Inferior Vena caval Injury- A case Report (Northern Medical Journal, PDF)

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Inferior Vena caval Injury- A case Report (Northern Medical Journal, PDF)

  1. 1. 101 Northern Medical Journal 2009; 18(2): I01-105 PENETRATING ABDOMINAL TRAUMA CAUSING INFERIOR VENA CAVAL INJURY - A CASE REPORT Hriday Hanjan Royl, SM Abu Taleb2, Bimal Chandra Roy3, MA Basuniaa Abstract: lnfenor vena cava injury is a grave condition. Patient present with severe shock and become reluctant to the procedure of resuscitation. We performed an emergency operation of inferior vena cava injurywho had non recordable blood pressure, ieeble pulse and scanty urine output even after resuscitation by l/V fluid and blood transfusion. The patient was rescued. However, due to associated pancreatic injury, an embarrassing pancreatic pseudo cyst developed later on. A second operation was done 2 months later; patient recovered completely and at present leading a normal life. Nofthern Medical Journal 2009; 18 (2): 101-105 lndexing words: Penetrating abdominal trauma, lnferior vena caval injury, Pancreatic injury. lntroduction: The incidence of injuries to major abdominal vessels in a patient sustaining penetrating abdominal trauma is 1A/.1. Most abdominal vascular injuries result from penetrating trauma and are associated with other abdominal injuries 2. lnferior vena cava (lVC) is themost frequently injured vessel in the abdomen ". The mortality o. rate for this type o{ injury is 37% The high mortality is due to blood loss either from the vena cava or from associated vascular injuries resulting in multiple organ f ailure caused 1. Junior Consultant (Surgery) & 2. Senior Consultant (Surgery) 5 by delayed resuscitation and surgical intervention 6. Clinically the patient will present either as free intra peritoneal hemorrhage or As a contained retro peritoneal haematoma.''o Penetrating wounds of the vena cava are usuallV fatal either before any aid can be rendered e or later. despite surgical treatmentl0. Knowledge of the anatomical location of the major vessels and the course of the penetrating object brings into a major vascular injury '. However, the definite diagnosis of vena caval injury is usually established only at laparotomy, b"ing no, inf requently an consid,eration the possibility of unexpected f inding.e'1 0,,, J. Rangpur Medical College Hospital Consultant (Surgery) Sadar Hospital, Lalmonirhat Case Report: 4 Asst. Prof. Dept. of Surgery & A 28 years young male hailing from Gangachara. Rangpur Medical College Rangpur was admitted into this hospital havrng
  2. 2. 102 Roy, Taleb, RoY, Basunia history of stab injury on right upper abdomen' Assault on him was occurred at 10 am and he '1.30 pm on the same day' reached hospital at On admission, he was restlessness and his cloths were stained with profuse blood' There was continuous oozing of blood through the wound and omentum came out through it' Examination findings on admission were, Fig-1 : rncrough ar: thorough injur'.' '' r'1:' -' ' appearance- restlessness, anemic, urine output- scanty, pulse- rapid, thready and feeble, B.P- non recordable' RaPid resuscitation was tried by l/V fluid and blood transfusion. But the result of resuscitation was failed. So, the patient was submitted for urgent laparotomy with double risk bond consent At 7.30 pm, abdomen was opened by a generous right paramedian incision. The whole peritoneal civity was full of clotted and f resh blood' lt was sucked out and mopped out rapidly (about 2/3 liters). But continuous severe exsanguinations of blood made the field so ditficult to identify the injury. An injury on stomach at its antral part anO UtooO stained lesser sac - which was full of blood, draw the attention' So, lesser sac was accessed rapidly by opening the gaslrocolic ligament. There was terrible bleeding like an igneous of volcano through an inlury at the site of OoOy and head of the pancreas medial to duodenal C-cap. Pressure by mop failed to control the bleeding. So, manual finger pressure (introducing finger into the injury) was applied and it was controlled' Keeping it controlled by an assistant, duodenum was kocherized from laterally and the IVC was explored. The injury was found extended up to vertebral column injuring both anterior and posterior wall of IVC (Fig-1)' Meticulous dissection of IVC was done and control taken by rubber catheter both above and below of the injury (Fig-1). There was about 1 inch linear longitudinal tnlui-,' in both anterior and posterior aspect o{ IVC in its infrararenal part. Both were repaired prolene (Fig-2). Fig-2: After- r'epair of posterior wali of IVC by 5/0
