Surgical Treatment of Victims With Gunshot Shrapnel Wounds to the Liver Under Martial Law Conditions

Introduction. In the structure of modern combat abdominal trauma, the proportion of gunshot wounds to the liver is increasing, which are accompanied by the development of severe bleeding, traumatic disease and high mortality. According to modern authors, liver damage in penetrating gunshot shrapnel wounds to the abdomen is 22.4% of the total number of injuries, and mortality varies from 13% to 28%. After severe liver trauma, cholecystitis can become a complex problem, which will require multidisciplinary step-by-step treatment. Damage to the extrahepatic biliary tree and gallbladder is the most common consequence of liver trauma and can be observed in 13% of patients. Materials and Methods of the study. The results of treatment of 43 patients with explosive injuries who had penetrating gunshot wounds to the abdomen with massive liver damage were analyzed. Among the patients, 20 (46.5%) were women, 23 (53.5%) were men. The age of the patients ranged from 27 to 75 years. Results of the study and discussion. In the structure of injuries, only 2 (4.65%) patients had isolated liver injury, the rest – 41 patients (95.35%) – had combined and multiple injuries. The classification of the American Association for the Surgery of Traumatology (AAST) was used to determine the degree of liver damage. The study included patients with AAST grade II-IV liver injury. The extent of each surgical intervention depended on the specific clinical situation, without violating the “Damage control surgery” tactic. In all cases, laparotomy and dense liver tamponade after manual compression were performed. Bile leakage was diagnosed in 15 (34.88%) patients on the 3rd-6th postoperative day. The daily output in this category of patients ranged from 350 ml to 700 ml. Patients in this group underwent endoscopic retrograde cholangiopancreatography to determine the condition of the biliary tract, as well as endoscopic papillosphincterotomy with subsequent stenting of the common bile duct for the purpose of biliary decompression. Of the 15 patients, 1 developed bleeding from the papillotomy wound, and 3 had clinical and laboratory signs of acute pancreatitis. Conclusions. The scope of surgical intervention for gunshot wounds to the liver should be aimed primarily at ensuring hemostasis with minimal risk to the victim’s life. Endoscopic interventional techniques are a useful diagnostic and surgical tool for the safe treatment of bile duct lesions after severe liver injury and should be part of a multidisciplinary treatment algorithm.