Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis
Abstract Background Although mandatory laparotomy has been standard of care for patients with abdominal gunshot wounds (GSWs) for decades, this approach is associated with non-therapeutic operations, morbidity, and long hospital stays. This systematic review and meta-analysis sought to summarize out...
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| Format: | Article |
| Language: | English |
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BMC
2018-11-01
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| Series: | World Journal of Emergency Surgery |
| Subjects: | |
| Online Access: | http://link.springer.com/article/10.1186/s13017-018-0215-0 |
| _version_ | 1829137381656100864 |
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| author | Aziza N. Al Rawahi Fatma A. Al Hinai Jamie M. Boyd Christopher J. Doig Chad G. Ball George C. Velmahos Andrew W. Kirkpatrick Pradeep H. Navsaria Derek J. Roberts |
| author_facet | Aziza N. Al Rawahi Fatma A. Al Hinai Jamie M. Boyd Christopher J. Doig Chad G. Ball George C. Velmahos Andrew W. Kirkpatrick Pradeep H. Navsaria Derek J. Roberts |
| author_sort | Aziza N. Al Rawahi |
| collection | DOAJ |
| description | Abstract Background Although mandatory laparotomy has been standard of care for patients with abdominal gunshot wounds (GSWs) for decades, this approach is associated with non-therapeutic operations, morbidity, and long hospital stays. This systematic review and meta-analysis sought to summarize outcomes of selective nonoperative management (SNOM) of civilian abdominal GSWs. Methods We searched electronic databases (March 1966–April 1, 2017) and reference lists of articles included in the systematic review for studies reporting outcomes of SNOM of civilian abdominal GSWs. We meta-analyzed the associated risks of SNOM-related failure (defined as laparotomy during hospital admission), mortality, and morbidity across included studies using DerSimonian and Laird random-effects models. Between-study heterogeneity was assessed by calculating I 2 statistics and conducting tests of homogeneity. Results Of 7155 citations identified, we included 41 studies [n = 22,847 patients with abdominal GSWs, of whom 6777 (29.7%) underwent SNOM]. The pooled risk of failure of SNOM in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis was 7.0% [95% confidence interval (CI) = 3.9–10.1%; I 2 = 92.6%, homogeneity p < 0.001] while the pooled mortality associated with use of SNOM in this patient population was 0.4% (95% CI = 0.2–0.6%; I 2 = 0%, homogeneity p > 0.99). In patients who failed SNOM, the pooled estimate of the risk of therapeutic laparotomy was 68.0% (95% CI = 58.3–77.7%; I 2 = 91.5%; homogeneity p < 0.001). Risks of failure of SNOM were lowest in studies that evaluated patients with right thoracoabdomen (3.4%; 95% CI = 0–7.0%; I 2 = 0%; homogeneity p = 0.45), flank (7.0%; 95% CI = 3.9–10.1%), and back (3.1%; 95% CI = 0–6.5%) GSWs and highest in those that evaluated patients with anterior abdomen (13.2%; 95% CI = 6.3–20.1%) GSWs. In patients who underwent mandatory abdominopelvic computed tomography (CT), the pooled risk of failure was 4.1% versus 8.3% in those who underwent selective CT (p = 0.08). The overall sample-size-weighted mean hospital length of stay among patients who underwent SNOM was 6 days versus 10 days if they failed SNOM or developed an in-hospital complication. Conclusions SNOM of abdominal GSWs is safe when conducted in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis. Failure of SNOM may be lower in patients with GSWs to the back, flank, or right thoracoabdomen and be decreased by mandatory use of abdominopelvic CT scans. |
| first_indexed | 2024-12-14T18:57:29Z |
| format | Article |
| id | doaj.art-890b59e3d0da4208b7a7227390d402e6 |
| institution | Directory Open Access Journal |
| issn | 1749-7922 |
| language | English |
| last_indexed | 2024-12-14T18:57:29Z |
| publishDate | 2018-11-01 |
| publisher | BMC |
| record_format | Article |
| series | World Journal of Emergency Surgery |
