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Ghosh S, Kazi FN, Sharma JVP. Extrahepatic Bile Duct Injury Caused by Blunt Abdomen Trauma: A Case Report. Cureus 2022; 14:e25662. [PMID: 35686195 PMCID: PMC9170451 DOI: 10.7759/cureus.25662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 11/16/2022] Open
Abstract
Traumatic injuries to the extra-hepatic biliary tract are uncommon and may be suspected intraoperatively by the presence of bile-stained fluid in the subhepatic area. We present a case of injury to the common bile duct in a polytrauma patient. The initial CT scan did not suggest biliary injury. However, intraoperatively, bile-stained fluid in the subhepatic space raised suspicion of bile duct injury. This was confirmed postoperatively in the development of a biliary fistula after the primary laparotomy. The patient was treated by endoscopic biliary stenting with complete resolution of the fistula.
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Affiliation(s)
- Shaurav Ghosh
- General Surgery, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
| | - Farah Naaz Kazi
- Surgery, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
| | - J V Pranav Sharma
- General Surgery, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
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2
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García IC, Villalba JS, Iovino D, Franchi C, Iori V, Pettinato G, Inversini D, Amico F, Ietto G. Liver Trauma: Until When We Have to Delay Surgery? A Review. Life (Basel) 2022; 12:life12050694. [PMID: 35629360 PMCID: PMC9143295 DOI: 10.3390/life12050694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/06/2022] [Accepted: 04/29/2022] [Indexed: 01/09/2023] Open
Abstract
Liver involvement after abdominal blunt trauma must be expected, and in up to 30% of cases, spleen, kidney, and pancreas injuries may coexist. Whenever hemodynamics conditions do not contraindicate the overcoming of the ancient dogma according to which exploratory laparotomy should be performed after every major abdominal trauma, a CT scan has to clarify the liver lesions so as to determine the optimal management strategy. Except for complete vascular avulsion, no liver trauma grade precludes nonoperative management. Every attempt to treat the injured liver by avoiding a strong surgical approach may be considered. Each time, a nonoperative management (NOM) consisting of a basic “wait and see” attitude combined with systemic support and blood replacement are inadequate. Embolization should be considered to stop the bleeding. Percutaneous drainage of collections, endoscopic retrograde cholangiopancreatography (ERCP) with papilla sphincterotomy or stent placement and percutaneous transhepatic biliary drainage (PTBD) may avoid, or at least delay, surgical reconstruction or resection until systemic and hepatic inflammatory remodeling are resolved. The pathophysiological principle sustaining these leanings is based on the opportunity to limit the further release of cell debris fragments acting as damage-associated molecular patterns (DAMPs) and the following stress response associated with the consequent immune suppression after trauma. The main goal will be a faster recovery combined with limited cell death of the liver through the ischemic events that may directly follow the trauma, exacerbated by hemostatic procedures and surgery, in order to reduce the gross distortion of a regenerated liver.
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Affiliation(s)
- Inés Cañas García
- General and Digestive Surgery, Hospital Clínico San Cecilio of Granada, 18002 Granada, Spain;
| | - Julio Santoyo Villalba
- General and Digestive Surgery, Hospital Virgen de Las Nieves of Granada, 18002 Granada, Spain;
| | - Domenico Iovino
- General, Emergency and Transplant Surgery Department, ASST-Settelaghi and University of Insubria, 21100 Varese, Italy; (D.I.); (C.F.); (V.I.); (D.I.)
| | - Caterina Franchi
- General, Emergency and Transplant Surgery Department, ASST-Settelaghi and University of Insubria, 21100 Varese, Italy; (D.I.); (C.F.); (V.I.); (D.I.)
| | - Valentina Iori
- General, Emergency and Transplant Surgery Department, ASST-Settelaghi and University of Insubria, 21100 Varese, Italy; (D.I.); (C.F.); (V.I.); (D.I.)
| | - Giuseppe Pettinato
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA;
| | - Davide Inversini
- General, Emergency and Transplant Surgery Department, ASST-Settelaghi and University of Insubria, 21100 Varese, Italy; (D.I.); (C.F.); (V.I.); (D.I.)
| | - Francesco Amico
- Trauma Service, Department of Surgery, University of Newcastle, Newcastle 2308, Australia;
| | - Giuseppe Ietto
- General, Emergency and Transplant Surgery Department, ASST-Settelaghi and University of Insubria, 21100 Varese, Italy; (D.I.); (C.F.); (V.I.); (D.I.)
