Management of Distal Esophageal Injury in Penetrating Polytrauma

Farah Karipineni, MD, MPH, Lawrence Cetrulo, MD, Jay Strain, MD, FACS, Mark Kaplan, MD, FACS, Pak Leung, MD, FACS. Albert Einstein Healthcare Network

We report the case of a 22-year-old male who presented to our Level 1 trauma center after a gunshot wound to the right hemiabdomen. He was initially tachycardic and hypotensive, and was taken emergently to the operating room for laparotomy. On exploration he was found to have massive hemoperitoneum, and a splenectomy and multiple gastrotomy repairs were initially performed. He was also found to have a distal esophageal injury which was temporarily controlled.  Bilateral retroperitoneal hematomas were explored, revealing shattered kidneys with bilateral hilar injury. At this time the decision was made to place a temporary abdominal dressing and evaluate the patient’s renal system with CT angiogram (CTA) prior to returning for possible nephrectomy. CTA confirmed bilateral grade V kidney injury with active extravasation of both renal hila. CTA also displayed a grade IV liver laceration involving segments 2, 4a, and 8, with active extravasation. The patient was taken emergently back to the operating room where a right nephrectomy and liver segmentectomy were performed, with sparing of the left kidney. The patient was subsequently taken to the interventional radiology suite for angioembolization of bleeding hepatic and left renal arterial branches. He was then admitted to the surgical intensive care unit for resuscitation and continuous renal replacement therapy. Over the next several days, he returned to the operating room for reexploration and underwent pyloroplasty and Dor fundoplication. He began to make adequate urine. His fascia was closed on hospital day seven. He developed a urine leak on postoperative day eight, for which a ureteral stent was placed. He was ultimately discharged home three weeks after admission in stable condition. On follow-up, he has no evidence of gastric dumping or gas bloat syndrome, and is tolerating an oral diet with no complaints.

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