Surgical tactics for gunshot wounds of the abdomen with damage to the small intestine

INTRODUCTION. Small intestine injuries from gunshot wounds of the abdomen are detected in 41–60 % of cases and are accompanied by the development of life-threatening complications: ongoing intra-abdominal bleeding (20.4–60.0 %), widespread peritonitis (31.0–60.0 %), sepsis (14.3–21.7 %), eventration (8.6–9.5 %). The current level of injury surgery development fundamentally includes two tactical solutions for such wounded: single-stage surgical treatment (SSST) and multi-stage surgical treatment (MSST). The advantages and disadvantages of using these surgical approaches at the evacuation stages are still being debated, which is explained by the lack of reasonable indications for choosing each of them. Nevertheless, the incidence of postoperative complications (24.5–42.2 %) and the mortality rate (6.8–53.3 %) remain high.
The OBJECTIVE was to analyze the results of surgical care for patients with gunshot wounds of the abdomen with damage to the small intestine at the stages of medical care and identify reliable criteria that influence the choice of surgical tactics.
METHODS AND MATERIALS. The results of treatment of 104 patients with gunshot wounds of the small intestine at various stages of evacuation in military medical organizations (MMO) and admitted to the Clinic of Faculty Surgery named after S. P. Fedorov at the Military Medical Academy from March 2022 to May 2024 were analyzed. The wounded were divided into 2 groups, depending on the used treatment tactics: 1st (n=29/27.9 %) – patients who underwent SSST; 2nd (n=75/72.1 %) – patients who were used MSST tactics. All calculations were performed using Microsoft Excel 2007 and IBM SPSS Statistics 27 software.
RESULTS. It was found that the most serious complications of surgical treatment of the wounded with gunshot wounds of the abdomen with damage to the small intestine upon admission to a specialized stage of treatment in groups 1 and 2, respectively, are: failure of intestinal sutures – 10.3 % and 13.4 %, the development of acute perforated ulcers of the small intestine – 6.9 % and 9.3 %, the formation of entero-atmospheric fistulas – 0 % and 2.7 %, leading to the development of secondary peritonitis – 13.8 % and 20 %, abdominal sepsis – 6.9 % and 6.7 %, septic shock – 6.9 % and 2.7 %. Mortality in groups 1 and 2 was 3.4 % and 4.0 %, respectively. The main reliable criteria influencing the choice of surgical tactics at the stages of medical evacuation are highlighted: the general condition of the wounded according to the MFS-AS scale (p<0.001), the severity of damage to the small intestine according to the AAST-OIS classification (p=0.007), the development of widespread peritonitis with systemic inflammatory reaction syndrome (SIRS) (p=0.012), late delivery (more than 13 hours after injury) of qualified surgical care (p=0.003) and non-compliance with the principles of intestinal and intraabdominal decompression during surgical care (p<0.002). Extrapolation of the data obtained to the victims of the studied groups allowed us to establish indications for the use of MSST tactics in 75 % of the wounded, including 3.8 % with primary enterostomy. The remaining 25 % of the wounded had relative indications for damage control tactics and could be operated on in one stage for wounds with grade I–II small intestine damage according to the AAST-OIS classification and the average general condition of the patient (on the MFS-AS scale), in the absence of widespread peritonitis with SIRS, as well as a favorable medical and tactical environment.
CONCLUSION. The refinement of reliable criteria and their use in determining treatment tactics in the wounded with damage to small intestine ensure not only the differentiation of surgical approaches at the stages of medical care, but also improve the results of treatment of victims.

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