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Less Aggressive Approach to Abdominal Gunshot Wounds Possible

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Not all abdominal gunshot wounds should be treated with an immediate laparotomy, trauma surgeons from Massachusetts General Hospital conclude based on their 11-year experience.

“A significant number of them do not result in internal injuries and therefore should be managed non-operatively,” lead authors Dr. Karim Fikry and Dr. George Velmahos wrote in an e-mail to told Reuters Health.

For the patient with an abdominal gunshot wound who appears to be in stable condition, they’ve found that it’s safe to take a “wait and see” approach, as opposed to performing immediate laparotomy, even in trauma centers that don’t see a lot of abdominal gunshot wounds.

This less aggressive approach, known as selective nonoperative management, or SNOM, is widely practiced for stab wounds, the clinicians point out. It’s also used for abdominal gunshot wounds in large trauma centers with experienced trauma teams that manage high volumes of penetrating trauma wounds.

“Our study makes the case that a large volume of abdominal gunshot wounds is not a prerequisite for practicing SNOM,” they note in the May issue of Archives of Surgery.

“We wanted to dispel the myth that non-operative treatment belongs only to urban trauma centers with a lot of stab wound and gunshot wound victims. We aimed to prove that a dedicated trauma team driven by critical thinking and adequate experience matters more than blind policies,” Drs. Fikry and Velmahos added.

In addition, a high volume of cases “should not be an excuse” for routine laparotomy, they say.

But in an invited critique in the journal, Dr. Lenworth M. Jacobs of the department of traumatology, Hartford Hospital in Hartford, Connecticut, says he doesn’t think this strategy should be widely practiced.

“It is not worth putting those patients who may develop significant morbidity and mortality at risk by observing them when an exploratory laparotomy would completely exclude an injury or would allow for immediate management of an injured organ or viscus,” Dr. Jacobs writes.

The Mass General Experience

Despite being the largest trauma center in New England, the Massachusetts General Hospital trauma center sees only about 15 cases of abdominal gunshot wounds a year.

Among 125 patients with anterior and posterior abdominal gunshot wounds treated at the center between 1999 and 2009, 87 (70%) received immediate laparotomy due to hemodynamic instability, peritonitis, an inability to evaluate clinically, or CT scan findings suggestive of clinically significant organ injury.

The other 38 patients (30%) were initially managed by SNOM; they were observed with frequent physical examinations and CT scans. Thirty of these patients (79%) were successfully discharged without the need for an exploratory laparotomy.

“It was mostly interesting that 20% of anterior and 38% of posterior gunshot wounds were discharged from the hospital without a laparotomy,” Drs. Fikry and Velmahos commented. It’s commonly felt that posterior abdominal gunshot wounds are more likely to produce delayed symptoms from retroperitoneal organ injuries, they note in their paper.

“It was also noteworthy,” the clinicians say, “that there was no major morbidity by this selective approach and that patients who were subjected to delayed laparotomies did not suffer any adverse events.” Successful SNOM was associated with fewer complications and shorter hospital stays relative to immediate laparotomy.

Of the remaining 8 patients, 1 died the day after admission due to an associated gunshot wound to the head and 7 (18%) required a delayed laparotomy an average of 5 hours after admission and as late as 11 hours after admission due to worsening abdominal signs and symptoms, often in the presence of suspicious CT scan findings.

“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,” the study team concludes.

Based on their experience, they say nearly 1 in 4 abdominal gunshot wound victims does not need a laparotomy and a low volume of these cases seen at a trauma center should not be a factor in SNOM implementation.

They acknowledge that “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 abdominal gunshot wound population.”

In his commentary, Dr. Jacobs says this is a “provocative and interesting article.” Nonetheless, in his opinion, it would be “extremely unwise” for this to become a widespread practice since the majority of patients with abdominal gunshot wounds will require surgery.

Arch Surg 2011