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Traumatic injuries to the biliary system in children
Traumatic
Injuries to the Biliary System in Children*
SHERMAN W. HARTMAN, M.D. AND E. M. GREANEY, JR., M.D., Los Angeles, From tbe Department of Surgery, Cbildrens Hospital of Los Angeles, Los Angeles, California.
HE MANAGEMENT of abdomina1 trauma is a growing concern to the surgeon. A number of recent reports indicate an increasing incidence of these injuries [6,11,15,18]. BIunt trauma accounts for a high percentage of the cases encountered. In the pediatric age group, nonpenetrating injuries account for aImost a11 of the patients treated [2,4]. The genera1 principIes of management of these patients have been frequentIy reviewed and are fairIy uniformIy appIied in areas where this problem is often encountered [4,6, I I, 15,181, Injuries to the biliary tract, however, are rare and onIy sporadic reports of isoIated cases appear [I,4,5,8,g]. The cIinica1 course in these cases is often confusing, and deIay in diagnosis and treatment seems to be a recurring diffrcuIty. It appears necessary to re-emphasize the benign nature of biIe peritonitis and the necessity for accurateIy defining the type of
T
FIG. I.
Case
I.
injury invoIved. We have encountered five cases of injury to the biIiary tract due to bIunt trauma in the period from 1954 through 1963. The experience in these cases emphasizes the diff&Ities in diagnosis and the varied nature of the type of injury encountered. CASE REPORTS CASE I. M. P., a three and a haIf year oId white boy was admitted to the ChiIdrens HospitaI on January 5, 1955. Four days prior to admission he was thrown from a moving car after he reIeased the brake. He was observed at a IocaI hospita1 for two days and then discharged. At home he deveIoped increasing abdomina1 pain and weakness and was admitted to the ChiIdrens Hospital of Los Angeles. Admission temperature was IOO.~“F., puIse Izo/minute and respirations go/minute. The abdomen was distended, tender and doughy. Recta1 examination reveaIed nothing abnorma1. Laboratory studies reveaIed hemoglobin of 8.6 gm./Ioo cc., white blood celIs g,3oo/cu. mm. with
72 per cent poIymorphonucIear Ieukocytes, IO of which were band forms. Roentgenograms of the abdomen reveaIed free air over the Iiver and were reported as pneumoperitoneum and probabIe hemoperitoneum. A Iaparotomy was performed under genera1 anesthesia. The Ieft lobe of the Iiver was compIeteIy severed and suspended from the diaphragm by the trianguIar Iigament. (Fig. I.) The Iine of transection was at the Iigamentum teres of the Iiver. The major biIiary and vascuIar structure had been transected. There were approximateIy 500 cc. of bIood free in the peritonea1 cavity. There was no evidence of perforation of the gastrointestina tract and no evidence of active bIeeding at the time of expIoration. The Ieft Iobe of the Iiver was removed and the area of the cut surface of the remaining Iiver tissue was drained with Iarge Penrose drains. The patient made an uneventfu1 recovery and was discharged on January 18, 1955.
* Presented at the annual meeting of the Pacific Coast SurgicaI Association, February g-12, 1964. American Journal of Surgery. Volume IO& August 1964
150
Culi;fornia
San Francisco,
California,
Injuries
FIG.
2.
to RiIiary System
Case II.
CASE II. M. T., a six year oId white boy was admitted to the Childrens HospitaI on ApriI 30, 1955. Twenty-eight days prior to admission he was involved in an automobile accident and admitted to another hospita1 for observation. He was discharged after three days. He remained at home for three or four days and then was taken to another hospita1 where a Iaparotomy was performed. A biIe duct injury was found but no repair attempted. A large Penrose drain was pIaced in the region of the site of injury and the abdomen closed. He was discharged on the ninth postoperative day after the drain had been removed. WhiIe at home he did poorIy, his weight dropped to 37 pounds from the preaccident weight of 52 pounds. He became progressiveIy distended and jaundiced and was admitted to the Childrens HospitaI on advice of consuItant. On admission the temperature was IOI’F., the puIse Iqo/minute, bIood pressure 105/7o mm. Hg, and the respiration 35/minute. He was cachectic with a hugeIy distended abdomen and grossly jaundiced. Laboratory examination reveaIed a hemogIobin of 50.1 gm./Ioo cc., a white bIood count of Ig,8oo/cu. mm. with 88 per cent poIymorphonucIear forms. Roentgenograms reveaIed diffuse greyness compatibIe with free fluid in the abdomina1 cavity. The patient was prepared for surgery and just prior to transfer to the operating room, paracentesis was performed and 5,150 of biIe removed. At Iaparotomy the Ieft hepatic duct was found severed from the common duct at the point of junction. (Fig. 2.) This was repaired over a T tube pIaced from the common duct. His postoperative course was reIativeIy uneventfu1 and he was discharged on June IO, 1955, after satisfactory T tube choIangiogram x-rays.
