Many abdominal gunshot wounds can be managed nonoperatively

Last Updated: 2017-03-10

By Will Boggs MD

NEW YORK (Reuters Health) - As many as 30% of patients with abdominal gunshot wounds (AGSW) can be safely managed without surgery, according to findings from the Research Consortium New England Centers for Trauma.

"Repeated studies have shown that between 15% and 30% of the patients with AGSW can be managed without an operation,” Dr. George C. Velmahos from Massachusetts General Hospital in Boston told Reuters Health by email. “The percentage fluctuates according to the location of the GSW, the type of missile, the body habitus of the patient, and other parameters.”

Despite these studies, some surgeons are still reluctant to adopt selective nonoperative management, Dr. Velmahos and colleagues note in an article published online March 1 in the Journal of the American College of Surgeons.

The team investigated current practices regarding the management of AGSW at 10 Level I and II trauma centers in New England.

From 1996 to 2015, 76.7% of patients with AGSW received an immediate exploratory laparotomy and 23.3% were initially selected for selective nonoperative management (SNOM).

The rate of SNOM was 18% before 2010 and 27% after 2010, a significant change.

Most patients selected for SNOM (91.6%) were successfully managed and discharged without receiving any abdominal surgery, whereas 8.4% eventually received a delayed laparotomy. None of these patients died from causes related to their AGSW (one died as a result of the GSW to his head).

Compared with immediate laparotomy patients, SNOM patients had significantly lower Injury Severity Score and Abbreviated Injury Score abdomen and were significantly less likely to have anterior AGSW.

The SNOM group had significantly lower morbidity rates (8.5% vs. 34.7% for immediate laparotomy), mortality rates (0.5% vs. 5.2%), median ICU stay (0 vs. 1 day), and median hospital stay (2 vs. 8 days).

These outcomes did not differ significantly in the subgroup analysis of SNOM patients who did and did not require delayed laparotomy, with the exception of complication rates, which were significantly higher in the delayed laparotomy (50%) group than in the group without delayed laparotomy (4.6%).

“A hole in the abdominal wall from a GSW does not equal a laparotomy,” Dr. Velmahos concluded. “Careful clinical exam, appropriate tests, and - above all - a committed trauma team can select those patients who can be managed without an operation.”

“More importantly,” he added, “if there are still centers that operate on 100% of AGSW patients, they are definitely performing many unnecessary laparotomies.”

Dr. Timothy Craig Hardcastle from Inkosi Albert Luthuli Central Hospital in Mayville, South Africa, who recently reviewed SNOM of AGSW, told Reuters Health by email, "This practice has been routine in South African trauma practice for many years. SNOM is safe and does not lead to worse clinical outcomes than immediate routine laparotomy and will save much-needed expensive operative time and ICU beds.”

“Other injuries should not create an aversion to SNOM in the patient who is evaluable, or where the imaging excludes significant injury in those who were neurologically impaired,” he said. “The vast majority of correctly selected patients will have successful SNOM.”

Dr. Sizenando Starling from Fundacao Hospitalar do Estado de Minas Gerais in Belo Horizonte, Brazil, has investigated the use of SNOM for isolated liver GSW. He told Reuters Health by email, “Although the findings of the clinical examination (hemodynamic stability and without signs of peritonitis) are the most important and reliable criteria used to select the patients, I believe that, also, CT has a very important value and should always be done in all patients.”

He concluded, “The SNOM of abdominal GSW has been shown to be a safe approach and decreases the length of hospital stay, the final cost of treatment and the incidence and complications of non-therapeutic laparotomies. In order for SNOM to be employed you must have a well-defined protocol, respect your inclusion criteria accurately, and especially prepare your trauma team properly.”

SOURCE: http://bit.ly/2nmbhdY

J Am Coll Surg 2017.