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Use of CT Tractography in anterior abdominal stab wounds

Three Part Question

In [patients with anterior abdominal stab wounds] does [CT tractography] reliably detect [intra-abdominal injury / peritoneal perforation].

Clinical Scenario

A 35-year-old male presents to the Emergency Department with a penetrating anterior abdominal stab wound. He is haemodynamically stable and you are unsure what the best method of investigation is for him.

Search Strategy

NICE Healthcare Databases (1985-2016) including: AMED, PubMED, BNI, EMBASE, HBE, HMIC, Medline, PsycINFO, CINAHL
(anterior abdominal stab tractography).ti,ab
(anterior abdominal stab).ti,ab
(abdominal stab investigations).ti,ab

Search Outcome

82 papers found. Abstracts were reviewed for relevance of which 16 were duplicates and 64 were irrelevant. 2 papers were relevant and of sufficient quality and are included in this BET. Relevant papers are shown in the table below.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Ertan et al.
2015
United States
20 haemodynamically stable patients with AASW. Patients with single and multiple stab wounds included. Case series / Prospective observational study Sensitivity Identified necessity of laparotomy accurately in 90%Limited number of patients. No direct comparison with other methods e.g. CT alone
NPV/Specificity0% of patients without peritoneal penetration required surgery
Uzunosmanoğlu et al.
2017
Germany
73 patients with AASW. Managed with combined contrast abdominal enchanced CT scans and CT tractography, later undergoing laparotomy. Comparison with CT alone. Retrospective studySensitivity of detecting peritoneal penetration100%Unknown exclusion criteria. Patient stability unknown. Unclear how many in each group or if compared to separate CT group.
Specificity of detecting peritoneal penetration100%
PPV 100%
NPV100%
Accuracy100%

Comment(s)

Only one prospective observational study was found, with no randomised controlled trials comparing CT tractography to other methods of investigation (e.g. CT scanning, SCA or laparoscopy). However, the above studies suggest CT tractography is highly sensitive in identifying the need for laparotomy and is useful alternative to local wound exploration in haemodynamically stable patients. Nonetheless randomised controlled trials as well as a thorough patient selection protocol are required to recommend this as a routine diagnostic procedure.

Editor Comment

retained for Trauma

Clinical Bottom Line

Although evidence is limited, it appears CT tractography (in conjunction with clinical judgement) can be used to safely and accurately assess the need for laparotomy in haemodynamically stable patients.

References

  1. Ertan T, Sevim Y, Sarigoz T, Topuz O, Tastan B. Benefits of CT tractography in evaluation of anterior abdominal stab wounds The American Journal of Emergency Medicine 2015 Sep 1;33(9):1188-90.
  2. Uzunosmanoğlu H, Çorbacıoğlu ŞK, Çevik Y, Akıncı E, Hacıfazlıoğlu Ç, Yavuz A, Yüzbaşıoğlu Y. What is the diagnostic value of computed tomography tractography in patients with abdominal stab wounds?. European Journal of Trauma and Emergency Surgery 2017 Apr 1;43(2):273-7.