J.R. Coll. Surg. Edinb., 43, August 1998, 230—234

General surgery section

Civilian abdominal gunshot wounds in Lagos

A. A. ADESANYA, I. R. AFOLABI AND J. T. DA ROCHA-AFODU
Department of Surgery, Lagos University Teaching Hospital and College of Medicine, University of Lagos, Nigeria

This prospective study of 78 patients who sustained abdominal gunshot wounds was performed to evaluate the pattern of injuries, treatment outcome and the role of selective conservative management. Three (3.8%) patients died before laparotomy. Four (5.1%) patients with superficial wounds were managed by local wound care. Fourteen (18%) patients who had equivocal or minimal abdominal signs were selected for conservative management. Laparotomy was performed in 57 (73.1%) patients who presented with an acute abdomen. The commonly injured organs were the small bowel (56.1%), colon (38.6%), liver (22.8%) and stomach (19.3%). Prolonged injury to arrival and surgical intervention time were contributing factors to the high incidence of sepsis (63.2%) and mortality (22.8%) after laparotomy. Two patients selected for conservative management required delayed laparotomy, one of which was negative. A 10-fold increase in prevalence of abdominal gunshot wounds has occurred in our institution in the 1990s. Selective conservative management is feasible without the use of expensive investigations.

Keywords: abdominal gunshot wounds, selective conservative management.

The incidence of civilian abdominal gunshot wounds is on the increase in many cities.^1-9 The suggested reasons for this ever-increasing problem include easy availability of firearms, premeditated arrangements, acts of spontaneous violence and civil strife.^4,10,11 The current laws governing the possession of firearms has led to the blurring of the precise line between war and peace.^2,6 More than ever before, it is important that surgeons should be conversant with the management of gunshot wounds, more so of the abdomen, which presents a large surface area to assault. Most civilian abdominal gunshot wounds are caused by low velocity missiles fired from handguns.^1,2 Mandatory laparotomy, irrespective of abdominal signs, was the treatment of choice before the proposal of selective conservatism by Shaftan in 1960.¹² This approach based on non-operative management of a carefully selected group of patients, presenting with minimal or equivocal abdominal signs after sustaining gunshot wounds of the abdomen, has been reappraised and popularized.^6,7,13-16 However, 70—80% of patients present with signs of an acute abdomen necessitating emergency laparotomy.^6,7. Selective conservative management has been found to safely reduce the incidence of unnecessary and negative laparotomies in the remaining patients.^6,7,12-16

In the 30 years after 1960, civilian gunshot wounds of the abdomen were very uncommon in our region, with less than five cases per year seen at many teaching hospitals.^17-21 Most were due to inadvertent gunshots that occurred during the gun salute of burial ceremonies and when hunters mistook others for game.^19,20 Since 1990, with the escalation of interpersonal violence and civil upheavals in our cities, abdominal gunshot wounds have become a common problem. Although the Nigerian civil war presented the opportunity to study war wounds,^17,22,23 selective conservative management of civilian abdominal gunshot wounds has not gained popular acceptance. The purpose of this prospective study was to evaluate the pattern of injuries, treatment outcome and the role of selective conservative management in patients with abdominal gunshot wounds.

