10-Management of thoracoabdominal gunshot wounds – Experience from a major trauma centre in South Africa

<table><tr><td colspan="3"></td></tr><tr><td colspan="3"><img src="/media/202408//1724856296.446014.jpeg" /><img src="/media/202408//1724856296.519723.jpeg" /><a href="https://doi.org/10.1016/j.injury.2023.111186">Injury xxx xxxx) xxx(</a>Contents lists available at <a href="https://www.sciencedirect.com/science/journal/00201383">ScienceDirect</a>Injuryjournal homepage: <a href="https://www.elsevier.com/locate/injury">www.elsevier.com/locate/injury</a></td></tr><tr><td colspan="3">Management of thoracoabdominal gunshot wounds – Experience from a major trauma centre in South Africa<a id="bookmark1"></a>Jonah Qi <a href="#bookmark1">a, Victor Kongb,</a><a href="#bookmark2">c,</a><a href="#bookmark3">*, Jonathan Ko</a><a href="#bookmark1">a, Anantha Narayanana, Jim Wanga, Priscilla Leowa,</a> John Bruce <a href="#bookmark2">c, Grant Laingc, Damian Clarke</a><a href="#bookmark1">b,</a><a href="#bookmark2">c</a>a Department of Surgery, University of Auckland School of Medicine, Auckland, New Zealand <a id="bookmark2"></a>b Department of Surgery, University of the Witswatersrand, Johannesburg, South Africac Department of Surgery, University of KwaZulu-Natal, Durban, South Africa</td></tr><tr><td>A R T I C L E I N F O</td><td rowspan="2"></td><td>A B S T R A C T</td></tr><tr><td>Keywords:Trauma surgeryThoracoabdominal gunshot wounds Computed tomography scanSelective non-operative management</td><td>Introduction: The management of thoracoabdominal (TA) gunshot wounds (GSW) remains challenging. This study reviewed our experience with treating such injuries over a decade.Materials and methods: A retrospective study was conducted at a major trauma centre in South Africa over a ten- year period from December 2012 to January 2022.Results: Two hundred sixteen cases were included (male: 85 %, mean age: 33 years). Median RTS: 8 and medianISS: 17 (IQR: 10–19). The mean value of physiological parameters: Heart Rate (HR): 98/min, Systolic BloodPressure (SBP): 119 mmHg, Temperature (T): 36.2 ◦ C, pH: 7.35, Lactate 3.7 mmol/l. Ninety-nine (46 %) un- derwent a CT scan of the torso. One hundred fifty-four cases (69 %) were managed operatively: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy [6/154 (4 %)]. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. The overall morbidity was 30 % (69). 82 % required intensive care (ICU) admission. The mean length of hospital stay was 14 days. The overall mortality was 13 % (28). Over the 10-year study period, there was a steady increase in the number of cases of TA GSWs managed at our institution. Over the study period, an increasing use of CT was noted, along with a steady reduction in the proportion of operations performed.Conclusions: Thoraco-abdominal GSWs remain challenging to manage and continue to be associated with sig- nificant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches.</td></tr><tr><td colspan="3"><img src="/media/202408//1724856296.6345248.png" />The management of thoracoabdominal gunshot wounds (TAGSW) is complicated by the fact that the missile traverses two body compart- ments, resulting in potential injuries in both. This creates a clinical dilemma as the managing surgeon must decide which body cavity contains the most pressing and life-threatening injuries and prioritize the injuries in this cavity. In the acute setting, this may not always be clear clinically. In addition, the breach of two body cavities increases morbidity as cross-contamination occurs <a href="#bookmark4">[1–5]</a>. This situation has been described as one of ’double jeopardy. ’ The evolution and integration of modalities such as computed tomography (CT) scan <a href="#bookmark5">[6–8]</a> in traumaIntroductioncare, as well as changes in philosophies in terms of damage control surgery and fluid-restrictive resuscitation means that the clinical algo- rithms designed to assist in these situations need to be regularly reviewed and updated [<a href="#bookmark6">9</a>,<a href="#bookmark7">10</a>]. This study utilized data from a well-established regional electronic registry at a single major trauma centre in South Africa. The aim of the study was to review our experi- ence in the management of this injury over the past decade and to ensure that they are contemporary and evidence-based.