Non-operative management of Gunshot wounds to the liver

Isolated gunshot wounds to the right upper quadrant may be candidates for non-operative management, similar to what we do with blunt liver injury.

• Associated injury (ie to colon, duodenum, etc) must be ruled out by CT scan
• Patient must be hemodynamically stable
• Because the potential for diaphragmatic injury exists, the patient should be counseled for awareness of delayed SBO

From EAST Practice Management Guidelines:

In 1994 Renz and Feliciano published a prospective series of stable patients with GSW to the right thoracoabdomen^[40]. Thirteen patients were identified. Twelve of these had CT. All patients had a right hemothorax treated with a chest tube. Complications included atelectasis (n=4), a small persistent pneumothorax (n=2), and pneumonia (n=1). None required laparotomy. It was concluded that stable patients without peritonitis after sustaining a GSW to the right thoracoabdomen can be managed nonsurgically with a low incidence of minor intrathoracic complications.

Demetriades subsequently reported a prospective series of 43 patients who suffered penetrating abdominal trauma from May 2004 to January 2006, did not have immediate criteria for operation, and had evidence of solid organ but not hollow viscus injury on CT^[41]. Thirty-two of these patients had injuries to the liver. Four patients with a contrast blush underwent angioembolization of the liver. Forty-one of these patients were successfully managed without laparotomy without complication; two required delayed laparotomy, both 41 hours after admission, and survived without complication. Two underwent laparoscopic evaluation for suspected left diaphragm lacerations, and both had laparoscopic repair of these injuries. In all 28.4% of all patients with penetrating trauma to the liver, mostly GSWs, were safely managed nonoperatively.

http://www.east.org/research/treatment-guidelines/penetrating-trauma,-selective-non-operative-management-of