Rare surgery: 20-cm knife removed from 28-year-old man’s liver

New Delhi, Jul 27: After a rare and challenging three-hour surgery, doctors at the AIIMS here successfully removed a 20-cm-long kitchen knife from a man's liver who had bizarrely swallowed it in a fit of psychosis. The doctors said they were perplexed as to how the 28-year-old gulped down the saw-edged knife without any damage being caused to his wind-pipe, lungs, heart and other vital organs.

“The knife could have easily perforated the esophagus and gone in to the trachea, heart or big vessels, on its journey from mouth to liver via duodenum,” said Dr Nihar Ranjan Dash, professor of Gastrointestinal Surgery and Liver Transplant at AIIMS.

He said, “We have searched the literature, but such a big sharp knife ingestion has not been reported. We are searching for more literature.” He said there are reports of small needles and fish bones going into liver after perforating duodenum.

The man, a daily wage worker from Palwal in Haryana, has a history of psychosis and had a habit of smoking cannabis. "He was not an addict but took cannabis quite often,” said the doctor.

The man told the doctors that one-and-a-half-months ago, during the coronavirus lockdown when “he was in his kitchen, he felt like eating the knife. He tried to chew it and finally gulped it down with water”. He had no problems for a month. But subsequently, he developed issues like difficulty in eating, weight loss, fever, abdominal pain which soon became unbearable, the doctors said. He was taken to local hospitals and was referred to the Safdarjung hospital in Delhi.

"An ultrasound and an X-ray of the abdomen revealed blade of a kitchen knife stuck in the liver. Anticipating the challenges involved in removing the object, doctors there referred the patient to the Gastrointestinal Surgery and Liver Transplant department at AIIMS," Dr Dash said.

The patient came to the emergency of the AIIMS on July 12. A COVID-19 test was done to rule out coronavirus infection.

The reports came out negative. While the patient was admitted in the emergency, an ultrasound, CT scan and other investigations were carried out to know the exact position of the knife, its relation to the vital organs and the complications it had caused, the doctors said.

"On CT scan, we found the blade of the knife was entirely inside the liver and the handle inside the duodenum, which is the first part of the small intestine. "The knife actually had perforated the duodenum and had gone into the liver. It had led to bleeding, infection, abscess formation in the liver and sepsis. His hemoglobin level was very low. A sepsis had set in, there was loss of weight and water had accumulated in his right chest," Dr Dash elaborated.

"An immediate surgery was not possible," he said, adding removing the knife through endoscopy was ruled out as it was very risky and could have caused injuries to the organs. Doctors decided to first control the sepsis and gave him blood transfusion. He was put on high antibiotics and was under critical care. The doctors said under X-ray guidance, a tube was put inside the liver to drain the pus that sucked around 100 ml pus everyday for four to five days.

Another tube was inserted to take out the water from the chest, Dr Dash explained. He said the man was given nutrition intravenously as he was not in a condition to take food orally. He was also being provided psychiatric counselling all throughout. After seven days, though his condition improved to a certain extent, the sepsis could not be controlled entirely.

"It was then that we decided to take him for surgery. Challenges during the surgery were the possibility of heavy bleeding, injuring the liver, controlling bleeding after removing the knife and to do it as quickly as possible with minimum complications.

"When a patient is septic and anemic, giving anesthesia for a longer period and conducting longer procedures could turn fatal," Dr Dash said. In a challenging surgery lasting three hours, the knife was removed by opening the intestine on July 19, Dash said.

A team of doctors from the department of Anaesthesia, Critical Care, Radiology and Gastroenterology besides the Gastrointestinal Surgery and Liver Transplant were also involved in the surgery and the knife was pulled out under ultrasound guidance.

“The patient was in the ICU for seven days. He is out of danger now and out of ICU care,” Dr Dash said. "We had put a food pipe during the surgery in his abdomen and through that tube he is being given food. Very soon we will start giving him food orally. He is conscious and able to walk around. He is being given psychiatric counselling," he said.