図１〜図７で遊離ガス（↑）があるが，それだけでは消化管穿孔の確定診断とならないし，刺創例では手術の適応でもない．図５〜図１２でSMAとSMV周囲にややdensityの低い液貯留（△）を認め，不均一だから血腫であろう．図７〜図１２には左腸腰筋周囲にも血腫（▲）を認める．いずれも量的には少量でextravasationはなくminor injuryと解釈する．他に消化管穿孔を示唆する所見はない．腹部所見で筋性防御はないのに，遊離ガスを理由に手術となったが，活動性出血を伴わない鶏卵大の腸間膜血腫を認めるのみで消化管穿孔や腸管壊死はなかった．後腹膜は検索されていない．1週間で全治退院した．

文献考察：銃創でも刺創と同様に保存的治療が可能である．38％は保存的治療に成功，全例手術すると47％はnegative laparotomyとなる．
Ann Surg. 2001 Sep;234(3):395-402; discussion 402-3.
Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care?
Velmahos GC, Demetriades D, Toutouzas KG, Sarkisyan G, Chan LS, Ishak R, Alo K, Vassiliu P, Murray JA, Salim A, Asensio J, Belzberg H, Katkhouda N, Berne TV.

OBJECTIVE: To evaluate the safety of a policy of selective nonoperative management (SNOM) in patients with abdominal gunshot wounds. SUMMARY BACKGROUND DATA: Selective nonoperative management is practiced extensively in stab wounds and blunt abdominal trauma, but routine laparotomy is still the standard of care in abdominal gunshot wounds. METHODS: The authors reviewed the medical records of 1,856 patients with abdominal gunshot wounds (1,405 anterior, 451 posterior) admitted during an 8-year period in a busy academic level 1 trauma center and managed by SNOM. According to this policy, patients who did not have peritonitis, were hemodynamically stable, and had a reliable clinical examination were observed. RESULTS: Initially, 792 (42%) patients (34% of patients with anterior and 68% with posterior abdominal gunshot wounds) were selected for nonoperative management. During observation 80 (4%) patients developed symptoms and required a delayed laparotomy, which revealed organ injuries requiring repair in 57. Five (0.3%) patients suffered complications potentially related to the delay in laparotomy, which were managed successfully. Seven hundred twelve (38%) patients were successfully managed without an operation. The rate of unnecessary laparotomy was 14% among operated patients (or 9% among all patients). If patients were managed by routine laparotomy, the unnecessary laparotomy rate would have been 47% (39% for anterior and 74% for posterior abdominal gunshot wounds). Compared with patients with unnecessary laparotomy, patients managed without surgery had significantly shorter hospital stays and lower hospital charges. By maintaining a policy of SNOM instead of routine laparotomy, a total of 3,560 hospital days and ,555,752 in hospital charges were saved over the period of the study. CONCLUSION: Selective nonoperative management is a safe method for managing patients with abdominal gunshot wounds in a level 1 trauma center with an in-house trauma team. It reduces significantly the rate of unnecessary laparotomy and hospital charges.PMID: 11524592