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Please opine: A Trauma Case

navin goyal drnavingoyal at yahoo.co.in
Wed Jun 11 08:05:14 BST 2008

A middle age man  to the Emergency h/o RTA on 18.05.08 . Patient
was irritable on admission, with hematoma over right Eye , tachycardiac  ,
maintaining Blood pressure , and oxygen saturation over 90%. Patient was
investigated and C T scan of head , chest and abdomen was done. CT scan showed
depressed # frontal bone, Liver Laceration and hemoperitoneum . Patient was
initially resuscitated and conservative management was planned. He still had tachycardia and later on his
urine outoput decreased. Considering his decreasing urine output and non
resolving tachycardia he was taken for Surgery. On Opening the abdomen 2 liters
of hemoperitoneum was found and there was perforation in the jejunum. No fresh
bleeding from the liver was found . Perforation was repaired in layers. Frontal
wound was debrided , depressed fracture was elevated , sinus bleeding was
occluded with surgicell / Gelfoam.


 Patient had normal
recovery from these surgeries however urine Output decreases to nil. Service of
Nephrologists was taken and patient was kept on hemodialysis. 


 However three days
thereafter patient showed increase in the abdominal girth , illeus and
distension with pus which was not fecal smelling coming out from the drain site.
Patient was again taken up for the laprotomy and on opening gut was found
edematous and distended , some pus pockets were found in the abdominal cavity ,
which were cleaned. 


Later after two days patient had bilious leak from the
abdominal wound, this fluid was sent for biochemistry which showed very high
level of amylase and Lipase . Suspecting leak from the intestine patient was
again explored on 5 th day post surgery and this time he had two perforations in the ileum. One site was
in the distal ileum and another at 1 feet distal to the previous jejunal perf
site.  No leak was present from the
previous sutured site, . Proximal perforation which was
small  about 1 cm size , and at
mesenteric border was repaired.  Illeostomy
was taken out from the site of distal perforation. Abdominal cavity was
thoroughly lavaged and abdomen closed.


Patient’s drain again showed bilious fluid coming from the
peritoneal cavity through the drain on the third day . Illeostomy was showing minimal function.
On  exploring the
abdomen , a new perforation near the previously sutured jejunal perforation at
the mesentric border was found  and another from the previously sutured site in jejunum.  . Since the new
perforation was very close to the jejunal repaired , part was resected and re
anastomosis was done . . Abdomen was closed via
tension wiring  . 


Four  days after the surgery patient again showed leak form
the wound site . 

At present , illeostomy is showing minimal to moderate
function with , fistula fluid leaking from the wound site. Patient kidneys are
still not functional and he is requiring hemodialysis support. . He is managed
conservatively and is fed through RT @ 150 ml 2 hrly.He is requiring minimal
ventilator support in the form of pressure support. He is conscious , Some leak
of CSF fluid is present from the frontal wound. Parentral Nutrition is being
added to support the patient. Lower part of the abdominal wound has been opened up to allow the fistula to drain out. Over a week has passed , fistula is showing no sign of decrease.

What should be the next stratergy for this patient?Any explaination or suggestion for new developing perforation in the mesentric border of the intestine?


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