Selective Nonoperative Management Research Articles

Cost-Effectiveness of Total Neoadjuvant Therapy With Selective Nonoperative Management for Locally Advanced Rectal Cancer: Analysis of Data From the Organ Preservation for Rectal Adenocarcinoma Trial.

The clinical efficacy of total neoadjuvant therapy (TNT) followed by selective nonoperative management (NOM) for locally advanced rectal cancer (LARC) was examined in the Organ Preservation for Rectal Adenocarcinoma (OPRA) trial. We investigated the cost and quality-of-life implications of adopting this treatment approach. We analyzed clinical, cost, and quality-of-life outcomes for TNT with selective NOM in comparison with chemoradiotherapy (CRT)-surgery-adjuvant chemotherapy (standard of care [SOC]) using data from OPRA, prospective cohorts, and published studies. Cost-effectiveness was evaluated over varying willingness-to-pay thresholds, and sensitivity analyses evaluated cost-effectiveness for different surgical contexts and SOC variants as well as a 10-year time horizon. SOC was dominated by TNT with selective NOM in the base case analysis. TNT in which CRT was followed by consolidation chemotherapy (CNCT) was the least costly at $89,712 in Medicare proportionate US dollars (MP$), followed by TNT in which induction chemotherapy was followed by CRT (INCT) at MP$90,259 and SOC at MP$98,755. INCT was the preferred strategy, with 4.56 quality-adjusted life years, followed by CNCT at 4.42 and SOC at 4.29. TNT with selective NOM dominated SOC in all sensitivity analyses except when SOC omitted adjuvant chemotherapy without an impact on disease-free survival. CNCT was more cost effective than SOC when the proportion of patients entering NOM after TNT was ≥22% or ≥43%, for SOC with and without adjuvant therapy, both well below the rates seen in OPRA. TNT with selective NOM is cost effective. The cost-effectiveness of CNCT with NOM relative to SOC is dependent on CNCT being made available to a sufficiently large proportion of patients with LARC. Additional analyses are needed to validate these findings from a societal perspective and in the context of other emerging treatment paradigms for LARC.

Selective nonoperative versus operative management of liver gunshot injuries: a retrospective cohort study.

Experience accumulated over the last decades suggests nonoperative management (NOM) of civilian gunshot liver injuries can be safely applied in selected cases. This study aims to compare the outcomes of selective NOM versus operative management (OM) of patients sustaining gunshot wounds (GSW) to the liver. A registry-based retrospective cohort analysis was performed for the period of 2008 to 2016 in a Brazilian trauma referral. Patients aged 16-80 years sustaining civilian GSW to right-sided abdominal quadrants and liver injury were included. Baseline data, vital signs, grade of liver injury, associated injuries, injury severity scores, blood transfusion requirements, liver- and non-liver-related complications, length-of-stay (LOS), and mortality were retrieved from individual registries. A total of 54 patients were eligible for analysis, of which 37 underwent NOM and 17 underwent OM. The median age was 25 years and all were male. No statistically significant differences were observed between groups regarding patients' demographics, injury scores, grade of liver injury and associated lesions. NOM patients tended to sustain higher-grade injuries (86.5% vs 64.7%; p = 0.08), and failure of conservative management was recorded in two (5.4%) cases. The rate of complications was 48% with no between-group statistically significant difference. Blood transfusion requirements were significantly higher in the OM group (58.8% vs 21.6%; p = 0.012). The median LOS was seven days. No deaths were recorded. Patients with liver GSW who are haemodynamically stable and without peritonitis are candidates for NOM. In this study, NOM was safe and effective even in high-grade injuries.

Outcomes of selective non-operative management in adults with abdominal gunshot wounds: a systematic review and meta-analysis.

