Algorithm of management of abdominal gunshot wound patients during the entire study period (January 1, 1999, through December 31, 2009). There was no specific transition year between the initial and subsequent periods. The transition was gradual because computed tomography (CT) was increasingly used in the 2000s. SNOM indicates selective nonoperative management.
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Fikry K, Velmahos GC, Bramos A, et al. Successful Selective Nonoperative Management of Abdominal Gunshot Wounds Despite Low Penetrating Trauma Volumes. Arch Surg. 2011;146(5):528–532. doi:10.1001/archsurg.2011.94
To determine whether selective nonoperative management of abdominal gunshot wounds (AGSW) is safe in trauma centers with a low volume of penetrating trauma.
Academic level 1 trauma center with approximately 10% penetrating trauma.
All patients with anterior and posterior AGSW (January 1, 1999, through December 31, 2009), excluding tangential injuries, transfers, and deaths in the emergency department. Patients with hemodynamic instability or peritonitis received an urgent laparotomy. The remaining patients had selective nonoperative management. A delayed laparotomy was offered for worsening symptoms or worrisome computed tomography findings.
Main Outcome Measures
Hospital stay, complications, and mortality.
Of 125 AGSW patients, 38 (30%) were initially managed by selective nonoperative management (25 of 99 anterior and 13 of 26 posterior AGSW patients). Seven selective nonoperative management patients received delayed laparotomy as late as 11 hours after admission. At the end, 30 of the 125 patients (24%) were successfully managed without an operation (20 of 99 anterior and 10 of 26 posterior AGSW patients). There were no predictors of delayed laparotomy and no complications or mortality attributed to it. Ten patients (8%) had a nontherapeutic laparotomy, and 3 of them developed complications.
Selective nonoperative management of AGSW is feasible and safe in trauma centers with low penetrating trauma volumes. Nearly 1 in 4 AGSW patients does not need a laparotomy, and nontherapeutic laparotomies are associated with complications. The volume of AGSW per se should not be an excuse for routine laparotomies. These data become particularly important because penetrating trauma volumes are decreasing around the country.
After decades of operating on abdominal gunshot wounds (AGSW) routinely, Shaftan and McAlvanah1,2 proposed in the late 1960s “selective conservatism” as an alternative. In the 1990s, studies from South Africa and Los Angeles reported on the effectiveness and safety of selective nonoperative management (SNOM) of AGSW in a large series of patients evaluated retrospectively and prospectively.3-8 Despite the encouraging results and follow-up studies in the 2000s,9-13 this practice is still not universally accepted. Penetrating trauma volumes are dwindling around the country,14-16 and experience with the management of AGSW is concentrated in only a few urban trauma centers. Most other trauma centers admit limited volumes of penetrating trauma. This lack of exposure has been repeatedly mentioned as a reason to avoid SNOM and to prefer routine laparotomy.4,13,17,18
In a pattern of admissions similar to that of most other trauma centers, our penetrating trauma admissions comprise less than 15% of our entire volume. The ratio of stab wounds to gunshot wounds is 2:1, which allows a rather limited annual exposure of the staff and residents to AGSW. We hypothesized that by following a simple algorithm for the management of AGSW, as previously described in the literature, SNOM of AGSW is feasible and safe despite the lack of large penetrating injury volumes.
This is an 11-year retrospective study (January 1, 1999, through December 31, 2009) of patients with anterior or posterior AGSW admitted to our academic level 1 trauma center. Patients with obvious tangential injuries and deaths in the emergency department (ED) were excluded. Similarly, transfers from other hospitals were excluded because we did not have precise admission data for analysis.
