The operative management of penetrating injury by pulmonary tractotomy with selective vascular ligation has been well described. We report a case of stapled tractotomy resulting in contralateral lung collapse.
The patient, a 19 year old male, sustained multiple gunshot wounds: four head and neck and four chest wounds. He had shortness of breath, bilateral decreased breath sounds, GCS 14, BP 130/82, pulse 140 and respirations 26. Bilateral chest tubes were placed and he was emergently intubated. The abdomen was soft and nontender, FAST examination was negative twice and Hg levels were stable.Total left sided output increased to 1400 cc and head CT was aborted and he was taken to the OR. A diaphram laceration, two lower lobe injuries and a central anterior segment injury were found at left thoracotomy. Bullet tracts were divided with a GIA stapler and bleeding pulmonary vessels were oversewn. No residual airleak or bleeding was observed. Laparotomy was performed with splenectomy and repair of injuries to the stomach, colon, jejunum, duodenum and ureter.The patient returned to the SICU with a temperature of 34.1 °C and a pH of 7.19 and was placed on a high frequency percussive ventilator. Soon thereafter, the airleak increased and oxygen saturation decreased and bedside bronchoscopy confirmed proper ETT position and demonstrated no active bleeding. Desaturation persisted and the patient was returned to the OR. Chest exploration was negative and oxygen saturation dropped further prompting right thoracotomy showing total lung collapse. Anatomical left upper lobe resection was performed and bronchoscopy cleared the airway and oxygenation and ventilation improved.DISCUSSION: Nearly 80% of penetrating lung injuries can be treated with chest tube and observation alone. The remaining 20% of penetrating lung injuries require operation. In the past, this meant formal anatomical lung resection. However, with the advent of stapled tractotomy, 80% of operative lung injuries can be managed without formal lung resection.1Wall outlines the application of stapled tractotomy.1 In general, it is unacceptable to simply oversew the entrance and exit lung wounds as this may lead to a large intrapulmonary hematoma, infection, abcess, life threatening air-embolism and persistant airleak and difficulty ventilating. The technique of tractotomy is non-anatomical and is dictated by the bullet trajectory. Adequate arterial and venous collateral circulation allows the lung to remain viable and functional. The goal is to expose and ligate injured broncheoles and deep bleeding vessels and preserve lung and avoid formal lobe resection or pneumonectomy. Uncontrolled bleeding can result in internal blood aspiration and difficulty ventilating. Wall recommends using tractotomy only for wounds located from one half to two thirds centrally toward the hilum.1 Once the tract is opened the hilar structures should be inspected to assure that formal resection is not needed.1In this case, inspection revealed no major bronchial or pulmonary vascular compromise such that formal resection was not initially done. However, as is pointed out by Richardson, superficial suturing of parenchymal lung wound, as in the edges of the tractotomy, may only stop bleeding externally and can inadvertently convert the bleeding to an endobroncheal nature.2 He advises that the endobrocheal tube be carefully suctioned before the end of the operation to ensure that internal bronchial bleeding has not occurred.2
Application of stapled tractotomy to central lung injuries is potentially dangerous as this case demonstrates. Unrecognized intra-broncheal bleeding can occur.
E.J. Kuncir, None.