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BOSTON – Sometimes, the best medical treatment is to do as little as possible.
As surprising as it might be to some emergency clinicians, that even appears to be the case for some patients with abdominal gunshot wounds (aGSW).
A study published online by the Journal of the American College of Surgeons reports that, in selected patients, nonoperative management can be an acceptable and effective treatment.
“Selective nonoperative management of abdominal gunshot wounds is safe and avoids unnecessary laparotomies, which are invasive open operations that may sometimes cause complications in the short and long term,” explained lead author George C. Velmahos, MD, PhD, chief of trauma, emergency surgery, and surgical critical care at Massachusetts General Hospital and the John F. Burke professor of surgery at Harvard Medical School.
Severe gunshot injuries almost always require surgery to repair damaged organs, according to the researchers, but selective nonoperative management (SNOM) is a reasonable alternative for less severe injuries that do not involve any major organ damage or significant blood loss.
To determine that, the study team analyzed medical records of 922 gunshot wound patients admitted to 10 Level I and II trauma centers in New England – members of the Research Consortium of New England Centers for Trauma (ReCoNECT) – from January 1996 to June 2015.
Among patients included in the study, 707 (77%) had immediate surgery, and the remaining 215 were managed with SNOM.
Using the Injury Severity Score (ISS), it was determined that study subjects who had SNOM had an average ISS of 8 (moderate to serious) vs. 16 (severe) for those who underwent surgery. Furthermore, the results indicate, SNOM patients had significantly lower rates of complications – 8.5% vs. 34.7% of surgical patients – and mortality – 0.5% vs. 5.2%. They also spent less time in the intensive care unit, median of zero days vs. one, and in the hospital, median of two days vs. eight days.
A small percentage, 8.4, of the patients initially assigned to SNOM eventually underwent an operation, but none had complications related to the delay in having a procedure and none of them died because of that. The one death in the SNOM group was related to a gunshot wound to the head.
“The explosive evolution of high-speed, high-resolution, multi-slice CT scan has definitely made clinicians more comfortable to practice selective nonoperative management,” Velmahos said. “A good, reliable CT scan that has been read by a qualified individual – that is, an attending radiologist and/or an attending trauma surgeon – can be very helpful because it can map the trajectory of the bullet quite accurately and tell the trauma team whether the bullet traveled through or close to internal organs, or if it traveled completely outside the abdominal cavity.”
One question to ask during the clinical exam, he added, is whether the patient has pain just around the gunshot wound site or also in more remote areas. “If the latter happens, there’s an injury inside the abdomen that has spilled blood or abdominal contents throughout the abdomen,” Velmahos suggested, and that likely would require surgery. That also would be the case in patients who are hemodynamically unstable, he added.
“SNOM of aGSW despite being a heresy only a few years ago, has now been established as an acceptable method of management in Level I and II trauma centers of New England,” study authors conclude.