Elsevier

Injury

Volume 45, Issue 4, April 2014, Pages 659-666
Injury

Review
Selective non-operative management of civilian gunshot wounds to the abdomen: A systematic review of the evidence

https://doi.org/10.1016/j.injury.2013.07.008Get rights and content

Abstract

Background

Selective non-operative management (SNOM) of penetrating abdominal wounds has become increasingly common in the past two or three decades and is now accepted as routine management for stab wounds. Gunshot wounds are more frequently managed with mandatory laparotomy but recently SNOM has been successfully applied. This review systematically appraises the evidence behind SNOM for civilian abdominal gunshot wounds.

Methods

A Medline search from 1990 to present identified civilian studies examining success rates for SNOM of abdominal gunshot wounds. Case reports, editorials and abstracts were excluded. All other studies meeting the inclusion criteria of reporting the success rate of non-operative management of abdominal gunshot wounds were analysed.

Results

Sixteen prospective and six retrospective studies met the inclusion criteria, including 18,602 patients with abdominal gunshot wounds. 32.2% (n = 6072) of patients were initially managed non-operatively and 15.5% (n = 943) required a delayed laparotomy. The presence of haemodynamic instability, peritonitis, GI bleeding or any co-existing pathology that prevented frequent serial examination of the abdomen from being performed were indications for immediate laparotomy in all studies. Delayed laparotomy results in similar outcomes to those in patients subjected to immediate laparotomy. Implementation of SNOM reduces the rates of negative and non-therapeutic laparotomies and reduces overall length of stay.

Conclusions

SNOM can be safely applied to some civilian patients with abdominal gunshot wounds and reduces the rates of negative or non-therapeutic laparotomy. Patients who require delayed laparotomy have similar rates of morbidity and mortality and similar length of stay to those patients who undergo immediate laparotomy.

Introduction

The surgical management of gunshot wounds (GSW) to the abdomen has for many years been mandatory laparotomy [1], [2], whereas more recently blunt trauma and stab wounds have been successfully managed non-operatively in selected patients [3], [4], [5], [6]. Such a policy of selective non-operative management (SNOM) significantly reduces the rates of negative or non-therapeutic laparotomy and reduces patient morbidity, length of stay and cost [7], [8], [9].

Potential candidates for SNOM after penetrating abdominal injury must be haemodynamically stable and without peritonitis on examination [9], [10]. They should be routinely investigated with contrast enhanced computed tomography (CT) scans to identify intra-abdominal injury. CT evidence of hollow viscus injury mandates laparotomy but solid organ injury in the stable patient may not necessitate surgery [11], [12], [13]. SNOM is not ‘doing nothing’ and is an active process in which a patient is serially and regularly assessed by an experienced surgeon, preferably the same one, to detect changes in the abdominal examination. Any other injury that precludes serial examination such as a decreased conscious level from drugs, drink or head injury, or another indication for surgery such as extremity trauma should also mandate laparotomy in the presence of penetrating abdominal injury [14], [15].

GSWs and other ballistic injuries to the abdomen are perceived to be less amenable to non-operative management as the energy transfer involved is usually far greater than in stabbings and the likelihood of significant intra-abdominal injury much higher [16]. Studies of surgery for civilian abdominal GSW describe rates of non-therapeutic laparotomy of up to 25%, suggesting that NOM could be successfully and usefully pursued in this group [14], [17].

Over the last two decades a number of studies looking at SNOM of abdominal GSW have been published and demonstrate that it is a viable technique in selected patients. This article reviews the evidence regarding SNOM of civilian GSW to the abdomen.

Section snippets

Materials and methods

An electronic search was performed of the Medline database covering the period 1990–Oct 2012 using the terms “abdominal gunshot wounds” and “conservative management” and the MeSH headings: “gunshot wounds”, “non-operative management”, “conservative management” and “ballistic wounds”. The search was limited to English language publications and human subjects. All titles and abstracts were reviewed, and appropriate papers further assessed. The reference sections of all relevant papers deemed

Results

Twenty-two studies were identified that fitted the inclusion criteria, comprising 18,602 patients with abdominal gunshot wounds (Table 1).

The largest group of patients by far was that provided by Nabeel Zafar et al. [34]. Their study analysed data from more than 12,000 patients from the North American National Trauma Database between 2002 and 2008 and is likely to include duplicate patients from other American studies published during or after this period [13], [27], [31], [32]. It is also

Discussion

Ideally this systematic review would have included a meta-analysis of SNOM of abdominal GSW, but the quality of the available data, differing definitions of SNOM and of what constitutes an abdominal GSW all preclude this possibility. Even if these definitions had been standardised throughout the studies reviewed, the likely degree of overlap and duplication seen in the published results would have significantly reduced the validity and power of such an analysis.

One of the principle difficulties

Conclusions

Non-operative management of abdominal gunshot wounds can be safely applied to approximately one third of civilian abdominal gunshot wounds – haemodynamic stability and an absence of signs of peritonitis are a pre-requisite. Other injuries that preclude serial clinical examination of the abdomen or a CT scan that shows hollow viscus injury are an indication for laparotomy even in the absence of clinical signs. In non-operatively managed patients, the development of abdominal signs or evidence of

Disclaimer

Any opinions expressed within this article are those of the authors and do not reflect the official position or policies of the Ministry of Defence.

Conflict of interest statement

The Authors declare that they have no conflicts of interest in the publication of this article. Both authors are employees of the UK Ministry of Defence and work as military surgeons within the UK National Health Service.

Acknowledgements

Many thanks to Mr Mike Rowe and his staff at the DMLS Central Library, Lichfield, for their assistance in obtaining the papers used for this article.

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