An increasing number of abdominal gunshot and stab wounds are being treated without the need for unnecessary operations, according to a study in the January Trauma Supplement published by the British Journal of Surgery. Researchers from The Johns Hopkins School of Medicine, USA, and the Aga Khan University in Pakistan reviewed nearly 26,000 patients with penetrating abdominal gunshot or stab injuries from the American College of Surgeons' National Trauma Data Bank.
The study found that just over 22 percent of the gunshot wounds were treated using selective non-operative management (SNOM), together with just under 34 percent of stab wounds. The remainder of the surviving patients received laparotomy surgery. "SNOM rates for stab wounds increased by 50 percent between 2002 and 2008 and rates for gunshot injuries increased by 28 percent, " says co-author Dr Adil H Haider, associate professor of surgery and co-director of the Center for Surgery, Trials and Outcomes Research at Johns Hopkins. "This correlated with a decrease in the number of non-therapeutic laparotomies (NTL).
"In most instances, failed SNOM was associated with increased death rates, underlining the importance of careful patient selection and protocols to reduce failure rates. However, it is important to point out that failure rates fell for both injuries during the seven-year study period and that successful SNOM was associated with shorter hospital stays." Key findings of the study relating to gunshot wounds included:
- SNOM rates averaged 22 percent during the study period, increasing by 28 percent between 2002 and 2008.
- During the same time period, the trend for NTL showed a strong negative correlation with SNOM, decreasing by 9 percent.
- Failure rates fell from to 20 percent over the study period - a reduction of 37 percent - and just over three-quarters of those failed within 24 hours. The percentage of failed SNOM patients who went on to have surgery was almost the same as the percentage operated on immediately.
- Just under two percent of the 12,707 patients with gunshot wounds died from their injuries. After adjusting for demographics, injury severity and clinical variables, patients who failed SNOM were four-and-a-half times more likely to die than those successfully managed without surgery.
- Average hospital stays for successful SNOM patients were approximately six days, compared with 13 days for patients who had surgery and 14 days for the patients who failed SNOM.
For stab wounds:
- SNOM rates averaged 34 percent over the study period, increasing by 50 percent between 2002 and 2008.
- During the same time period, the rate of NTL showed a strong negative correlation with SNOM, decreasing by 22 percent.
- Failure rates fell by 33 percent, and 87 percent of those patients were operated on within 24 hours of presenting to the trauma center.
- After adjusting for demographics, injury severity and clinical variables, patients who failed SNOM were almost ten times more likely to die than those successfully managed without surgery.
- Average hospital stays for successful SNOM patients were approximately four days, compared with seven days for the patients who had surgery and eight days for the patients who failed SNOM.
"Our study looked at level one and two trauma centres that provide comprehensive, round-the-clock emergency care and have the staff and facilities to provide close monitoring and emergency surgery" concludes Dr Haider. "The results show that SNOM has a success rate of up to 80 percent in select patients, improved diagnostic imaging has made it easier to identify suitable patients, and use of the technique has become more widespread. And they demonstrate that correctly selecting patients for non-operative management leads to shorter hospital stays, better outcomes and reduced pressure on healthcare budgets.
"However they also show that SNOM failure, which is most common in patients with severe injuries, those needing blood transfusions and those with spleen injuries, is independently associated with increased death rates and longer hospital stays."