TRANSPELVIC GUNSHOT WOUNDS - ROUTINE LAPAROTOMY OR SELECTIVE MANAGEMENT

Citation
Gc. Velmahos et al., TRANSPELVIC GUNSHOT WOUNDS - ROUTINE LAPAROTOMY OR SELECTIVE MANAGEMENT, World journal of surgery, 22(10), 1998, pp. 1034-1038
Citations number
14
Categorie Soggetti
Surgery
Journal title
ISSN journal
03642313
Volume
22
Issue
10
Year of publication
1998
Pages
1034 - 1038
Database
ISI
SICI code
0364-2313(1998)22:10<1034:TGW-RL>2.0.ZU;2-Z
Abstract
Mandatory exploration is the standard method for managing patients wit h gunshot wounds to the abdomen and hack. This policy is associated wi th a high incidence of unnecessary laparotomies and significant morbid ity. Reports from our center have shown that a policy of selective man agement, based on clinical findings, is safe in such patients. Patient s with bullet trajectories that carry a high likelihood for intraabdom inal organ injury may constitute a subgroup at particular risk. The ne ed for routine or selective exploration in similar patients must be as sessed. Therefore we decided to analyze patients with transpelvic guns hot wounds. The objective of the study was to examine if a policy of s elective management of patients with transpelvic gunshot wounds is saf e. This prospective study was conducted at an academic level I trauma center. We admitted 37 patients with transpelvic gunshot wounds over a 12-month period. All patients were managed according to a protocol th at dictated laparotomy in the presence of significant clinical finding s (peritoneal signs, hemodynamic instability, gross hematuria, rectal bleeding) and observation in the absence of the above. Additional diag nostic workup was performed only in appropriate cases rather than rout inely. Nineteen (51.3%) patients were immediately operated on the basi s of clinical findings. Sixteen of these laparotomies were therapeutic . Eighteen (48.6%) patients were initially observed, Subsequently, thr ee of them underwent exploration for development of abdominal tenderne ss. All three laparotomies were nontherapeutic. The remaining 15 (40.5 %) patients were successfully managed nonoperatively. There were no de lays in diagnosis or missed injuries, Clinical examination had a sensi tivity of 100% and specificity of 71.4% in detecting the need for lapa rotomy. A policy of selective management is thus safe, even for patien ts who suffer gunshot wounds with a high likelihood for intraabdominal organ injury, Clinical examination, supported by additional studies i n appropriate cases, is the main method of selecting patients for oper ation or nonoperative treatment.