Machado Norman Oneil
Norman Oneil Machado, Department of Surgery, Sultan Qaboos University Hospital, Muscat 123, Oman.
World J Gastrointest Surg. 2016 Apr 27;8(4):335-44. doi: 10.4240/wjgs.v8.i4.335.
To study the etiopathogenesis, management and outcome of duodenal injury post laparoscopic cholecystectomy (LC).
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.
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.
Duodenal injuries are caused by thermal burns or by dissection during LC and require prompt treatment. Delay in repair could negatively influence the outcome.
研究腹腔镜胆囊切除术（LC）后十二指肠损伤的病因、处理方法及预后。
使用搜索词“十二指肠损伤”和“LC”在Medline数据库中检索所有关于LC后十二指肠损伤的英文文章。进一步检索这些文章的参考文献，查找潜在的关于十二指肠损伤的文章，并进行研究。纳入标准包括病例报告、病例系列和综述。即使某些研究参数缺乏详细信息的文章也进行了分析。研究时间段涵盖截至2015年1月发表的所有病例。提取的数据包括人口统计学细节、就诊性质和日期、十二指肠损伤的潜在原因、十二指肠损伤部位、检查、处理方法及预后。基于Q和I²统计量选择荟萃分析的模型（固定效应或随机效应）。使用STATA软件绘制森林图，并计算损伤发现时间及其对死亡率影响的总体估计值和95%置信区间。使用带有Yate校正的χ²检验估计损伤发现时间与死亡率之间的关联。基于Kaplan-Meier生存曲线概念，估计损伤后不同天数的累积生存概率。
文献综述发现74例LC后十二指肠损伤病例。患者的平均年龄为58岁（23 - 80岁），其中46%为男性。损伤原因包括电灼（46%）、解剖（39%）和牵拉（14%）。46%的病例在手术台上被发现有损伤。损伤的常见部位是十二指肠第二部，其中46%在乳头上方，15%在乳头下方，31%在十二指肠第一部。十二指肠缝合术（一期缝合）是63%的主要手术干预方式，其中21%通过腹腔镜进行。其他手术包括经皮引流、十二指肠造瘘管置入、胃切除术、胰十二指肠切除术和幽门旷置术。存活患者的损伤发现平均时间为1.6天（包括手术台上发现的患者），而死亡患者为4.25天。基于随机效应模型，损伤发现的总体平均持续时间为1.6（1.0 - 2.2）天（95%置信区间）。基于固定效应模型，这些研究的总体死亡率为10%（0% - 25%）。应用Kaplan-Meier生存概率，如果在第1天发现损伤，累积生存概率为94%，如果在第2天发现则为80%。在之后发现损伤的患者中，生存概率急剧下降。
十二指肠损伤是由LC期间的热灼伤或解剖引起的，需要及时治疗。修复延迟可能对预后产生负面影响。