The abdomen was defined as the area between the nipple line and pubic symphysis anteriorly and between the tip of the scapulae and the gluteal folds posteriorly. The midaxillary lines served to divide the anterior from the posterior part. The patients were managed by a trauma team that, inevitably, was subjected to multiple changes in personnel and protocols during the study period. After 2004, the trauma center was managed by an unchanging dedicated trauma and acute care surgery team. The basic infrastructure and focus in trauma care was present throughout the study. The management of AGSW patients followed a relatively simple protocol. Patients who were hemodynamically unstable, had peritonitis, or were clinically unevaluable (eg, with intubation or head injury) received an immediate exploratory laparotomy (IMMLAP). Selective nonoperative management was offered to all other patients. The patients were initially observed either in the ED or regular wards, but after 2004 a dedicated and highly monitored observational unit was built to house such patients during the first 12 to 24 hours after injury. The increasing use of computed tomography (CT) for penetrating trauma patients in the past 10 years interfered with the initial simple algorithm because more patients underwent CT before the final decision was made. In the last 5 years of the study, all patients managed by SNOM had a CT scan. In short, AGSW patients with hemodynamic instability or obvious peritonitis were still taken directly to the operating room. The remaining patients underwent CT in a frequency that increased over the years. There was no specific point of transition from no CT to CT but rather a gradual increase in use because the technology evolved and the confidence of physicians in its findings grew. Patients with clear evidence of clinically significant injuries on CT were taken to the operating room, even if diffuse peritonitis or hemodynamic instability was not yet developed. Patients with bullet trajectories away from vital structures were offered SNOM. Patients with equivocal signs on CT were managed operatively or nonoperatively at the discretion of the trauma surgeon (Figure). If, during observation, patients developed clinical symptoms consistent with significant organ injury, a delayed laparotomy (DELLAP) was offered. An operation was considered nontherapeutic if it failed to find any clinically significant organ injuries, ie, injuries requiring surgical intervention. For example, a nonbleeding superficial liver injury was not considered clinically significant and, if this were the only finding, the laparotomy was defined as nontherapeutic.
The following information was collected: age, sex, site of gunshot wound (anterior or posterior), vital signs and hematocrit level on admission, Abbreviated Injury Score for the abdomen, Injury Severity Score, time from arrival at the ED to transfer to the operating room, and hospital course, including morbidity, duration of hospital stay, and mortality. Patients who were taken to the operating room within 2 hours of arrival in the ED were included in the IMMLAP group. Patients who had a clear note in the medical record about SNOM or who were not operated on within 2 hours were included in the SNOM group. The 2-hour limit was set arbitrarily on the basis of our center's infrastructure, which allows immediate access to resources such as CT and the operating room. It was assumed that if a patient were not taken to the operating room within 2 hours, a deliberate decision was made against IMMLAP. The SNOM patients who eventually had a laparotomy were included in the DELLAP group. The IMMLAP, DELLAP, and SNOM patients were compared. The t test was used for continuous variables and the χ2 or Fisher exact test for categorical variables. A P value of .05 was considered statistically significant. The study was approved by the institutional review board.
Of 150 AGSW patients admitted during the study period, 12 died in the ED, 11 were transferred from other hospitals, and 2 had tangential wounds and were admitted for other reasons. The remaining 125 patients constitute the study population. Of them, 87 patients (70%) received an IMMLAP because of hemodynamic instability (n = 30), peritonitis (n = 38), inability to evaluate clinically (n = 5), or CT scan findings suggestive of clinically significant organ injury (n = 14). Of the 38 SNOM patients, 30 (79% of SNOM patients and 24% of all patients) were successfully discharged without the need for an exploratory laparotomy. Seven patients received a DELLAP (18% of SNOM patients and 6% of all patients) because of worsening abdominal signs and symptoms, often in the presence of suspicious CT scan findings. No patients had a DELLAP because of hemodynamic instability. Five of the DELLAP patients had a CT scan that showed either a solid parenchymal injury or free fluid without an apparent injury. The patients did not satisfy criteria for immediate exploration and were observed until the abdominal tenderness increased. There was no difference in the distribution of DELLAP throughout the study period. The mean interval from arrival at the ED to DELLAP was 5 hours (range, 3-11 hours). Table 1 describes the 7 DELLAP patients. One of them died on the day after admission because of an associated gunshot wound to the head. None of the other DELLAP patients developed a complication. Of the 31 patients who were successfully managed by SNOM, 24 had an abdominal CT scan. In 15 patients, there were no injuries found; the remaining 9 had the following findings: nonbleeding liver lacerations (n = 5), renal lacerations (n = 1), combined liver and renal lacerations (n = 2), and bowel wall edema (n = 1).
