range l-10 units). Morbidity rate was 30 per cent and thoracic complica- tions occurred in I1 patients (Table VII). Of the 42 patients with an external wound in the thoracoabdominal function, Table IV. Associated njuries Organ N Liver 54 Diaphragm 26 Colon 16 Small bowel 13 Spleen 9 Biliary tree 1 Duodenum 9 Kidney 9 Pancreas 7 Vascular 4 Gallbladder 3 Table V. Anatomic location of the gastric njury Location N Corpus 84 Antrum 33 Fundus 6 Total 123 Table VI. Gastric njury cIassification’5 Grade 1 2 3 ‘4 5 Total Description Single wall Through-and-through Minor debridement Wedge resection > 35% resection N % 3 4.1 28 38.4 40 54.8 2 2.7 73 100.0 Table VII. Complications N Thoracic Pneumonia Empyema Total Abdominal Wound infection Intra-abdominal abscess Pancreatic fistula Gastric fistula Colonic fistula Total 5 6 11 5 3 3 1 1 13  Coimbra et al.: Factors related to postoperative gastric injuries 465 PTl>25 (N=6) Diaphragmatic injury + - Complication + (N=26) (N=14) lf’T,<25 (N=8) PTI>25 (N=6) Diaphragmatic injury - - Complication + (N=47) (N=8) PTI < 25 (N= 2) (P= 0.003) Figure 1. Diaphragmatic njury vs complications. Table VIII. Gross contamination vs complications Contamination Contamination P= 0.004. Complications + Complications - N 03 N f%) 10 (62.5) (21.0) 465 (37.5) 12 (79.0) 26 had diaphragmatic injuries (thoracoabdominal injuries) and 54 per cent of them developed postoperative compli- cations, with PATI values above 25 in six patients. Of the remaining 47 patients without diaphragmatic injuries, only eight developed complications (P= 0.003) (Figure I). .Of the 26 patients with diaphragmatic injuries, seven developed pleuropulmonary complications compared with four of 47 without diaphragmatic injury (P= 0.046). Of 16 patients who had gross contamination secondary to gastric injury, characterized by the presence of food or great amounts of gastric contents in the peritoneal cavity, 10 developed postoperative complications compared with 12 of 57 without gross contamination (P=O.O04) (Table VIII). Overall mortality was 1 per cent, particularly due to infection and sepsis. Discussion Diaphragmatic injury takes place n a significant number of abdominal and thoracoabdominal wounds. The concomit- ance of gastric and diaphragmatic injuries at about 30 per cent is expected considering the close anatomic relation between these organs. The development of pleuropul- monary complications, especially of infectious srcin, in patients with such injuries was reported by many authors as the principal cause of late deathsZ*11-14. urham et al.’ analyzed 81 patients with thoracoabdominal injuries and found an incidence of empyema close to 12.5 per cent when the stomach was the only injured organ. Many trauma ndices have been used n order to identify which group of patients have increased chances of devel- oping complications or have a lower probability of survival. In this series, 12 patients who developed post- operative complications had a PTI above 25. The mechanism of injury is also important in the occurrence of complications. In our series, he incidence of associated injuries was three times higher in gunshot wounds (GSW) compared with victims of stab wounds (SW). Higher PTIs were noted in victims of GSW as well. GSW were responsible or 60 per cent of all complications. It was our objective to evaluate the morbidity rate in patients with concomitant gastric and diaphragmatic in- juries, as well as to assess he significance of gross contamination due to gastric injuries n the development of postoperative complications. We found that the incidence of postoperative complications was significantly higher when the diaphragm was also njured. Seven of 11 patients who developed pleuropulmonary complications had con- comitant injuries to the diaphragm. It was also apparent that six of 14 patients who developed postoperative complications and presented diaphragmatic injuries had a PTI over 25, compared with six of eight without diaphrag- matic injuries. This suggests that in the absence of diaphragmatic injury, complications are related to the severity of the anatomic injuries. Conversely, in the presence of diaphragmatic injury, severity of abdominal associated injuries might not be the main cause of complications. The higher incidence of empyema after penetrating thoracoabdominal injuries has been described by others. Villalba et al.” reported that the presence of a diaphragma- tic injury is the major risk factor for the development of empyemas after trauma. Coselli et al.” reported the incidence of empyema of 1.3 per cent in patients with traumatic haemothorax treated with tube thoracostomy. Over half of them had thoracoabdominal injuries. The liver and stomach were the most frequently injured organs in the abdomen in both cited series. Durham et al? also emphasized hat empyema occurs hree to four times more frequently in patients with gastric and diaphragmatic injuries than those with isolated thoracic trauma. Lavage of the pleural space can be performed through a separated thoracic incision, through the chest tube or through the diaphragmatic wound*1,12,17. Our