Despite increasing numbers of patients with abdominal gunshot and stab wounds being able to successfully avoid emergency “exploratory” surgery and the likelihood of suffering complications during surgery, a new Johns Hopkins study published in the British Journal of Surgery indicates that the risk of mortality significantly increases if the wrong patients are chosen for the ‘watchful waiting’ approach.
Senior author and 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 states:
“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, but not every hospital should pursue this course because if physicians make a mistake, the patient pays. It’s not a slam-dunk decision.”
Within the last century managing penetrating abdominal injuries has seen a major shift in scientific patterns, says Haider. Whilst surgery was avoided due to the lack of infection control, killing many patients until the early 1900s, during World War I, surgeons achieved better survival rates through mandatory exploratory surgery, which subsequently become the standard care for such wounds.
For decades surgeons were instructed to rapidly open up the abdomen of almost all gunshot and most deep stab wounds as it was believed that failing to detect severe intestinal injuries or bleeding would be much worse than performing an abdominal exploration that turns up nothing, however recently some clinicians have explored approaches to decrease the number of unnecessary ‘negative’ surgeries by using improved diagnostic imaging and careful monitoring.
Haider and his team, including researchers from the Aga Khan University in Karachi, Pakistan decided to examine records from the United States’ National Trauma Data Bank from 2002 to 2008 and identified 25,737 patients with abdominal gunshot or stab wounds who had a long-enough survival time to be admitted to a trauma center. Marginally more than half of the patients had been stabbed.
The researchers discovered that over 22% of gunshot wounds and over one-third of stab wounds were treated without immediate surgery during the seven-year period, whilst the remaining patients underwent immediate exploratory abdominal surgery.
The researchers observed a 50% rise for stab wounds and a 28% rise for gunshot wounds in the so-called selective non-operative management (SNOM) of trauma patients during the study period, which according to Haider highlights that the acceptance of applying a watchful waiting approach is increasing. The researchers also noted that the rate of negative or unnecessary abdominal surgeries over the study period decreased by around 10%.
21% of gunshot victims and 15% of stabbing victims that were chosen for SNOM ultimately did require surgery despite doctors’ initial belief that their injuries would not necessitate an operation. These patients, known as SNOM ‘failures’ had a 4.5 times higher risk of mortality compared with those who were successfully managed without surgery, however, the team states that it remains unclear whether or not those patients would still have died from their wounds had they immediately undergone surgery.
The researchers noted that SNOM failure was more prevalent in severely injured patients who required blood transfusions and those whose spleens were damaged.
Haider comments that the financial benefits for successful SNOM are substantial, with the average hospital stay for successful SNOM patients with gunshot wounds being about six days compared with 13 days for those who had immediate exploratory surgery, whilst those who underwent SNOM but ended up requiring surgery later had an average hospital stay of 14 days.
The average hospital stay for stab victims who successfully underwent SNOM was four days, whilst those who had immediate surgery had an average hospital time of seven days compared with eight days for those who failed SNOM and required surgery.
Haider, who is also co-director of Johns Hopkins’ Center for Surgery Trials and Outcomes Research commented:
“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. But places that want to start doing it need to be very careful. This is not something you can just decide to do overnight.”
He adds that in order to successfully implement this strategy, a hospital must have a well-staffed intensive care unit that enables extremely close monitoring of those undergoing SNOM, as well as in-house surgeons and an operating room that is ready 24-hours a day should a SNOM patient take a turn for the worse and requires immediate surgery.
Written by Petra Rattue