ABSTRACT
- This report presents the case of a 20-year-old man who sustained a severe liver injury from a close-range shotgun blast. A prompt medical intervention, including damage control exploratory laparotomy and surgical debridement, was undertaken due to the extent of liver damage. Despite challenges such as a nondirected biliary fistula and extensive liver parenchymal injury, comprehensive surgical management led to successful treatment. Postoperative complications, including biloma and fungal infection, were managed appropriately, highlighting the importance of vigilant follow-up care. The case underscores the complexity of managing severe liver trauma and emphasizes the evolving role of trauma damage control strategies and minimally invasive procedures in achieving favorable outcomes.
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Keywords: Liver; Wounds and injuries; Firearms; Gunshot wounds; Case reports
INTRODUCTION
- Liver injuries rank among the most frequent types of abdominal injuries in patients with severe trauma [1]. Blunt abdominal trauma, often resulting from motor vehicle crashes, is the primary cause of liver injuries. Penetrating trauma to the liver may result from bullets, shrapnel, knives, and other sharp objects. Currently, there are no official nationwide data on gunshot wound injuries in Argentina due to the lack of a centralized registry system for these types of injuries.
- The approach to treating traumatic liver injuries depends on factors such as the patient’s physiology, the nature and severity of the injury, any concurrent abdominal or extra-abdominal injuries, as well as the expertise available locally. Advancements in diagnostic and therapeutic modalities have contributed to the evolution of diagnosis and management strategies for hepatic trauma [2–4].
- This case report highlights the challenges and management strategies in treating severe liver trauma caused by a close-range shotgun injury, emphasizing the evolving role of trauma damage control strategies and minimally invasive procedures.
CASE REPORT
- A 20-year-old man was shot at close range with a shotgun during a dispute with his friend. He was rapidly transported to the emergency department of a secondary hospital. The physical examination revealed an afebrile and anxious man with mild right upper quadrant pain from a single entry shot with no exit wound (Fig. 1A). His vital signs were as follows: heart rate, 88 beats/min and blood pressure, 122/78 mmHg. The respiratory rate and oxygen saturation on room air were normal. Laboratory studies demonstrated hemoglobin levels of 14 g/dL and leukocytosis of 21.39×103/μL. A computed tomography scan of the thorax, abdomen, and pelvis with intravenous contrast revealed fractures of the 10th to the 12th right ribs with grade 2 pneumothorax, along with shotgun pellets distributed throughout the hepatic gland and minimal free fluid (Fig. 1B). The patient was admitted to the operating room for a right tube thoracostomy and a damage control laparotomy. A thorough and prompt exploration of the abdomen revealed an obliterated right anterior sector of the liver with no significant active bleeding (grade IV laceration of the American Association for the Surgery of Trauma [AAST] classification) (Fig. 1C). Perihepatic gauze packing was performed, achieving an open abdomen with a Bogota bag. After 12 hours, the surgical team contacted us and the patient was transferred to our institution, a tertiary level care hospital with trained hepato-pancreato-biliary surgeons, on mechanical ventilatory support. He remained hemodynamically stable, with bile emanating from the wounds and surgical drains (Fig. 1D) with altered renal function (creatinine, 2.04 mg/dL) and liver function tests (total bilirubin, 2.13 mg/dL; aspartate transaminase, 723 U/L; alanine, 904 U/L; alkaline phosphatase, 65 IU/L).
- Because the patient presented with a nondirected biliary fistula with choleperitoneum, he was immediately brought to the operating room. We first explored the cavity, ruling out hollow viscera lesions or vascular injuries. We removed all the previous pieces of gauze from the packing. The liver presented an anfractuous, lacerated wound compromising segments 4B and 5, with the gallbladder completely hanging (Fig. 2A) and no signs of active bleeding. Surprisingly, the cartridge wad was embedded in the liver parenchyma, with a few pellets loose in the cavity. After completely mobilizing the gland, we fully debrided the devitalized parenchyma with a harmonic scalpel and performed cholecystectomy with intraoperative cholangiography (Fig. 2B), which showed biliary leakage in the topography of the right anterior sectoral branch with a good passage to the duodenum and the pellets distributed along the liver in a way that resembled “a starry night.” A few loose pellets were found in the cavity and retrieved for a medicolegal examination. The remaining pellets were left in place due to the risk of causing more harm during the extraction process. Because we were not able to find the orifice from which bile was emanating and considering the risk of injuring other structures while attempting to close the lesion (Fig. 2C), we concluded the procedure by performing hemostasis (Fig. 2D) and closing and draining the liver wound (with a 24F Blake silicone drain along the traumatized area) and abdominal cavity, as well as cleaning the entry shotgun wound.
- The patient was discharged home on postoperative day 23 after developing a biloma on postoperative day 4, which required percutaneous drainage (Fig. 3A, B). The biloma, measuring 45 × 55 mm, was located near segment 4B. Due to the presence of Candida albicans in the culture, he required antifungal treatment. The drain was left in place until postoperative day 42, at which point there was no discharge, and an abdominal ultrasound revealed no collections. Six weeks after the initial procedure, all drainage tubes were removed (Fig. 3C), and the patient had a follow-up appointment at 1 month without any further problems.
- Ethics statement
- Informed consent for publication of the research details and clinical images was obtained from the patient.
DISCUSSION
- The degree of liver damage depends on the type of object that causes damage and the mechanism of injury [1,2]. The surgical approach to managing patients with liver injuries has evolved significantly in recent years, shifting from nonoperative treatment in low-grade injuries to a damage control strategy in cases of more severe trauma [2]. The concept of prioritizing the stabilization of critically ill patients over extensive surgery has replaced the need for primary reconstructive-resection procedures.
