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Endoscopic retrograde biliary drainage for posttraumatic intrapancreatic biliary stenosis in a child
Journal of Pediatric Surgery (2009) 44, E25–E28
www.elsevier.com/locate/jpedsurg
Endoscopic retrograde biliary drainage for posttraumatic intrapancreatic biliary stenosis in a child Shigeru Takamizawa a,⁎, Nahoko Nozaki b , Nobuo Aoyama c , Eiji Nishijima d , Toshihiro Muraji e a
Department of Surgery, Nagano Children's Hospital, Azumino City, Nagano 399-8288, Japan Division of Pediatric Surgery, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan c Aoyama Clinic, Gastrointestinal Endoscopy & Inflammatory Bowel Disease Center, Kobe 650-0015, Japan d Department of Surgery, Kobe Children's Hospital, Kobe 654-0081, Japan e Department of Surgery, Ibaraki Children's Hospital, Mito 311-4145, Japan b
Received 31 March 2009; revised 8 June 2009; accepted 8 June 2009
Key words: Bile duct injury; Traumatic; Endoscopic retrograde biliary drainage
Abstract Bile duct injury caused by blunt abdominal trauma is rare and usually associated with liver parenchymal injury. The authors report the case of a 15-year-old boy with jaundice caused by a posttraumatic isolated common bile duct stricture without associated liver injury. Endoscopic retrograde biliary drainage (ERBD) was performed and the jaundice disappeared 2 months after drainage commenced. Although restenosis and mild jaundice was revealed 2 years after injury, ERBD can be a first-line minimally invasive treatment of pediatric posttraumatic biliary stricture. © 2009 Elsevier Inc. All rights reserved.
1. Case report A 15-year-old boy was referred to the Department of Surgery of Kobe Children's Hospital because of jaundice (Japan). He had been hit in the abdomen by a bare steel cable from a tennis net while running in a tennis court 45 days before admission. The abdominal computed tomographic scan and laboratory data that were taken on the day of injury showed no remarkable findings except mild duodenal hematoma (Fig. 1). Eleven days after injury, he complained of abdominal pain and loss of appetite. Laboratory data showed hyperbilirubinemia, and magnetic resonance cholangiopancreatography revealed common bile duct stenosis ⁎ Corresponding author. Tel.: +81 263 73 6700; fax: +81 263 73 5432. E-mail address: [email protected] (S. Takamizawa). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.06.010
in the pancreas and dilated intrahepatic bile ducts (Fig. 2). Forty-five days after injury, he was transferred to our hospital. Laboratory data revealed hyperbilirubinemia (total bilirubin, 15.9 mg/dL; direct bilirubin, 10.9 mg/dL) and high γglutamyl-transpeptidase level (80 IU/L) but otherwise normal liver function (aspartate transaminase/alanine transaminase, 32/50 IU/L) and a normal serum amylase level (109 IU/L). Endoscopic retrograde cholangiopancreatography revealed common bile duct stenosis at the intrapancreatic portion of the bile duct. Biliary drainage was commenced with endoscopically inserted 5F nasobiliary drainage catheter (Flexima endoscopic nasobiliary drainage catheter [ENBD] Catheter, Boston Scientific, Natick, MA) (Fig. 3). An ENBD catheter was switched to 10F × 7 cm endoscopic retrograde biliary drainage (ERBD) tube (Flexima Biliary Stent System, Boston Scientific) after endoscopic sphincterotomy, 3 days after
E26
S. Takamizawa et al. ENBD catheter insertion (Fig. 4). Total bilirubin level was gradually decreased to 5.2 mg/dL 12 days after ERBD tube insertion. He developed intestinal bleeding because an antimigrating tube flap injured the duodenal mucosa, which required endoscopic ethanol injection for hemostasis. He was discharged from the hospital 14 days after ERBD tube insertion, and total bilirubin level recovered to reference range (0.9 mg/dL) 2 months after biliary drainage commenced, although the drainage tube had slipped off
Fig. 1 Computed tomographic scan of the abdomen (right after injury) shows thickening of the duodenal wall, probable hematoma (A). A and B, No hepatic or pancreatic injuries are visualized.
