AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Background

Isolated injury to the extrahepatic biliary tract and the gallbladder may occur from a thoracoabdominal injury or an iatrogenic trauma. 

This article considers both blunt trauma and penetrating trauma to the extrahepatic biliary tract and the gallbladder. This article also covers the impact of laparoscopic cholecystectomy, which has led to an increasing incidence of bile duct injury.

Pathophysiology

Typically, a mechanism of crushing or shear injury to the right upper quadrant causes biliary disruption leading to bile peritonitis. The retroduodenal region of the superior portion of the pancreas is the most common site of biliary transection following blunt trauma. 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.

Frequency

United States

Although the exact incidence of nonoperative biliary trauma is unknown, isolated biliary injury without trauma to associated intra-abdominal structures is extremely rare. Fewer than 40 cases of common bile duct avulsion following blunt trauma are reported; however, it is much more rare than penetrating trauma and more difficult to diagnose.

Mortality/Morbidity

• 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).

Sex

No sexual predilection exists.

Age

Biliary trauma can occur at any age.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

History

• Suspect extrahepatic biliary tract trauma when the patient presents with a mechanism of injury consistent with the application of significant blunt force to the thoracoabdominal region. Mechanisms of injury can range from motor vehicle crashes to short falls.
• Penetrating trauma to the extrahepatic biliary tract may be obvious based on the external trajectory of the object, especially in stab wounds. In gunshot wounds to the abdomen, which may have a varied intra-abdominal trajectory, the path of injury may be less obvious.
• A patient's history of laparoscopic cholecystectomy is an important consideration in defining an extrahepatic biliary tract injury caused by a prior procedure.

Physical

• Signs of trauma to the extrahepatic biliary tract caused by thoracoabdominal injury are as follows:  
• • Early signs of biliary leakage may be difficult to appreciate on physical examination.
  • Hypovolemic shock can occur from intense chemical peritonitis when diagnosis is delayed. This can be followed by septic shock from bacterial overgrowth within a period of hours to days; however, with minimal biliary leakage, shock may not occur and abdominal signs may be absent.
  • Jaundice is usually observed 3-5 days after injury, along with the passage of clay-colored stools and dark-colored urine.
  • Increasing abdominal girth accompanied by signs of dehydration and low-grade sepsis may be observed during the first week after trauma.
  • Direct observation with laparoscopy or laparotomy is used to aid in diagnosing penetrating extrahepatic biliary trauma.
  • The hepatoduodenal ligament may show contusion, edema, fresh clot formation, or active bleeding.
• Signs of trauma to the extrahepatic biliary tract caused by operative laparoscopy are as follows:  
• • Diagnosis of extrahepatic biliary tract trauma may be made during laparoscopy by direct observation of copious amounts of biliary drainage emanating from the porta hepatis or, if suspected, by contrast leak during an intraoperative cholangiogram.  
  • Extrahepatic biliary trauma may also be determined by patient complaints of abdominal pain, nausea, or increasing abdominal discomfort, occurring during the first week after laparoscopic cholecystectomy.
  • Jaundice may also be present.

Causes

• Blunt trauma mechanisms (eg, motor vehicle deceleration injuries, falls, assaults)
• Penetrating injuries caused by a simple direct force (eg, knife wound) or by a complex, indirect injury (eg, gunshot wound)
• Causes of laparoscopic injury to the extrahepatic biliary tract  
• • Direct trauma by grasping forceps
  • Excessive use of electrocautery and dissection around the porta hepatis, causing tearing of the common bile duct wall or ischemia with resultant stricture formation
  • Transection of the common bile duct or the right hepatic duct by not identifying the “critical view” during the cystic duct dissection
  • Improper placement of clips, lacerating the extrahepatic biliary tract
  • Endoscopic stenting of the biliary tree, increasing the incidence of iatrogenic injuries

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Associated injury to the portal vein, the hepatic artery, the pancreas, and the liver

