The use of a liver with a gunshot injury as a donor for auxiliary liver transplantation: Case report

INTRODUCTIONliver transplantation can be the only treatment for acute liver failure.PRESENTATION OF CASEA 59 year-old female patient with acute liver failure due to mushroom poisoning underwent auxiliary liver transplantation. The liver graft was harvested from a brain-dead donor with a deep gunshot wound in the posterior sector of the graft. The postoperative course was uneventful with rapid recovery of the recipient and no complications associated with the gunshot wound.DISCUSSIONPatients scheduled for urgent liver transplantation should have rapidly a liver graft otherwise the mortality rate is high. In our case, an injured liver graft by gunshot was successfully used allowing liver transplantation and increasing the pool of liver grafts.CONCLUSIONA gunshot liver graft can be used if the major vascular or biliary structures are not injured.     

Is Routine Angiography Necessary in Patients with a Gunshot Wound to the Neck? A Retrospective Analysis

Aim: The aim of this study was to investigate the implication of clinical findings of vascular injury and routinely employing angiography in patients who sustained a gunshot to the neck. Patients and Methods: We retrospectively studied the demographics, bullet tract, clinical findings, diagnostic investigations, methods of treatment, outcome, and time in hospital of 70 patients who sustained a gunshot to the neck and who all underwent angiography. Results: In nine cases angiography revealed lesions to the common carotid artery (four patients), internal carotid artery (three patients), vertebral artery (one patient), and lingual artery (one patient). Physical examination had already indicated vascular damage in seven of these patients with findings such as expanding hematoma (four patients), absent carotid pulsations (two patients), bruit (one patient), and hypovolemic shock (one patient). Subsequently, these seven patients were treated operatively by performing elective neck exploration. Of these seven patients who underwent surgical repair, vascular damage was already suspected based on physical examination. The two patients with injury on angiography without clinical evidence did not deteriorate on conservative management. Conclusions: Careful clinical assessment proves to be a useful instrument in determining the necissity of surgical exploration. In our experience in 70 patients, the results of angiography did not alter the management of the patients who sustained a gunshot to the neck. Our results on conservative management with selective angiography indicate that morbidity and mortality of unnecessary neck explorations are avoided without increased risk. Received: March 21, 2001; revision accepted: February 25, 2002     

Minimally invasive retrieval of a bullet from the L5–S1 neural foramina after transperitoneal gunshot wound

Background contextIn victims of gunshot wounds with retained bullet fragments in the central nervous system, delayed neurological deficit may result from copper-induced neurotoxicity. The mainstay of therapy involves surgical exploration and retrieval of fragments.PurposeA patient who presented with delayed neurological deficit after a transperitoneal gunshot wound is presented.Study designTechnical report.MethodsA 25-year-old male, who was the victim of a transperitoneal gunshot wound with a copper-jacketed bullet, presented several weeks after recovering from his abdominal injury. The patient presented with a worsening radiculopathy in the L5 distribution and progressive dorsiflexion weakness. Subsequent imaging demonstrated a bullet lodged lateral to the L5–S1 neural foramina.ResultsA minimally invasive approach with the use of a tubular retractor was used to retrieve the retained bullet. The lateral location of the bullet, the proximity of the nerve root to the bullet, and the limited visualization of the operative field from a minimally invasive approach, placed the nerve root at increased risk. Intraoperative myelography and electrophysiological monitoring were used to locate the nerve root in relation to the bullet and guide the extraction of the bullet. Postoperatively, the patient had complete resolution of his preoperative symptoms.ConclusionsIn cases where proximity to neural structures and limited visualization of bony landmarks may increase the risk of injury when extracting a foreign body, intraoperative myelography and electrophysiological monitoring are valuable adjuncts to further elucidate the surgical anatomy for a minimally invasive approach.     

