Papers by imraan sardiwalla
International journal of surgery case reports, May 1, 2024
Hpb, Apr 1, 2016
Methods: Surgical treatment performed at 17 patients with Mirizzi symdrome in period of five year... more Methods: Surgical treatment performed at 17 patients with Mirizzi symdrome in period of five years. Mean age of 62.9 years(40 to 83 years) Main parameters(clinical changes, lab results,sonography) were evaluated. Results: According to the Csendes classification : type I-7 patients-(41.0%)type II-2 (11.8%)type III-6(35.4%)type IV-2(11.8%).Laparoscopy as a first step of surgical treatment was performed at 5 patients with Mirizzi syndrome type I-II. At 8 patients open cholecystectomy was performed. At 6 patients-cholecystectomy with drainage of bile ducts, and at 3 patients-cholecystectomy and hepaticojejunostomy(all with type 3 Mirizzy. In cases with significant defect of common bile duct we performed reconstruction or partial(2 cases) cholecystectomy.Concomitant and related surgical pathology (at 8 cases gangrenous cholecystitis with local peritonitis, 1 case-liver abscess, 1 case-multiple liver abscesses, 1 case of combination of cholecystocholedocheal and cholecysto-duodenal fistula) provide significant impact on type of treatment and process of recovery. Leukocytic index of intoxication by Kalf-Kalif(LII) measured at all patients, RR-0.51-2.1. At admission mean level of LII were 3.82 (from11.2 to 0.47) At 5e7 day after the surgical treatment LII normalized (mean 1.0)All patients recovered well and were discharged from hospital in satisfactory conditions. Conclusions: Preoperetive diagnosis of Myrizzi syndrome is difficult task. Combination of anamnesis of current disease, length of cholecystitis, and results of ultrasonography(size of gallbladder, presence of gallstones in neck area) reflects high possibility of significant changes in Calot triangle. Open approach safe and effective especially for patients with type 3-4 Mirizzy. We recommend length of postsurgical in-hospital stay at 5e7 days, as the time for normalization of basic parameters.
PubMed, Mar 1, 2017
Background: Hypercalcemia in association with hyperthyroidism is a well-recognized phenomenon. Pr... more Background: Hypercalcemia in association with hyperthyroidism is a well-recognized phenomenon. Primary hyperparathyroidism due to parathyroid adenoma in association with thyroid adenoma is extremely rare. These cases can present a diagnostic and therapeutic challenge to the treating physician as the patient may present with symptoms of either disease. Case summary: A 47-year-old female patient presented with non-specific complaints including fatigue and muscle cramps. Diagnostic workup revealed significantly elevated plasma calcium levels in association with hyperthyroidism. There was a considerable delay in measuring the parathyroid hormone levels which were significantly elevated. Nuclear medicine studies revealed features consistent with a parathyroid adenoma and a concurrent thyroid adenoma. The patient was rendered euthyroid and subsequently taken to theatre for a thyroid lobectomy and removal of the associated parathyroid adenoma. One year later the patient remains normocalcemic, euthyroid and clinically well. Conclusion: Toxic thyroid adenoma with concurrent parathyroid adenoma and primary hyperparathyroidism is rare. The possibility of primary hyperparathyroidism should be considered where hypercalcemia persists on correcting the hyperthyroidism. Removal of both adenomas will result in cure of the patient.
