GUNSHOT WOUNDS TO THE RIGHT THORACOABDOMEN - A PROSPECTIVE-STUDY OF NONOPERATIVE MANAGEMENT

Dissatisfied with our unnecessary laparotomy rate in patients with gun shot wounds (GSWs) to the right thoracoabdomen (RTA), a prospective st udy was designed to test the hypothesis that hemodynamically stable pa tients without peritonitis could be managed without a surgical procedu re. From 1990 through 1993, 13 consecutive patients with a GSW between the right nipple, costal margin, right posterior axillary line, and a nterior midline were studied. No patient had or developed more than lo cal wound tenderness. All patients had a right hemothorax treated with a chest tube. Computed tomographic (CT) scanning of the RTA was perfo rmed within 8 hours of admission in 12 of the 13 patients, and the fol lowing injuries were noted: pulmonary contusion (12), hepatic lacerati on (seven), spinal cord transection (two), and a renal laceration (one ). Follow-up CT scans, 3 to 14 days after injury, in six of the seven patients with hepatic wounds showed partial or complete resolution of the injury in all. In one patient, an associated renal injury was unch anged on the follow-up CT scan. Mean length of hospitalization for the 11 patients who did not have an injury to the spinal cord was 5.1 day s (3-8 days). Complications included atelectasis (four), a small persi stent pneumothorax (two), and pneumonia (one). No complications occurr ed after discharge. Conclusions from this prospective study were: (1) hemodynamically stable patients without peritonitis after sustaining a GSW to the RTA can be managed nonsurgically with a low incidence of m inor intrathoracic complications; (2) thoracoabdominal CT scanning is a comprehensive means of diagnosis and follow-up when nonsurgical mana gement is chosen; and (3) such patients will usually have injury to th e right lung and the liver.