Article Type : Case Report
Authors : Arredondo GP
Keywords : Abdominal gunshot wound; Penetrating injury; Surgery; Trauma; Malnutrition
Introduction:
The use of firearms is a common cause of traumatic injuries, and an average of
120,232 firearm injuries are estimated to have occurred annually between 2009
and 2017. Despite the prevalence of firearm injuries, treatment decisions are
still largely based on beliefs.
Clinical
case: A 30-year-old male presented with penetrating abdominal trauma from a
firearm projectile at the left flank, subcostal level in the mid-axillary line
without active bleeding (entrance orifice). Exploratory laparotomy is
performed. Intraoperative findings: multiple lesions of the small intestine. He
also presented large intestine lesions, three of the transverse colon from the
middle third to the splenic angle. Resection of that area was performed with
distal closure in two planes and exteriorization of the transverse colon the
ostomy was matured. During her postoperative period, she required parenteral
nutrition. He was discharged with an ostomy, and after one year in colostomy
status, bowel restitution was performed. Post-surgical stay with five days of
fasting without complications and data of anastomosis dehiscence.
Discussion:
Regardless of prevalence, malnutrition negatively affects clinical outcomes and
increases hospital costs in addition to other factors. Patients are regularly
admitted malnourished, and pre-admission factors associated with this may be
underlying diseases, aging, and adverse socioeconomic conditions.
Conclusions:
Penetrating abdominal wounds by firearms involve several organs, mainly hollow
organs, and their treatment will depend on different variables inherent to the
case.
The use of firearms is a common cause of traumatic
injuries, and an average of 120,232 firearm injuries are estimated to have
occurred annually between 2009 and 2017. Despite the prevalence of firearm
injuries, especially in centers in high-volume trauma, treatment decisions are
still largely based on anecdotal beliefs. A common myth is that the heat
produced by the ignition of the powder during the discharge of the firearm is
sufficient to sterilize the bullet. Wolf et al refuted this idea by coating the
bullets with a small amount of S. aureus, shooting into sterile ballistic
blocks, and culturing the same from the bullet tracts. A penetrating injury
creates an open pathway of entry into which projectiles and their components
can carry bacteria and debris from the skin, clothing, environment, or other
intermediate targets directly into a wound. Despite evolving understanding
regarding possible infection, historical misconceptions likely played a role in
the lack of lucid consensus on the use of antibiotics in gunshot wounds [1,2].
In patients with penetrating injuries, it is important to assess their
nutritional status to support them in their post-surgical recovery in the
shortest possible time, and the diagnosis of malnutrition should be based on a
low BMI (<18.5 kg/m2) or on the combined finding of weight loss
together with a low (age-specific) BMI or low FFMI using sex-specific cutoffs
[3].
A 30-year-old male patient presented with penetrating
abdominal trauma from a firearm projectile at the left flank, subcostal level
in the mid-axillary line without active bleeding (entrance orifice). At the
level of the right hypochondrium, he presented rounded ecchymosis. He was
consulted by the surgery department requesting surgical time to perform the
exploratory laparotomy. Intraoperative findings: double lesion 1 cm
approximately in the greater curvature of the stomach, multiple small intestine
lesions at 15 cm the angle of Treitz grade III; to 20 cm grade IV; at 35 and 45
cm degree V; grade II a lesion 50 cm, for which resection of injured tissues
and primary anastomosis, are performed in two planes. He also presented large
intestine lesions, three of the transverse colon from the middle third to the
splenic angle. Resection of this area was performed with distal closure in two
planes, and exteriorization of the transverse colon towards the right flank the
ostomy was matured. During her postoperative period, she required parenteral
nutrition after evaluation by the hospital nutrition service indicating 2131
kcal/day and continuing with nutritional support at 79% with 1700 kcal in 2430
ml with osmolality of 830 mOsm through a central catheter. He was discharged
with an ostomy, and after one year in colostomy status, he was scheduled for
bowel restitution. The stoma was disassembled with the usual technique, the
distal end was identified at the level of the descending colon, it was
dissected and a manual end-to-end anastomosis was performed in two planes, and
patency was identified. Post-surgical stay with five days of fasting without
complications and data of anastomosis dehiscence (Figures 1 and 2). Your
discharge at home is decided.
The prevalence of hospital malnutrition varies between 15 and 70% depending on the type of institution and nutritional measurements. Regardless of prevalence, malnutrition negatively affects clinical outcomes and increases hospital costs regardless of other factors. Patients are frequently admitted malnourished, and factors before admission associated with this may be underlying diseases, aging, and socioeconomic situations [4]. Hospital malnutrition results in the deterioration of multiple systems. This cumulative nutritional deficit is often underestimated as its initial symptoms. Malnutrition manifests clinically as anorexia, dysphagia, and an inability to digest and absorb nutrients.