A large renal bullet that resembles a large renal stone. A rare case scenario

IntroductionGenitourinary trauma secondary to a gunshot wound is uncommon as it only occurs in about 10% of cases. We present a case of a gentleman who suffered a gunshot wound to the kidney.Presentation of caseA 28 year old man presented with irritative lower urinary tract symptoms (LUTs) since three months. The medical history was irrelevant. He is known case of neurogenic bladder maintained on regular clean intermittent catheterization (CIC). He has history of gunshot to the back since few years that resulted in spinal injury. CTUT showed retained bullet inside the right kidney that look alike hyperdense renal stone, Moreover, multiple vesical stones. The vesical stones were treated with cystolitholapaxy. Given that the patient is asymptomatic, conservative management for the retained right renal bullet is the feasible option.DiscussionBased on the ASST classification, renal gunshot injury results in a grade IV injury. Abdominal exploration was reserved only in selected scenarios. Gunshot injuries to the kidney are commonly associated with thoracic and abdominal injuries. Gunshot injuries may be caused by low-velocity or high-velocity bullets. Given the paucity of cases reported in the literature, it is not obvious what is the optimum management of such patients with a retained renal bullet? We present the radiological findings and a clinical case summary as well for those who have Grade IV kidney injury and retained bullet managed conservatively.ConclusionRetained renal bullet post gunshot injury to the back is unusual presentation. A characteristic star-like pattern produced by lead shots and not by “stone,” consisting of plastic detonating cap will aid the urologist to differentiate retained renal bullet from renal stone. In such scenario, asymptomatic renal bullet look alike renal stone doesn't necessitate treatment.     

Reverse shoulder arthroplasty for deltoid-deficient shoulder following latissimus dorsi flap transfer. Case report

IntroductionThe usual indication for reverse shoulder arthroplasty is glenohumeral arthritis with inadequate rotator cuff and intact deltoid muscle. We report here a case of reverse shoulder arthroplasty using a lattisimus dorsi flap in a patient with deltoid-deficient shoulder following a gunshot injury.Presentation of the caseThe patient was an otherwise healthy 51-year-old male with a history of gunshot injury of the left shoulder 2006. Upon presentation in 2011, the patient had a loss of most of his shoulder bony and muscular structures. Due to deltoid muscle deficiency, the patient underwent Lattisimus Dorsi muscle flap followed by reverse shoulder arthroplasty in order to establish an upper limb function.Upon discharge, 11 days after the surgery, the patient was able to achieve 150° flexion and 90° abduction while in the supine position and 45° in each direction, while sitting. He was able to perform internal rotation (behind back) up to the level of the L1 vertebra, assisted active abduction of 90°, and external rotation of 20°. Power tests showed power of grade 4/5 for both shoulder flexion and extension and grade 2+/5 for both abduction and adduction.At the last follow up one year after the operation, The patient still had passive pain-free full range of motion, but no progress in active range of motion beyond that upon discharge.ConclusionReverse shoulder arthroplasty after Latissmus dori flap in patient with deltoid deficient shoulders can be a successful and reproducible approach to treat such conditions.     

Surgical management of late bullet embolization from the abdomen to the right ventricle: Case report

IntroductionSecondary embolus from gun projectile is a rare entity, it represents a clinical and therapeutic dilemma because the potential complications involving central and peripheral circulation. Each case reported in the literature represents a challenge because their unique and different clinical scenarios.Presentation of caseWe present the management of a 33-year-old man with past history of a gunshot wound on left flank with no evidence of any exit wounds, treated with exploratory laparotomy without removing the gunshot bullet from the abdomen. The patient presents 6 years later with non-productive cough and retrosternal pain with no other symptoms; the patient underwent a chest x-ray, electrocardiogram, thoracoabdominal CT, echocardiogram and cardiac catheterization and showed a bullet in the right ventricular floor. The projectile was extracted by sternotomy with extracorporeal circulation through the right atrium, without any complications.DiscussionIn 1834, Thomas David reported for the first time a wood-fragment embolization. There have been reported less than 200 cases including embolization of other materials; most of the gunshot bullet embolization cases reported on literature were reported after war. Clinical manifestations are associated with the anatomical site of embolism and mortality rate for a retained bullet is 6% associated with complication in 25% of cases. Mortality rate decreases to 1–2% if the bullet is removed.ConclusionThere are no established guidelines about the management of migrating foreign bodies or bullets, however, conservative, endovascular and surgical management have been proposed. In the cases of bullet embolization to the thoracic cavity, surgery represents a safe, low risk approach with high success rates.     

A retained intrahepatic bullet in the Bermuda triangle: A case report of surgical extraction

Introduction and importanceThe management of retained gunshot injury in the liver is not properly discussed in the literature.Case presentationWe describe a rare case of intrahepatic retained foreign body (bullet). Our patient is a 39-year old Yemeni soldier, who was exposed to firearm injury 10 months previously. The patient sought medical advice to extract the foreign body, and it was successfully extracted through abdominal exploration, with no intraoperative or postoperative complications.DiscussionRetained liver foreign bodies have three types, penetrating, medical, and migrating. Before the removal of the foreign body, good patient evaluation along with good surgical expertise should be present.ConclusionThere is a need for general guidelines to manage such patients who should be assessed by high volume surgeons.     

