Extrahepatic bile ducts injury : a report on 14 cases

Traumatic injuries of the extrahepatic biliary tract are infrequent, occurring in approximately 0.5 % of all patients with blunt and penetrating abdominal trauma. The incidence of this injury due to blunt abdominal trauma is rare. This study reviewed patients with injuries of the extrahepatic biliary tract due to abdominal trauma over a 6-year period to determine the incidence, trauma scores, associated injuries, surgical treatment performed, complications and mortality rate. We report our experience with 14 patients with extrahepatic biliary tract trauma. A review of the literature and the discussion about the management are presented.


INTRODUCTION
T raumatic injuries to the extrahepatic bile ducts remain relatively rare even in the busiest trauma centers.Formerly, blunt trauma to the right upper quadrant accounted for most of the reported injuries to the bile ducts, but in recent years, penetrating trauma has been the most common cause.Because of the variable complexity of injuries, a wide variety of surgical options for repair of the bile ducts is possible.We report, herein, on our experience with patients who sustained traumatic injuries to the extrahepatic bile ducts over a six-year period.

MATERIALS AND METHODS
During the 6-year period from 1986 to 1991, 5,069 patients underwent laparotomy for abdominal trauma at the Department of Surgery, University of Sao Paulo School of Medicine, Brazil.Eighteen patients (0.35%) had injuries involving the extrahepatic bile ducts.Records, including operative and pathology reports, were reviewed to study the site of injury, associated intra-abdominal injuries, incidence, trauma scores, type of repair, morbidity and mot1ality rates.

RESULTS
Eighteen patients with extrahepatic bile ducts injuries were identified in a group of 5,069 patients (0.35%) who sustained intra-abdominal trauma over a six-year period.The patients age ranged from 15 to 30 years with a mean age of 22.5 years; 17 of the 18 patients were male.
Of the 18extrahepatic bile ducts injuries, 15(83.3%)were caused by penetrating wounds, and three by blunt trauma.All patients underwentexploratOlY laparotomy.In the 18 patients, 63 intra-abdominal injuries were found, or 3.5 per patient.Thirteen of the 18 patients (72.2%) had lacerations of the liver.Pancreas lacerations (II patients), gastric lacerations (6 patients) and duodenal lacerations (6 patients) were the next most commonly seen injuties (Table.I).The disttibution of injuries to the extrahepatic bile ducts was as follows: the left hepatic duct in one patient, the common hepatic duct junction in one patient, the common hepatic duct in three patients, the cystic duct in one patient and distal common bile duct or ampulla of Vater in 12 patients (Fig. I).Five of the 18 patients died (27.7%), none as a result of their bile duct injury.Two of these patients had simple lateral repairs, one of whom underwent decompression with aT tube.Five patients with simple repairs survived, and none hacl problems related to the repair of the bile tract at the time of discharge.Two of ten patients with complex repairs died in the hospital.Six patients with an intrapancreatic common bile duct il~ury underwent a duodenopancreatectomy.Two patients with a complete transection of the common hepatic duct and common hepatic duct junction underwent Roux-en-Y hepaticojejunostomy.One patient with distal common bile duct lesion underwent Roux-en-Y choledochojejunostomy.One patient with distal common bile duct injury underwent choledochoduodenostomy (Table 2).acholic stools occur.The jaundice is due to the absorption of bile pigment by the peritoneum.
Extrahepatic bile duct injuries are usually detected at the time of laparotomy and are seldom diagnosed preoperatively.Even during celiotomy, these lesions may  Trauma to the extrahepatic bile ducts is a rare but insidious diagnostic problem which is potentially fataL Increasing civilian violence and a greater frequency of motor vehicle accidents are resulting in a higher incidence of trauma to the extrahepatic biliary system.Injury to the ducts themselves is rarely fatal, however associated injuries result in significant mortality.Furthermore, bile tract injuries themselves can be associated with considerable morbidity such as bilestenosis and leakage.Extrahepatic bile tree injury due to blunt abdominal trauma is rarer than penetrating injury.In the present series, the incidence was 0.12% and 0.57%, respectively.
The clinical picture is variable.Initially, there could be shock with severe or moderate low blood pressure, accompanied by considerable upper abdominal pain and rigidness, usually most severe in the right upper quadrant.Usually the period of shock and pain is a matter of few hours or less, and is followed by relatively symptom-free interval, unless there are associated injuries.With leakage of bile into the peritoneal cavity, jaundice, bileascites and be missed unless the bile tract is carefully inspected, a process which is more likely to be omitted in the presence of life-threatening wounds.Intra-operative cholangiography is extremely helpful in making the diagnosis of bile duct injury and in accurately localizing the injury.
Management of patients with traumatic extrahepatic lesions of the bile tract depends upon the site, type of injury and general conditions of the patient.In the profoundly hypotensive patient with a partial tear, external drainage will prevent bileascites and may occasionally be curative, although the formation of a stricture often occurs.On occasion, a small perforation or tear may be present in the retro-panreatic portion of the common bile duct.In the unstable patient or the stable patient in whom visualization is difficult, another alternative is the insertion of a proximal tube to decrease the output from the expected fistula.If the patient is stable and has a partial tear, cystic duct avulsion, or small through injury, a primary repair with an absorbable suture can be performed.
If the transection is clean and simple without significant contusion of both ends of the duct, an end-to-end anastomosis may be utilized.Dissection around the duct will cause additional devascularization of the ends, and should be avoided.When tension is present at the anastomosis, a stricture will result.When a complex transection has occurred, or a portion of the common bile duct has been destroyed or devascularized in a stable patient, a bilioenteric anastomosis using a Roux-en-Y limb should be performed.

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On occasion, the combination of a hepatic ductal injury and a parenchymal injury will lead to a hepatic lobectomy.Duodenopancreatectomy is best reserved for rare distal bile duct injuries combined with injuries to the pancreatoduodenal complex or ampulla of Vater, as occurred in three of our patients.
We concluded that the type of repair employed in our series was related to the hemodynamic stability and clinical conditions (based on trauma scores) of the patient more than to the site and complexity of the injury.

Figure 1 -
Figure 1 -Distribution of lesions in extrahepatic biliary ducts