International Surgery Journal, May 24, 2018
Background: Oesophageal carcinoma continues to be a major cause of cancer related deaths worldwid... more Background: Oesophageal carcinoma continues to be a major cause of cancer related deaths worldwide. Metal stents are an established treatment option for palliation of dysphagia. These stents are classically deployed using endoscopy with fluoroscopic control. An alternative technique is using the paediatric endoscope. Methods: The study is a retrospective review of all cases of esophageal stenting at Dr George Mukhari Academic Hospital, Pretoria, South Africa were included. A prospectively maintained database Olympus Endobase ® is used in the endoscopy suite. All cases between March 2015-February 2018, where the oesophagus was stented were reviewed. Cases where the paediatric scope was used were analysed further. Data captured from the database included demographics, tumour length, the presence of trahceoesophageal fistula. Results: A total of 233 patients were stented, the paediatric scope was used in 217. The procedure was successfully completed in 84,7% of the patients. Repeat stenting was required in 20 patients. The mean age was 57 years (32-97). Average length of the stricture 9,6cm (5-15cm). The reasons for palliation were patient unfit for surgery (n=159), associated TOF (n=15), unspecified (n=38). The reasons for repeat stenting were stent migration (n=5), tumour overgrowth (n=10) and blocked stent (n=5). Complications were recorded in 1 case where an iatrogenic perforation was caused which was successfully stented. In the 33 cases that failed the reason for failure was inability of the scope to negotiate the stricture. These cases were subsequently completed successfully using a guidewire with fluoroscopy. There was no periprocedural mortality. Conclusions: It is safe and feasible to use the paediatric endoscope to stent tumours of the oesophagus. If the procedure is successful it prevents the exposure of the staff and the patient to radiation. It ensures reliable placement of the guidewire into the stomach as well as confirming appropriate positioning of the stent.
Journal of Laparoendoscopic & Advanced Surgical Techniques, Oct 1, 2018
Laparoscopic common bile duct exploration (LCBDE) is used to treat choledocholithiasis. Flexible ... more Laparoscopic common bile duct exploration (LCBDE) is used to treat choledocholithiasis. Flexible choledochoscopy is usually performed; however, this instrument is fragile and liable to breakage. Data were collected and reviewed retrospectively from a prospectively maintained database. All cases of attempted LCBDE with the rigid ureteroscope at the institution since January 2014 were included. Demographic characteristics, preoperative attempted endoscopic retrograde cholangiopancreatography (ERCP), size of the bile duct, findings at laparoscopy, use of drain or T-tube, conversions, and morbidity or mortality were documented. A total of 37 patients were identified. The median age was 51 years (32-71). The male to female ratio was 1:5. Twenty-eight patients had failed ductal clearance at ERCP (75.7%). The mean common bile duct (CBD) diameter was 11.4 mm (10-13.5). There were five conversions. Cirrhosis in 2 patients, bleeding in 1 patient, impacted stone in 1, and equipment failure in 1. T-tubes were placed in 5% of cases. N = 8 (21.6%) of the patients had a Mirizzi syndrome. Average hospital stay was 4 days (3-7). Two patients had complications postoperatively-bleeding and collections. LCBDE using the rigid ureteroscope is feasible. It can be performed with acceptable morbidity. Use of the rigid ureteroscope represents a good alternative to the flexible choledochoscope with high duct clearance rates. One disadvantage is cirrhosis where the scope may not be negotiated into the CBD due to a stiff liver. It is a viable option when preoperative ERCP has failed to clear the CBD.
International Surgery, Jul 1, 2018
Background: Laparoscopic appendectomy for complicated appendicitis presents a challenge with conc... more Background: Laparoscopic appendectomy for complicated appendicitis presents a challenge with concerns about pelvic collections. It is unclear whether lavage or if simple suctioning of pus influences complications. Methods: A prospective, single,-blinded, randomized control trial was conducted. Patients with suspected acute appendicitis were consented. Those found to have complicated appendicitis (perforation, localized pus, or four-quadrant pus) at laparoscopy were randomized to suction or lavage. Exclusions included conversions and drainage of abscess only. Lavage consisted of 3 liters of lavage. Intra-abdominal abscess that required reintervention (i.e., relook, percutaneous drainage) was the primary outcome. Hospital stay and return of bowel function were also recorded. Results: A total of 213 patients were assessed for eligibility. We excluded 157 patients, as they had simple appendicitis; 7 patients were converted to laparotomies; 5 had abscesses but the appendix was not removed. We analyzed 86 