It has been reported that the causes of horizontal duodenal perforation are trauma or iatrogenic injury due to ERCP mainly. Duodenal injury is present, on average, in 3.7–5% of abdominal injuries and may be due to either blunt trauma of the abdomen or penetrating injuries . Though incidence of iatrogenic injuries during upper gastrointestinal endoscopy alone is extremely rare, it is significantly higher in ERCP, estimated to be between 0.4 and 1% [5, 7].
Chest and erect abdominal radiography and ultrasonography are not of diagnostic value, and the modality of choice is CT scan with both oral and intravenous contrast media [2, 3]. Factors like anatomical location of the injury, type and extent of injury, associated injuries to other structures and organs, and time of surgery determine the type of surgical options and their outcome . The American Association for the Surgery of Trauma has suggested the Organ Injury Scale , but the grading may not always dictate the management . Likewise, several authors have proposed the immediate surgical repair of ERCP-related duodenal perforations .
The surgical options available for repairing perforation are simple repair (duodenorrhaphy), resection and anastomosis, repair and decompressive enterostomy, serosal or mucosal patch, pyloric exclusion, duodenal diverticulization, and pancreaticoduodenectomy . Majority of perforations can be managed by simple repair or resection and anastomosis. Duodenal diverticulization and pancreaticoduodenectomy are rarely required [3, 11]. In our first case, blunt trauma to the abdomen resulted in perforation of approximately half of the circumference of the duodenum (grade III injury). Side-to-side duodenojejunostomy was preferred and a safe method for this case. For the protection of the suture line by decompression of the anastomotic site, we made a tube gastrostomy, tube duodenostomy, and percutaneous transhepatic drainage.
Damage control surgery consisting of an initial abbreviated surgery to control bleeding and contamination, followed by correction of hypothermia, coagulopathy, and acidosis in the critical care unit and timely re-exploration, has promising outcomes in the management of patients with critical trauma . Endoscopic closure by endoclips is found to be a safe, feasible, and effective technique for the treatment of ERCP-related duodenal perforation .
The injury in the second case was due to therapeutic endoscopic coagulation which was diagnosed in the third postoperative day. Due to the presence of a diverticulum in the third part, unhealthy wound margins, and adjacent superior mesenteric artery, segmental resection of the duodenum was effective. It was important to make an anastomosis at the healthy descending duodenum. In the third case, injury to the third part of the duodenum during ERCP was most probably the result of a duodenal abnormality secondary to neoplasm. We preferred non-surgical management initially because of the elderly patient’s poor general condition and associated comorbidities, which ultimately led to a failure to respond. Due to the presence of a tumor site close to the perforation area, narrowing of the descending duodenum, and adhesions, we opted for duodenojejunostomy and gastric bypass by gastrojejunostomy and jejunojejunostomy.
An association of duodenal rupture with other intraabdominal organ injuries and leakage of a large volume of pancreatic and biliary secretion causes severe sepsis, contributing to its significant mortality (6 to 25%) and morbidity (30 to 60%) . Among our cases, the first case had a significant morbidity (Clavien-Dindo grade IV ), and the second case had grade II complications. However, the postoperative period of the third case was uneventful, and there was no mortality among the cases. All of the emergency surgeries were done in a single setting, and we did not feel the need of damage control surgery in our cases. We also recommend pyloric exclusion as an alternative approach in case of suspicion of possible wound leakage.