- Correspondence: ; Tel.: +39-339-8758024
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Abstract
The liver is one of the most commonly injured solid organs in blunt abdominal trauma. Non-operative management is considered to be the gold standard for the care of most blunt liver injuries. Angioembolization has emerged as an important adjunct that is vital to the success of the non-operative management strategy for blunt hepatic injuries. This procedure, however, is fraught with some possible serious complications. The success, as well as rate of complications of this procedure, is determined by degree and type of injury, hepatic anatomy and physiology, and embolization strategy among other factors. In this review, we discuss these important considerations to help shed further light on the contribution and impact of angioembolization with regards to complex hepatic injuries.
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Affiliation(s)
- Ali Cadili
- Department of Surgery, University of Connecticut, CT, USA
| | - Jonathan Gates
- Department of Surgery, University of Connecticut, CT, USA
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4
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Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, Biffl W, Peitzman A, Horer T, Abu-Zidan FM, Sartelli M, Fraga GP, Cicuttin E, Ansaloni L, Parra MW, Millán M, DeAngelis N, Inaba K, Velmahos G, Maier R, Khokha V, Sakakushev B, Augustin G, di Saverio S, Pikoulis E, Chirica M, Reva V, Leppaniemi A, Manchev V, Chiarugi M, Damaskos D, Weber D, Parry N, Demetrashvili Z, Civil I, Napolitano L, Corbella D, Catena F. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020; 15:24. [PMID: 32228707 PMCID: PMC7106618 DOI: 10.1186/s13017-020-00302-7] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy.
| | - Raul Coimbra
- Riverside University Health System, CECORC Research Center, Loma Linda University, Loma Linda, USA
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | - Felipe Vega
- Department of Surgery, Hospital Angeles Lomas, Huixquilucan, Mexico
| | | | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital La Jolla, San Diego, CA, USA
| | - Andrew Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, FL, USA
| | - Mauricio Millán
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Nicola DeAngelis
- Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | - Kenji Inaba
- General and Trauma Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - George Velmahos
- General and Emergency Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Salomone di Saverio
- General and Trauma Surgery Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mircea Chirica
- Chirurgie Digestive, CHUGA-CHU Grenoble Alpes, Grenoble, France
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | | | - Ian Civil
- Trauma Surgery, Auckland University Hospital, Auckland, New Zealand
| | - Lena Napolitano
- Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
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Temiz A, Ezer SS, Gedikoğlu M, Serin E, İnce E, Gezer HÖ, Canan MO, Hiçsönmez A. Management of traumatic bile duct injuries in children. Pediatr Surg Int 2018; 34:829-836. [PMID: 29948144 DOI: 10.1007/s00383-018-4295-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE Pediatric experience with biliary tract injuries (BTI) is limited and mostly consists of case presentations. The purpose of this study is to evaluate clinical and radiological findings of possible BTI, treatment strategies, and results. METHODS The records of nine patients with the diagnosis of BTI between July 2009 and November 2017 were reviewed retrospectively. RESULTS There were seven boys and two girls (mean 8.05 ± 4.39 years). The mechanisms were motor vehicle occupant, fall, crush and gunshot wound. Hepatic laceration routes that extended into the porta hepatis and contracted the gall bladder were demonstrated on computerized tomography (CT). Bile duct injury was diagnosed with bile leakage from the thoracic tube (n = 2), from the abdominal drain (n = 2) and by paracentesis (n = 5). Extrahepatic (n = 8) and intrahepatic (n = 1) bile duct injuries were diagnosed by cholangiography. Endoscopic retrograde cholangiography, sphincterotomy, and stent placement were successfully completed in five patients. Peritoneal drainage stopped after 3-17 days of procedure in four patients. The fifth patient was operated with the diagnosis of cystic duct avulsion. Cholecystectomies, primary repair of laceration, cystic duct ligation, and Roux-en-Y hepatoportoenterostomy were performed in the remaining four patients. All patients presented with clinically normal findings, normal liver functions, and normal ultrasonographic findings in the follow-up period. CONCLUSIONS The presentation of the parenchymal injury extending to the porta hepatis with contracted gall bladder on CT and diffuse homogenous abdominal fluid should be considered as signs of BTI. We suggest a multi-disciplinary approach for the diagnosis and treatment of BTIs. Surgery may be indicated according to the patient's clinical condition, radiological findings and failure of non-operative treatment.
