Endoscopic Management of Perforation of Right Hepatic Duct Following Non-Surgical Abdominal Trauma

Isolated bile duct injuries after blunt abdominal trauma are rare. Surgery is the usual mode of treatment. We report a patient with a right hepatic duct injury following blunt abdominal trauma who was managed successfully by endoscopic papillotomy.     

Gallbladder and extrahepatic biliary duct injury following abdominal trauma.

Extrahepatic biliary tract and gallbladder injuries are rare, but many occur after both blunt and penetrating abdominal trauma. During a 5-year period, 24 patients requiring laparotomy for abdominal trauma were found to have an extrahepatic biliary tract injury, representing 13 per cent of all patients admitted with hepatic trauma during the same period. The majority of patients had injury to the gallbladder; only one case of common bile duct injury was identified. Of the patients, 50 per cent had an associated hepatic injury; 17 per cent had important pancreatic trauma. Isolated gallbladder injury occurred in only 8 per cent of patients. The overall mortality associated with gallbladder trauma was 16 per cent. This uncommon injury usually results from severe trauma and is associated with a high incidence of other major visceral injuries.     

An unusual bile duct injury in a child after blunt abdominal trauma.

Bile duct injuries are rare in children after blunt trauma. This report describes a 3-year-old child who sustained a blunt abdominal trauma resulting in bile duct, liver, and small bowel injuries. The initial management at another hospital included recognition and repair of a small bowel perforation. However, the postoperative course was complicated by a large biliary leak. The child was transferred to our institution where radioisotope scanning and endoscopic retrograde cholangiography confirmed the extent of the ductal injury. At laparotomy there were injuries of both right and left hepatic ducts, and an anomaly of bile duct course was noted. The right hepatic duct was repaired primarily and the left one was repaired with Roux-en-Y hepaticojejunostomy. Postoperatively, normal bile drainage was documented by radioisotope scan and the patient remains symptom free at 1 year follow-up.     

Biliary stricture due to neuroma after an innocent blunt abdominal trauma

A traumatic neuroma of the biliary tract is rarely associated with biliary obstruction. However, when it arises in the common bile duct (CBD) and is associated with obstructive jaundice, it is difficult to distinguish it from bile duct cancer. We describe a patient who developed obstructive jaundice and itching, due to CBD stricture, 8 years after innocent blunt abdominal trauma. The stricture was resected and hepatico-jejunal anastomosis was performed. Histological examination revealed a traumatic neuroma and a fibrous scar around the common bile duct. Symptoms disappeared following surgical removal of the lesion. Blunt abdominal injury may cause the late onset of a fibrous scar and traumatic neuroma in the common bile duct. To our knowledge, a traumatic neuroma of the biliary tract after blunt abdominal trauma has not been reported previously. We review the clinical picture of this relatively rare problem, along with its diagnosis, pathogenesis and treatment.     

Extrahepatic bile duct injury due to abdominal trauma

The diagnosis of bile duct injury due to abdominal trauma is usually not feasible preoperatively, but it must be suspected interoperatively with the presence of bile staining fluid in the subhepatic area. Four patients with bile duct injuries were encountered; these were the results of blunt injury in three and penetrating injury in one. The injury sites were in the common bile duct in two patients, and in the right hepatic duct just proximate to the bifurcation in two patients. One patient was diagnosed on the finding of bile stain discharged from the drainage tube after the first abdominal exploration. The other three patients were diagnosed by the amount of bile stained fluid collected in the subhepatic area during the primary laparotomy. The injuries of the common bile duct were treated by primary repairs and T-tube choledochostomy in two patients. The other two patients with right hepatic duct injuries were treated by right lobectomy because of extensive liver parenchyma injury. The postoperative courses were smooth and there were no deaths. We reviewed 27 reports (1984–1994) from around the world. The total operative mortality of the 75 patients in these reports was 18.67% (14/75) for the primary operation, and 7.14% (1/14) for re-operation in patients in whom reoperation was performed due to overlooked injuries or biliary complications.     

