Gunshot bullet blind penetrating wound to the chest with damage to the mediastinum and thymus (a clinical case)

Abstract

Background. In modern military conflicts, the frequency of gunshot wounds to the chest is 8–12 %, of which 79.4 % are nonpenetrating, and 20.4 % are penetrating, with damage to intrathoracic organs. The aim is to demonstrate the peculiarities of diagnosis and operative treatment of a penetrating gunshot wound to the chest with damage to the mediastinum and thymus. Materials and methods. Patient M., 33 years old, was wounded to the chest during mortar shelling. An hour after the injury, he was taken to the frontline surgical team in a satisfactory condition, a chest X-ray was performed. After 4 hours, he was taken to the Military Medical Clinical Center of the Northern Region of the Medical Forces Command and hospitalized to the emergency department. The diagnosis was made of an isolated gunshot bullet blind penetrating wound to the chest with damage to the mediastinum and the presence of a foreign body (bullet) in the area of the aortic arch. Results. Data of chest multislice computed tomography upon admission: a 5.45 mm caliber bullet in the anterosuperior mediastinum at the level of the aortic arch. A video esophagogastroduodenoscopy was performed, damage to the esophagus was ruled out. Sternotomy was performed. A foreign body (bullet) was removed from the thymus with a magnetic instrument under the control of an electronic-optical converter, drainage of the sternotomy wound was performed. The final diagnosis was established: an isolated gunshot bullet blind penetrating wound to the chest with damage to the mediastinum and the presence of a foreign body (bullet) in the thymus. On day 3 after surgery, the drainage was removed from the mediastinum. Subsequently, after 2 weeks, the stitches were removed, the patient was presented to the military medical commission and discharged from the hospital. During the histological examination of a fragment of the thymus tissue, a large hemorrhage, fullness of venous vessels, phenomena of involution and transformation into adipose tissue were revealed. Conclusions. Gunshot wounds to the chest with mediastinal injury are rare. The use of modern magnetic surgical instruments allows the removal of ferromagnetic foreign bodies in case of mediastinal trauma. When choosing the scope of primary surgical treatment of the thymus wound, it is necessary to consider its role in providing the immune system and apply an organ-sparing approach.