UROGENITAL TRAUMA

Abdominal Computed Tomographic Scan for Patients with Gunshot Wounds to the Abdomen Selected For Nonoperative Management
Velmahos GC, Constantinou C, Tillou A, Brown CV, Salim A, Demetriades D
Department of Surgery, Division of Trauma and Critical Care, University of Southern California Keck School of Medicine, Los Angeles County/University of Southern California Medical Center, Los Angeles, California, USA
J Trauma. 2005; 59: 1155-60; discussion 1160-1

• Background: Computed tomographic (CT) scanning is increasingly used in patients with abdominal gunshot wounds (AGSWs) selected for nonoperative management (NOM). Triple-contrast CT scanning (i.e., intravenous, oral, and rectal) has produced encouraging initial results. The exact role and usefulness of CT scanning with intravenous contrast only is unknown.
• Methods: Hemodynamically stable AGSW patients without generalized abdominal tenderness were offered a trial of NOM, underwent single-contrast (intravenous) CT scanning, and were prospectively followed from July 1, 2002, to May 31, 2004. The sensitivity and specificity of CT scanning to detect organ injuries requiring repair were calculated against the clinical results of NOM. The effect of CT scanning in management was recorded.
• Results: One hundred patients with nontangential AGSWs were included. Twenty-six required laparotomy, which was nontherapeutic in five (19%). These five patients underwent operation on the basis of misleading CT findings (n = 3) or development of clinical symptoms (n = 2). Two CT scans were false-negative, and these patients were operated on at 121 and 307 minutes after arrival for hollow visceral injuries and recovered without postoperative complications. Three CT scans were false-positive and resulted in nontherapeutic laparotomies without postoperative complications. The sensitivity and specificity of CT scanning was 90.5% and 96%, respectively. CT findings resulted in a change of management in 40 patients. In nine, the decision to operate was changed to a decision to manage nonoperatively; whereas in eight, the opposite occurred. In addition, in 17, the decision to observe was changed to a decision to discharge; whereas in 1, the opposite occurred. Finally, five patients had additional tests after the findings of CT scanning.
• Conclusion: Abdominal CT scanning is a safe and useful method of selecting AGSW patients for NOM. Further exploration is needed to define the precise benefits of routine CT scanning over clinical examination with selective CT scanning.
  
  
• Editorial Comment
  It is well accepted that most blunt trauma to solid organs can be managed effectively by a nonoperative approach. In the past, it was dogma that all penetrating injuries to the abdomen or retroperitoneum required surgical exploration. However, there is mounting evidence that in the properly selected patient, there has been a paradigm shift to an increasing nonoperative or expectant management of penetrating abdominal injuries (where the patient has no peritoneal signs and is hemodynamically stable). Overall, kidney injuries that end up needing surgical exploration is often determined by the mechanism of injury, namely, blunt trauma 2 to 4 %, stab wounds roughly 50%, and gunshot wound roughly 75%. The reason penetrating injuries more commonly require exploration is that the injuries are typically of higher Grade 3 to 5, which more commonly require exploration. Logically, grade for grade, kidney injuries should be teated the same, regardless of the mechanism. Thus, in highly select cases where the kidney is an isolated injury, expectant management can be considered. The proviso being that delayed bleeding may be more common, and secondary procedures such as selective embolization or ureteral stent placement needed in a delayed fashion.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA