Journal of Pediatric Surgery 49 (2014) 345–348
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Treatment and outcome of traumatic biliary injuries in children Elizabeth S. Soukup ⁎, Katie W. Russell, Ryan Metzger, Eric R. Scaife, Douglas C. Barnhart, Michael D. Rollins Division of Pediatric Surgery, Primary Children’s Medical Center, University of Utah, Salt Lake City, UT 84113, USA
a r t i c l e
i n f o
Article history: Received 8 October 2013 Accepted 10 October 2013 Key words: Biliary injury Hepatobiliary injury Gallbladder injury Pediatric trauma
a b s t r a c t Background/Purpose: 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. Methods: 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. Results: 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. Conclusion: 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. © 2014 Elsevier Inc. All rights reserved.
Traumatic biliary tract injuries in children are rare but may result in significant morbidity [1–4]. Injuries can involve intrahepatic or extrahepatic ducts, or the gallbladder, and range from minor ductal injuries to complete transection. Historically, laparotomy and hepaticojejunostomy has been the gold standard for treatment of biliary injuries [5]. Recently, reports in the adult literature advocate for conservative measures such as placement of endoscopic stents and peritoneal drains to facilitate healing [6,7]. Injuries are commonly associated with other intraabdominal injuries, including blunt liver trauma and pancreatic and duodenal injuries [5,8]. Biliary injury may be diagnosed early, but is more commonly identified in a delayed fashion as a postoperative biliary fistula, bile peritonitis, biloma, or biliary stricture [5,9]. Most of the literature on biliary injuries is in adults after laparoscopic cholecystectomy [8], and is sparse for traumatic injuries in children [1–4]. The objective of this study was to review the occurrence of traumatic biliary tract injuries in children, management strategies, and outcome. ⁎ Corresponding author at: Division of Pediatric Surgery, Primary Children's Medical Center, University of Utah, Salt Lake City UT 84113, USA. Tel.: +1 801 662 2950; fax: +1 801 662 2980. E-mail address: [email protected] (E.S. Soukup). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.10.011
1. Methods We conducted a retrospective review of all children with injury to the biliary tract at our level 1 pediatric trauma center from 2002 to 2012. Patients were identified using our trauma registry, and charts were reviewed to confirm and characterize the nature of the biliary injury. Patient information including demographics, mechanism of injury, associated injuries, Injury Severity Score (ISS), methods and timing of diagnosis, operative and nonoperative treatment, complications and long-term follow-up were collected from inpatient records and outpatient follow-up charts. Approval was obtained from our institutional review board. 2. Results During the study period from 2002 through 2012, there were 13,582 trauma admissions. Twelve patients were identified with biliary injury, representing 0.09% of all trauma patients, and 2.6% of patients with hepatic trauma. A total of 462 patients sustained liver injury, including 237 with severe liver injuries (grade III–V). Patient characteristics, management and outcomes are summarized in Table 1.
346
E.S. Soukup et al. / Journal of Pediatric Surgery 49 (2014) 345–348
Table 1 Summary of patient characteristics, management, and outcomes. Patient and mechanism
ISS
Injury
Evaluation, management and Outcome
1
5 yo F MVA, ejected, rollover
35
LHD injury (and delayed stricture)
2
15 yo M Trampled by bull
16
Biloma
3
14 yo M Bicycle crash
18
Gallbladder
4
4 yo F Non-accidental trauma
54
CBD/ampulla disruption
5
4 yo F Filing cabinet fell on abdomen
26
CBD transection
6
5 yo M Rolled over by vehicle in driveway 8 yo M ATV crash 15 yo M Trampled by bull
50
Biloma
29
CBD injury
25
Gallbladder avulsion & CBD injury (and delayed stricture)
9
9 yo M Bicycle crash (handlebar injury)
9
No known injury initially (delayed CBD/ampullary stricture)
10
13 yo F ATV crash 12 yo M ATV crash
43
Biloma
33
Intrahepatic duct injury
12 yo M Pedestrian struck
38
Biloma
HIDA PTD 5, ERCP/stent & IR drainage (PTD 6 and 7). Injury: LHD obstruction and leak. Complicated by infected biloma (IR drain ×3) and subsequent stricture (ERCP ×2, PTC ×1). Persistent stricture but normal LFTs and no cholangitis. Stent removed. Managed with observation. *Initial normal bilirubin, rise with delayed stricture. PTD 6 laparoscopic washout and drainage of biloma prior to transfer to our facility. Persistent biloma on CT scan PTD 10. IR drainage PTD 11. Complicated by infected biloma (IR drain ×2) and pelvic abscess (laparotomy washout). *Normal bilirubin. Initial CT with concern for gallbladder disruption. Confirmed by HIDA and underwent laparotomy and cholecystectomy. No complications. *Normal bilirubin. Emergent laparotomy and packing: mesenteric injury with exsanguination, duodenal perforation, and complete disruption of ampulla. Cannulation of the transected ampulla to an external drain. Profound hemodynamic instability/CPR. Died PTD 1 of head injury/hypoxic brain injury with herniation. *Bilirubin not checked. PTD 5 HIDA, PTD 6 ERCP suggesting CBD/CHD disruption, unable to stent. Temporary IR drain placed. PTD 7 laparotomy and IOC confirmed complete transection of RHD and LHD from CHD. Hepatico-jejunostomy performed. Complicated by residual biloma (POD 17 IR drain). 