- Email: [email protected]
Closed abdominal trauma in a child causing avulsion of the common bile duct and gastric stasis
Injury (1985) 16, 235-237
Printedin GreatBritain
235
Closed a b d o m i n a l t r a u m a in a child causing avulsion of the c o m m o n bile d u c t and gastric stasis R. M. K e r n o h a n Department of Surgery, Queen's University, Belfast W. G. H u m p h r e y s
Waveney Hospital Ballymena, Co. Antrim Summary A case of closed abdominal trauma causing complete transection of the supraduodenal common bile duct and gastric stasis in an 8-year-old boy is described. Surgical management involved re-establishment of biliary-enteric continuity and later gastric drainage to overcome gastric stasis. It is postulated that this child had sustained a traumatic vagotomy resulting in failure of gastric emptying. The literature does not report this complication of blunt abdominal injury.
CASE REPORT An 8-year-old boy was admitted to hospital 20 minutes after he had been run over by a light van, the front wheel of which was seen to cross the upper part of his abdomen. On examination he was hypotensive (60/40mmHg) with a tachycardia (I 10/rain). Minor injuries were present on his face and left antecubital fossa. Abdominal examination revealed bruising in the right hypochrondrium and lower part of the right side of his chest. Tenderness was present in the right upper quadrant with no associated guarding or rebound; bowel sounds were present. Immediate intravenous resuscitation produced a good clinical response but during subsequent X-ray examination, he suddenly became profoundly hypotensive and was transferred to the operating theatre for further resuscitation, with whole blood, followed by laparotomy. At exploration there was brisk bleeding from the pyloroduodenal region, the head of pancreas and the lesser sac. There was a large haematoma at the porta hepatis with a 4-mm tear in the right hepatic artery. The lesser omentum was completely avulsed from the stomach and the gall-bladder was detached 'from the liver, being suspended by the cystic duct; the cystic artery had been divided. The common bile duct (CBD) was completely transected at the upper border of the pancreas and the distal end could not be identified in the haematoma. The liver had a 4-cm tear on its superior surface. There were no other intra-abdominal injuries. An extensive Kocher's manoeuvre was carried out to locate the bleeding points. In view of the patient's rapid deterioration, the abdominal aorta was isolated and clamped for 25 minutes to help gain control of the haemorrhage. The hepatic artery was repaired, the liver sutured and haemostasis achieved by ligature, suture and diathermy. The distal end of the CBD could not be located, therefore the proximal end (4mm diameter) was anastomosed end to side with interrupted 4/0 Dexon sutures to the posterior wall of the second part of the duodenum. A no. 12 polythene Ryle's tube, in which side holes were fashioned to allow free flow of bile into the duodenum was passed through the anastomosis. This tube
was subsequently led to the exterior through a distal duodenotomy to act as a support and to allow subsequent radiological investigation. Initial postoperative progress was good but 24 hours later the child again became hypotensive with severe abdominal pain. At re-operation, there was bleeding from the splenic artery at the upper border of the pancreas and from the left triangular ligament of the liver, with fresh clot at the hilum of the spleen. The biliary anastomosis was intact but there was moderate bruising of the anterior duodenal wall which was considered viable. Splenectomy was carried out and the remaining bleeding points secured. The abdomen was closed with drainage and subsequently the patient's recovery was satisfactory. Seventy-two hours after laparotomy he was observed to have a high gastric aspirate which did not diminish, despite normal bowel sounds and the passage of flatus. A gastrografin meal on the 8th postoperative day demonstrated complete gastric atony with no emptying after 5 hours. X-ray examination on the 13th postoperative day confirmed no gastric motility or emptying. A tube cholangiogram demonstrated a small leak at the biliary anastomosis (Fig. 1) but contrast medium entered the duodenum, passed proximally to a normal duodenal cap and was carried distally by peristalsis. Examination 1 week later showed that the leak had healed. The child was well maintained and nourished on total parenteral nutrition. When there was no gastric emptying by the 22nd postoperative day a third laparotomy was undertaken to examine the pyloroduodenal region and to establish gastric drainage. No gross abnormality was found in the stomach or duodenum and the choledochoduodenostomy was intact. Gastric drainage was achieved via an antecolic gastrojejunostomy. Subsequently his progress to discharge was excellent. It was planned to leave the supporting tube in position for 3 months but it came out spontaneously after 10 weeks and the fistula healed quickly. At review after I year the child is well, growing steadily and without complication.
