Complex Organ Injury Management in Abdominal Trauma: Case of a Heavy Iron Plate Accident

Introduction

Severe open abdominal trauma with rupture of multiple organs, including the colon, duodenum, kidney, liver and diaphragm, is very rare and infrequently reported. It is a great challenge to the hospital and doctors, because of the patient’s high risk of dying and poor prognosis during emergency operations. Patients can experience massive bleeding and shock at any time, or serious postoperative infection, anastomotic fistula, and other severe complications. How to effectively treat this kind of patient is a clinical problem that requires constant attention.

Today, medicine is divided into many different specialties, but no specialist can handle this kind of patient alone. Emergency laparotomy is associated with increased mortality and morbidity and demands fully equipped hospitals and surgical critical care, which vary between populations and countries [1]. Multidisciplinary collaborative therapy is necessary, including, but not limited to, general surgeons, thoracic surgeons, urologists, trauma surgeons, anesthesiologists, and intensive care physicians [2–4]. The aim of this study is to present a complex case of abdominal trauma that was effectively treated with a multidisciplinary approach.

Case Report

On July 27, 2022, a 44-year-old man with a height of 172 cm and a body weight of 60 kg (calculated body mass index 20.3 kg/m2) was injured by a heavy falling iron plate on a construction site. The right side of his abdomen was severely lacerated, with his intestines and liver exposed, while there was severe bleeding from the wound. He was admitted to the Emergency Department of our hospital within 2 h, with gauze covering the wound. The emergency surgeon checked the patient, who was awake with clear mind, anemic appearance, blood pressure 100/70 mmHg, heart rate 120 beats per min, percutaneous arterial oxygen saturation 96%, Glasgow Coma Scale score 14, normal orientation, increased breathing frequency, and decreased sound on the right chest. The right abdomen wound extended outward and backward from the midclavicular line to the posterior abdominal wall, which was about 30–40-cm long, exposing the omentum and bowel, with a smell of feces and no more bleeding (Figure 1). He was sent to the Emergency Department, given intensive care, blood tests, fluid rehydration, hemostasis, and transfusion therapy. After initial treatment, the patient’s bleeding was controlled, and his vital signs were stable with blood pressure of 110/70 mmHg, heart rate of 100 beats per min, and clear consciousness.

An emergency head-neck-chest-abdomen computed tomography (CT) scan without intravenous contrast showed a massive abdominal wall defect, right kidney rupture, hepatic rupture, pneumoperitoneum, periduodenal hematoma, hepatic flexure injury of colon, fracture of ribs 6–11 on the right side, fracture of transversal process on the left side of L1-4, right hemopneumothorax, and pneumonia (Figure 2). No other fractures or brain injuries could be identified. A multidisciplinary consultation was done, including doctors from gastrointestinal surgery, hepatobiliary surgery, urology surgery, thoracic surgery, anesthesiology, and intensive care medicine (ICU) departments. Indication for emergency surgery was set, and the patient underwent emergency surgery after admission to the Gastrointestinal Surgery Department. A thoracic drainage tube was not placed before surgery, because the patient had no significant dyspnea.

Emergency rescue surgery was performed from 18: 20 to 3: 16 a.m. During surgery, we found that the abdominal organs were heavily contaminated with feces, hepatic flexure of colon was ruptured with a hole of approximately 5 cm, right kidney was severely ruptured, liver was mildly lacerated, descending duodenum was ruptured and hematoma formed, and right diaphragm was ruptured with right hemopneumothorax. The right kidney, right half colon, gallbladder, duodenum, and part of the head of the pancreas were removed (Figure 3). An end ileostomy was done (without ileum-colon anastomosis), and gastric-intestine, biliary-intestine, and pancreas-intestine anastomosis were also done. The liver wound surface was treated with electrocoagulation. The right diaphragm was repaired, closed thoracic drainage was placed, and the wound of the abdominal wall was sutured after irrigation with plenty of saline. The intraoperative blood loss was about 350 mL, and the patient received 9000 mL crystalloid fluids, 4 units of red blood cells, 760 mL plasma, and 10 units of cryoprecipitation during surgery, in order to increase hemoglobin and prevent blood clot disorders, which might be caused by excessive bleeding. After the operation, the patient was transferred to the emergency ICU for intensive care treatment.

After the operation, the patient was given symptomatic support, such as blood transfusion, antibacterial drug, proton pump inhibitor, hepatoprotective drug, total parenteral nutrition, and regular dressing changes at the incision. The patient was extubated and awake 4.5 h after surgery. On day 5 after surgery, the patient underwent bilateral pleural puncture catheter drainage under the guidance of ultrasound, due to bilateral pleural effusion. After that, the patient was transferred back to the general ward. On day 22 after surgery, the patient was recovered and discharged without a second operation (Figure 4). After a year of recovery, he returned to our department for closing the ileostomy. The operation of closing the ileostomy was difficult because of severe abdominal adhesions. After surgery, the patient experienced prolonged postoperative ileus and gastroparesis. After being given treatment of acupuncture therapy, gastrointestinal motility agent, infrared irradiation, and naso-intestinal tube implantation for enteral nutrition, the patient recovered and was discharged (Figure 4).