8 month follow-up normal. *Elevated bilirubin. PTD 14 laparoscopic washout & drainage of biloma, no discrete injury visualized. No complications. *Normal bilirubin. PTD 3 HIDA, PTD 5 ERCP/stent. Injury: CBD/CHD leak. PTD 7 IR drain. Follow-up ERCP normal, stent removed. No complications. *Elevated bilirubin. Emergent laparotomy and packing. PTD 2 reexploration with cholecystectomy for gallbladder avulsion, washout and drainage of biloma. PTD 5 ERCP/stent. Injury: CBD/CHD leak. Complicated by delayed LHD stricture (rising bilirubin and biloma on CT, PTD 45 IR drain, PTD 46 ERCP LHD occlusion/leak, PTD 48 PTC unable to cannulate, L hepatectomy PTD 55). Three subsequent laparotomies for SBO. *Initial normal bilirubin, rise with delayed stricture. Duodenal hematoma, blunt pancreatic injury, initial discharge PTD 4. Complicated by delayed CBD/ampullary stricture (rising bilirubin, PTD 27 MRCP, PTD 29 ERCP/sphincterotomy/stent, PTD 34 ERCP for cautery of sphincterotomy bleeding, PTD 137 ERCP for persistent stricture, and normal follow-up ERCP at 11 months for stent removal. *Initial normal bilirubin, rise with stricture. PTD 7 HIDA. PTD 9 IR drain of biloma. No long-term follow-up. *Elevated bilirubin. PTD 5 CT scan with biloma. PTD 7 HIDA, PTD 9 ERCP/stent left intrahepatic duct leak. Follow-up ERCP normal, stent removed. No complications. *Elevated bilirubin. PTD 6 HIDA, PTD 8 Exploratory laparotomy, washout & drainage of biloma. No ductal injury visualized. No complications. *Elevated bilirubin
7 8
11
12
MVA, motor vehicle accident; LHD, left hepatic duct; HIDA,; PTD, post-trauma day; IR, interventional radiology; ERCP, endoscopic retrograde cholangiopancreatography; PTC, percutaneous transhepatic cholangiography; CT, computed tomography; CBD, common bile duct; CPR, cardiopulmonary resuscitation; POD, post-operative day; CHD, common hepatic duct; SBO, small bowel obstruction; MRCP, magnetic resonance cholangiopancreatography.
All biliary injuries were secondary to blunt trauma, including bicycle crash (2), ATV crash (3), trampled by bull (2), pedestrian struck (2), non-accidental trauma (1), struck by falling object (1), and motor vehicle crash (1). Mean age was 9.7 years [range 4-15] and mean injury severity score was 31 ± 14. Eight (67%) patients were male. Ninety-two percent of patients had an associated liver injury (grade 1 = 1; grade 3 = 1; grade 4 = 3; grade 5 = 6). The remaining patient never underwent abdominal CT before urgent laparotomy, and therefore hepatic trauma could not be fully assessed. The most common associated abdominal injuries included 2 duodenal injuries (one hematoma and one perforation), 6 pancreatic injuries, 4 splenic injuries, and 1 intestinal injury. Three patients underwent immediate laparotomy for exploration and hemorrhage control. One patient died of associated injuries prior to definitive repair with an overall survival in our cohort of 92%. The diagnostic evaluation of biliary injury included HIDA scan in 7 patients and ERCP in 6 patients. One patient who initially presented with a duodenal hematoma, developed delayed jaundice and underwent magnetic resonance cholangiopancreatography (MRCP) on post-trauma day (PTD) 26, followed by ERCP and stent of a common bile duct (CBD) stricture. Two other patients underwent percutaneous
transhepatic cholangiogram (PTC) for delayed presentation of CBD stricture after unsuccessful ERCP and biliary stent. Initial diagnostic studies were prompted by clinical indications including rising bilirubin levels, persistent bilious output from drains after laparotomy, or free fluid on repeat imaging (ultrasound or CT scan) of the abdomen. One patient with ampullary disruption was diagnosed on initial laparotomy. One patient underwent HIDA scan within 24 hours to confirm findings on CT concerning for gallbladder disruption. The remainder presented in a delayed fashion after a mean of 7.6 (range 0–26) days following trauma. Five (42%) had a normal bilirubin level at the time of diagnosis. Total bilirubin levels at diagnosis in the remaining patients were 9.0 ± 6.6 mg/dL with a direct bilirubin of 4.5 ± 4.7 mg/dL. Hepatic transaminases were universally elevated early post-injury with mean AST 998 [80–4256] U/L and ALT 1036 [39–2548] U/L. Similarly pancreatic enzymes were commonly elevated post-injury with lipase 545 [201–1505] U/L, and subsequently decreased thereafter. Classification of biliary injuries is shown in Fig. 1. Major ductal injuries involved the common bile duct (2), common hepatic duct (2), left hepatic duct (1) and a common bile duct/ampullary avulsion (1). Five major ductal injuries were managed by ERCP and biliary stent.