DISCUSSION Recent reviews by C o r l e y et al. (1975), Stone a n d F a b i a n (1979) a n d K i t a h a m a et al. (1982) indicate that C B D injuries are relatively u n c o m m o n and are usually associated with injury to the pancreas, liver, spleen a n d d u o d e n u m . G a s t r i c stasis does n o t a p p e a r to have been t r o u b l e s o m e in these series. In this patient the injuries were caused by the wheel o f a light van passing across the u p p e r p a r t o f his a b d o m e n a n d illustrates the m o s t c o m m o n m o d e o f injury in children. Bile duct injuries
Injury: the British Journal of Accident Surgery (1985) Vol. 16/No. 4
236
Fig. 1. Tube cholangiogram demonstrating small leak of contrast at anastomosis between CBD and duodenum.
may only be seen when the laparotomy is for other intraabdominal injuries, However, when the duct is injured in isolation the presenting signs may be very slight. A considerable number of bile duct injuries are missed at laparotomy; Longmire (1966) reported that of 24 patients operated on for injury, 15 had bile duct injuries which were unrecognized due to attention being focused on more obvious lesions. When biliary injuries are suspected but there are no definite indications for laparotomy, Christensen et al. (1981) and Sty et al. (1982) have shown that a 9 9 T c m H I D A isotope scan is effective in demonstrating the biliary tree. This technique was used to demonstrate a functioning gall-bladder in this patient 44 days after operation. The position of transection of the CBD at the upper border of the pancreas is typical of this type of injury and Fletcher et al. (1961) found this to be so in all the cases which they reviewed. Kitahama et al. (1982) found no cases associated with hepatic or portal vein injury. However, this patient had a 4-mm tear in the right hepatic artery. The blood supply to the middle third of the common bile duct is precarious, as shown by Terblanche et al. (1983), and for this reason a biliary-enteric anastomosis is preferable to an end-to-end anastomosis. Longmire (1966), Busuttil et al. (1980) and Kitahama et al. (1982) have reported a reduced incidence of stricture and fistula when this technique is used. Attempts to identify the distal CBD may cause further damage and are unnecessary as leakage of duodenal content or pancreatic juice has not been reported.
The most interesting sequel of this case was gastric stasis with apparently normal gastric and duodenal anatomy confirmed on radiologic examination on two occasions. Dragsted et al. (1947) have described gastric stasis following total gastric vagotomy and it is possible that avulsion of the lesser omentum had produced a complete vagotomy in this child. Gastric emptying proceeded normally after gastrojejunostomy. An insulin test was not done as it was thought unjustifiable in a child of this age. No reference to traumatic vagotomy has been found in the literature. This case is reported as an example of a rare injury in a child which consists of avulsion of the c o m m o n bile duct in association with possible traumatic vagotomy.
REFERENCES Busuttil R. W., Kitahama A., Cerise E. et al. (1980) Management of blunt and penetrating injuries to the porta hepatis. Ann. Surg. 191,641. Christensen Per B., Oester-Joergensen E,, Schoubye J. et al. ( 1981 ) Scintigraphy with Tc-(2,6-diethylacetanilide)iminodia-acetic acid as a diagnostic test in traumatic lesions of the liver and biliary tract. Gastrohltest. Radiol. 6, 43. Corley R. D., Norcross W. J. and Shoemaker W. C. (1975) Traumatic injuries to the duodenum. Ann. Surg. 181, 92. Dragstet L. R., Harper P. B., Tovee E. B. et al. (1947) Section of the vagus nerves to the stomach in the treatment of peptic ulcer. Ann. Surg. 126, 687.
Kernohan and Humphreys: Avulsion of common bile duct
Fletcher W. S., Mahnke D. E. and Dunphy J. E. (1961) Complete division of the common bile duct due to blunt trauma. J. Trauma 1, 87. Kitahama A., Elliott L. F., Overby J. L. et al. (1982) The extrahepatic biliary tract injury. Ann. Surg. 196, 536. Longmire W. P. (1966) Early management of injury to the extrahepatic biliary tract. JAMA 195, 623. Stone H. H. and Fabian T. C. (1979) Management of duodenal wounds. J. Trauma 19, 334.
237
Sty J. R., Starshak R. J. and Hubbard A. M. (1982) Radionuclide hepatobiliary imaging in the detection of traumatic biliary tract disease in children. Pediatr. Radiol. 12, 115. Terblanche J., Alison H. F. and Northover J. M. A. (1983) An ischaemic basis for biliary strictures. Surgery 94, 52. Paper accepted 14 May 1984.
Requestsfor reprints should be addressed to: R. M. Kernohan, Department of Surgery, Queen's University of Belfast, Grosvenor Road, Belfast, Northern Ireland.
