Extrahepatic Biliary Tract Injuries Research Articles

Trauma to the gallbladder is associated with concurrent injuries to the extra hepatic biliary system: A South African experience

IntroductionGallbladder trauma is a rare injury. This study aimed to describe the significance of these injuries and the appropriate management strategies. MethodsA retrospective study was undertaken at a major trauma centre in South Africa and included all patients diagnosed with a gallbladder injury between January 2012 and October 2020. ResultsA total of 51 cases were included (88% male, mean age: 38 years), with 44 (86%) penetrating trauma cases [28 stab wounds (SW), 16 sustained gunshot wounds (GSW)]. Of the 7 (13%) blunt trauma cases, five were involved in a motor vehicle crash, and two were injured via assault. All patients underwent laparotomy. Full-thickness gallbladder laceration or perforation was the most common type of injury (84%) and all patients with a gallbladder perforation or laceration had a cholecystectomy at index operation. Two out of 5 patients with a gallbladder contusion were managed conservatively without a cholecystectomy and the remaining three had evidence of gallbladder necrosis which were managed with cholecystectomy. Associated extrahepatic bile duct injuries occurred in 4% of cases, and 18 cases (35%) required intensive care unit (ICU) admission. The overall mortality was 8%. ConclusionGallbladder injury is rare but when encountered implies a significant degree of trauma. Although cholecystectomy is usually definitive, there is an association with other occult extra-hepatic biliary tract injuries. The severity of the associated injuries usually determines patient outcomes.

Iatrogenic injuries of the extrahepatic biliary system

BackgroundIatrogenic traumatic extrahepatic biliary tract injuries though rarely occur; they can lead to exceedingly morbid complications. The aim of this study was to evaluate the management strategies and outcomes of patients presented with iatrogenic bile duct injuries. MethodsThis is a retrospective study. Over 19 y, 124 patients were managed for iatrogenic biliary injuries at our institution. The data related to the etiology of biliary tract injury, symptoms of injury, laboratory and radiologic studies, injury-to-diagnosis time, type of biliary tract injury, injury management, hospitalization time, and postoperative complications were reviewed. ResultsThe main clinical presentations were jaundice or recurrent cholangitis in 64 (51.61%) patients, followed by bile peritonitis in 34 (56.67%) and biliary fistula in 26 (43.33%) patients. Only in 23 (18.54%) cases, the injury was recognized intraoperatively. The most frequent surgical procedure was open cholecystectomy in 81 (65.32%) of 124 patients. The remaining patients were operated on laparoscopically. Good results were achieved in 99 of 101 patients with direct suture repair including hepaticojejunostomy, choledocoduodenostomy, and choledochocholedochostomy (98.02% success rate) at the first attempt. Three cases (2.97%) of biliary strictures after direct suture technique and four (3.96%) cases of postoperative mortalities were detected. The mortality rate was mostly affected by male gender, advanced age, and existence of bile peritonitis. Totally, 111 (89.52%) patients are still alive with a mean follow-up time of 78 ± 38 (2–230) mo. ConclusionsBiliary injuries can be sometimes life-threatening complications. A successful repair may provide patients with a lifelong relief from symptoms, whereas a failed repair may result in recurrent biliary obstruction, reoperation, and even death.

Biliary tract injuries

Injury to the extrahepatic biliary tract occurs frequently due to damage inflicted during upper abdominal operations, cholecystectomy being the commonest situation followed by other upper abdominal surgeries, and less often due to blunt or penetrating abdominal injury. Most traumatic extrahepatic biliary tract injuries are caused by penetrating trauma and are usually discovered during laparotomy. Diagnosis is made by noting the accumulation of bile in the upper quadrant. The gallbladder is the most commonly injured structure. Regardless of the type of biliary injury and/or management, wide and adequate drainage is essential. Any upper abdominal operation can result in biliary tract injuries. Cholecystectomy is the procedure most implicated in biliary tract injuries because it is one of the most common elective surgeries performed worldwide. If not managed properly, bile duct injuries can lead to life-threatening complications. Identification and management of biliary tract injuries demand precise judgement, expertise, timely and appropriate intervention and prevention of complications. This study aims to present detailed information and an update on biliary tract injuries.