E.S. Soukup et al. / Journal of Pediatric Surgery 49 (2014) 345–348 8 7 6 5 4 3 2 1 0 Major ductal injury
Minor ductal injury with biloma
Gallbladder injury
Intrahepatic ductal injury
Fig. 1. Classification of bile duct injuries.
The remaining major ductal injury was a complete transection of the CBD identified on diagnostic ERCP. A biliary stent could not be placed across this injury, and the patient underwent early Roux-en-Y hepaticojejunostomy on PTD 7. In the 5 patients who underwent initial ERCP and biliary stent placement, 2 (40%) required only a single follow-up ERCP to document resolution of injury and remove the stent. Two (40%) developed delayed stricture requiring multiple ERCP procedures and/or laparotomy for repair, and another developed post-ERCP bleeding after sphincterotomy requiring a total of four ERCP procedures before resolution of the biliary injury. Associated bilomas were managed with percutaneous drainage (7), laparoscopic drainage (2), or during laparotomy (3). The four patients with biloma but without major ductal injury on HIDA underwent peritoneal drainage alone with 100% successful resolution of the injury. The one ampullary disruption was temporarily controlled by cannulation and external drainage during initial laparotomy, but the patient died from a devastating head injury prior to definitive repair. Mean length of stay for survivors was 17.1 ± 11.5 days. The overall complication rate was 50% (n = 6). One patient died of associated injuries. Two patients required placement of additional drains and prolonged antibiotics for superinfection following percutaneous biloma drainage. Three patients developed delayed or persistent strictures. One presented in a delayed fashion and was managed successfully with ERCP and biliary stent, although it took 11 months and 4 ERCP procedures. The other two injuries were each diagnosed within a week post-trauma and underwent ERCP with stent but developed delayed strictures. Each of these patients underwent 3–4 total ERCP or PTC procedures and neither stricture resolved: one patient required hepatectomy for persistent cholestasis after 2 months, and the other never resolved the obstruction after 4 ERCP or PTC procedures, but had no cholestasis or cholangitis and has been managed by observation.
suspected [1]. Arguably this could have been used more frequently in our patient population. Abnormal HIDA scans were followed up by ERCP to further characterize and treat the injury, although in one patient, a concern for gallbladder perforation on CT and HIDA scan prompted urgent laparotomy and cholecystectomy. Adjunctive treatments such as ERCP with biliary stent, and percutaneous drainage by interventional radiology (IR) has become more commonplace in the management of many iatrogenic and traumatic biliary injuries due to advancements in endoscopic and radiologic skills. This is true in the pediatric population as well [1,9]. In our series, patients with bilomas and a normal HIDA scan were managed by peritoneal drainage alone with 100% success. These bilomas are due to parenchymal or minor duct injuries, and the majority will close without subsequent intervention. Peritoneal drainage was achieved by either a percutaneous approach by IR or operative washout. The occurrence of biloma superinfection and need for multiple IR drains in two of our patients may argue for a laparoscopic washout with drain placement as a more definitive strategy for control of the biloma. Occasionally persistent drainage from peritoneal drains may necessitate ERCP and biliary stent [6, Carillo et al.]. In our series, all major ductal injuries seen on HIDA scan were subsequently evaluated by ERCP. However the success of ERCP with biliary stenting was lower than that reported in the literature [1,9]. Two out of 5 (40%) patients were successfully managed with a single attempt with ERCP and biliary stent. Another patient required multiple attempts at ERCP and stent, which were ultimately successful, making the overall success rate 60%. The remaining two patients (40%) developed persistent strictures that did not resolve with ERCP and biliary stent. Patients with a discrete ductal injury are at higher risk for stricture and require close follow-up. In the setting of damage control laparotomy for hemodynamic instability or associated injuries, biliary tract injury, if identified, can be controlled with temporary drains with delay of definitive characterization of the injury and repair at a later operation [5]. Cholecystectomy remains the definitive treatment for gallbladder injury [8]. One patient in our series sustained a complete extrahepatic bile duct transection identified on diagnostic ERCP and underwent hepaticojejunostomy. This remains the definitive repair for major biliary tract injuries [5]. Fig. 2 outlines our proposed management strategy based on type of biliary injury. In contrast to what is described in the literature, our series highlights the fact that complications are common after adjunctive interventions such as ERCP, PTC, and IR drainage. Each intervention represents a general anesthetic to a pediatric patient. Repeat percutaneous procedures were necessary in half of the patients who underwent placement of IR drains, ranging from 2 to 4 total IR procedures. Similarly, in all patients who underwent ERCP with stent, a
