Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care?

Abstract

To evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds. 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. 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. 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 $9,555,752 in hospital charges were saved over the period of the study. 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.