If i encounter a case of gunshot with a foreign body in the chest and the patient is stale after chest tube drainage shall i remove the bullet?
This problem was studied extensively during and after WWII. Still, if there is no specific complication, e.g., hemoptysis, bronchial obstruction, infection, it may be left alone and simply observed over the years. Certainly, I would not operate shortly after the chest tubes were removed, assuming none of the above complications.
Dear Sameh -- I will surely go along with Prof. James Pete - because - all efforts by all doctors in this world is to save a life and never attempt to cause a threat to any human life --- UNLESS the condition is earned by the patient with any complications of the foreign body in the lung. Thanks
The exception would be if it is a shotgun pellet or a small bullet fragment which is close enough to a large vessel (pulmonary vein) to embolise to the heart. Even in the Right heart, it may remain benign and be left alone and observed. However, it is necessary to ensure via echo that there is no septal defect by which it could possibly enter the left heart. Obviously, a shotgun pellet or small bullet fragement in the left heart is an entirely different prospect. The potential for arterial embolisation to a critical area (carotids or gut vessels or even limb vessels) would mandate retrieval via opening the chest and heart. Kind regards, Paul
THANKS A LOT PROF. James Pate , Dr. Tajudeen Abdul Hameed and DR Paul Rickards.
I agree, the retrieval of bullets is something endorsed by American entertainment television and motion pictures, rarely is there a true indication to remove intrathoracic bullets. One caveat is Shotgun bullet blasts with lead shot - an attemot to debride/debulk some lead nay be indicated as lead poisoning has been reported in the literature in certain cases.
Dear Dr Sameh
the indications for removal the retained FB in the thoracic cavity particularly the bullet or sharp object depends on the size (1.5 cm or more), the location (relations to vital structure e.g heart or great vessels..) presence of another indication of thoractomy and the complications. the other indication which is the main indication in my hundred cases is the patient's preference due to psychological factor ( they are fearing from FB inside the chest and the possible complications especially in the patients of rural areas in which the close follow-up is difficult or costly.
Dear Sameh,
more than 99% of all projectiles leave the thoracic cavity they have entered before. As lung tissue, which comprised the largest target area of the chest, is of low density, only few projectiles loose their small final energy and get stuck within the soft tissues. The thoracotomy rate with retained or without retained metal is the same at around 15% in gsw chest (although surgeons tend to be curious to operate find and extract the bullet and keep it). Complications are usually due to the surface of the fragment or the constant movement of breathing and heart beat. Chronic empyema in the presence of a retained fragment, movement onto the hilar vessels and recurrent hemoptysis in sharp fragments may be good indications. Pain on breathing (fragment stuck between two ribs) may be another one. Lead is not a problem, as lead hydrogene carbonate and lead carbonate have a low solubility in watery solutions. So any fragment removed needs a sound indication - otherwise the damage of removal will much outweigh any benefit.
(See also: Penetrating Trauma - a Practical Guide on Operative Technique and Peri-Operative Management).
Kind regards,
Dietrich Doll
Agree, very conservative. Unless potential for complications, such as on a vessel or heart. Lead toxicity is extremely rare, even with "birdshot" injuries. Thirty year follow-up of thousands of cases, with only a handful of cases of lead toxicity. Usually occurs in cases where there is a severe change in metabolism, such as severe weight loss, hyperthyroidism, etc. Bullets inside articular surfaces should be removed as the synovial fluid tends to dissolve the bullet and cause complications. Yes the movies and TV shows have it totally wrong with regards to removing bullets. They don't realize that you have to fix the injury and not the bullet. How many shows have I seen where someone sticks some sort of forceps inside the gunshot wound blindly, until they find the bullet and pull it out, then everything is okay. Probing gunshot wounds blindly like that is actually a script for a disaster!
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