Minor ductal injuries with biloma (no leak on HIDA): Peritoneal drainage alone Intrahepatic ductal injuries (leak on HIDA scan): ERCP and biliary stent, with peritoneal drainage of biloma
3. Discussion In this study at our level I pediatric trauma hospital, we found that injuries to the biliary tract are rare in children, representing less than 0.1% of trauma admissions. All had associated intraabdominal injuries, most commonly to the liver, pancreas and duodenum. In all but two patients, the diagnosis of biliary injury was delayed, which is consistent with the literature [1,9]. In our series, injuries were identified after approximately 7 days following initial trauma. Diagnostic evaluation of biliary injury was prompted by rising bilirubin levels or biloma. Fever, abdominal pain, or prolonged ileus were the most common symptoms that prompted repeat imaging to find a biloma. Early diagnosis requires a high index of suspicion, and HIDA scan is an excellent screening modality if biliary injury is
347
Major ductal injuries seen on HIDA scan: ERCP and biliary stent, with peritoneal drainage of biloma. Hepaticojejunostomy if complete transection.
Gallbladder injury: cholecystectomy
Fig. 2. Proposed management for biliary injuries.
348
E.S. Soukup et al. / Journal of Pediatric Surgery 49 (2014) 345–348
subsequent ERCP was necessary to document resolution of the injury and remove the stent, and in 60% multiple procedures were required (ranging from 3 to 4 ERCP or PTC procedures for each patient). Three patients developed delayed or persistent strictures after injury and all required multiple endoscopic and radiologic procedures. There are several limitations to this study. First, it is a retrospective study which may introduce selection bias and limits the information that can be gathered. Information about decisionmaking cannot be fully elucidated. Although patients were managed by a cohesive group of surgeons, uniformity of care cannot be assured among the surgeons. We did limit patient selection to the most recent decade to ensure that adjunctive therapies such as ERCP performed by skilled gastroenterologists and percutaneous procedures performed by interventional radiologists were available for all patients in the series. In addition, although this is the largest pediatric series of its kind, it is based on a relatively small number of injuries, and trends and risk factors cannot be elucidated. For example, there were no patients in our series who sustained biliary injury after penetrating trauma. Biliary injury is a rare but important injury after abdominal trauma, and can result in significant morbidity, requiring multiple procedures and operations. Cholecystectomy remains the definitive treatment for gallbladder injury. Percutaneous or laparoscopic drainage of a biloma alone can resolve the majority of minor ductal injuries. ERCP and biliary stenting of major ductal injuries, with or
without percutaneous drainage, can successfully manage the injury, although multiple procedures and frequent complications including delayed stricture may be expected. Hepaticojejunostomy remains the definitive repair for complete bile duct disruption. This study reports the largest series of pediatric biliary injuries with a large proportion of major ductal injuries.
References [1] 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. [2] Bourque MD, Spigland N, et al. Isolated complete transection of the common bile duct due to blunt trauma in a child, and review of the literature. J Pediatr Surg 1989;24:1068–70. [3] Church NG, May G, Sigalet DL. A minimally invasive approach to bile duct injury after blunt liver trauma in pediatric patients. J Pediatr Surg 2002;37:773–5. [4] Poli ML, Lefebvre F, et al. Nonoperative management of biliary tract fistulas after blunt abdominal trauma in a child. J Pediatr Surg 1995;30:1719–21. [5] Thomson BNJ, Nardino B, et al. Management of blunt and penetrating biliary tract trauma. J Trauma Acute Care Surg 2012;72:1620–5. [6] Stein M, Battistella FD. Percutaneous management of traumatic biliary injuries. Semin Interv Radiol 2003;20:141–9. [7] Carrillo EH, Spain DA, et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma 1999;46:619–22. [8] Ball CG, Dixon E, et al. A decade of experience with injuries to the gallbladder. J Trauma Manag Outcomes 2010;4:1752. [9] Sawaya DE, Johnson LW, et al. Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multi-institutional review. Am Surg 2001;67:473–7.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Treatment and outcome of traumatic biliary injuries in children Elizabeth S. Soukup ⁎, Katie W. Russell, Ryan Metzger, Eric R. Scaife, Douglas C. Barnhart, Michael D. Rollins Division of Pediatric Surgery, Primary Children’s Medical Center, University of Utah, Salt Lake City, UT 84113, USA
a r t i c l e
i n f o
Article history: Received 8 October 2013 Accepted 10 October 2013 Key words: Biliary injury Hepatobiliary injury Gallbladder injury Pediatric trauma
a b s t r a c t Background/Purpose: 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. Methods: 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. Results: 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. Conclusion: 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. © 2014 Elsevier Inc. All rights reserved.
