Biliary Trauma
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Isolated injury to the extrahepatic biliary tract and/or the gallbladder is an uncommon event. Predisposing mechanisms include blunt right upper quadrant force, deceleration injuries, penetrating injuries and, most commonly, iatrogenic injury after cholecystectomy.
This article considers both blunt and penetrating trauma to the extrahepatic biliary tract and the gallbladder as well as bile duct injury after cholecystectomy.
Typically, a mechanism of crushing or shear injury to the right upper quadrant causes biliary disruption and subsequent bile-peritonitis. The retroduodenal region of the superior portion of the pancreas is the most common site of biliary transection following blunt trauma, possibly secondary to the relative fixation of the bile duct in that location. The average delay until diagnosis is reportedly 9 days and ranges from hours to 9 months. A perforation or an avulsion of the gallbladder from a blunt thoracoabdominal trauma is extremely rare; penetrating abdominal trauma is a more frequent cause of gallbladder injuries.
Although the exact incidence of nonoperative biliary trauma is unknown, isolated biliary injury without trauma to associated intra-abdominal structures is extremely rare (less than 1% of all blunt abdominal injuries in most series). Fewer than 40 cases of common bile duct avulsion following blunt trauma are reported; however, it is much rarer than penetrating trauma and more difficult to diagnose.
A study by Halbert et al reported that the rate of ate of bile duct injury following laparoscopic cholecystectomy has now decreased to 0.08 % in New York State. [1]
See the list below:
Mortality depends directly on the delay in the diagnosis and the treatment, as well as on the severity of the injury.
Patients with lesions that are promptly discovered and appropriately treated within hours of injury have a mortality rate of less than 10%, while patients with extensive injuries and delayed treatment may have a mortality rate nearing 40%.
Most of the morbidity associated with the extrahepatic biliary tract is related to bile leak and vascular injuries within the hepatoduodenal ligament (hepatic artery/portal vein).
No gender predilection exists.
Biliary trauma can occur at any age but, just like all blunt and penetrating trauma, it is more common in adolescents and young adults. [2]
Halbert C, Pagkratis S, Yang J, Meng Z, Altieri MS, Parikh P, et al. Beyond the learning curve: incidence of bile duct injuries following laparoscopic cholecystectomy normalize to open in the modern era. Surg Endosc. 2016 Jun. 30 (6):2239-43. [Medline].
Soukup ES, Russell KW, Metzger R, Scaife ER, Barnhart DC, Rollins MD. Treatment and outcome of traumatic biliary injuries in children. J Pediatr Surg. 2014 Feb. 49(2):345-8. [Medline].
Sharma P, Kumar R, Das KJ, Singh H, Pal S, Parshad R, et al. Detection and localization of post-operative and post-traumatic bile leak: hybrid SPECT-CT with 99mTc-Mebrofenin. Abdom Imaging. 2012 Feb 1. [Medline].
Thapar PM, Ghawat RM, Dalvi AN, Rokade ML, Philip RM, Warawdekar GM, et al. Massive Liver Trauma-Multidisciplinary Approach and Minimal Invasive Surgery can Salvage Patients. Indian J Surg. 2013 Jun. 75:449-52. [Medline]. [Full Text].
Lau WY, Lai EC. Classification of iatrogenic bile duct injury. Hepatobiliary Pancreat Dis Int. 2007 Oct. 6(5):459-63. [Medline].
Thomson BN, Nardino B, Gumm K, Robertson AJ, Knowles BP, Collier NA, et al. Management of blunt and penetrating biliary tract trauma. J Trauma Acute Care Surg. 2012 Jun. 72(6):1620-5. [Medline].
Wahaibi AA, Alnaamani K, Alkindi A, Qarshoubi IA. A novel endoscopic treatment of major bile duct leak. Int J Surg Case Rep. 2014 Feb 7. 5(4):189-192. [Medline].
Stewart L, Way LW. Laparoscopic bile duct injuries: timing of surgical repair does not influence success rate. A multivariate analysis of factors influencing surgical outcomes. HPB (Oxford). 2009 Sep. 11(6):516-22. [Medline]. [Full Text].
Bourque MD, Spigland N, Bensoussan AL, Garel L, Blanchard H. Isolated complete transection of the common bile duct due to blunt trauma in a child, and review of the literature. J Pediatr Surg. 1989 Oct. 24(10):1068-70. [Medline].
Burgess P, Fulton RL. Gallbladder and extrahepatic biliary duct injury following abdominal trauma. Injury. 1992. 23(6):413-4. [Medline].
Busuttil RW, Kitahama A, Cerise E, et al. Management of blunt and penetrating injuries to the porta hepatis. Ann Surg. 1980 May. 191(5):641-8. [Medline].
Carmichael DH. Avulsion of the common bile duct by blunt trauma. South Med J. 1980 Feb. 73(2):166-8. [Medline].