By comparison of SNOM patients with IMMLAP patients, we found that SNOM patients had fewer complications and shorter hospital stays (Table 2). By comparison of patients with successful SNOM with all patients who received a laparotomy (IMMLAP and DELLAP), we again found fewer complications and shorter hospital stays among successful SNOM patients (Table 3).
There were 10 patients (8%) with a nontherapeutic laparotomy, all of them included in the IMMLAP group. Two patients had nonbleeding liver injuries, 1 had a nonbleeding splenic injury, 1 had a small serosal tear in the small bowel, 1 had a nonexpanding renal hematoma, and 1 showed intraperitoneal blood without evidence of active bleeding. In addition, there were 4 laparatomies that revealed no intra-abdominal injuries. Of these 10 patients, 3 developed complications. One had pneumonia, another had a protracted urinary tract infection, and the third had deep venous thrombosis, pneumonia, and multiple infections.
Since the introduction of selective conservatism for penetrating abdominal wound by Shaftan,1 McAlvanah and Shaftan,2 Nance and Cohn,19 Demetriades and Rabinowitz,20,21 and Demetriades et al,22 the concept has found widespread application for stab wounds but not for gunshot wounds. Born out of necessity more than ingenuity in the high-volume trauma centers of South Africa3,7,20-22 and the county hospitals of the United States,1,2,19 where some patients were unexpectedly found to improve while waiting for an operation, the selective approach emerged as a valid alternative to routine laparotomy. For reasons that are poorly understood, stab wounds were quickly considered appropriate for SNOM but AGSW were not. The arguments for routine laparotomy after AGSW—the unreliability of a clinical examination, the high likelihood of organ injury, and the “benign” nature of a nontherapeutic laparotomy—have been debated for years and refuted in a number of studies.4,8,18,23 In short, we and others have argued that (1) if a clinical examination is reliable for stab wounds, then it should be as reliable for AGSW6,8; (2) the likelihood for intraperitoneal penetration and organ injury is high, but the likelihood for clinically significant organ injury is lower than initially thought4; and (3) nontherapeutic laparotomies are anything but “benign” and are associated with a significant rate of postoperative complications.24,25
For the most part, SNOM for AGSW has been practiced in large trauma centers with experienced trauma teams that manage high volumes of penetrating trauma. A legitimate concern remains that this concept may not be applicable to centers with lower numbers and inevitably limited experience in managing AGSW. However, this argument would prevent the majority of trauma centers around the country from practicing SNOM because penetrating trauma volumes are on the decrease and most trauma centers—even level 1—treat only a few AGSW patients per year. Such volumes, distributed across the entire trauma faculty of a specific center, would allow only single-digit numbers of AGSW to be managed by any given trauma surgeon, offering theoretically a rather inadequate experience. The problem may be even worse in smaller trauma centers.14-16,26
To evaluate this argument, we set out to examine the management of AGSW in our trauma center. The Massachusetts General Hospital is the largest trauma center in New England but, nevertheless, admits penetrating trauma volumes that are relatively low compared with those of centers that have published on SNOM previously. On average, every year we admit 278 patients with penetrating injuries. Approximately 120 of these injuries are caused by a gunshot wound, with an even smaller number (approximately 15) located in the abdomen. During those years, 5 to 8 surgeons shared the trauma calls, indicating that each was managing approximately 2 or 3 AGSW per year. Thirty-eight of these patients (30%) were offered a trial of SNOM (approximately one-third of anterior [66%] and two-thirds of posterior [34%] AGSW). Finally, 30 patients (24%) (25 [66%] with anterior and 13 [34%] with posterior AGSW) were discharged from the hospital without an operation. These numbers are remarkably similar to those reported in the largest analysis of AGSW to date.4 In that study, 42% of the patients were initially managed by SNOM and 38% were discharged without an operation. The proportions of anterior and posterior AGSW were similar to those in our experience.
