April 9, 2012

To Operate or Not to Operate
By Carolyn Gutierrez
For The Record
Vol. 24 No. 7 P. 24

Researchers have released findings that show more gunshot and stab wounds are being treated without unnecessary operations.

Analyzing data from the National Trauma Data Bank, researchers from Johns Hopkins University School of Medicine in Baltimore and Aga Khan University in Karachi, Pakistan, found a marked increase in the use of selective nonoperative management (SNOM) of abdominal gunshot and stab wounds. The majority of patients treated nonoperatively thrived, but those who failed nonoperative treatment had a high mortality rate.

In an article published in the British Journal of Surgery, researchers determined that careful patient selection by an experienced and astute emergency department team was paramount when choosing this treatment method.

“We looked at patients [in the data bank] over a six-year period, 2002 to 2008—essentially almost 26,000 patients,” explains Amy Rushing, MD, an assistant professor of surgery, anesthesiology, and critical care medicine at the Johns Hopkins University School of Medicine and second author of the study. “The contents of the bank are very much dependent on the reporting of the individual trauma centers, which is an inherent limitation to any study that you do, based on the data. But typically, it’s representative of patient outcomes of level 1 and level 2 trauma centers—hospitals that have seen more trauma—higher numbers and higher acuity as far as injuries are concerned. What we were interested in seeing was the evolution of management of penetrating abdominal injuries because what we’re seeing in practice is that not everybody is getting a mandatory exploratory laparotomy as soon as they come in the door just because they were stabbed or shot in the abdomen. When people who are not in medicine hear that, they become very nervous, saying, ‘What do you mean? They’ve been shot or stabbed. Of course they need to go to the operating room.’ That was the teaching for some time.”

During World War I, exploratory laparotomies became the standard of care for treating penetrating abdominal injuries. With the advancement of blood transfusions and antibiotics, the overall mortality rate for patients with abdominal wounds decreased throughout the 20th century. As more laparotomies were performed, the number of negative exploratory laparotomies, also known as nontherapeutic laparotomies (in which the surgeon opens the abdomen and finds nothing wrong), increased. In the late 1960s and early 1970s, around the same time that the first CT scanner was invented, it was determined that selected abdominal injury patients could be managed with careful watching and waiting to avoid unnecessary surgery.

“Any time you make an incision on someone,” says Rushing, “you make a scar. When you operate on someone, they develop internal scarring; they can get small-bowel obstructions later on down the road from intestinal scarring and adhesions. Surgeons can accidentally injure something while they’re in there exploring for what turns out to be a negative exploration. It comes with risk.”

In the recent study, researchers were looking to see if trauma surgeons are changing the way they approach abdominal injuries and the outcomes of this change.

The study population comprised 12,707 patients who suffered abdominal gunshot wounds and 13,030 who suffered abdominal stab wounds. Most of the gunshot victims were men between the ages of 16 and 45, while the majority of stab victims were men with an average age of 34.

Researchers found that the rates of nonoperative management were about 22% for gunshot wounds and 34% for stab wounds, with the numbers increasing over the six-year period. “Trauma surgeons at these densely populated, high-acuity centers were operating less and less on these patients,” says Rushing, “and the patients overall were doing well or having good outcomes.”

According to the study, successful use of SNOM increased from 70% in 2002 to 80% in 2008. The number of nontherapeutic laparotomies decreased as the number of effective SNOM cases increased.

However, the researchers also found that the nonoperative approach failed in 21% of the gunshot patients and 15% of the stab wound patients, leading the research team to look for the specific risk factors associated with the failure rate. The researchers were unable to discern whether the patients whose SNOM failed would have died from their wounds if they had undergone emergency surgery.

Risk Factors
The need for a blood transfusion; a high Injury Severity Score (ISS) based on the location, type, and number of injuries; low blood pressure; and advanced age are some of the risk factors associated with SNOM failure. In their most dramatic finding, the researchers determined that if a gunshot wound patient failed SNOM, the mortality rate was almost five times that of a patient who was successfully managed through surgery.

“Out of everything that we’ve published, that’s what people tend to comment on the most—and highly criticize,” says Rushing. “They say, ‘What are you guys trying to do? Are you advocating for not operating?’ And we’re not. What we’re trying to say is that [SNOM] is becoming a more common practice, and that fortunately, as trauma surgeons are doing it more, they’re getting better at it over time. Technology has a lot to do with that.”

Protocols for SNOM
When abdominal gunshot or stab wound victims present in the emergency department, their vital signs are assessed immediately. If the vital signs are abnormal and the patient is bleeding excessively and going into shock, he or she is rushed into the operating room.

“But that’s not how the majority of our shot or stabbed patients present,” says Rushing. “I would say that the majority of patients that are shot or stabbed come in with stable hemodynamics. Some of them are drunk or high, and so their sensorium is altered so they’re not really conveying pain one way or another. But their vitals look good, they’re talking to you, they’re moving everything, and now you’ve got a stable patient with a wound, and you’ve got to figure out what is the best thing to do.”

According to the study, trauma centers that have shown high success rates with SNOM have developed finely tuned criteria for assessing which patients may be managed without surgery. A 2009 meta-analysis in the American Journal of Roentgenology found that the use of CT imaging was found to have an accuracy rate of 94.7% in determining whether hemodynamically stable abdominal wound patients needed surgery. Diagnostic imaging can help physicians ascertain whether the abdominal wounds are tangential injuries—those that haven’t entered the abdominal cavity or chest cavity—or whether they are solitary injuries to the liver or the spleen.