| spelling | doaj.art-890b59e3d0da4208b7a7227390d402e62022-12-21T22:51:03ZengBMCWorld Journal of Emergency Surgery1749-79222018-11-0113111610.1186/s13017-018-0215-0Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysisAziza N. Al Rawahi0Fatma A. Al Hinai1Jamie M. Boyd2Christopher J. Doig3Chad G. Ball4George C. Velmahos5Andrew W. Kirkpatrick6Pradeep H. Navsaria7Derek J. Roberts8Department of Surgery, University of CalgaryDepartment of Surgery, University of CalgaryDepartment of Critical Care Medicine, University of CalgaryDepartment of Critical Care Medicine, University of CalgaryDepartment of Surgery, University of CalgaryDivision of Trauma, Emergency Surgery, and Critical Care, Department of Surgery, Massachusetts General HospitalDepartment of Surgery, University of CalgaryDepartment of Surgery, University of Cape Town Health Sciences FacultyDivision of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa HospitalAbstract Background Although mandatory laparotomy has been standard of care for patients with abdominal gunshot wounds (GSWs) for decades, this approach is associated with non-therapeutic operations, morbidity, and long hospital stays. This systematic review and meta-analysis sought to summarize outcomes of selective nonoperative management (SNOM) of civilian abdominal GSWs. Methods We searched electronic databases (March 1966–April 1, 2017) and reference lists of articles included in the systematic review for studies reporting outcomes of SNOM of civilian abdominal GSWs. We meta-analyzed the associated risks of SNOM-related failure (defined as laparotomy during hospital admission), mortality, and morbidity across included studies using DerSimonian and Laird random-effects models. Between-study heterogeneity was assessed by calculating I 2 statistics and conducting tests of homogeneity. Results Of 7155 citations identified, we included 41 studies [n = 22,847 patients with abdominal GSWs, of whom 6777 (29.7%) underwent SNOM]. The pooled risk of failure of SNOM in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis was 7.0% [95% confidence interval (CI) = 3.9–10.1%; I 2 = 92.6%, homogeneity p < 0.001] while the pooled mortality associated with use of SNOM in this patient population was 0.4% (95% CI = 0.2–0.6%; I 2 = 0%, homogeneity p > 0.99). In patients who failed SNOM, the pooled estimate of the risk of therapeutic laparotomy was 68.0% (95% CI = 58.3–77.7%; I 2 = 91.5%; homogeneity p < 0.001). Risks of failure of SNOM were lowest in studies that evaluated patients with right thoracoabdomen (3.4%; 95% CI = 0–7.0%; I 2 = 0%; homogeneity p = 0.45), flank (7.0%; 95% CI = 3.9–10.1%), and back (3.1%; 95% CI = 0–6.5%) GSWs and highest in those that evaluated patients with anterior abdomen (13.2%; 95% CI = 6.3–20.1%) GSWs. In patients who underwent mandatory abdominopelvic computed tomography (CT), the pooled risk of failure was 4.1% versus 8.3% in those who underwent selective CT (p = 0.08). The overall sample-size-weighted mean hospital length of stay among patients who underwent SNOM was 6 days versus 10 days if they failed SNOM or developed an in-hospital complication. Conclusions SNOM of abdominal GSWs is safe when conducted in hemodynamically stable patients without a reduced level of consciousness or signs of peritonitis. Failure of SNOM may be lower in patients with GSWs to the back, flank, or right thoracoabdomen and be decreased by mandatory use of abdominopelvic CT scans.http://link.springer.com/article/10.1186/s13017-018-0215-0Abdominal gunshot woundsSelective nonoperative managementPenetrating traumaWounds and injuries |
| spellingShingle | Aziza N. Al Rawahi Fatma A. Al Hinai Jamie M. Boyd Christopher J. Doig Chad G. Ball George C. Velmahos Andrew W. Kirkpatrick Pradeep H. Navsaria Derek J. Roberts Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis World Journal of Emergency Surgery Abdominal gunshot wounds Selective nonoperative management Penetrating trauma Wounds and injuries |
| title | Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis |
| title_full | Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis |
| title_fullStr | Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis |
| title_full_unstemmed | Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis |
| title_short | Outcomes of selective nonoperative management of civilian abdominal gunshot wounds: a systematic review and meta-analysis |
| title_sort | outcomes of selective nonoperative management of civilian abdominal gunshot wounds a systematic review and meta analysis |
| topic | Abdominal gunshot wounds Selective nonoperative management Penetrating trauma Wounds and injuries |
| url | http://link.springer.com/article/10.1186/s13017-018-0215-0 |
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