Profuse haemorrhage from inguinal sinus track - life-threatening complication in “groin injecting” drug users

Abstract

Introduction: Inguinal way usually serves as final gate selected for intravenous access by injecting drug abusers, when other routes have failed or are not available. Repeated injections in groin area for femoral vein approach increase the risk of surgical complications, often life-threatening, among the most common being listed: abscess, superficial thrombophlebitis, deep vein thrombosis with subsequent embolic events, chronic venous insufficiency, arteriovenous fistula, arterial pseudoaneurysm with eventual thrombosis and arterial insufficiency. The aim: presentation of two clinical cases of relatively rare complication occurred in “groin injecting” drug users - profuse external haemorrhage following inguinal sinus formation, stopped definitively by surgical intervention. Material and methods: Two young male patients aged 29 years and 34 years respectively, with the stage of intravenous drug abuse of at least 5 years, were emergently admitted to the department of General Surgery with recent haemorrhage from a pre-existing skin lesion in the left inguinal area. General signs of bleeding were well manifested in both subjects, being observed also traces of blood on their clothes and left groin area. During the inspection there was noted a skin dimpling (with a diameter of 9 mm and 11 mm, respectively) localized right below the inguinal crease corresponding to projection of femoral vessels with a cyanotic prominence in the center of lesions. Subsequent revision revealed the presence of formed tunnel lined with epithelial cells, leading directly to the wall of femoral vein - diagnosed as sinus track. Imaging study (duplex scanning) confirmed the presence of abnormal channel (sinus) just above the common femoral vein and concomitant hypo-hyperechoic thrombotic masses in deep veins of ipsilateral lower extremity extended till the common femoral and external iliac vein, respectively. Both patients developed preoperative recurrence of haemorrhage: one after the primary physical examination (required temporary hemostasis by compression bandage and short-term resuscitation in conditions of ICU) and other - on the operating table, immediately before surgical exposure. In both cases operation was carried out under local anesthesia, limited excision of skin mark being performed. After clear localization of the external orifice of sinus tract it was closed by applying continuous suture using synthetic non-absorbable thread (polypropylene 5/0). Results: No major complications were registered in early postoperative period. Primary healing of postoperative wound was observed in one patient, but small wound dehiscence occurred in other, followed by subsequent healing by secondary intention. Recurrent episodes of haemorrhage from inguinal scars at 6 months and 8 months after surgery, respectively, were not declared. Conclusions: Sinus track formation in inguinal area of “groin injecting” drug users carries a risk of threatening external haemorrhage with recurring character. Continuous suturing of external orifice of groin sinus with synthetic non-absorbable thread can serve as surgical option to achieve sustainable hemostasis in cases of external bleeding. Drug use and addiction possess negative consequences for individuals and public health, and surgical complications among intravenous injecting are throughout emerging. In this context the urging of medical students must be more active promotion of healthy.