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Affiliation(s)
- Abdulkerim Temiz
- Department of Pediatric Surgery, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Educational Hospital, Dadaloğlu mah. 39 sokak, No: 6, Yüreğir, 01250, Adana, Turkey.
| | - Semire Serin Ezer
- Department of Pediatric Surgery, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Educational Hospital, Dadaloğlu mah. 39 sokak, No: 6, Yüreğir, 01250, Adana, Turkey
| | - Murat Gedikoğlu
- Department of Radiology, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Educational Hospital, Adana, Turkey
| | - Ender Serin
- Department of Gastroenterology, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Educational Hospital, Adana, Turkey
| | - Emine İnce
- Department of Pediatric Surgery, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Educational Hospital, Dadaloğlu mah. 39 sokak, No: 6, Yüreğir, 01250, Adana, Turkey
| | - Hasan Özkan Gezer
- Department of Pediatric Surgery, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Educational Hospital, Dadaloğlu mah. 39 sokak, No: 6, Yüreğir, 01250, Adana, Turkey
| | - Mehmet Oğuz Canan
- Department of Pediatric Gastroenterology, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Educational Hospital, Adana, Turkey
| | - Akgün Hiçsönmez
- Department of Pediatric Surgery, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Educational Hospital, Dadaloğlu mah. 39 sokak, No: 6, Yüreğir, 01250, Adana, Turkey
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6
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Keil R, Drabek J, Lochmannova J, Stovicek J, Rygl M, Snajdauf J, Hlava S. Endoscopic treatment of bile duct post-traumatic and post-operative lesions in children. Scand J Gastroenterol 2017; 52:870-875. [PMID: 28388849 DOI: 10.1080/00365521.2017.1309453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND STUDY AIMS The aim of this study was to assess the significance and safety of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing and treating bile duct injuries in children. PATIENTS AND METHODS Fourteen pediatric patients, with traumatic or postoperative bile duct injury, in which ERCP was performed, were retrospectively evaluated. RESULTS We performed 46 ERCP and 12 endoscopic papillotomies in children with suspected bile duct injuries. A bile stent was primarily inserted in 13 patients and there were 20 replacements. Endoscopic treatment of bile leakage without need for bile duct sutures or reconstruction was successful in 85.7%. Post ERCP complications included cholangitis and recurrent bleeding, which occurred only in two patients each. CONCLUSIONS ERCP and endoscopic bile stent insertion is a highly effective, minimally-invasive treatment for bile duct injury and should be included as part of the therapeutic procedures in pediatric patients with suspected bile duct injury.
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Affiliation(s)
- Radan Keil
- a Department of Internal Medicine , Motol University Hospital , Prague , Czech Republic
| | - Jiri Drabek
- a Department of Internal Medicine , Motol University Hospital , Prague , Czech Republic
| | - Jindra Lochmannova
- a Department of Internal Medicine , Motol University Hospital , Prague , Czech Republic
| | - Jan Stovicek
- a Department of Internal Medicine , Motol University Hospital , Prague , Czech Republic
| | - Michal Rygl
- b Department of Pediatric Surgery , Motol University Hospital , Prague , Czech Republic
| | - Jiri Snajdauf
- b Department of Pediatric Surgery , Motol University Hospital , Prague , Czech Republic
| | - Stepan Hlava
- a Department of Internal Medicine , Motol University Hospital , Prague , Czech Republic
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7
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Ou J, Yu L, Nan-Sheng C. Ligation of the Left Hepatic Duct and Proper Hepatic Artery Following a Traffic Accident Injury. Indian J Surg 2017; 79:461-463. [PMID: 29089711 DOI: 10.1007/s12262-017-1608-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 02/23/2017] [Indexed: 02/05/2023] Open
Abstract
A 32-year-old man was admitted to our hospital due to a traffic accident. Intraoperative observations revealed hemoperitoneum, splenic transection, pancreatic tail contusion, comminuted injury in the porta hepatis, rupture in the left hepatic duct, an irregular crevasse in the ductus hepaticus communis, the caudate lobe was transversely broken on the left, and under the gap, there was a fracture in retrohepatic inferior vena cava with huge retroperitoneal hematoma. We carried out a ligation of the left hepatic duct and the proper hepatic artery. Postoperation, the man recovered smoothly. At 5 years and 5 months postoperation, MRI showed that the left liver had atrophied partly. So, we consider that the ligation of the left hepatic duct is a safe procedure for patients without cirrhosis under the conditions of ligation of the proper hepatic artery.
