The Brave Challenge of NOM for Abdominal GSW Trauma and the Role of Laparoscopy As an Alternative to CT Scan
We are amazed and we all would like to congratulate with Navsaria et al for sharing their tremendous experience in the treatment of penetrating trauma and in the challenging nonoperative management of patients with abdominal gunshot wound (GSW) injuries.1 The South African trauma surgeons present an impressive series of 1106 patients with abdominal GSW seen in 5½ years (meaning almost 17 patients/month). The aim of the study was to assess feasibility and failure rate of nonoperative management for patients with abdominal GSW and no hard signs and intact neurology. Patients deemed safe for NOM were either clinically examined or investigated with contrast-enhanced CT. Further aims were the incidence of unnecessary laparotomies in both operative and NOM groups, the morbidity and mortality associated with NOM failure and/or with a delayed laparotomy, and finally the role of CT in evaluating patients candidates for NOM or during their observation.
Most of us have worked in trauma centers around the globe and have personally experienced the differences between high-volume centers with limited resources and low-volume centers with good resources. We feel we can provide both sides’ view and would like to highlight a few differences with our esteemed South African colleagues.
We doubt that the excellent results achieved by the South African Trauma Center would be easily reproducible in less busy settings around the world (particularly in Europe, Canada, Australia, and eastern Asia), and even in some regions of USA or in many other places where GSW are less common. The achievement of highly successful results in nonoperative management of GSW, with selective use of CT scan and low complication rate, seems to be feasible only in centers having highly specific expertise. These differences in practice were recently highlighted by several authors.2–4
In other words, it is reasonable that in Cape Town, receiving 17 cases of abdominal GSW/month, on top of all other cases of SW and other penetrating or blunt trauma, and acute care surgery cases, the resident staff is not only comfortable but is somehow pushed to attempt NOM in those patients that are stable and nonperitonitic (imagine how it is being on call in a busy summer night in South Africa!). Nonetheless, in most of the other centers, the same approach may not be so easily applicable for a number of reasons. First of all, the junior or resident staff may have hardly seen very few cases of abdominal GSW and may feel safer to surgically explore these patients, rather than admit them in the ward for overnight observation, even more if an advanced imaging investigation by abdominal CT scan has not been done. Therefore, in centers where the load is substantially less (as in most European and Australian centers), CT scan is standard of care for all patients without hard signs and the threshold for an exploratory laparotomy is usually very low. Last but not least, we must say that the medico-legal issues in Europe, Australia, and North America are probably much different from South Africa, again this reason contributing to make NOM a “brave challenge.”
Finally, from my experience in emergency laparoscopy for Acute Care Surgery5 and Trauma,6 I would like to ask Navsaria et al if a diagnostic (and eventually therapeutic) laparoscopy may have played a role in assessing and managing the patients with abdominal GSW who have started NOM, or at least in the stable patients with equivocal peritoneal signs.