腹腔镜胆道手术并发症的腹腔镜处理体会:附17例临床报告

目的 探讨腹腔镜胆道手术并发症的同期或再次腹腔镜下处理的可行性和有效性.方法 对17例腹腔镜胆道手术并发症经腹腔镜下处理的方法 和结果 进行总结分析.结果 术中发现肝总管损伤3例,胆囊床肝中静脉损伤出血3例,胆囊管残端同缩和十二指肠损伤各1例;术后发现胆漏6例,胆囊床和胆囊动脉出血各1例,戳孔疝1例.该组病例均经同期或再次腹腔镜处理治愈,未增加腹部戳孔,术后平均住院3.7 d.胆管修复者平均随访7.7个月,无胆管狭窄发生.结论 腹腔镜胆道手术并发症,对已掌握丰富微创技术者,大多数能在腹腔镜下获得安全、有效处理.     

Porta hepatis disruption from blunt trauma

Extrahepatic porta hepatis injuries from blunt abdominal trauma are exceedingly rare; all recently reported cases involve disruption of the common bile duct at its intrapancreatic portion. We herein report a patient with lacerations of the proper hepatic artery and bile duct occurring from deceleration/torsion of the porta hepatis after high speed vehicular collision.     

腹腔镜胆道修复重建术治疗腹腔镜胆囊切除术中的胆管损伤

目的腹腔镜手术出现胆管损伤后通常需要中转开放手术修复或二期手术,给患者增加极大的痛苦。能否采用腹腔镜手术的方法修复胆管损伤是一个值得探讨的问题。本研究的目的是探讨腹腔镜修复术治疗术中和术后早期发现的医源性胆管损伤的方法和可行性。方法总结分析2002年11月至2012年12月采用腹腔镜修复重建术治疗的11例术中或术后早期发现的医源性胆管损伤的资料。11例发生在腹腔镜胆囊切除术中（11／1485,0．74％）。男7例,女4例,平均年龄57．4岁（26～70岁）。其中6例为胆管轻度损伤,5例为高位胆管横断的重度胆管损伤。按刘允怡分类法,11例胆管损伤的损伤类型分别是：I型2例,ⅡA型2例,IIIA型2例,ⅣA型3例,ⅣB型2例。9例胆管损伤在术中发现,另2例在术后2d发现。针对不同的损伤类型采用不同的修复方法。2例肝总管部分轻度损伤（UA型）的患者采用镜下缝合修补、T管引流来修复g1例右肝管孔状损伤的患者采用镜下单纯缝合修复;1例胆总管误扎的患者在镜下松解结扎线、胆总管探查、T管引流;1例胆囊床迷走小胆管横断的患者镜下缝扎封闭;1例胆囊颈残余胆漏的患者采用镜下切除残余胆囊、缝扎胆囊管的方法修复;另外5例高位胆管横断伤（肝总管或者左、右肝管横断伤）的患者采用镜下损伤的胆管对端吻合、硅胶支架管内引流的方法修复。结果11例胆管损伤（BDI）患者均完全腹腔镜下一期修复术,无中转开腹手术。术后患者恢复顺利,无腹腔感染、无伤口感染等并发症发生。胆管修复术后平均住院时间是8．9d（5～15d）。患者均获得随访,随访时间8个月-10年不等。11例患者均无胆管狭窄。有1例患者发生过一次胆管炎,CT发现胆总管轻度扩张,行经内镜逆行性胰胆管造影术检查未发现胆总管结石,无胆管狭窄、肿瘤,考虑胆管轻度扩张为十二指肠乳头炎性狭窄引起,行经内镜下乳头括约肌切开术后治愈。其余10例患者无胆管炎、胆管狭窄等长期并发症。结论轻度胆管损伤可以采用镜下单纯缝合修补或T管引流治疗,胆管横断损伤可以采用腹腔镜下胆管对端吻合术、支架引流管内引流管术的治疗。腹腔镜下胆管修复术用于治疗医源性胆管损伤是有效可行的。然而,手术的难度极大,技术要求高,必须由具有丰富的胆道外科手术和娴熟的腹腔镜技术的专家进行手术。     

自体组织修复肝门部胆管良性狭窄

目的 总结应用自体组织修复肝门部胆管良性狭窄的经验。方法 回顾分析我院自1989～2002年应用带蒂胆囊壁瓣修复肝门部胆管良性狭窄33例，应用肝圆韧带修复肝总管狭窄2例。结果 35例术后无明显胆瘘、出血等并发症，无手术死亡。术后T管造影显示无狭窄。术后30例(30/35)随访2个月至12年，仅有2例因术后胆管炎发作，经非手术治愈，收到良好效果。结论 应用自体组织带蒂胆囊壁瓣及肝圆韧带修复肝门部胆管良性狭窄符合生理性，取材方便，操作简便，效果良好。     