PATIENTS AND METHODS

This is a prospective study of all patients with abdominal gunshot wounds admitted into the accident and emergency centre of the Lagos University Teaching Hospital, between January 1992 and June 1996. The surface anatomical definition of the abdomen was from the nipple line to the pubis anteriorly and from a line joining the inferior angles of the scapulae to the lower buttock crease, posteriorly.⁶ Patients with entrance wounds outside these surface landmarks and clinical features of abdominal injury or radiological evidence of missiles in the abdomen were also included in the study. The posterior trunk or back was defined as the area between the inferior angles of the scapulae, the iliac crest and both midaxillary lines.²⁴ Data were recorded on proforma sheets, scrutinized regularly by one of the authors (A.A.A.). Patients’ characteristics, injury to arrival time, events during assault, enemy, type of gun, symptoms, signs, surgical intervention time, operative findings and postoperative complications were noted. Pre-operative packed cell volume, serum electrolytes and urea, radiographs (chest and abdomen) and urinalysis were obtained. Intravenous urography was reserved for patients with macroscopic haematuria. Shock, peritonitis, evisceration, leakage of intestinal content through wound, haematemesis, proctorrhagia and haematuria with entrance wound, suggestive of bladder injury, were indications for emergency laparotomy after vigorous resuscitation. Laparotomy was performed immediately in all patients with exsanguinating haemorrhage. A laparotomy was considered unnecessary if visceral injury did not require repair or drainage, negative if there was no peritoneal penetration or penetration without visceral injury. Shock was defined as systolic pressure of less than 100 mmHg and pulse rate greater than 100 per mm. Surgical intervention time was defined as the period between arrival in hospital and induction of general anaesthesia.

Haemodynamically stable patients with equivocal or minimal abdominal signs were selected for conservative management.Review by a consultant surgeon before selection was mandatory. In these patients an intravenous line was established, a nasogastric tube was inserted, radiographs of chest (erect anteroposterior view) and abdomen (supine, erect and lateral views) were obtained. Diagnostic paracentesis and urinalysis were also performed. Observation was based on serial physical examinations and monitoring of vital signs. The likely path of the bullet or pellets and peritoneal penetration were assessed using a combination of physical examination and radiographs of chest and abdomen. Laparotomy was performed in patients that developed acute abdomen during observation, otherwise they were discharged home after a few days.

Statistical analysis

Data were entered and analysed on a personal computer using EpiInfo version 5.0 (Centers for Disease Control, Atlanta, GA) and Sigmastat version 1.0 (Jondel Corp.) statistical software. Students t-test and Pearson product moment correlation were employed as indicated. P < 005 was considered significant.

RESULTS

Seventy-eight patients who sustained abdominal gunshot wounds were included in the study. Sixty-nine (88.5%) were males and 9 (11.5%) were females. The average age was 30 years with a range of 8 to 65 years; 48.7% were between the age of 20 and 30 years. The time between injury and arrival in hospital (n = 74) ranged from 20 min to 34 h with a median of 200 mm. Injury to arrival time was </=1 hour in 19 (25.7%) patients, </=3h in 35 (47.3%) patients, </=6h in 59(79.7%) patients, but was >6h in 15 (20.3%) patients, respectively. The wounding weapon in patients was the pistol in 27 (34.6%), shotgun in 19 (24.4%), rifle in 19 (24.4%) and unknown in 13 (16.6%) patients, respectively. A common weapon used in the last 18 months of the study was a handgun that fires a cartridge containing 120 pellets. Seventeen of the 19 shotgun wounds occurred in 1995 and 1996. Forty-eight (61.6%) patients were shot by armed robbers, 21 (26.9%) were shot during civil strife, four (5.1%) were hit by stray bullets, one (1.3%) was inadvertently shot during a struggle for gun possession, assailants could not be categorized by four (5.1%) patients. Car hijacking and home robberies meant victims were within close range of their assailants. One patient was kicked several times in the abdomen before being shot twice. Three (3.8%) patients admitted with profound shock and generalized peritonitis died before laparotomy. Four (5.1%) patients sustained superficial wounds of the gluteal region (three patients) and back (one patient). They were managed by local wound care.

