Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis

Abstract

BackgroundAlthough mandatory laparotomy has been standard of care for patients with abdominal gunshot wounds (GSWs) for decades, this approach is associated with non-therapeutic operations, morbidity, and long hospital stays. This systematic review and meta-analysis sought to summarize outcomes of selective nonoperative management (SNOM) of civilian abdominal GSWs.MethodsWe searched electronic databases (March 1966–April 1, 2017) and reference lists of articles included in the systematic review for studies reporting outcomes of SNOM of civilian abdominal GSWs. We meta-analyzed the associated risks of SNOM-related failure (defined as laparotomy during hospital admission), mortality, and morbidity across included studies using DerSimonian and Laird random-effects models. Between-study heterogeneity was assessed by calculating I2 statistics and conducting tests of homogeneity.ResultsOf 7155 citations identified, we included 41 studies [n = 22,847 patients with abdominal GSWs, of whom 6777 (29.7%) underwent SNOM]. The pooled risk of failure of SNOM in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis was 7.0% [95% confidence interval (CI) = 3.9–10.1%; I2 = 92.6%, homogeneity p < 0.001] while the pooled mortality associated with use of SNOM in this patient population was 0.4% (95% CI = 0.2–0.6%; I2 = 0%, homogeneity p > 0.99). In patients who failed SNOM, the pooled estimate of the risk of therapeutic laparotomy was 68.0% (95% CI = 58.3–77.7%; I2 = 91.5%; homogeneity p < 0.001). Risks of failure of SNOM were lowest in studies that evaluated patients with right thoracoabdomen (3.4%; 95% CI = 0–7.0%; I2 = 0%; homogeneity p = 0.45), flank (7.0%; 95% CI = 3.9–10.1%), and back (3.1%; 95% CI = 0–6.5%) GSWs and highest in those that evaluated patients with anterior abdomen (13.2%; 95% CI = 6.3–20.1%) GSWs. In patients who underwent mandatory abdominopelvic computed tomography (CT), the pooled risk of failure was 4.1% versus 8.3% in those who underwent selective CT (p = 0.08). The overall sample-size-weighted mean hospital length of stay among patients who underwent SNOM was 6 days versus 10 days if they failed SNOM or developed an in-hospital complication.ConclusionsSNOM of abdominal GSWs is safe when conducted in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis. Failure of SNOM may be lower in patients with GSWs to the back, flank, or right thoracoabdomen and be decreased by mandatory use of abdominopelvic CT scans.Electronic supplementary materialThe online version of this article (10.1186/s13017-018-0215-0) contains supplementary material, which is available to authorized users.

Conservative management versus surgical intervention for penetrating abdominal shotgun injuries

“…This approach is known to be associated with numerous unnecessary and negative laparotomies, in addition to the relatively high risk of postoperative complications in 22-41% of cases and more lengthy hospital stay. 3,7,8 Unnecessary laparotomy rate in the current study was 64.3%, with significantly more extended hospital stay compared to conservative management.…”

Status of cellular immunity in rats under conditions of acute widespread petitonitis in the setting of diabetes mellitus

“…The level of CD3 + cells at 1 st day after the simulation of experiment decreased 4,1 times compared with intact animals, which is 53,78% statistically significantly less compared to the group of animals with simulated AWP. Such abnormalities are associated with marked pain syndrome and induced stress, as a result of the release of catabolic hormones that block the migration of immunocompetent cells from thymus [3,4] and the redistribution of circulating lymphocytes from the vascular bed into damaged tissues. On 3 rd day, a further decrease by 49,18% and 79,90% were observed, respectively, compared with control of the amount of CD3 + cells in animals with simulated AWP and AWP in the setting of DM.…”

“…Acute generalized peritonitis (AGP) is increasingly occurring in patients with concomitant pathology, resulting in changes of the mechanisms of its development, worsening treatment effects and, as a consequence, high mortality [1][2]. According to some authors, in severe forms of widespread purulent peritonitis, the mortality rate reaches 50-80 % [3][4][5]. Such high mortality is due to the fact that peritonitis occurs on the background of pre-existing pathological changes caused by a comorbid condition, in particular diabetes mellitus (DM), the feature of which is the absence of clear boundaries, the rapid spread of pathological process in abdominal cavity, and complexity.…”

Gunshot injuries: patterns, presentations, and outcomes of civilian hospital experiences in a developing country setting

“…The deaths in our study population occurred within the rst and second weeks of injury. All 5 deceased patients had gunshots to the abdomen, which are known carry high morbidity and mortality rate according to a national and international studies [5,22,23].…”