创伤性肝胆管损伤的外科处理

目的探讨创伤性肝胆管损伤的处理方法。方法回顾性分析近10年我院收治220例肝创伤中12例肝胆管损伤患者的临床资料：结果除外院转入1例因来院过晚,失去手术时机衰竭死亡外,另11例均获痊愈：其中7例再手术治疗：1例持续胆漏予以近端漏口缝扎,胆总管引流;3例因反复发作化脓性胆管炎、梗阻性黄疸,行胆管空肠Roux—Y吻合术：另3例伴有肝萎缩、创伤性胆道出血分别行肝段、叶切除术。尚有4例胆漏维持通畅引流．亦获满意结果．于2周内停止胆漏。结论肝创伤合并肝胆管损伤,经初期和后期认真处理,均可获得良好预后．     

医源性胆管损伤的原因及处理(附66例报告)

目的探讨胆管损伤和狭窄的防治方法。方法回顾性分析６６例胆囊切除（或伴）胆总管探查术发生胆管损伤及狭窄的原因和治疗。结果１３例胆管损伤在术中发现并立即修复,其中１２例手术治愈,１例术后发生胆管狭窄。５３例胆管狭窄或胆漏在术后被诊断,其中４例行胆管对端吻合（术后均复发狭窄）;４４例行胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合,３６例治愈;５例吻合口狭窄经再手术治愈。８例死亡（死于胆漏感染５例,胆汁性肝硬化３例）。结论胆管损伤若能术中发现并妥善修复常可避免发生狭窄。胆肠Ｒｏｕｘ－ｅｎ－Ｙ吻合治疗胆管狭窄可取得较好疗效。     

Conservative management of hepatic duct injury after blunt trauma: a case report

Nonoperative management of solid organ injury in children with blunt abdominal trauma represents the standard of care. In rare cases, a major duct injury with persistent bile leakage may result from blunt trauma to the liver. This injury is of concern in patients treated nonoperatively because it generally must be treated with major abdominal surgery. The authors describe a case of hepatic duct injury from blunt trauma in which healing occurred without surgical repair or resection.     

创伤性肝门部胆管损伤的诊断与治疗

目的 探讨创伤性肝门部胆管损伤的诊断与治疗。方法 回顾性总结肝门部胆管损伤8例，近期裂口全部使用修补 支撑管引流术，7例合并2个以上脏器损伤，术中同时作了处理，远期并发胆管狭窄行胆肠内引流术。结果 8例胆管损伤中，5例是在手术探查时发现，其中损伤裂口＜周径50％者3例，行修补术，1例死亡，2例良好；＞周径50％者2例，修补术后1例死亡，1例并发胆管狭窄，行二次手术。另3例是因术后胆漏而发现，胆管狭窄后行胆肠内引流术，均恢复良好。结论 创伤性胆管损伤极易漏诊，术中细致探查、彻底清除局部积血和坏死组织是避免得诊的关键。治疗上应因伤而异，一般可采用修补 支撑管引流术；损伤范围＞胆管周径50％、炎症较重者应行胆肠内引流术。并发胆管狭窄后可采用手术或内镜及介入治疗。     

Extrahepatic Duct Injury in Blunt Trauma: Two Case Reports and a Literature Review

Traumatic injuries of the extrahepatic biliary tract are rare. Associated injuries are usually responsible for immediate indication for surgical treatment, the time when an injury to the extrahepatic biliary ducts may be diagnosed. However, missed injuries are often common. The primary aim of this paper is to describe the clinical features, diagnosis, treatment, and outcome of two patients with left hepatic duct injury after blunt abdominal trauma. As a secondary objective, a literature review is presented. The two cases presented in this study are as follows: (1) A young male, involved in a motor vehicle crash, was admitted with blunt hepatic trauma in a general hospital. Endoscopic retrograde cholangiography was conducted 3 weeks later and revealed a large leakage at the left hepatic duct. Exploratory laparotomy was performed 26 days after the initial traumatic event and identified a complete section of the left hepatic duct, treated with anastomosis. (2) A male fell from a height. On exploratory laparotomy, a 30 % partial injury of the left hepatic duct was found in addition to hemoperitoneum, liver injury, gallbladder detachment together with cystic duct rupture, retroperitoneal hematoma to the right, and cecum hematoma. A high level of suspicion is necessary to identify injuries to the hepatic ducts. Early diagnosis that occurs during laparotomy due to associated injuries is important to reduce complications.     

