, it may be fatal in there is injury caused to the cardiac cavity , an intercostal artery , pulmonary vessels , or intraabdominal organs 2 , 3 . in this situation ,
invasive management such as emergency surgery and transcatheter arterial embolization ( tae ) may be required 4 , 5 , 6 . however ,
if there is no severe adverse event immediately after injury of vital organs by the tube insertion , emergency treatment may not be required 7 . here , we describe successful noninvasive management for iatrogenic penetrating splenic injury caused by chest tube insertion .
a 61yearold japanese male visited the internal medicine department complaining of a tenday episode of fatigue and left chest pain .
he had a high fever ( body temperature , 40.0c ) , but was lucid with stable vital signs ( heart rate , 96 beats / min ; blood pressure , 119/70 mmhg ) .
blood examination showed an elevated inflammatory response ( white blood cell , 12,350 cells/l ; creactive protein , 35.1 mg / dl ) .
chest xray and computed tomography ( ct ) scan showed an accumulation of a large amount of fluid in the left thoracic cavity .
a chest tube was immediately inserted , and a further 800 ml of purulent pleural effusion was drained .
additionally , he was administered antibiotics . on hospital day 7 , the chest tube was removed as the amount of drainage had decreased . on hospital day 13 , he developed exacerbation of empyema and the chest tube was inserted again . under local anesthesia , a 20french trocar tube was inserted through the 9th left intercostal space at the posterior axillary line after the location of the empyema cavity was confirmed by ultrasonography .
it was gathered that fluid in the empyema cavity was too sticky to be drained .
the patient was subsequently transferred to our department due to the persistent empyema despite drainage and antibiotics , and videoassisted thoracoscopic decortications for left empyema were performed on hospital day 17 .
thoracoscopic observation revealed that the chest tube was not in the thoracic cavity and was therefore left intact during operation . after the operation , ct revealed that the chest tube was malpositioned into the abdominal cavity as it had penetrated through the spleen ( fig .
his vital signs were stable ( heart rate , 89 beats / min ; blood pressure , 99/63 mmhg ; body temperature , 36.2c ) , and there was no drop in his hemoglobin level .
the chest tube was malpositioned into the abdominal cavity as it had penetrated through the spleen .
there were no severe adverse events such as massive bleeding immediately after accidental insertion of the tube into the spleen .
a substantial time had elapsed between the accidental insertion of the tube and the diagnosis of tube malpositioning .
furthermore , his condition was stable with no evidence of bleeding at the time of diagnosis of iatrogenic splenic injury by ct .
a treatment plan was developed to remove the malpositioned tube penetrating through the spleen 2 weeks after insertion .
the treatment for empyema was continued with antibiotics and drainage , while abdominal findings were examined and the drainage fluid from the malpositioned tube was checked every day . on hospital day 27 ( 14 days after insertion of the malpositioned tube ) , contrast study through the malpositioned tube showed that only a tube track was visualized without spreading of the contrast into the abdominal cavity , suggesting that formation of a fistula around the tube had occurred ( fig .
2 ) . as there was a potential of bleeding in the fistula after removal , a radiologist was prepared and ready to perform tae if severe bleeding occurred .
the malpositioned tube was successfully removed through a slow , stepwise withdrawal with careful attention paid to bleeding .
3 ) . the patient 's empyema was cured , and he was discharged on hospital day 34 .
only the tube track was visualized , without spreading of the contrast into the abdominal cavity .
we provided a sufficient explanation and an apology concerning iatrogenic splenic injury caused by chest tube insertion for a patient and family .
if splenic injury unfortunately occurs as a complication after chest tube insertion , it often develops into a critical situation such as severe bleeding and shock and requires emergency treatment . in emergency surgery for iatrogenic splenic injury , attempts to preserve the spleen must be made because of the risk of overwhelming postsplenectomy infection syndrome 8 .
successful hemostasis with splenic preservation by some materials , such as fibrin glue , argon beam coagulation , and absorbable mesh wrapping , has been reported 9 , 10 , 11 .
angiographic embolization of splenic bleeding has been reported as a noninvasive emergency management for iatrogenic splenic injury 12 .
if there is no severe adverse event immediately after injury of spleen by the tube insertion , emergency treatment may not be required .
there have been two reported methods of conservative treatment for iatrogenic penetrating splenic injury 13 , 14 , 15 , 16 . in one method ,
thrombin hemostatic sealant and an absorbable gelatincompressed sponge along the transsplenic tube tract 13 , 14 . in the second method that was the most noninvasive management ,
the penetrating tube was removed about 2 weeks after the insertion without any treatment 15 , 16 .
our case is the first report in noninvasive management with delayed removal of the tube for iatrogenic splenic injury after chest tube insertion .
noninvasive treatments require a long hospital stay but provide the advantage of a less invasive treatment for patients who unfortunately suffer an iatrogenic injury . in the present case , we chose a noninvasive management with delayed removal of the malpositioned tube .
first , the hemorrhage from the damaged spleen had to be restrained by compression of the transsplenic track of the tube .
as the tube had only a few lateral holes near the tip , these lateral holes were located outside of the spleen and consequently no bleeding from the spleen occurred .
however , there was a potential of severe bleeding from the spleen if the tube was removed too early .
therefore , an attempt was made to restrain the hemorrhage through compression of the transsplenic track of the malpositioned tube for an extended duration .
there was a risk of intraabdominal bleeding from the spleen even if the tube was removed after compression for an extended duration .
if a fistula was formed around the tube , removal of the tube might result in bleeding in the fistula , but without intraabdominal bleeding .
a time of 2 weeks was estimated for granulation and fistula formation around the malpositioned tube . in the present case , a radiologist was prepared and ready to perform tae during the delayed removal of the malpositioned tube .
in conservative management , it is important to make preparations to control for any unexpected bleeding .
it should be kept in mind that conservative management may fail . to prevent this serious complication on chest tube insertion
, the most important thing is to use ultrasonography to demonstrate a good site for insertion with the patient in the same position as insertion . in the present case ,
ultrasonography was used prior to chest tube insertion . however , the 9th left intercostal space was very low for chest tube insertion , so it was inferred that the internal medical doctor who inserted chest tube misidentified a spleen as the empyema cavity and did not make a count of ribs .
ultrasonography to demonstrate a good site for insertion prior to chest tube insertion must be performed or witnessed by a clinician who has familiarity with positional relationship between ribs and thoracic cavity .
we report a case of iatrogenic penetrating splenic injury that was successfully treated with noninvasive management and subsequent removal of the malpositioned tube 2 weeks after insertion . if a patient who unfortunately suffers an iatrogenic injury is hemodynamically stable , noninvasive management with delayed removal of the malpositioned tube may be considered .
ko , rh , rc , mm , ss , ys , tl and ns treated the patient .
rh , rc , mm , ss , ys , tl , ns , kk and ym helped to draft the manuscript .
 key clinical messagesplenic injury is one of the most critical complications of chest tube insertion and often requires invasive emergency management . 
 however , noninvasive management such as delayed removal of the malpositioned tube may be considered for a stable patient without severe adverse event . 
Introduction
Case Report
Discussion
Conflict of Interest
Authorship