14-Retrieval of ferromagnetic fragments from the lung using video-assisted thoracoscopic surgery and magnetic tool- a case report of combat patient injured in the war in Ukraine

Lurin etal.International Journal of Emergency Medicine (2023) 16:51<a href="https://doi.org/10.1186/s12245-023-00527-8">https://doi.org/10.1186/s12245-023-00527-8</a>International Journal of Emergency Medicine	CASE REPORT Open Access<img src="/media/202408//1724838786.923583.png" />Retrieval of ferromagnetic fragments <img src="/media/202408//1724838786.937363.png" /> from the lung using video-assistedthoracoscopic surgery and magnetic tool: a case report of combat patient injured in the warin UkraineIgor Lurin1,2, Eduard Khoroshun3,4, Volodymyr Negoduiko3,4, Volodymyr Makarov3,4, Serhii Shypilov3,4, Volodymyr Boroday3, Maksym Gorobeiko5 and Andrii Dinets5*AbstractBackground Gunshot wounds injury to the thorax is common in armed conficts or war, including the war of Rus-sia against Ukraine. Injury to the chest is associated with a high mortality or physical disability due to damage to the lungs, heart, and major vessels.The aim of this report is to demonstrate a case of successful management of severe gunshot injury to the lungs using video-assisted thoracoscopic surgery and magnetic tool for a combat patient injured in the war in Ukraine.Case presentation A 51-year-old soldier of the Armed Forces of Ukraine received a gunshot injury due to shellingfrom artillery strikes in the Donbas battlefeld area. After evacuation to Level II, a forward surgical team performed primary surgical debridement. Two hours after the injury, the patient was evacuated to the Level IV of medicalcare (Kharkiv). At Level IV, a CT scan showed penetrating gunshot wounds to the left part of the chest with injury to the upper lobe of the left lung with the presence of the 2 metal fragments of the artillery projectile with the size of 2.5 × 2.0 cm and 1.0 × 1.0 cm. These two fragments were removed by using video-assisted thoracoscopic surgery (VATS) using the inlet gunshot hole in the left lateral chest area, as well as the assistance of a magnetic tool.Conclusions VATS and magnetic technologies should be considered for hemodynamically stable combat patientswith a gunshot injury to the lungs in the ongoing war. Each combat patient could be treated by individualizedapproach such as using the wound canal as a scope port after primary surgical debridement of the wound and antibi- otic prophylaxis.Keywords War in Ukraine, Russo-Ukrainian war, Gunshot injury to lung, Gunshot injury to chest, Video-assisted thoracoscopic surgery, Surgical magnetic tool*Correspondence: Andrii Dinetsandrii.dinets@knu.uaFull list of author information is available at the end of the article<img src="/media/202408//1724838786.946676.png" />BMC© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, whichpermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of thislicence, visit <a href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</a>. The Creative Commons Public Domain Dedication waiver (<a href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecom-</a> <a href="http://creativecommons.org/publicdomain/zero/1.0/">mons.org/publicdomain/zero/1.0/</a>) applies to the data made available in this article, unless otherwise stated in a credit line to the data.Lurin etal. International Journal of Emergency Medicine (2023) 16:51BackgroundGunshot injury to the chest is common in armed con- flicts or warfare, including the war of Russia against Ukraine, which is ongoing since 2014 as hybrid war- fare, and an active invasive phase has been started on February 24, 2022 [<a href="#bookmark1">1</a>, <a href="#bookmark2">2</a>]. Injury to the chest is associ- ated with a high mortality or physical disability due to damage to the lungs, heart, major vessels, etc. Since World War II, injury to the chest was and remained the common cause of up to 1/3 of deaths among com- batants. Ongoing warfare in Ukraine is associated with the frequent use of multiple-launch rocket sys- tems (MLRS) as well as various high-energy weapons causing severe injuries, limb amputations, bleeding, and lethal outcomes [<a href="#bookmark3">3</a> –<a href="#bookmark4">5</a>]. According to our clinical observations, gunshot injury to the lungs is the most frequent as compared to other locations, which is constituted up to 80% out of all other wounds to the chest (e.g., wounds to the pericardium, heart, major vessels) in the war in Ukraine since 2014. Gunshot injury to the lung is usually accompanied by dam- age to the ribs, severe bacterial contamination, and a high mortality rate (up to 37%) due to massive hem- orrhage and acute respiratory failure [<a href="#bookmark5">6</a>]. The applica- tion of computed tomography (CT) scan is useful for the