STAGED MANAGEMENT OF A PATIENT WITH STAB INJURY AND DAMAGE TO THREE ABDOMINAL ORGANS

STAGED MANAGEMENT OF A PATIENT WITH STAB INJURY AND DAMAGE TO THREE ABDOMINAL ORGANS

Panasyuk A. I., Inozemtsev E. O., Grigoryev E. G.

Irkutsk State Medical University, Irkutsk Scientific Center of Surgery and Traumatology, Irkutsk, Russia

 Damages to adjacent organs in case of kidney injury occur in 77-100 % of cases [1]. In its turn, 8 % of patients with concomitant injury have injuries to the organs of the urinary system [2]. The incidence of pancreatitis after splenectomy can reach 24.3 % [3, 4], including the formation of pancreatic fistulas [5].

Post-traumatic (false) aneurysm of the renal artery is a rare complication, which, according to autopsies, accounts for 0.01 % in the general population [6] and can be cured by X-ray endovascular surgery.

The objective of the publication - to discuss the features of the diagnosis and staged treatment of a stab wound to the abdomen with damage to three organs.

The study complies with WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human (2013), and the Rules of clinical practice in the Russian Federation confirmed by the Order of Health Ministry of RF (June 19, 2003, No. 266). The patient gave informed consent to the publication of the clinical observation in the open press in an anonymized form. 

CLINICAL OBSERVATION

A 37-year-old patient was admitted to the Irkutsk Regional Clinical Hospital on April 22, 2022. It was found that on April 8, 2022, he underwent laparotomy, splenectomy, suturing of the wound of the left kidney, and drainage of the abdominal cavity due to a stab thoracoabdominal wound on April 8, 2022. In the postoperative period, pancreatitis developed, in connection with which the patient was sent for treatment to the clinic.
He had complaints of pain in the left hypochondrium after eating, bloating, evening temperature rise to 38 ºС. General condition of moderate severity. Height - 173 cm, weight - 100 kg, BMI - 33.4. Consciousness is clear, position is active. The skin and mucous membranes are pale. Blood pressure - 150/80 mm H., heart rate - 70 per minute. On auscultation of the lungs, breathing is weakened in the lower back sections on the left. There are no wheezes. There is a scar 2.4 cm long in the ninth intercostal space along the posterior axillary line after a stab wound. The belly of the usual form is enlarged in volume due to the development of subcutaneous adipose tissue, the anterior abdominal wall evenly participates in breathing, on palpation it is soft, painful in the left hypochondrium. The scar after the upper median laparotomy without signs of inflammation. Stool daily, urination normal.
Complete blood count: hemoglobin - 115 g/l, erythrocytes - 3.7 × 1012, hematocrit - 34.3 %, leukocytes - 13.87 × 109, platelets - 120 × 109. Biochemical blood test: urea - 6.98 mmol/l, total bilirubin - 3 87 µmol/l, direct bilirubin - 2.62 µmol/l, ALT - 20.5 IU/l, AST - 19.2 IU/l, amylase - 68 IU/l. Urinalysis: erythrocytes - 0, leukocytes - 1, relative density - 1.015, pH - 6, protein - no.
MSCT data showed blood clots in the bed of the removed spleen with a volume of 42 × 23 mm. There was a small accumulation of fluid (4 units N) in the left lateral canal of the abdomen. The tail of the pancreas is non-structural, 26.5 mm thick, the head and body have even wavy contours, the lobulation is preserved, the structure is homogeneous, without pathological densitometry fields. Parapancreatic tissue in the tail area is infiltrated. Conclusion: hematoma of the removed spleen bed, signs of caudal pancreatitis. The kidneys are usually located, bean-shaped, with even contours, homogeneous structure. Dimensions: 10.2 × 5.5 cm right, 10.7 × 7.0 cm left. The parenchyma of the left kidney accumulates contrast more slowly after intravenous amplification. Above the upper pole of the left kidney, against the background of infiltrated perirenal tissue, a rounded liquid (22 units N) formation up to 25 mm in size is determined. The cavitary system of the right kidney is not changed. On the left, the calyx is up to 7-9 mm, the pelvis is up to 19 mm.
Preliminary diagnosis: “Tail infected pancreatic necrosis; hematoma of the left subphrenic space; pararenal infiltrate on the left.
After the appointment of antibacterial and antisecretory therapy, the pain syndrome and dyspepsia decreased, the temperature returned to normal, and the state of health improved. Against this background, on May 5, 2022, macrohematuria and bladder tamponade were diagnosed.
Selective angiorenography was performed: the left renal artery departs from the aorta at the level of L-1. In the upper pole of the kidney, extravasation of contrasted blood 5 × 6 mm is a false aneurysm of a branch of the superior pole artery (Fig. 1).

Figure 1. Selective angiogram: 1 – catheter, 2 – renal artery, 3 – post-traumatic aneurysm (pulsating hematoma) of the upper polar branch of the renal artery

The distal end of the Merit microcatheter is placed in the neck of the aneurysm. Superselective embolization was performed with microspheres of 500-700 nm. The control angiogram showed no extravasation (Fig. 2).

Figure 2. Selective angiogram after endovascular occlusion. Extravasation is absent: 1 – renal artery, 2 – branch of the upper pole

 

Then pcystoscopy, emptying of blood and sanitation of the bladder were carried out. The hematuria has stopped. Smooth course of the postoperative period. The patient was discharged in a satisfactory condition. Questioning was conducted after 5 months. There were no complaints.

DISCUSSION

The clinical observation presents the discussion of the staged care for a thoracoabdominal stab wound complicated by intra-abdominal bleeding, post-traumatic pancreatitis and massive hematuria with bladder tamponade.
The surgeon of the first contact performed a splenectomy, sutured the wound of the kidney capsule, which preserved the organ. Due to the fact that the revision of the wound channel was not carried out and superficial sutures were applied, the damaged upper pole branch of the renal artery was not ligated. A pulsating intraorgan hematoma formed, which drained into the pelvicalyceal system on the 28th day after the operation. Bleeding continued, bladder tamponade developed.
In this situation, as a rule, relaparotomy is performed with a high probability of removal of the damaged kidney [7]. In this the case, renoangiography showed the source of bleeding. Organ-preserving X-ray endovascular superselective occlusion of the peripheral branch of the superior polar renal artery was performed with reliable final hemostasis and preservation of organ function.
Pancreatic necrosis was most likely caused by injury to the tail of the pancreas. Antisecretory and antibacterial therapy proved to be effective.

CONCLUSION

An alternative to traditional surgery, minimally invasive endovascular diapeutic intervention made it possible to identify the source of bleeding and provide reliable hemostasis while maintaining the function of the left kidney.

Funding and conflict of interest information

The study was not sponsored.
The authors declare the absence of obvious and potential conflicts of interest related to the publication of this article.

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