Selective Nonoperative Management of Abdominal Shotgun Wounds

Morgan Schellenberg; Natthida Owattanapanich; Emily Switzer; Meghan Lewis; Kazuhide Matsushima; Lydia Lam; Kenji Inaba

doi:10.1016/j.jss.2020.10.025

Selective Nonoperative Management of Abdominal Shotgun Wounds

J Surg Res. 2021 Mar:259:79-85. doi: 10.1016/j.jss.2020.10.025. Epub 2020 Dec 3.

Authors

Morgan Schellenberg¹, Natthida Owattanapanich², Emily Switzer², Meghan Lewis², Kazuhide Matsushima², Lydia Lam², Kenji Inaba²

Affiliations

¹ Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California. Electronic address: morgan.schellenberg@med.usc.edu.
² Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California.

PMID: 33279847
DOI: 10.1016/j.jss.2020.10.025

Abstract

Background: Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) has not been specifically examined after shotgun injuries. Because of the unpredictable nature of shotgun pellets, it is unclear if SNOM after shotgun wounds is safe. The study objective was to examine outcomes after SNOM for shotgun wounds to the abdomen.

Methods: Patients with isolated abdominal shotgun wounds were identified from the National Trauma Data Bank (2007-2017). Transfers, arrival without signs of life, death in the emergency department, severe (Abbreviated Injury Scale ≥3) extra-abdominal injuries, abdominal Abbreviated Injury Scale = 6, and missing data were exclusion criteria. Patients with abdominal handgun wounds (GSWs) were used for comparison. Study groups of shotgun-injured patients were defined by management strategy: operative management (OM) (exploratory laparotomy ≤4h) versus SNOM (no exploratory laparotomy ≤4h). Outcomes were compared by mechanism of injury (shotgun versus GSW) and management strategy (OM versus SNOM) using univariate and multivariate analyses.

Results: After exclusions, 1425 patients injured by abdominal shotgun wounds were included. Shotgun-injured patients underwent SNOM more frequently than GSW patients (42% versus 34%, P < 0.001). On multivariate analysis, injury by shotgun was independently associated with SNOM (OR 1.443, P = 0.040). Shotgun injuries were significantly more likely to fail SNOM (OR 2.401, P = 0.018). Failure of SNOM occurred earlier among shotgun-than GSW-injured patients (15 versus 24h, P = 0.011). SNOM after shotgun injury was associated with lower mortality than OM, even when patients failed SNOM (P < 0.001). Complications were uniformly higher after OM than SNOM, even when SNOM failed (P < 0.05).

Conclusions: SNOM was utilized more commonly after shotgun wounds than GSWs. However, SNOM was more likely to fail after shotgun injury and tended to occur earlier after admission. SNOM after shotgun injury was associated with improved mortality and decreased complication rates when compared with OM, even when patients failed SNOM. SNOM appears to be a safe and beneficial management strategy after shotgun wounds to the abdomen.

Keywords: Gunshot wounds; Penetrating trauma; Selective nonoperative management; Shotgun wounds; Trauma.

Publication types

Comparative Study
Observational Study

MeSH terms

Abdominal Injuries / diagnosis
Abdominal Injuries / etiology
Abdominal Injuries / mortality
Abdominal Injuries / therapy*
Adult
Conservative Treatment / methods*
Female
Firearms / statistics & numerical data*
Hospital Mortality
Humans
Injury Severity Score
Male
Registries / statistics & numerical data
Retrospective Studies
Trauma Centers / statistics & numerical data
Treatment Outcome
Wounds, Gunshot / diagnosis
Wounds, Gunshot / etiology
Wounds, Gunshot / mortality
Wounds, Gunshot / therapy*
Young Adult