evaluation of both chest damage as well as a pro- jectile trajectory in civil and combat conditions [<a href="#bookmark6">7</a>, <a href="#bookmark7">8</a>]. Open thoracotomy is the method of choice in gunshot injuries to the chest, and video-assisted thoracoscopic surgery (VATS) is uncommonly applied to remove foreign bodies [<a href="#bookmark7">8</a> –<a href="#bookmark8">13</a>]. It is also important to mention that the Armed Forces of Ukraine and civil people are in permanent violation of international humanitar- ian law during the war by the Russian army because of such high-energy weapons as artillery strikes, cruise missiles, and drone attacks on medical facili- ties, causing significant problems for the safe evacua- tion of wounded to appropriate levels of medical care and interruption in supplying of medical goods [<a href="#bookmark2">2</a>, <a href="#bookmark9">14</a> –<a href="#bookmark10">17</a>]. The management of all kinds of wounds is a difficult task for both civil people and military person- nel under the abovementioned conditions. It is also worth mentioning that despite a sufficient experience in the management of gunshot injuries to the chest, it is sometimes a clinical challenge for choosing the most appropriate treatment approach for multiple gunshot injuries to the chest by high-energy weapons.The aim of this report is to demonstrate a case of successful management of severe gunshot injury to the lungs using video-assisted thoracoscopic surgery and magnetic tool for a combat patient injured in the war in Ukraine.Page 2 of 5Case presentationA 51-year-old soldier of the Armed Forces of Ukraine received a gunshot injury due to shelling from artillery strikes in the Donbas battlefeld area (East Ukraine). Te shelling trauma was judged as severe because it was pen- etrating body armor and caused bleeding from the chest. Te patient received medical aid at the place of injury according to the principles of damage control surgery and inline with the levels system of medical care as shown in our previous reports <a href="#bookmark2">[2</a>–<a href="#bookmark11">4</a>, <a href="#bookmark9">14</a>, <a href="#bookmark12">16</a>, <a href="#bookmark10">17</a>]. One hour after the injury, the patient was evacuated to Level II, and forward surgical team (FST) performed primary surgical debride- ment of the gunshot wounds, including the application of drainage for chest decompression. Two hours after the injury, the patient’s condition was judged as severe, and the decision was made to evacuate him to the Level IV of medical care, which is the Military Medical Teaching Center of the Northern Region in Kharkiv. Upon admis- sion to Level IV, the patient was subjected to a physical examination, presenting a wound of 3.0 ×2.0 cm in the left inguinal area along the middle inguinal line, and another wound of 1.5 ×1.0 cm was found in the area of the left shoulder blade. Te weak breathing sounds were in the left parts of the chest. A spiral computed tomog- raphy (CT) scan of the chest was performed on a device with a tomograph step of 0.5 mm (Toshiba Activion 16, Japan). CT scan showed penetrating gunshot wounds to the left part of the chest with injury to the upper lobe of the left lung with the presence of the 2 metal fragments of the artillery projectile with the size of 2.5 ×2.0 cm and 1.0 ×1.0 cm. Tese two metal fragments showed radi- odensity over 15,000 U by the Hounsfeld scale, indi- cating the presence of ferromagnetic features (Fig. <a href="#bookmark13">1</a>). Although the patient had severe wounds, he was in stable condition; therefore, the decision was made to perform video-assisted thoracoscopic surgery (VATS) for visual inspection of the pleural cavity as well as to remove metal fragments from the lung. An endoscopic magnetic tool was used to remove foreign bodies from the pleural or abdominal cavity, according to the previously described approach [<a href="#bookmark14">18</a>]. Te video of the procedure is available as Additional fle <a href="#bookmark15">1</a>. Te inlet hole in the left lateral chest area was considered convenient to use as a scope port for the magnetic tool (Fig. <a href="#bookmark16">2</a>). An endoscopy magnetic retrieval tool was manually inserted into the chest cavity through the wound channel in the upper lobe of the left lung to the metal fragments under the video-endoscopic control. First, the smaller metal fragment (1.0 ×1.0 cm) was caught by the magnetic tool and removed using the same path from the wound channel. In the same manner, the larger metal fragment (2.5 ×2.0 cm) was also caught by the endoscopic magnetic tool; however, the size of that fragment did not ft the diameter of the wound channel,Lurin etal. International Journal of Emergency Medicine (2023) 16:51 Page 3 of 5<img