Clinical examination was and still is the main method for repeat evaluation of patients managed by SNOM. The addition of CT scan has expedited the diagnosis of asymptomatic organ injury and allowed early discharge in the absence of a suspicious bullet trajectory.12,27,28 On occasion, it has contributed to less desired outcomes, such as a nontherapeutic laparotomy based on trajectory proximity, free air, or free fluid.12 We, like others, have been using CT scan with increasing frequency during the past few years and have incorporated it in our therapeutic algorithm. We have been reluctant to discharge patients from the ED on the basis of negative CT scan results unless the trajectory is obviously tangential. Such patients with tangential wounds were excluded from our analysis. In general, the precise role of CT scan for AGSW is not supported by high-level evidence. It has become a widespread practice and there is evidence supporting its use, but to our knowledge, there have been no comparative studies proving that patient outcomes have improved compared with patient outcomes relying primarily on clinical examination.
Seven SNOM patients developed symptoms during the period of observation and received a DELLAP that proved therapeutic on all of them. Five of them had anterior AGSW in contrast to the common belief that posterior AGSW are more likely to produce delayed symptoms from retroperitoneal organ injuries. Selective nonoperative management for patients with gunshot wounds to the back and buttocks is similarly safe.6,22,29 The mean delay to operation was only 5 hours, with the longest delay being 11 hours. Within these short periods, no adverse events were caused by the delays. This study confirms the findings of previous research, indicating that an observation period of 24 hours is adequate for most patients and that the operative risk does not increase in patients initially managed by SNOM and eventually requiring an operation.4,6-8,10
The benefits of SNOM are obvious. Patients who eventually did not receive an operation had fewer complications and shorter hospital stays than those operated on. The financial superiority of SNOM over routine laparotomy has been proved in previous studies unequivocally.4 The rate of nontherapeutic laparotomy in our study was 8% and similar to that of other studies.2-4,8,13 It seems that this rate represents an irreducible statistic and a point of reference for successful SNOM protocols.
Our study makes the case that a large volume of AGSW is not a prerequisite for practicing SNOM. Obviously, the infrastructure of a mature level 1 trauma center, the collective experience of the trauma surgeons group, and the functioning protocols assuring around-the-clock monitoring were crucial elements of the uneventful application of SNOM in our AGSW population. Our hospital may serve as an example to other trauma centers with predominantly blunt trauma populations on the feasibility and safety of SNOM. The modest delays may be a result of our strict definition of IMMLAP (within 2 hours of arrival) or our focus on repeat evaluation of SNOM patients, which allowed early identification of evolving symptoms. We accept that the concept still needs to be tested in smaller centers. We agree that the success of SNOM relies on a multitude of factors, including the appropriate resources and group commitment. However, we find little rationale in the vague arguments about lack of experience or expertise as reasons for avoiding SNOM. The assessment of abdominal pain, hemodynamic stability, and CT findings is a skill familiar to every surgeon and should not be considered the privilege of only a few. If a surgeon can assess a patient with a stab wound to the abdomen, the surgeon can assess a patient with AGSW. This claim does not argue against regionalization of trauma care. Complex trauma patients should be managed in specialized centers by specialized teams. By the same token, not every AGSW patient needs an urban trauma megacenter. Given the commitment of human and other resources implicit in the definition of a trauma center, we believe that SNOM for AGSW is safe and effective in most of them, and as such it should be practiced.
Correspondence: Karim Fikry, MD, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, 165 Cambridge St, Ste 810, Boston, MA 02114 (email@example.com).
Accepted for Publication: January 31, 2011.
Previous Presentation: This study was presented at the 91st Annual Meeting of the New England Surgical Society; October 31, 2010; Saratoga Springs, New York.
Author Contributions:Study concept and design: Fikry, Velmahos, Bramos, Janjua, de Moya, King, and Alam. Acquisition of data: Fikry and Bramos. Analysis and interpretation of data: Fikry and Velmahos. Drafting of the manuscript: Fikry, Velmahos, Bramos, and Janjua. Critical revision of the manuscript for important intellectual content: Fikry, de Moya, King, and Alam. Statistical analysis: Fikry and Bramos. Administrative, technical, and material support: Fikry. Study supervision: Velmahos, de Moya, King, and Alam.
Financial Disclosure: None reported.
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