title: Delayed laparotomy after selective non-operative management of penetrating abdominal injuries.
abstract: BACKGROUND
  Main concern during the practice of selective non-operative management (SNOM) for abdominal stab wounds (SW) and gunshot wounds (GSW) is the potential for harm in patients who fail SNOM and receive a delayed laparotomy (DL). The aim of this study is to determine whether such patients suffer adverse sequelae because of delays in diagnosis and treatment when managed under a structured SNOM protocol.
  
  
  METHODS
  190 patients underwent laparotomy after an abdominal GSW or SW (5/04-10/12). Patients taken to operation within 120 min of admission were included in the early laparotomy (EL) group (n =153, 80.5 %) and the remaining in the DL group (n =37, 19.5 %). Outcomes included mortality, hospital stay, and postoperative complications.
  
  
  RESULTS
  The median time from hospital arrival to operation was 43 min (range: 17-119) for EL patients and 249 min (range: 122-1,545) for DL patients. The average number and type of injuries were similar among the groups. Mortality and negative laparotomy were observed only in the EL group. There was no significant difference in the hospital stay between the groups. The overall complications were higher in the EL group (44.4 vs. 24.3 %, p =0.026). DL was independently associated with a lower likelihood for complications (OR 0.39, 95 % CI 0.16-0.98, p =0.045). Individual review of all DL patients did not reveal an incident in which complications could be directly attributed to the delay.
  
  
  CONCLUSIONS
  In a structured protocol, patients who fail SNOM and require an operation are recognized and treated promptly. The delay in operation does not cause unnecessary morbidity or mortality.
authors.affiliation: Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital & Harvard Medical School, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA, miroslav.peev@tufts.edu.
authors.forename: Miroslav P
authors.initials: MP
authors.lastname: Peev
authors.forename: Yuchiao
authors.initials: Y
authors.lastname: Chang
authors.forename: David R
authors.initials: DR
authors.lastname: King
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Yeh
authors.forename: Haytham
authors.initials: H
authors.lastname: Kaafarani
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Fagenholz
authors.forename: Marc A
authors.initials: MA
authors.lastname: De Moya
authors.forename: George C
authors.initials: GC
authors.lastname: Velmahos
mesh_terms: D000007:Abdominal Injuries / Q000601:surgery* / Q000628:therapy; D000293:Adolescent; D000328:Adult; D002985:Clinical Protocols; D057210:Delayed Diagnosis; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007813:Laparotomy / Q000009:adverse effects; D007902:Length of Stay; D008297:Male; D013997:Time Factors; D061665:Time-to-Treatment; D014948:Wounds, Gunshot / Q000601:surgery* / Q000628:therapy; D014951:Wounds, Stab / Q000601:surgery* / Q000628:therapy; D055815:Young Adult