FIG. 3. Case III. abdomina1 hemorrhage. He was given three units of bIood and the bIeeding was controlled. His postoperative course was fairIy good unti1 the tweIfth day when jaundice was noted. This increased unti1 admission to the ChiIdrens HospitaI. He continued ora intake during this period. On admission, temperature was IO~.I’F., the bIood pressure I 18/70 mm. Hg, the puIse 12a/minute and the respiration 32/minute. He was miIdIy icteric and the abdomen was distended and tympanic. Recta1 examination reveaIed a browngrey soft stoo1. Laboratory studies reveaIed the hemogIobin of 16.3 gm./Ioo cc. and the white bIood count of 28,ooo/cu. mm. of which 75 per cent were poIymorphonucIear forms. Roentgenograms revealed iIeus and fluid in the abdomen. An abdomina1 tap was performed and 15 cc. of yellowgoId fluid obtained. He was prepared with intravenous fluids and coIIoid and operated upon December 29, 1954. A Iaparotomy was performed and transection of the common duct at the head of the pancreas discovered. The open end of the duct was ligated and a Ioop choIecystojejunostomy carried out. (Fig. 3.) The postoperative course was uneventfu1 and he was discharged on January 22, 1955. CASE IV. J. H., a twenty-two month old white gir1 was admitted to the hospita1 on December 17, 1957, shortIy after being struck by a sIow-moving car.* There was no other history. PhysieaI examination reveaIed a temperature of IO~“F., the bIood pressure of o/o mm. Hg, the puIse 16a/minute and respiration 36/minute. There were muItipIe abrasions of the skin and the abdomen was distended and tender in the upper half. Rectal examination was noncontributory. Roentgenograms reveaIed the chest to be clear. There was abdomina1 iIeus. Voiding cystograms were normal. The hemogIobin was 8.5 gm./roo cc. The patient was vigor-
CASE III. G. L., a three year old white boy was admitted to Childrens HospitaI on December 27, 1954. Fifteen days prior to admission he had sustained bIunt trauma to the abdomen by tipping a cement bird bath onto his abdomen. He was taken to another hospita1 where paracentesis reveaIed bIood, and a Iaparotomy was performed which reveaIed Iacerations of the liver with intra-
* Treated at St. Joseph fornia by E. M. G., Jr. 151
Hospital,
Burbank,
Cali-
Hartman
and Greaney
FIG. 4. Case IV. FIG. 5. Case v.
ousIy transfused and taken to the operating room immediateIy where a Iaparotomy was performed. There were 650 cc. of blood in the peritonea1 cavity as a resuIt of a fracture of the caudate Iobe of the liver. ExpIoration of the porta triad reveaIed a rent in the common duct at the point where the right and left hepatic ducts joined. (Fig. 4.) The anterior portion of the rent was cIosed with interrupted catgut sutures and a poIyethyIene Y-shaped spIint inserted and threaded through the ampuIIa of Vater and brought out through a stab wound in the duodenum. A choIecystostomy was aIso performed. The postoperative course was stormy but the recovery was rapid. The choIecystostomy tube was removed on January 7, 1958, and the poIyethyIene spIint was removed on January 20, 1958. The patient continued to do we11 and was discharged on January 23, 1958.
Serum amyIase was 54 p. Serum protein was 6.4 gm./Ioo cc. of which 2.4 was albumin and 4.0 gIobuIin. Roentgenograms reveaIed a distended abdomen containing ffuid. AbdominaI paracentesis was carried out and 1,350 cc. of reddish-bIack-yeIIow-tinged fluid aspirated. After suitabIe preparation he was taken to the operating room and a Iaparotomy performed which reveaIed approximateIy 3 L. of fluid in the abdomen, a Iarge portion of which was a coIIection of biIe in the right upper quadrant. There was a I cm. perforation in the gaIIbIadder which was freeIy communicating with the peritonea1 cavity. (Fig. 5,) The tube was inserted in the gaIIbIadder and the choIangiogram made which demonstrated integrity of the remainder of the biIiary tract. ChoIecystectomy was performed. The postoperative course was somewhat stormy but the patient made rapid progress and was discharged approximateIy one month after admission.
