title: Selective nonoperative management of penetrating abdominal solid organ injuries.
abstract: OBJECTIVE
  To assess the feasibility and safety of selective nonoperative management in penetrating abdominal solid organ injuries.
  
  
  BACKGROUND
  Nonoperative management of blunt abdominal solid organ injuries has become the standard of care. However, routine surgical exploration remains the standard practice for all penetrating solid organ injuries. The present study examines the role of nonoperative management in selected patients with penetrating injuries to abdominal solid organs.
  
  
  METHODS
  Prospective, protocol-driven study, which included all penetrating abdominal solid organ (liver, spleen, kidney) injuries admitted to a level I trauma center, over a 20-month period. Patients with hemodynamic instability, peritonitis, or an unevaluable abdomen underwent an immediate laparotomy. Patients who were hemodynamically stable and had no signs of peritonitis were selected for further CT scan evaluation. In the absence of CT scan findings suggestive of hollow viscus injury, the patients were observed with serial clinical examinations, hemoglobin levels, and white cell counts. Patients with left thoracoabdominal injuries underwent elective laparoscopy to rule out diaphragmatic injury. Outcome parameters included survival, complications, need for delayed laparotomy in observed patients, and length of hospital stay.
  
  
  RESULTS
  During the study period, there were 152 patients with 185 penetrating solid organ injuries. Gunshot wounds accounted for 70.4% and stab wounds for 29.6% of injuries. Ninety-one patients (59.9%) met the criteria for immediate operation. The remaining 61 (40.1%) patients were selected for CT scan evaluation. Forty-three patients (28.3% of all patients) with 47 solid organ injuries who had no CT scan findings suspicious of hollow viscus injury were selected for clinical observation and additional laparoscopy in 2. Four patients with a "blush" on CT scan underwent angiographic embolization of the liver. Overall, 41 patients (27.0%), including 18 cases with grade III to V injuries, were successfully managed without a laparotomy and without any abdominal complication. Overall, 28.4% of all liver, 14.9% of kidney, and 3.5% of splenic injuries were successfully managed nonoperatively. Patients with isolated solid organ injuries treated nonoperatively had a significantly shorter hospital stay than patients treated operatively, even though the former group had more severe injuries. In 3 patients with failed nonoperative management and delayed laparotomy, there were no complications.
  
  
  CONCLUSIONS
  In the appropriate environment, selective nonoperative management of penetrating abdominal solid organ injuries has a high success rate and a low complication rate.
authors.affiliation: Division of Trauma and Surgical Intensive Care, Department of Surgery, USC School of Medicine, Los Angeles, CA 90033, USA. demetria@usc.edu
authors.forename: Demetrios
authors.initials: D
authors.lastname: Demetriades
authors.forename: Pantelis
authors.initials: P
authors.lastname: Hadjizacharia
authors.forename: Costas
authors.initials: C
authors.lastname: Constantinou
authors.forename: Carlos
authors.initials: C
authors.lastname: Brown
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Peter
authors.initials: P
authors.lastname: Rhee
authors.forename: Ali
authors.initials: A
authors.lastname: Salim
mesh_terms: D000007:Abdominal Injuries / Q000000981:diagnostic imaging / Q000628:therapy*; D000328:Adult; D000465:Algorithms; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007668:Kidney / Q000293:injuries*; D008099:Liver / Q000293:injuries*; D008297:Male; D011446:Prospective Studies; D013154:Spleen / Q000293:injuries*; D014057:Tomography, X-Ray Computed; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging / Q000628:therapy*