Nagy K K, Krosner S M, Joseph K T, Roberts R R, Smith R F, Barrett J
Department of Trauma, Cook County Hospital, Chicago, Illinois, USA.
J Trauma. 1997 Aug;43(2):242-5; discussion 245-6. doi: 10.1097/00005373-199708000-00006.
It has previously been shown that 98% of gunshot wounds that penetrate the peritoneal cavity cause injuries that require surgical repair. Many gunshot wounds in the vicinity of the abdomen (GSWA) may actually be tangential and not penetrate the peritoneal cavity at all. Patients with such wounds may not require laparotomy. It is important to determine which patients with a potential tangential GSWA actually have penetration of the peritoneal cavity to minimize negative laparotomies. This study was undertaken to determine the sensitivity, specificity, and accuracy of diagnostic peritoneal lavage (DPL) in the determination of peritoneal penetration for patients who sustain GSWA.
DPL was performed for all patients who had sustained a GSWA in whom peritoneal penetration was unclear, i.e., patients whose GSWA appeared to be tangential, thoracoabdominal, or transpelvic and for whom a clear indication for laparotomy (shock, peritonitis, etc.) did not exist. Our threshold for a positive DPL was 10,000 red blood cells (RBC)/mm3. A prospective data base was kept with information on the location of the wound, DPL result, findings at laparotomy, and outcome.
During a 4-year period, 429 consecutive DPLs were performed for GSWA at our urban Level I trauma center. One hundred fifty DPLs were positive, with more than 10,000 RBC/mm3. Six of these patients were found to have no peritoneal penetration at laparotomy (false-positive). The remaining 144 patients with positive DPLs were found to have operative injuries (true-positive). Of the 279 patients with DPL counts less than 10,000 RBC/mm3, 2 developed indications for laparotomy and were found to have intraperitoneal injuries (false-negative). The remaining 277 patients had no peritoneal injuries (true-negative). This was demonstrated either by laparotomy done for another indication (n = 7) or by uneventful inpatient observation for 24 hours (n = 270). The sensitivity, specificity, and accuracy of DPL in determining peritoneal penetration in GSWA is therefore 99, 98, and 98%, respectively.
For patients who sustain GSWA for whom peritoneal penetration is unclear, DPL is a sensitive, specific, and accurate test to determine the need for laparotomy. It remains our test of choice when confronted with these patients.
此前研究表明，98%穿透腹膜腔的枪伤会造成需要手术修复的损伤。许多腹部附近的枪伤（GSWA）实际上可能是切线伤，根本未穿透腹膜腔。这类伤口的患者可能不需要剖腹手术。确定哪些潜在切线伤的GSWA患者实际穿透了腹膜腔，对于减少不必要的剖腹手术至关重要。本研究旨在确定诊断性腹腔灌洗（DPL）在判定GSWA患者腹膜是否穿透时的敏感性、特异性和准确性。
对所有腹膜穿透情况不明的GSWA患者进行DPL，即那些GSWA看似为切线伤、胸腹联合伤或经盆腔伤且无明确剖腹手术指征（休克、腹膜炎等）的患者。我们将DPL阳性阈值设定为每立方毫米10000个红细胞（RBC）。建立了一个前瞻性数据库，记录伤口位置、DPL结果、剖腹手术发现及预后等信息。
在4年期间，我们一级城市创伤中心对GSWA患者连续进行了429次DPL。150次DPL呈阳性，红细胞计数超过每立方毫米10000个。其中6例患者剖腹手术时发现未穿透腹膜腔（假阳性）。其余144例DPL阳性患者发现有手术损伤（真阳性）。在279例DPL计数低于每立方毫米10000个红细胞的患者中，2例出现剖腹手术指征，发现有腹腔内损伤（假阴性）。其余277例患者无腹膜损伤（真阴性）。这通过因其他指征进行的剖腹手术（n = 7）或24小时住院观察无异常（n = 270）得以证实。因此，DPL在判定GSWA患者腹膜穿透时的敏感性、特异性和准确性分别为99%、98%和98%。
对于腹膜穿透情况不明的GSWA患者，DPL是一种敏感、特异且准确的检测方法，可用于判定是否需要剖腹手术。面对这类患者时，它仍是我们的首选检测方法。