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Affiliation(s)
- Jiang Ou
- Department of Biliary Surgery, West China School of Medicine/West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041 China
| | - Liu Yu
- Department of Surgical Oncology, The Second People's Hospital of Neijiang, Neijiang, Sichuan Province 641100 China
| | - Cheng Nan-Sheng
- Department of Biliary Surgery, West China School of Medicine/West China Hospital, Sichuan University, Chengdu, Sichuan Province 610041 China.,Department of Biliary Surgery, West China Medical Center of Sichuan University, No. 37 Guo Xue Valley, Chengdu, Sichuan Province 610041 China
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8
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Park CI, Park SJ, Lee SB, Yeo KH, Choi SU, Kim SH, Kim JH, Baek DH. Successful Endoscopic Treatment of Hepatic Duct Confluence Injury after Blunt Abdominal Trauma: Case Report. JOURNAL OF TRAUMA AND INJURY 2016. [DOI: 10.20408/jti.2016.29.3.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Chan Ik Park
- Department of Trauma Surgery, Division of Gastroenterology, Pusan National University Hospital, Busan, Korea
| | - Sung Jin Park
- Department of Trauma Surgery, Division of Gastroenterology, Pusan National University Hospital, Busan, Korea
| | - Sang Bong Lee
- Department of Trauma Surgery, Division of Gastroenterology, Pusan National University Hospital, Busan, Korea
| | - Kwang Hee Yeo
- Department of Trauma Surgery, Division of Gastroenterology, Pusan National University Hospital, Busan, Korea
| | - Seon Uoo Choi
- Department of Trauma Surgery, Division of Gastroenterology, Pusan National University Hospital, Busan, Korea
| | - Seon Hee Kim
- Department of Trauma Surgery, Division of Gastroenterology, Pusan National University Hospital, Busan, Korea
| | - Jae Hun Kim
- Department of Trauma Surgery, Division of Gastroenterology, Pusan National University Hospital, Busan, Korea
| | - Dong Hoon Baek
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
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9
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Zago TM, Pereira BMT, Calderan TRA, Hirano ES, Fraga GP. Extrahepatic duct injury in blunt trauma: two case reports and a literature review. Indian J Surg 2014; 76:303-7. [PMID: 25278655 DOI: 10.1007/s12262-013-0885-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 02/03/2013] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Thiago Messias Zago
- Division of Trauma Surgery, University of Campinas, Campinas, Brazil ; Cidade Universitaria "Prof. Zeferino Vaz", Rua Alexander Fleming, 181, 13.083-970 Campinas, São Paulo Brazil
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10
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Isolated avulsion of the common hepatic duct from blunt abdominal trauma. Case Rep Surg 2012; 2012:254563. [PMID: 22830067 PMCID: PMC3398579 DOI: 10.1155/2012/254563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 06/12/2012] [Indexed: 01/25/2023] Open
Abstract
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.
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11
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de Mestral C, Razek T, Khwaja K, Fata P. Blunt Left Extrahepatic Bile Duct Injury: Case Report and Literature Review. Eur J Trauma Emerg Surg 2008; 34:595-600. [PMID: 26816286 DOI: 10.1007/s00068-008-7102-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Accepted: 12/18/2007] [Indexed: 12/07/2022]
Abstract
BACKGROUND Extrahepatic biliary tract injuries following blunt abdominal trauma are very rare and pose a diagnostic and therapeutic challenge. CASE REPORT 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. CONCLUSION 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.
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Affiliation(s)
| | | | | | - Paola Fata
- Department of Surgery, Montreal General Hospital, McGill University Health Center, Montreal, QC, Canada, H3G 1A4.
- Department of Surgery, Montreal General Hospital, McGill University Health Center, 1650 Cedar Avenue, Montreal, QC, Canada, H3G 1A4.