patients. The mean age was 26.6 years (14-74). We lavaged 42 (48.8%) patients and 44 (51.2%) were suctioned. Four-quadrant pus was present in 26 (30.2%) of the patients overall. Complications developed in 20 (47.5%) of the patients that were lavaged versus 12 patients (27.1%) with suction only. The difference did not reach significance due to sample size (P ¼ 0.0739). Operative time was longer in the lavage group by 30 minutes (P ¼ 0.086). If a complication developed, then the hospital stay was significantly prolonged 13.5 days versus 5 days (P , 0.001). The study was stopped by the internal review board due to the excess risk with lavage. Conclusions: This exploratory study into lavage versus suction only in complicated appendicitis revealed potential harm with lavage. The study was stopped prematurely by
Annals of Hepato-Biliary-Pancreatic surgery, Apr 30, 2022
Background: The evolution of management of hepatic trauma has followed a course from mandatory ex... more Background: The evolution of management of hepatic trauma has followed a course from mandatory exploration for all patients to selective non-operative management and presently, to non-operative management with selective operation. There is, however, in specialized referral centers in countries with a high volume of trauma and limited access to facilities such as interventional radiology, still a role for major surgical resection in the management of the complex grades of liver injury. We report on our experience in a tertiary academic hospital in South Africa. Methods: A retrospective analysis of all patients with liver injuries following trauma (blunt and penetrating) at a single referral center (Dr. George Mukhari Academic Hospital) was performed. The data was obtained from a prospectively maintained database from January 2018 till November 2021. Data on identified patients was analyzed for demographic information, mechanisms of injury, associated injuries, hemodynamic stability on presentation, need for damage control surgery, overall management route (nonoperative vs. operative), and outcome. All complications were analyzed and reported using the Clavien-Dindo scoring system. Results: A total of 212 patients were managed at our center over the 4-year period. There were 57 blunt trauma patients (27%) and 155 penetrating trauma patients (73%). Non-operative management rate was 75% in blunt group vs. 7% in penetrating group. Those patients who were managed operatively, 90% had associated injuries, 55% had liver injuries that could be managed by simple measures (diathermy and suturing) and 45% had high grade injuries that required more complex maneuvers (hepatotomy and vessel ligation, resectional debridement, lobar resection, perihepatic packing and relaparotomy, hepatic isolation). Overall mortality was 15% and was highest in the blunt injury group (20%) compared to penetrating trauma. Complications occurred in 72 (41%) out of 181 surviving patients. The complications correlated with the type and severity of the injuries (19% in stab wounds, 49% in gunshot wounds and 55% in blunt trauma) as well as with the number of associated injuries. Conclusions: The management of complex liver injuries often requires advanced surgical techniques. This is especially the case in our setting where there is limited access to interventional radiology thus increasing the need for definitive surgical management of these patients. Surgical management of complex liver injuries is feasible in our setting and demonstrates a unique challenge with a unique solution.
Annals of Hepato-Biliary-Pancreatic surgery, Apr 30, 2022
Background: ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) i... more Background: ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) is becoming more established for the management of colorectal liver metastases where a future liver remnant is not deemed sufficient. Our institute has expanded into performing the challenging procedure laparoscopically. Methods: A retrospective analysis of all consecutive patients undergoing ALPPS at a single referral center (Dr. George Mukhari Academic hospital) for colorectal liver metastases with a small future liver remnant was performed using a prospective database from January 2020 till August 2021. Feasibility was assessed by analysis of conversions. The 90-day mortality and complications were analyzed using the Clavien-Dindo scoring system. Operative time, blood loss, volumetric growth and hospital stay were all studied. Results: Laparoscopic ALPPS was performed in 3 patients. There was no mortality and no complication grade greater than IIIb was observed. One patient required a relook laparoscopy for sepsis at the site of the liver partition. Liver failure was not observed in any of the patients. The average hospital stay was 20 days. Conclusions: Laparoscopic ALPPS is a feasible procedure in patients with colorectal liver metastases and a small future liver remnant. It is a complex procedure requiring significant resources and skill, but it is definitely feasible within the South African setting.