src="/media/202408//1724838786.989629.jpeg" /><a id="bookmark13"></a>Fig. 1 Illustration of 3D computed tomography scan of the chest showing localizations of two metal fragments in the lung (marked with two yellow pins)and the decision was made to temporarily keep the frag- ment at the level of the intercostal space by using mag- netic control system (Fig. <a href="#bookmark17">3</a>). Te Mikulicz forceps were inserted into the area of the metal fragment (2.5 ×2.0 cm) location followed by fragment fxation and removed from the chest (Fig. <a href="#bookmark18">4</a>). Te patient was discharged from the hospital 2 weeks after the surgery and received 30 days of vacation according to the decision of the military-medi-cal committee.DiscussionIn this case report, we presented our clinical experience in the management of gunshot wounds with the applica- tion of VATS with magnet guidance to remove ferromag- netic fragments in combat patient. We believe this case report provides additional knowledge about the role of minimally invasive surgery and the magnets in the active war conditions accompanied by the violation of humani- tarian law by the Russian army and in terms of limited medical resources in Ukraine [<a href="#bookmark2">2</a>, <a href="#bookmark9">14</a>, <a href="#bookmark19">15</a>, <a href="#bookmark10">17</a>]. In regards to our previous reports, management of gunshot injury to the lungs is presented for the frst time in the patient <a id="bookmark17"></a>injured during the active (invasion) period of the Russo- Ukrainian war. Tis study is also supported by previous reports of the possibility to apply modern technologies and tools in conditions of limited medical recourses and<img src="/media/202408//1724838786.996901.jpeg" /><a id="bookmark16"></a>Fig. 2 Intraoperative photograph showing inlet gunshot holeon the left side of the patient which is used as a thoracic portfor video-thoracoscopic instruments. Two magnetic tools were used to fx the metal fragments in the lung before helping with its removal (marked with two arrows)<img src="/media/202408//1724838787.002242.jpeg" />Fig. 3 Intraoperative photograph of the thoracic cavity showing an internal view of the gunshot inlet hole (A), thoracoscopicinstrument (B), lung (C)Lurin etal. International Journal of Emergency Medicine (2023) 16:51 Page 4 of 5<img src="/media/202408//1724838787.0052931.jpeg" />Fig. 4 Intraoperative photograph of the removed metal fragment <a id="bookmark18"></a>from the lunghigh risk of strikes by high-energy weapons <a href="#bookmark2">[2</a>, <a href="#bookmark9">14</a>, <a href="#bookmark19">15</a>, <a href="#bookmark10">17</a>]. Limited medical resources were and remained a common problem for healthcare in Ukraine due to various causes, including bad planning <a href="#bookmark20">[19</a>]. However, military and civil surgeons can diagnose and consider the management of such a severe vascular injury even in unstable combat conditions and available resources.Similar to other reports, in this study, we have shown the utility of using a chest CT scan for evaluation of the damage to soft tissues, bones, mediastinum, pleura, and lungs <a href="#bookmark6">[7</a>, <a href="#bookmark7">8</a>]. Te accuracy and sensitivity of the CT scan are high to detect foreign bodies of any localization, signs of hemothorax or pneumothorax, and intrapulmo- nary hematoma. CT scan showed its utility in war con- ditions and specifcally for gunshot injury to determine the trajectory of the wound channel and to characterize in detail the changes in the anatomical structures of the chest cavity organs due to injury. By using a CT scan ashort time after the injury, it is possible to obtain topo-graphical and anatomical characteristics of the wound channel, detect foreign bodies, determine their relation- ships with surrounding organs and structures, and obtain comprehensive data on the nature of damage to the chest organs and adjacent cavities. Te abovementioned approach is associated with choosing of most rational treatment tactics, optimal access for surgical interven- tion and drainage area, and the choice to apply minimallyinvasive treatment methods such as VATS and magnets. Te limitation exists the wide application of CT scan in Ukraine within the area of 20–40 km from the frontline due to the high risk of MLRS or autonomous pusher- prop drones’ application, and risk is lesser but still exists due to the risk of cruise missile attacks in the hospitals at Levels III and IV.It is well known that the presence of the large foreign fragments in the lungs is an indication for surgical treat- ment <a href="#bookmark7">[8</a>, <a href="#bookmark21">9</a>]. We used a gunshot wound channel as a path for the retrieval of the metal fragments, which is in con- trast to other reports. Usually, the