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Traumatic pediatric bile duct injury: nonoperativeintervention 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

0022-3468/$ – see front matter D 2006

doi:10.1016/j.jpedsurg.2006.01.057

Presented at the 37th Annual Meetin

Paediatric Surgeons, Quebec, Canada, S

* Corresponding author. Tel.: +966

E-mail address: qahtani@yahoo.com

Index words:Bile duct injury;

Conservative

management;

Bile leak;

Surgical management;

ERCP;

Stent

AbstractBackground: 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

Elsevier Inc. All rights reserved.

g of the Canadian Association of

eptember 22-25, 2005.

14671575.

(A.R. Al-Qahtani).

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].

Journal of Pediatric Surgery (2006) 41, 943–945

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.

H. Almaramhi, A.R. Al-Qahtani944

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

Table 2 Management, complications, and hospital stay

No. Age (y) Sex Type of injury Method of ma

1 3 Male Junction of cystic

duct and CBD

Percutaneous d

ERCP + stent

2 6 Female Right hepatic duct Percutaneous d

ERCP + stent

3 6 Male Right hepatic duct Percutaneous d

ERCP + stent

4 8 Male Intrahepatic Percutaneous d

5 11 Male Intrahepatic Percutaneous d

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,

nagement Complications Hospital stay (d) Follow-up

rainage, Infection 36 1 y

rainage, – 25 2 y

rainage, Infection 20 2 y

rainage – 26 2.5 y

rainage – 20 5 mo

Traumatic pediatric bile duct injury 945

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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