Abdominal gunshot wounds (GSWs), a clinically devastating injury, can result in a variety of severe and lethal complications. Traditionally, exploratory laparotomy is the first-line approach for the management of abdominal GSWs, but it is associated with a considerable amount of unnecessary surgeries. At present, selective non-operative management (SNOM) of abdominal GSWs is becoming an effective and well-recognized approach, but it remains widely disputed since many surgeons are skeptical about the validity of SNOM in clinical practice. This meta-analysis aims to estimate the outcomes of SNOM and immediate laparotomy in patients with GSWs by collecting the currently available evidence. The PubMed , EMBASE , and Cochrane Library databases were searched. A random-effects model was employed. A pooled proportion with 95% confidence intervals (CIs) was calculated. Heterogeneity was evaluated using Cochran's Q test and I2 statistics. Overall, 53 studies involving 60291 participants were included. The pooled proportions of SNOM and SNOM failure were 27.0% (95% CI=24.0-30.0%) and 10.0% (95% CI=7.0-13.0%), respectively. The pooled mortality after SNOM and SNOM failure were 0.0% (95% CI=0.0-1.0%) and 0.0% (95% CI=0.0-0.0%), respectively. The pooled proportions of immediate laparotomy and unnecessary immediate laparotomy were 73.0% (95% CI=70.0-76.0%) and 10.0% (95% CI=8.0-13.0%), respectively. The pooled mortality after immediate laparotomy and unnecessary immediate laparotomy was 10.0% (95% CI=8.0-13.0%) and 0.0% (95% CI=0.0-1.0%), respectively. Heterogeneity was statistically significant in nearly all meta-analyses. Immediate laparotomy is still the mainstay approach for the management of abdominal GSWs. Approximately one-third of patients with abdominal GSWs undergo SNOM. SNOM failure is not frequent, and its related mortality is also rare.

Pancreatic and Duodenal Injuries: Experience at A Single Trauma Centre

Background: Pancreatic and duodenal injuries are uncommon due to relative protection by their posterior anatomical position and have an incidence of less than 1% of all hospital admissions for trauma. Auckland City Hospital is a tertiary referral hospital in New Zealand with Trauma and Hepatopancreatobiliary units and admits approximately 384 patients with major trauma per year, predominantly from blunt mechanisms. This study is used to assess the incidence, diagnosis and clinical management of pancreatic and duodenal injuries in trauma patients at a single trauma centre. Method: A retrospective study was undertaken using data from a prospectively collected trauma registry. Inpatient notes including all patients admitted from 2007 to 2020 were reviewed. Pancreatic and duodenal injuries were graded using the American Association for the Surgery of Trauma (AAST) organ injury scale (OIS) grading system. Investigations including radiology and biochemistry and clinical management were noted. Results: A total of 45 trauma patients admitted to Auckland City Hospital had sustained pancreatic or duodenal injuries. Six patients had combined pancreaticoduodenal injuries, 16 had duodenal and 23 had pancreatic injuries. Grade I organ injuries were the most common in pancreatic (19/29) and duodenal injuries (9/22). Majority of patients underwent laparotomy (33/45) for associated haemodynamic instability. All organ specific indications for surgery occurred in Grade II and higher injuries. 10/45 patients were managed non-operatively, of which the majority had Grade I or II organ injuries (9/45). 3/45 patients died. Conclusion: The incidence of pancreaticoduodenal injuries is rare (45 patients in 13 years) and in keeping with trauma literature. In our series, haemodynamically stable patients with Grade I - II pancreatic and Grade I - II (non-laceration type) duodenal injuries did not require operative management. Endoscopic pancreatic stenting may facilitate selective non-operative management in some patients with pancreatic injury or complications.

Injury Patterns and Treatment Strategies in Civilian and Military Isolated Abdominal Gunshot Wounds.

Combat-related gunshot wounds (GSW) may differ from those found in civilian trauma centers. Missile velocity, resources, logistics, and body armor may affect injury patterns and management strategies. This study compares injury patterns, management, and outcomes in isolated abdominal GSW between military (MIL) and civilian (CIV) populations. The Department of Defense Trauma Registry (DoDTR) and TQIP databases were queried for patients with isolated abdominal GSW from 2013 to 2016. MIL patients were propensity score matched 1:3 based on age, sex, and extraabdominal AIS. Injury patterns and in-hospital outcomes were compared. Initial operative management strategies, including selective nonoperative management (SNOM) for isolated solid organ injuries, were also compared. Of the 6435 patients with isolated abdominal GSW, 183 (3%) MIL were identified and matched with 549 CIV patients. The MIL group had more hollow viscus injuries (84% vs. 66%) while the CIV group had more vascular injuries (10% vs. 21%) (p < .05 for both). Operative strategy differed, with more MIL patients undergoing exploratory laparotomy (95% vs. 82%) and colectomy (72% vs. 52%) (p < .05 for both). However, no difference in ostomy creation was appreciated. More SNOM for isolated solid organ injuries was performed in the CIV group (34.1% vs. 12.5%; p < 0.05). In-hospital outcomes, including mortality, were similar between groups. MIL abdominal GSW lead to higher rates of hollow viscus injuries compared to CIV GSW. MIL GSW are more frequently treated with resection but with similar ostomy creation compared to civilian GSW. SNOM of solid organ injuries is infrequently performed following MIL GSW.

