LAUSR

sharing their tremendous experience in the treatment of penetrating trauma and in the challenging nonoperative management of patients with abdominal gunshot wound (GSW) injuries. The South African trauma surgeons present an impressive series of 1106 patients with abdominal GSW seen in 51/2 years (meaning almost 17 patients/month). The aim of the study was to assess feasibility and failure rate of nonoperative management for patients with abdominal GSWand no hard signs and intact neurology. Patients deemed safe for NOM were either clinically examined or investigated with contrastenhanced CT. Further aims were the incidence of unnecessary laparotomies in both operative and NOM groups, the morbidity and mortality associated with NOM failure and/or with a delayed laparotomy, and finally the role of CT in evaluating patients candidates for NOM or during their observation. Most of us have worked in trauma centers around the globe and have personally experienced the differences between highvolume centers with limited resources and low-volume centers with good resources. We feel we can provide both sides’ view and would like to highlight a few differences with our esteemed South African colleagues. We doubt that the excellent results achieved by the South African Trauma Center would be easily reproducible in less busy settings around the world (particularly in Europe, Canada, Australia, and eastern Asia), and even in some regions of USA or in many other places where GSW are less common. The achievement of highly successful results in nonoperative management of GSW, with selective use of CT scan and low complication rate, seems to be feasible only in centers having highly specific expertise. These differences in practice were recently highlighted by several authors. In other words, it is reasonable that in Cape Town, receiving 17 cases of abdominal GSW/month, on top of all other cases of SW and other penetrating or blunt trauma, and acute care surgery cases, the resident staff is not only comfortable but is somehow pushed to attempt NOM in those patients that are stable and nonperitonitic (imagine how it is being on call in a busy summer night in South Africa!). Nonetheless, in most of the other centers, the same approach may not be so easily applicable for a number of reasons. First of all, the junior or resident staff may have hardly seen very few cases of abdominal GSW and may feel safer to surgically explore these patients, rather than admit them in the ward for overnight observation, even more if an advanced imaging investigation by abdominal CT scan has not been done. Therefore, in centers where the load is substantially less (as in most European and Australian centers), CT scan is standard of care for all patients without hard signs and the threshold for an exploratory laparotomy is usually very low. Last but not least, we must say that the medico-legal issues in Europe, Australia, and North America are probably much different from South Africa, again this reason contributing to make NOM a ‘‘brave challenge.’’ Finally, from my experience in emergency laparoscopy for Acute Care Surgery and Trauma, I would like to ask Navsaria et al if a diagnostic (and eventually therapeutic) laparoscopy may have played a role in assessing and managing the patients with abdominal GSW who have started NOM, or at least in the stable patients with equivocal peritoneal signs. We feel that diagnostic laparoscopy may be a valid alternative to CT and therefore may allow avoidance of ‘‘unnecessary CT scan’’ in selected patients, thus making it easier to follow-up the patients in the ward with less anxiety and possibly discharge earlier a significant proportion of patients. We assume that not all NOM patients from this series from Navsaria et al were doing clearly well and/or able to perfectly tolerate oral feeding after just 24 hours and/or could be discharged early. Therefore, what would you do for patients who seem to be clinically ‘‘borderline,’’ for those with equivocal signs and those who just ‘‘do not look right’’ after 24 to 48 hours? Diagnostic laparoscopy may easily be a valuable diagnostic tool with even better diagnostic accuracy than CT and perhaps potentially therapeutic, if in experienced hands. In conclusion, we feel that diagnostic laparoscopy may be a better alternative to CT or to exploratory laparotomy in: clinically not assessable patients; patients with equivocal peritoneal signs; patients, who despite a reassuring CT remain clinically ‘‘borderline’’ or those ‘‘not looking right’’ after 24 to 48 hours. We realize the busy background and the logistic constraints in Cape Town, but we wholeheartedly believe that laparoscopy should be included in the diagnostic and therapeutic algorithm.