title: Duodenal injury post laparoscopic cholecystectomy: Incidence, mechanism, management and outcome.
abstract: OBJECTIVE
  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 I (2) 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 χ (2) 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.
  
  
  CONCLUSIONS
  Duodenal injuries are caused by thermal burns or by dissection during LC and require prompt treatment. Delay in repair could negatively influence the outcome.
authors.affiliation: Norman Oneil Machado, Department of Surgery, Sultan Qaboos University Hospital, Muscat 123, Oman.
authors.forename: Norman Oneil
authors.initials: NO
authors.lastname: Machado
keywords: Duodenal injury; Duodenorapphy; Laparoscopic cholecystectomy