Laparoscopic exploration of the retroperitoneum in a gunshot victim: A case report.

INTRODUCTION: Non-operative management and minimally invasive surgery reduce the burden of negative laparotomies in patients with penetrating gunshot wounds (GSW). Careful patient selection is key. Although challenging, in experienced hands laparoscopic exploration of the retroperitoneal space can be carried out. CASE PRESENTATION: A 38year old man was brought to the emergency room after sustaining a GSW to his right groin. Due to evidence of intoxication, clinical picture was unreliable, although the patient was hemodynamically stable and there were no signs of peritonitis. Furthermore, the presence of retained bullet fragments created significant artifact on imaging. Clinical and radiological uncertainty urged us to proceed with laparoscopic exploration. Following mobilization, the ascending colon wall was fully inspected and no injury was identified. The pelvic fracture was managed non-operatively. After an uneventful hospital course, the patient was discharged home in stable condition and outpatient follow up was re-assuring. DISCUSSION: Avoiding morbidity from missed colonic injury is important, particularly in patients with unclear clinical and radiological findings, that were present in our case. Non-operative management by serial examination and minimally invasive surgical techniques are considered an alternative to the classical exploratory laparotomy approach. Furthermore, utilization of laparoscopy in retroperitoneal injury has gained much attention in the recent years particularly in well-established centers. CONCLUSION: Laparoscopic exploration is a safe and effective surgical approach in patients who have sustained GSW to the abdomen and to the retroperitoneal space. However, it requires careful patient selection and surgical expertise.

Multiple primary gastrointestinal tumors of gastric, pancreatic and rectal origin; a case report.

INTRODUCTION: The occurrence of multiple primary synchronous or metachronous malignancies is a described phenomenon. Such cases may have genetic predisposition or could be related to environmental risk factors but may also be sporadic. We are reporting a unique combination of triple primary synchronous malignancies in the same patient. CASE PRESENTATION: A 71 year old man presented with constipation and per rectal bleeding with a palpable mass 5-6 cm from the anal verge on physical examination. Colonoscopy with biopsy confirmed adenocarcinoma of rectal origin. After multi-disciplinary tumor board meeting, the patient received neoadjuvant chemoradiation therapy followed by single-stage surgery. Re-staging work up showed the presence of pancreatic lesion. Incidental finding of a gastric nodule upon surgical exploration which was confirmed to be a gastrointestinal stromal tumor. The patient had an uneventful postoperative course. DISCUSSION: Multiple primary malignancies of the gastrointestinal system has previously been reported in the literature; whether in the form of double, triple, quadruple or even quintuple primaries. Furthermore, gastrointestinal malignancies have been reported to be combined with extra-intestinal malignancies. However, this unique combination of pancreatic adenocarcinoma, rectal adenocarcinoma and gastric gastrointestinal stromal tumor has not been previously reported in the literature. Single-stage multiple resections was successful. CONCLUSION: We are reporting a unique case of three primary malignancies involving the rectum, pancreas and stomach. For such patients, there is no clear guidelines regarding management or surveillance, but rather should be individualized.