- In cases of extensive liver damage, prompt bleeding control is crucial. Following damage control surgery, a second operation is performed to remove the previously placed gauze swabs and assess the need for reconstructive procedures or resection [2]. Furthermore, intra-abdominal packing of major liver injuries also facilitates transfer from a peripheral hospital to a tertiary center for definitive management [3]. The reconstructive phase entails addressing damage to the bile ducts, usually by targeted suturing of the site of bile leakage. However, in this instance, we were unable to perform this procedure because the damaged bile duct was not adequately visualized. Furthermore, during this phase, as demonstrated in this case, it is advisable to selectively excise necrotic liver tissue. In a study involving 304 patients with gunshot injuries to the liver, 52% of those with grade IV liver injuries required debridement, while 38% required perihepatic packing [4].
- Several case reports have shown that the presence of a shotgun slug wad can indicate the firing range, as it may accompany the slug for distances up to at least 6.7 m [5]. Additionally, in cases of close-range injuries, other types of shotgun slug attachments, such as a sabot, may be retained [6].
- Traumatic liver injuries, particularly those resulting from gunshot wounds, are associated with significant morbidity and mortality. Severe liver injuries are linked to a high incidence of liver-related complications such as biloma/bile leak, abscess, necrosis, haemobilia, rebleeding, and pseudoaneurysm. Studies report these complications in 11% to 48% of cases involving severe hepatic trauma [7–10]. An analysis of 153 liver gunshot wounds revealed that 7% (11 cases) involved shotgun injuries [11]. These injuries had a 36% mortality rate and a 71% morbidity rate, compared to 15% mortality and 48% morbidity in cases of single-missile gunshot wounds. This highlights the critical need to recognize the severity of complex injuries caused by shotgun projectiles early in the treatment process.
- The comprehensive treatment of liver trauma now incorporates a multidisciplinary approach to manage the subsequent complications of gunshot wounds. Techniques such as ultrasonography, percutaneous aspiration or catheter drainage, angiographic embolization, and interventional endoscopy are essential for identifying and treating septic, arterial, or biliary complications associated with these injuries in contemporary medical practice [12].
- Due to the large number of shotgun pellets retained in the liver, two primary concerns arise: the potential for lead toxicity, which is rare but likely underdiagnosed [13], and the risk of pellet embolism within the vascular system [14]. There are only a few clear indications for pellet removal, such as situations where they are located in the joints, cerebrospinal fluid, or the eye. Additionally, pellets that impinge on a nerve or nerve root, as well as those situated in the lumen of a vessel that pose a risk of ischemia or remobilization, should be extracted [15].
- There is limited information regarding the advantages and disadvantages of extracting retained lead pellets. A review conducted by Moazeni et al. [14] found that, between 25 patients with some retained lead pellets in their bodies due to shotgun, the serum lead levels were not significantly different compared to 25 volunteers without similar lead exposure. An elevated serum lead level, even if accurately measured, does not confirm lead poisoning—instead, it simply indicates recent exposure or absorption of lead. Most experts agree that lead toxicity is diagnosed based on clinical symptoms rather than a specific serum lead level [15]. The symptoms of lead toxicity appear as follows: anemia, lead paralysis and wrist drop, peripheral neuropathy, high uric acid levels in the blood, anorexia, diarrhea or constipation, skin and breast cancers, lymphoma, high serum cholesterol, and elevated blood pressure [15].
- There are no established guidelines for follow-up in these patients. Most case series advise against extensive surgery to remove lead pellets. However, patients with numerous retained lead pellets are considered at risk for lead poisoning and should be carefully monitored [15].
- In conclusion, this case highlights the importance of a multidisciplinary approach in the management of complex liver injuries caused by penetrating trauma. The positive outcome highlights the necessity for swift diagnosis, immediate surgical intervention, damage control strategies, and thorough postoperative care.
ARTICLE INFORMATION
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Conflicts of interest
The authors have no conflicts of interest to declare.
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Funding
The authors received no financial support for this study.
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Author contributions
Conceptualization: all authors; Investigation: all authors; Methodology: all authors; Project administration: all authors; Visualization: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.
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Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.
Fig. 1.Clinical images of the patient. (A) A single entry shot with no exit wound. (B) Computed tomography scan of the thorax, abdomen, and pelvis with intravenous contrast, revealing fractures of the 10th to the 12th right ribs with grade 2 pneumothorax, along with shotgun pellets distributed throughout the hepatic gland in a billiard ball ricochet manner, showing a grade IV laceration (American Association for the Surgery of Trauma classification) and minimal free fluid (arrow). (C) An obliterated right anterior sector of the liver with no significant active bleeding. (D) An open abdomen with a Bogota bag with bile emanating from the wounds and surgical drains.
Fig. 2.Intraoperative images. (A) A nonfractured, lacerated wound compromising liver segments 4B and 5, with the gallbladder completely hanging; the cartridge wad was embedded in the liver parenchyma (inset, arrow). (B) Intraoperative cholangiography showing biliary leakage (arrow) in the topography of the right anterior sectoral branch, with good passage to the duodenum, and the pellets distributed along the liver resembling “a starry night.” (C) Site of bile leakage with no visualization of the bile duct lesion. (D) Hemostasis and cavity drainage.
Fig. 3.Postoperative images. (A) Computed tomography scan shows a developing biloma (arrow). (B) Biloma after 23 days postoperatively, requiring percutaneous drainage. (C) Six weeks after the initial procedure, all drainage tubes were removed.
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