Discussion

Worldwide, traumatic injuries are the sixth leading cause of death and the fifth leading cause of moderate and severe disability, and the kidney is the most commonly injured genitourinary organ [5]. According to the American Association for the Surgery of Trauma (AAST) organ injury severity scale for the kidney, renal injuries are divided into 5 grades, which guide the treatment of patients with renal trauma [6–8]. This patient should be classified as grade IV because the right inferior pole of the kidney was crushed. Surgical removal of the right kidney was recommended, because of the risk of massive bleeding from multiple organ injuries and severe abdominal contamination due to open trauma.

The incidence of adult duodenal trauma is 0.2% to 0.6% in all trauma patients and 1% to 4.7% in all abdominal trauma patients [9]. Penetrating trauma is the most common cause of duodenal injury in adult patients, and the duodenum injury scale is classified using the AAST grading scale as grade I to V [9]. Although many approaches have been proposed to cure duodenal trauma, the risk of complications remains high. Especially in complex duodenal injury, the incidence of complications is as high as 65%, and overall mortality ranges from 5% to 30% [10]. Principles of surgical treatment of duodenal trauma include damage control techniques, resection of non-viable tissue, restoring continuity of the gastrointestinal tract, diverting gastrointestinal contents, restoring bile and pancreatic enzymes, creating conditions for healing, and providing enteral nutrition access [9–12]. Pancreaticoduodenectomy is the only possible treatment indicated for the most complex injuries (grades IV and V) [13]. Our patient required careful exploration of the duodenum in surgery, to avoid missing duodenal injury, as retroperitoneal periduodenal hematoma was found on preoperative CT.

Colonic rupture occurs occasionally in abdominal trauma. It is often not difficult to diagnose by physical examination or CT results, which reveal free gas in the abdominal cavity and discontinuity of the colon. Some patients with open trauma have the colon exposed outside, or even stool flows out of the abdominal cavity. Early emergency surgery, after controlling shock, is recommended as soon as the diagnosis is made. Bowel resection with colostomy is preferred for colon perforation regardless the cause of injury, because this procedure ensures the best immediate results [14–16].

Liver trauma is one of the most common abdominal lesions. Contrast-enhanced CT is the best method to evaluate hepatobiliary injury in patients with trauma who are hemodynamically stable [2,17]. Most minor liver trauma, such as grades I–II injuries of the AAST liver trauma classification, can be treated without surgery [2,18]. This patient had minor liver damage, and the reason for the surgery was that the damage to other organs was serious. During the operation, the liver was explored and hemostasis was performed. Traumatic diaphragmatic rupture is a rare injury that is reported in less than 0.5% of all trauma cases. It is difficult to diagnose, and it sometimes involves herniation of abdominal organs into the chest [19,20]. Open diaphragmatic injury requires hemostasis, suture of the diaphragmatic defect, and placement of a chest drainage tube.

Damage control surgery has become a life-saving tool for critically ill patients, in appropriate conditions. The principle includes a rapidly abbreviated operation aimed at arresting ongoing hemorrhage and reducing intestinal contamination in a patient approaching physiologic exhaustion. Patients are then returned to the operating theater for definitive reconstruction once their physiology has been stabilized. However, overuse of this technique can lead to increased patient morbidity and high costs [21,22]. Considering that the diaphragmatic injury, duodenal rupture, renal rupture, and colon rupture that occurred in this patient required early treatment, secondary surgery might have been difficult and caused other complications. Since the patient’s physiology was stable during the surgery, we removed multiple injured organs and reconstructed in a single operation.

Management of the severe abdominal wall trauma was determined by a multidisciplinary team of general and plastic surgeons, intensivists, and specialist nurses [23]. Muscle fascia defects should be managed during the same hospitalization, to prevent intestinal strangulation and occlusion [24]. When defects are large, mesh could be used for tension-free reconstruction. In our case, the abdominal wall wound was long, but with no necrosis, and the incision tension after suture was not significant. No serious infection or rupture occurred on the incision.

Intestinal handling during abdominal surgery stimulates postoperative ileus via both the neuropathic and inflammatory pathways [25]. Prolonged surgical duration and postoperative complications increase the risk for prolonged postoperative ileus. Gentle handling and minimal manipulation of the intestines is recommended to reduce postoperative gastrointestinal dysmotility [26]. Postoperative gastroparesis is associated with partial gastrectomy and can be related to exogenous denervation of the gastric stump or abnormal movement of anastomotic jejunal loops [27]. Treatment of gastroparesis should include assessment and correction of nutritional status, relief of symptoms, improvement of gastric emptying, reversal of iatrogenic gastroparesis, and control of blood sugar in patients with diabetes [27,28].

In addition, ICU admission is suggested for severe lesions [2]. The management of severe abdominal trauma should be multidisciplinary, including trauma surgeons of gastrointestinal surgery, hepatobiliary surgery, urology surgery, and thoracic surgery, anesthesiology interventional radiologists, and emergency and ICU physicians [2,4,29]. Multiple-stage surgery in severe abdominal trauma is recommended, and a multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes [3,14,29].

Conclusions

Multidisciplinary collaboration and adherence to evidence-based guidance are important for rescuing patients with severe chest and abdominal trauma. Hospitals should continue to strengthen the ability of multi-disciplinary cooperation in diagnosis and treatment of patients with severe trauma.