Exploratory laparotomy revealed two injuries to the first portion of the duodenum and a third injury to the third portion of the duodenum. After satisfactory repair of these injuries there continue to be accumulation of bile in the right upper quadrant. With further exploration the bile was found to be coming from the porta hepatis and ultimately a common bile duct injury was identified. There was an anterior injury that appeared amenable to primary repair however the posterior wall of the common duct was found to be irreparable. The decision was made to ligate the duct proximally and distally, leaving the biliary tree in discontinuity. In addition, a liver laceration was identified in the anterior right lobe as well as an injury directly to the gallbladder, necessitating a cholecystectomy. The patient was extubated and brought to the trauma observation unit.
Six days after the original injury the patient was returned to the operating room for Roux-en-Y hepaticojejunostomy. His post-operative course was complicated by a bile leak causing biliary sepsis as well as respiratory failure. Interventional radiology placed a percutaneous transhepatic cholecystostomy tube across the bilio-enteric anastomosis. Both this drain and the JP drain in the RUQ continued to have high bilious output, until somatostatin was initiated. Drainage decreased and sepsis resolved and the patient continued to improve until the writing of this case.
Traumatic injuries to the common bile duct are reported infrequently in the literature. The majority of case reports are of blunt trauma injuries associated with concomitant liver injuries. One series reported 53 traumatic injuries to the common bile duct, with 39/53 due to stab wounds. Of these only 5/53 patients had complete transection as our patient did. Based on this small series of patients the authors concluded that complete transection was best treated by bilio-enteric reconstruction (i.e. hepaticojejunostomy) while partial transections were successfully managed with primary repair and a T-tube. (1) In a retrospective review of 30 patients with trauma to the biliary tree extra-hepatic injuries remained exceedingly rare and were again fixed with either internal drainage and primary repair (i.e. primary repair + T-tube placement) or biliary enteric reconstruction, with hepaticojejunostomy considered the gold standard. (2).
Injuries to the extra-hepatic biliary tree are, fortunately, quite uncommon. Depending on the exact location and degree of injury the surgical (or non-surgical) management has not been well studied. While patients like ours, with complete transections of the bile duct, seemed to be best managed by hepaticojejunostomy or other bilioenteric reconstruction these are challenging procedures and are best managed together with hepatobiliary experts for the best results. In our particular patient a T-tube was not placed at the time of repair and in each of these larger series T-tube was routinely used after surgical repair of these injuries. While this would not necessarily have prevented the presumed anastomotic leak this would have provided internal decompression of the anastomosis that had to be obtained with PTC in our patient. The use of T-tubes is largely surgeon dependent and has not been well studied in the setting of acute illness and traumatic injury to the extra-hepatic bile duct.
References
1. Bade PG, Thomson SR, Hirshberg A and Robbs JV. Surgical options in traumatic injury to the extrahepatic biliary tract. B Journal Surg. 1989; 7(3): 256-258.
2. Thomson BNJ et al. Management of blunt and penetrating biliary tract trauma. J Trauma Acute Care Surg. 2012; 72(6):1620-1625.
from Dr. Tasha Hughes
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