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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.
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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.

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