CASE v. J. L., a seven and one haIf year oId Mexican boy was admitted to the ChiIdrens Hospita1 on March 2, 1963. On January 17, 1963, he was struck by a truck near his home in a smaI1 Mexican border community. He was examined by a physician and no serious injuries were noted. After four days abdomina1 distention deveIoped which became progressiveIy severe unti1 fourteen days prior to admission. He was hospitaIized in a IocaI hospita1. SeveraI abdomina1 taps were done but no other diagnostic or therapeutic measures were instituted, and the patient was discharged after four days in a near moribund condition. Transfer to this hospital was recommended by a consuItant after reviewing roentgenograms. On admission, the bIood pressure was r4o/g5 mm. Hg, puIse Izo/minute, respiration 36/minute, and temperature I 02’F. The patient was a cachectic maIe with an enormousIy distended abdomen containing Auid. Laboratory examination reveaIed hemogIobin of 8.1 gm./Ioo cc., white bIood count of 10,300/cu. mm., with 57 per cent poIymorphonucIear forms and 6 band forms. Serum biIirubin was 3.0 mg./Ioo ml. with 1.3 direct and 1.7 indirect.
COMMENT
The most striking feature of the cIinica1 course in these cases was the deIay in diagnosis and treatment of the biIe peritonitis. As much as six weeks eIapsed before the free escape of biIe into the peritonea1 cavity was corrected. The benign nature of biIe peritonitis has been observed for many years, but this fact apparently needs periodic re-emphasis. WangenSteen’s exhaustive review documents reports as earIy as 1844 which describe surviva1 for weeks with biIe peritonitis [r4]. In a recent report by Santschi there was Iong deIay in treatment of three patients with operative injury to the common duct. The nature of the IethaI factors in biIe peritonitis has been the subject of considerabIe investigation [JJ, 141. The factors impIicated are the toxicity of biIe 152
Injuries
to BiIiary
System
6. GLENN, F. and injuries to the IOI: 176, 1961. 7. HARKINS, H. N., LethaI factors
Saks, ffuid and eIectroIyte Ioss, and bacterial infection. No entireIy satisfactory evidence has yet been produced which indicates which of these factors is most important. Despite the proIonged peritonitis in severa of our cases as we11 as in many of the others reported, successfu1 repair resuIted in compIete recovery. Our experience demonstrates the varied nature of the biIiary tract injuries. In the surgica1 treatment of bIunt abdomina1 trauma evidence of the integrity of the biIiary system must be obtained. At times, operative choIangiogram may be the onIy way to estabIish this. Preparation for this procedure shouId be a part of the operative management. The actua1 repair of the injury requires improvisation. In generaI, restoration of the integrity of the tree, spIinting and drainage are required. The postoperative management presents no specia1 probIems. Accurate diagnosis and correction of the Iesion converts a IethaI situation to one that usuaIIy resuIts in compIete recovery.
THOKBJARNSON, B. Traumatic abdominal organs. Am. J. Surg., HARMON, P. H. and HUDSON, J. in biIe peritonitis. Arch. Surg.,
33: 576, ‘936. 8. HICKS. J. H. A case of traumatic oerforation of the gaIlbladder in a chiId of three years. Brit. J. I
Surg., 3 1: 305, 1944. 9. HICKEN, N. F. and STEVENSON,V. L. Traumatic rupture of the choIedochus associated with acute hemorrhagic pancreatitis and biIe peritonitis. Ann. Surg., 128: 1178, 1948. IO. LADD, W. E. and GROSS, R. E. AbdominaI Surgery in Infancy and ChiIdhood, p. 295. PhiIadeIphia, 1941. W. B. Saunders Co. I I. MORTON, J. H., HINSHAW, J. R. and MORTOK,J. J. BIunt trauma to the abdomen. Ann. Surg., 145: 699, 1957. 12. SANTSCHI, D. R., HUIZENGA, K. A., SCUDAMORI, H. H.. DEARING. W. H. and WAUGH. J. M. Bile ascites. Arch. S&g., 87: 851, 1963. ’ 13. THOMPSON, J. The diagnosis and management of cIosed injuries of the extra-hepatic biIiary tract. J. Roy. Army, M. Corps, 106: 1o7, 1960. 14. WANGENSTEEN, 0. H. On the significance of the escape of steriIe biIe into the peritonea1 cavity. Ann. Surg., 84: 691, 1926. 15. WATKINS, G. L. BIunt trauma to the abdomen. Arch. Surg., 80: 187, 1960. 16. WAUGH, G. E. Traumatic rupture of the common biIe duct in a boy six years old. Brit. J. Surg., 3: 685, 1916. 17. WESTLAND, J. C., GREANEY, E. M., JR. and SNYDER, W. H.. JR. Exnerience with abdomina1 trauma in chiIdhood. *est. J. Surg., 63: 609, 1955. 18. WILLIAMS, R. D. and ZOLLINGER, R. M. Diagnostic and prognostic factors in abdomina1 trauma. Am. J. Surg., 97: 575, 1959. 19. WILLARD, W. Traumatic rupture of the gaI1 bIadder without injury of the liver. New York J. Med.,
SUMMARY
I. BIunt abdomina1 trauma is an increasing probIem. 2. BiIiary tract injury due to bIunt trauma is rare but does occur at any point in the biIiary tree. 3. There is often Iong deIay in diagnosis and treatment due to the indoIent nature of biIe peritonitis. 4. Facilities for operative ChoIangiography shouId be avaiIabIe in expIoration for bIunt trauma. 5. The site of injury must be identified and repair improvised to suit each case. 6. Diagnosis and treatment usuaIIy resuIt in recovery.
