A 48-year-old male with no significant past medical history who was a restrained driver in a motor vehicle accident sustained multiple injuries in the crash () and had a prolonged and difficult extrication from the crash site before being brought to Ryder Trauma Center with a Glasgow Coma Scale of 15 approximately 1-2 hours after his accident. While in the resuscitation bay, bilateral chest tubes were placed for bilateral pneumothoraces and he had a positive FAST exam with tachycardia and severe hypotension (HR 128, BP 69/50). He was immediately brought to the operating room (OR) for emergency exploratory laparotomy, and splenectomy was performed for Grade V splenic injury, followed by abdominal packing without complete abdominal closure. His condition stabilized intraoperatively; no active abdominal bleeding or hematoma could be identified at that moment.\nA full-body CT scan was then requested to investigate other injuries. A list of numerous bone fractures that demonstrate the serious extent of the traumatic injury is shown in . The patient had also a scalp injury and needed additional workup to rule out traumatic brain injury. Head CT was negative. Chest CT demonstrated no further injuries other than minor pulmonary contusions and pneumothoraxes already being treated by the previously placed chest tubes. Abdominal contrasted CT identified a left renal artery injury and a nonenhancing ischemic left kidney but no other abdominal organ injuries (). In an attempt to salvage left kidney function despite over 4 hours of warm ischemia at that point, the patient was taken back to the OR for emergent repair of his left renal artery/in situ autotransplantation.\nAn occlusive 2 cm intra-arterial thrombus was removed, and a corresponding 2 cm damaged segment of the renal artery was excised. The kidney was flushed through the renal vein with histidine-tryptophan-ketoglutarate perfusion solution during the anastomosis of the renal artery. The left kidney was adequately perfused postreconstruction of the left renal artery ().\nDuring the two operations, the patient received a total of 7 units of packed red blood cells, 6 units of fresh frozen plasma, 2 units of cryoprecipitate, and 2 platelet transfusions. The patient was subsequently admitted to the Trauma Intensive Care Unit (TICU) for postoperative care. His hospital course was significant for worsening azotemia in the setting of decreased kidney function and falling urine output with a peak creatinine above 8 mg/dL. Dialysis and pressors were started on postoperative day 4. Eventually, his renal function improved, and his creatinine fell, and urinary output increased. He exhibited hypertension 2-3 weeks postrenal artery repair, but his systolic blood pressures eventually stabilized between 110 and 130 mmHg. He recovered in our TICU after multiple episodes of fungemia and bacteremia, was transferred to the trauma floor, and was discharged two months after admission. He is currently being followed in an outpatient clinic. After 18 months of follow-up, his serum creatinine level is 1.3 mg/dL and vital signs were within normal limits, without hypertension.\nOutpatient nuclear medicine renal scan indicated partial preservation of left renal function with a shrunken left kidney, and 16.3% () of split renal function attributed to the left kidney. Renal biopsy of the revascularized kidney was not performed. Left renal artery stenosis was not noted after its reattachment.
A 25-year-old man was admitted to the emergency department after falling off his bicycle. He was hit by the bicycle's handle bar into the left side of the abdomen. The clinical examination revealed a fit young man who had only a scratch (abrasion) on the abdominal wall left of the umbilicus. Hemodynamically he was normal and alert and referred to intense pain at the abrasion site. The abdomen was soft, without signs of peritoneal irritation while sensitivity was only at the point of the abrasion. Laboratory tests, including white blood cells, liver enzymes, and amylase, were normal. The abdominal X-ray in upright (standing) position did not reveal the presence of free intraperitoneal air. Abdominal ultrasound did not reveal any solid abdominal organ injury nor the presence of free intraperitoneal fluid. The pain was attributed to hematoma of the rectus abdominis muscle pricey below the abrasion which was revealed by ultrasound.\nThe pain of the young man was gradually worsening and was mostly described diffusely throughout the whole abdomen. The abdomen remained soft and tender without signs of peritoneal irritation. We proceeded to the administration of per os contrast material and CT abdomen. The CT scan revealed the presence of sufficient amount of free intraperitoneal contrast but did not allow the clarification of the exact point of escape. The free contrast material was detected at the left side of the abdomen, at the area of the descending colon but mainly in the pelvis (). The intraluminal contrast had even reached up the level of the transverse colon.\nThe patient was taken to the operating room for exploratory laparotomy immediately after the CT scan (4 hours after the arrival at the emergency department and about 4.5 hours after the time of injury). Intraoperatively, fecal peritonitis due to isolated rupture of jejunum 30 cm from the ligament of Treitz was revealed. The rupture was at the center of an extensive jejunum serous layer fissure giving the picture of “blow out” perforation. At the jejunal mesentery there was minimal bruising. Multiple washings of the peritoneal cavity were performed with normal saline, and the restoration of jejunal injury was done with partial resection and end-to-end anastomosis ().\nThe postoperative course of the patient was uncomplicated, and he was discharged on the 6th postoperative day. 9 days later he returned with clinical and radiological signs of ileus that led us to the operating room 48 hours later due to deterioration of his clinical picture. The cause of the ileum was adhesions, so we proceeded to lysis of adhesions. The anastomosis was normal without leakage. Five days later the patient was discharged, and a year later he is still free of symptoms.