Laparotomy group (n= 57)

Laparotomy was undertaken in 57 (73.1%) patients who presented with an acute abdomen. Forty-five (78.9%) patients had one entrance wound each, while 12 (21.1%) had multiple entrance wounds. Four patients were shot twice in the abdomen. Nineteen (33.3%) patients had exit wounds. The entrance wounds were in the anterior abdominal wall in 40 patients, posterior trunk in eight, gluteal region in eight and thorax in one patient, respectively. Symptoms and signs are listed in Table 1. Paresis of one lower limb, usually ipsilateral to the entrance or exit wounds in posterior trunk occurred in eight patients. Evisceration occurred in seven patients, bowel in three, omentum in two, spleen in one and liver and stomach in one patient, respectively. Rib fracture and fracture dislocation of the hip occurred in one patient each. Abdominal paracentesis was performed in 25 patients, it was positive in 16 and negative in 9 patients, respectively. Patients with negative paracentesis had gastrointestinal perforations, mesenteric haematomas and superficial liver lacerations. Indications for emergency laparotomy in all patients were shock and or generalized peritonitis. The median, injury to arrival time (n = 56), surgical intervention time (n= 56) and injury to surgery time (n= 55) were 205, 535 and 775 min, respectively. Surgical intervention time was </=3 h in 6 (10.7%) patients, </=6h in 16 (28.6%) patients, </=12h in 34 (60.7%) patients, but was >12 h in 22 (39.3%) patients, respectively. The surgical intervention time was significantly lower in non-survivors (n= 13, mean=38Smin) than in survivors (n= 43, mean = 688 min P= 0.0 12. The injury to arrival time and injury to surgery time were not significantly different between survivors and non-survivors, P= 0.79 and P= 0.10, respectively.

Table 1 Clinical features of abdominal gunshot wounds (n= 57)

The organs injured are listed in Table 2. The commonest injured organ was the small bowel (56.1%). Injuries to this organ were perforations and tangential lacerations, with the number of perforations ranging from two to 11. Simple suture closure or resection of segment containing multiple perforations followed by anastomosis was performed as appropriate in all patients. Twenty-two (38.6%) patients sustained injuries of the right colon (14 patients) and left colon (eight patients). Colon injuries were treated by debridement with simple closure of perforations in five patients, resection of the segment containing perforations followed by anastomosis in four patients, simple closure of perforations with proximal colostomy in two patients, exteriorization of injured colon as colostomy in eight patients, resection of injured segment followed by exteriorization as colostomy in three patients, respectively. Eight of 22 (36.4%) patients with colon injuries died in the post-operative period of systemic sepsis (five patients), intra-abdominal abscess (one patient), faecal fistula (one patient) and complication of colostomy closure (one patient). Thirteen (22.8%) patients sustained hepatic injuries. Ten injuries were superficial or deep lacerations, two were through and through penetrations, one was complex with associated hepatic veins and inferior vena cava injuries. Two lacerations and two penetrations were not bleeding at the time of surgery. Hepatic injuries were treated by suturing and or drainage, application of surgicel or gelfoam and diathermy. Non-bleeding injuries were left alone. Three patients with hepatic injuries died; two because of colon injury related complications. Lacerations and perforations of the stomach, bladder and diaphragm were repaired with sutures. Four injured spleens were treated with splenectomy (three patients) and splenorrhaphy (one patient). Perforated gallbladders were removed. Three contused kidneys were treated conservatively. Repaired rectal lacerations were protected with proximal colostomies. Two patients with retroperitoneal major vessel injuries and one with pancreatic injury died during surgery.

Table 2 Type of organ injured (n = 57)

The organs injured vs. mortality rate is depicted in Table 3. A total of 101 abdominal organs were injured in the 57 patients who required laparotomy. A positive linear relationship was demonstrated between the number of organs injured and mortality (correlation coefficient (r) = 0.41, P= 0.002). Colon injury related complications were the causes of death in six of eight patients with two organ injuries. Cocaine withdrawal syndrome was the cause of death in the only patient who died from one organ injury. There were four (7%) unnecessary and two (3.5%) negative laparotomies. Post-operative complications included wound infection (38.6%), septicaemia (14%), enterocutaneous fistula (14%), intra-abdominal abscess (3.5%), burst abdomen (3.5%), incisional hernia (3.5%) and cocaine withdrawal syndrome (1.8%). Sepsis (wound infection, septicaemia and intra-abdominal abscess) occurred in 36 (63.2%) patients. Enterocutaneous fistula was an important cause of prolonged hospital stay, manifesting usually about 10 days after laparotomy. A missed small bowel perforation resulted in high output faecal fistula, noticed within 24 h of operation. Four of the eight fistulae closed spontaneously, three fistulae required operative closure and one patient died before intervention. Five deformed bullets and one bullet fragment, were extracted from six patients. Numerous shotgun pellets ranging from five to 30 were extracted from seven patients. Deformed bullets were 38 calibre in three patients, 25 calibre in one patient and non-copper jacketed hollow point bullet in one patient.