75: 369. 1902. DISCUSSION
HARRY E. PETERS. JR. (OakIand. Calif.): AIthough traumatic rupture of the liver is not uncommon, the four chiIdren presented by the authors with injury to the extrahepatic biliary
REFERENCES
system is one of the Iargest personal series on record. Injuries to the liver are legend, and there is no time in this discussion to review the probIems and modaIities of therapy concerned therein. The protection of the rib cage, location of the Iiver and kidney and the recessed Iocation of the gaIIbIadder and major biIe ducts wouId suggest that injury to the extrahepatic biliary system wouId be uncommon without concomitant injury to adjacent viscera. That such does occur is we11 attested by the cases reported by the authors and by numerous isoIated reports in the Iiterature. Injury to the gaIIbIadder is manifested by contusion, Iaceration or avuIsion. AIthough simpIe
I. BENSON, C. D. and PREIST, F. W. Traumatic injuries of the liver, gallbIadder and bitiary tract in infants and chiIdren. S. Clin. Nortb America, 33 : 1187, 1953. 2. BENSON, C. D., MUSTARD, W. T., RAVITCH, M. M., SNYDER. W. H.. JR. and WELCH. K. J. Pediatric Surgery, vol. I, p. 601. Traumatic Lesions of the Abdomen. Chicago, Year Book Pub- 1962. _ Iishers, Inc. 3. COHN, I., JR., COLTAR, A. M. ATIK, M., LUMPKIN, W. M., HUDSON, T. C. and WERNETTE. G. J. BiIe peritonitis. Ann. Surg., 152: 827, I&. A. DRYSDALE. T. M. Case of ruoture of the common duct of the Iiver. Am. J. h?f. SC., 41: 339, 1861. 5. GARRETT, R. W. Traumatic rupture of the bile duct. Ann. Surg., 31: 227, ~goo.
