Nonoperative management of biliary tract fistulas after blunt abdominal trauma in a child

doi:10.1016/0022-3468(95)90463-8

Journal of Pediatric Surgery

Volume 30, Issue 12, December 1995, Pages 1719-1721

https://doi.org/10.1016/0022-3468(95)90463-8 Get rights and content

Abstract

Nonoperative treatment was carried out in a 12-year-old girl who presented with biliary fistulas after blunt abdominal trauma with hepatic injury. A computed tomography-guided percutaneous puncture showed biliary peritonitis and permitted the positioning of an efficient intraperitoneal drainage. Endoscopic retrograde cholangiography was very helpful for visualization and accurate localization of biliary injuries. This permitted positioning a nasobiliary drain to reduce intrabiliary pressure and to bypass a lesion of the common hepatic duct. This nonoperative management allowed healing of fistulas within 20 days, without bile duct stricture (noted on the follow-up intravenous cholangiogram 18 months later).

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Cited by (39)

Treatment and outcome of traumatic biliary injuries in children
2014, Journal of Pediatric Surgery
Traumatic 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.
We conducted a retrospective review of patients with biliary tract injury using the trauma registry at our level 1 pediatric trauma center from 2002–2012.
Twelve out of 13,582 trauma patients were identified, representing 0.09% of all trauma patients. All were secondary to blunt trauma. Mean age was 9.7 years [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.
Biliary 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.
Minimally invasive management of bile leaks after blunt liver trauma in children
2006, Journal of Pediatric Surgery
Management of bile leaks after blunt abdominal trauma remains controversial. Conventionally, open surgery has been considered necessary, but new modalities of treatment, including endoscopic biliary stenting and laparoscopy, offer a minimally invasive alternative.
A retrospective review of all cases of blunt liver trauma in children treated at our institution between May 2002 and October 2004 was performed looking for possible biliary injury.
Five children (3 boys), median age 13 years (range, 10-15 years), were referred to our institution at a median time of 4 days (1-15 days) after the initial trauma. Mechanism of injury was motor vehicle accident (n = 3), fall from a motorbike/Quad bike (n = 2), and a scooter handlebar injury (n = 1). Two, who were hemodynamically unstable, required laparotomy within 24 hours, although their subsequent management was minimally invasive. Endoscopic retrograde cholangiopancreatography, performed at a median time of 15 days (2-28 days), demonstrated an intrahepatic biliary leak in all 5 patients. Biliary stenting was performed in each case, with 2 also having a sphincterotomy. One subsequently developed a bile duct stricture that was managed by endoscopic dilatation. Four required additional percutaneous external drainage of intraabdominal collections. Two underwent laparoscopy to facilitate peritoneal lavage and rule out bowel injuries. No child required open surgery to treat the bile leak. Median hospital stay was 43 days (range, 15-58 days).
A minimally invasive, multidisciplinary approach to traumatic bile leaks, as an alternative to open surgery, is practical and safe. It requires flexibility, particularly if the diagnosis has been delayed, and may still involve a prolonged hospital stay.
Medical imaging in the management of abdominal trauma
2006, Journal de Chirurgie
La prise en charge non opératoire des traumatismes abdominaux fermés est devenue un standard chez le patient hémodynamiquement stable en absence de signes péritonéaux. Ce choix thérapeutique impose la disponibilité d’une imagerie médicale diagnostique et/ou thérapeutique pour guider la prise de décisions.
There is a marked trend toward nonoperative management of abdominal trauma. This hasbeen possible thanks to the advances in imaging and interventional techniques. Computed tomography (CT), angiography, and endoscopic retrograde cholangiopancreatography (ERCP) can guide the nonoperative management of abdominal trauma.
Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention
2006, Journal of Pediatric Surgery
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.
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.
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.
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.
Posttraumatic biliary stricture in a child
2005, Injury Extra
Endoscopic management for hepatic duct injury in children
2005, Archives de Pediatrie
Le traitement conservateur et la surveillance chirurgicale dans un service de réanimation pédiatrique sont de règle dans le traumatisme hépatique de l'enfant, à la condition d'un état hémodynamique stable. Dans de rares cas, des plaies des voies biliaires sont découvertes à distance de l'accident et viennent compliquer les suites et la surveillance. La chirurgie hépatobiliaire traumatique est périlleuse. Nous rapportons le cas d'un enfant de 13 ans avec un traumatisme hépatique compliqué d'une plaie des voies biliaires, chez lequel le traitement endoscopique apportait les solutions diagnostiques et thérapeutiques avec d'excellents résultats.
Non-operative management of hepatic injury in children with abdominal trauma represents a standard of care. A major duct injury with persistent bile leakage may result from trauma to the liver. This injury is of concern in patients treated non operatively because it generally requires major hepatic surgery. We report on a case of a 13-year-old boy with an hepatic duct injury from trauma in which healing occurred without surgical repair or resection.

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Case reportNonoperative management of biliary tract fistulas after blunt abdominal trauma in a child

Abstract

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Gastrointest Endosc

Gastrointest Endosc

Nonoperative management of major blunt liver injury with hemoperitoneum

Arch Surg

Rupture isolée du cholédoque au cours d'un traumatisme fermé chez l'enfant

Chir Pédiatr

Isolated extrahepatic bile duct injury: Diagnosis and surgical management

Pediatr Surg Int

Cholépéritoine par rupture des voies biliaires intra-hépatiques lors d'un traumatisme fermé de l'abdomen

Chir Pédiatr

Case report
Nonoperative management of biliary tract fistulas after blunt abdominal trauma in a child