Although more patients with abdominal gunshot and stab wounds can successfully forego emergency "exploratory" surgery and its potential complications, new Johns Hopkins research suggests that choosing the wrong patients for this "watchful waiting" approach substantially increases their risk of death from these injuries.
"Managing gunshot and stab wounds without exploratory surgery prevents complications, saves money and keeps 80 percent of patients from getting operations that end up being unnecessary," says trauma surgeon Adil H. Haider, M.D., M.P.H., an associate professor of surgery, anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine and senior author of the study published in BJS, the British Journal of Surgery. "But not every hospital should pursue this course because if physicians make a mistake, the patient pays. It's not a slam-dunk decision."
Haider says management of penetrating abdominal injury has undergone a major paradigm shift in the last century. Until the early 1900s, surgery was avoided because the lack of infection-control killed many injured patients. During World War I, mandatory exploratory surgery for such wounds led to better survival rates and soon became the standard of care. For generations, surgeons have been taught to open the abdomen rapidly following nearly all gunshot and most deep stab wounds with the idea that failing to identify severe intestinal injury or bleeding is far worse than doing an abdominal exploration that turns up nothing.
More recently however, some clinicians have sought ways to reduce these unnecessary "negative" surgeries with improved diagnostic imaging and careful monitoring, according to Haider and his team, which included researchers from Aga Khan University in Karachi, Pakistan.
They studied records from the United States' National Trauma Data Bank from 2002 to 2008, identifying 25,737 patients who survived long enough with abdominal gunshot or stab wounds to be admitted to a trauma center. Just over half had been stabbed. For the seven-year period, more than 22 percent of the gunshot wounds were treated without immediate surgery, together with more than one-third of stab wounds. The remaining patients received immediate exploratory abdominal surgery.
Over the study period, the rate of so-called selective non-operative management (SNOM) of these trauma patients rose 50 percent for stab wounds and 28 percent for gunshot wounds, which Haider says points to a growing acceptance of this watchful waiting approach. During the same time period, the rate of negative or unnecessary abdominal operations decreased by about 10 percent.
Ultimately, some patients chosen for SNOM needed surgery -- 21 percent of gunshot victims and 15 percent of stabbing victims -- even though doctors initially believed that their injuries did not require operations. Such patients, called SNOM "failures," were 4.5 times more likely to die than those who were successfully managed without surgery. It is unclear whether those patients would have died from their wounds if they had undergone surgery immediately, the team reported.
SNOM failure was more common in patients with severe injuries requiring blood transfusions and those with damaged spleens.
The payoff for successful SNOM is big, Haider notes. The average hospital stay for successful SNOM patients with gunshot wounds was approximately six days, compared with 13 days for those who underwent immediate exploratory surgery and 14 for those who underwent SNOM but ended up needing surgery later. For stabbing victims, the average hospital stay for those who successfully underwent SNOM was four days, compared with seven days for those who had immediate surgery and eight for those who failed SNOM and needed surgery.
"For hospitals that are practicing selective non-operative management for abdominal wounds, it's seems to be working well with a more than 80 percent success rate" says Haider, co-director of Johns Hopkins' Center for Surgery Trials and Outcomes Research. "But places that want to start doing it need to be very careful. This is not something you can just decide to do overnight."
Haider says success depends on having a well-staffed intensive care unit, where those undergoing SNOM can be very closely monitored, as well as in-house surgeons and a ready operating room 24 hours a day in case a SNOM patient takes a turn for the worse and requires immediate surgery.
Other Hopkins researchers contributing to this study include Amy Rushing, M.D.; Elliott R. Haut, M.D.; Cassandra V. Villegas, M.D., M.P.H.; Albert Chi, M.D.; Kent Stevens, M.D., M.P.H.; and David T. Efron, M.D.
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