Nutritional deficiency is related to the loss of
nutrients, increased nutritional requirements, and lack of consumption to meet
these requirements, due to medications, prescription of restrictive diets,
prolonged fasting, inability to eat without help, and disorganization of
hospital nutrition services [5]. A study conducted found that there has been a
marked resurgence in firearm injury submissions to the emergency department in
2016, in line with the Metropolitan Police firearms crime statistics [6]. The victims
are young. Gunshot injuries place a burden on hospital resources and often
require the expertise of multiple surgical specialties or a designated trauma
surgeon with extensive capabilities. The introduction of the acute surgery and
trauma department and the implementation of the major trauma network in 2010
have improved the management and outcomes of gunshot injuries at the South-East
London trauma center. On the other hand, report in their study that abdominal
trauma predominantly affects men and economically productive age [7]. Traffic
accidents, stab wounds, and firearms were the main causes of abdominal
injuries, which are why research studies are required on the correct use of
weapons and sharp objects, as well as public awareness of traffic prevention.
Accidents. In Germany, gunshot and stab wounds have a low incidence, and are
mostly caused by violent crimes or suicide attempts. However, they account for
more than half of all penetrating injuries. Depending on the affected region,
they are associated with a high mortality rate. The injuries often lead to
considerable blood loss requiring early transfusion. Injuries to the chest or
abdomen are two-chamber injuries. Due to the low incidence of these types of
injuries, more data must be collected, and analyzed to assess and improve the
quality of long-term care for patients with gunshot and stab wounds, special
attention should be paid to focus on treatments that provide a survival
advantage [8]. Reports that penetrating trauma is more common than blunt trauma
and that the intestines are the most affected by penetrating and blunt trauma.
For blunt trauma, the liver is most affected, followed by the spleen. The
liver, as the largest organ, is prone to injury [9]. Abdominopelvic trauma is
usually due to cavity violation from a gunshot or stab wound and is the leading
cause of morbidity and mortality from traumatic injuries. Penetrating trauma
can have subtle or complex imaging findings, posing a diagnostic challenge for
radiologists. Contrast-enhanced CT is the choice to evaluate penetrating
injuries, with good sensitivity and specificity for solid and hollow organs
[10]. It would appear that stab wounds to the colon and gunshot wounds to the
colon are different in terms of the severity of the injury and terms of
outcome. This means that while the primary repair is almost always in stab
wounds to the colon, the same cannot be said for gunshot wounds to the same
organ because in gunshot wounds dehiscence of anastomosis and have higher
mortality [11]. When feasible, intestinal continuity should be preserved as
often as possible in the management of intestinal trauma, regardless of the
site of injury. Anastomoses and sutures are safe in most cases, with a 2%
fistula rate. Stoma creation is a risk factor for postoperative morbidity,
which must be weighed against the hypothetical risk of anastomotic leakage
[12]. Report that in their experience more than 90% of all combined penetrating
intestinal injuries can be managed through the primary or delayed anastomosis,
even in the most severe cases that require the application of the principles of
control of damage. By applying this strategy, the overall need for an ostomy
(primary or delayed) could be reduced to less than 10%. Hollow visceral
injuries account for a significant portion of injuries sustained during
penetrating trauma [13]. Currently, isolated lesions of the small or large
intestine are commonly treated through primary anastomosis in patients
undergoing definitive laparotomy or delayed anastomosis in patients requiring
damage control surgery. The traditional ostomy surgical dogma has proven
unnecessary and, in many cases, increases morbidity. Selective non-operative
management (SNOM) is a feasible management method in the treatment of abdominal
gunshot wounds, especially in patients with solid organ injuries only. It is
not possible to predict the success of SNOM in advance. The most sensitive
point in adopting this approach is the selection of the appropriate patients.
To decrease morbidity and mortality in SNOM, patient selection and management
must be performed carefully. In the presence of alarming symptoms, laparotomy
should always be considered. Decision-making about the selection of patients
for selective non-surgical management is essential to guarantee favorable
results. It is not possible to predict the success of selective non-surgical
management in advance. Careful clinical examination and close monitoring of
these patients are vital; however, emergency laparotomy should be performed in
case of changes in vital signs and positive symptoms related to peritonitis
[14].
Penetrating abdominal wounds by firearms generally
involve several organs, mainly hollow organs, and their treatment will depend
on different variables inherent to the caliber of the projectile, the region
involved, the distance between the attacker and the victim, the age of the
patient, their nutritional status. And if he presents a state of hypovolemic
shock at the time of being treated, in such a way that each case is unique and
its immediate surgical management will depend on the variables present.
None
This work did not receive any funding.