title: Multiple pancreaticoduodenal penetrating gunshot trauma evolving into acute necrotizing pancreatitis. A combined surgical and minimally invasive approach.
abstract: BACKGROUND
  Shotgun injuries are the cause of increasing surgical problems related to the proliferation of firearms. Gunshot pancreaticoduodenal traumas are unusual in urban trauma units. Their management remains complex because of the absence of standardized, universal guidelines for treatment and the high incidence of associated lesions of major vessels as well as of other gastrointestinal structures. Surgical treatment is still controversial, and the possibilities offered by the safe and effective mini-invasive techniques seem to open new, articulated perspectives for the treatment of pancreaticoduodenal injury complications.
  
  
  METHODS
  We present the case of a 27-year-old man with multiple penetrating gunshot trauma evolving into acute necrotizing pancreatitis, treated by combining a surgical with a mini-invasive approach. At admission, he presented a Glasgow Coma Score of 4 due to severe hemorrhagic shock. First, surgical hemostasis, duodenogastric resection, multiple intestinal resections, peripancreatic and thoracic drainage were carried out as emergency procedures. On the 12th postoperative day, the patient underwent re-surgery with toilette, external duodenal drainage with Foley tube and peripancreatic drainage repositioning as a result of a duodenal perforation due to acute necrotizing pancreatitis. Eight days later, following the accidental removal of the peripancreatic drains, a CT scan was done showing a considerable collection of fluid in the epiploon retrocavity. Percutaneous CT-guided drainage was performed by inserting an 8.5 Fr pigtail catheter, thus avoiding further re-operation. The patient was successfully discharged on the 80th postoperative day.
  
  
  CONCLUSIONS
  The treatment of multiple pancreaticoduodenal penetrating gunshot traumas should focus on multidisciplinary surgical and minimally invasive treatment to optimize organ recovery.
authors.affiliation: Section of General and Thoracic Surgery, Department of Applications in Surgery of Innovative Technologies, University Medical School of Bari, Bari, Italy. mario.testini@chirgen2.uniba.it
authors.forename: Mario
authors.initials: M
authors.lastname: Testini
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Piccinni
authors.forename: Pasquale
authors.initials: P
authors.lastname: Pedote
authors.forename: Germana
authors.initials: G
authors.lastname: Lissidini
authors.forename: Angela
authors.initials: A
authors.lastname: Gurrado
authors.forename: Domenica
authors.initials: D
authors.lastname: Lardo
authors.forename: Luigi
authors.initials: L
authors.lastname: Greco
authors.forename: Rinaldo
authors.initials: R
authors.lastname: Marzaioli