Background
Isolated injury to the extrahepatic biliary tract and/or the gallbladder is an uncommon event. Predisposing mechanisms include blunt right upper quadrant force, deceleration injuries, penetrating injuries and, most commonly, iatrogenic injury after cholecystectomy.
This article considers both blunt and penetrating trauma to the extrahepatic biliary tract and the gallbladder as well as bile duct injury after cholecystectomy.
Pathophysiology
Typically, a mechanism of crushing or shear injury to the right upper quadrant causes biliary disruption and subsequent bile-peritonitis. The retroduodenal region of the superior portion of the pancreas is the most common site of biliary transection following blunt trauma, possibly secondary to the relative fixation of the bile duct in that location. 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.
Epidemiology
Frequency
Although the exact incidence of nonoperative biliary trauma is unknown, isolated biliary injury without trauma to associated intra-abdominal structures is extremely rare (less than 1% of all blunt abdominal injuries in most series). Fewer than 40 cases of common bile duct avulsion following blunt trauma are reported; however, it is much rarer than penetrating trauma and more difficult to diagnose.
A study by Halbert et al reported that the rate of ate of bile duct injury following laparoscopic cholecystectomy has now decreased to 0.08 % in New York State. [1]
Mortality/Morbidity
See the list below:
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Mortality depends directly on the delay in the diagnosis and the treatment, as well as on the severity of the injury.
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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%.
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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 gender predilection exists.
Age
Biliary trauma can occur at any age but, just like all blunt and penetrating trauma, it is more common in adolescents and young adults. [2]
Tables
Type |
Criteria |
1 |
Low common hepatic duct stricture, with a length of the common hepatic duct stump of >2 cm |
2 |
Proximal common hepatic duct stricture, with a hepatic stump length of < 2 cm |
3 |
Hilar stricture, no residual common hepatic duct, but the hepatic ductal confluence is preserved |
4 |
Hilar stricture, with involvement of confluence and loss of communication between right and left hepatic duct |
5 |
Involvement of aberrant right sectorial hepatic duct alone or with concomitant stricture of the common hepatic duct |
Type |
Criteria |
A |
Cystic duct leaks or leaks from small ducts in the liver bed |
B |
Occlusion of a part of the biliary tree, almost invariably the aberrant right hepatic ducts |
C |
Transection without ligation of the aberrant right hepatic duct |
D |
Lateral injuries to major bile ducts |
E |
Subdivided as per Bismuth’s classification into E1 to E5 |
Type of Injury |
Criteria |
Major bile duct injury (at least one of the following present) |
Laceration >25% of bile duct diameter Transection of common hepatic duct or common bile duct Development of postoperative bile duct stricture |
Minor bile duct injury |
Laceration of common bile duct < 25% of diameter Laceration of cystic-common bile duct junction ("buttonhole tear") |
Classification System |
Year |
Types |
Amsterdam Academic Medical Center’s classification |
1996 |
A-D |
Neuhaus’ classification |
2000 |
A-E |
Csendes’ classification |
2001 |
I-IV |
Stewart-Way’s classification of laparoscopic bile duct injuries |
2004 |
I-IV |
Chinese University of Hong Kong (CUHK) classification |
2007 |
1-5 |
