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Doctor pulls a miracle : removes 97 pellets and bullet case from chest cavity just above the heart of 27-year-old

Story by Sumesh RajanMumbai: March 26, 2018

In what can be termed as a ‘miracle’, a doctor in India has recently saved from sure death a 27-year-old man -- in whose chest close to the heart was lodged 97 pellets, a bullet case and cotton fibres when he was shot at almost 5 years ago – in a rare and risky surgery which other doctors refused to do.

On March 17, 2013, early morning while Arif Hussain, a farmer from Moradabad in the North Indian state of Uttar Pradesh, was sleeping with his quilt on, he was shot point blank in the chest by one of his close relatives using a country made gun called ‘katta’ over some property dispute. He was immediately taken to a local hospital and was managed without any major surgical procedure. Though he bled significantly into left chest cavity which was managed with the insertion of chest tubes and blood transfusions, he was indeed very lucky to have survived the serious injury as the large bullet containing around 100 pellets went through fracturing and shattering his breastbone (sternum) and got lodged by dispersing in an area around 10 x10cm, in the chest cavity just above the heart around the great vessels.

Arif’s entry wound over the chest healed over time but he knew that he was ‘containing’ multiple pellets in his chest which was more of a kind of psychological burden rather than a physiological problem at that time. Subsequently, he went to many surgeons, who kept on refusing to operate upon him, obviously for good reasons. Around 8 months back, the foreign materials which were inside his chest started showing first signs of its ill effects - he developed osteomyelitis (infection of the bone) of the sternum along with a pus discharging sinus at the site of the entry wound of the bullet -- the front part of the upper chest wall. Now he became distressed and again went to several surgeons in a nearby Meerut city who again refused to operate on him, and suggested him to visit doctors at All India Institute of Medical Sciences (AIIMS) in New Delhi.

It was indeed a very difficult and challenging case as the pellet injuries are indeed very difficult to treat surgically as they are small in size (like black pepper seeds) and they are multiple in number usually. Therefore removing them completely and managing their damages are almost impossible practically even in areas like abdomen and other parts of the body. The area where these pellets got lodged is a very vital and dangerous area -- as it contained major vessels and heart. Even attempting to remove the pellets from such an area can kill the patient. Since infection had set in, there was a lot of inflammation and adhesions inside the chest. This makes the surgical job even more difficult and dangerous as there were no simple planes or access through which the surgeon can operate even. Experienced General Thoracic surgeons who should operate upon such patients usually are very less in number, though Cardiac surgeons are more readily available.

So this case was definitely a surgeon’s nightmare. So why not leave the patient as such without operating upon him? At least he was living and might otherwise incur more risk than attempting to remove the foreign bodies and dead infected breast bone!

That’s the dilemma along with the surgical challenge which was faced by Dr. Biplab Mishra, when this patient ultimately approached him a few months back. Dr. Biplab Mishra is a Professor of Surgery at the premier institute of India - the All India Institute of Medical Sciences (AIIMS), New Delhi. He is a world-renowned Trauma surgeon who is known for his surgical skills and managing very difficult cases of trauma. One such case was impalement of torso of a 22-year young patient in 2008 which he managed successfully and most dramatically even though he was a junior surgeon at that time. Two medical entities are even known by his name (Mishra’s sign and Mishra phenomenon).

According to Dr. Biplab this case was a ‘ticking time bomb’, because of all the pellets inside the chest along with the infection was literally ‘eating’ away the ‘surrounding tissues’ and these tissues were not simple tissues - they were major blood vessels!

“These vessels can bleed any time after erosions leading to almost instantaneous death. This ‘ticking time bomb’ was confirmed when I explored the patient’s chest. And there were much to discover which could have been confirmed if only this patient’s chest was explored. Considering these facts, is ‘safe and easy’ for a surgeon to avoid and refuse surgery in this particular case,” said Dr. Biplab.

He added, “However, I took this as a challenge to operate on him. But before that, I explained in detail the pros and cons of the surgery to the patient. Not only this, the patient was given almost a month’s time to think about and decide whether to go ahead with the surgery or not.”

After one month, Arif went for the decision to get operated. Subsequently, he was worked up including undergoing a fresh CT scan of his chest. Dr. Biplab operated upon him on 16th December 2017.

“The plan was to excise the sinus tract in the chest, excise all the infected bone of the breastbone, remove all the foreign bodies from inside the chest and finally to reconstruct the chest defect. All these plans were carried out successfully but not without difficulty and surprises. The most difficult part was entering into his chest cavity after excising the infected breastbone because there were so many adhesions and obscured anatomy due to physical damage and infection. This was followed by meticulous removal of all the pellets, bullet case and lot of cotton fibres from the quilt that he was wearing at the time he was shot at. Cotton can be more dangerous in such cases as it is more tissue reactive (with the potential to cause more infection and tissue erosion) than metallic pellets. Also, they are not easily visible on CT scan or X-rays, unlike metallic pellets. It was also found, during the surgery, that these foreign materials along with infection were actually eroding away one of the major blood vessels in the chest. The foreign bodies were meticulously removed from his chest cavity and were checked by fluoroscopy on OT table itself,” said Dr. Biplab.

All in all, 97 pellets were removed along with it lots of cotton fibres and bullet case from Arif’s chest cavity. Anterior chest defect was reconstructed using a muscle flap with the help of a plastic surgeon. The whole surgery took more than 4.5 hours.

“The patient had a speedy recovery after the surgery so much so that he was discharged on the fourth day after surgery. Considering the complexity of the surgery, usually such patients take more than seven days to recover. Almost three months have passed and after multiple follow-ups, the patient does not have any residual disability or side effects. He is back to normal life again,” says Dr. Biplab.


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