wound channel is not used as a thoracic path in case of penetrating wounds to the chest due to the possible presence of microbial con- tamination. However, in this particular case, we decided that the wound channel would play the most optimal role as a thoracic port because it was the shortest path to remove the foreign body, and the patient was under anti- biotics therapy. Te combination of VATS with the guid- ance of a magnetic tool made it possible to remove metal fragments minimally invasive and without conversion to the thoracotomy.Similarly, Kakamad et al. and Khalil et al. also showed the utility of VATS to remove bullets from the chest <a href="#bookmark21">[9</a>, <a href="#bookmark8">13</a>]. However, in contrast to that studies, we decided to use also magnet, considering the ferrous nature of the gunshot fragments and the availability of special mag- netic tools.In line with Essa et al., we also decided to use VATS in war-related shrapnel injury to the lungs, consider- ing hemodynamically stable patients and faster recovery after the surgery <a href="#bookmark22">[20</a>]. As also suggested in other reports, we also decided to use a surgical instrument (Mikulicz forceps) to remove the large metal fragment, indicating such an approach to be a useful part of the VATS applica- tion <a href="#bookmark23">[21</a>].It is also worth to mention that VATS is infrequently performed for the foreign bodies in the lungs and bron- chi. Te majority of reports of VATS or conventional thoracotomy are related to the removal of foreign bodies in pediatric patients, whereas adult patients with gunshot trauma are treated by conventional thoracotomy <a href="#bookmark24">[22</a>].ConclusionsVATS and magnetic technologies should be considered for hemodynamically stable combat patients with a gun- shot injury to the lungs in the ongoing war. Each com- bat patient could be treated by individualized approach such as using the wound canal as a scope port after pri- mary surgical debridement of the wound and antibiotic prophylaxis.Lurin etal. International Journal of Emergency Medicine (2023) 16:51<a id="bookmark15"></a><a id="bookmark11"></a>Supplementary InformationThe online version contains supplementary material available at <a href="https://doi.org/10.1186/s12245-023-00527-8">https://doi.</a> <a href="https://doi.org/10.1186/s12245-023-00527-8">org/10.1186/s12245-023-00527-8</a>.Additional fle 1. Intraoperative video of using video-assisted thora- coscopic surgery (VATS) and surgical magnetic tool to remove metal fragments.AcknowledgementsNone.Authors’ contributionsIL – designed the study, acquisition of data, drafted manuscript, literaturesearch, and analyses; EK – designed the study, drafted manuscript, literature search, and analyses. VN – study conception and design, collected the data; VM – study conception and design, collected the data, preparation offgures; SS – drafted the manuscript; VB – drafted the manuscript; MG –literaturesearch and analyses; AD – analysis, and interpretation of data, critical revi- sion; fnal approval and submission of the manuscript. All authors read and approved the fnal manuscript.FundingThe study received no funding.<a id="bookmark9"></a>Availability of data and materialsAll data regarding this case report has been reported in the manuscript. Please contact the corresponding author in case of requiring any further information.Declarations<a id="bookmark12"></a>Ethics approval and consent to participateThis study was approved by the Ethical Committee at the Kharkiv NationalMedical University (Kharkiv, Ukraine). The study was performed under theethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from the participant.Consent for publication<a id="bookmark20"></a>Written informed consent was obtained from the patient for publication ofthis case report and any accompanying images. A copy of the written consent is available for review by the editor in chief of this journal.Competing interestsThe authors declare no competing interests.<a id="bookmark24"></a>Author details1 National Academy of Medical Sciences of Ukraine, Kiev, Ukraine. 2StateAdministrative Department, State Institution of Science“Research and Practi- cal Center of Preventive and Clinical Medicine, Kiev, Ukraine. 3 Departmentof Thoraco-Abdominal Surgery, Military Medical Teaching Center of the North- ern Region of Ministry of Defense of Ukraine, Kharkiv, Ukraine. 4 Departmentof Surgery #4, Kharkiv National Medical University, Kharkiv, Ukraine. 5 Depart- ment of Surgery, Institute of Biology and Medicine, Taras Shevchenko National University of Kyiv, Kiev 03039, Ukraine.Received: 27 March 2023 Accepted: 20 August 2023published online:24August2023 References<a id="bookmark1"></a>1. Yatsun V. 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