Approach Considerations
The treatment modality of choice depends on patient stability, associated injuries, and imaging findings. If the clinician has a high index of suspicion for concurrent injuries other than a solid organ injury, a diagnostic laparoscopy or exploratory laparotomy may be indicated. Alternatively, in the rare event that an isolated extrahepatic bile duct or gallbladder injury is identified on imaging, endoscopic techniques may be favored.
Consultations
A surgeon or a trauma specialist should have primary responsibility for the care of all patients with biliary injury caused by traumatic mechanisms. A gastroenterologist well versed in endoscopic retrograde cholangiopancreatography (ERCP) techniques is a valuable resource to provide minimally invasive therapies to manage biliary leaks.
Surgical Care
Intrahepatic biliary tract injury
If a distal intrahepatic bile duct injury is observed at surgery, an attempt to ligate it at that time is recommended. After ligation, the duct and surrounding liver parenchyma should be monitored for signs of bile drainage. Larger ducts near the hilum need to be repaired. Occasionally, a partial hepatectomy may even be indicated.
If significant blood is identified on exploration, packing of all 4 quadrants of the abdomen is the initial step. Bleeding from the right upper quadrant that is not controlled by packing may require a Pringle maneuver (compression of the hepatoduodenal ligament), which occludes portal vein and hepatic artery blood flow to the liver. In unstable patients with large liver lacerations and an intrahepatic bile duct injury, damage control should take priority over definitive bile duct management, which can be addressed after the patient has been resuscitated and stabilizes.
Penetrating extrahepatic biliary tract injury
Patients suspected of having an intra-abdominal injury following a penetrating injury should undergo urgent exploration.
After proximal and distal control of the hepatoduodenal ligament has been obtained, the edges of the injured bile duct should be debrided to healthy tissue. Circumferential dissection of the common duct should be avoided, if possible, to preserve the vascular supply to the biliary tree.
If the bile duct is completely transected, performing a Roux-en-Y choledochojejunostomy or a choledochoduodenostomy, in a stable patient, is recommended. If the duct is partially transected, primary repair may be possible using absorbable suture. Often a T-tube is placed through a separate site where the bile duct is healthy to provide decompression while the bile duct heals.
If the patient is unstable and cannot tolerate a lengthy operative procedure, a T-tube bridge between the ends of the defect or simple drainage is recommended. To avoid the sequelae of recurrent biliary strictures, definitive repair should be performed when the patient is stabilized.
Blunt extrahepatic biliary tract injury
Management of blunt abdominal trauma is similar to that of penetrating trauma.
As with penetrating injuries, a complete transection to the bile duct often requires either a Roux-en-Y choledochojejunostomy or a choledochoduodenostomy in a stable patient. A T-tube may be used if the duct is partially transected.
A T-tube bridge between the ends of the defect or a simple drain may be required during damage control surgery with the plan for a delayed repair of the bile duct after the patient has been adequately resuscitated.
Gallbladder injury
Injury to the gallbladder, either from penetrating or blunt injury, is best managed with a cholecystectomy.
Medical Care
Over the past 2 decades, advancements in endoscopic techniques have led to less invasive strategies to manage biliary injuries. Given the rarity of these injuries, only case reports and small case series describe the use of ERCP to manage biliary injuries. In all cases, a biliary stent was placed across the injured duct and a sphincterotomy was often performed.
The successful use of ERCP has been described in both penetrating and blunt trauma. [14, 15, 16] This strategy has been successful in children as well. [17, 18] Stents are removed several weeks after the injury, with a fluoroscopic contrast evaluation for a persistent leak or stricture. Although several studies have described the short-term benefit of this strategy, long-term outcomes have not been reported.
Diet and Activity
Diet
Patients may resume a regular diet after postoperative ileus has resolved. There are no dietary restrictions.
Patients with a complex postoperative course may be fed by a transpyloric feeding tube.
Activity
No activity restrictions are implemented for isolated bile duct system injuries, but restrictions may be necessary for patients with the frequently associated solid organ injury (eg, liver lacerations).
Long-Term Monitoring
Long-term follow-up is important to identify bile duct strictures, which usually occur within 2 years of injury.
A complete metabolic panel, including fractionated bilirubin, alkaline phosphatase (ALP), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels, may suggest a post-injury complication.
Endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) can be used to assess patients for late extrahepatic biliary tract strictures.
