Abdominal perforation after rupture of a diamond-studded wire: a case report
© Schmelzle et al; licensee BioMed Central Ltd. 2008
Received: 27 August 2008
Accepted: 13 November 2008
Published: 13 November 2008
There are numerous cases of abdominal injuries due to bullets. Abdominal injuries due to bullets are a diagnostic and therapeutic challenge. Here, an unusual case of an abdominal perforation caused by a metal projectile, lead to confusion in the interpretation of the preoperative computer tomography.
We present an unusual case of a 32-year-old male worker who sustained a "shot" to the left upper abdominal quadrant, as a result of a work-related accident. The projectile derived from a special wire that tore during operation. One chain element happened to accelerate towards the patients belly and perforated the abdominal wall. Computer tomography located the radiopaque projectile to the cortex of the left kidney and showed a lesion of the tail of the pancreas. The presence of intraperitoneal free air suggested a gastrointestinal perforation. Immediate open exploration of the peritoneal cavity and the retroperitoneal space revealed perforating lesions of the anterior and posterior gastric wall, as well as the pancreatic tail. The projectile was finally retrieved in the upper pole of the left kidney. The patient had a good clinical course subsequent to surgery and was discharged in good general condition.
This case represents a rare form of a retained bullet injury and corroborates the need of sufficient measures of worker-protection in area of diamond-studded wire cutting devices.
Exploration revealed about 400 ml fresh, partly coagulated blood. Perforations of the ventral (entrance wound) and dorsal (exit wound) gastric wall respectively (5 mm in diameter) were identified and closed by single suturetechnique utilising resorbable material. Broad exposure of the bursa omentalis showed a wound correspondending to the dorsal stomach lesion. After mobilisation of the spleen and the pancreatic tail, a tangential injury of the pancreas could be demonstrated. The major pancreatic duct was not lacerated by the metal fragment. The adipose capsule of the kidney was completely blood-filled. We split Gerota's fascia and mobilized the kidney. The upper pole showed an entrance hole on the anterior side without an exit wound. A metal fragment was removed guided by x-ray fluoroscopy. The pancreatic and the renal injuries were treated without sutures, but drained adequately transcutaneously with soft silastic drains. The exocrine pancreas was blocked by subcutaneous application of 100 μg per die octreotide for the following seven days to minimize the development of post-operative pancreas-fistula.
After surgery, the patient was transferred to our intermediate care unit for 11 days. Retrospectively the mechanism of injury was reconstructed. Not involved in the trenching of a dilapidated building with a special wire, the worker was hurt while walking by in a distance of about 12 meters to a diamond wire divice in motion in the moment of wire rupture. A fragment hit the person by maximum speed and penetrated into the abdomen.
The patient further stabilized under antibiotic coverage by Piperacillin and Sulbactam with declining infection signs in clinical chemistry. A low output pancreatic fistula closed 8 weeks after endoscopic retrograde pancreaticoscopy with placement of a decompressing stent to the common duct four days after surgery [Figure 2B]. The patient was transferred to regular ward and discharged from hospital in good condition and closed wounds after closure of the pancreatic fistula. The stent could be removed on an outpatient basis without any complications after 4 month.
Penetrating injuries to the abdomen are a diagnostic and therapeutic challenge. The majority of these injuries require surgical intervention . Penetrating injuries can be classified into stab wounds, gunshot wounds and impalement injuries. Gunshot wounds are the most frequent injuries of these . In the majority of cases they are caused by an act of aggression or in suicide intent . Most frequently, a single organ is affected such as the liver, kidney or spleen . In case of penetration, multi organ injuries still remain a problem, as they considerably increase mortality.
Pancreatic organ injury scale.
Minor contusion or laceration without ductal injury
Major contusion without duct injury or tissue loss
Distal transection or parenchymal injury with duct injury
Proximal (to right of superior mesenteric vein) transection or parenchymal injury, not involving ampulla
Massive disruption of pancreatic head
In the present case we demonstrate an unusual mechanism of injury, which has not been previously reported and is a result of an industrial accident. It should be noted that the diamond armed pearls lined up on the wire on intact devices can be accelerated to maximum speed in a whip-like mechanism after a tear of the basic wire. The injury pattern in our patient was comparable to those caused by gun shots. Surgeons should keep in mind the enormous motive force which follows from breaking off of moving parts and leads to the demonstrated degree of damage. Furthermore, the present case highlights the potential "firing range" those diamond-studded wire cutting devices bear and the need of sufficient measures of worker-protection in the area of operation.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Cairns BA, Oller DW, Meyer AA, Napolitano LM, Rutledge R, Baker CC: Management and outcome of abdominal shotgun wounds. Trauma score and the role of exploratory laparotomy. Ann Surg. 1995, 221 (3): 272-7. 10.1097/00000658-199503000-00009.PubMed CentralView ArticlePubMedGoogle Scholar
- Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, Salim A: Selective Nonoperative Management of Penetrating Abdominal Solid Organ Injuries. Ann Surg. 2006, 244 (4): 620-628.PubMed CentralPubMedGoogle Scholar
- Cerwenka H, Bacher H, El-Shabrawi A, Kornprat P, Lemmerer M, Portugaller HR, Mischinger HJ: Management of pancreatic trauma and its consequences–guidelines or individual therapy?. Hepatogastroenterology. 2007, 54 (74): 581-4.PubMedGoogle Scholar
- Tyburski JG, Dente CJ, Wilson RF, Shanti C, Steffes CP, Carlin A: Infectious complications following duodenal and/or pancreatic trauma. Am Surg. 2001, 67 (3): 227-30. discussion 230–1PubMedGoogle Scholar
- Vasquez JC, Coimbra R, Hoyt DB, Fortlage D: Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center. Injury. 2001, 32 (10): 753-9. 10.1016/S0020-1383(01)00099-7.View ArticlePubMedGoogle Scholar
- Krige JE, Beningfield SJ, Nicol AJ, Navsaria P: The management of complex pancreatic injuries. S Afr J Surg. 2005, 43 (3): 92-102.PubMedGoogle Scholar
- Young PR, Meredith JW, Baker CC, Thomason MH, Chang MC: Pancreatic injuries resulting from penetrating trauma: a multi-institution review. Am Surg. 1998, 64 (9): 838-43. discussion 843–4PubMedGoogle Scholar
- Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Champion HR, Gennarelli TA, McAninch JW, Pachter HL, Shackford SR, Trafton PG: Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum. J Trauma 30. 1990, 30 (11): 1427-1429.View ArticleGoogle Scholar
- Hsieh CH, Liu NJ, Chen RJ, Fang JF, Lin BC: Endoscopically placed pancreatic stent in a patient with concomitant two locations of main pancreatic duct disruption following pancreatic trauma. Hepatogastroenterology. 2003, 50 (49): 269-71.PubMedGoogle Scholar
- Wolf A, Berhardt J, Patrzyk M, Heidecke CD: The value of endoscopic diagnosis and the treatment of pancreas injuries following blunt abdominal trauma. Surg Endosc. 2005, 19 (5): 665-9. 10.1007/s00464-003-9276-5.View ArticlePubMedGoogle Scholar
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