Operative and non-operative management of children with abdominal gunshot injuries

BACKGROUND: Non-operative management (NOM) is a standard treatment method for solid organ injuries worldwide. There is no consensus on the management of gunshot wounds (GSW) because of the higher frequency of hollow viscus injuries (HVI) and the unpredictable depth of tissue damage produced by kinetic energy transfer during retardation of the bullet. Here we aimed to re-evaluate indications for surgery and NOM based on our pediatric patients with abdominal GSW.
METHODS: We performed a retrospective analysis of patients evaluated and treated for abdominal GSW at University of Dicle between January 2010 and October 2016. Patients with hemodynamic instability, signs of peritonitis on serial abdominal examination, and free air in the abdomen underwent laparotomy; these were included in group I (n=17). Patients managed non-operatively were included in group II (n=13).
RESULTS: Our statistical analysis showed significantly lower Hb levels and systolic blood pressure levels (p<0.001) and higher pulse rate, higher mean injury severity score, and longer length of stay at intensive care unit in patients in group I than in those in group II (p<0.001). We further detected colon perforation (n=10) and small bowel perforation (n=7) in patients in group I; liver laceration (n=4), splenic injury (n=1), and renal injury (n=3) but no solid organ injury or HVI (n=5) were detected in patients in group II.
CONCLUSION: The major drawback of NOM is the difficulty in diagnosing HVI in abdominal GSW, which may delay treatment. We suggest that patients with solid organ damage who are hemodynamically stable and exhibit no signs of peritonitis upon serial abdominal exam may be treated with NOM.

Batýn ateþli silah yaralanmasý olan çocuklarda cerrahi ve cerrahi olmayan yaklaþýmýmýz

AMAÇ: Solid organ yaralanmalarýnda, bütün dünyada standart tedavi yöntemi “nonoperative management”dýr (NOM). Kurþun, trakt boyunca yaydýðý yüksek enerjiden dolayý oluþturmuþ olduðu doku hasarýnýn derinliði öngörülememekte ve içi boþ ogan (ÝBO) yaralanma sýklýðý yüksek olduðundan ateþli silah yaralanmasý (ASY) ile ilgili bir konsensüs bulunmamaktadýr. Bu çalýþmada, karýn bölgesinde ASY olan hastalarýn cerrahi ve NOM kriterlerini ortaya koymayý amaçladýk.
GEREÇ VE YÖNTEM: Ocak 2010–Nisan 2016 tarihleri arasýnda karnýnda ASY olan hastalar geriye dönük olarak analiz edildi. Hemodinamik instabilitesi olan, seri karýn muayenelerinde peritonit bulgusu devam eden, karýnda serbest havasý olan grup 1 (n=17) operasyona alýndý. NOM ile tedavi edilen olgular ise grup 2 (n=13) idi.
BULGULAR: Grup 1 ile grup 2’yi karþýlaþtýrdýðýmýzda; grup 1’de hemoglobin (Hb) seviyesi ve sistolik kan basýncý istatistiksel olarak düþük iken (p<0.001), yoðun bakýmda kalýþ süresi ve ortalama yaralanma þiddet skoru (ISS) ise istatistiksel olarak yüksek idi (p<0.001). Ayrýca Grup 1’deki olgularýn 10’unda kolon perforasyonu, yedisinde ise ince baðýrsak perforasyonu saptadýk. Grup 2’deki olgularýmýzýn dördünde karaciðer yaralanmasý, birinde dalak, üçünde ise renal yaralanma var iken, beþinde ise parankimatoz organ yaralanmasý ve ÝBO saptamadýk.
TARTIÞMA: Karýnda ASY’lerindeki problem ÝBO yaralanmasý tanýsýndaki zorluklara baðlý olarak tedavinin gecikmesidir. Hemodinamik olarak stabil ve seri karýn muayenelerinde peritonit bulgusu olmayan parankimatoz organ yaralanmalarý NOM olarak tedavi edilebilinir.