Gunshot injuries in Benghazi–Libya in 2011: The Libyan conflict and beyond

BackgroundSince independence, Libya has never experienced personal ownership of arms. That changed during the Libyan conflict where weapons became widespread in the society. As a result gunshot injuries became a concern for surgeons at our principal surgical hospital (Al-Jalaa). This study aims at analyzing the gunshot injuries that took place during 2011 and highlighting the peculiarities in the Libyan scenario.MethodsPatient records were obtained and gunshot injuries were analyzed for various parameters. Statistical analyses were made taking into consideration situations faced by neighbouring countries.ResultsIn 2011, 1761 patients were admitted with over 95% being male and over 97% were Libyan. The average age of a GSI patient was 28.32 ± 10.01 years. Patients aged 18–35 formed over 70% of the cases with half of all cases being treated by the orthopedics department. Sixty-eight percent of cases were injured in the extremities followed by chest (12.5%) and abdomen injuries (7.8%). The mortality rate for GSI's was found to be 5.6% overall with young age, site of injury (i.e. chest and head) and cause of injury (i.e. war or civilian fighting) being important risk factors.ConclusionsTaking into consideration the difficult operating conditions and limited resources, surgeons at our hospital were able to maintain a low mortality rate. Disarmament needs to begin as soon as possible because these injuries will continue to occur so long firearms are available in society.     

Lag screw fixation of remote bilateral pedicle fractures of the fourth and fifth lumbar vertebrae after a single gunshot wound: a case report and technical pearl

Background contextOf the injuries involving the lumbar spine, pedicle fractures are among the least common; those involving bilateral pedicles are rare.PurposeThe aims of the study were to provide the first documentation of bilateral pedicle fractures at two consecutive levels after a gunshot, to review the mechanism of injury, and to evaluate a nonfusion treatment option for pedicle fractures.Study designThis is a technical note and case report.Outcome measureThe outcome measures were lumbar range of motion, return of motor and sensory functions, and return to normal activities.MethodsA 20-year-old male sustained bilateral pedicle fractures at L4 and L5 with a massive dural tear, progressive neurologic deficits, and urinary incontinence. He underwent repair of the dural tear and lag screw fixation of the pedicle fractures without fusion.ResultsThe patient had full range of motion of his lumbar spine, full strength in his lower extremities, and bladder control.ConclusionsThis is the first report of bilateral multilevel lumbar pedicle fractures after a single penetrating gunshot wound. The case documents this injury pattern after a gunshot, reviews the mechanism of injury, and presents the successful application of a nonfusion treatment option.     

Dynamic simulation and preliminary finite element analysis of gunshot wounds to the human mandible

ObjectiveDue to the complications arising from gunshot wounds to the maxillofacial region, traditional models of gunshot wounds cannot meet our research needs. In this study, we established a finite element model and conducted preliminary simulation and analysis to determine the injury mechanism and degree of damage for gunshot wounds to the human mandible.MethodsBased on a previously developed modelling method that used animal experiments and internal parameters, digital computed tomography data for the human mandible were used to establish a three-dimensional finite element model of the human mandible. The mechanism by which a gunshot injures the mandible was dynamically simulated under different shot conditions. First, the residual velocities of the shootings using different projectiles at varying entry angles and impact velocities were calculated. Second, the energy losses of the projectiles and the rates of energy loss after exiting the mandible were calculated. Finally, the data were compared and analysed.ResultsThe dynamic processes involved in gunshot wounds to the human mandible were successfully simulated using two projectiles, three impact velocities, and three entry angles. The stress distributions in different parts of mandible after injury were also simulated. Based on the computation and analysis of the modelling data, we found that the injury severity of the mandible and the injury efficiency of the projectiles differ under different injury conditions.ConclusionsThe finite element model has many advantages for the analysis of ballistic wounds, and is expected to become an improved model for studying maxillofacial gunshot wounds.     