Fig. 2 Magnetic resonance cholangiopancreatography (43 days after injury) shows a dilated common bile duct (CBD) proximal to the stenosis and intrahepatic bile duct.
Fig. 3 A, Endoscopic retrograde cholangiopancreatography shows CBD stenosis. B, A 5F nasobiliary drainage catheter was endoscopically inserted.
ERBD for past traumatic intrapancreatic biliary stenosis
E27
Fig. 4 A 10F × 7 cm ERBD tube was inserted after endoscopic sphincterotomy, 3 days after ENBD catheter insertion.
Fig. 6 Endoscopic retrograde cholangiopancreatography shows mild CBD stenosis at the intrapancreatic portion and slightly dilated CBD proximally, 2 years after ERBD catheter insertion. The diameter of endoscope is 11.3 mm.
spontaneously (Fig. 5). Although the stenosis of the common bile duct at the intrapancreatic portion remained and the bilirubin level was slightly high (total bilirubin, 1.58 mg/dL; direct bilirubin, 0.39 mg/dL) 2 years after the injury, the patient is doing well without liver dysfunction (alkaline phosphatase, 274 IU/L; aspartate transaminase/alanine trasaminase, 11/9 IU/L) or any other symptoms (Fig. 6).
2. Discussion Posttraumatic biliary stricture is a rare clinical condition. If penetrating bile duct injury is recognized by diagnostic
Fig. 5
imaging after blunt abdominal injury, it is treated by open surgery conventionally or recently by minimally invasive alternatives such as laparoscopic surgery or endoscopic biliary stenting. Biliary stricture could be easily anticipated as a sequela to penetrating bile duct injury. However, biliary stricture caused by nonpenetrating bile duct injury tends to delay diagnosis until jaundice becomes apparent. The exact incidence of posttraumatic biliary stricture is unknown. Park et al [1] reported that 11 patients with posttraumatic biliary stricture were identified in 14,000 endoscopic retrograde cholangiopancreatography (ERCP) procedures performed. Yoon et al [2] also reported 5 biliary strictures after blunt abdominal trauma was found of more than 5000 ERCP procedures performed.
Clinical course and serum bilirubin level.
E28 Several mechanisms of posttraumatic biliary stenosis have been proposed: inflammation (pericholangitis) induced by a small tear in the bile duct resulted in fibrosis or stricture, compression by intramural or pericholangial hematoma, ischemia, traumatic pancreatitis, and neuroma [3-6]. However, the exact cause of posttraumatic biliary stricture is not clearly understood. Therapeutic modalities for extrahepatic bile duct stenosis include percutaneous transhepatic biliary drainage, endoscopic biliary stenting [1,2], insertion of cholecystostomy tube (laparotomy, laparoscopic, ultrasound guidance [7]), cholecystoenterostomy, and choledochojejunostomy with Roux-en-Y anastomosis [8]. Recently, nonsurgical interventions such as endoscopic insertion of the biliary stent (ENBD and ERBD) are used for treating posttraumatic extrahepatic biliary stenosis. Yoon et al [2] reported 4 patients, including a 4-year-old child, with posttraumatic biliary stricture treated by ERBD. Recently, such minimally invasive treatment has been applied even for traumatic biliary tract laceration or transection as first-line treatment [9-11]. Although the reported length of time for stenting posttraumatic bile duct injury varies from 3 to 8 weeks [9], the ideal length is unknown. In our case, the spontaneous dislocation of the stenting material was found 2 months after insertion. This short duration of stenting may have caused the restenosis of the common bile duct at the intrapancreatic portion. This was revealed by an ERCP performed 2 years after injury. If stenosis becomes apparent hereafter, re-ERBD or surgical intervention such as choledochojejunostomy with Roux-en-Y anastomosis should be considered. Although the dilatation effect may not last for years and there are limitations regarding the usable size of the stenting materials for children, ERBD can be a first-line minimally invasive treatment of pediatric biliary stricture after blunt
S. Takamizawa et al. abdominal trauma. This modality may be applicable for postlaparoscopic cholecystectomy bile duct stricture.