  3. 3. 103 Penetrating abdominal trauma causing inferior vena cavai injury-Acasereport Control was removed. During this procedure, only carotid pulse was recorded by the anesthesiologist. After removal of control, pulse, B.P and urine output began to reappear. Oozing from pre-vedebral area was controlled by cauterization. The renal and gonadal veins were found to be intact. There was also associated injury to the stomach injuring both anterior and posterior wall near its antral pafi. Both An ultrasonogram report reveals huge encysted thick (inf ected) collection in upper abdomen. Patrent also had respiratory distress. Aspiration was done by wide bore needle by which the patient felt comfort. The aspirate was clear pancreatic flurd. Later on a folley catheter was inserted into the cyst by local anesthesia. lnitially, about 1 to 1112liter of collection per 24 were repaired by double layered suture, Nothing was done for the associated pancreatic rnjury. Ti;o drain: hours was there. But it was gradually decreasing day by day. Later on, the catheter was removed and he was discharged from the hospital. one in pelvis and anoiher in lesser sac (through foramen of Winslow; were inserled. Closure of incision wound and stab wound was done accordingly. Recovery f rom anesthesia was uneventful. Four units of fresh blood were given peroperatively. lnjection calcium gluconate and sodi bi carb was also given. Postoperative period was uneventful. At Sth post operative day, a cystic swelling began to appear in left hypochondriac region which was gradually enlarging occupying the left hypochondriac, epigastria, umbilicaland left lumber region (Fig-3). Fig-3: Cysl c sr,relllng in upper abdomen After about 11/, months (>2months f rom initial operation), he again admitted into surgery unit with the complaints of huge swellrng over the upper abdomen which typically became enlarged and painful during meal. lt made him discomfort and dyspnoeic. Repeat ultrasonogram revealed the same picture as before. Repeated aspiration by wide bore needle (clear fluid) made him temporary comfort, but the problem remain to be continued. At Iast, the decision of laparotomy was taken for a cysto-jejunostomy with roux-enY reconstruction. Abdomen was opened through the previous incision line excising the scar of previous operation. There was a huge swelling behind the stomach, aspiration f rom which revealed clear fluid. Lesser sac could not be accessed due to huge adhesions. So, after opening of the anterior wall of stomach, it was reached by incising the posterror wall of stomach and a cysto-gastrostomy was constructed. Recovery from anesthesia was smooth and postoperative period was uneventful. He was discharged from hospital on 8th postoperative day. Further follow up was done after one month and he had no more complaints and was leading completely normal life. Discussion: lnferior vena caval injury is a serious and rare condition more oftei" encountered with penetrating than with blur,t traumass. Despite the
  4. 4. Roy, Taleb, Roy, Basunia progress in 104 surgery and preoperative care technique, the mortality rate for IVC injury is still high". Thirty six per cent patients die before reaching hospital.s The factors, which play significant role in mortality, are presence of shock on admission, suprarenal IVC injury and bleeding without retroperitoneal haematoma6. Survival was best when the-injury was located in the infrarenal IVC (68%)." ln a study, it was shown that the patients with IVC injury with shock had a 286-fold increase in the risk oJ death8. For patients whose hemorrhage through IVC is stopped by the retroperitoneal haematoma the mortalitv rate is 26% and those without iI is 74"/..8 ln a siudy,t3 91% survival rate with retroperitoneal temponade f rankly contrasted to 93% mortalrty rate without temponade. ln our case, the patient was in severe shock and there was no temponade ef{ect by haematoma, rather severe continuous bleeding was present. The only favorable situation was that the injury was infrarenal. The early intervention with appropriate technique made the patient safe. About 100 cases have been published in the Enqlish literature with successful surgical treatmeni.e'11'14'15'16'17'18 Gunshot wounds are the main cause of penetrating caval injuries and half of the patients are dead on arrival at hospital.l' Of those still alive, half will die in spite of therapy.lo Our case was a victim of stab injury by a sword. Upon admission, most show signs of severe blood loss and_ peritonitis, suggesting a major vascular injury." ln our case, signs of severe shock and continuous oozing of blood through the stab was present. We guessed about the major vascular injury, but the definite site was uncertain. A number, however, do not appear gravely injured and the presence of a major vascular injury is . pre-operatively not even remotely suspected.'" The patient who had an abdominal penetrating trauma with shock should be operated immediatelyo. We also performed urgent surgery despite unstable haemodynamic condition, reluctant to resuscitation procedures. During operation, control of hemorrhage is the first step of intervention.o The determination of the pathway of the penetrating wound is essential Jor the diagnosis.s Any haematoma in Zone '1 of retroperitoneum (Midline lnframesocolic Area which includes infrarenal abdominal aorta and inferior vena cava) should be explored.le lf inf ramesocolic haematoma appears to be more extensive on the right side of abdomen than left and if there is active