Accuracy of CT Scan for Detecting Hollow Viscus Injury in Penetrating Abdominal Trauma

BackgroundIn penetrating abdominal trauma, computed tomography (CT) is routinely performed to evaluate stable patients for selective non-operative management (SNOM). Triple-contrast CT (oral, rectal, and IV) has traditionally been used. However, due to its disadvantages, most trauma centres, including our unit at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), now perform single-contrast intravenous-only CT scans. We performed a retrospective review to determine the accuracy of single-contrast CT scans for detecting hollow viscus injuries (HVI) in penetrating abdominal trauma.MethodsA retrospective review of all patients who presented to CMJAH with penetrating abdominal injuries was performed between 01 August 2017 and 31 August 2019 and were evaluated for SNOM with CT (IV contrast only). Patient records were reviewed to determine pertinent demographics, mechanism, and site of injury, as well as metabolic parameters. CT findings were compared to findings at laparotomy.ResultsA total of 437 patients met the inclusion criteria. The majority were male (92.7%), with a mean age of 31.5 yrs (SD 8.7). Injuries were predominantly due to stab wounds (72,5%, n = 317). CT scan was negative in 342 patients, of which 314 completed SNOM successfully. A total of 93 patients proceeded to laparotomy. CT had a sensitivity of 95.1%, specificity of 44.2%, positive predictive value of 57.4%, and negative predictive value of 92%.ConclusionSingle-contrast CT in penetrating abdominal trauma is a valuable investigative tool in identifying patients for SNOM. Features of HVI on single-contrast CT are not very specific and should be interpreted along with other clinical factors including wound trajectory and serial abdominal examinations. Other associated injuries such as diaphragmatic and solid organ injuries should be considered in the final management plan.

Indicative factors for surgical or angiographic intervention in hemodynamically stable patients with blunt abdominal trauma: A retrospective cohort study.

The standard of care for intraperitoneal injury in hemodynamically stable patients after blunt abdominal trauma has been replaced by non-operative management (NOM). However, selective NOM, depending on the situation, seems necessary in determining the treatment plan. In this study, we attempted to identify risk factors for surgical or angiographic intervention (SAI) in hemodynamically stable blunt abdominal trauma patients. This retrospective study which included adult patients who were brought to a regional trauma center was conducted from March 2015 to October 2019. We evaluated the characteristics of blunt abdominal trauma patients and analyzed factors that were related to the requirement of SAI in these patients. Patients were divided into SAI and conservative management (CM) groups. We reviewed 1,176 patients, and after exclusions, of whom 248 blunt abdominal trauma and free fluid observed on CT were identified. The mean pulse rate was higher in the SAI than in the CM (P=0.025). Laboratory findings showed that lactate and delta neutrophil index (DNI) levels were higher in the SAI than in the CM (P=0.002 and 0.026 respectively). Additionally, the mean free fluid size in the SAI (85.69mm) was significantly larger than that in the CM (68.12mm; P=0.001), and blush was more frequently observed in the SAI (P<0.001). In multivariate analysis, only blush was an independent prognostic factor for SAI (OR 11.7, 95% CI, 5.1-30.8, P<0.001). In hemodynamically stable patients with blunt abdominal trauma, blush but also high lactate and DNI are associated with the requirement of interventional radiology and/or surgery.

Results of Selective Non-Operative Management for Penetrating Neck Trauma in 594 patients.