preference was the lavage and aspiration of the pleural cavity through the diaphragmatic defect and placement of a chest tube. Due to the small number of patients however, we were not able critically to evaluate this issue. All empyemas were treated with tube thoracostomy and antibiotics. No thor- acotomies and decortications were necessary n this series. Although difficult to define because of personal inter- pretation, gross contamination has been cited as an important cause of late complications following gastric injuries. As stated before, we found that 62.5 per cent of the patients with gross contamination developed late complications. The role of the extravasation of gastric contents in the genesis of postoperative complications is closely related to the dynamics of the gastric flora. Usually many micro- organisms srcinating from the naso and oropharynx reach the stomach through the saliva and nasal mucus. Changes  466 Injury: International Journal of the Care of the Injured Vol. 26, No. 7,199s in gastric pH are frequent after eating, drinking and saliva ingestion, which act in an attempt to neutralize gastric acidity. When gastric pH is below 4, gastric juice has bactericidal properties and acts to inhibit bacterial enzy- matic activity. In this situation, microorganisms such as Streptococcus salivarum, Streptococcus uiridans, Lactobacillus, Bacterioides, Veillonella, Micrococcus, Staphylococcus and Neisseria are found in very low concentrations, usually below lOOO/ml. Inversely, when the gastric pH is neutral- ized, bacterial properties of the gastric juice are extremely suppressed, which leads to prompt bacterial growth. Concentrations can reach as high as lO”/ml and remain there for approximately I hour before returning to normal levels. If the neutralization occurs or prolonged periods ot time, bacteria from the lower digestive tract such as Bacteroides fragilis, Escherichia coli, Streptococcus faecalis and enterobacterias can be found inside the stomach. This fact is especially important in trauma patients who frequently have great amounts of food and liquid inside the stomach’8-21. In conclusion, we found that the presence of a diaphrag- matic injury as well as the gross contamination of the abdominal cavity in a series of patients with gastric wounds are important ‘factors related to the development of postoperative complications. Acknowledgments The authors wish to acknowledge Mr Richard Davis for his assistance n reviewing the manuscript. References Nance FC and Cobin I. Surgical udgement n the manage- ment of stab wounds o the abdomen: A retrospective and prospective analysis based on a study of 600 stabbed patients. nn Surg 1969; 170: 569. Durham R, Olson S and Weigelt JA. Penetrating njuries to the stomach. urg Gynecol bstef 1991; 172: 298. Asch MJ, Coran AG and Johnson PW. Gastric perforation secondary o blunt trauma n children. Trauma 1975; 15: 187. Yajko RD, Seydel F and Trimble C. Rupture of the stomach from blunt abdominal rauma. Trauma 975; 15: 177. Siemens RA and Fulton RL. Gastric rupture as a result of blunt trauma. m Surg 1977; 43: 229. 6 Cox EF. Blunt abdominal rauma: five-year analysis f 870 patients equiring celiotomy. Ann surg 1984; 199: 467. 7 Brunsting LA and Morton JH. Gastric rupture from blunt abdominal rauma. Trauma 1987; 27: 887. 8 Nichols RL, Smith JW and Klein DB. Risk of infection after penetrating abdominal rauma. N Engl ] Med 1984; 311: 1065. 9 Kish G, Kosloff L, Joseph WL et al. Indications or early thoracotomy n the management f chest rauma. nn Thorac . rg1976;22: 23. 10 Oparah SS and Mandal AK. Penetrating unshot wounds of the chest n civilian practice: Experience with 250 consecu- tive cases. r J Surg 1978; 65: 45. 11 Villalba M, Lucas CE, Ledgerwood AM et al. The etiology of post-traumatic empyema and the role of decortication. Trauma 1979; 19: 414. 12 Coseli JS, Mattox KL, Beall AC et al. Reevaluation f early evacuation of clotted hemothorax. Am ] Surg 1984; 148: 786. 13 Adkins RR, Whiteneck JM and Woltering EA. Penetrating chest wall and thoracic njuries. m Surg 1985; 51: 140. 14 Mattox KL, Moore EE and Feliciano DV (eds) Trauma. East Norwalk, Connecticut: Appleton & Lange, 988, p. 422. 15 Moore EE, Dunn EL, Moore JB et al. Penetrating abdominal trauma index. 1 Trauma 1981; 21: 439. 16 Ivatury RR, Nallathambi MN, Stahl WM et al. Penetrating cardiac trauma: Quantifying the severity of anatomic and physiologic njury. Ann Surg 1987; 205: 61. 17 Graham M, Mattox KL and Beall AC. Penetrating rauma of the ung. ] Trauma 1979; 19: 665. 18 Drasar BS, Shiner M and McLeod GM. Studies on the intestinal lora. Gasfroenferology 1969; 56: 71. 19 Gorbach SL. ntestinal microflora. Gastroenferology 1971; 60: 1110. 20 Stone HH, Kolb LB and Geheber CE. Incidence nd signifi- cance of intraperitoneal anaerobic acteria. nn Surg 1975; 181: 705. 21 McNulty CAM and Wise R. Gastric microflora. Br Med f 1985; 291:367. Paper accepted 19 April 19 . Reqtrests or reprints hould be addressed to: Dr Raul Coimbra MD, 7025 Charmant Drive apt 250, San Diego, California 92122, USA.
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