Table 3 Organs injured vs. mortality rate

Non-operative group (n = 14)

Fourteen (18%) patients were carefully selected for conservative management. The median injury to arrival time (n = 14) was 240 min. The wounding weapon was the shotgun in six, rifle in five and pistol in three patients, respectively. Eleven patients sustained entrance wounds only, two patients had entrance and exit wounds and one had an extensive tangential wound of the anterior abdominal wall. Six patients sustained entrance wounds in the posterior trunk, one in the gluteal region and six in the anterior trunk, respectively. Posterior trunk entrance wounds were associated with paraplegia in two patients, paresis of the right lower limb, haemothorax and haematuria in one patient each, respectively. In the 11 patients with entrance wounds only, radiographs of abdomen (lateral view) showed that bullets, bullet fragments and pellets were mostly arrested by the posterior trunk musculature and bones in six patients, iliac bone in one patient, anterior abdominal wall in four patients. A rifle bullet was arrested by the anterior abdominal wall of one patient after it pierced the car door. Peritoneal penetration by missiles was strongly suspected in the two patients with entrance and exit wounds. Both were shot with pistols. The first sustained an entrance wound 5 cm medial to the right anterior superior iliac spine and an exit wound in the right gluteal region. The second patient had an entrance wound in the left hypochondrium with an exit wound in the right hypochondrium.

On hospital admission, signs of shock were absent and diagnostic paracenteses were negative in these patients. Patients had soft abdomen with mild tenderness around entrance, exit and tangential wounds. However, two patients with anterior trunk shotgun wounds with wide pellet scatter developed signs of peritonitis during observation. Both required delayed laparotomy, one of which was negative with no peritoneal penetration. The second was positive revealing small bowel perforations. Twelve patients, including the two with suspected peritoneal penetration, were successfully managed applying the policy of selective conservatism. They were all discharged home after treatment of associated injuries. No death occurred in patients who required delayed laparotomy.

DISCUSSION

Civilian gunshot wounds of the abdomen were very rare in Lagos.¹⁷ But this is no longer so. Availability of firearms, escalation of inter-personal violence and civil strife has increased the incidence almost 10-fold. In the past, one or two cases per year were seen at our teaching hospitals,^17,20 compared with 78 cases in 4.5 years in the 1990s, as shown by this study. Overall, this incidence of about 17 cases per year is still very low compared with those of hospitals in other cities.¹⁹ Abdominal gunshot wounds are an injury of the young, but no age is spared. A study of events during assault revealed that patients were shot at very close range. Pistols were the weapons most commonly used while shotguns and rifles were less commonly used. A sturdy hand gun that fires a cartridge containing 120 pellets was a popular weapon. Extracted bullets confirmed that 38 and 25 calibre pistols were commonly used. Although it was suggested that non-fatal gunshot injuries outnumber fatal gunshot injuries by at least three to one,¹¹ this ratio will continue to decrease as weapons of assault become more lethal.