Background: The management of penetrating neck trauma (PNT) evolved from a policy of mandatory exploration to one of selective non-operative management (SNOM) based on clinical examination, and the liberal use of Computed Tomography Angiography (CTA) irrespective of the zone of injury for those patients who are stable on presentation.&#x0D; Methods: A retrospective audit of patients with penetrating neck injuries managed at Chris Hani Baragwanath Academic Hospital (CHBAH) Trauma Unit, from 2010 to 2015 was conducted. Statistical analysis was performed for all collected variables. A p-value of ≤ 0.05 was considered statistically significant. &#x0D; Results: The results of treatment of 594 patients were reviewed. There was a predominance of young males (93.4%) with a median age of 28 years (IQR 18-67) presenting with injuries in zone 2, left side of the neck, commonly due to stab wounds (89.3%). Immediate surgical exploration was needed in 145(24.4%), while the remaining (75.4%) were investigated with CTA. CTA showed a sensitivity and specificity of over 90% for vascular injuries and more than 80% for aerodigestive injuries. Major vascular injuries were the most common surgical finding. The overall negative exploration rate was 6%, and the mortality 2.5%.&#x0D; Conclusions: Our unit’s SNOM protocol relies on liberal CTA use. Despite the obvious limitations of a retrospective study our results showed an acceptable negative and non-therapeutic exploration rate and a low incidence of complications and mortality.

Selective nonoperative management (SNOM) for penetrating abdominal wounds

The authors summarize the world experience in the management of patients with penetrating abdominal wounds. A gradual transition from the concept of «mandatory laparotomy» to selective management and active-expectant approach in appropriate cases is described.

In Solid Organ Injury Patients Requiring Blood Transfusion, Hemostatic Procedures are Associated with Improved Survival Over Observation.

Selective nonoperative management (NOM) is the standard of care for blunt solid organ injury (SOI). Hemodynamic instability is a contraindication for NOM, but it is unclear whether the need for blood transfusion should be a criterion for instability. This study looks at the outcome of blood-transfused SOI patients to determine whether NOM is safe for this group. This is a retrospective cohort study using the National Trauma Data Bank years 2017 through 2019. We selected patients with blunt liver, spleen, and kidney injuries. Within this group, we compared the mortality for those managed with NOM versus the hemostatic procedures of laparotomy and angioembolization. Significance for univariate analysis is tested with Chi-square for categorical variables. Multivariate analysis is performed with Cox proportional hazards regression with time-dependent covariate. 108,718 (3.5%) patients for the years 2017 through 2019 had a SOI. 20,569 (18.9%) of these received at least one unit of packed red blood cells (PRBCs) within the first 4 h. Of the SOI patients who received blood, 8264 (40.2%) underwent laparotomy only, 2924 (14.2%) underwent embolization only, and 1119 (5.4%) underwent both procedures. The adjusted odds ratios (ORs) of death for transfused SOI patients who underwent laparotomy only, embolization only, and both procedures are 0.93 (P = not significant), 0.27 (P < 0.001), and 0.48 (P < 0.001), respectively. The ORs of death with laparotomy for patients receiving >1 through 4 units are 0.87, 0.78, 0.75, and 0.72, respectively (P ≤ 0.01 for all). For embolization, the ORs are 0.27, 0.30, 0.30, and 0.30, respectively (P < 0.001 for all). Laparotomy is independently associated with survival for patients who receive >1 unit of PRBCs. Angioembolization is independently associated with survival for the entire cohort, including transfused patients. Given the protective association of laparotomy in the blood-transfused SOI group, need for blood transfusion should be considered a meaningful index of instability and a relative indication for laparotomy. The protective association with angioembolization supports current practices for angioembolization of high-risk patients in the transfused and nontransfused groups.

