The Iliad and the Odyssey of metallic foreign body extraction

j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 5 ( 2 0 1 3 ) e 3 1 ee 3 3

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Commentary

The Iliad and the Odyssey of metallic foreign body extraction: commentary on “Novel methods of removing metallic foreign body from human soft tissue: a report of 7390 cases” Mazen E. Iskandar, MD, Simon D. Eiref, MD, and I. Michael Leitman, MD* Department of Surgery, Albert Einstein College of MedicinedBeth Israel Medical Center, New York, New York

article info Article history: Received 20 December 2012 Received in revised form 20 December 2012 Accepted 3 January 2013 Available online 23 January 2013

Surgeons have been extracting metallic foreign bodies (MFB) for centuries. Perhaps the earliest literary account comes from Homer’s epic poem The Iliad (ca BC 800), based on events of the Trojan War from Greek mythology. Makaon operated on an arrow wound to the abdomen of King Menelaus by extracting the arrow, sucking blood from the wound to remove poison, and applying a salve [1]: The shaft he drew, but left the head behind. Straight the broad belt with gay embroidery graced, He loosed; the corslet from his breast unbraced; Then suck’d the blood, and sovereign balm infused, Which Chron gave, and Aesculapius used [2]. Specific details of MFB extraction were reported by Aulus Cornelius Celsus, a Roman medical writer (ca BC 50). In his

treatise De Medicina, Celsus included instructions for removing barbed arrowheads, spearheads, and lead bullets from slings and catapults [3]: “In all such cases the wound should be laid open freely, and the retained object pulled out by forceps the way it entered” [4]. Celsus cautioned that removing deep or large foreign bodies could have significant operative morbidity. He described a technique for pulling a deep-seated MFB through the body’s opposite side, and described a rudimentary MFB extractor called the Dioclean cyathiscus [5]. Bullet probes and extractors continued to evolve slowly over the next centuries, being used mainly to extract MFB from the superficial soft tissues. Their development accelerated in the 16th century as firearms became increasingly sophisticated. Whereas the management of wartime trauma shaped the initial history of MFB extraction, subsequent radiologic advances in the modern era have made a critical contribution by enabling MFB to be localized and removed less invasively, and by improving antiseptic practice [1]. The development of fluoroscopy in the mid 20th century enabled improved localization and real-time visualization. In

DOI of original article: 10.1016/j.jss.2012.12.018. * Corresponding author. Department of Surgery, Albert Einstein College of MedicinedBeth Israel Medical Center, 10 Union Square East, Suite 2M, New York, NY 10003. Tel.: þ1 212 844 8570; fax: þ1 212 844 8440. E-mail address: [email protected] (I.M. Leitman). 0022-4804/$ e see front matter ª 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2013.01.010

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addition, computed tomography (CT) scan technology in the late 20th century provided greater information regarding MFB location, orientation, and relationship to adjacent anatomic structures. In civilian life, MFB are introduced into soft tissue by a variety of mechanisms. Industrial workers are at increased risk of being affected by MFB due to their occupational exposure to needles, pins, and metallic splinters [6]. Penetrating trauma from bullets and shotgun pellets is an uncommon event. Because of an immune and inflammatory response, the MFB becomes encapsulated within an avascular and fibrotic capsule [7]. Moreover, scarring prevents the migration of the MFB and subsequent additional soft tissue injury and erosion into vital structures. Usually an MFB gives patients a sensation of a foreign body, anxiety, and discomfort, causing them to seek its extraction. The resulting encapsulation greatly minimizes the chances of the MFB serving as a nidus of infection, and typically infection rates are as low as 3% [8]. Though relatively rare, reports of migration along the spinal cord and brain and into blood vessels, leading to embolization, do exist, causing delayed morbidity [9e13]. MFB composed of toxic materials, such as lead, can rarely cause systemic toxicity, particularly if found within an open space such as a joint, with limited scar tissue encapsulation [14,15]. The majority of patients with MFB initially present to the emergency room and frequently have other associated injuries. As for any patient with an open wound, initial management should consist of local wound care with irrigation; debridement of devitalized tissue, when present; and evaluation of the need for administration of tetanus prophylaxis based on the mechanism of injury and immunization history. Antibiotic prophylaxis is not typically recommended for simple wounds [16]. Because MFB are radiopaque, they are easily identified on plain x-ray films, with a sensitivity as high as 98% [17]. Ultrasound has a better yield than plain x-ray only in the case of nonradiopaque foreign bodies [17,18]. CT scans are particularly helpful if the foreign body is located in proximity to other vital structures and in planning surgical extraction [19]. The decision to remove MFB from soft tissues requires a careful evaluation of the risks of extraction versus the risks of leaving them in situ, and should be carefully considered [20]. The military experience advocates against the routine removal of retained projectiles, as they seldom cause complications [21]. In addition to pain, removal of MFB is indicated if they cause an abscess or draining sinus, or if they restrict function, such when they are within joint spaces [6,7,20]. Less common indications are systemic lead poisoning and their location within vital organs such as the spine or blood vessels. A variety of methods have been described to facilitate the task of surgical excision once the decision has been made for extraction, as MFB are usually small and nonpalpable, frequently resulting in lengthy and failed procedures. Percutaneous extraction under fluoroscopic guidance is a popular method, achieving success in 94%e100% of cases [19,22]. Ultrasound has also been used successfully, especially in the case of nonradiopaque foreign bodies, and has the advantage of avoiding radiation, with a success rate as high as

88% [23e25]. CT guidance offers the advantage of accurate localization of the foreign body, especially with three-dimensional (3D) technology, and has also been reported with satisfactory results [26,27]. Novel and creative approaches such as using small endoscopes through wound tracks and even the use of strong magnets to attract MFB through the skin have also been described [20,28,29]. In a paper recently published in the Journal of Surgical Research, Xing et al. present their experience of using a 3D locator and special magnetic forceps for MFB extraction from the soft tissues. Over a 10-y period, the authors treated 7390 patients. The majority of injuries occurred in builders and construction workers, resulting in fragments of steel, iron, wire, nails, and aluminum products. Symptoms occurred in 93% of cases and included pain, numbness, local mass, and prolonged healing from wound infections. Their 3D locator is composed of two pieces of gridded Plexiglas, placed at a 90 angle. The locator is fixed on the body part of interest, and radiographs are taken to pinpoint the exact depth and location of the MFB. Through a minimally invasive incision, a calibrated magnetic forceps is inserted to retrieve the MFB. In 95.5% of cases, the MFB could be successfully removed using this technique, in an average time of 5 min, with no reported iatrogenic injuries or complications [30]. Their 3D MFB locator appears to be a simple, inexpensive, and efficient method for removing MFB. The locator should be useful in a variety of settings including the emergency and operating room. Nevertheless, the decision to surgically remove a metallic foreign body and the surgical technique will continue to challenge trauma surgeons.

references

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