<a id="bookmark3"></a>* Corresponding author at: Trauma Centre, Sunnybrook Hospital, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada. E-mail address: <a href="mailto:victorywkong@yahoo.com">victorywkong@yahoo.com</a> (V. Kong).<a href="https://doi.org/10.1016/j.injury.2023.111186">https://doi.org/10.1016/j.injury.2023.111186</a>Accepted 3 November 2023Available online 7 November 20230020-1383/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (<a href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</a>).</td></tr><tr><td colspan="3">Please cite this article as: Jonah Qi et al., Injury, <a href="https://doi.org/10.1016/j.injury.2023.111186">https://doi.org/10.1016/j.injury.2023.111186</a></td></tr></table><img src="/media/202408//1724856296.741735.png" /><img src="/media/202408//1724856296.77966.png" />J. Qi et al. Injury xxx (xxxx) xxx<table><tr><td><img src="/media/202408//1724856296.8179011.png" /></td></tr></table><img src="/media/202408//1724856296.8486881.png" /><img src="/media/202408//1724856296.913835.png" /><img src="/media/202408//1724856297.15562.png" /><img src="/media/202408//1724856297.162667.png" /><img src="/media/202408//1724856297.1833768.png" /><img src="/media/202408//1724856297.193168.png" /><img src="/media/202408//1724856297.205495.png" />↓<table><tr><td><img src="/media/202408//1724856297.249651.png" /></td></tr></table>Fig. 1. Initial management of 216 TA GSW cases. NOM = non-operative management. OT = operating theatre.<a id="bookmark8"></a>Materials and methodsClinical settingThe Pietermaritzburg Metropolitan Trauma Service (PMTS) is based in the city of Pietermaritzburg and provides definitive trauma care for the western part of Kwa Zulu Natal (KZN) Province, South Africa. It is one of the largest academic trauma centers in the region, with over 4000 admissions per year covering a catchment population of over 3 million people. The PMTS maintains an electronic registry called the Hybrid Electronic Medical Record (HEMR). Ethics approval to maintain the HEMR and to conduct this study was granted by the BiomedicalResearch Ethics Committee (BREC) of the University of KwaZulu Natal(Reference number: BE 207/09).Management protocolAll patients who present with TA GSWs are initially managed ac- cording to Advanced Trauma Life Support (ATLS) principles. Those who are hemodynamically unstable and/or present with generalized perito- nitis are expedited to the operating room (OR) without cross-sectional imagining. Clinical assessment, in conjunction with adjuncts such as plain radiography and FAST scan is used to predict the cavity containing the most pressing injuries, which require definitive management. Pa- tients without an immediate indication for operation undergo cross- sectional imaging with a CT scan of the torso.The studyThe HEMR was retrospectively reviewed over the ten-year period from December 2012 to January 2022. All patients who sustained TA GSWs were included. Thoraco-abdominal GSW injuries in this study were defined as any GSW that traversed both the thoracic and abdom- inal cavities. The definition included injuries located within the <a id="bookmark9"></a>following anatomical boundaries: Inferior to trans-nipple line anteriorly,infra-scapular line posteriorly, and superior to costal margins. Basic demographic data were reviewed. Further information regarding admission physiology, investigations, imaging findings, additional in- terventions, and clinical outcomes was reviewed. Where applicable, formal consent and permission for the use of clinical photography have been obtained from patients. IBM SPSS Statistics for Windows (IBM Corp. Released 2022. Version 29.0. Armonk, NY: IBM Corp) was used to perform Student t-tests on mean values, Mann-Whitney tests on median values, and Chi-squared tests with Yates ’ continuity correction and a Fisher-Freeman-Halton Exact Test on categorical data. All flow chart figures were created using Microsoft® PowerPoint® for Microsoft 365 MSO.ResultsOverviewOver the ten-year study period,a total of 216 patients who sustained a TAGSW were identified. This equates to approximately 7 cases per million people per year within our catchment area. It should be noted that as our cohort only includes patients who survived adequately to undergo a CT scan or operation, the annual incidence reported in our study likely underestimates the true incidence of TA GSWs within the