Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, NY.
Department of Emergency Medicine, Kings County Hospital Center, Brooklyn, NY.
Acad Emerg Med. 2018 Jul;25(7):744-757. doi: 10.1111/acem.13380. Epub 2018 Apr 2.
Workup for patients presenting to the emergency department (ED) following an anterior abdominal stab wound (AASW) has been debated since the 1960s. Experts agree that patients with peritonitis, evisceration, or hemodynamic instability should undergo immediate laparotomy (LAP); however, workup of stable, asymptomatic or nonperitoneal patients is not clearly defined.
The objective was to evaluate the accuracy of computed tomography of abdomen and pelvis (CTAP) for diagnosis of intraabdominal injuries requiring therapeutic laparotomy (THER-LAP) in ED patients with AASW. Is a negative CT scan without a period of observation sufficient to safely discharge a hemodynamically stable, asymptomatic AASW patient?
We searched PubMed, Embase, and Scopus from their inception until May 2017 for studies on ED patients with AASW. We defined the reference standard test as LAP for patients who were managed surgically and inpatient observation in those who were managed nonoperatively. In those who underwent LAP, THER-LAP was considered as disease positive. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) to evaluate the risk of bias and assess the applicability of the included studies. We attempted to compute the pooled sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) using a random-effects model with MetaDiSc software and calculate testing and treatment thresholds for CT scan applying the Pauker and Kassirer model.
Seven studies were included encompassing 575 patients. The weighted prevalence of THER-LAP was 34.3% (95% confidence interval [CI] = 30.5%-38.2%). Studies had variable quality and the inclusion criteria were not uniform. The operating characteristics of CT scan were as follows: sensitivity = 50% to 100%, specificity = 39% to 97%, LR+ = 1.0 to 15.7, and LR- = 0.07 to 1.0. The high heterogeneity (I > 75%) of the operating characteristics of CT scan prevented pooling of the data and therefore the testing and treatment thresholds could not be estimated.
The articles revealed a high prevalence (8.7%, 95% CI = 6.1%-12.2%) of injuries requiring THER-LAP in patients with a negative CT scan and almost half (47%, 95% CI = 30%-64%) of those injuries involved the small bowel.
In stable AASW patients, a negative CT scan alone without an observation period is inadequate to exclude significant intraabdominal injuries.
自 20 世纪 60 年代以来，对于接受腹部前侧刺伤（AASW）的急诊科（ED）患者的检查一直存在争议。专家一致认为，对于腹膜炎、内脏脱出或血流动力学不稳定的患者，应立即进行剖腹手术（LAP）；然而，对于稳定、无症状或非腹膜患者的检查尚不清楚。
本研究旨在评估腹部和骨盆计算机断层扫描（CTAP）在诊断 ED 中接受 AASW 的患者需要治疗性剖腹手术（THER-LAP）的腹部内损伤的准确性。阴性 CT 扫描且不进行观察是否足以安全地排出血流动力学稳定、无症状的 AASW 患者？
我们检索了从成立开始到 2017 年 5 月的 PubMed、Embase 和 Scopus 数据库，以获取有关接受 AASW 的 ED 患者的研究。我们将参考标准测试定义为对接受手术治疗的患者进行剖腹手术，对接受非手术治疗的患者进行住院观察。在接受 LAP 的患者中，将需要 THER-LAP 的患者视为疾病阳性。我们使用诊断准确性研究的质量评估工具（QUADAS-2）来评估偏倚风险并评估纳入研究的适用性。我们使用 MetaDiSc 软件尝试使用随机效应模型计算合并的敏感性、特异性、阳性似然比（LR+）和阴性似然比（LR-），并应用 Pauker 和 Kassirer 模型计算 CT 扫描的检测和治疗阈值。
纳入了 7 项研究，共 575 名患者。THER-LAP 的加权患病率为 34.3%（95%置信区间 [CI] = 30.5%-38.2%）。研究的质量存在差异，纳入标准不统一。CT 扫描的操作特征如下：敏感性为 50%至 100%，特异性为 39%至 97%，LR+为 1.0 至 15.7，LR-为 0.07 至 1.0。CT 扫描的操作特征存在高度异质性（I>75%），无法对数据进行汇总，因此无法估计检测和治疗阈值。
文章显示，阴性 CT 扫描的患者中需要 THER-LAP 的损伤发生率很高（8.7%，95%CI=6.1%-12.2%），而这些损伤中近一半（47%，95%CI=30%-64%）涉及小肠。
对于稳定的 AASW 患者，阴性 CT 扫描单独且不进行观察期不能排除明显的腹腔内损伤。
