ABDOMINAL TRAUMA: FIVE YEARS EXPERIENCE IN NATIONAL CENTRE HOSPITAL, MAURITANIA

Trauma care including abdominal trauma is a big challenge. It is associated with high morbidity and mortality and continues to be a public health problem worldwide. The main aims of our study were to assess the patterns and outcomes of our patients, and to describe our experience in management of abdominal trauma. This descriptive retrospective study was conducted in general surgery department at National Centre Hospital of Nouakchott in Mauritania. We recruited patients presented at our department with abdominal trauma (2012-2016). Out of 100 cases, 92% were men. Mean age: 22.78 years (5 - 70 years). Eighty percent of patients suffered of penetrating abdominal trauma. Stab injuries were the most frequent mechanism (60%). The commonest organ injury was small intestine (16%). Mortality has been strongly related to road traffic accidents. Cares of severe abdominal traumas are not common in our hospital, due to lack of required overall data. Emergency health system is needed to better care of trauma patients in Mauritania.


Introduction
Trauma continues to be a major public health problem worldwide.Abdominal trauma (AT) is usually associated with high morbidity and mortality [1].It may be blunt or penetrating and may involve damage to the abdominal organs.
Management of AT should be approached in an organized manner, require a challenge public health among all countries, regardless of the socioeconomic status [2].Missed or delayed diagnoses remain the most serious pitfalls in the management of abdominal injuries [3].Most deaths resulting from abdominal the violation of the abdominal cavity by a stab wound or gunshot wound (GSW) [4].Blunt Abdominal Trauma related to greater mortality more than PAT and more difficult to diagnose [5].In developing countries including Mauritania, trauma in general and AT in particular are increasing due to road traffic, industrialization, civil violence and criminal activities in some areas [6].Study reported motor vehicle crashes (MVCs), fall from height and assaults to be the most common causes of blunt abdominal trauma [7].The penetrating trauma is mainly caused by gunshot, stab, and other objects that enter the peritoneal cavity.Mauritania is very large country located in West Africa.For about two decades, the authority has developed a road system covering almost the entire country, an increase in road accidents has been noted.But in the absence of trauma center and emergency system medical help, the majority of the seriously wounded die before, or at arriving to hospitals.Moreover, increase in incidence of occupational injuries, as well as assaults and stab injuries results in morbidity and mortality.To our knowledge, there are no publications concerning abdominal trauma in Mauritania.Penetrating abdominal trauma especially stab wound (60%) occurs more than blunt abdominal trauma in Mauritania.In our hospital, the management of AT includes as well as expectancy and the exploratory laparotomies.After several laparotomies without identifiable injuries, Shaftan [8] suggested selective management of patients with abdominal stab wound after observing an in-creased rate of negative laparotomies.Recently several studies have favored a more conservative approach as opposed to mandatory exploratory laparotomy [9] [10].
The aim of this study was to describe our experience on the management of AT, injury characteristics and treatment outcome as seen in main single institution in Mauritania.

Patients and Methods
This retrospective descriptive study of AT patients was conducted over a period of five years (2012-2016) at the single hospital named Nouakchott National Hospital Centre which is a third level teaching hospital in Nouakchott, Mauritania.
Total of 100 files were collected.For each patient socio demographic data (age, gender and ethnicity), circumstances and mechanism, body region injured, hemodynamic status, clinical, damaged organs, length of stay at the hospital were collected.All data were entered and analyzed with Statistical Package for Social Sciences (SPSS) version 20.Quantitative variables were expressed on average while qualitative variables were expressed as a percentage.Chi-square for categorical variables and P-value < 0.05 was used.

Inclusion Criteria
We included all emergency referred patients and recorded having evidence of Open Journal of Emergency Medicine intra-abdominal visceral injury, also those with penetrating AT.Depending on the injury location, patients with extra abdominal injury were managed after an initial evaluation of the associated lesions and an agreement with the team of the specialty concerned.

Exclusion Criteria
All cases with death observed before or upon arrival at the emergency department were excluded.

Results
Approximately every year, more than 6000 operative procedures are performed in our hospital, a third of which were performed in visceral surgery.During the study period a total of 8926 patients operated in the General surgery department.
Abdominal trauma was present in 100 (1.1%) cases.There were 92 males and 8 females with a male to female ratio 11:5.The demographic characteristics and mechanism of abdominal injury are depicted in  1) injuries (8%).In Table 3, the association of type of injury with number of organs injured was significant in Chi-square with P-value: 0.002.Twenty (20%) patients had more than one organ injured; 4patients had negative laparatomies and 14 (14%) cases showed evisceration of organs.The commonest organ injury was small intestine 16 (16%) followed by stomach 14 (14%   rate in this study was 2%.All deaths were related to road traffic accident whereas surgical site infections were related stab injuries.

Discussion
During our research, we do not found any reports that describe the incidence and the outcome of the abdominal trauma in Mauritania.This is a descriptive retrospective study, the reasons for an underestimation of the rate of abdominal trauma are due to either unreported patients or patient who died at the site of accident or who did not reach our general surgery department.To better assess abdominal trauma the data including police records, ICU admissions and mortuary records in all centers are required.Penetrating abdominal Injuries (PAIs) in Africa constituted 30 -66% of the overall abdominal trauma in the accident and emergency department [10] [11]; this was slightly in agreement with our study 68%.Majority of our patient were found to be young; the age of patients ranged from 5 to 70 years (median age: 20 years).The commonest age affected was 20 years, and those aged 20 to 30 years have been the most frequent victims.Our findings are consistent with recent studies from Qatar [1] and Egypt [12].In the present study, significantly more males than females present with abdominal trauma (92% vs. 8%) which is consistent with Arumugam S. et al.'s report of a male to female ratio 13:1.
Blunt injuries have been reported to predominate in many studies [1] [13] [14] but in our series no such pattern.Consistent with our results, in Africa previous studies found most abdominal injuries were caused by penetrating abdominal injuries [10] [15].
In this study stab injuries (interpersonal violence) were the most common mechanism of penetrating abdominal injuries followed by gun-shot wound.The most frequent causes of blunt trauma were road traffic accidents, followed by falls from height, this finding occurred during day-time agrees with that other study [13].These outcomes reflect difference in early or not care of patients from motor vehicles crash.Example the patients with associated injuries had been complicated or died, usually delayed and not managed by an emergency health system which was not available in Mauritania; consequently, the interval between injury and care was too long (from hours to days) and more deeded patients were not reported.No patients were presented in the first golden hour and this had affected our outcomes.

Table 1
. The age of patients ranged from 5 -70 years (mean age: 22.78 years and median age: 20 years).The majority of patients 68 (68%) presented with penetrating abdominal trauma and 32 (32%) had blunt abdominal trauma.Violent activities were the prompt causes of the abdominal trauma, Stab injuries were the most frequent mechanism (Table2), followed by road traffic accident 12 (12%), fall from height 6 (6.3%), domestic accidents 4 (4%) and sports or leisure accidents 4 (4%).In PAT the most affected anterior abdominal site (53%) of them (26.6%)umbilical 16 (16.6%)epigastrium.Back sites of PAI seen in 14.3%.Thoracoabdominal sites of PAT were 20%, whereas only the anterior abdominal regions were affected in abdominal blunt trauma.The most common associated injury was chest (Figure

Table 3 .
Association of type of injury with number of organs injured.