Choosing the Best Treatment for Grade IV Renal Injuries that Are Isolated and Not Isolated

Objective: Grades I to III are the most common kidney injuries, and they are successfully treated non-operatively with high functional preservation. The objective of this study was to review all grade IV renal injuries and report outcomes. It also sought to ascertain whether operative and selective non-operative management could result in high salvage rates and whether management and outcomes varied noticeably between cases of isolated grade IV renal injuries and those with concomitant multi-organ injuries. Method: The data of 50 grade IV kidney injuries that occurred at Department of Urology, Rajendra Institute of Medical Science, Ranchi for ten years. These were split into two groups: those with isolated grade IV renal injuries (30) and those with accompanying nonrenal injuries (20), and both groups were analyzed with regard to the kind of renal injury, operative vs. nonoperative care, operational nephrectomy rate, and operational renal salvage rate. Salvage was defined as having a 50% or greater function of the injured kidney and an overall renal function of at least 20%. Results: With an overall salvage rate of 83%, 35 of the 50 patients were operated on and 15 were not. 35 injuries were caused by penetrating trauma, 10 by blunt trauma, and 5 out of 50 (51%) were renal vascular injuries. Grade IV renal injuries requiring operational exploration that also had concurrent related injuries were healed at exploration with a 14% nephrectomy rate and an 82% salvage rate. With an average transfusion need of 8.5 units packed red blood cells, 15 (41%) of the 30 patients with isolated injuries required surgical exploration. One patient (10%) required a nephrectomy, two kidneys were postoperatively nonfunctional, and one mild complication was found. Only 10 patients needed transfusions (average 2.5 units), and 87% of the remaining 20 isolated grade IV renal injuries were handled nonoperatively. There was no need for delayed nephrectomy in any of the 35 nonoperative patients of solitary or nonisolated renal injury. Three individuals had minimal problems, while five cases had non-functioning kidneys. Conclusion: Since isolated grade IV renal injuries provide a special case where the patient must be treated purely based on the severity of the renal injury, nonoperative therapy is applied more frequently. The primary reason for exploring and reconstructing the kidneys is persistent bleeding. Non-operative therapy should only be used in all cases of severe renal damage when patients are hemodynamically stable and have undergone full renal staging.

Selective Non-operative Management of High Grade Splenic Injuries Is Safe in Both the Short and Long Term

Selective Non-operative Management of High Grade Splenic Injuries Is Safe in Both the Short and Long Term

EGS P03 Selective non-operative management of high grade splenic injuries is safe in both the short and long term

Abstract Background Blunt and penetrating splenic injuries represent a significant component of the workload in major trauma centres in the UK. International guidelines recommend intervention for patients suffering high grade injuries. This single centre retrospective cohort study assessed current management of adults with splenic injuries, stratified by World Society of Emergency Surgery (WSES) classification, and compared this to the recommended management proposed by the WSES guidelines. Methods Patients admitted between April 2014 to January 2021 to a major trauma centre with splenic injuries were prospectively assessed. Data on AAST grade, WSES class, radiological imaging, definitive interventions performed, length of admission, follow-up imaging and short and long-term outcome were collected. Results 143 patients with splenic injuries were admitted during the study period. 5 patients were excluded due to inadequate clinical information. 138 patients with splenic injury were analysed. 50 suffered WSES grade 1 injuries, 25 WSES grade 2, 18 WSES grade 3 and 45 WSES grade 4. Patients with WSES grade 3 and 4 injuries were managed as follows: conservative 13, angioembolisation 38 and splenectomy 12. Length of stay did not differ between groups. No patient undergoing non-operative management required salvage splenectomy. One patient undergoing angioembolisation required laparoscopic drainage of splenic abscess secondary to infarction. During the study period 4 patients died (2.7)%. The cause of death in each case was due to other injuries. Long term imaging follow up was organised in 31 patients undergoing angioembolisation. 30 patients (97%) had imaging features suggestive of perfused splenic tissue. Conclusions Conservative management of splenic injuries with the addition of angioembolisation for high grade injuries led to a splenectomy rate of less than 10% in this study. This strategy led to low morbidity with only one patient requiring subsequent intervention and no splenic injury related mortality. This study validates the increasing trend towards non-operative management for splenic injuries.

Selective Nonoperative Management of Penetrating Splenic Injuries: A Nationwide Analysis

Selective Nonoperative Management of Penetrating Splenic Injuries: A Nationwide Analysis

Traumatic injuries to the trachea and bronchi: a narrative review.

