Non-operative management of abdominal gunshot injuries: Is it safe in all cases?

Abstract

Objective: In line with advances in diagnostic methods and expectation of a decrease in the number of negative laparotomies, selective non-operative management of abdominal gunshot wounds has been increasingly used over the last three decades. We aim to detect the possibility of treatment without surgery and present our experience in selected cases referred from Syria to a hospital at the Turkish-Syrian border. Material and Methods:Between February 2012 and June 2014, patients admitted with abdominal gunshot wounds were analyzed. Computed tomography was performed for all patients on admission. Patients who were hemodynamically stable and did not have symptoms of peritonitis at the time of presentation were included in the study. The primary outcome parameters were mortality and morbidity. Successful selective non-operative management (Group 1) and unsuccessful selective non-operative management (Group 2) groups were compared in terms of complications, blood transfusion, injury site, injury severity score (ISS), and hospital stay. Results:Of 158 truncal injury patients, 18 were considered feasible for selective non-operative management. Of these, 14 (78%) patients were treated without surgery. Other Four patients were operated upon progressively increasing abdominal pain and tenderness during follow-up. On diagnostic exploration, all of these cases had intestinal perforations. No mortality was observed in selective non-operative management. There was no statistically significant difference between Group 1 and Group 2, in terms of length of hospital stay (96 and 127 h, respectively). Also, there was no difference between groups in terms of blood transfusion necessity, injury site, complication rate, and injury severity score (p>0.05). Conclusion:Decision making on patient selection for selective non-operative management is critical to ensure favorable outcomes. It is not possible to predict the success of selective non-operative management in advance. Cautious clinical examination and close monitoring of these patients is vital; however, emergency laparotomy should be performed in case of change in vital signs and positive symptoms concerning peritonitis.Keywords: Abdominal, gunshot, non-operative management, selective INTRODUCTIONIn 1960, Shaftan (1) reported that 34.1% of patients with abdominal injury were laparotomy negative and suggested that the need for surgery in abdominal injury patients should be determined with physical examination. In his series, the non-operatively treated patients comprised mostly patients with stab wounds, but included some with gunshot wounds. The negative laparotomy rate of about 20% determined during the Vietnam War was found acceptable because of the low morbidity in laparotomy negative cases (2). Subsequently, serious objections to obligatory laparotomy were raised, and consequently, a selective conservative approach in penetrating abdominal traumas was introduced to treatment (3, 4). In 1986, Demetriades et al. (5) non-operatively treated penetrating hepatic injuries with a su...

Syrian Civil War: a systematic review of trauma casualty epidemiology

“…In total, 38 publications met the inclusion criteria of this systematic review as shown in Figure 1 10–47. There was no other systematic review on this area of research found.…”

“…Of the 30 papers which documented the site of injury, only three were not specific to the injured anatomical region, allowed subcategorisation according to the AIS regions and were not case studies 12 16 27. Eighteen papers were site specific 10 13 18–22 24–26 28 29 33 38 39 42 44 46. Four could not be categorised in relation to the AIS 14 31 43 45.…”

The Evolution of Nonoperative Management of Abdominal Gunshot Wounds in the United States

“…In terms of injury parameters, 49% of the population presented with a solid organ injury, and 61% presented with a bowel injury. The overall median ISS was 18 (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25), and the median abdomendAIS was 3 (1-4). Most patients were transferred to level I ACS-verified trauma center (59%) ( Table 1).…”

“…[22][23][24][25] The NOM of an AGW in select patients reduces the potential of postoperative complications, morbidity, and mortality associated with negative laparotomies. 20 A recently published Western Trauma Association critical decisions algorithm tackles the evaluation and management of AGWs. It recommends that patients selected for NOM should be awake, alert, and have a reliable abdominal examination that can be followed with serial examinations.…”

“…13 Although the selection of the ideal patient presenting with an abdominal gunshot wound (AGW) for nonoperative management (NOM) remains challenging, 14 the utilization of NOM in a select group of patients with penetrating abdominal trauma has proved to be successful. [15][16][17] The safety of NOM for AGWs has been suggested in the literature [18][19][20] ; however, there is paucity of data regarding the degree of its utilization and its effects on outcomes. The aim of this analysis was to review the utilization of NOM and mortality after an AGW.…”