Selective nonoperative management in 1106 patients with abdominal gunshot wounds: Conclusions on safety, efficacy, and the role of selective ct imaging in a prospective single-center study

Objective: The primary aim of this studywas to delineate the role of computed tomography (CT) in patients undergoing NOM for AGSW. Background: Nonoperative management (NOM) of abdominal gunshot wounds (AGSWs) remains controversial. Methods: This prospective study included all patients with abdominal gunshot injuries admitted to our trauma center from April 1, 2004 to September 30, 2009. Exclusion criteria included patients with peritonitis, hemodynamic instability, unreliable physical examination, head and spinal cord injury with an AGSW underwent immediate laparotomy. The remaining patients were selected for NOM. Nonperitonitic stable patients with right-sided thoracoabdominal/ right upper quadrant gunshots and/or hematuria underwent mandatory CT with intravenous contrast. CT to detect missile trajectorywas optional. The primary outcome measurewas failure of NOM. Secondary outcomeswere unnecessary laparotomy rates and mortality. Results: A total of 1106 patients with abdominal gunshot injuries were admitted. Of these, 834 (75.4%) underwent immediate laparotomy, whereas 272 (24.6%) were selected for NOM. In the former group, there were 56 (6.7%) deaths and 29 (3.5%) unnecessary laparotomies, whereas in the latter NOM group, 82 (30.1%) patients were managed by serial clinical examination alone, whereas 190 (69.9%) patients underwent abdominal CT scanning, in addition to serial clinical examination. The overall NOM success rate was 95.2%. Of the 13 patients undergoing delayed laparotomy, there were 10 therapeutic, 2 nontherapeutic, and 1 negative laparotomy. Conclusions: The NOM of appropriately selected patients with AGSW with selective use of CT scanning is feasible, safe, and effective, but largely based on findings from serial clinical examinations.