Traumatic biliary tract injuries in children are rare but may result in significant morbidity [1–4]. Injuries can involve intrahepatic or extrahepatic ducts, or the gallbladder, and range from minor ductal injuries to complete transection. Historically, laparotomy and hepaticojejunostomy has been the gold standard for treatment of biliary injuries [5]. Recently, reports in the adult literature advocate for conservative measures such as placement of endoscopic stents and peritoneal drains to facilitate healing [6,7]. Injuries are commonly associated with other intraabdominal injuries, including blunt liver trauma and pancreatic and duodenal injuries [5,8]. Biliary injury may be diagnosed early, but is more commonly identified in a delayed fashion as a postoperative biliary fistula, bile peritonitis, biloma, or biliary stricture [5,9]. Most of the literature on biliary injuries is in adults after laparoscopic cholecystectomy [8], and is sparse for traumatic injuries in children [1–4]. The objective of this study was to review the occurrence of traumatic biliary tract injuries in children, management strategies, and outcome. ⁎ Corresponding author at: Division of Pediatric Surgery, Primary Children's Medical Center, University of Utah, Salt Lake City UT 84113, USA. Tel.: +1 801 662 2950; fax: +1 801 662 2980. E-mail address: [email protected] (E.S. Soukup). 0022-3468/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.10.011
1. Methods We conducted a retrospective review of all children with injury to the biliary tract at our level 1 pediatric trauma center from 2002 to 2012. Patients were identified using our trauma registry, and charts were reviewed to confirm and characterize the nature of the biliary injury. Patient information including demographics, mechanism of injury, associated injuries, Injury Severity Score (ISS), methods and timing of diagnosis, operative and nonoperative treatment, complications and long-term follow-up were collected from inpatient records and outpatient follow-up charts. Approval was obtained from our institutional review board. 2. Results During the study period from 2002 through 2012, there were 13,582 trauma admissions. Twelve patients were identified with biliary injury, representing 0.09% of all trauma patients, and 2.6% of patients with hepatic trauma. A total of 462 patients sustained liver injury, including 237 with severe liver injuries (grade III–V). Patient characteristics, management and outcomes are summarized in Table 1.
346
E.S. Soukup et al. / Journal of Pediatric Surgery 49 (2014) 345–348
Table 1 Summary of patient characteristics, management, and outcomes. Patient and mechanism
ISS
Injury
Evaluation, management and Outcome
1
5 yo F MVA, ejected, rollover
35
LHD injury (and delayed stricture)
2
15 yo M Trampled by bull
16
Biloma
3
14 yo M Bicycle crash
18
Gallbladder
4
4 yo F Non-accidental trauma
54
CBD/ampulla disruption
5
4 yo F Filing cabinet fell on abdomen
26
CBD transection
6
5 yo M Rolled over by vehicle in driveway 8 yo M ATV crash 15 yo M Trampled by bull
50
Biloma
29
CBD injury
25
Gallbladder avulsion & CBD injury (and delayed stricture)
9
9 yo M Bicycle crash (handlebar injury)
9
No known injury initially (delayed CBD/ampullary stricture)
10
13 yo F ATV crash 12 yo M ATV crash
43
Biloma
33
Intrahepatic duct injury
12 yo M Pedestrian struck
38
Biloma
HIDA PTD 5, ERCP/stent & IR drainage (PTD 6 and 7). Injury: LHD obstruction and leak. Complicated by infected biloma (IR drain ×3) and subsequent stricture (ERCP ×2, PTC ×1). Persistent stricture but normal LFTs and no cholangitis. Stent removed. Managed with observation. *Initial normal bilirubin, rise with delayed stricture. PTD 6 laparoscopic washout and drainage of biloma prior to transfer to our facility. Persistent biloma on CT scan PTD 10. IR drainage PTD 11. Complicated by infected biloma (IR drain ×2) and pelvic abscess (laparotomy washout). *Normal bilirubin. Initial CT with concern for gallbladder disruption. Confirmed by HIDA and underwent laparotomy and cholecystectomy. No complications. *Normal bilirubin. Emergent laparotomy and packing: mesenteric injury with exsanguination, duodenal perforation, and complete disruption of ampulla. Cannulation of the transected ampulla to an external drain. Profound hemodynamic instability/CPR. Died PTD 1 of head injury/hypoxic brain injury with herniation. *Bilirubin not checked. PTD 5 HIDA, PTD 6 ERCP suggesting CBD/CHD disruption, unable to stent. Temporary IR drain placed. PTD 7 laparotomy and IOC confirmed complete transection of RHD and LHD from CHD. Hepatico-jejunostomy performed. Complicated by residual biloma (POD 17 IR drain). 