INCIDENCE

Gastric injuries usually result from penetrating trauma and occur in approximately 20% of gunshot wounds and 10% of stab wounds.^1–3 Blunt gastric trauma is much less common. The American Association for the Surgery of Trauma (East) multi-institutional study on hollow viscus injury reported that the prevalence of blunt gastric rupture was 0.06% in patients undergoing evaluation for blunt abdominal trauma and 2.1% of all patients found to have hollow viscus injury.⁴

MECHANISM OF INJURY

The stomach is at risk for injury after stab wounds to the left thoracoabdominal region of the body. A single perforation occurs in over 50% of these cases.² However, injury to adjacent organs is common. Gunshot wounds result in two or more gastric wounds in 90% of cases.² Although often associated with some surrounding tissue damage to the stomach, this is usually only significant with high-velocity missiles. Shotgun wounds at close range (<15 feet) are often associated with massive destruction of the abdominal wall, stomach, and other intra-abdominal organs.

Blunt injury to the stomach is most often the result of motor vehicle crashes, or motor vehicle–pedestrian trauma.^5–7 Less common causes include falls, assaults, and improperly performed cardiopulmonary resuscitation. Blunt gastric injuries include linear lacerations and complete gastric rupture. The postulated mechanisms for blunt gastric injury include sudden increases in intraluminal pressure resulting in a balloon-bursting type of phenomenon of a full stomach, compression against the spine (seat-belt injury), or a deceleration injury with shearing forces resulting in a laceration of the anterior stomach wall.

DIAGNOSIS

Gastric perforations caused by blunt forces are often large, and intraperitoneal contamination is usually significant. Peritoneal signs are usually obvious, leading to early surgical intervention. Patients with blunt gastric rupture are frequently in shock related to other significant injuries including spleen and/or liver wounds.

Patients with stab wounds and hypotension, peritonitis, or both should undergo laparotomy immediately. Asymptomatic patients without central nervous system injury (brain or spinal cord injury) or drug or alcohol involvement may be observed with repeated physical exams. In other patients, local wound exploration, diagnostic peritoneal lavage (DPL), or laparoscopy are alternatives. Laparoscopy is most helpful with thoracoabdominal stab wounds in identifying associated injuries to the diaphragm.⁸ Focused assessment with sonography for trauma (FAST) may not identify the small amount of fluid initially associated with hollow viscus injury, and thus may be misleading with isolated gastric injuries.

Early operation is indicated for symptomatic gunshot wounds to the abdomen. Occasionally, a tangential gunshot wound in a stable patient may be observed, or such a wound may be found after the patient undergoes either DPL or laparoscopy. Abdominal CT is also helpful in this situation. In patients suspected to have either blunt or penetrating gastric injury, the placement of a nasogastric tube is helpful. Not only does proper placement of a nasogastric tube minimize the risk of aspiration, but a bloody aspirate when present is highly suspicious for a gastric injury. In patients with blunt gastric injury and no obvious peritoneal signs, a supine film of the abdomen discloses free air in less than 50% of cases. In this situation, abdominal CT is more sensitive in identifying free air.

SURGICAL MANAGEMENT

The abdomen is explored through a midline incision. Visualization of the stomach is facilitated by nasogastric tube decompression. Control of hemorrhage is the first priority, followed by control of enteric spill. Gastric wounds may be rapidly initially controlled by a running locking full-thickness closure with absorbable sutures. A seromuscular layer of nonabsorbable sutures is placed later in the operation. This not only affords hemostasis, but also controls further peritoneal contamination by gastric contents. Alternatively a TA-stapler or Allis or Babcock clamp may be used for temporary control.

After attention to the more life-threatening injuries, the stomach wound may be addressed. The stomach should first be carefully inspected for ecchymosis or hematomas along either the lesser or greater curvature. Certain areas of the stomach are particularly difficult to assess: the gastroesophageal junction, high in the gastric fundus, the lesser curvature, and the posterior wall. Perixiphoid extension of the midline incision, the use of a self-retaining retractor, and positioning of the hemodynamically stable patient in the reverse Trendelenburg position may aid in exposure of these problematic areas. The gastroesophageal junction area may also be better exposed by division of the left triangular ligament and mobilization of the lateral segment of the left lobe. The posterior wall of the stomach is exposed by opening the gastrocolic ligament just outside the gastroepiploic arcade along the greater curvature of the stomach. Division of the short gastric vessels may be necessary to adequately expose the proximal gastric fundus. Occasionally, air insufflated into the stomach via the nasogastric tube with the stomach submerged in saline may help identify an occult injury to the stomach. Tangential wounds and/or single perforations of the stomach do occur, but this is a diagnosis of exclusion.

Gastric injuries thus identified are treated according to their severity (Table 1, Figure 1). Most intramural hematomas (grades I and II) are treated by careful evacuation, hemostasis, and closure with seromuscular sutures made of nonabsorbable material. Small grade I and II perforations can be closed in one or two layers. Because of the vascularity of the stomach, I prefer a two-layer closure after hemostasis is achieved.

Table 1 AAST Organ Injury Scale for Stomach

Figure 1 Algorithm for treatment of gastric injury.