International Journal of Surgery Open, 2018
The use of self expanding metals stents (SEMS) is established for management of left sided coloni... more The use of self expanding metals stents (SEMS) is established for management of left sided colonic obstruction. Its use for right sided malignant colonic obstructing (RMCO) tumours is less established with risks related to perforation of the colon. The use of a right sided colonic stent can be used to decompress the colon or small bowel and facilitate subsequent laparoscopic resection. A 68 year old gentleman presented with a history of right upper quadrant pain associated with fever, chills, loss of weight and abdominal distention. Examination revealed a tender right upper quadrant mass, workup revealed an empyema of the gallbladder with an associated colonic mass. The sepsis was controlled via percutaneous transhepatic cholecystomy and subsequent colonscopy revealed an obstructing hepatic flexure colonic tumour and multiple large left sided colonic polyps not amenable to snare excision. This tumour was stented at endoscopy under fluoroscopic control. The patient was taken to theatre and a laparoscopic subtotal colectomy with complete mesocolic excision and en bloc cholecystectomy was performed. In this case report, we demonstrate the use of SEMS for RMCO as a bridge for laparoscopic subtotal colectomy in a patient with right sided colonic cancer. This case also presented a unique challenge with the associated gallbladder empyema due to cystic duct obstruction. The stenting for RMCO and subsequent laparoscopic subtotal-colectomy was performed successfully for this patient, showing promise in the future utility of SEMS placement in RMCO. This report therefore adds to increasing evidence that emphasize the viability of SEMS in RMCO as a bridge to laparoscopic surgery for more proximal obstructions. According to our literature search, this is the third reported case of laparoscopic colectomy following SEMS for RMCO.
International Journal of Surgery Open, 2016
Penetrating injury due to gunshot wounds is a common problem seen in trauma centres around South ... more Penetrating injury due to gunshot wounds is a common problem seen in trauma centres around South Africa. Gunshot wounds can injure organs directly or may cause indirect injury. The temporary cavity is responsible for injury to organs distant to the wound tract. Organs with higher density such as bone or liver are more prone to injury due to the temporary cavity. Presentation of case: A 25 year old male patient sustained a gunshot wound to the right lower chest from a handgun. He was haemodynamically and metabolically stable with no evidence of peritonitis. CT scan of the abdomen revealed a Grade 2 injury of the liver. There was subcutaneous emphysema along the tract of the bullet. No injury to the lung or pleura was reported. The patient was explored laparoscopically to rule out diaphragmatic injury. At exploration the peritoneum was not breeched but the liver had a grade two laceration caused by an indirect ballistic injury Discussion: Penetrating trauma to the right lower chest can potentially injure multiple organs. CT scan can reliably diagnose the bullet tract as well as solid organ injuries. In this case the diaphragm was contused and the liver was lacerated by energy created by the temporary cavity. The difference in severity of the injury of these organs is related to the pliability of the tissue. Conclusion: Gunshot wounds can injure organs directly as well as those located close to the bullet tract. These injuries may be found in adjacent cavities not traversed by the bullet. A high index of suspicion, as well as imaging, is important to diagnose and grade these injuries. The possibility of indirect ballistic injury should always be kept in mind when managing patients with gunshot wound even in the lower velocity handgun injuries.
Annals of Hepato-Biliary-Pancreatic Surgery
Background: ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) i... more Background: ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) is becoming more established for the management of colorectal liver metastases where a future liver remnant is not deemed sufficient. Our institute has expanded into performing the challenging procedure laparoscopically. Methods: A retrospective analysis of all consecutive patients undergoing ALPPS at a single referral center (Dr. George Mukhari Academic hospital) for colorectal liver metastases with a small future liver remnant was performed using a prospective database from January 2020 till August 2021. Feasibility was assessed by analysis of conversions. The 90-day mortality and complications were analyzed using the Clavien-Dindo scoring system. Operative time, blood loss, volumetric growth and hospital stay were all studied. Results: Laparoscopic ALPPS was performed in 3 patients. There was no mortality and no complication grade greater than IIIb was observed. One patient required a relook laparoscopy for sepsis at the site of the liver partition. Liver failure was not observed in any of the patients. The average hospital stay was 20 days. Conclusions: Laparoscopic ALPPS is a feasible procedure in patients with colorectal liver metastases and a small future liver remnant. It is a complex procedure requiring significant resources and skill, but it is definitely feasible within the South African setting.