8 month follow-up normal. *Elevated bilirubin. PTD 14 laparoscopic washout & drainage of biloma, no discrete injury visualized. No complications. *Normal bilirubin. PTD 3 HIDA, PTD 5 ERCP/stent. Injury: CBD/CHD leak. PTD 7 IR drain. Follow-up ERCP normal, stent removed. No complications. *Elevated bilirubin. Emergent laparotomy and packing. PTD 2 reexploration with cholecystectomy for gallbladder avulsion, washout and drainage of biloma. PTD 5 ERCP/stent. Injury: CBD/CHD leak. Complicated by delayed LHD stricture (rising bilirubin and biloma on CT, PTD 45 IR drain, PTD 46 ERCP LHD occlusion/leak, PTD 48 PTC unable to cannulate, L hepatectomy PTD 55). Three subsequent laparotomies for SBO. *Initial normal bilirubin, rise with delayed stricture. Duodenal hematoma, blunt pancreatic injury, initial discharge PTD 4. Complicated by delayed CBD/ampullary stricture (rising bilirubin, PTD 27 MRCP, PTD 29 ERCP/sphincterotomy/stent, PTD 34 ERCP for cautery of sphincterotomy bleeding, PTD 137 ERCP for persistent stricture, and normal follow-up ERCP at 11 months for stent removal. *Initial normal bilirubin, rise with stricture. PTD 7 HIDA. PTD 9 IR drain of biloma. No long-term follow-up. *Elevated bilirubin. PTD 5 CT scan with biloma. PTD 7 HIDA, PTD 9 ERCP/stent left intrahepatic duct leak. Follow-up ERCP normal, stent removed. No complications. *Elevated bilirubin. PTD 6 HIDA, PTD 8 Exploratory laparotomy, washout & drainage of biloma. No ductal injury visualized. No complications. *Elevated bilirubin
7 8
11
12
MVA, motor vehicle accident; LHD, left hepatic duct; HIDA,; PTD, post-trauma day; IR, interventional radiology; ERCP, endoscopic retrograde cholangiopancreatography; PTC, percutaneous transhepatic cholangiography; CT, computed tomography; CBD, common bile duct; CPR, cardiopulmonary resuscitation; POD, post-operative day; CHD, common hepatic duct; SBO, small bowel obstruction; MRCP, magnetic resonance cholangiopancreatography.
All biliary injuries were secondary to blunt trauma, including bicycle crash (2), ATV crash (3), trampled by bull (2), pedestrian struck (2), non-accidental trauma (1), struck by falling object (1), and motor vehicle crash (1). Mean age was 9.7 years [range 4-15] and mean injury severity score was 31 ± 14. Eight (67%) patients were male. Ninety-two percent of patients had an associated liver injury (grade 1 = 1; grade 3 = 1; grade 4 = 3; grade 5 = 6). The remaining patient never underwent abdominal CT before urgent laparotomy, and therefore hepatic trauma could not be fully assessed. The most common associated abdominal injuries included 2 duodenal injuries (one hematoma and one perforation), 6 pancreatic injuries, 4 splenic injuries, and 1 intestinal injury. Three patients underwent immediate laparotomy for exploration and hemorrhage control. One patient died of associated injuries prior to definitive repair with an overall survival in our cohort of 92%. The diagnostic evaluation of biliary injury included HIDA scan in 7 patients and ERCP in 6 patients. One patient who initially presented with a duodenal hematoma, developed delayed jaundice and underwent magnetic resonance cholangiopancreatography (MRCP) on post-trauma day (PTD) 26, followed by ERCP and stent of a common bile duct (CBD) stricture. Two other patients underwent percutaneous
transhepatic cholangiogram (PTC) for delayed presentation of CBD stricture after unsuccessful ERCP and biliary stent. Initial diagnostic studies were prompted by clinical indications including rising bilirubin levels, persistent bilious output from drains after laparotomy, or free fluid on repeat imaging (ultrasound or CT scan) of the abdomen. One patient with ampullary disruption was diagnosed on initial laparotomy. One patient underwent HIDA scan within 24 hours to confirm findings on CT concerning for gallbladder disruption. The remainder presented in a delayed fashion after a mean of 7.6 (range 0–26) days following trauma. Five (42%) had a normal bilirubin level at the time of diagnosis. Total bilirubin levels at diagnosis in the remaining patients were 9.0 ± 6.6 mg/dL with a direct bilirubin of 4.5 ± 4.7 mg/dL. Hepatic transaminases were universally elevated early post-injury with mean AST 998 [80–4256] U/L and ALT 1036 [39–2548] U/L. Similarly pancreatic enzymes were commonly elevated post-injury with lipase 545 [201–1505] U/L, and subsequently decreased thereafter. Classification of biliary injuries is shown in Fig. 1. Major ductal injuries involved the common bile duct (2), common hepatic duct (2), left hepatic duct (1) and a common bile duct/ampullary avulsion (1). Five major ductal injuries were managed by ERCP and biliary stent.