Printedin GreatBritain
235
Closed a b d o m i n a l t r a u m a in a child causing avulsion of the c o m m o n bile d u c t and gastric stasis R. M. K e r n o h a n Department of Surgery, Queen's University, Belfast W. G. H u m p h r e y s
Waveney Hospital Ballymena, Co. Antrim Summary A case of closed abdominal trauma causing complete transection of the supraduodenal common bile duct and gastric stasis in an 8-year-old boy is described. Surgical management involved re-establishment of biliary-enteric continuity and later gastric drainage to overcome gastric stasis. It is postulated that this child had sustained a traumatic vagotomy resulting in failure of gastric emptying. The literature does not report this complication of blunt abdominal injury.
CASE REPORT An 8-year-old boy was admitted to hospital 20 minutes after he had been run over by a light van, the front wheel of which was seen to cross the upper part of his abdomen. On examination he was hypotensive (60/40mmHg) with a tachycardia (I 10/rain). Minor injuries were present on his face and left antecubital fossa. Abdominal examination revealed bruising in the right hypochrondrium and lower part of the right side of his chest. Tenderness was present in the right upper quadrant with no associated guarding or rebound; bowel sounds were present. Immediate intravenous resuscitation produced a good clinical response but during subsequent X-ray examination, he suddenly became profoundly hypotensive and was transferred to the operating theatre for further resuscitation, with whole blood, followed by laparotomy. At exploration there was brisk bleeding from the pyloroduodenal region, the head of pancreas and the lesser sac. There was a large haematoma at the porta hepatis with a 4-mm tear in the right hepatic artery. The lesser omentum was completely avulsed from the stomach and the gall-bladder was detached 'from the liver, being suspended by the cystic duct; the cystic artery had been divided. The common bile duct (CBD) was completely transected at the upper border of the pancreas and the distal end could not be identified in the haematoma. The liver had a 4-cm tear on its superior surface. There were no other intra-abdominal injuries. An extensive Kocher's manoeuvre was carried out to locate the bleeding points. In view of the patient's rapid deterioration, the abdominal aorta was isolated and clamped for 25 minutes to help gain control of the haemorrhage. The hepatic artery was repaired, the liver sutured and haemostasis achieved by ligature, suture and diathermy. The distal end of the CBD could not be located, therefore the proximal end (4mm diameter) was anastomosed end to side with interrupted 4/0 Dexon sutures to the posterior wall of the second part of the duodenum. A no. 12 polythene Ryle's tube, in which side holes were fashioned to allow free flow of bile into the duodenum was passed through the anastomosis. This tube
was subsequently led to the exterior through a distal duodenotomy to act as a support and to allow subsequent radiological investigation. Initial postoperative progress was good but 24 hours later the child again became hypotensive with severe abdominal pain. At re-operation, there was bleeding from the splenic artery at the upper border of the pancreas and from the left triangular ligament of the liver, with fresh clot at the hilum of the spleen. The biliary anastomosis was intact but there was moderate bruising of the anterior duodenal wall which was considered viable. Splenectomy was carried out and the remaining bleeding points secured. The abdomen was closed with drainage and subsequently the patient's recovery was satisfactory. Seventy-two hours after laparotomy he was observed to have a high gastric aspirate which did not diminish, despite normal bowel sounds and the passage of flatus. A gastrografin meal on the 8th postoperative day demonstrated complete gastric atony with no emptying after 5 hours. X-ray examination on the 13th postoperative day confirmed no gastric motility or emptying. A tube cholangiogram demonstrated a small leak at the biliary anastomosis (Fig. 1) but contrast medium entered the duodenum, passed proximally to a normal duodenal cap and was carried distally by peristalsis. Examination 1 week later showed that the leak had healed. The child was well maintained and nourished on total parenteral nutrition. When there was no gastric emptying by the 22nd postoperative day a third laparotomy was undertaken to examine the pyloroduodenal region and to establish gastric drainage. No gross abnormality was found in the stomach or duodenum and the choledochoduodenostomy was intact. Gastric drainage was achieved via an antecolic gastrojejunostomy. Subsequently his progress to discharge was excellent. It was planned to leave the supporting tube in position for 3 months but it came out spontaneously after 10 weeks and the fistula healed quickly. At review after I year the child is well, growing steadily and without complication.
