Duodenal injury post laparoscopic cholecystectomy: Incidence, mechanism, management and outcome

Abstract

AIM: To study the etiopathogenesis, management and outcome of duodenal injury post laparoscopic cholecystectomy (LC).

METHODS: A Medline search was carried out for all articles in English, on duodenal injury post LC, using the search word duodenal injury and LC. The cross references in these articles were further searched, for potential articles on duodenal injury, which when found was studied. Inclusion criteria included, case reports, case series, and reviews. Articles even with lack of details with some of the parameters studied, were also analyzed. The study period included all the cases published till January 2015. The data extracted were demographic details, the nature and day of presentation, potential cause for duodenal injury, site of duodenal injury, investigations, management and outcome. The model (fixed or random effect) for meta analyses was selected, based on Q and I² statistics. STATA software was used to draw the forest plot and to compute the overall estimate and the 95%CI for the time of detection of injury and its outcome on mortality. The association between time of detection of injury and mortality was estimated using χ² test with Yate’s correction. Based on Kaplan Meier survival curve concept, the cumulative survival probabilities at various days of injury was estimated.

RESULTS: Literature review detected 74 cases of duodenal injury, post LC. The mean age of the patients was 58 years (23-80 years) with 46% of them being males. The cause of injury was due to cautery (46%), dissection (39%) and due to retraction (14%). The injury was noted on table in 46% of the cases. The common site of injury was to the 2^nd part of the duodenum with 46% above the papilla and 15% below papilla and in 31% to the 1^st part of duodenum. Duodenorapphy (primary closure) was the predominant surgical intervention in 63% with 21% of these being carried out laparoscopically. Other procedures included, percutaneous drainage, tube duodenostomy, gastric resection, Whipple resection and pyloric exclusion. The day of detection among those who survived was a mean of 1.6 d (including those detected on table), compared to 4.25 d in those who died. Based on the random effect model, the overall mean duration of detection of injury was 1.6 (1.0-2.2) d (95%CI). Based on the fixed effect model, the overall mortality rate from these studies was 10% (0%-25%). On application of the Kaplan Meier survival probabilities, the cumulative probability of survival was 94%, if the injury was detected on day 1 and 80% if detected on day 2. In those that were detected later, the survival probabilities dropped steeply.

CONCLUSION: Duodenal injuries are caused by thermal burns or by dissection during LC and require prompt treatment. Delay in repair could negatively influence the outcome.

Keywords: Laparoscopic cholecystectomy, Duodenal injury, Duodenorapphy

Core tip: Inadvertent duodenal injury is a rare potentially fatal complication of laparoscopic cholecystectomy. Such injuries often go unrecognized at the time of the procedure and manifest later with significant morbidity and mortality. Literature review revealed 74 cases of duodenal injury. The injury was caused by cautery in 46%, dissection in 39% and retraction in 14% of the cases. The predominant site of injury was to the 2^nd part in 61% and in 31% to 1^st part. Duodenorapphy was the primary treatment carried out in 63% of the cases among which 21% was laparoscopically. When detected on table, 88.9% survived in contrast to 76.5% detected later. Overall mortality was 18%. The major impact of this review in clinical practice is in emphasizing the need for prompt detection of a potential duodenal injury in every patient who has unexplained postoperative course following a difficult laparoscopic cholecystectomy due to gall bladder adhesions or dissection. The change of clinical practice it should lead to is an attempt by surgeons in early detection of potential duodenal injury in such patients, which could be achieved by estimating the amylase content in subhepatic fluid collection or by upper gastrointestinal contrast studies. It also highlights the need for immediate surgical repair as any delay beyond the first postoperative day has adverse effect on outcome.