Extrahepatic biliary tract injury: operative management plan

Trauma to the extrahepatic biliary tract is rare but, if overlooked or improperly managed, may be associated with significant morbidity. The following is our most recent 6-year experience with this unusual injury. Among 949 patients undergoing laparotomy for acute trauma, there were 32 (3%) injuries to the gallbladder and five (0.5%) to the common bile duct. All patients with gallbladder injury underwent abdominal exploration because of associated trauma. Cholecystectomy was preferred for 24 (96%) of the 25 with penetrating wounds and three (43%) of the seven with blunt trauma. Nine (28%) patients developed postoperative complications but none were related to the biliary injury. All common bile duct injuries (CBD) were penetrating. Associated intra-abdominal trauma was always present. Partial lacerations were closed primarily over a T-tube. An intrapancreatic CBD lesion was managed by sphincteroplasty and stented with a T-tube. The one patient with complete transection underwent choledochoenterostomy. Postoperative complications were common (50%) but none were related to the biliary injury.     

Treatment of recurrent bile duct stricture after primary reconstruction for laparoscopic cholecystectomy-induced injury

Laparoscopic cholecystectomy (LC) has been accepted as a primary treatment modality for various benign gallbladder diseases. However, bile duct injury has occurred in a non-negligible proportion of patients who undergo LC. The outcome of primary reconstruction for LC-induced major bile duct injuries is usually favorable, but a small proportion of patients revealed serious biliary stricture during follow-up. We described the experience on the treatment for such delayed-onset bile duct strictures that occurred in 5 patients. One patient showed biliary strictures 6 months after primary hepaticojejunostomy, which were successfully treated with radiologic intervention. Other 4 patients underwent right lobectomy and redo hepaticojejunostomy 4 to 16 months after primary biliary reconstruction. No recurrent biliary stricture occurred during mean follow-up of 40 months. In conclusion, prolonged surveillance over 5 years seems necessary for the detection of delayed-onset biliary stricture after primary biliary reconstruction. Delayed-onset bile duct stricture should be treated on the case-by-case basis, with radiologic intervention or radical biliary reconstruction combined with liver resection.     

腹腔镜胆囊切除术中肝外胆管损伤及处理

自１９９２年１月～１９９６年１月，１２５０例病人因胆囊结石或胆囊息肉样病变在本院施行ＬＣ，胆管损伤７例（０．５６％），损伤类型包括：（１）总胆管或总肝管横断各１例；（２）总肝管部分横断２例；（３）电凝损伤总肝管及右肝管各１例；（４）钛夹钳夹右肝管１例。本组处理方法为胆管修补、胆管对端吻合及空肠Ｒｏｕｘ－Ｙ吻合术。本文认为术者操作经验不足、不适当的止血操作、胆囊病变因素及解剖不清是导致胆管损伤的原因。胆管损伤最重要的仍然是术中发现及时处理，则预后良好。     

NON-IATROGENIC TRAUMA TO THE EXTRAHEPATIC BlLlARY TRACT

Between 1980 and 1991, 15 cases of non-iatrogenic extrahepatic biliary tract trauma have been managed at Westmead and the Royal Canberra Hospitals. There were seven cases of gall-bladder injury and eight bile duct injuries. Four cases resulted from penetrating trauma whereas 11 resulted from blunt trauma. Associated injuries were common. Cholecystectomy was the preferred method of management for gall-bladder injuries whereas the bile duct injuries were managed by a variety of techniques. There were three deaths in the series, mostly related to associated injuries. Bile duct injuries were associated with longer hospitalization than gallbladder injuries.     

Repair of a traumatic noncircumferential hepatic bile duct defect using a vein patch: case report

Injury to the bile ducts secondary to blunt trauma is a rare but potentially fatal condition that presents a difficult diagnostic and treatment challenge. Various treatment options exist for repair. Vein patch repairs have been criticized because of reports of subsequent fibrosis and stricture formation. This case report describes the successful repair of a traumatic, noncircumferential defect of a hepatic bile duct with a vein patch, and stresses the importance of an adequate duration of stenting.     

Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention

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 percutaneous 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.