Perseverance pays: A complicated case of post laparoscopic cholecystectomy duodenal injury

Introduction

Laparoscopic cholecystectomy (LC) is the gold standard today for the treatment of gallstone disease. The rates of major complication of this procedure are around 3%.¹ While the biliary complications, with rates of 0.1–0.6%,^{2, 3, 4} have been well documented, the non-biliary complications have not been well reported, though these could be equally morbid and life threatening. Duodenal injuries are distinct non-biliary complications which have a different mechanism of injury. They pose difficult diagnostic and therapeutic challenges and are potentially fatal if not promptly recognized and managed. In one series of four cases of post LC duodenal injuries, three patients died.⁵ We report a case of a post LC duodenal injury that was referred to us which was complicated by other events and was successfully managed.

Case report

A 39-year-old female patient underwent LC at a civil hospital. Per op, the patient had a thin-walled gallbladder with minimal adhesions. The operative time was 3 h with issues of maintaining pneumoperitoneum, the blood loss was negligible and as a routine, a tube drain was placed. Post-operatively, she developed hypotension, had bilious content in drain and a USG abdomen showed free fluid. The patient was resuscitated with fluids and was referred to tertiary center as a bile duct injury where she underwent an exploratory laparotomy on POD 2. Per-operatively, the patient was found to have a duodenal injury. A T-tube duodenostomy (TTD) through the injury and a feeding jejunostomy (FJ) was done. Post-operatively, she developed fever, pain abdomen, wound dehiscence and bilious drainage from the wound.

Her relatives sought discharge from there and admitted her to another tertiary center where CECT abdomen revealed a leak of contrast from the second part of duodenum along with superior vena cava thrombosis. She was managed conservatively for one month, a period which was complicated with intercurrent sepsis.

She was then brought to our center for further management. On evaluation, she was sick, was febrile, had tachycardia, tachypnea and pedal edema. Per abdomen, there was wound dehiscence with an expelled T-Tube that had led to an uncontrolled high output duodenal fistula, and an exposed jejunal loop that was fistulated with FJ feeds leaking from it (Fig. 1). There were extensive skin excoriations. She was managed with effluent control along with skin protection, sepsis control by culture based antibiotics/antifungals and aggressive fluid/electrolyte management. Special emphasis was placed on feeding fortified feeds through fistuloclysis along with supplemental parenteral nutrition through a femoral line. Low molecular weight heparin and other routine care of bed ridden a patient were also initiated. During hospitalization, sepsis worsened with respiratory distress and ARDS needing ventilatory support A CT angiogram done showed an extensive ileo-femoral venous thrombosis and ARDS but no pulmonary thromboembolism. Anticoagulation was escalated to therapeutic doses following which she developed massive hemoptysis with desaturation and hypotension necessitating inotropes. The patient had diffuse alveolar hemorrhage (anti coagulant associated) and was transfused blood products and vitamins K. Anticoagulation was withheld and an IVC filter placed. She developed septicemia with multi-organ dysfunction, which was managed aggressively and finally, weaned off from the ventilator.

Fig. 1.

The condition of the patient at presentation to our center. (A) Dehisced wound with duodenal contents pooling in its lateral aspect causing extensive skin excoriations; (B) Displaced T-tube from duodenal rent; (C) Jejunal fistula; (D) Feeding jejunostomy; (E) Tube drain in Morrison pouch draining duodenal contents.

She was taken up for surgery after nutritional build-up, ambulation and chest physiotherapy. She was explored through a midline laparotomy and was found to have dense adhesions between transverse colon, duodenum stomach and omentum as well as liver with a large fistula in exposed jejunum. Two fistulae in the 2nd part of duodenum 2.5 × 2.5 cm and 1 × 1 cm with saponification all over the omentum and mesentery of small and large bowel were present (Fig. 2). The jejunal fistula was dismantled and adhesiolysis was done. The larger duodenal fistula was repaired while the smaller one was closed over a T-tube. In addition, a pyloric exclusion along with an FJ was done (Fig. 3). The post-op recovery was uneventful. The IVC filter was removed and she was discharged on the 14th POD, four months after her initial surgery. Her TTD was removed after 4 weeks and FJ after 6 weeks. She has now completed 6 months of follow-up and is doing well. She is being worked up for thrombophilia.

Fig. 2.

Operative photograph showing the larger duodenal fistula (Black arrow) and the smaller fistula (Black arrow head) with a T-tube inserted in to it.

Fig. 3.

The surgical procedure done. (A) The smaller duodenal fistula repaired over a t-tube; (B) The larger fistula closed with interrupted sutures. (C) Pyloric exclusion; (D) Jejuno-jejunostomy following segmental resection of jejunal fistula; (E) Feeding jejunostomy.