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Imaging Studies

• Abdominal CT scanning can evaluate the right upper quadrant in blunt abdominal trauma cases.
• Transabdominal sonography may be useful to observe a bile leak or a dilated common bile duct.
• Endoscopic retrograde cholangiopancreatography (ERCP) may be useful for the diagnosis of suspected, but not obvious, extrahepatic biliary tract trauma from laparoscopic operation.
• Percutaneous transhepatic cholangiography may also be indicated for delineation of the anatomy in more complicated cases.
• Intraoperative ultrasonography can provide important information by aiding in localization of occult injuries. However, it is highly operator dependent.
• Magnetic resonance cholangiopancreatography (MRCP) has been shown to be useful in detecting pancreaticobiliary injuries after blunt trauma.

Procedures

• In patients with extrahepatic biliary tract trauma caused by nonoperative mechanisms (eg, thoracoabdominal trauma), diagnostic peritoneal lavage may be useful for detecting bile or nonclotting blood in the peritoneal fluid.
• In patients with possible laparoscopic trauma to the extrahepatic biliary tract, concomitant sphincterotomy of the sphincter of Oddi and possible stenting may be appropriate.

Staging

Several injury classification systems have been described for biliary tract trauma. Most of them are in the context of iatrogenic injuries during cholecystectomy and provide a recommended surgical approach for repair.

None of the classification systems is universally accepted, but the classification systems of Bismuth and Strasberg are presently the most widely used.

Table 1. Bismuth's Classification (1982)¹

Table 2. Strasberg's Classification (1995)¹

McMahon et al suggested that the type of injury can be subdivided into bile duct laceration, bile duct transection or excision, and bile duct stricture. The level of stricture may be further graded by Bismuth's classification and also makes a distinction on the size of the duct (major vs minor).

Table 3. Definition of Major and Minor Bile Duct Injures by McMahon et al (1995)¹

More comprehensive classification systems have been described; some of them include various types of laparoscopic extrahepatic bile duct injuries and cover the whole spectrum of possible lesions.

Table 4. Summary of Classification Systems¹

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Surgical Care

• Blunt extrahepatic biliary tract injury
• • Perform complete medial reflection of the duodenum to explore the retroperitoneal biliary system and to identify the injury.
  • Choledochoduodenostomy or choledochojejunostomy are currently the preferred methods of treatment. Simple peribiliary drainage is not recommended because of the high biliary stricture and mortality rates.
• Penetrating extrahepatic biliary tract injury
• • Perform exploratory surgery on patients with significant penetrating abdominal trauma. If the patient is coagulopathic, hypothermic, and acidotic, perform damage control with 4-quadrant packing and intensive care unit resuscitation.
  • Acutely control hepatoduodenal hemorrhage by compression of the hepatoduodenal ligament (Pringle maneuver).
  • After proximal and distal control of the hepatoduodenal ligament is obtained, dissect apart the bile duct, the portal vein, and the hepatic artery to identify injury to each structure.
  • If the bile duct is completely transected, perform a biliary-enteric anastomosis (eg, Roux-en-Y choledochojejunostomy). If the duct is partially transected, then primary repair may be possible; a T-tube may be required in such instances.
  • If the patient cannot tolerate a lengthy operative procedure, a T-tube bridge between the ends of the defect may be possible; however, to avoid the sequelae of recurrent biliary strictures, perform definite repair at a later date. Anastomosis between the gallbladder and a loop of the small intestine with ligation of the proximal and distal ends of the injured common bile duct may be more expeditious.
• Laparoscopic extrahepatic biliary tract injury (2 categories)
• • Minor ductal injuries are those that have intact ductal anatomy without associated strictures (eg, tangential holes in the sidewall of the bile duct from ischemic injury, thermal injury, excessive stripping of the common duct wall). Sphincterotomy and stenting are helpful in controlling the biliary fistula; however, operative reconstruction is necessary if a stricture later develops.
  • Major ductal injuries to the common bile duct occur when large segments of the duct are excised, severely destroyed, or occluded by clips. Practically all of these injuries require formal operative repair.
• Gallbladder injury
• • Cholecystectomy is the best treatment of most injuries of the gallbladder regardless of the mechanism of injury.
  • When injury of other organs or hemodynamic instability precludes cholecystectomy, perform cholecystostomy. This usually requires the placement of drains around the subhepatic space. The cholecystostomy tube can be removed after one month, providing a cholangiogram shows normal biliary flow.
  • Primary suture repair of the gallbladder is not recommended because of the high likelihood of bile leakage.

