Selective nonoperative management in 1,856 patients with abdominal gunshotwounds: Should routine laparotomy still be the standard of care?

Objective To evaluate the safety of a policy of selective nonoperative mana gement (SNOM) in patients with abdominal gunshot wounds. Summary Background Data Selective nonoperative management is practiced exte nsively in stab wounds and blunt abdominal trauma, but routine laparotomy i s still the standard of care in abdominal gunshot wounds. Methods The authors reviewed the medical records of 1,856 patients with abd ominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8- year period in a busy academic level 1 trauma center and managed by SNOM. A ccording to this policy, patients who did not have peritonitis, were hemody namically stable, and had a reliable clinical examination were observed. Results Initially, 792 (42%) patients (34% of patients with anterior and 68 % with posterior abdominal gunshot wounds) were selected for nonoperative m anagement. During observation 80 (4%) patients developed symptoms and requi red a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all pa tients). If patients were managed by routine laparotomy, the unnecessary la parotomy rate would have been 47% (39% for anterior and 74% for posterior a bdominal gunshot wounds). Compared with patients with unnecessary laparotom y, patients managed without surgery had significantly shorter hospital stay s and lower hospital charges. By maintaining a policy of SNOM instead of ro utine laparotomy, a total of 3,560 hospital days and $9,555,752 in hospital charges were saved over the period of the study. Conclusion Selective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an i n-house trauma team. It reduces significantly the rate of unnecessary lapar otomy and hospital charges.