Obesity and Anterior Abdominal Gunshot Wounds: A Cushion Effect

Background Although the standard of care for anterior abdominal gunshot wounds (AAGSWs) is immediate laparotomy, these operations are associated with a high rate of negativity and potentially serious complications. Recent data suggest the possibility of selective non-operative management (SNOM) of AAGSWs, but none implicate body mass index (BMI) as a factor in patient selection. Anecdotal experience at our trauma center suggested a protective effect of obesity among patients with AAGSWs, and given the exceptionally high rate of obesity in the Bronx, we sought to analyze the associations of AAGSWs and BMI to inform future trauma research and management. In this study, we aimed to evaluate whether BMI is associated with injury severity, resource utilization, and clinical outcomes of AAGSWs. Methodology From our prospectively accrued trauma registry, we retrospectively abstracted all patients greater than 16 years old with Current Procedural Terminology codes associated with gunshot wounds from 2008 to 2016. The electronic medical record was reviewed to define a cohort of patients with at least one AAGSW. Patients were divided into the following cohorts based on BMI: underweight (UW, BMI: <18.5), normal weight (NW, BMI: 18.5-24.9), overweight (OW, BMI: 25-29.9), and obese (OB, BMI: ≥30). Among these cohorts, we analyzed data regarding injury severity, resource utilization, and clinical outcomes. Results In this study, none of the patients were UW, 17 (42.5%) patients were NW, 15 (37.5%) patients were OW, and eight (20%) patients were OB. One patient each in the NW and OB cohorts was successfully managed non-operatively, while all others underwent immediate exploratory laparotomy. The mean new injury severity score was significantly lower as BMI increased (NW = 30.9 ± 17.0, OW = 22.9 ± 16.1, and OB = 12.8 ± 13.7; p = 0.039). Patients in the OB cohort were less likely to have abdominal fascial penetration compared to the OW and NW cohorts (p = 0.027 and 0.004, respectively) and sustained fewer mean visceral injuries compared to the OW and NW cohorts (p = 0.027 and 0.045, respectively). OB patients were significantly more likely to have sustained two or more AAGSWs (OB = 27.5%, OW = 6.7%, and NW = 5.9%; p = 0.033), suggesting higher rates of tangential soft tissue injuries. The mean hospital length of stay down-trended as BMI increased but did not achieve statistical significance (NW = 7.4 ± 5.3, OW = 6.6 ± 6.7, and OB = 3.1 ± 2.3; p = 0.19). The OB cohort had the lowest mean hospital charges. Conclusions Obesity may yield a protective effect among AAGSW victims, and BMI may provide trauma surgeons another tool to triage patients for SNOM of AAGSWs, potentially diminishing the risks associated with negative laparotomy. Our data serve as the basis for the analysis of a larger patient cohort.