George C. Velmahos, Elias Degiannis and Dietrich Doll (eds.)Penetrating Trauma10.1007/978-3-662-49859-0_57

57. SNOM: Conservative Management of Solid Viscera

Pradeep H. Navsaria¹

(1)

Department of Surgery, Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa

Pradeep H. Navsaria

The selective nonoperative management (SNOM) of hemodynamically stable, clinically evaluable patients with abdominal stab and low-velocity gunshot wounds without an intra-abdominal injury is safe. The high success rates of the nonoperative management of patients with blunt solid organ injuries have been extended to select patients with documented penetrating liver, kidney, and spleen injuries. While this is not a universally accepted mode of treatment, there is a small, but growing body of evidence to support the SNOM of penetrating solid organs.

The concept of the SNOM of penetrating solid organs is one that deals with patients who have sustained a penetrating abdominal injury, who do not have an emergent indication for laparotomy (hemodynamic instability or peritonitis), who are neurologically (centrally and peripherally) intact, who have undergone computerized tomography (CT) documenting a solid organ injury, and who are then managed nonoperatively, without a laparotomy.

57.1 SNOM: Liver

Patients with penetrating injury to the right thoracoabdomen and right upper quadrant with injury to the right lung, right diaphragm, and liver may be safely observed in the presence of stable vital signs, minimal or no abdominal tenderness, and reliable clinical examination.

57.1.1 The Patient

Right thoracoabdominal/right upper quadrant penetrating injury

57.1.2 Clinical Findings

Stable vital signs
No central or spinal cord neurological deficit
Minimal or no abdominal tenderness

57.1.3 Plain Chest Radiograph

Normal
Right pneumothorax
Right hemothorax
Right hemo-/pneumothorax
Right-sided pulmonary opacity signifying lung contusion and/or intrapulmonary hematoma

57.1.4 Special Investigation

Contrasted computerized axial tomography essential (lower chest and upper abdomen).

CT scan confirms lung and liver injury (diaphragm injury by inference).
Grades liver injury.
Determines the amount of pleural fluid and degree of lung contusion.
Any contrast “blush” on CT scan is considered a finding of bleeding or false aneurysm and must be followed up immediately by angiography and angioembolization, if the patient remains hemodynamically stable.
Free air, free fluid with no solid organ involvement, localized bowel wall thickening, mesentery stranding, and hematoma/free air surrounding hollow viscus suggest hollow viscus injury – proceed to laparotomy.

57.1.5 Management

Admit to high observation unit for at least 48–72 h
Single-dose second-generation cephalosporin prophylactic antibiotic
Two-hourly blood pressure and hemoglobin estimation for 24 h, then four-hourly
Four-hourly serial abdominal examination
Nil per mouth for 24 h, then feed; if tolerated, hollow visceral injury unlikely
Transfer to general surgical ward

57.1.6 Complications

Failed abdominal observation: Development of peritonitis and hypotension warrants immediate surgery. Pyrexia and raised leukocyte count must be taken in context of clinical abdominal findings and not necessarily imply failure of nonoperative management.

Infected fluid (bile and/or blood) collections: Infected subphrenic, subhepatic, and intrahepatic collections usually manifest 3–5 days post-injury. Patients are usually generally well, but have a swinging pyrexia, elevated leukocyte count, and maybe some increase in localized tenderness to the right upper quadrant. Repeat CT scan is essential for diagnosis, and treatment consists of percutaneous drainage and broad-spectrum antibiotic cover (antistaphylococcal agent and anaerobic cover is essential). Patients without drainable collections should be empirically commenced on broad-spectrum antibiotics for suspected infected liver “tract hematoma.”

57.2 Thoracobiliary Fistulae

All patients with a liver gunshot traversing the diaphragm treated nonoperatively are at risk of thoracobiliary (pleurobiliary and bronchobiliary) fistulae. Diagnosis is usually suspected with bilious drainage from tube thoracostomy or reaccumulation of pleural fluid collections that are bile-stained and bile-stained sputum. Management consists of adequate pleural drainage, percutaneous drainage of any peri-/intrahepatic collections, endoscopic retrograde cholangiography with sphincterotomy, and placement of a biliary stent.

57.3 The Evidence

The first reported prospective study by Renz and Feliciano on the SNOM of liver gunshot injuries included 13 patients with right-sided thoracoabdominal gunshot wounds, seven of whom had CT-confirmed liver injuries, with a 100 % nonoperative management success rate. Similarly, Chmielewski et al., in a series of 12 patients with lower right chest gunshot wounds, confirmed eight hepatic injuries (grades II–III) in those undergoing ultrasound or CT. One patient required delayed laparotomy without any adverse outcome. Ginzburg et al. managed four patients with liver gunshot injuries successfully nonoperatively. In their retrospective series, Demetriades et al. proposed the notion that only selected patients with grade I–III injuries should be managed nonoperatively. In a prospective study of SNOM of liver gunshot injuries, Omoshoro-Jones et al. showed that increasing injury severity was associated with an increasing rate of complications; however, injury grade itself was not shown to be an independent predictor of nonoperative management failure. Overall, of the 188 cases of nonoperatively managed liver gunshot injuries identified in the English literature, a success rate of greater than 90 % has been reported. This high success rate could be attributed to the fact that most gunshot injuries to the liver require no treatment. In a prospective study by Navsaria et al., of 195 liver gunshot injuries, 81/195 (41.5 %) liver injuries required no treatment at laparotomy, and 63/195 (32.3 %) patients were considered for nonoperative management without laparotomy. Hence, a total of 144/195 (73.8 %) of all liver gunshot injuries in their series were managed conservatively. The surgeon, however, must recognize the risks of SNOM of penetrating liver injuries and have the resources (angiography with angioembolization, percutaneous interventional techniques, endoscopic interventional cholangiography) available to address potential complications. Arterial phase contrast extravasation may predict failure of SNOM and adjunctive angioembolization should be considered for this group. SNOM of penetrating abdominal wounds, with or without liver injury, with or without advanced CT technology, is still based largely on the findings from serial clinical examinations.