Traumatic pediatric bile duct injury: nonoperative

intervention as an alternative to surgical intervention
Hamdi Almaramhi, Aayed R. Al-Qahtani
*
Division of Pediatric Surgery, College of Medicine, King Khalid University Hospital, PO Box 84147,
Riyadh 11671, Saudi Arabia
Abstract
Background: Nonoperative management of blunt pediatric liver injuries has become the standard of care
in the absence of hemodynamic instability. However, associated bile duct injuries remain as difficult
challenges. Few case reports have demonstrated the benefits of conservative approaches, but others have
found better outcomes with surgical intervention. In this study, we report on our experience with
interventional endoscopic and radiologic management of 5 pediatric patients with bile duct injuries who
underwent unsuccessful surgical interventions.
Methods: We conducted a retrospective review of medical records of all pediatric patients who were
admitted with major blunt liver trauma and bile duct injuries over a period of 5 years.
Results: There were 5 patients (4 boys and 1 girl) whose ages range from 3 to 11 years in this study. All
patients had major liver laceration and bilomas. Two had intrahepatic and 3 had extra hepatic bile duct
injuries (2 right hepatic ducts and 1 junction of cystic duct with common bile duct). All of them
underwent previous laparotomies, once in 2 patients, twice in 2 patients, and thrice in 1 patient. All
5 patients were eventually treated successfully with interventional endoscopic and radiologic
techniques. Three underwent endoscopic retrograde cholangiopancreatography stenting with percuta-
neous drainage. Two patients were managed with percutaneous drainage alone. The follow-up is up to
2.5 years with normal liver function test and bile duct ultrasound.
Conclusion: With the current advancement in endoscopic retrograde cholangiopancreatography and
intervention radiology techniques, we believe that interventional endoscopic and radiologic
management of bile duct injuries caused by blunt trauma in children is successful and efficacious
even after multiple laparotomies.
D 2006 Elsevier Inc. All rights reserved.
In children, nonoperative management of blunt liver
injuries has become the standard of care in the absence of
hemodynamic instability. However, associated bile duct
injuries remain as difficult challenges. The diagnosis is
difficult and usually missed, initially resulting in substantial
morbidity and prolonged hospitalization and has led to death
in some cases [1-11].
Surgery has been the mode of treatment in traumatic bile
duct injuries [3,4]. With the advancements in endoscopy and
interventional radiology, few case reports have demonstrat-
ed the benefits of nonoperative approaches [2,6,7,9,12-16].
0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2006.01.057
Presented at the 37th Annual Meeting of the Canadian Association of
Paediatric Surgeons, Quebec, Canada, September 22-25, 2005.
* Corresponding author. Tel.: +966 14671575.
E-mail address: qahtani@yahoo.com (A.R. Al-Qahtani).
Index words:
Bile duct injury;
Conservative
management;
Bile leak;
Surgical management;
ERCP;
Stent
Journal of Pediatric Surgery (2006) 41, 943–945
www.elsevier.com/locate/jpedsurg
We present our experience with 5 pediatric patients with
traumatic bile duct injury missed during the initial laparot-
omy. All were successfully managed nonoperatively.
1. Patients and methods
Between June 1999 and February 2005, 5 patients were
admitted to our hospital with the diagnosis of major blunt
liver trauma and bile duct injuries.
These patients’ medical records were reviewed retro-
spectively for demographic data, mechanism and type of
injury, associated injury, time delay to definitive diagnosis,
diagnostic and therapeutic modalities, length of hospital
stay, and outcomes.
2. Results
There were 5 patients (4 boys and 1 girl) with an average
age of 6.8 years (range: 3-11 years) in this study. The
primary cause of blunt abdominal trauma was a fall from a
motorbike in 1 patient and an automobile accident in
4 patients. All patients were transferred from other hospitals
after local initial management allowing hemodynamic
stabilization. All of them underwent previous laparotomies
before their transfer: once in 2 patients, twice in 2 patients,
and thrice in 1 patient (Table 1). The indication of the initial
laparotomy in all patients was hemodynamic instability. The
repeated laparotomies were for bile leaks that were not
controlled. In all cases, there were major liver laceration and
bilomas. Two had intrahepatic and 3 had extrahepatic bile
duct injuries (2 right hepatic ducts and 1 junction of cystic
duct and common bile duct).
One of the patients had fractures of both the tibia and
fibula and another one had a fractured right humerus and
colonic tear. The average delay before diagnosis was
24.8 days (range: 3-60 days). All patients were eventually
treated successfully with interventional endoscopic and
radiologic techniques. Three patients underwent endoscopic
retrograde cholangiopancreatography (ERCP) stenting with
percutaneous drainage and 2 were managed by percutaneous
drainage alone (Table 2). One patient required total parenteral
nutrition for 3 weeks, 2 patients required peripheral parenteral
nutrition for a short period before starting oral intake, and
1 patient did not require nutritional support. The average
follow-up was 19 months (range: 5-30 months). All were
clinically free of symptoms with normal liver function and
bile duct ultrasound.
