Migration of foreign bodies through the digestive tract after gunshot shrapnel blind facial wound with partial destruction of the maxillary bridge prosthesis

Migration of foreign bodies through the digestive tract after gunshot shrapnel blind facial wound with partial destruction of the maxillary bridge prosthesis

Russia's large-scale invasion of Ukraine has led to a significant increase in the number of people with gunshot wounds and foreign bodies (FB) in various anatomical areas [1][2][3].Due to the functioning of the muscles and, accordingly, the motor activity of the injured person, foreign bodies can migrate through fascial sheaths and between muscle fibres, and if they enter the digestive tract, they move through it with a peristaltic wave.However, reports of CT migration in the medical literature are rare and usually refer to paediatric practice [4][5][6].
In the case of migration of STs, it is necessary to control their condition and movement, which is aimed at preventing the development of complications, in particular, in the case of STs of the digestive tract, perforation of the wall of the hollow organ, bleeding or peritonitis [7,8].
Given the low frequency of migration of STs of gunshot origin, the treatment of each such patient is a challenge for the surgeon and requires a personalised approach.Here is a clinical observation.
Patient L., 53 years old, was wounded wearing body armour and a helmet at around 9 o'clock as a result of enemy artillery shelling.He was taken to the advanced surgical team of one of the military mobile hospitals 1 hour after the injury, where he underwent general blood and urine tests, Xray of the head, abdomen and left thigh, and primary surgical treatment of gunshot wounds to the face and left thigh.
He was diagnosed with a combined gunshot shrapnel wound to the head and lower limb; blunt force trauma to the soft tissue of the nasolabial region on the right; blunt force trauma to the soft tissue of the left thigh.
After 24 hours, he was taken to the Military Medical Clinical Centre of the Northern Region for further examination and treatment, where he was examined.He was found to have a sutured wound of 1.5 0.5 cm in the nasolabial area on the right and 4.0 2.0 cm wounds on the anterior surface of the middle third of the left thigh.
Spiral computed tomography (SCT) of the head, chest and abdomen was performed (on a Toshiba Activion 16 with a tomographic step of 0.5 mm), radiography of the left thigh (KRD-50 "INDiascar-01").Based on the results of the SCT analysis, fibrocolonoscopy was performed (OLYMPUS CV-170).The patient was examined by a dentist.

The Ukrainian Journal of Clinical Surgery
Head radiograph (Fig. 1) revealed partial destruction of the fixed metal-ceramic bridge prosthesis of the right upper jaw.No bone-traumatic changes were detected on the X-ray of the left thigh.
Abdominal CT scan revealed CTs of 1.0 0.8 cm, 1.2 0.4 cm and 4 small ones up to 0.4 cm in the largest dimension of metal density in the lumen of the cecum and CTs of 1.5 1.2 cm pararectally on the left (Fig. 2).
The results of fibrocolonoscopy showed no evidence of intestinal damage.
The diagnosis was made: combined gunshot shrapnel wound to the head and lower limb; blunt wound to the nasolabial area on the right with partial destruction of the upper jaw bridge; migration of metal density CT through the digestive tract with their presence in the lumen of the cecum; blunt wound to the soft tissues of the left thigh with a foreign body (metal fragment) pararectally on the left.
The next day, he underwent surgery under general anaesthesia to remove the CT (metal fragment) located pararectally on the left, and a control X-ray of the abdominal cavity, which revealed the CT in the lumen of the cecum.
It should be noted that there was no history of gunshot wounds of the abdomen and adjacent areas, the abdomen was painless during the examination, and there were no peritoneal symptoms.Given the absence of data on intestinal perforation, we continued to observe the migration of CT along the course of the digestive tract (Fig. 3).
Within 3 days after the injury, fragments of the fixed metal-ceramic bridge prosthesis of the upper jaw migrated along the alimentary canal and came out during defecation (on the 3rd and 5th day, respectively).On the 5th day, a control radiography of the abdominal cavity was performed, and there was no evidence of the presence of CT in the lumen of the colon and rectum.
The patient was transferred for staged treatment to one of the territorial bases, and later discharged on the 16th day after his injury.
Clinical observation is interesting due to the fact of migration of CT in the form of a metal fragment and fragments of a fixed bridge-like metal-ceramic prosthesis of the upper jaw through the digestive tract without corresponding clinical manifestations.Dynamic monitoring of the patient allowed treatment without surgical intervention in the digestive tract, which does not contradict the literature [7,8].CT in the lumen of the cecum is detected.

Fig. 1 .
Fig. 1.Radiograph of the head of patient L., 53 years old, on the 1st day after injury: defect of the fixed bridgework of the upper jaw on the right.

Fig. 2 .
Fig. 2. Screenshots of abdominal organs of patient L., 53 years old, on the 2nd day after injury: fragment and small remnants of a fixed metal-ceramic bridge prosthesis of metal density in the lumen of the cecum and CT (metal fragment) measuring 1.0 0.8 cm (A -coronal projection; B -3D reconstruction).

Fig. 3 .
Fig. 3.Control radiography of the abdominal cavity of patient L., 53 years old, on the 3rd day after injury:CT in the lumen of the cecum is detected.