ObjectiveIn this narrative review, we aim to provide a definition of traumatic tracheo-bronchial injuries as well as an approach to their diagnosis and management, including operative and non-operative strategies.BackgroundTraumatic tracheo-bronchial injuries are relatively uncommon, but are associated with a high mortality, both at the scene and among patients who survive to hospital. Management often requires an emergency airway, usually intubation over a flexible bronchoscope, followed by definitive repair.MethodsThe published literature on the diagnosis and management of traumatic airway injuries was searched through PubMed. Additional references were identified from the bibliography of relevant publications identified. The evidence was then summarized in a narrative fashion, incorporating the authors’ knowledge, experience, and perspective on the topic.ConclusionsDefinitive diagnosis of traumatic tracheo-bronchial injuries usually involves direct visualization through liberal use of bronchoscopy in addition to cross-sectional imaging to evaluate for associated injuries, notably to the great vessels and esophagus. Important considerations for management include concerns for airway obstruction, uncontrolled air leak, and mediastinitis. Early repair of injuries recognized acutely is favored in attempts to prevent the development of airway stenosis. Key operative principles include exposure, conservative debridement to preserve length when possible, creation of a tension-free anastomosis, preservation of the blood supply, and creation of a tracheostomy, particularly in polytrauma patients. An interposition muscle flap is also required, specifically in the setting of combined esophageal and airway injuries. Patients with penetrating injuries tend to have more favorable outcomes, possibly on account of fewer concomitant injuries. Selective non-operative management is also an option in the subset of patients with iatrogenic injuries to the posterior membranous wall of the trachea, and includes broad-spectrum antibiotics and surveillance bronchoscopy.

Pediatric abdominal trauma in a National Referral Hospital.

Trauma is a major contributor to pediatric morbidity and mortality. Injury and violence are a major killer of children throughout the world. Unintentional injuries account for almost 90% of these cases. They are the leading cause of death for children aged 10-19 years. More than 95% of all injury deaths in children occur in low income and middle-income countries. Abdominal trauma is present in approximately 25% of pediatric patients with major trauma and is the most common cause of unrecognized fatal injury in children. To describe the patterns, the management and outcomes of pediatric abdominal trauma.This was a descriptive retrospective study. Data was extracted from the Pediatric surgery Unit database from January 2012 to July 2019 on all abdominal trauma admissions to the unit. Falls were the commonest (51.3%) mechanism for trauma on the unit. Most (84%) of the admissions had blunt abdominal trauma, with the majority (77%) managed non operatively. Only 16% had penetrating trauma, with the majority (84%) of these managed operatively. The average length of hospital stay for most (71.9%) of the patients was less than 7 days, with 96.1% of all admitted patients being discharged upon recovery. Blunt abdominal trauma is the most common pattern of pediatric abdominal trauma, with majority of these patients being managed non-operatively with good outcomes. Selective non-operative management for penetrating pediatric abdominal trauma has good patient outcomes as well.

Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds.

Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW. This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed. Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99). While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI. Diagnostic Test or Criteria; Level II.

Trends in the Management of Abdominal Gunshot Wounds Over the Last Decade: A South African Experience

This study aimed to review our decade-long experience with the management of abdominal gunshot wounds (GSWs), to document trends in our approach and to develop an evidence base for our contemporary management algorithms in a major trauma in South Africa. This was a retrospective study that included all adult patients with abdominal GSWs between January 2013 and October 2020 managed at a major trauma centre in South Africa. Five hundred and ninety-six cases were included (87% male, mean age: 32years). The median Injury Severity Score (ISS) was 12. 52% (309/596) of cases had indications of immediate laparotomy and proceeded directly to the operating room without any CT imaging. Of this cohort, the laparotomy was positive in 292 and in the remainder (5%) was negative. Of the remaining 287 cases, 209 underwent a CT scan (35%). 78 were managed without any CT imaging. Of the 78 who did not undergo CT scan, all were managed without any operation and discharged home well. Of the 209 who underwent CT scan, 99 were observed and only one case in this group subsequently required a laparotomy. The remaining 110 cases underwent a laparotomy, which was negative in 7. There were correlations with increasing use of CT, as well as a decrease in those proceeding directly to laparotomy. The overall morbidity rate was 8% (47/596). 32% (190/596) require intensive care unit (ICU) admission. The overall mortality rate was 8% (67/596). The management of abdominal GSWs has continued to evolve. There is now a well-defined role for selective non-operative management in this group of patients and relies on accurate CT assessment. CT scan is now an important component in the management of abdominal GSW even in our resource-constrained environment.