Isolated Left Hepatic Duct Injury in Blunt Trauma Abdomen: Two Case Reports with Literature Review

Isolated extrahepatic biliary tract injury following blunt abdominal trauma is rare. The underlying pathogenic mechanisms remain obscure, but include shear and/or compression forces on the biliary system. Associated morbidity rates are high and largely the result of delays in diagnosis. . 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 crush injury by a motor vehicle, was referred with history of blunt hepatic trauma thirty days back and abdominal distension from a general hospital. His vitals were stable. Sonography of abdomen demonstrated a large fluid collection in upper abdomen. A percutaneous drain was placed in this collection and drained approximately 5000ml of bile. Due to continued drainage of several hundred millilitres of bile per day an Endoscopic retrograde cholangiography (ERCP) was obtained. This demonstrated a leakage at the left hepatic duct and stenting was done. Over the next several days, the drainage markedly decreased. A repeat ERCP was conducted 12 weeks later and stent was replaced. This further decreased bilious discharge to 20 ml/day for three days and then nil. Stent and drain was removed and patient was comfortably discharged and followed up. (2) A young male fell from a height. On exploratory laparotomy, hemoperitoneum, liver injury, retroperitoneal hematoma to the right with no biliary leak was noted at that time. 600ml/day bilious discharge was noted in drain from post-operative day 2. Endoscopic retrograde cholangiography was conducted 2 weeks later and revealed a large leakage at the left hepatic duct. Repeat exploratory laparotomy was performed and revealed left hepatic duct injury. Primary closure of left hepatic duct over t-tube was done. 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.

Treatment and outcome of traumatic biliary injuries in children

Background/PurposeTraumatic biliary tract injuries in children are rare but may result in significant morbidity. The objective of this study was to review the occurrence of traumatic biliary tract injuries in children, management strategies, and outcome. MethodsWe conducted a retrospective review of patients with biliary tract injury using the trauma registry at our level 1 pediatric trauma center from 2002–2012. ResultsTwelve out of 13,582 trauma patients were identified, representing 0.09% of all trauma patients. All were secondary to blunt trauma. Mean age was 9.7years [range 4–15], and mean Injury Severity Score was 31±14, with overall survival of 92%. Biliary injuries included major ductal injury (6), minor ductal injury with biloma (4), gallbladder injury (2), and intrahepatic ductal injury (1). Major ductal injuries were managed by endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent (5) and Roux-en-Y hepaticojejunostomy (1). Associated gallbladder injury was managed by cholecystectomy. In addition, the associated biloma was managed with percutaneous drainage (7), laparoscopic drainage (2), or during laparotomy (3). Two patients with ductal injuries developed late strictures after initial management with ERCP and stent placement. One of the two patients ultimately required a left hepatectomy, and the other has been managed conservatively without evidence of cholangitis. Two patients required placement of additional drains and prolonged antibiotics for superinfection following biloma drainage. ConclusionBiliary tract injuries are rare in children, and many are amenable to adjunctive therapy, including ERCP and biliary stent placement with or without placement of a peritoneal drain. Patients with a discrete ductal injury are at higher risk for stricture and require close follow up. Hepaticojejunostomy remains the definitive repair for large extrahepatic biliary tract injuries or transections.

Isolated Avulsion of the Common Hepatic Duct from Blunt Abdominal Trauma

Isolated extrahepatic biliary tract injury following blunt abdominal trauma is rare. The underlying pathogenic mechanisms remain obscure, but include shear and/or compression forces on the biliary system. Associated morbidity rates are high and largely the result of delays in diagnosis. Imaging modalities commonly employed for diagnosis include ultrasonography, computed tomography, nuclear medicine, and magnetic resonance imaging. Percutaneous and endoscopic techniques have been used both for diagnosis and treatment. Treatment options are dictated by the stability of the patient and the extent of bile duct and concomitant injuries. In this paper, we discuss a case of isolated avulsion of the hepatic duct confluence following blunt trauma that was successfully managed with Roux-en-Y hepaticojejunostomy. To our knowledge, this specific injury pattern has not been previously reported.

