Find best premium and Free Joomla templates at GetJoomlaTemplatesFree.com

Iatrogenic common bile duct injury in a neonate. What to do?

Ahmed H. Al-Salem, Mukul Kothari

Department of Pediatric Surgery, Maternity and Children Hospital, Dammam, Saudi Arabia


Correspondence:

Ahmed H. Al-Salem

P. O. Box 61015

Qatif 31911, Saudi Arabia

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Mobile: 00966546102999

Fax: 00966138630009


Abstract

Isolated extrahepatic biliary injury in children is extremely rare and there are no previous reports of such an injury or its management in newborns. We present a case of iatrogenic extrahepatic biliary injury in a newborn and describe a technique to treat it.

Keywords: biliary injury, children, iatrogenic, treatment

 

Introduction

Isolated injury to the extrahepatic biliary ducts and/or the gallbladder is rare in the pediatric age group. There are several predisposing mechanisms to this including blunt abdominal trauma to the right upper quadrant, deceleration injuries, penetrating injuries and iatrogenic injury after cholecystectomy [1-6]. Traumatic injuries of the extrahepatic biliary ducts are infrequent, occurring in less than 0.5 % of all patients with blunt and penetrating abdominal trauma [3, 6, 7]. Currently, one of the most common causes of bile duct injuries is iatrogenic trauma to the bile ducts during laparoscopic cholecystectomy. It is estimated that as many as 1% of gallbladder operations may lead to injury to the bile duct with subsequent development of a bile duct stricture in a significant number of them [8-12].

This is the case in adults but in children cholecystectomy is not a common procedure as cholelithiasis is relatively rare in the pediatric age group. Iatrogenic bile duct injuries may also occur during upper abdominal surgery other than cholecystectomy but this is extremely rare. The management of these injuries is variable depending on the cause, site of injury and time of diagnosis and include conservative nonoperative management, primary surgical repair, biliary-enteric anastomosis (choledochoduodenostomy or choledochojejunostomy) or transampullary biliary decompression [13-18]. This report describes an unusual case of iatrogenic common bile duct injury in a newborn and a technique to its management.

Case Report

A female girl was born by an emergency caesarean section. The mother had two previous caesarean sections. There was a history of polyhydramnios which was also detected by antenatal ultrasound. There is also a history of a death of a child in the family affected by the same problem. On the maternal side, there was also a history of death of a couple of children affected by the same problem. Her birth weight was 2.45 Kg. Clinically, she was found to have epidermolysis bullosa affecting the ankles, knees, part of the abdomen and right wrist (Fig. 1). She was diagnosed to have junctional epidermolysis bullosa. Abdominal x-ray revealed a dilated stomach with no air distally (Fig. 2). She was diagnosed to have congenital pyloric atresia. She was operated and during laparotomy she was found to have type 1 congenital pyloric atresia (a diaphragm obstructing the lumen).

Figure 1: A clinical photograph showing epidermolysis bullosa

10.4 7 1

Figure 2: Abdominal X-ray showing dilated stomach with no gas distally.

10.4 7 2

The duodenum was mobilized because of adhesions at the site but during mobilization, there was injury to the common bile duct. The site of injury was distal to the insertion of the cystic duct which was long. A primary choledochojejunostomy or choledochoduodenostomy was not possible due to the small size of the common bile duct. A decision was made to drain the gall bladder and also the common bile duct, so two small vascular catheters size 3Fr were inserted, one in the gallbladder and another in the proximal common bile duct. The proximal common bile duct was tied over the inserted catheter and the distal part of common bile duct was also tied. The aim was to temporary obstruct the common bile duct and let it dilate to a manageable size to do a choledochojejunostomy. The pylorus was opened longitudinally, the diaphragm was excised and the pylorus was closed longitudinally. A nasogastric tube was inserted and a small abdominal drain was also left.

Postoperatively, she did well and was extubated the next day. The two drains drained minimal fluid. She passed greenish stool first but later the stools were clay colored. The nasogastric tube drainage was high initially but then it tapered off. Her total bilirubin was high soon after surgery with high indirect bilirubin levels. Slowly the total bilirubin came down and eventually was 6.1 mg /dl before the second surgery. The direct bilirubin rose to a maximum of 5.0 mg/dl. She was started feeds on the 5th postoperative day and increased slowly. The initial contrast studies through the catheters in the common bile duct and gallbladder revealed dilated common bile duct (Fig. 3 and 4).

Figures 3 and 4: Contrast studies through the catheters in the gallbladder and common bile duct showing dilated bile ducts especially the common bile duct.