catchment area. Eighty-five percent (185/216) were men and the me- dian age was 31 (IQR 25 - 38) years. The median RTS (Revised Trauma Score) was 8 (IQR: 8–8). The median ISS (Injury Severity Score) was 17 (IQR: 10–19). The mean values of physiological parameters on presen- tation were as follows: Heart Rate (HR): 98 (SD: 20) beats/minute, Systolic Blood Pressure (SBP): 119 (SD: 22) mmHg, Temperature (T): 36.2 (SD: 0.9) ◦ C, pH: 7.35 (SD: 0.1), Lactate 3.7 (SD: 3.2) mmol/l. As this was a retrospective review of medical records, there were instances where data was missing. The number of missing data points in each variable areas follows: 3 in SBP, 2 in HR, 3 in Temperature, 13 in pH and 19 in Lactate. These were assumed to be missing at random and avail- able data for each variable was analysed.<img src="/media/202408//1724856297.280235.png" /><img src="/media/202408//1724856297.284487.png" /><img src="/media/202408//1724856297.2893188.png" /><img src="/media/202408//1724856297.2916732.png" /><img src="/media/202408//1724856297.298363.png" /><img src="/media/202408//1724856297.301756.png" /><table><tr><td><img src="/media/202408//1724856297.305196.png" /><img src="/media/202408//1724856297.308953.png" /></td></tr></table><img src="/media/202408//1724856297.311583.png" />La paro to my+Thora cotomy(n=6)Fig. 2. Summary of Operative Management in the 154 cases.<img src="/media/202408//1724856297.315222.png" />J. Qi et al.<a id="bookmark10"></a>Table 1Spectrum of organ injury in 154 cases.<table><tr><td></td><td>Organ</td><td>N</td></tr><tr><td rowspan="2">Thoracic</td><td>Lung</td><td>106 (69 %)</td></tr><tr><td>Diaphragm</td><td>84 (55 %)</td></tr><tr><td rowspan="5">Solid Organs</td><td>Heart</td><td>8 (5 %)</td></tr><tr><td>Liver</td><td>75 (49 %)</td></tr><tr><td>Spleen</td><td>40 (26 %)</td></tr><tr><td>Kidney</td><td>26 (17 %)</td></tr><tr><td>Pancreas</td><td>19 (12 %)</td></tr><tr><td rowspan="3">Hollow Viscous</td><td>Stomach</td><td>61 (40 %)</td></tr><tr><td>Gallbladder</td><td>56 (36 %)</td></tr><tr><td>Large Bowel</td><td>54 (35 %)</td></tr><tr><td rowspan="4">Pelvic/Urinary</td><td>Small Bowel</td><td>36 (67 %)</td></tr><tr><td>Duodenum</td><td>7 (5 %)</td></tr><tr><td>Rectum</td><td>7 (5 %)</td></tr><tr><td>Ureter</td><td>5 (3 %)</td></tr><tr><td rowspan="3">Other</td><td>Bladder</td><td>4 (3 %)</td></tr><tr><td>Abdominal vasculature</td><td>12 (8 %)</td></tr><tr><td>Mesentery</td><td>6 (4 %)</td></tr></table><a id="bookmark11"></a>Table 2<img src="/media/202408//1724856297.3225129.png" />Direct comparison of cases who underwent an operation following preoperative CT vs those who underwent an operation without a preoperative CT.<table><tr><td></td><td></td><td>SurgeryfollowingPreoperative CT (N = 44)</td><td>SurgerywithoutPreoperative CT(N = 110)</td><td>P-Value</td></tr><tr><td rowspan="3">Demographics</td><td>Median age: years (IQR)</td><td>32 (24 – 38)</td><td>31 (26 - 39)</td><td>.448</td></tr><tr><td>Male (%)</td><td>77</td><td>93</td><td>.001</td></tr><tr><td>Female (%)</td><td>23</td><td>7</td><td></td></tr><tr><td rowspan="9">Physiology</td><td>Median RTS (IQR)</td><td>8 (8 - 8)</td><td>8 (8 - 8)</td><td>0.227</td></tr><tr><td>Median ISS (IQR)</td><td>18 (13 - 24)</td><td>17 (10 - 19)</td><td>0.387</td></tr><tr><td>Mean HR:</td><td>95 (18)</td><td>103 (20)</td><td>0.190</td></tr><tr><td>beats/min (SD)</td><td></td><td></td><td></td></tr><tr><td>Mean SBP: mmHg (SD)</td><td>119 (20)</td><td>115 (23)</td><td>0.246</td></tr><tr><td>Mean</td><td>36.3 (0.8)</td><td>36.4 (0.9)</td><td>0.643</td></tr><tr><td>Temperature: Co (SD)</td><td></td><td></td><td></td></tr><tr><td>Mean pH (SD)</td><td>7.36 (0.08)</td><td>7.35 (0.10)</td><td>0.899</td></tr><tr><td>Mean Lactate: mmol/L (SD)</td><td>2.8 (2)</td><td>4.6 (3)</td><td>0.001</td></tr><tr><td rowspan="4">Operation</td><td>Laparotomy only</td><td>40 (91 %)</td><td>103 (94 %)</td><td></td></tr><tr><td>Thoracotomy</td><td>3 (7 %)</td><td>2 (2 %)</td><td>0.244</td></tr><tr><td>only</td><td></td><td></td><td><a href="#bookmark12">*</a></td></tr><tr><td>Dual Cavity Exploration</td><td>1 (2 %)</td><td>5 (4 %)</td><td></td></tr><tr><td rowspan="2">ClinicalOutcome</td><td>Morbidity</td><td>18 (41 %)</td><td>41 (37 %)</td><td>0.814</td></tr><tr><td>Mortality</td><td>3 (7 %)</td><td>18 (16 %)</td><td>0.194</td></tr></table>Note: As this was a retrospective review of medical records, there were instances where data was missing. Number of missing data points in each variable are as follows: 3 in SBP, 2 in HR, 3 in Temperature, 13 in pH and 19 in Lactate. These were assumed to be missing at random and available data for each variable was analysed.