Bilioptysis due to a single transcavitary thoracoabdominal gunshot wound

A 27-year-old man was transported to our trauma center after sustaining a single gunshot wound. On arrival, he was hemodynamically stable and neurologically intact, with a non-tender abdomen and negative FAST (focused assesment with sonography in trauma). Complete skin examination revealed a wound on his left hip and no additional injuries. CT demonstrated a trans-thoracoabdominal trajectory with a single projectile embedded in the right chest wall and suspected injuries to the duodenum, descending colon, pancreatic head, gall bladder, liver, and diaphragm (figure 1). Figure 1 CT of chest and abdomen showing tract of the projectile. A trauma laparotomy was performed, and the patient was found to have gross disruption of the anterior first and second parts of the duodenum, distal common bile duct injury, perforation of the gall bladder, liver injury traversing segments 4b and 8, sigmoid mesocolon injury, right diaphragm perforation, and right hemopneumothorax. No definitive pancreatic duct injury was identified. Given ongoing hemodynamic and metabolic stability, definitive repair was completed, including right chest tube insertion, primary repair of the right diaphragm, cholecystectomy, primary duodenal repair, pyloric exclusion with Roux-en-Y gastrojejunostomy, hepaticojejunostomy, sigmoid mesocolon repair, and wide drainage for possible pancreatic injury. Postoperatively, a pancreatic leak was noted, which resolved with medical treatment including total parenteral nutrition and a somatostatin analogue. Three weeks after …