Consultations

• Ensure that a surgeon or a trauma specialist has primary responsibility for the care of all patients with biliary trauma caused by traumatic mechanisms.
• Ensure that a surgeon qualified in general surgical, endoscopic, and laparoscopic techniques is involved in the care of patients with operative and iatrogenic injury to the extrahepatic biliary tract.

Diet

• Patients with a complex postoperative course may be fed by a transpyloric feeding tube that is placed intraoperatively.
• Patients may resume a regular diet after postoperative ileus has resolved.

Activity

No activity restrictions are required for isolated extrahepatic bile duct system injuries.

FOLLOW-UP

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Long-term follow-up care is important to detect postoperative biliary stricture, which is usually detected within 2 years of repair.
• ERCP can be critical in defining extrahepatic biliary tract strictures.

Complications

Complications may arise from the trauma itself or from its treatment.

• Bilomas: Bile leak causing localized collections may be treated by ERCP and stent to favor bile drainage into the duodenum with or without percutaneous drainage by interventional radiology.
• Fistulas/abscess: Most will resolve spontaneously after adequate drainage.
• Strictures: They may cause early complications (eg, cholangitis) or chronic liver problems (eg, biliary cirrhosis). If detected, strictures can be treated by ERCP and stent.

MISCELLANEOUS

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to promptly diagnose extrahepatic biliary tract injuries because of the rarity and vague presentation of isolated extrahepatic biliary tract injury caused by nonoperative mechanisms is a pitfall. The average delay is reportedly 9 days.
• In patients with blunt thoracoabdominal trauma, failure to evaluate associated injuries to the vascular structures within the hepatoduodenal ligament (portal vein and hepatic artery) is a pitfall because these injuries can be life threatening.
• In terms of operative trauma to the extrahepatic biliary tract, failure to obtain an ERCP to confirm the leak, to identify its site and cause, and to help define a therapeutic plan is a pitfall.  
• • In minor leaks, endoscopic diversion by sphincterotomy or stenting provides rapid treatment.
  • In more significant injuries, ERCP with percutaneous transhepatic cholangiogram often helps assess the extent of injury and determines the strategy for operative repair.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• References

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10. Ragozzino A, Manfredi R, Scaglione M, et al. The use of MRCP in the detection of pancreatic injuries after blunt trauma. Emerg Radiol. Apr 2003;10(1):14-8. [Medline].
11. Sawaya DE Jr, Johnson LW, Sittig K, et al. Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multi-institutional review. Am Surg. May 2001;67(5):473-7. [Medline].
12. Shires GT, Thal ER, Jones RC. Trauma. In: Schwartz SI, ed. Principles of Surgery. 6^th ed. New York, NY: McGraw-Hill; 1994:175-224.
13. 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. May 2005;241(5):786-92; discussion 793-5. [Medline].
14. Sriram PV, Ramakrishnan A, Rao GV, et al. Spontaneous fracture of a biliary self-expanding metal stent. Endoscopy. Nov 2004;36(11):1035-6. [Medline].
15. Walsh RM, Henderson JM, Vogt DP, et al. Long-term outcome of biliary reconstruction for bile duct injuries from laparoscopic cholecystectomies. Surgery. Oct 2007;142(4):450-6; discussion 456-7. [Medline].

Article Last Updated: Aug 14, 2008