*<a id="bookmark12"></a>P-value of ‘Operation ’ obtained via a Fisher-Freeman-Dalton Exact Test.Clinical managementOf the 216 patents in the study, 99 (46 %) underwent aCTscan of the torso while the remaining 117 (54 %) did not. <a href="#bookmark8">Fig. 1</a> summarises the initial management of the 216 cases.Operative managementA total of 154 cases (72 %) were managed operatively. <a href="#bookmark9">Fig. 2</a> sum- marises the operations performed, grouped under three distinctInjury xxx (xxxx) xxxcategories as follows: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy (dual cavity exploration in the same setting) [6/154 (4 %)]. <a href="#bookmark10">Table 1</a> summa- rises the spectrum of organ injuries in these 154 cases.Subgroup analysisOf the 154 cases that were managed operatively, 110 (71 %) did not undergo preoperative CT imaging while 44 (29 %) underwent CT prior to operation. A direct comparison was made between these two groups. This is shown in <a href="#bookmark11">Table 2</a>. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. There was no difference in overall clinical outcome between the two groups.Clinical outcomeOf the 216 patients, the overall morbidity was 30 % (69). These were: respiratory in 12 % (25), renal in 9 % (20), gastrointestinal in 4 % (9), wound-related in 8 % (17),sepsis in 12 % (26), and miscellaneous in 2 % (5). Thirty-eight per cent (82) of patients required intensive care (ICU) admission with a median length of ICU stay of 4 days (IQR 2–14). The median length of hospital stay was 7 (IQR 3–17) days. The overall mortality was 13 % (28).TrendOver the ten-year study period, there was an increase in the number of cases of TA GSWs managed as shown in <a href="#bookmark13">Fig. 3</a>. The mean number of cases managed per year was approximately 24 (SD: 6). An increasing use of CT was noted over the study period, summarised in <a href="#bookmark14">Fig. 4</a>. During the same period, there was also a steady reduction in the proportion of operations performed, as demonstrated in <a href="#bookmark15">Fig. 5</a>.DiscussionThoracoabdominal GSWs are associated with significant morbidity and mortality, as demonstrated in this study. This is because there are injuries in more than one body cavity, and cross-contamination occurs between the two body compartments. It is challenging to manage these patients, as the operating surgeon faces a clinical dilemma in deciding which body cavity to prioritize first <a href="#bookmark4">[1–5]</a>, and this situation is commonly referred to as one of ’double jeopardy. ’ Opening more than one body cavity is associated with increased morbidity and mortality rates. Opening the incorrect body cavity primarily delays definitive management of the injured viscera and is also associated with increased rates of mortality <a href="#bookmark16">[2</a>,<a href="#bookmark17">11</a>]. The clinical assessment of these patients prior to operative intervention needs to take these considerations into ac- count. There have been numerous developments that have assisted surgeons in their clinical decision-making. There has been a strong trend towards selective non-operative and minimalistic approaches to the management of penetrating torso trauma over the last three decades [<a href="#bookmark17">11</a><a href="#bookmark18">,12</a>]. This was initially confined to patients with right upper quad- rant trajectories where the most likely injury was confined to the liver <a href="#bookmark19">[7]</a>. This approach was made possible by the widespread availability of CT scans, which could accurately delineate the tract of the missile and exclude potential injuries to adjacent hollow viscera <a href="#bookmark5">[6]</a>. The other major advance in surgical minimalism was the rediscovery of the sub-xiphoid window approach as a means of both treating and excluding mild penetrating cardiac injuries <a href="#bookmark20">[13–19]</a>. The combination ofthese two developments has altered the clinical approach to TAGSWs over the past decades.Worldwide, there has been a steady increase in the use of CT scans following penetrating