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Abstract & Commentary
Source: Velmahos GC, et al. Selective nonoperative management of 1856 patients with abdominal gunshot wounds: Should routine laparotomy still be the standard of care? Ann Surg 2001;234:396.
The authors performed a retrospective chart review of 1856 patients with abdominal gunshot wounds (1405 anterior, 451 posterior) admitted during an eight-year period at Los Angeles County Medical Center. According to a previously developed protocol, these patients underwent either laparotomy or selective nonoperative management (SNOM). Patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination (absence of head injury, intoxication, spinal cord injury) were observed. Patients in the SNOM group underwent CT scanning to define bullet trajectory and organ injury. Frequent serial examinations on individual patients were performed by the same treating surgeon, typically a junior resident, for a 24-hour period. Patients who experienced a change in their clinical status underwent delayed laparotomy.
Initially 792 (42%) patients (34% of patients with anterior and 68% of patients with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 patients (4% of total; 10% of SNOM group) developed symptoms and required a delayed laparotomy, which revealed organ injury requiring repair in 57. The majority of delayed laparotomies occurred within eight hours of presentation. Five patients (0.3% of total; 0.6% of SNOM group) suffered complications potentially related to delay in laparotomy. Four of these five were intraabdominal abscess; all were managed successfully. Seven hundred-twelve patients (38%) were managed successfully without operation. The rate of non-therapeutic laparotomy was 14%. Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges.
Comment by Michael A. Gibbs, MD, FACEP
Classic mantra underscores the importance of immediate laparatomy in all patients with abdominal gunshot wounds. This assertion is based on the long-held belief that the rate of intra-abdominal organ injury in this population approaches 90%. While this may be true for military wounds, more recent data suggest that abdominal gunshot wounds from civilian violence are associated with a much lower incidence of clinically significant intra-abdominal injuries, ranging from 30-74%.
This study confirms the results of two smaller prospective studies by the same authors, demonstrating that roughly one-third of anterior abdominal gunshot wounds1 and two-thirds of posterior gunshot wounds2 can be managed without surgery.
I think this approach undoubtedly will become more popular at major trauma centers with experienced trauma surgeons and dedicated resources. It is unlikely ever to become reality at most small centers. After all, few hospitals can boast the Los Angeles experience of 232 abdominal gunshot wounds per year! While this study has several important weaknesses (most importantly a lack of precise definitions for the indications for surgery), it represents an important paradigm shift that challenges traditional surgical dogma.
(Dr. Gibbs, Residency Program Director, Medical Director, Medcenter Air, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, is on the Editorial Board of Emergency Medicine Alert.)
1. Demetriades D. Selective nonoperative management of gunshot wounds to the anterior abdomen. Arch Surg 1997;132:178-183.
2. Velmhos GC. A selective approach to the management of gunshot wounds to the back. Am J Surg 1997;174:342-346.