Invited Critique |

Abdominal Gunshot Wounds: Not Yet Ready for Implementation:  Comment on “Successful Selective Nonoperative Management of Abdominal Gunshot Wounds Despite Low Penetrating Trauma Volumes”

Lenworth M. Jacobs, MD
Arch Surg. 2011;146(5):533. doi:10.1001/archsurg.2011.80.
Text Size: A A A
Published online


The authors have addressed a controversial clinical issue in trauma surgery. They have evaluated if selective nonoperative management of AGSW is a safe practice in trauma centers with a low volume of penetrating trauma. They retrospectively examined patients with anterior and posterior gunshot wounds and chose to use nonoperative management in those patients who appeared stable. This practice is counter to the current practice of operating on patients who have AGSW. Fikry et al chose to observe these patients in an observation unit in which frequent physical examinations and CT scans occur. The authors report that 7 patients (18%) required a delayed laparotomy, 6 of whom had worsening abdominal signs and symptoms. They report that none of their patients with a delayed laparotomy had hemodynamic instability. Presumably, those patients who had major hemorrhage presented either immediately or within 2 hours and were taken to the operating room. This delayed group either had injuries to the small bowel or colon that presented in a delayed fashion. Whereas this is a provocative and interesting study, it would not be wise for trauma surgeons to observe patients with AGSW who have an injured viscus. The risk of contamination, abscess formation, adhesions, morbidity, and mortality far outweighs the potential benefit of observation. The authors also selectively managed a patient with a gunshot wound to the abdomen who had free air under the diaphragm. It would be extremely unwise for this to become a widespread practice since the majority of these patients would have a major visceral injury with clear need for surgical repair. The authors do state that they found few complications and shorter hospital stays among those patients who they selectively managed without an operative procedure. Whereas this is laudable, again it is not worth putting those patients who may develop significant morbidity and mortality at risk by observing them when an exploratory laparotomy would completely exclude an injury or would allow for immediate management of an injured organ or viscus. This is a provocative article. However, it would not be recommended that selectively managing gunshot wounds to the abdomen become a widely accepted practice by trauma surgeons.

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours

First Page Preview

View Large
First page PDF preview





Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Topics
PubMed Articles