Discussion

As compared to biliary injuries, post LC duodenal injuries have not been reported often and as such have not been well documented. It is a rare complication, but can be life threatening if not recognized early and treated. In large series of LC, the reported rate of duodenal injuries has been 0.03–0.2%.^{6, 7} One of the earliest cases was reported in 1994, a full-thickness necrosis of the duodenal wall with delayed perforation.⁸

The mechanism of duodenal injuries is distinct from those of other bowel injuries during LC. Small bowel injuries are usually due to inadvertent injury by Veress needle or trocars during the initial entry into the abdomen. In contrast, duodenal injuries usually result from thermal damage from energy devices, either contact or conductive.⁹ This danger is potentiated by working in compromised conditions like in this case where the operating surgeon had problems with maintaining the pneumoperitoneum. Alternatively, they can arise during separation of duodenum when it is densely adherent to the gallbladder.¹⁰ Duodenal injuries due to improper use of suction-irrigators¹⁰ and compression by titanium clips¹¹ have also been described.

Only occasionally are duodenal injuries recognized during surgery. Free perforation and egress of duodenal juices into the peritoneal cavity usually occurs hours later. They present early in the post op period or in a delayed manner when the injury is due to a conductive thermal damage. Just like biliary injuries, duodenal injuries should be suspected if the recovery of patient's is not as smooth as expected. Abdominal pain and tenderness either diffuse or at the right upper quadrant are usually present. Abdominal palpation may show signs of peritonitis though, at times, this may be absent due to the retroperitoneal location of the injury. It may also become evident when an intraoperatively or post-operatively placed drain has bilious content.

Imaging in the form of an abdominal ultrasound or CT may show a localized collection (subhepatic or retroduodenal) or diffuse intraperitoneal fluid. Needle aspiration will yield bile. Evidently, it is difficult to differentiate between a biliary injury and a duodenal injury at this time. A review of the video of the surgery, if available, may be helpful in identifying the site of injury. A retroduodenal location of collection would point towards a duodenal injury.^{8, 10} A high amylase content in the bilious drainage will also point to a duodenal injury while a gastrograffin upper GI study would clinch the diagnosis. At reoperation, if a duodenal injury is not obvious, absence of bile leak from the gallbladder fossa or the bile duct should prompt a thorough search for a duodenal or small bowel injury.

The management of such injuries depends on the time delay since the index surgery, the location and the extent. The proximal portion of the duodenum is often involved. Duodenal bulb injuries, usually, have better outcome than descending duodenal injury. Our case had descending part of duodenum injury Small perforations, when detected early can be managed by suturing along with an omental patch.¹⁰ Some cases of laparoscopic repair have been described for injuries of the duodenal cap.¹⁰ Contained perforations have been managed with pigtail drainage.⁶ In many cases, a pyloric exclusion has been used successfully.⁸ We believe that this is a safe and a versatile technique, and most cases, except for the early/small perforation should be managed with this procedure in conjunction with an FJ. A point that needs emphasis is that it is better to give a single time solution to a problem, though at times, it may seem to be an overkill. It surely would avoid the misery that such patients would have to undergo and it may not always be possible to pull the patient out from the brink of death.

This patient initially underwent a TTD more than 48 h after the index operation. This was a suboptimal management for the duodenal injury associated with sepsis and extensive retroperitoneal contamination. She had already spent more than a month at two tertiary care centers. When the patient was admitted to us, she was in sepsis, had an uncontrolled duodenal fistula with extensive skin excoriation. She had another enteric fistula distal to the FJ rendering it ineffective thereby adding to nutritional problems and creating a complex wound that was extremely difficult to manage. This was compounded by extensive DVT and ARDS needing prolonged ventilator support and the final straw was the pulmonary hemorrhage necessitating prolonging of ventilator support and stopping of anticoagulation, resulting in the need for an IVC filter. We could manage to pull her out of these problems with perseverance and dedicated effort of the whole team. What was more important was the resolve and motivation that the patient showed and the dedication of the husband who was constantly by her side offering her unconditional psychological support.

Conclusion

A duodenal injury, though rare, should always be borne in mind in a patient with less than normal post op recovery and/or bile in the drain or on percutaneous aspiration. They should be picked up promptly and managed optimally which would, almost always, need surgery. An adequate surgery in the window of opportunity would help avoid further complications which can become a vicious circle with one leading to another. At such times, what is needed is not to give up because, more often than not, perseverance pays.

Conflicts of interest

All authors have none to declare.