haemorrhage coming through base of mesentery of ascending colon or hepatic flexure of colon, injury to IVC below the liver should be suspected.ls Survival rates for patrents with injury to IVC depend on location of injury.ls The average survival rates for 515 patients with injuries to infrahepatic IVC was 72.2/o20'2t'22. When injury to infrarenal IVC alone are included the averaoe survival for 318 patients was 70.1"/o.zo'zt'zz'z{2s Ours was a case of infrarenal IVC injury. The reported articles cited here did not show any associated pancreatic injury. We had fetched it with a severe postoperative complication" After about two and half months, by which the cyst wall matured, a second operation of cystogastrostomy was done. The question is, whether the pancreatic injury could be handled safely at the first time with a pancreatico-enterostomy reconstruction. During first operation, the patient was in critical condition and duration of surgery and anesthesia was a factor. Should we go to handle the pancreatic injury during f irst operation, in this situation? Conclusion: Penetrating injury of IVC remains a challenging problem. The key to effective management includes early diagnosis, resuscitation and prompt surgical intervention. Associated solid or hollow visceral injuries negatively affect survival. ln case of haemodynamic instability, sometimes,
  5. 5. 't05 Penetrating abdominal trauma causing inferior vena caval injury-Acase report a technically simpler procedure is more beneficial than a complex, time consuming reconstruction. ln our patient, the early recognition, prompt intervention culminated in satisfactory outcome. The associated pancreatic injury made a problem for us, though it was managed successfully at a later time. 3. 4. 5. 6. 7. Mattox KL, Feliciano DV, Burch J et al. Five thousand seven hundred sixty cardiovascular binjuries in 4459 patients: Epidemiologic evolution 1 958 to 1 987. Ann Surg 1 989; 209: 698-707. Feliciano DV, Bitondo CG, Mttox KL et al. Civilian trauma in 1980s, A 1-year experience of 456 15 16. 17. 18. Bar-Jiv J, Mares AJ, Hirsch M. lnjury to the inferior vena cava. British-Journal of Radiology 19. et al. Abdominal vascular injuries. J Trauma 1997; 43:. Carillo EH, Bergamini TM, Miller FB 9. JS & Moore EE. Critical factors in Surgical Clinics of North America 1963, 43: 387-400 Gaspar MR, and Treiman RL. The management of injuries to major veins. American Journal of Surgery 1960; 45(532): 171-175. Perdue GD and Smith RB. lntra-abdominal vascular injuries. Surgery 1968; 64: 562-568 Duke JH, Jones RC and Shires GT. Management of injures to the inferior vena cava. American Journal of Surgery 1965; 1 10: 759-763. Chandler JG and Knapp RW. Early definitive treatment of vascular injuries in the Vietnam conflict. Journal of American Medical Association 1967;202: 136-142. Shah P & Shah N. Penetrating Abdominal Trauma - A Case of lsolated lnferior Vena Cava lnjury. Bombay Hospital Journal 2008; 50(2): 286-287. 20. Kashuk JL, Moore EE, Millikan JS et al. Major abdominal vascular trauma-a unified approach. J Trauma 1982:22: 672. 21 Jackson MR, Olson DW, Beckett WC et al. Abdominal vascular trauma. Am Surg 1992;58:622. 164-71. 8. Millikan determining mortality in abdominal aodic trauma. Surg. Gynecol. Obstet 1 985; 160: 313-316. 14. Starzl TE, Kaupp H A, Beheler EM, and Freemark RJ. Penetrating injuries of the inferior vena cava. vascLllar and cardiac injuries. Ann Surg 1984; 199:717-724. Burch JM, Feliciano DV. Mttox KL, and Edelman M. lnjuries of the inferior vena cava. Am. J. Surg 1 988; 1 56: 548-551 . 1972, 45(532): 307-31 0 Ozkokeli M, Ates M, Topaloglu U, Muftuoglu T. A case of successfully treated inferior vena cava injury. Tohoku J. Exp. Med 2003; 200: 99-101. Wood M. Penetrating wounds of the vena cava, recommendations for treatment. Surgery 1966; 60: 31 1-3'16. 12. Porter JM, lvatury RR, lslam SZ, Vinzons A & Stahl WM. lnferior vena cava injuries: Noninvasive followup of venography. J. Trauma, lnjury, lnfection and Critical Care 1997; 42:913-918. 13. References: 1. Spjut-Patrinely V, Feliciano DV. Data from Ben Taub General Hospital, Houston, Texas, July 1985 to June 1988, unpublished. 2. '11. Frezza EE, Valenziano CP. Blunt traumatic of the inferior vena cava. J Trauma Coimbra R, Hoyt D, Winchell R et al. The ongoing challenge of retroperitoneal vascular inuries. Am J Surg 1996; 172: 541-45. 22. Ochsner JL, Crawford ES, and Debakey ME. lnjuries of the vena cava caused by external lJ. 1997; 42: 141. Graham JM, Mattox KL, Beall AC Jr. Traumatic injuries of the inferior vena cava. Arch Surg 1978; 113:413. 24. Wiencek RG, Wilson RF. Abdominal venous trauma. Surgery 1961 ; 49: 397-405. 10. Quast DC, Shirkey AL, Fitzgerald JB, Beall AC, and Debakey ME. Surgical correction of injuries of the vena cava: an analysis of sixty-one cases. Journal of Trauma 'l 965; 5: 3-9. avulsion injuries. J Trauma 1986: 26: 771 25. . Klein SR, Baumgartner FJ, Bongard FS. Contemporary management strategy for major inferior vena caval injuries. J Trauma 1994; 37: 35.

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