Catheter-Directed Retrieval of an Infected Fragment in a Vietnam War Veteran
Background: Shrapnel injuries are commonly encountered in war zones. The severity of these injuries depends on the initial damage and both the anatomical and immune response at the time of injury or at more remote times in the case of reactivation.
Case Presentation: A veteran sustained a shrapnel injury to his left lower abdomen while serving in the Vietnam War. Nearly 50 years later, the patient presented with a recurrent retroperitoneal abscess associated with a residual fragment. In cooperation between interventional radiology and surgery, traditional endovascular techniques and devices were used to relocate an extravascular, secondarily infected fragment to an area more suitable for a minor surgical approach in the left inguinal region. Subsequent surgical excision and removal required only a superficial incision as opposed to a large retroperitoneal dissection, minimizing recovery time and allowing quick and full healing of the patient.
Conclusions: This case demonstrates a multidisciplinary approach to transforming an otherwise large retroperitoneal dissection to a minimally invasive and technically efficient abscess drainage and foreign body retrieval.
In our patient, the retained fragment was embedded in the wall of an abscess located retroperitoneally in his iliopsoas muscle. When considering the proximity of the iliopsoas muscle to the digestive tract, urinary tract, and iliac lymph nodes, it is reasonable for infectious material to come in contact with the foreign body from these nearby structures, resulting in secondary infection.11 Surgery was previously considered the first-line treatment for retroperitoneal abscesses until the advent of imaging-guided percutaneous drainage.12
In some instances, surgical drainage may still be attempted, such as if there are different disease processes requiring open surgery or if percutaneous catheter drainage is not technically possible due to the location of the abscess, thick exudate, loculation/septations, or phlegmon. In these cases, laparoscopic drainage as opposed to open surgical drainage can provide the benefits of an open procedure (ie, total drainage and resection of infected tissue) but is less invasive, requires a smaller incision, and heals faster.13 Percutaneous drainage is the current first-line treatment due to the lack of need for general anesthesia, lower cost, and better morbidity and mortality outcomes compared to surgical methods.12 While percutaneous drainage proved to be immediately therapeutic for our patient, the risk of abscess recurrence with the retained infected fragment necessitated coordination of procedures across specialties to provide the best outcome for the patient.
Conclusions
This case demonstrates a multidisciplinary approach to transforming an otherwise large retroperitoneal dissection to a minimally invasive and technically efficient abscess drainage and foreign body retrieval.