10.4 7 3 10.4 7 4

Twenty days postoperatively, she developed abdominal distension and intolerance to feeds and septic workup revealed gram positive organisms in her blood. She was treated with intravenous antibiotics for 10 days and her feeds were restarted gradually and reached 25 ml every 3 hours. A contrast study was attempted through the catheter in the common bile duct (CBD) but was unsuccessful as the catheter was blocked. A contrast was injected through the catheter in the gall bladder but this only filled the gallbladder and failed to visualize the CBD. An abdominal ultrasound showed the CBD to be 0.57 cm in diameter. A repeat scan showed the CBD to be 0.78 cm in diameter (Fig. 5). Four weeks postoperatively, she was re-operated on. Exploration revealed a dilated CBD. Cholecystectomy, and a roux-in-y choledochojejunostomy were performed. Postoperatively, she did well and she started to pass green stools. Her direct bilirubin level dropped to 1.1 by the 6th postoperative day. She was started on feed on the 7th postoperative day gradually and she tolerated full feeds. The bilirubin levels returned to normal (Fig. 6). She recovered fully and was tolerating feeds but two months later, she developed an attack of sever sepsis and died.

Figure 5: Abdominal ultrasound showing dilated common bile duct measuring about 0,78 cm in diameter.

10.4 7 5 

Figure 6: A diagram showing the levels of total and direct bilirubin. Note the rise of bilirubin following the first operation and the drop of the bilirubin following the second operation which is marked by the green arrow.

10.4 7 6

Discussion

Extrahepatic bile duct injuries are very rare in the pediatric age group and most reported cases are seen following blunt abdominal trauma and rarely penetrating injury. Aljdaan et al. over a period of two years treated 1015 pediatric patients with trauma. One hundred and three of them were blunt abdominal trauma but only two patients had injury to the extrahepatic bile ducts [3]. Traumatic biliary tract injuries in children although rare but may result in significant morbidity and sometimes mortality. Soukup et al. reported twelve out of 13,582 trauma patients with injury to the bile ducts representing 0.09% of all trauma patients [7]. All were secondary to blunt abdominal trauma. Biliary injuries included major ductal injury (6 patients), minor ductal injury with biloma (4 patients), gallbladder injury (2 patients), and intrahepatic ductal injury (1 patient).

Major ductal injuries were managed by endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent (5 patients) and Roux-en-Y hepaticojejunostomy (1 patient). Associated gallbladder injury was managed by cholecystectomy. In addition, the associated biloma was managed with percutaneous drainage (7 patients), laparoscopic drainage (2 patients), or during laparotomy (3 patients). 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 was managed conservatively without evidence of cholangitis. Two patients required placement of additional drains and prolonged antibiotics for superinfection following biloma drainage [7].

The diagnosis of bile duct injury due to abdominal trauma is usually not feasible preoperatively, but it must be suspected intraoperatively with the presence of bile staining fluid in the subhepatic area. 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. Interventional endoscopic and radiologic management of bile duct injuries caused by blunt trauma in children is successful and efficacious [1, 3, 4, 19]. Nonoperative management of blunt pediatric liver injuries carries a risk of persistent bile leakage. Moulton et al. reported three of 87 children with blunt liver injuries initially managed without operation required late intervention for bile leakage [6]. Transampullary biliary decompression is a newer, effective modality for management of the proximal and/or partial bile duct injuries [4].

Treatment however, must be individualized according to the site and extent of injury. End-to-end primary ductal anastomosis and T-tube choledochostomy is a physiologic biliary reconstruction that is commonly used in liver transplantation and less frequently in the surgical treatment of iatrogenic bile duct injuries [18]. This anastomosis is technically simple and associated with fewer early postoperative complications than the Roux-en-Y hepaticojejunostomy; however, end-to-end ductal anastomosis is not possible to perform in all patients. Internal drainage by a Roux-en-Y hepaticojejunostomy remains the definitive repair for large extrahepatic biliary tract injuries or transections [18].

The incidence of iatrogenic bile-duct injury is currently estimated at 0.3-0.9% and the rate of clinically-relevant bile leaks after conventional open cholecystectomy ranges from 0.1% to 0.5% [8, 9, 10, 20]. Though rare, bile duct injuries during laparoscopic cholecystectomy represent a major potential complication with significant associated morbidity. Raval et al. reviewed 31,653 patients undergoing cholecystectomy, 28,243 (89.2%) of them underwent laparoscopic cholecystectomy [20]. They found that over time, the proportion of laparoscopic cholecystectomy (LC) has risen from 81% in 1997 to 91% in 2006 (P < .001). They also found that of patients undergoing LC, 0.44% had bile duct injuries [20]. As laparoscopic cholecystectomy gained wider acceptance, complications which were rarely seen with open cholecystectomy, such as bile duct injury, were reported in as many as 5 percent of patients. The development of laparoscopic cholecystectomy has increased the incidence of biliary leakages by up to 3% during the learning curve [11-14]. Therefore, endoscopic procedures gain an increasing role in the management of postoperative bile duct injuries. Various endoscopic techniques, including biliary sphincterotomy, biliary stent placement, and nasobiliary drainage, are used in several published series [15, 16, 17].