References [1] Park DH, Kim MH, Kim TN, et al. Endoscopic treatment for suprapancreatic biliary stricture following blunt abdominal trauma. Am J Gastroenterol 2007;102:544-9. [2] Yoon KH, Ha HK, Kim MH, et al. Biliary stricture caused by blunt abdominal trauma: clinical and radiologic features in five patients. Radiology 1998;207:737-41. [3] Mohardt JH. Traumatic rupture of the common bile duct; report of a case and review of the literature. Q Bull Northwest Univ Med Sch 1956;30:16-20. [4] Skow JR, Longmire Jr WP. Common duct strictures secondary to blunt abdominal trauma. Am Surg 1974;40:576-8. [5] Rohrmann Jr CA, Baron RL. Biliary complications of pancreatitis. Radiol Clin North Am 1989;27:93-104. [6] Katsinelos P, Dimiropoulos S, Galanis I, et al. Biliary stricture due to neuroma after an innocent blunt abdominal trauma. Surg Endosc 2002;16:1494. [7] vanSonnenberg E, D'Agostino HB, Goodacre BW, et al. Percutaneous gallbladder puncture and cholecystostomy: results, complications, and caveats for safety. Radiology 1992;183:167-70. [8] Tröbs RB, Siekmeyer W, Bühligen U, et al. Treatment of transient posttraumatic bile-duct stenosis by laparoscopic-assisted cholecystectomy. Pediatr Surg Int 2002;18:503-4. [9] Castagnetti M, Houben C, Patel S, et al. Minimally invasive management of bile leaks after blunt liver trauma in children. J Pediatr Surg 2006;41:1539-44. [10] Church NG, May G, Sigalet DL. A minimally invasive approach to bile duct injury after blunt liver trauma in pediatric patients. J Pediatr Surg 2002;37:773-5. [11] Sharpe RP, Nance ML, Stafford PW. Nonoperative management of blunt extrahepatic biliary duct transaction in the pediatric patient: case report and review of the literature. J Pediatr Surg 2002;37: 1612-6.
www.elsevier.com/locate/jpedsurg
Endoscopic retrograde biliary drainage for posttraumatic intrapancreatic biliary stenosis in a child Shigeru Takamizawa a,⁎, Nahoko Nozaki b , Nobuo Aoyama c , Eiji Nishijima d , Toshihiro Muraji e a
Department of Surgery, Nagano Children's Hospital, Azumino City, Nagano 399-8288, Japan Division of Pediatric Surgery, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan c Aoyama Clinic, Gastrointestinal Endoscopy & Inflammatory Bowel Disease Center, Kobe 650-0015, Japan d Department of Surgery, Kobe Children's Hospital, Kobe 654-0081, Japan e Department of Surgery, Ibaraki Children's Hospital, Mito 311-4145, Japan b
Received 31 March 2009; revised 8 June 2009; accepted 8 June 2009
Key words: Bile duct injury; Traumatic; Endoscopic retrograde biliary drainage
Abstract Bile duct injury caused by blunt abdominal trauma is rare and usually associated with liver parenchymal injury. The authors report the case of a 15-year-old boy with jaundice caused by a posttraumatic isolated common bile duct stricture without associated liver injury. Endoscopic retrograde biliary drainage (ERBD) was performed and the jaundice disappeared 2 months after drainage commenced. Although restenosis and mild jaundice was revealed 2 years after injury, ERBD can be a first-line minimally invasive treatment of pediatric posttraumatic biliary stricture. © 2009 Elsevier Inc. All rights reserved.