Relationship between the anatomical location and the selective non-operative management of penetrating stab wounds in the abdomen

IntroductionThe relationship between the anatomical location of penetrating abdominal stab wounds (SW) and the rate of selective non-operative management (SNOM) based on that location is scarcely reflected in the specialized literature. Our main objective has been to assess this rate based on the anatomical location, and our results. MethodsRetrospective review of a prospective registry of abdominal trauma from April 1993 to June 2020. The two study groups considered were the Operative Management (OM), and the SNOM, including in this one the use of diagnostic laparoscopy. Penetrating SWs in the abdomen were classified according to anatomical location. ResultsWe identified 259 patients who fulfilled the inclusion criteria. SNOM was applied in 31% of the patients with a success rate of 96%, and it was more frequent in the lumbar, flank, and thoraco-abdominal regions; within the anterior abdomen it was more applicable in the RH, followed by the LH and epigastrium, respectively. An unnecessary laparotomy was done in 21% of patients, with the highest number in the epigastrium. Taking into account the unnecessary laparotomies and the rates of successful SNOM, 70.5% of lumbar, 66.5% of epigastric, 62% of flank, and 59% of RH penetrating SW could have been managed without a laparotomy. ConclusionsSNOM of penetrating SW in the abdomen has been safer and more applicable in those located in the lumbar, flank, epigastric, and RH regions.

Obesity and Anterior Abdominal Gunshot Wounds: A Cushion Effect.

BackgroundAlthough the standard of care for anterior abdominal gunshot wounds (AAGSWs) is immediate laparotomy, these operations are associated with a high rate of negativity and potentially serious complications. Recent data suggest the possibility of selective non-operative management (SNOM) of AAGSWs, but none implicate body mass index (BMI) as a factor in patient selection. Anecdotal experience at our trauma center suggested a protective effect of obesity among patients with AAGSWs, and given the exceptionally high rate of obesity in the Bronx, we sought to analyze the associations of AAGSWs and BMI to inform future trauma research and management. In this study, we aimed to evaluate whether BMI is associated with injury severity, resource utilization, and clinical outcomes of AAGSWs.MethodologyFrom our prospectively accrued trauma registry, we retrospectively abstracted all patients greater than 16 years old with Current Procedural Terminology codes associated with gunshot wounds from 2008 to 2016. The electronic medical record was reviewed to define a cohort of patients with at least one AAGSW. Patients were divided into the following cohorts based on BMI: underweight (UW, BMI: <18.5), normal weight (NW, BMI: 18.5-24.9), overweight (OW, BMI: 25-29.9), and obese (OB, BMI: ≥30). Among these cohorts, we analyzed data regarding injury severity, resource utilization, and clinical outcomes.ResultsIn this study, none of the patients were UW, 17 (42.5%) patients were NW, 15 (37.5%) patients were OW, and eight (20%) patients were OB. One patient each in the NW and OB cohorts was successfully managed non-operatively, while all others underwent immediate exploratory laparotomy. The mean new injury severity score was significantly lower as BMI increased (NW = 30.9 ± 17.0, OW = 22.9 ± 16.1, and OB = 12.8 ± 13.7; p = 0.039). Patients in the OB cohort were less likely to have abdominal fascial penetration compared to the OW and NW cohorts (p = 0.027 and 0.004, respectively) and sustained fewer mean visceral injuries compared to the OW and NW cohorts (p = 0.027 and 0.045, respectively). OB patients were significantly more likely to have sustained two or more AAGSWs (OB = 27.5%, OW = 6.7%, and NW = 5.9%; p = 0.033), suggesting higher rates of tangential soft tissue injuries. The mean hospital length of stay down-trended as BMI increased but did not achieve statistical significance (NW = 7.4 ± 5.3, OW = 6.6 ± 6.7, and OB = 3.1 ± 2.3; p = 0.19). The OB cohort had the lowest mean hospital charges.ConclusionsObesity may yield a protective effect among AAGSW victims, and BMI may provide trauma surgeons another tool to triage patients for SNOM of AAGSWs, potentially diminishing the risks associated with negative laparotomy. Our data serve as the basis for the analysis of a larger patient cohort.