‘53
Hartman and Greaney suture is permissibIe with smaI1 cIean Iacerations, choIecystostomy is an effective form of therapy. With extensive injury to the gaIIbIadder, choIecystectomy shouId be performed. With Iaceration of the major bile ducts, meticuIous cIosure over a T tube, as advocated by the authors, is the treatment of choice. With transection of the common duct, end to end anastomosis over a T tube is to be preferred. If this is not feasibIe, then a shortcircuiting procedure shouId be performed, using the gaIIbIadder with or without a Roux-en-Y hook-up. The cIinica1 picture of the sIow Ieakage of noncontaminated biIe in children is characterized by the nonacute, gradua1 and reIativeIy benign onset of biIiary ascites, jaundice, achoIic stooIs and anorexia. This is we11 demonstrated in the cases presented by the authors and in numerous case reports in the Iiterature, in which not infrequentIy these chiIdren are observed after bIunt trauma, discharged as apparentIy we& onIy to be readmitted at a later date with the cIassica1 findings aIready mentioned. We have had just one patient with injury to the extrahepatic biliary system. This was a three and a haIf year oId child that was invoIved in an automobiIe accident, was hospitalized eIsewhere for a period of eight days and, then discharged as apparentIy weI1. The chiId was admitted to our hospita1 two and a haIf weeks Iater with a rather typica history of progressive enIargement of the abdomen, Iaboratory jaundice and achoIic stooIs. Examinations incIuded a norma upper gastrointestina1 series and intravenous pyeIograms, norma Iiver function tests and normal serum amylase. VisuaIization of the gaIIbIadder was not possibIe with the oral dye. At surgery a Iaceration of the common hepatic duct was found and repaired over a T tube, and operative choIangiogram reveaIed a satisfactory repair. The chiId made a satisfactory recovery. I wouId agree with Drs. Hartman and Greaney that each case must be individuaIized as to therapy as long as it embodies the principIes mentioned. VERNON 0. LUNDMARK (Seattle, Wash.): I have had an experience with a smaI1 group of aduIts. Some have been extremely puzzIing and dramatic in the outcome of their cases. A young Iady compIeteIy severed her common duct and yet did not deveIop biIe peritonitis. She was a twenty-nine year oId airline stewardess whom I saw in March, 1957. She had been invoIved in an auto accident with her husband in Iate October, 1956, had sustained a skuI1 fracture, fractured ribs and two compression fractures of Iumbar vertebrae, in addition to muItipIe Iacerations. The husband, an airIine piIot, had a seat beIt properIy appIied and was totaIIy uninjured. The patient had her seat belt on Iike a young girl
with a huIa-hoop, and consequentIy sustained severe injuries. About five weeks after this injury she deveIoped jaundice and at first the jaundice was ascribed to the Thorazine medication she had received. As the jaundice deepened extensive Iiver studies were performed. Her hepatogram was extremeIy confusing, aIthough the picture of obstruction with Iiver damage was quite suggestive. There was nothing to indicate serious intra-abdomina1 injury earIy in the course, because the patient had extreme paraIytic iIeus, due undoubtedIy to her compression fractures, it was thought. Examination of the abdomen some five or six weeks Iater was noncontributory. Her jaundice was extreme; her bIood choIestero1 was ZJOO, aIkaIine phosphatase 49 units/loo mI., and her bromsuIphaIein indicated extensive Iiver damage. After due preparation she was expIored. The gaIIbIadder was found to be grossIy enIarged, perhaps four to five times; the gastrohepatic Iigament was about 7 to 8 cm. in thickness, with a sandy fee1 to paIpation but otherwise intact and without biIe spiIIage. It was quite obvious that some extensive damage had been done in the biIiary tree, The common duct above the entry of the cystic duct was greatIy diIated and paIpation reveaIed nothing notabIe otherwise. An operative choIangiogram was made and a compIete break just beIow the take-off of the cystic duct was found. An attempt to fiI1 the Iower segment was not successfu1. Because of the poor condition of the patient a choIocystoduodenostomy was performed with a z cm. opening with the hope of bypassing the point of injury. She gained strength and weight over the next few months. The folIowing year she began to have occasiona bouts of chiIIs and fever, which responded very we11 to chIoromycetin. However, these bouts of chiIIs and fever became more and more frequent and severe, and as time went on it was beiieved a second expIoration was necessary. She was explored again in ApriI, 1960 and a cholecystojejunostomy was performed, this time using the Roux-en-Y technic. ExpIoration by way of the common duct at this time revealed compIete obstruction at the sites previousIy noted. The Iower duct was expIored and was found to be aImost compIeteIy obIiterated and cordIike. We were unabIe to get a probe up through the common duct from beIow through a duodenostomy. After this procedure she was very we11 for about three or four years. In the summer of 1963 she began to have jaundice again, and definite enIargement of the liver. The possibility of a stone was suggested. EXpIoration in June reveaIed this to be quite true and the stone was removed. There was no obstruction of the choIecystojejunostomy. Except for a
I54
Iniuries biliary 6stuJ.t of two weeks’ duration
to BiIiary System
