TY - JOUR
AU - Jurkovich, G J
AB - This paper addresses an important issue in the treatment of patients with penetrating abdominal injuries, namely the advisability and role of non-operative management. This concept is largely iconoclastic, in that generations of surgeons have been taught to explore the abdomen early following nearly all gunshot injuries and most stab wounds that traverse the abdominal wall fascia. This teaching is based on the concept that early recognition and repair of bleeding vessels and hollow viscus injury will prevent morbidity and mortality, and that the consequences of a negative or non-therapeutic laparotomy are less than the morbidity and mortality increases caused by delayed or missed recognition of intestinal injury or ongoing bleeding. This paper can only be written now that most trauma centres and hospitals have cross-sectional imaging readily available in the form of computed tomography (CT), and timely and expert performance and interpretation of this diagnostic technique can allow more selective management. In other words, the authors believe that trauma surgeons can use CT to predict more accurately who will have an injury and be more selective in who warrants a laparotomy. However, I believe exactly the opposite conclusion could be reached from this paper. The authors conclude that selective non-operative management (SNOM) of penetrating abdominal injury is recommended in facilities with adequate resources, experience, and the capability to provide immediate surgical intervention. But how is this select group of hospitals and patients identified? The rate of SNOM failure was 15·2 per cent for stab wounds and 20·8 per cent for gunshot injuries. This could be considered ‘high’, depending on the bias of the reader. Furthermore, the mortality rate of failed SNOM in this report was higher by severalfold (4·5–9·8) than the mortality rate of negative laparotomy, in both patients with gunshot wounds and those with stab wounds. It could thus be argued that SNOM is a concept that subjects patients to a higher risk of death. So why undertake it? The importance of patient selection is apparent: if a surgeon knew there was an injury that needed operative repair, the presumption is that SNOM would not be attempted. The key is how to select those patients. The failure (or success) rates reported here are based on 20 or 25 trauma centres in the USA. This is a minority of the more than 500 hospitals submitting data to the National Trauma Data Bank, and is certainly a tiny minority of the total number of hospitals in the world. I would submit that this failure rate is high, not low, particularly if this is the best that these select, and presumably experienced and heavily resourced, hospitals and surgeons can obtain. This likely represents the ‘best’ that can be achieved at this time and, although it does show that under some circumstances SNOM can be practised and is increasing in frequency, it is not perfect care, and certainly not for everyone. Disclosure The author declares no conflict of interest. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Selective non-operative management in 25 737 patients with penetrating abdominal injuries (Br J Surg 2011; 99(Suppl 1): 157–167)
JO - British Journal of Surgery
DO - 10.1002/bjs.7736
DA - 2011-12-22
UR - https://www.deepdyve.com/lp/oxford-university-press/selective-non-operative-management-in-25-737-patients-with-penetrating-zeHl6EUq8b
SP - 164
EP - 165
VL - 99
IS - Supplement_1
DP - DeepDyve
ER -