trauma and it commonly forms part of the man- agement algorithm in many trauma centers <a href="#bookmark5">[6–8]</a>. Provided there is no absolute indication for urgent exploration and the patient is stable<img src="/media/202408//1724856297.356402.png" /><a id="bookmark13"></a>J. Qi et al. Injury xxx (xxxx) xxx<table><tr><td><img src="/media/202408//1724856297.36322.png" /><img src="/media/202408//1724856297.366692.png" /><img src="/media/202408//1724856297.369313.png" /><img src="/media/202408//1724856297.372156.png" /><img src="/media/202408//1724856297.380209.png" />cases<table><tr><td colspan="4"><img src="/media/202408//1724856297.409913.png" /></td></tr><tr><td colspan="4"><img src="/media/202408//1724856297.424737.png" /></td></tr><tr><td>2723</td><td><img src="/media/202408//1724856297.449572.png" /></td><td>25</td><td>27</td></tr><tr><td colspan="4"><img src="/media/202408//1724856297.465577.png" /></td></tr><tr><td colspan="4"></td></tr></table><img src="/media/202408//1724856297.509953.png" />year</td></tr></table><a id="bookmark14"></a>Fig. 3. Trend in the number of TA GSWs managed at our institution.<img src="/media/202408//1724856297.513263.png" /><table><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr></table><img src="/media/202408//1724856297.524408.png" />year<img src="/media/202408//1724856297.538187.png" /><img src="/media/202408//1724856297.5964632.png" /><img src="/media/202408//1724856297.619937.png" />52 474252<img src="/media/202408//1724856297.6288378.png" />%9080706050403020100<img src="/media/202408//1724856297.637672.png" /><img src="/media/202408//1724856297.6399949.png" />Fig. 4. Trend in the use of CT for TA GSWs.enough to undergo imaging, a CT scan is useful. In our study, the lactate level was lower in the group who underwent a preoperative CT, which was a reflection of the physiology in which patients were sufficiently stable to undergo such investigations. CT can assist in two distinct ways. A CT scan can facilitate non-operative management by identifying the missile tract and excluding a visceral injury <a href="#bookmark5">[6–8]</a>. In our cohort, this approach resulted in successful non-operative management in over 90 % of cases. It can also assist in minimizing the extent of operation required by excluding injuries to retroperitoneal structures such as the intra-abdominal vasculature and the duodenum or kidney <a href="#bookmark5">[6</a>,<a href="#bookmark21">20</a>]. The overall rate of dual cavity exploration in our study was lower in the preoperative CT group, although it did not reach statistical significance.This may have been related to the relatively low numbers to demon- strate the difference. Further multi-centre studies in the future may be useful.ConclusionsThoraco-abdominal GSWs remain challenging to manage and continue to be associated with significant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches.<img src="/media/202408//1724856297.64895.png" /><a id="bookmark15"></a>J. Qi et al. Injury xxx (xxxx) xxx<img src="/media/202408//1724856297.652404.png" />%<table><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr><tr><td></td></tr></table><img src="/media/202408//1724856297.6553202.png" />year<img src="/media/202408//1724856297.658066.png" /><img src="/media/202408//1724856297.660542.png" /><img src="/media/202408//1724856297.663372.png" /><img src="/media/202408//1724856297.6654148.png" /><img src="/media/202408//1724856297.667745.png" />745277Fig. 5. Trend in reduction in the proportion of cases who required operation.Declaration of Competing InterestThe authors report no conflicts of interest.<a id="bookmark4"></a>References[1] Saadia R, DegiannisE, Levy RD. Management of combined penetrating cardiac and abdominal trauma. Injury 1997;28(5–6):343–7. <a href="https://doi.org/10.1016/S0020-1383(97)00091-0">https://doi.org/10.1016/S0020-</a> <a href="https://doi.org/10.1016/S0020-1383(97)00091-0">1383(97)00091-0</a>.<a id="bookmark16"></a>[2] <a href="http://refhub.elsevier.com/S0020-1383(23)00903-8/sbref0002">Hirshberg A, Wall Jr MJ, Allen MK, Mattox KL. Double jeopardy:</a><a href="http://refhub.elsevier.com/S0020-1383(23)00903-8/sbref0002">thoracoabdominal injuries requiring surgical intervention in both chest and</a> <a href="http://refhub.elsevier.com/S0020-1383(23)00903-8/sbref0002">abdomen. 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