猪后肢枪弹伤所致肺远达效应CT特征与生化因子的关系

目的探讨猪后肢枪弹伤所致肺远达效应损伤的CT特征及发生机制。方法对14头猪随机采用高速弹射击,建立猪后肢枪弹伤轻等程度损伤（轻伤组,7头）和重伤动物（重伤组,7头）模型。分别在枪击前、后3、10、40min、6h,利用CT对动物模型的肺部组织结构进行观察,同时在枪击前、后3、10、25、40min、6h测定主要的血管活性物质[内皮素（ET）、皮质醇（COR）]及炎性反应指标[白细胞总数、白细胞介素-6（IL-6）]的变化。结果两组实验猪枪击后的肺部CT征象变化包括组织渗出、出血、细支气管炎、肺间质、实质渗出。肺损伤发展程度与枪弹伤伤情及ET、COR及IL-6的变化趋势相一致。IL-6在枪击后升高,ET、COR水平在枪击后各时间点均较枪击前上升。结论猪后肢枪弹伤所致肺远达效应是在致伤物动能、应激反应及神经体液因素等多种条件作用下的损伤,肺远达效应损伤伤情程度与枪弹伤伤情相一致。     

Spinal Cord Injury Caused by Gunshot Wound During Pregnancy

Abstract

We report a case of a pregnant woman with acute spinal cord injury (CS) caused by gunshot wound and discuss the respective maternal and fetal considerations. Neither decompressive surgery nor corticosteroid protocols were used. At 37 weeks, the patient delivered a normal female infant after induction of labor and epidural anesthesia, with no medical or obstetrical complications. With conservative management and rehabilitation, this patient had significant recovery of function.     

Fatal gunshot wound to the head: the impact of aggressive management

BackgroundPatients with fatal gunshot wounds (GSWs) to the head often have poor outcomes but are ideal candidates for organ donation. The purpose of this study was to evaluate the effects of aggressive management on organ donation in patient with fatal GSWs to the head.MethodsA 5-year review of all patients at a trauma center with GSWs to the head was performed. The primary outcome was organ donation after fatal GSW to the head.ResultsA total of 98 patients with fatal GSWs to the head were identified. The rate of potential organ donation was 70%, of whom 49% eventually donated 72 solid organs. Twenty-five percent of patients were not considered eligible for donation as a result of disseminated intravascular coagulopathy. The T4 protocol lead to significant organ procurement rates (odds ratio, 3.6; 95% confidence interval, 1.3 to 9.6; P = .01). Failures to organ donation in eligible patients were due to lack of family consent and cardiac arrest.ConclusionsOrgan donation after fatal GSW to the head is a legitimate goal. Management goals should focus on early aggressive resuscitation and correction of coagulopathy.     

Riddle of a Bullet: Transmediastinal or Unilateral Chest Injury?

Abstract Thoracic gunshot injuries are relatively rare in Western European Trauma Departments. In the case of a thoracic gunshot wound it is vital to establish if mediastinal structures are damaged. Non-mediastinal injuries often only require tube-thoracostomy followed by close observation. We report a case were the localisation of the gunshot wound together with the initial X-ray were suggestive of a transmediastinal injury pattern. A helical CT-scan could exclude this. A forensic reconstruction was performed retrospectively; the most likely chain of events and injury pattern is explained.     

The surgical management of facial trauma in British soldiers during combat operations in Afghanistan

IntroductionThe recent Afghanistan conflict caused a higher proportion of casualties with facial injuries due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK service personnel from blast or gunshot wounds during the highest intensity period of combat operations in Afghanistan.MethodsHospital records and Joint Theatre Trauma Registry data were collected for all UK service personnel killed or wounded by blast and gunshot wounds in Afghanistan between 01 April 2006 and 01 March 2013.Results566 casualties were identified, 504 from blast and 52 from gunshot injuries. 75% of blast injury casualties survived and the IED was the most common mechanism of injury with the mid-face the most commonly affected facial region. In blast injuries a facial fracture was a significant marker for increased total injury severity score. A facial gunshot wound was fatal in 53% of cases. The majority of survivors required a single surgical procedure for the facial injury but further reconstruction was required in 156 of the 375 of survivors aero medically evacuated to the UK.ConclusionsThe presence and pattern of facial fractures was significantly different in survivors and fatalities, which may reflect the power of the blast that these cohorts were exposed to. The Anatomical Injury Scoring of the Injury Severity Scale was inadequate for determining the extent of soft tissue facial injuries and did not predict morbidity of the injury.     