E.S. Soukup et al. / Journal of Pediatric Surgery 49 (2014) 345–348 8 7 6 5 4 3 2 1 0 Major ductal injury
Minor ductal injury with biloma
Gallbladder injury
Intrahepatic ductal injury
Fig. 1. Classification of bile duct injuries.
The remaining major ductal injury was a complete transection of the CBD identified on diagnostic ERCP. A biliary stent could not be placed across this injury, and the patient underwent early Roux-en-Y hepaticojejunostomy on PTD 7. In the 5 patients who underwent initial ERCP and biliary stent placement, 2 (40%) required only a single follow-up ERCP to document resolution of injury and remove the stent. Two (40%) developed delayed stricture requiring multiple ERCP procedures and/or laparotomy for repair, and another developed post-ERCP bleeding after sphincterotomy requiring a total of four ERCP procedures before resolution of the biliary injury. Associated bilomas were managed with percutaneous drainage (7), laparoscopic drainage (2), or during laparotomy (3). The four patients with biloma but without major ductal injury on HIDA underwent peritoneal drainage alone with 100% successful resolution of the injury. The one ampullary disruption was temporarily controlled by cannulation and external drainage during initial laparotomy, but the patient died from a devastating head injury prior to definitive repair. Mean length of stay for survivors was 17.1 ± 11.5 days. The overall complication rate was 50% (n = 6). One patient died of associated injuries. Two patients required placement of additional drains and prolonged antibiotics for superinfection following percutaneous biloma drainage. Three patients developed delayed or persistent strictures. One presented in a delayed fashion and was managed successfully with ERCP and biliary stent, although it took 11 months and 4 ERCP procedures. The other two injuries were each diagnosed within a week post-trauma and underwent ERCP with stent but developed delayed strictures. Each of these patients underwent 3–4 total ERCP or PTC procedures and neither stricture resolved: one patient required hepatectomy for persistent cholestasis after 2 months, and the other never resolved the obstruction after 4 ERCP or PTC procedures, but had no cholestasis or cholangitis and has been managed by observation.
suspected [1]. Arguably this could have been used more frequently in our patient population. Abnormal HIDA scans were followed up by ERCP to further characterize and treat the injury, although in one patient, a concern for gallbladder perforation on CT and HIDA scan prompted urgent laparotomy and cholecystectomy. Adjunctive treatments such as ERCP with biliary stent, and percutaneous drainage by interventional radiology (IR) has become more commonplace in the management of many iatrogenic and traumatic biliary injuries due to advancements in endoscopic and radiologic skills. This is true in the pediatric population as well [1,9]. In our series, patients with bilomas and a normal HIDA scan were managed by peritoneal drainage alone with 100% success. These bilomas are due to parenchymal or minor duct injuries, and the majority will close without subsequent intervention. Peritoneal drainage was achieved by either a percutaneous approach by IR or operative washout. The occurrence of biloma superinfection and need for multiple IR drains in two of our patients may argue for a laparoscopic washout with drain placement as a more definitive strategy for control of the biloma. Occasionally persistent drainage from peritoneal drains may necessitate ERCP and biliary stent [6, Carillo et al.]. In our series, all major ductal injuries seen on HIDA scan were subsequently evaluated by ERCP. However the success of ERCP with biliary stenting was lower than that reported in the literature [1,9]. Two out of 5 (40%) patients were successfully managed with a single attempt with ERCP and biliary stent. Another patient required multiple attempts at ERCP and stent, which were ultimately successful, making the overall success rate 60%. The remaining two patients (40%) developed persistent strictures that did not resolve with ERCP and biliary stent. Patients with a discrete ductal injury are at higher risk for stricture and require close follow-up. In the setting of damage control laparotomy for hemodynamic instability or associated injuries, biliary tract injury, if identified, can be controlled with temporary drains with delay of definitive characterization of the injury and repair at a later operation [5]. Cholecystectomy remains the definitive treatment for gallbladder injury [8]. One patient in our series sustained a complete extrahepatic bile duct transection identified on diagnostic ERCP and underwent hepaticojejunostomy. This remains the definitive repair for major biliary tract injuries [5]. Fig. 2 outlines our proposed management strategy based on type of biliary injury. In contrast to what is described in the literature, our series highlights the fact that complications are common after adjunctive interventions such as ERCP, PTC, and IR drainage. Each intervention represents a general anesthetic to a pediatric patient. Repeat percutaneous procedures were necessary in half of the patients who underwent placement of IR drains, ranging from 2 to 4 total IR procedures. Similarly, in all patients who underwent ERCP with stent, a
