Reply: The Brave Challenge of NOM for Abdominal GSW Trauma and the Role of Laparoscopy as an Alternative to CT Scan
We agree with many of the comments by our Italian colleagues and thank them in advance for their thoughtful analysis. We would also like to point out, however, that the experience of Selective nonoperative management (SNOM) of gunshot wounds (GSW) is currently practiced far beyond South Africa.1 More specifically, many regionalized trauma centers in Canada and the US (among others) practice SNOM for GSW. At a previously (and repeatedly) published complication rate of over 40% for nontherapeutic laparotomies, it is simply too “risky” to lower the threshold to a management plan that includes “mandatory exploration.”2 Certainly, some centers without in-house expertise (ie, faculty or good trainees) may be limited in this regard. But we should be clear that these centers are substituting an invasive and potentially unnecessary exploration because of a health care system issue. Although we all understand this reality at many global locations, it does not alter the tremendous amount of science that clearly supports SNOM as a strong clinical algorithm and one that is often believed to be the standard of care in many countries/centers. To be specific, any general surgeon in the world is able to detect diffuse peritonitis and/or hypotension/hemodynamic instability on either an initial or a repeated examination. Consequently, all of these surgeons should be able to identify the initial trigger criteria for operative management (or conversely, in the absence of these findings, SNOM). In other words, these are more truly academic battles between science versus resource limitations.
The second interesting comment by our colleagues surrounds the use of laparoscopy. We would argue that laparoscopy cannot replace either Computed tomography (CT) or observation. The first issue is technical: more specifically, to adequately eliminate the risk of injury, the operator needs to be able to evaluate all aspects of the peritoneal domain including evaluation from the GE junction to the rectum, and the lesser sac, retroperitoneum, and so on. Unfortunately, very few surgeons currently posses this talent … especially in resource challenged countries. The second issue is that even if we ignore concern number one, it must be asked: exactly what is the threshold for a laparotomy? Are our colleagues really using diagnostic laparotomy (DL) to look for peritoneal penetration as a trigger for laparotomy, or are they hunting for an actual injury that requires repair? Third, DL is not a surrogate for CT. That argument would support the concept of trading a more aggressive investigation (DL) for a lesser risky one (CT). From a medical and ethical point of view, this makes little sense and is more reflective of resource limitations than science.
At the end of the day, missed injuries are unacceptable in any context. If a center or person can offer repeated clinical examinations by someone who can identify diffuse peritonitis and hypotentsion, then SNOM is reasonable. If they cannot, then the patient should be transferred to a center that can provide these services. If the region of note does not have a referral/accepting center that can offer these basic services, then patients will need to accept a lower standard of care with a higher potential risk of complications due to resource limitations. In this case, health care regions and hospital systems should be clear and honest about this limitation with their patients and the community.