Annals of Hepato-Biliary-Pancreatic Surgery
Background: The evolution of management of hepatic trauma has followed a course from mandatory ex... more Background: The evolution of management of hepatic trauma has followed a course from mandatory exploration for all patients to selective non-operative management and presently, to non-operative management with selective operation. There is, however, in specialized referral centers in countries with a high volume of trauma and limited access to facilities such as interventional radiology, still a role for major surgical resection in the management of the complex grades of liver injury. We report on our experience in a tertiary academic hospital in South Africa. Methods: A retrospective analysis of all patients with liver injuries following trauma (blunt and penetrating) at a single referral center (Dr. George Mukhari Academic Hospital) was performed. The data was obtained from a prospectively maintained database from January 2018 till November 2021. Data on identified patients was analyzed for demographic information, mechanisms of injury, associated injuries, hemodynamic stability on presentation, need for damage control surgery, overall management route (nonoperative vs. operative), and outcome. All complications were analyzed and reported using the Clavien-Dindo scoring system. Results: A total of 212 patients were managed at our center over the 4-year period. There were 57 blunt trauma patients (27%) and 155 penetrating trauma patients (73%). Non-operative management rate was 75% in blunt group vs. 7% in penetrating group. Those patients who were managed operatively, 90% had associated injuries, 55% had liver injuries that could be managed by simple measures (diathermy and suturing) and 45% had high grade injuries that required more complex maneuvers (hepatotomy and vessel ligation, resectional debridement, lobar resection, perihepatic packing and relaparotomy, hepatic isolation). Overall mortality was 15% and was highest in the blunt injury group (20%) compared to penetrating trauma. Complications occurred in 72 (41%) out of 181 surviving patients. The complications correlated with the type and severity of the injuries (19% in stab wounds, 49% in gunshot wounds and 55% in blunt trauma) as well as with the number of associated injuries. Conclusions: The management of complex liver injuries often requires advanced surgical techniques. This is especially the case in our setting where there is limited access to interventional radiology thus increasing the need for definitive surgical management of these patients. Surgical management of complex liver injuries is feasible in our setting and demonstrates a unique challenge with a unique solution.
South African journal of surgery. Suid-Afrikaanse tydskrif vir chirurgie, 2017
BACKGROUND Hypercalcemia in association with hyperthyroidism is a well-recognized phenomenon. Pri... more BACKGROUND Hypercalcemia in association with hyperthyroidism is a well-recognized phenomenon. Primary hyperparathyroidism due to parathyroid adenoma in association with thyroid adenoma is extremely rare. These cases can present a diagnostic and therapeutic challenge to the treating physician as the patient may present with symptoms of either disease. CASE SUMMARY A 47-year-old female patient presented with non-specific complaints including fatigue and muscle cramps. Diagnostic workup revealed significantly elevated plasma calcium levels in association with hyperthyroidism. There was a considerable delay in measuring the parathyroid hormone levels which were significantly elevated. Nuclear medicine studies revealed features consistent with a parathyroid adenoma and a concurrent thyroid adenoma. The patient was rendered euthyroid and subsequently taken to theatre for a thyroid lobectomy and removal of the associated parathyroid adenoma. One year later the patient remains normocalcemic...
Anaesthesia, 2021
SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this stu... more SummaryPeri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery wi...
Anaesthesia, 2021
SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critica... more SummarySARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism. We conducted a planned sub‐study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS‐CoV‐2 diagnosis was defined as peri‐operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre‐operative anti‐coagulation for baseline comorbidities was no...