Minor ductal injuries with biloma (no leak on HIDA): Peritoneal drainage alone Intrahepatic ductal injuries (leak on HIDA scan): ERCP and biliary stent, with peritoneal drainage of biloma
3. Discussion In this study at our level I pediatric trauma hospital, we found that injuries to the biliary tract are rare in children, representing less than 0.1% of trauma admissions. All had associated intraabdominal injuries, most commonly to the liver, pancreas and duodenum. In all but two patients, the diagnosis of biliary injury was delayed, which is consistent with the literature [1,9]. In our series, injuries were identified after approximately 7 days following initial trauma. Diagnostic evaluation of biliary injury was prompted by rising bilirubin levels or biloma. Fever, abdominal pain, or prolonged ileus were the most common symptoms that prompted repeat imaging to find a biloma. Early diagnosis requires a high index of suspicion, and HIDA scan is an excellent screening modality if biliary injury is
347
Major ductal injuries seen on HIDA scan: ERCP and biliary stent, with peritoneal drainage of biloma. Hepaticojejunostomy if complete transection.
Gallbladder injury: cholecystectomy
Fig. 2. Proposed management for biliary injuries.
348
E.S. Soukup et al. / Journal of Pediatric Surgery 49 (2014) 345–348
subsequent ERCP was necessary to document resolution of the injury and remove the stent, and in 60% multiple procedures were required (ranging from 3 to 4 ERCP or PTC procedures for each patient). Three patients developed delayed or persistent strictures after injury and all required multiple endoscopic and radiologic procedures. There are several limitations to this study. First, it is a retrospective study which may introduce selection bias and limits the information that can be gathered. Information about decisionmaking cannot be fully elucidated. Although patients were managed by a cohesive group of surgeons, uniformity of care cannot be assured among the surgeons. We did limit patient selection to the most recent decade to ensure that adjunctive therapies such as ERCP performed by skilled gastroenterologists and percutaneous procedures performed by interventional radiologists were available for all patients in the series. In addition, although this is the largest pediatric series of its kind, it is based on a relatively small number of injuries, and trends and risk factors cannot be elucidated. For example, there were no patients in our series who sustained biliary injury after penetrating trauma. Biliary injury is a rare but important injury after abdominal trauma, and can result in significant morbidity, requiring multiple procedures and operations. Cholecystectomy remains the definitive treatment for gallbladder injury. Percutaneous or laparoscopic drainage of a biloma alone can resolve the majority of minor ductal injuries. ERCP and biliary stenting of major ductal injuries, with or
without percutaneous drainage, can successfully manage the injury, although multiple procedures and frequent complications including delayed stricture may be expected. Hepaticojejunostomy remains the definitive repair for complete bile duct disruption. This study reports the largest series of pediatric biliary injuries with a large proportion of major ductal injuries.
References [1] 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. [2] Bourque MD, Spigland N, et al. Isolated complete transection of the common bile duct due to blunt trauma in a child, and review of the literature. J Pediatr Surg 1989;24:1068–70. [3] Church NG, May G, Sigalet DL. A minimally invasive approach to bile duct injury after blunt liver trauma in pediatric patients. J Pediatr Surg 2002;37:773–5. [4] Poli ML, Lefebvre F, et al. Nonoperative management of biliary tract fistulas after blunt abdominal trauma in a child. J Pediatr Surg 1995;30:1719–21. [5] Thomson BNJ, Nardino B, et al. Management of blunt and penetrating biliary tract trauma. J Trauma Acute Care Surg 2012;72:1620–5. [6] Stein M, Battistella FD. Percutaneous management of traumatic biliary injuries. Semin Interv Radiol 2003;20:141–9. [7] Carrillo EH, Spain DA, et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma 1999;46:619–22. [8] Ball CG, Dixon E, et al. A decade of experience with injuries to the gallbladder. J Trauma Manag Outcomes 2010;4:1752. [9] Sawaya DE, Johnson LW, et al. Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multi-institutional review. Am Surg 2001;67:473–7.