Blunt Left Extrahepatic Bile Duct Injury: Case Report and Literature Review.

Extrahepatic biliary tract injuries following blunt abdominal trauma are very rare and pose a diagnostic and therapeutic challenge. We report a case of blunt liver injury with left extrahepatic duct transection following a motor vehicle collision. Technetium 99m dimethyliminodiacetic acid scan confirmed a bile leak and endoscopic retrograde cholangiopancreatography (ERCP) diagnosed the injury of the left extrahepatic duct. Management was initially conservative, consisting of external drainage along with trials of stent placement. Ultimately, partial left hepatectomy was required to definitively treat the injury. In the setting of suspected biliary tract injury, early ERCP is essential to localize a leak and guide management decisions. In the event of a confirmed bile leak, a trial of nonoperative management consisting of endoscopic ductal decompression along with percutaneous drainage may initially be warranted although is not always successful.

Repair of extrahepatic biliary duct.

A new technique is reported for repair of extrahepatic biliary tract injury at the confluence of right and left hepatic and common bile duct. This is an experience of 03 cases of such an injury. We used T-tube, angulated in such a way as to make a Y-tube with short limbs for right hepatic duct and left hepatic duct.

Post-hepatorrhaphy biloma and biliary fistula in patients with liver trauma

During the period 1986–1994, 6250 patients were admitted to the Accident and Emergency Unit of the University Hospital, Kuala Lumpur, with 175 patients requiring hepatoorhaphy. Eleven of these 175 patients developed either a biloma, biliary fistula or both. The patients' ages ranged from 15 to 40 years, with a mean injury severity score of 23. Seven patients suffered penetrating injury and 4 were victims of blunt trauma. The right lobe was injured in 10 patients, with 1 patient sustaining left lobe injury. All liver injuries were either grade 3 (7 patients) or grade 4 (4 patients). No patient sustained extrahepatic biliary tract injury. Biloma and fistulas were diagnosed 14–30 days post-injury (mean, 24 days) by computed tomography (CT) or99mTc-2,6-dimethylacetanilideiminodiacetic acid (HIDA) scans. All were managed by CT-guided percutaneous drainage. One patient also required percutaneous transhepatic cholangiography with biliary stent placement, due to bile-stained ascites. Fistulas persisted for 5–120 days (mean, 44 days). No patient required further operative intervention and all fistulas closed spontaneously without complication.

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.

FOUR RARE CASES OF TRAUMATIC GALLBLADDER AND EXTRAHEPATIC BILE DUCT INJURY

Among extrahepatic biliary tract injuries due to abdominal blunt trauma, which are only rarely observed in clinical practice, four interesting cases of injury to the gallbladder and extrahepatic bile duct have been encountered over the past seven years. According to the classification of gallbladder injuries into 1) contusion, 2) laceration, 3) avulsion, 4) traumatic cholecystitis and 5) biliary peritonitis without perforation, the morbid condition of the first case was considered to be contusion, that of the second case traumatic cholecystitis, and that of the third case traumatic cholecystectomy. The fourth case was an injury in which the extrahepatic bile duct was released and exposed from the common hepatic duct to the intra-pancreatic bile duct, accompanied by crushing injuries to the duodenum and pancreatic head. Since to our knowledge there has been no previous report on this type of injury in the literature, the term “exposed injury” was adopted for this case. In addition to reports on these four cases, the classification, pathogenetic mechanism, diagnosis and treatment methods for these injuries were discussed together with a review of the literature.

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.

The extrahepatic biliary tract injury: perspective in diagnosis and treatment.

Nonsurgical trauma to the extrahepatic biliary tract is being reported with increasing frequency. There has been no recent review of the management of these injuries. Forty patients over the past twelve years at Charity Hospital, New Orleans, were studied. The 10% mortality rate was due to associated injuries. Tangential injuries were best managed by suture closure and T-tube drainage. Biliary-enteric anastomoses were most successful in the treatment of complete transections. Delayed diagnosis is not uncommon, and new methods of diagnosis are discussed. Injuries of this nature are responsible for high morbidity rates due to fistula or stricture formation. Successful management of these injuries is vital, even in those patients with more severe associated injuries.