Resources and Support Staff
“We’re very fortunate,” says Rushing when describing the resources at Johns Hopkins Hospital. “Our CT scanner is 10 feet away from our trauma bay, so when we have a gunshot or stab wound patient, we can immediately image them. The trauma surgeon can look at the images in real time as the patient is going through [the scanner], and then the patient can go back to their room in the emergency department. By then, a lot of the time, we’ve already figured out that the bullet was tangential and didn’t even enter the abdominal cavity or it just nicked the liver, and that’s it—the bleeding will stop.”

High-volume emergency centers such as Johns Hopkins that specialize in comprehensive trauma care are generally better equipped to practice SNOM than smaller, low-volume centers, although the researchers point out in the study that with the appropriate number of skilled and experienced personnel, SNOM can be practiced at smaller centers as well.

According to Rushing, a tenacious nursing staff, a 24-hour in-house attending trauma surgeon, and a strong radiology department are of the utmost importance for emergency centers practicing SNOM. Clinical changes in a SNOM patient demand swift intervention to prevent a dire outcome.

“You have to have a nursing staff that’s comfortable taking care of these types of patients,” says Rushing. “You have to train your resident team and your midlevel practitioners—your nurse practitioners and physician assistants. You’ve got to work together. I think a lot of the level 1 trauma centers have that structure nowadays—they’re pretty sophisticated. They could do this. The study shows that trauma surgeons are starting to adapt to this kind of triage and are using the technology that we have at hand for the stable patients that come in. But it’s not perfect, obviously, because we have a failure rate, and those patients who fail can die.”

Different Wound Types
Because it is a high-energy, penetrating injury, gunshot wound treatment with SNOM is controversial. Clearly, a bullet traveling at a high rate of speed can produce blast injuries and extensive tissue damage in the abdominal cavity. Although it seems counterintuitive, in a subset of abdominal gunshot patients—those who are hemodynamically stable and show no signs of peritonitis—the researchers found that it may not be necessary to operate.

“A bullet does not always have to be removed,” says Rushing. “In fact, a lot of the time, there’s more harm involved in removing a bullet because you’ve got to cut through tissue, traumatize tissue in addition to what was already traumatized by the bullet to get it out. More often than not, the bullet stays where it is. What gets us to the operating room is not necessarily where the bullet is in the body, but the bullet’s trajectory—where we think it’s been.”

Through detailed trajectory imaging with a CT scanner, emergency personnel look for evidence that the bullet has traversed the patient’s abdominal wall. If it has, surgery is generally needed.

Stab wounds are considered low-energy penetrating injuries. Generally, they cause less damage than gunshot wounds. If the patient is stable and evidence has been found that the knife has compromised the abdominal cavity, emergency physicians sometimes perform diagnostic laparoscopy to determine if any damage has been done to the diaphragm. If injuries to the diaphragm are found, the physicians instead perform traditional abdominal surgery to make repairs.

Patient and Family Input
According to Rushing, patients and their families generally do not have a say in whether to treat a gunshot or stab wound surgically. This is mostly due to the inherent nature of the emergency department environment.

“These [incidents] usually occur in the middle of the night, and there are usually legal ramifications, so there are police, there are paramedics, there are emergency department staff [present]. It’s a very dramatic environment,” Rushing says. “For the first couple of minutes, it moves pretty quickly. The patient is emotionally and mentally traumatized. They’re upset for a number of reasons. One, they’re hurt; two, they may be in trouble with the law; three, they want to make sure that whoever did this to them gets in trouble as well. They’re usually very scared, so the patients don’t really get a choice [of treatment].”

Rushing adds that more often than not, family members are unaware that the patient is even at the hospital. If they are aware, they are not yet present when urgent treatment decisions are made. “Rarely is family there at the time of our assessment,” says Rushing. “I typically don’t meet families until either after the OR [operating room] or probably several hours after that when the police have done their part and the drama has more or less calmed down. Because it’s an emotional, scary situation, we make the decisions.”

Cost Savings
Financial considerations were not a particular focus of the study. “We didn’t want it to be construed that this is about money and saving money,” says Rushing. However, the researchers did note that if done properly, SNOM can reduce the number of complications brought on by surgery and reduce costs and the use of hospital resources.

A stable wound patient managed nonoperatively can potentially go home after 12 hours, although some are admitted overnight for 24 hours. The difference in cost between a one-night stay in the hospital vs. the average three- to five-day stay required for abdominal surgery is daunting.

 “You take someone to the operating room, you do a formal exploration of their abdomen, you turn up nothing, you close them,” explains Rushing. “Now they’ve got to recover. They’re going to have postoperative pain, their bowels may have difficulty waking up from the anesthesia and the shock of the surgery … so that means extra days in the hospital for the patient because you can’t send somebody home who can’t eat. You also can’t send somebody home who doesn’t have adequate pain control. And then you also have to make sure that they avoid any other complications associated with surgery or general anesthesia. That includes urinary tract infections, pneumonia, and DVT [deep vein thrombosis].”

When you factor in surgeon and anesthesia fees and the price of additional days in the hospital the costs quickly mount.

Final Thoughts
In the study, Rushing and colleagues determined that SNOM is a practice that has been on the rise nationwide, with emergency surgeons becoming savvier in identifying the interventions that abdominal wound patients truly need.

“The practice of trauma surgery has really evolved quite a bit,” says Rushing, “especially in the last 20 to 30 years. It’s gotten to the point where we can be selective in who gets an operation, but we’ve got to be smart about it.”

— Carolyn Gutierrez is a freelance writer based in New York City.