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Selective nonoperative management of renal gunshot wounds

Schellenberg, Morgan MD, MPH; Benjamin, Elizabeth MD, PhD; Piccinini, Alice MD; Inaba, Kenji MD; Demetriades, Demetrios MD, PhD

Journal of Trauma and Acute Care Surgery: December 2019 - Volume 87 - Issue 6 - p 1301–1307
doi: 10.1097/TA.0000000000002475
ORIGINAL ARTICLES
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BACKGROUND Selective nonoperative management (SNOM) of blunt kidney injuries has been the standard of care for decades. However, the role of SNOM after renal gunshot wounds (GSWs) remains unclear. The purpose of this study was to assess the safety and outcomes of SNOM of renal GSWs at a national level.

METHODS The National Trauma Data Bank was queried for patients who sustained a GSW to the kidney (January 2007 to December 2014). Patients with emergency department death, transfer, nonsurvivable (Abbreviated Injury Scale score = 6) injuries, absent vitals on arrival, associated hollow viscus or major abdominal vascular injury, or missing procedure/discharge data were excluded. Study groups were defined according to management strategy, with operative management (OM) defined as laparotomy 4 hours or less from admission and SNOM defined by the lack of laparotomy 4 hours or less from admission. Demographics, injury data, and outcomes (mortality, complications, need for nephrectomy, failure of SNOM [defined as laparotomy 5–72 hours after admission], and hospital length of stay [LOS]) were collected. Logistic regression compared outcomes between SNOM and OM.

RESULTS Over the study period, 1,329 patients met inclusion and exclusion criteria. Of these, 459 (34.5%) underwent SNOM (38.6% of American Association for the Surgery of Trauma kidney injury grades I–II, 39.4% of grade III, 24.0% of grade IV, and 5.2% of grade V). SNOM was associated with significantly shorter hospital LOS (6 days vs. 9 days, p < 0.001). Failure of SNOM occurred in 10.2%. Logistic regression showed no association between SNOM and mortality (odds ratio [OR], 0.614, p = 0.244). However, SNOM was independently associated with fewer complications (OR, 0.711; p = 0.008) and a reduction in need for nephrectomy (OR, 0.056; p < 0.001).

CONCLUSION SNOM of GSWs to the kidney has become a common practice in the United States. It is safe and has a high success rate, even in severe kidney injuries. It decreases hospital LOS and is independently associated with fewer complications and reduced need for nephrectomy.

LEVEL OF EVIDENCE Therapeutic/Care Management, level IV.

From the Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California.

Submitted: April 14, 2019, Revised: July 29, 2019, Accepted: August 4, 2019, Published online: August 14, 2019.

Presentations: This paper has not been presented at a meeting.

Address for reprints: Morgan Schellenberg, MD, MPH, FRCSC, Division of Trauma and Surgical Critical Care, LAC + USC Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower, C5L100, Los Angeles, CA 90033; email: morgan.schellenberg@med.usc.edu.

Online date: August 16, 2019

© 2019 Lippincott Williams & Wilkins, Inc.