GUNSHOT WOUNDS TO THE RIGHT THORACOABDOMEN - A PROSPECTIVE-STUDY OF NONOPERATIVE MANAGEMENT

Dissatisfied with our unnecessary laparotomy rate in patients with gunshot wounds (GSWs) to the right thoracoabdomen (RTA), a prospective study was designed to test the hypothesis that hemodynamically stable patients without peritonitis could be managed without a surgical procedure. From 1990 through 1993, 13 consecutive patients with a GSW between the right nipple, costal margin, right posterior axillary line, and anterior midline were studied. No patient had or developed more than local wound tenderness. All patients had a right hemothorax treated with a chest tube. Computed tomographic (CT) scanning of the RTA was performed within 8 hours of admission in 12 of the 13 patients, and the following injuries were noted: pulmonary contusion (12), hepatic laceration (seven), spinal cord transection (two), and a renal laceration (one). Follow-up CT scans, 3 to 14 days after injury, in six of the seven patients with hepatic wounds showed partial or complete resolution of the injury in all. In one patient, an associated renal injury was unchanged on the follow-up CT scan. Mean length of hospitalization for the 11 patients who did not have an injury to the spinal cord was 5.1 days (3-8 days). Complications included atelectasis (four), a small persistent pneumothorax (two), and pneumonia (one). No complications occurred after discharge. Conclusions from this prospective study were: (1) hemodynamically stable patients without peritonitis after sustaining a GSW to the RTA can be managed nonsurgically with a low incidence of minor intrathoracic complications; (2) thoracoabdominal CT scanning is a comprehensive means of diagnosis and follow-up when nonsurgical management is chosen; and (3) such patients will usually have injury to the right lung and the liver.