UROGENITAL TRAUMA

Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care?
Velmahos GC, Demetriades D, Toutouzas KG, Sarkisyan G, Chan LS, Ishak R, Alo K, Vassiliu P, Murray JA, Salim A, Asensio J, Belzberg H, Katkhouda N, Berne TV.
Department of Surgery, Division of Trauma and Critical Care, University of Southern California Keck School of Medicine, Los Angeles, California, USA
Ann Surg. 2001; 234: 395-402; discussion 402-3

• Objective: To evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds.
• Summary Background Data: Selective nonoperative management is practiced extensively in stab wounds and blunt abdominal trauma, but routine laparotomy is still the standard of care in abdominal gunshot wounds.
• Methods: The authors reviewed the medical records of 1,856 patients with abdominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8-year period in a busy academic level 1 trauma center and managed by SNOM. According to this policy, patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination were observed.
• Results: Initially, 792 (42%) patients (34% of patients with anterior and 68% with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 (4%) patients developed symptoms and required a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all patients). If patients were managed by routine laparotomy, the unnecessary laparotomy rate would have been 47% (39% for anterior and 74% for posterior abdominal gunshot wounds). Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges. By maintaining a policy of SNOM instead of routine laparotomy, a total of 3,560 hospital days and US$9,555,752 in hospital charges were saved over the period of the study.
• Conclusion: Selective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.
  
  
• Editorial Comment
  This is not a new article, but it is an important one. By now, everybody knows that many renal injuries can be treated nonoperatively: adult blunt injuries (1), pediatric blunt injuries (2), stab wounds (3), and even some gunshot wounds (4). Understanding some of the other ways that nonoperative (or “selective”) management of trauma patients has been applied can be very useful when managing your own patients. Here is a paper from a major US trauma center, and written by well-regarded general surgery traumatologists, regarding 1,856 patients with gunshot wound to the abdomen. At most centers, such wounds would be treated with 1,856 laparotomies. In this series, 1,046 (57%) patients that were hemodynamically stable, did not have peritonitis, and were examinable (no significant head injury, etc.) were admitted to the intensive care unit for observation. No laparotomy was performed unless the patients developed peritoneal signs or hypotension. Only 4% of patients developed these symptoms and had to undergo delayed laparotomy. The benefits of avoiding the unnecessary operations were obvious: unnecessary laparotomy rate decreased by 47% and observed patients enjoyed a speedier discharge from the hospital.
  I think this study is amazing. Most of us that care for gunshot victims “know” that if you are shot in the abdomen you need a surgery. Clearly we were wrong. When you are trying to convince others or yourself to expand you own use of nonoperative therapy in those cases where it may be prudent (most hemodynamically stable renal injuries), remember this study.

References
1. Moudouni S M, Hadj Slimen M, Manunta A, Patard JJ, Guiraud PH, Guille F, Bouchot O, Lobel B: Management of major blunt renal lacerations: is a nonoperative approach indicated? Eur Urol. 2001; 40: 409-14.
2. Nance ML, Lutz N, Carr MC, Canning DA, Stafford PW: Blunt renal injuries in children can be managed nonoperatively: outcome in a consecutive series of patients. J Trauma. 2004; 474-8.
3. Heyns CF, Van Vollenhoven P: Selective surgical management of renal stab wounds. Br J Urol. 1992; 69: 351-7.
4. Hammer CC, Santucci RA: Effect of an institutional policy of nonoperative treatment of grades I to IV renal injuries. J Urol. 2003; 169: 1751-3

Dr. Richard A. Santucci
Assistant Professor of Urology
Wayne State University
Detroit, Michigan, USA