3. Discussion
Bile duct injuries caused by blunt abdominal trauma are
rare. They are usually associated with liver parenchymal
injury and seldom an isolated one.
The exact incidence of such injuries is unknown.
Bourque et al [1], in their review of the literature in 1989,
Table 1 Specification of injuries, time delay before diagnosis, and number of laparotomies
No. Age (y) Sex Mechanism
of injury
Type of
biliary injury
Associated
injuries
No. of previous
laparotomies
Delay before
diagnosis (d)
1 3 Male RTA Junction of cystic
duct and CBD
– 2 60
2 6 Female RTA Right hepatic duct Fractured tibia
and fibula
1 20
3 6 Male RTA Right hepatic duct Fractured humerus
and colonic tear
3 25
4 8 Male RTA Intrahepatic – 1 16
5 11 Male Fall from
motorbike
Intrahepatic – 2 3
RTA indicates road traffic accident; CBD, common bile duct.
Table 2 Management, complications, and hospital stay
No. Age (y) Sex Type of injury Method of management Complications Hospital stay (d) Follow-up
1 3 Male Junction of cystic
duct and CBD
Percutaneous drainage,
ERCP + stent
Infection 36 1 y
2 6 Female Right hepatic duct Percutaneous drainage,
ERCP + stent
– 25 2 y
3 6 Male Right hepatic duct Percutaneous drainage,
ERCP + stent
Infection 20 2 y
4 8 Male Intrahepatic Percutaneous drainage – 26 2.5 y
5 11 Male Intrahepatic Percutaneous drainage – 20 5 mo
H. Almaramhi, A.R. Al-Qahtani 944
reported 125 cases of extrahepatic bile duct injury—one
third of them were in pediatric patients. Dawson et al [5]
reported one case of bile duct injury in 10,500 consecutive
trauma patients.
The diagnosis is always difficult and often delayed,
especially in those cases where nonoperative management
of blunt liver injuries was implicated [6]. However, these
injuries can be missed even in those requiring laparotomies
[6,7]. Michelassi and Ranson [8] reported a 12% incidence
of missed ductal injury on initial laparotomies. The
diagnosis of bile duct injuries was missed in all our patients
on their initial laparotomies. Repeated laparotomies were
unsuccessful in controlling the bile leaks.
The time delay before diagnosis in our patients is similar
to that in others [1,2]. Early diagnosis requires a high index
of suspicion and timely use of diagnostic modalities such as
hepatobiliary scintigraphy, ultrasound, computed tomo-
graphic scan, magnetic resonance cholangiopancreatogra-
phy, ERCP, and intraoperative cholangiogram [2,9-12].
HIDA scan is the preferred screening tool for bile leak.
Weissman et al [11] recommended obtaining delayed
images if bile leak is suspected even if the study is normal
at 1 hour. All our patients had a positive HIDA scan
demonstrating bile leak. It was able to differentiate the
intrahepatic from the extrahepatic bile duct injuries without
specific localization. We did not find magnetic resonance
cholangiopancreatography useful in these cases. Endoscopic
retrograde cholangiopancreatography may be required to
obtain more precise data on the anatomy of the biliary
system. Its usefulness and safety have been advocated in
many recent publications, with greater than 90% ductal
visualization and lower than 10% morbidity [13].
The management of bile duct injuries has evolved over
the past few decades from a strategy where laparotomy was
required to one where laparotomy is used selectively.
With the current advancement in radiologic and endo-
scopic techniques, few pediatric case reports describing the
benefits and safety of nonoperative management using
ERCP stenting and/or percutaneous drainage have been
published. In our study, 5 patients were treated successfully
using this approach despite multiple laparotomies in some
of them. Three patients underwent ERCP stenting with
percutaneous drainage and 2 had percutaneous drainage
alone. This modality of management is not free from
complications. Hartle et al [14] claimed that the use of
percutaneous drainage may be beneficial if an active bile
leak is not present. They added that the risk of secondary
infection restricts this treatment to a relatively short period.
Two of our patients developed infection of the bile
collection. Both were treated by intravenous antibiotics
without significant morbidity.
Stents may migrate or clog. In adults, stent migration is
reported to occur in 2% to 5% of patients, whereas clogging
is reported to occur in 20% to 30% of patients within
3 months of insertion [15]. In children, the long-term effects
of biliary stenting are not known. A stent was used in 3 of
our patients and was removed after 3 months with no
particular adverse effect demonstrated over a follow-up
period ranging from 6 months to 2.5 years.
In conclusion, with current interventional endoscopic and
radiologic techniques, we believe that nonoperative man-
agement of blunt bile duct injuries in pediatric patients is
successful and efficacious even after multiple laparotomies.
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