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12
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Jaik NP, Hoey BA, Stawicki SP. Evolving role of endoscopic retrograde cholangiopancreatography in management of extrahepatic hepatic ductal injuries due to blunt trauma: diagnostic and treatment algorithms. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2008; 2008:259141. [PMID: 18475313 PMCID: PMC2202780 DOI: 10.1155/2008/259141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Revised: 04/13/2007] [Accepted: 08/02/2007] [Indexed: 11/29/2022]
Abstract
Extrahepatic hepatic ductal injuries (EHDIs) due to blunt abdominal trauma are rare. Given the rarity of these injuries and the insidious onset of symptoms, EHDI are commonly missed during the initial trauma evaluation, making their diagnosis difficult and frequently delayed. Diagnostic modalities useful in the setting of EHDI include computed tomography (CT), abdominal ultrasonography (AUS), nuclear imaging (HIDA scan), and cholangiography. Traditional options in management of EHDI include primary ductal repair with or without a T-tube, biliary-enteric anastomosis, ductal ligation, stenting, and drainage. Simple drainage and biliary decompression is often the most appropriate treatment in unstable patients. More recently, endoscopic retrograde cholangiopancreatography (ERCP) allowed for diagnosis and potential treatment of these injuries via stenting and/or papillotomy. Our review of 53 cases of EHDI reported in the English-language literature has focused on the evolving role of ERCP in diagnosis and treatment of these injuries. Diagnostic and treatment algorithms incorporating ERCP have been designed to help systematize and simplify the management of EHDI. An illustrative case is reported of blunt traumatic injury involving both the extrahepatic portion of the left hepatic duct and its confluence with the right hepatic duct. This injury was successfully diagnosed and treated using ERCP.
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Affiliation(s)
- Nikhil P. Jaik
- Department of Surgery, St Luke's Hospital and Health Network, Bethlehem, PA 18015, USA
| | - Brian A. Hoey
- Regional Level I Resource Trauma Center, St Luke's Hospital and Health Network, Bethlehem, PA 18015, USA
- University of Pennsylvania Trauma Network, Philadelphia, PA 19104, USA
| | - S. Peter Stawicki
- STAR/OPUS12 Foundation, 304 Monroe Boulevard, King of Prussia, PA 19406, USA
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13
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Almaramhi H, Al-Qahtani AR. Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention. J Pediatr Surg 2006; 41:943-5. [PMID: 16677889 DOI: 10.1016/j.jpedsurg.2006.01.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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 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.
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Affiliation(s)
- Hamdi Almaramhi
- Division of Pediatric Surgery, College of Medicine, King Khalid University Hospital, PO Box 84147, Riyadh 11671, Saudi Arabia
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Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, Kim JC, Jeong SW, Park JG, Kang HK. CT in blunt liver trauma. Radiographics 2006; 25:87-104. [PMID: 15653589 DOI: 10.1148/rg.251045079] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Nonsurgical treatment has become the standard of care in hemodynamically stable patients with blunt liver trauma. The use of helical computed tomography (CT) in the diagnosis and management of blunt liver trauma is mainly responsible for the notable shift during the past decade from routine surgical to nonsurgical management of blunt liver injuries. CT is the diagnostic modality of choice for the evaluation of blunt liver trauma in hemodynamically stable patients and can accurately help identify hepatic parenchymal injuries, help quantify the degree of hemoperitoneum, and reveal associated injuries in other abdominal organs, retroperitoneal structures, and the gastrointestinal tract. The CT features of blunt liver trauma include lacerations, subcapsular or parenchymal hematomas, active hemorrhage, juxtahepatic venous injuries, periportal low attenuation, and a flat inferior vena cava. It is important that radiologists be familiar with the liver injury grading system based on these CT features that was established by the American Association for the Surgery of Trauma. CT is also useful in the assessment of delayed complications in blunt liver trauma, including delayed hemorrhage, hepatic or perihepatic abscess, posttraumatic pseudoaneurysm and hemobilia, and biliary complications such as biloma and bile peritonitis. Follow-up CT is needed in patients with high-grade liver injuries to identify potential complications that require early intervention.
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Affiliation(s)
- Woong Yoon
- Department of Radiology, Chonnam National University Hospital, Chonnam National University Medical School, 8 Hak-dong, Dong-Ku, Gwangju 501-757, South Korea.
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