Gunshot-induced retroperitoneal trauma with complex duodenal injury: a case report

Abstract

Duodenal trauma is rare and frequently associated with severe concomitant injuries, particularly in penetrating retroperitoneal mechanisms. Management is complex and often requires staged surgical strategies, diversion, and multidisciplinary care. Herein the case of a middle-aged male who sustained a shotgun injury is reported, using review of electronic medical records and relevant literature to contextualize diagnostic and therapeutic decision-making. Initial evaluation revealed a retroperitoneal zone-2 hematoma without intraperitoneal contamination, and the patient underwent exploratory laparotomy with damage control surgery. Within 48 hours, he developed hemodynamic instability with active retroperitoneal and pancreaticoduodenal bleeding. Reoperation demonstrated expanding zone-1 and zone-2 hematomas, right renal injury, transverse colon perforation, and a complex duodenal lesion with devascularization. Management included arterial ligation, right nephrectomy, bowel repair, duodenal diversion, retroperitoneal drainage through the lumbar incision, and temporary abdominal closure. Persistent bile and enteric leakage required a hybrid surgical-endoscopic approach with endoscopic closure, pyloric exclusion, jejunostomy feeding access, and maintained retroperitoneal diversion. With prolonged multidisciplinary intensive care, infection control, nutritional optimization, and negative-pressure therapy, the patient achieved clinical stabilization and was discharged after 126 days. Severe duodenal trauma, although uncommon, carries substantial morbidity. Early application of damage control principles, selective repair and diversion, expert hepatobiliary involvement, and sustained multidisciplinary management are essential to sepsis control, physiologic recovery, and survival in complex retroperitoneal penetrating trauma.