Chi KD, Waxman I. Subcapsular hepatic hematoma after guide wire injury during endoscopic retrograde cholangiopancreatography: management and review. Endoscopy. 2004 Nov. 36(11):1019-21. [Medline].
de Reuver PR, Rauws EA, Bruno MJ, et al. Survival in bile duct injury patients after laparoscopic cholecystectomy: a multidisciplinary approach of gastroenterologists, radiologists, and surgeons. Surgery. 2007 Jul. 142(1):1-9. [Medline].
Erkan M, Bilge O, Ozden I, et al. Definitive treatment of traumatic biliary injuries. Ulus Travma Derg. 2004 Oct. 10(4):221-5. [Medline].
Gupta A, Stuhlfaut JW, Fleming KW, et al. Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics. 2004 Sep-Oct. 24(5):1381-95. [Medline].
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Ragozzino A, Manfredi R, Scaglione M, et al. The use of MRCP in the detection of pancreatic injuries after blunt trauma. Emerg Radiol. 2003 Apr. 10(1):14-8. [Medline].
Sawaya DE Jr, Johnson LW, Sittig K, et al. Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multi-institutional review. Am Surg. 2001 May. 67(5):473-7. [Medline].
Shires GT, Thal ER, Jones RC. Trauma. Schwartz SI, ed. Principles of Surgery. 6th ed. New York, NY: McGraw-Hill; 1994. 175-224.
Sicklick JK, Camp MS, Lillemoe KD, et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg. 2005 May. 241(5):786-92; discussion 793-5. [Medline].
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Walsh RM, Henderson JM, Vogt DP, et al. Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies. Surgery. 2007 Oct. 142(4):450-6; discussion 456-7. [Medline].
Type
Criteria
1
Low common hepatic duct stricture, with a length of the common hepatic duct stump of >2 cm
2
Proximal common hepatic duct stricture, with a hepatic stump length of < 2 cm
3
Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved
4
Hilar stricture, with involvement of confluence and loss of communication between right and left hepatic duct
5
Involvement of aberrant right sectorial hepatic duct alone or with concomitant stricture of the common hepatic duct
Type
Criteria
A
Cystic duct leaks or leaks from small ducts in the liver bed
B
Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts
C
Transection without ligation of the aberrant right hepatic duct
D
Lateral injuries to major bile ducts
E
Subdivided as per Bismuth’s classification into E1 to E5
Type of Injury
Criteria
Major bile duct injury
(at least one of the following present)
Laceration >25% of bile duct diameter
Transection of common hepatic duct or common bile duct
Development of postoperative bile duct stricture
Minor bile duct injury
Laceration of common bile duct < 25% of diameter
Laceration of cystic-common bile duct junction (“buttonhole tear”)
Classification System
Year
Types
Amsterdam Academic Medical Center’s classification
1996
A-D
Neuhaus’ classification
2000
A-E
Csendes’ classification
2001
I-IV
Stewart-Way’s classification of laparoscopic bile duct injuries
2004
I-IV
Chinese University of Hong Kong (CUHK) classification
2007
1-5
Frederick Merrill Karrer, MD, FACS Professor of Surgery and Pediatrics, Head, Division of Pediatric Surgery, University of Colorado School of Medicine; The Dr David R and Kiku Akers Chair in Pediatric Surgery, Surgical Director, Pediatric Transplantation, The Children’s Hospital
Frederick Merrill Karrer, MD, FACS is a member of the following medical societies: American Academy of Pediatrics, American Association for the Study of Liver Diseases, Children’s Oncology Group, International Liver Transplantation Society, Transplantation Society, International Society of Paediatric Surgical Oncology, Pacific Association of Pediatric Surgery, International Pediatric Transplant Association, Colorado Medical Society, Society of Critical Care Medicine, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society of Transplant Surgeons, Western Surgical Association
Disclosure: Nothing to disclose.
Matthew P Landman, MD, MPH Fellow in Pediatric Surgery, Children’s Hospital Colorado
Matthew P Landman, MD, MPH is a member of the following medical societies: American College of Surgeons, American Pediatric Surgical Association, Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American College of Surgeons
Disclosure: Received research grant from: Shriners Hospitals for Children; Physical Sciences Inc, Mediwound.
John Geibel, MD, DSc, MSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow
John Geibel, MD, DSc, MSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract
Disclosure: Nothing to disclose.
Ernest Dunn, MD Program Director, Surgery Residency, Department of Surgery, Methodist Health System, Dallas
Ernest Dunn, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Society of Critical Care Medicine, Texas Medical Association
Disclosure: Nothing to disclose.
Jose Fernando Aycinena Goicolea, MD Colorectal Surgeon, Somerset Surgical Services, Somerset Hospital
Jose Fernando Aycinena Goicolea, MD is a member of the following medical societies: American College of Surgeons and Pennsylvania Medical Society
Disclosure: Nothing to disclose. Anastasios K Konstantakos, MD Clinical Associate Surgeon, Department of Cardiovascular Surgery, Billings Clinic
Disclosure: Nothing to disclose.
Jeffrey L Ponsky, MD Chairman, Case Western Reserve University; Professor, Department of Surgery, University Hospitals of Cleveland
Jeffrey L Ponsky, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, and Association for Academic Surgery
Disclosure: Nothing to disclose.
Biliary Trauma
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