1. Case report A 15-year-old boy was referred to the Department of Surgery of Kobe Children's Hospital because of jaundice (Japan). He had been hit in the abdomen by a bare steel cable from a tennis net while running in a tennis court 45 days before admission. The abdominal computed tomographic scan and laboratory data that were taken on the day of injury showed no remarkable findings except mild duodenal hematoma (Fig. 1). Eleven days after injury, he complained of abdominal pain and loss of appetite. Laboratory data showed hyperbilirubinemia, and magnetic resonance cholangiopancreatography revealed common bile duct stenosis ⁎ Corresponding author. Tel.: +81 263 73 6700; fax: +81 263 73 5432. E-mail address: [email protected] (S. Takamizawa). 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.06.010
in the pancreas and dilated intrahepatic bile ducts (Fig. 2). Forty-five days after injury, he was transferred to our hospital. Laboratory data revealed hyperbilirubinemia (total bilirubin, 15.9 mg/dL; direct bilirubin, 10.9 mg/dL) and high γglutamyl-transpeptidase level (80 IU/L) but otherwise normal liver function (aspartate transaminase/alanine transaminase, 32/50 IU/L) and a normal serum amylase level (109 IU/L). Endoscopic retrograde cholangiopancreatography revealed common bile duct stenosis at the intrapancreatic portion of the bile duct. Biliary drainage was commenced with endoscopically inserted 5F nasobiliary drainage catheter (Flexima endoscopic nasobiliary drainage catheter [ENBD] Catheter, Boston Scientific, Natick, MA) (Fig. 3). An ENBD catheter was switched to 10F × 7 cm endoscopic retrograde biliary drainage (ERBD) tube (Flexima Biliary Stent System, Boston Scientific) after endoscopic sphincterotomy, 3 days after
E26
S. Takamizawa et al. ENBD catheter insertion (Fig. 4). Total bilirubin level was gradually decreased to 5.2 mg/dL 12 days after ERBD tube insertion. He developed intestinal bleeding because an antimigrating tube flap injured the duodenal mucosa, which required endoscopic ethanol injection for hemostasis. He was discharged from the hospital 14 days after ERBD tube insertion, and total bilirubin level recovered to reference range (0.9 mg/dL) 2 months after biliary drainage commenced, although the drainage tube had slipped off
Fig. 1 Computed tomographic scan of the abdomen (right after injury) shows thickening of the duodenal wall, probable hematoma (A). A and B, No hepatic or pancreatic injuries are visualized.
Fig. 2 Magnetic resonance cholangiopancreatography (43 days after injury) shows a dilated common bile duct (CBD) proximal to the stenosis and intrahepatic bile duct.
Fig. 3 A, Endoscopic retrograde cholangiopancreatography shows CBD stenosis. B, A 5F nasobiliary drainage catheter was endoscopically inserted.
ERBD for past traumatic intrapancreatic biliary stenosis
E27
Fig. 4 A 10F × 7 cm ERBD tube was inserted after endoscopic sphincterotomy, 3 days after ENBD catheter insertion.
Fig. 6 Endoscopic retrograde cholangiopancreatography shows mild CBD stenosis at the intrapancreatic portion and slightly dilated CBD proximally, 2 years after ERBD catheter insertion. The diameter of endoscope is 11.3 mm.
spontaneously (Fig. 5). Although the stenosis of the common bile duct at the intrapancreatic portion remained and the bilirubin level was slightly high (total bilirubin, 1.58 mg/dL; direct bilirubin, 0.39 mg/dL) 2 years after the injury, the patient is doing well without liver dysfunction (alkaline phosphatase, 274 IU/L; aspartate transaminase/alanine trasaminase, 11/9 IU/L) or any other symptoms (Fig. 6).
2. Discussion Posttraumatic biliary stricture is a rare clinical condition. If penetrating bile duct injury is recognized by diagnostic
Fig. 5
imaging after blunt abdominal injury, it is treated by open surgery conventionally or recently by minimally invasive alternatives such as laparoscopic surgery or endoscopic biliary stenting. Biliary stricture could be easily anticipated as a sequela to penetrating bile duct injury. However, biliary stricture caused by nonpenetrating bile duct injury tends to delay diagnosis until jaundice becomes apparent. The exact incidence of posttraumatic biliary stricture is unknown. Park et al [1] reported that 11 patients with posttraumatic biliary stricture were identified in 14,000 endoscopic retrograde cholangiopancreatography (ERCP) procedures performed. Yoon et al [2] also reported 5 biliary strictures after blunt abdominal trauma was found of more than 5000 ERCP procedures performed.
