NESS - Selective Non-Operative Management of Abdominal Gunshot Wounds - From Heresy to Standard of Care: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCONECT)

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Selective Non-Operative Management of Abdominal Gunshot Wounds - From Heresy to Standard of Care: A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCONECT)
*Thomas Peponis¹, *George Kasotakis², *Jielin Yu², *Reginald Alouidor³, *Barbara Burkott³, Adrian A. Maung⁴, Dirk C. Johnson⁴, *Noelle N. Saillant⁵, *Heath Walden⁵, Ali Salim⁶, *Elizabeth Bryant⁶, *Jon D. Dorfman⁷, *Eric N. Klein⁸, *Ronen Elefant⁸, *Maryam B. Tabrizi⁹, *Nikolay Bugaev¹⁰, *Sandra S. Arabian¹⁰, George C. Velmahos¹
¹Massachusetts General Hospital, Harvard Medical School, Boston, MA;²Boston Medical Center, Boston, MA;³Baystate Medical Center, Boston, MA;⁴Yale School of Medicine, New Haven, CT;⁵Beth Israel Deaconess Medical Center, Boston, MA;⁶Brigham and Women's Hospital, Boston, MA;⁷UMass Memorial Medical Center, Boston, MA;⁸Hartford Hospital, Hartford, CT;⁹North Shore Medical Center, Salem, MA;¹⁰Tufts Medical Center, Boston, MA

Objective: To evaluate the safety of selective non-operative management (SNOM) of abdominal gunshot wounds (aGSW) in patients, who are hemodynamically stable, clinically evaluable, and without peritoneal signs on admission.
Design: Retrospective multicenter study (1996-2015).
Setting: Ten Level I and II trauma centers in New England.
Patients: Patients who had an ED thoracotomy, obviously tangential aGSW, died within 60 minutes from arrival, or were younger than 16 years of age were excluded. Failure of SNOM was defined by a clear statement in the records or a laparotomy after 2 hours from hospital arrival.
Main Outcome Measures: Failure of SNOM, hospital length of stay, non-therapeutic laparotomies, complications, and mortality.
Results: Of 922 patients, 707 (77%) received an immediate laparotomy and 215 (23%) were managed with SNOM. Compared to patients with immediate laparotomy, those with SNOM had a lower ISS (17 vs. 9.9, p<0.05), lower incidence of complications (34% vs. 8%, p<0.05) and mortality (5.2% vs. 0.5%, p<0.05), and a shorter ICU and hospital stay (4.5/13.7 vs. 0.8/4.2 respectively, p<0.05). One SNOM patient died after three days, due to a GSW to the head. Eighteen patients with SNOM failure underwent a delayed laparotomy up to two days following admission. No significant difference was noted in the rate of non-therapeutic laparotomies (14.7% vs. 5.6%, p=0.49). Nine of them experienced complications, presumably unrelated to the delay, and none died.
Conclusions: SNOM of aGSW was offered frequently and successfully in this multicenter study. What used to be heresy, has become an acceptable standard of care.
Management of aGSW based on the location. *Unable to retrieve location-specific data for 4 patients.
Immediate Laparotomy Successful SNOM Delayed Laparotomy Mortality
Anterior Abdomen (n=654*) 546 (83%) 96 (15%) 12 (2%) 33 (5%)
Posterior Abdomen (n=264*) 158 (60%) 100 (38%) 6 (2%) 4 (1.5%)
All aGSW (n=922) 707 (77%) 197 (21%) 18 (2%) 38 (4%)

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