Outcomes of selective non-operative management in adults with abdominal gunshot wounds: a systematic review and meta-analysis

BACKGROUND AND AIMS

Abdominal gunshot wounds (GSWs), a clinically devastating injury, can result in a variety of severe and lethal complications. Traditionally, exploratory laparotomy is the first-line approach for the management of abdominal GSWs, but it is associated with a considerable amount of unnecessary surgeries. At present, selective non-operative management (SNOM) of abdominal GSWs is becoming an effective and well-recognized approach, but it remains widely disputed since many surgeons are skeptical about the validity of SNOM in clinical practice. This meta-analysis aims to estimate the outcomes of SNOM and immediate laparotomy in patients with GSWs by collecting the currently available evidence.

METHODS

The PubMed , EMBASE , and Cochrane Library databases were searched. A random-effects model was employed. A pooled proportion with 95% confidence intervals (CIs) was calculated. Heterogeneity was evaluated using Cochran's Q test and I2 statistics.

RESULTS

Overall, 53 studies involving 60 291 participants were included. The pooled proportions of SNOM and SNOM failure were 27.0% (95% CI=24.0-30.0%) and 10.0% (95% CI=7.0-13.0%), respectively. The pooled mortality after SNOM and SNOM failure were 0.0% (95% CI=0.0-1.0%) and 0.0% (95% CI=0.0-0.0%), respectively. The pooled proportions of immediate laparotomy and unnecessary immediate laparotomy were 73.0% (95% CI=70.0-76.0%) and 10.0% (95% CI=8.0-13.0%), respectively. The pooled mortality after immediate laparotomy and unnecessary immediate laparotomy was 10.0% (95% CI=8.0-13.0%) and 0.0% (95% CI=0.0-1.0%), respectively. Heterogeneity was statistically significant in nearly all meta-analyses.

CONCLUSION

Immediate laparotomy is still the mainstay approach for the management of abdominal GSWs. Approximately one-third of patients with abdominal GSWs undergo SNOM. SNOM failure is not frequent, and its related mortality is also rare.

Gastric Artery Injury Due to Blunt Abdominal Trauma

Gastric artery injury resulting from blunt abdominal trauma is rare, with only eight previous cases documented in the published literature. Our report describes a case involving an injury to the right gastric artery with concomitant injuries to the liver and spleen, for which arterial embolization targeting the right gastric artery was performed. The patient, a 66-year-old woman without any remarkable medical history, was involved in a motor vehicle accident. She was brought to the hospital in a state of shock and complaining of upper abdominal pain. Contrast-enhanced CT indicated hepatic and splenic injuries, intra-abdominal hemorrhaging, and effusion of contrast medium, suggesting involvement of the right gastric artery. Subsequent angiography confirmed irregularities in the diameter of the right gastric artery, prompting coil embolization. A conservative therapeutic approach was selected due to the absence of evidence regarding active hemorrhage or vascular injury within the hepatic or splenic regions. The patient remained clinically stable following the embolization, without any sequelae. Arterial embolization is warranted if preoperative contrast CT indicates signs of hemorrhage, even if hemostasis is ostensibly attained during angiography. Our findings allude to the feasibility of non-operative management (NOM) rather than laparotomy for cases of gastric artery injury.

Conservative Management of Gunshot Wound to Anterior Abdomen in a Resource-Poor Setting in the Caribbean

Previously, the management of gunshot wounds (GSWs) to the anterior abdomen required exploratory laparotomy; however, this was associated with a considerable number of non-therapeutic surgeries. The use of non-operative management (NOM) of GSW to the abdomen is controversial, with many surgeons sceptical to accept this into their practice. The NOM of GSW to the abdomen employed in a selected group of patients has been shown to be safe and acceptable. Penetrating GSW to the thoraco-abdomen, back and lateral abdomen has been the most successful compared to the anterior penetrating wound. Most of the anterior GSWs to the abdomen are associated with viscus injury and require exploratory laparotomy. We report the case of a 58-year-old male who presented with a single GSW to the epigastrium with a contrast computed tomography scan demonstrating grade 3 liver lacerations, contusion to the right adrenal gland, with moderate free fluids in the retroperitoneum and the pelvis. The patient was haemodynamically stable and managed successfully with NOM. It is one of the safe routes of anterior penetration of GSW to the abdomen and treated with conservative management.

Blunt and Penetrating Liver Trauma have Similar Outcomes in the Modern Era

BACKGROUND

The trend in liver trauma management has progressively become increasingly conservative. However, a vast majority of literature focuses heavily on the management of blunt trauma. This study reviews the management of hepatic trauma at a major trauma center in a developing world setting, in order to compare blunt and penetrating liver trauma and to define current management algorithms and protocols.

METHODS

All patients who sustained liver trauma between 2012 to 2018 were identified in the Hybrid Electronic Medical Registry and extracted for further analysis.

RESULTS

A total of 808 patients with hepatic trauma were managed by our trauma center. There were 658 males and 150 females. The mean age was 30 years (standard deviation 13.3). A total of 68 patients died (8.2%) and a total of 290 (35%) patients required intensive care unit admission. The mean presenting shock index was 0.806 (standard deviation 0.67-1.0), the median Injury Severity Score was 18 (interquartile range 10-25) and the mean Revised Trauma Score was 12 (standard deviation 11-12). There were 367 penetrating and 441 blunt liver injuries. The age distribution was similar in both groups. There were significantly less females in the penetrating group. The shock index and the Injury Severity Score on presentation were significantly worse in the blunt group, respectively: 0.891 (standard deviation 0.31) versus 0.845 (standard deviation 0.69) (p < 0.001) and score 21 (interquartile range 13-27) versus 16 (interquartile range 9-20) (p < 0.01). The opposite applied to the Revised Trauma Score of 11.75 (standard deviation 0.74) versus 11.19 (standard deviation 1.3) (p < 0.001). There were significantly more associated intra-abdominal injuries in the penetrating group than the blunt group, in particular that of hollow organs, and 84% of patients with a penetrating injury underwent a laparotomy while only 33% of the blunt injuries underwent a laparotomy. The mortality rate was comparable between both groups.

CONCLUSION

Hepatic trauma is still associated with a high morbidity rate, although there have been dramatic improvements in mortality rates over the last three decades. The mortality rates for blunt and penetrating liver trauma are now similar. Non-operative management is feasible for over two-thirds of blunt injuries and for just under 20% of penetrating injuries.