International Surgery, 2019
Background: Laparoscopic appendectomy for complicated appendicitis presents a challenge with conc... more Background: Laparoscopic appendectomy for complicated appendicitis presents a challenge with concerns about pelvic collections. It is unclear whether lavage or if simple suctioning of pus influences complications. Methods: A prospective, single,-blinded, randomized control trial was conducted. Patients with suspected acute appendicitis were consented. Those found to have complicated appendicitis (perforation, localized pus, or four-quadrant pus) at laparoscopy were randomized to suction or lavage. Exclusions included conversions and drainage of abscess only. Lavage consisted of 3 liters of lavage. Intra-abdominal abscess that required reintervention (i.e., relook, percutaneous drainage) was the primary outcome. Hospital stay and return of bowel function were also recorded. Results: A total of 213 patients were assessed for eligibility. We excluded 157 patients, as they had simple appendicitis; 7 patients were converted to laparotomies; 5 had abscesses but the appendix was not remove...
HPB, 2016
Methods: Surgical treatment performed at 17 patients with Mirizzi symdrome in period of five year... more Methods: Surgical treatment performed at 17 patients with Mirizzi symdrome in period of five years. Mean age of 62.9 years(40 to 83 years) Main parameters(clinical changes, lab results,sonography) were evaluated. Results: According to the Csendes classification : type I-7 patients-(41.0%)type II-2 (11.8%)type III-6(35.4%)type IV-2(11.8%).Laparoscopy as a first step of surgical treatment was performed at 5 patients with Mirizzi syndrome type I-II. At 8 patients open cholecystectomy was performed. At 6 patients-cholecystectomy with drainage of bile ducts, and at 3 patients-cholecystectomy and hepaticojejunostomy(all with type 3 Mirizzy. In cases with significant defect of common bile duct we performed reconstruction or partial(2 cases) cholecystectomy.Concomitant and related surgical pathology (at 8 cases gangrenous cholecystitis with local peritonitis, 1 case-liver abscess, 1 case-multiple liver abscesses, 1 case of combination of cholecystocholedocheal and cholecysto-duodenal fistula) provide significant impact on type of treatment and process of recovery. Leukocytic index of intoxication by Kalf-Kalif(LII) measured at all patients, RR-0.51-2.1. At admission mean level of LII were 3.82 (from11.2 to 0.47) At 5e7 day after the surgical treatment LII normalized (mean 1.0)All patients recovered well and were discharged from hospital in satisfactory conditions. Conclusions: Preoperetive diagnosis of Myrizzi syndrome is difficult task. Combination of anamnesis of current disease, length of cholecystitis, and results of ultrasonography(size of gallbladder, presence of gallstones in neck area) reflects high possibility of significant changes in Calot triangle. Open approach safe and effective especially for patients with type 3-4 Mirizzy. We recommend length of postsurgical in-hospital stay at 5e7 days, as the time for normalization of basic parameters.
International Journal of Surgery Open, 2016
Penetrating injury due to gunshot wounds is a common problem seen in trauma centres around South ... more Penetrating injury due to gunshot wounds is a common problem seen in trauma centres around South Africa. Gunshot wounds can injure organs directly or may cause indirect injury. The temporary cavity is responsible for injury to organs distant to the wound tract. Organs with higher density such as bone or liver are more prone to injury due to the temporary cavity. Presentation of case: A 25 year old male patient sustained a gunshot wound to the right lower chest from a handgun. He was haemodynamically and metabolically stable with no evidence of peritonitis. CT scan of the abdomen revealed a Grade 2 injury of the liver. There was subcutaneous emphysema along the tract of the bullet. No injury to the lung or pleura was reported. The patient was explored laparoscopically to rule out diaphragmatic injury. At exploration the peritoneum was not breeched but the liver had a grade two laceration caused by an indirect ballistic injury Discussion: Penetrating trauma to the right lower chest can potentially injure multiple organs. CT scan can reliably diagnose the bullet tract as well as solid organ injuries. In this case the diaphragm was contused and the liver was lacerated by energy created by the temporary cavity. The difference in severity of the injury of these organs is related to the pliability of the tissue. Conclusion: Gunshot wounds can injure organs directly as well as those located close to the bullet tract. These injuries may be found in adjacent cavities not traversed by the bullet. A high index of suspicion, as well as imaging, is important to diagnose and grade these injuries. The possibility of indirect ballistic injury should always be kept in mind when managing patients with gunshot wound even in the lower velocity handgun injuries.
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Papers by imraan sardiwalla