Cross-femoral bypass graft for combined iliac arterial venous injury

We report on the treatment of a patient who sustained combined arterial and venous injury to the left iliac vessels as a result of a gunshot wound. Repair was accomplished as a staged procedure following lifesaving ligation of both artery and vein, using extraanatomic, cross-femoral polytetrafluoroethylene (arterial) and saphenous vein (venous) bypass techniques, followed by prophylactic caval filter placement. Principles of management with respect to combined arterial venous vascular injury are discussed, with special reference to controversies surrounding repair of major venous injury.     

A global perspective on gun violence injuries

Introduction and definitionsCivilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients.Pre-hospital careThere are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents.Acute treatmentControl of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions.Definitive careThe need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation.Resources and ethicsThere are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.     

The initial management of complete urethral disruption in a deployed military field hospital

BackgroundThe management of male urethral trauma in the multiply injured battle casualty has proved challenging to the deployed military trauma surgeon. Foreign nationals will need culturally sensitive outcomes with adequate urinary function when further surgical management is unlikely to be available in a developing country. For those likely to undergo reconstructive surgery, the early restoration of anatomy is important as it may improve the long-term reconstructive outcome.MethodWe illustrate our technique with a case report and discuss salient points of other patients treated in the same manner, all of whom presented to a role 2 (enhanced) field hospital in Afghanistan with urethral injuries.ResultsA transpelvic high velocity gunshot wounds (HVGSW) was sustained and the patient underwent immediate anatomical re-alignment of the urethra with suture of the bladder neck to the pelvic floor. This case is discussed in detail.ConclusionsComplete disruption of the male urethra can be successfully managed in the field hospital by urethral catheterization at the time of initial surgery. In patients where further reconstruction may not be possible, urethral catheterization provides a culturally permissible solution for patients. In those who may undergo further reconstructive surgery, approximation of the bladder to the pelvic floor may reduce stricture rate in comparison with the suprapubic catheterization alone.     

Intrathecal migratory foreign body without neurological deficit after a gunshot wound

Background contextPenetrating bullets dissipate thermal and kinetic energy into surrounding tissues. Within the thecal sac, this is universally associated with neurological deficits.PurposeWe report a case of intrathecal penetration of a bullet without neurological deficit.Study designCase report.MethodsA 14-year-old girl was shot in the back, entering adjacent to the L3 vertebra and settling within the spinal canal adjacent to the S1 vertebra. In the absence of neurological deficits, initial management was nonoperative.ResultsOver the period of a week, the patient developed an episode of intense radicular pain, although her neurological examination remained normal. Location of the bullet was shown to vary from S1 to T12 on multiple imaging studies, and this was influenced by patient positioning. She subsequently underwent a bilateral hemilaminotomy and durotomy with excision of the intrathecal bullet.ConclusionsPatients can avoid neurological injury even with an intrathecal gunshot wound. However, intrathecal bullets may then migrate and cause variable neurological complaints, necessitating surgical removal. Patient positioning can influence bullet location which can be useful in surgical planning.     

Laparoscopic exploration of the retroperitoneum in a gunshot victim: A case report

IntroductionNon-operative management and minimally invasive surgery reduce the burden of negative laparotomies in patients with penetrating gunshot wounds (GSW). Careful patient selection is key. Although challenging, in experienced hands laparoscopic exploration of the retroperitoneal space can be carried out.Case presentationA 38year old man was brought to the emergency room after sustaining a GSW to his right groin. Due to evidence of intoxication, clinical picture was unreliable, although the patient was hemodynamically stable and there were no signs of peritonitis. Furthermore, the presence of retained bullet fragments created significant artifact on imaging. Clinical and radiological uncertainty urged us to proceed with laparoscopic exploration. Following mobilization, the ascending colon wall was fully inspected and no injury was identified. The pelvic fracture was managed non-operatively. After an uneventful hospital course, the patient was discharged home in stable condition and outpatient follow up was re-assuring.DiscussionAvoiding morbidity from missed colonic injury is important, particularly in patients with unclear clinical and radiological findings, that were present in our case. Non-operative management by serial examination and minimally invasive surgical techniques are considered an alternative to the classical exploratory laparotomy approach. Furthermore, utilization of laparoscopy in retroperitoneal injury has gained much attention in the recent years particularly in well-established centers.ConclusionLaparoscopic exploration is a safe and effective surgical approach in patients who have sustained GSW to the abdomen and to the retroperitoneal space. However, it requires careful patient selection and surgical expertise.