DISCUSSION Recent reviews by C o r l e y et al. (1975), Stone a n d F a b i a n (1979) a n d K i t a h a m a et al. (1982) indicate that C B D injuries are relatively u n c o m m o n and are usually associated with injury to the pancreas, liver, spleen a n d d u o d e n u m . G a s t r i c stasis does n o t a p p e a r to have been t r o u b l e s o m e in these series. In this patient the injuries were caused by the wheel o f a light van passing across the u p p e r p a r t o f his a b d o m e n a n d illustrates the m o s t c o m m o n m o d e o f injury in children. Bile duct injuries
Injury: the British Journal of Accident Surgery (1985) Vol. 16/No. 4
236
Fig. 1. Tube cholangiogram demonstrating small leak of contrast at anastomosis between CBD and duodenum.
may only be seen when the laparotomy is for other intraabdominal injuries, However, when the duct is injured in isolation the presenting signs may be very slight. A considerable number of bile duct injuries are missed at laparotomy; Longmire (1966) reported that of 24 patients operated on for injury, 15 had bile duct injuries which were unrecognized due to attention being focused on more obvious lesions. When biliary injuries are suspected but there are no definite indications for laparotomy, Christensen et al. (1981) and Sty et al. (1982) have shown that a 9 9 T c m H I D A isotope scan is effective in demonstrating the biliary tree. This technique was used to demonstrate a functioning gall-bladder in this patient 44 days after operation. The position of transection of the CBD at the upper border of the pancreas is typical of this type of injury and Fletcher et al. (1961) found this to be so in all the cases which they reviewed. Kitahama et al. (1982) found no cases associated with hepatic or portal vein injury. However, this patient had a 4-mm tear in the right hepatic artery. The blood supply to the middle third of the common bile duct is precarious, as shown by Terblanche et al. (1983), and for this reason a biliary-enteric anastomosis is preferable to an end-to-end anastomosis. Longmire (1966), Busuttil et al. (1980) and Kitahama et al. (1982) have reported a reduced incidence of stricture and fistula when this technique is used. Attempts to identify the distal CBD may cause further damage and are unnecessary as leakage of duodenal content or pancreatic juice has not been reported.
The most interesting sequel of this case was gastric stasis with apparently normal gastric and duodenal anatomy confirmed on radiologic examination on two occasions. Dragsted et al. (1947) have described gastric stasis following total gastric vagotomy and it is possible that avulsion of the lesser omentum had produced a complete vagotomy in this child. Gastric emptying proceeded normally after gastrojejunostomy. An insulin test was not done as it was thought unjustifiable in a child of this age. No reference to traumatic vagotomy has been found in the literature. This case is reported as an example of a rare injury in a child which consists of avulsion of the c o m m o n bile duct in association with possible traumatic vagotomy.
REFERENCES Busuttil R. W., Kitahama A., Cerise E. et al. (1980) Management of blunt and penetrating injuries to the porta hepatis. Ann. Surg. 191,641. Christensen Per B., Oester-Joergensen E,, Schoubye J. et al. ( 1981 ) Scintigraphy with Tc-(2,6-diethylacetanilide)iminodia-acetic acid as a diagnostic test in traumatic lesions of the liver and biliary tract. Gastrohltest. Radiol. 6, 43. Corley R. D., Norcross W. J. and Shoemaker W. C. (1975) Traumatic injuries to the duodenum. Ann. Surg. 181, 92. Dragstet L. R., Harper P. B., Tovee E. B. et al. (1947) Section of the vagus nerves to the stomach in the treatment of peptic ulcer. Ann. Surg. 126, 687.
Kernohan and Humphreys: Avulsion of common bile duct
Fletcher W. S., Mahnke D. E. and Dunphy J. E. (1961) Complete division of the common bile duct due to blunt trauma. J. Trauma 1, 87. Kitahama A., Elliott L. F., Overby J. L. et al. (1982) The extrahepatic biliary tract injury. Ann. Surg. 196, 536. Longmire W. P. (1966) Early management of injury to the extrahepatic biliary tract. JAMA 195, 623. Stone H. H. and Fabian T. C. (1979) Management of duodenal wounds. J. Trauma 19, 334.
237
Sty J. R., Starshak R. J. and Hubbard A. M. (1982) Radionuclide hepatobiliary imaging in the detection of traumatic biliary tract disease in children. Pediatr. Radiol. 12, 115. Terblanche J., Alison H. F. and Northover J. M. A. (1983) An ischaemic basis for biliary strictures. Surgery 94, 52. Paper accepted 14 May 1984.
Requestsfor reprints should be addressed to: R. M. Kernohan, Department of Surgery, Queen's University of Belfast, Grosvenor Road, Belfast, Northern Ireland.