[ccm-l] FW: GSW to liver

[Ronald Simon]

I must take some issue with the comment below.

Ben Reynolds wrote:
> The best data about missed hollow viscus injuries and their associated mortality is well described in the EAST Hollow Viscus Injury work group*.  These injuries are significant even when found EARLY and their morbidity and mortality goes up significantly with each passing HOUR.  Mind you they were looking at hollow viscus injury from BLUNT mechanism which itself is a rare entity.  Hollow viscus injury from PENETRATING injury is much more common and much less studied radiographically because almost all of the patients in this cohort traditionally get immediate laparotomy. 
There is ample literature that shows that ANTERIOR abdominal SW can be 
safely observed with patients with injuries showing themselves and being 
operated on with NO increase in morbidity or mortality. This is just one 
example of many.

Ann Surg. 1987 Feb;205(2):129-32.    Indications for operation in 
abdominal stab wounds. A prospective study of 651 patients.
Demetriades D, Rabinowitz B.
    This prospective study comprises 651 patients with knife wounds of 
the anterior abdomen. Three hundred and forty-five patients (53%) had 
symptoms of an acute abdomen on admission and were operated on 
immediately. The remaining 306 patients (47%) were managed 
conservatively with serial clinical examinations. This group included 26 
patients with omental or intestinal evisceration, 18 patients with air 
under the diaphragm, 12 patients with blood found on abdominal 
paracentesis, and 18 patients with shock on admission. Only 11 patients 
(3.6%) needed subsequent operation, and there was no mortality. The 
overall incidence of unnecessary laparotomies was 5% (completely 
negative, 3%). Of the 467 patients with proven peritoneal penetration, 
27.6% had no significant intra-abdominal injury. It is concluded that 
many abdominal stab wounds can safely be managed without operation. The 
decision to operate or observe can be made exclusively on clinical 
criteria. Peritoneal penetration, air under the diaphragm, evisceration 
of omentum or bowel, blood found on abdominal paracentesis, and shock on 
admission are not absolute indications for surgery. Alcohol consumption 
by the patient does not interfere with the clinical assessment.

ron simon
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