The median injury to arrival time of 200 min is the result of inefficient ambulance services in this part of the world. This is in contrast to other continents where gunshot victims are transferred to trauma centres within 30 min^25,26 The prolonged delay before medical care is reached may have affected the proportion of severe injuries presenting to trauma centres as critically injured patients possibly died during transit. It could also be detrimental in patients with non-fatal injuries as blood loss and faecal contamination of the peritoneal cavity becomes prolonged. It was previously shown that the longer the interval between injury and operation the greater the risk of developing post-operative sepsis.²⁷ This may partly explain why systemic sepsis was a common cause of death in our patients with colon injuries. Prolonged surgical intervention time was also observed by others.²⁸ In this study it was due to a great reluctance by surgeons to perform laparotomy before procurement of adequate units of donor blood. Elsewhere, it was a reflection of referral patterns and a large volume of trauma admissions.²⁸ Surgical intervention time of less than 2 h had been achieved.²⁹ Efficient ambulance and blood bank services would improve treatment outcome in our patients with gunshot wounds of the abdomen.

Sixty (76.9%) of our patients presented with indications for emergency laparotomy. In this study, and many others, the small bowel, colon, liver and stomach were the organs most commonly injured.^1,4,5 The frequency of penetrating injury to intra-abdominal organs is directly related to size, location and the protection offered by the pelvis and spine to these organs.⁴ The standard operative principles involved in the therapy of various organ injuries in patients with abdominal gunshot wounds has been well documented.^5,30,31 In spite of vigorous and meticulous treatment, important prognostic factors like injury to arrival time, number of organs injured and severity of injuries are outside the control of the surgeon.¹⁰

The policy of selective conservative management has been reap-praised by many authors, initially in the context of abdominal stab wounds, then in low velocity gunshot wounds of the abdomen.^6,7,32 Mandatory exploration irrespective of clinical signs carries a high rate of negative laparotomy." Consequences of this include incisional hernia, adhesive small bowel obstruction and sometimes death.^7,33 Seventy to 80% of patients with abdominal gunshot wounds present with indications for emergency laparotomy.^6,7 The remaining patients with minimal or equivocal abdominal signs would benefit from the policy of selective conservatism. Initial physical examination has been found to be reliable in detecting significant intra-abdominal injuries.^6,7 The absence of abdominal signs 5h after injury may exclude significant injury.⁶ Diagnostic peritoneal lavage and triple contrast computed tomography expected to further aid patient selection, have been found to be unreliable, expensive and time-consuming.^24,34 Laparoscopy has only an 18% sensitivity for the detection of gastrointestinal injuries,³⁵ which occur commonly in abdominal gunshot wounds.^1,4,5 We successfully managed 12 patients by applying the policy of selective conservatism. Patient selection was probably made easier by a median injury to arrival time of 4 h. After such prolonged pre-hospital time, evidence of significant intra-abdominal injury should be obvious. We found abdominal radiographs, especially the lateral view, helpful in assessing peritoneal penetration. But it should be remembered that extraperitoneal lodgement of bullet or pellets does not rule out previous penetration or the possibility of intra-abdominal injury.^36,37 Delayed laparotomy was required in two patients but one was negative. Stretching the policy of selective conservative management, to include patients with hepatic injuries who required blood transfusions,³⁸ may be very demanding. Nineteen (24.4%) patients in this study sustained rifle gunshot wounds of the abdomen. We expect a decline in the number of patients that would qualify for selective conservative management with the increasing use of rifles and high velocity handguns.

ACKNOWLEDGEMENTS

We thank Dr E. E. Ekanem, of the Department of Community Health, College of Medicine, University of Lagos, for statistical advice. We are grateful to resident doctors of the Department of Surgery, Lagos University Teaching Hospital, for their participation in the management of these patients. This paper was presented at the 32nd scientific conference of the Nigerian Surgical Research Society, held at the College of Medicine, University of Lagos, on the 6th December 1996.

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Paper accepted on 10 September 1997

Correspondence: Mr A. A. Adesanya, Department of Surgery, College of Medicine, University of Lagos, PMB 12003, Idiaraba, Lagos, Nigeria.

© 1998 The Royal College of Surgeons of Edinburgh. J.R. Coll. Surg. Edinb., 43, August 1998, 230—234