Conservative management versus surgical intervention for penetrating abdominal shotgun injuries
Keywords:Shotgun, Conservative, Operative, Trauma
Background: The objective of the study was to present our experience of selective conservative management of abdominal gunshot wounds in University hospital over three years.
Methods: This prospective study included 30 patients who presented with shotgun injuries to the abdomen. The study included only patients with bird shots (small pellets, number 6), who are vitally stable with evidence of penetration on CT scan, and with no hemoperitoneum, pneumoperitoneum, or collection. They were allocated to one of two groups according to the surgeon preference. Patients in the Operative Group were transferred for immediate exploratory laparotomy. Patients in the Conservative Group were closely observed for 48 hours, received nothing per oral with the administration of antibiotics and fluid and no analgesics. After 48 hours, if the patients were stable with no complications, they were discharged. Conservative management was terminated for vital instability, hemoglobin drop, rising white blood cells count, fever, abdominal symptoms, and signs of peritonitis.
Results: Exploration yielded a negative result in 9 out of 14 patients (64.3%) of the Operative Group. Four patients had significant injuries, and one had an insignificant injury. Postoperative complications occurred in 3 patients. Conservative management failed in one patient who developed high fever and abdominal symptoms.Conclusions:In patients with penetrating abdominal shotgun injuries with no evidence of abdominal organ injuries, conservative management is a safe and successful option based of strict selection criteria including small shots in a hemodynamically stable patient with evidence of penetration on CT scan, and with no hemoperitoneum, pneumoperitoneum or collection.
Nicholas JM, Rix EP, Easley KA, Feliciano DV, Cava RA, Ingram WL, et al. Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma. 2003;55:1095–110.
Pryor JP, Reilly PM, Dabrowski GP, Grossman MD, Schwab CW. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med. 2004;43:344–53.
Singh N, Hardcastle TC. Selective non operative management of gunshot wounds to the abdomen: a collective review. Int Emerg Nurs. 2015;23:22–31.
Navsaria PH, Berli JU, Edu S, Nicol AJ. Non-operative management of abdominal stab wounds--an analysis of 186 patients. South Afr J Surg Suid-Afr Tydskr Vir Chir. 2007;45:128–30, 132.
Saadia R, Degiannis E. Non-operative treatment of abdominal gunshot injuries. Br J Surg. 2000;87:393–7.
Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA, et al. Practice management guidelines for selective nonoperative management of penetrating abdominal trauma. J Trauma. 2010;68:721–33.
Renz BM, Feliciano DV. The length of hospital stay after an unnecessary laparotomy for trauma: a prospective study. J Trauma. 1996;40:187–90.
Al Rawahi AN, Al Hinai FA, Boyd JM, Doig CJ, Ball CG, Velmahos GC, et al. Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis. World J Emerg Surg. 2018;13:55.
Brown CVR, Velmahos GC, Neville AL, Rhee P, Salim A, Sangthong B, et al. Hemodynamically “stable” patients with peritonitis after penetrating abdominal trauma: identifying those who are bleeding. Arch Surg Chic Ill 1960. 2005;140:767–72.
Velmahos GC, Demetriades D, Toutouzas KG, Sarkisyan G, Chan LS, Ishak R, et al. Selective Nonoperative Management in 1,856 Patients With Abdominal Gunshot Wounds: Should Routine Laparotomy Still Be the Standard of Care? Ann Surg. 2001;234:395–403.
Bennett S, Amath A, Knight H, Lampron J. Conservative versus operative management in stable patients with penetrating abdominal trauma: the experience of a Canadian level 1 trauma centre. Can J Surg J Can Chir. 2016;59:317–21.
Múnera F, Morales C, Soto JA, Garcia HI, Suarez T, Garcia V, et al. Gunshot wounds of abdomen: evaluation of stable patients with triple-contrast helical CT. Radiology. 2004;231:399–405.
Velmahos GC, Constantinou C, Tillou A, Brown CV, Salim A, Demetriades D. Abdominal computed tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative management. J Trauma. 2005;59:1155–61.
Laing GL, Skinner DL, Bruce JL, Bekker W, Oosthuizen GV, Clarke DL. A multi faceted quality improvement programme results in improved outcomes for the selective non-operative management of penetrating abdominal trauma in a developing world trauma centre. Injury. 2014;45:327–32.
Velmahos GC, Demetriades D, Toutouzas KG, Sarkisyan G, Chan LS, Ishak R, et al. Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg. 2001;234:395–403.
Peponis T, Kasotakis G, Yu J, Alouidor R, Burkott B, Maung AA, et al. Selective Nonoperative Management of Abdominal Gunshot Wounds from Heresy to Adoption: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCoNECT). J Am Coll Surg. 2017;224:1036–45.
Inaba K, Branco BC, Moe D, Barmparas G, Okoye O, Lam L, et al. Prospective evaluation of selective nonoperative management of torso gunshot wounds: when is it safe to discharge? J Trauma Acute Care Surg. 2012;72:884–91.
Chamisa I. Civilian Abdominal Gunshot Wounds in Durban, South Africa: A Prospective Study of 78 Cases. Ann R Coll Surg Engl. 2008;90:581–6.
Hope WW, Smith ST, Medieros B, Hughes KM, Kotwall CA, Clancy TV. Non-operative management in penetrating abdominal trauma: is it feasible at a Level II trauma center? J Emerg Med. 2012;43:190–5.
Navsaria PH, Nicol AJ, Krige JE, Edu S. Selective nonoperative management of liver gunshot injuries. Ann Surg. 2009;249:653–6.
Inaba K, Barmparas G, Foster A, Talving P, David J-S, Green D, et al. Selective Nonoperative Management of Torso Gunshot Wounds: When Is It Safe to Discharge? J Trauma Inj Infect Crit Care. 2010;68:1301–4.
DuBose J, Inaba K, Teixeira PGR, Pepe A, Dunham MB, McKenney M. Selective non-operative management of solid organ injury following abdominal gunshot wounds. Injury. 2007;38:1084–90.
Ginzburg E, Carrillo EH, Kopelman T, McKenney MG, Kirton OC, Shatz DV, et al. The Role of Computed Tomography in Selective Management of Gunshot Wounds to the Abdomen and Flank. J Trauma Inj Infect Crit Care. 1998;45:1005–9.