Clinical course and serum bilirubin level.
E28 Several mechanisms of posttraumatic biliary stenosis have been proposed: inflammation (pericholangitis) induced by a small tear in the bile duct resulted in fibrosis or stricture, compression by intramural or pericholangial hematoma, ischemia, traumatic pancreatitis, and neuroma [3-6]. However, the exact cause of posttraumatic biliary stricture is not clearly understood. Therapeutic modalities for extrahepatic bile duct stenosis include percutaneous transhepatic biliary drainage, endoscopic biliary stenting [1,2], insertion of cholecystostomy tube (laparotomy, laparoscopic, ultrasound guidance [7]), cholecystoenterostomy, and choledochojejunostomy with Roux-en-Y anastomosis [8]. Recently, nonsurgical interventions such as endoscopic insertion of the biliary stent (ENBD and ERBD) are used for treating posttraumatic extrahepatic biliary stenosis. Yoon et al [2] reported 4 patients, including a 4-year-old child, with posttraumatic biliary stricture treated by ERBD. Recently, such minimally invasive treatment has been applied even for traumatic biliary tract laceration or transection as first-line treatment [9-11]. Although the reported length of time for stenting posttraumatic bile duct injury varies from 3 to 8 weeks [9], the ideal length is unknown. In our case, the spontaneous dislocation of the stenting material was found 2 months after insertion. This short duration of stenting may have caused the restenosis of the common bile duct at the intrapancreatic portion. This was revealed by an ERCP performed 2 years after injury. If stenosis becomes apparent hereafter, re-ERBD or surgical intervention such as choledochojejunostomy with Roux-en-Y anastomosis should be considered. Although the dilatation effect may not last for years and there are limitations regarding the usable size of the stenting materials for children, ERBD can be a first-line minimally invasive treatment of pediatric biliary stricture after blunt
S. Takamizawa et al. abdominal trauma. This modality may be applicable for postlaparoscopic cholecystectomy bile duct stricture.
References [1] Park DH, Kim MH, Kim TN, et al. Endoscopic treatment for suprapancreatic biliary stricture following blunt abdominal trauma. Am J Gastroenterol 2007;102:544-9. [2] Yoon KH, Ha HK, Kim MH, et al. Biliary stricture caused by blunt abdominal trauma: clinical and radiologic features in five patients. Radiology 1998;207:737-41. [3] Mohardt JH. Traumatic rupture of the common bile duct; report of a case and review of the literature. Q Bull Northwest Univ Med Sch 1956;30:16-20. [4] Skow JR, Longmire Jr WP. Common duct strictures secondary to blunt abdominal trauma. Am Surg 1974;40:576-8. [5] Rohrmann Jr CA, Baron RL. Biliary complications of pancreatitis. Radiol Clin North Am 1989;27:93-104. [6] Katsinelos P, Dimiropoulos S, Galanis I, et al. Biliary stricture due to neuroma after an innocent blunt abdominal trauma. Surg Endosc 2002;16:1494. [7] vanSonnenberg E, D'Agostino HB, Goodacre BW, et al. Percutaneous gallbladder puncture and cholecystostomy: results, complications, and caveats for safety. Radiology 1992;183:167-70. [8] Tröbs RB, Siekmeyer W, Bühligen U, et al. Treatment of transient posttraumatic bile-duct stenosis by laparoscopic-assisted cholecystectomy. Pediatr Surg Int 2002;18:503-4. [9] Castagnetti M, Houben C, Patel S, et al. Minimally invasive management of bile leaks after blunt liver trauma in children. J Pediatr Surg 2006;41:1539-44. [10] Church NG, May G, Sigalet DL. A minimally invasive approach to bile duct injury after blunt liver trauma in pediatric patients. J Pediatr Surg 2002;37:773-5. [11] Sharpe RP, Nance ML, Stafford PW. Nonoperative management of blunt extrahepatic biliary duct transaction in the pediatric patient: case report and review of the literature. J Pediatr Surg 2002;37: 1612-6.