In children, iatrogenic extrahepatic bile duct injuries are rare and commonly seen following open cholecystectomy and recently following laparoscopic cholecystectomy and their management are similar to those seen in adults [1, 5, 20]. Common bile duct injuries can have devastating consequences. There are however no reports of iatrogenic extrahepatic bile duct injuries in neonates or infants and no guidelines for their management. The size of the bile duct is an important factor in the management of these injuries and in our patient the common bile duct was very small and this made it impossible to do primary end to end anastomosis or to do a Roux-en-Y choledochoduodenostomy or choledochojejunostomy. Add to this the lack of small size T-tubes which may be required in such instances to splint the anastomosis if primary repair was feasible. We adopted the technique described to buy time and allow the common bile duct to dilate when it is obstructed. This technique proved useful, increased the size of the common bile duct and allowed us to do a Roux-en-Y choledochojejunostomy.

 

 

References:

1. Farinetti A, Le Hors H, Haddad M, Desvignes C, Laugier R, de Lagausie P. Major Bile Duct Injuries During Cholecystectomy in Children: Conservative Laparoscopic Approach is Possible. Surg Laparosc Endosc Percutan Tech 2012; 22 (2): p e91–e93.

2. Chen G.K, Tong K.Y, Chung J.Y, Chung Y.Y. Extrahepatic bile duct injury due to abdominal trauma. J Hep Bil Pancr Surg 1996; 3 (1): 78-83.

3. Al Jadaan S, Oda O, Crankson S, Al Namshaan M, Zamakhshary M. Is Bowel Rest a Prerequisite for Successful Outcome in Nonoperative Management of Extrahepatic Bile Duct Blunt Injury in Children? Ann Pediatr Surg 2010; 6 (3, 4): 170-173.

4. Almaramhi H, Al-Qahtani AR. Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention. J Pediatr Surg. 2006 ; 41(5):943-5.

5. Farinetti A, Le Hors H, Haddad M, Desvignes C, Laugier R, de Lagausie P. Major bile duct injuries during cholecystectomy in children: conservative laparoscopic approach is possible. Surg Laparosc Endosc Percutan Tech.2012; 22(2):e91-3.

6. Moulton SL, Downey EC, Anderson DS, Lynch FP. Blunt bile duct injuries in children. J Pediatr Surg. 1993; 28(6):795-7.

7. 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; 49 (2): 345-348.

8. Gouma DJ, Go PM. Bile duct injury during laparoscopic and conventional cholecystectomy. J Am Coll Surg 1994; 178: 229–33.

9. Morgenstern L, Wong L, Berci G. Twelve hundred open cholecystectomies before the laparoscopic era. A standard for comparison. Arch Surg 1992; 127: 400–3.

10. Roslyn JJ, Binns GS, Hughes EF et al. Open cholecystectomy. A contemporary analysis of 42 474 patients. Ann Surg 1993; 218: 129–37.

11. Barkun AN, Rezieg M, Mehta SN et al. Postcholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation, and management. McGill Gallstone Treatment Group. Gastrointest Endosc 1997; 45: 277–82.

12. Albasini JL, Aledo VS, Dexter SP et al. Bile leakage following laparoscopic cholecystectomy. Surg Endosc 1995; 9: 1274–8.

13. Peters JH, Ellison EC, Innes JT et al. Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients. Ann Surg 1991; 213: 3–12.

14. Bailey RW, Zucker KA, Flowers JL et al. Laparoscopic cholecystectomy. Experience with 375 consecutive patients. Ann Surg 1991; 214: 531–40.

15. Llach J, Bordas JM, Elizalde JI et al. Sphincterotomy in the treatment of biliary leakage. Hepatogastroenterology 2002; 49: 1496–8.

16. Chow S, Bosco JJ, Heiss FW et al. Successful treatment of post-cholecystectomy bile leaks using nasobiliary tube drainage and sphincterotomy. Am J Gastroenterol 1997; 92: 1839–43.

17. Kaffes AJ, Hourigan L, De Luca N et al. Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak. Gastrointest Endosc 2005; 61: 269–75.

18. Jabłonska B. End-to-end ductal anastomosis in biliary reconstruction: indications and limitations. Can J Surg. 2014; 57(4):271-7.

19. Kulaylat AN, Stokes AL, Engbrecht BW, McIntyre JS, Rzucidlo SE, Cilley RE. Traumatic bile leaks from blunt liver injury in children: A multidisciplinary and minimally invasive approach to management. J Pediatr Surg 2014, 49 (3): 424-427.

20. Raval MV, Lautz TB, Browne M. Bile duct injuries during pediatric laparoscopic cholecystectomy: a national perspective. J Laparoendosc Adv Surg Tech A. 2011; 21(2):113-8.