she made an uneventful recovery foIlowing removal of the stone, and lo the present time she has been in excellent health. This case, I think, iIIustrates a few points, namely, that seat belts are undoubtedly a bhssing when properly worn, but certainly can be exceedingIg dangerous when not properly applied. AIso that one can have rather serious bile duct injury without bile peritonitis; that the management of jaundice, its diagnosis and basic pathologic features when concerned with trauma can stiI1 be very trying, and certainiy operative cholangiography at the time of surgery is of inestimabIe value. WERNER E. ZELLER (PortIand, Ore.): I wouId like to re-emphasize one point, and that is if there is any question about trauma within the abdomen, one shouId expIore instead of waiting to observe. I had one boy of seventeen about three years ago who was invofved in an accident in which his hot rod hit a teIephone post, and he was thrown forward so that the Iower haIf of the steering whee1 struck him in the abdomen. His condition on entrance to the hospital in the afternoon was not remarkabIe. He compIained of some abdomina1 pain, but there was no IocaIization of pain or tenderness and the abdomen was soft. His white bIood count was not eIevated and the hemogIobin had not dropped. We watched him overnight. The foIIowing morning his condition stiI1 did not Iook bad, but his purse remained a IittIe higher than it should have been so we decided to expIore him. What we found was exactIy what Dr. Hartman showed on his Iast case, a perforation about z cm. Iong right in the very tip of the gaIIbIadder. He had a biIe peritonitis without any other evidence of abdomina1 injury inside. There was no hematoma anywhere in the mesentery, nothing on the posterior walI; there was not even a IittIe tear in the liver. In trying to reconstruct the type of trauma which could give this type of Iocalized injury to the gaIlbladder, one must consider the basic Iaw in physics, which states that in a cIosed ffuid system, a force exerted at one point is transmitted equahy in a11 portions of the system. With a tense galIbIadder, the sudden increased intra-abdomina1 pressure may have been sufficient to cause rupture without any direct bIow. HENRY N. HARKINS (SeattIe, Wash.): We have been interested in biIe peritonitis for a number of years. It was just thirty years ago with the Iate Edmund Andrews and with PauI Harmon that we demonstrated the importance of the irritating action of biIe, particuIarIy biIe saIts, in causing pIasma IOSS, hemoconcentration and shock. We recognize now, as Dr. Hartman has said, that this is not the only expIanation. On the other hand it
stiJ1 is a factor about which something can be done Therefore, I re-emphasize that after thirty years this factor stiI1 pIays a role. It is quite possibIe that in some of the cases presented herein, as we described, the diIute liver biIe, which is not so irritating, may be partIy the explanation as to why these patients Iived so Iong. Second, I wouId Iike to speak briefly on something the authors mentioned but did not especialIy emphasize, nameIy, the importance of biliary tract decompression in these cases of trauma. We usuaIIy drain the common duct in aduIts. In children, when one is sure that the cystic duct is patent, we may drain the gaIIbIadder only, and I did this in my Iast case, a gir1, five years of age, with extensive Iiver damage. The advantage, of course, is earIy decompression; Iater one can use ChoIangiography. The method prevents Ieakage. In one long term case of fistuIa extending to the skin, the hstuIa closed as soon as we drained the common duct. The question often raised is, “Why do it, if it is not aIways necessary?” In eIective biIiary tract surgery it is quite possible to cIose the common duct after choIedochotomy and expIoration. In fact, at Hopkins, VanderbiIt and a few other pIaces this is more or Iess the preferred method. On the other hand, most surgeons advise drainage because of possibIe leakage. The same men question the need for drainage in cases of trauma in which the Ieakage is not onIy possibIe but aIso probabIe, and I believe there is a much higher yieId in draining the biIiary tract in these cases than there is in the eIective. EDWARD M. GREANEY, JR. (cIosing): The purpose of this paper, as given by Dr. Hartman, was to re-emphasize the indoIent nature of biIe peritonitis and the diffrcmties of diagnosis and treatment. The IethaI factor in biIe peritonitis has been the basis of discussion for many, many years. Perhaps Dr. Wangensteen was the foremost proponent of the toxic factor of biIe sa1t.s; Dr. Harkins the ffuid Ioss and the setting up of the third space. RecentIy, Dr. Isidore Cohn has written a briIIiant paper on experimenta biIe peritonitis, the roIe of bacteria1 invasion and of antibiotic prophylaxis, and the IethaI factor in biIiary peritonitis. AI1 of our patients did receive preoperative and postoperative broad spectrum antibiotic therapy, a point that we think needs emphasis. In concIusion, the principIes of management of bihary tract trauma remain as outIined. In bIunt trauma of the abdomen, when the abdomen is opened, preparation for operative cholangiography shouId be made. Operative choIangiography shouId be utilized whenever the integrity of the extrahepatic biIiary system is in question. This is true whether or not there is Ieakage of biIe. Hematoma of the hepatoduodena1 Iigament might be the onIy objective finding.
Hartman
and Greaney
Drainage and decompression of the biIiary tree with reconstitution of the biIiary tree are extremeIy important factors. In the fourth case that Dr. Hartman presented, I think one factor needs re-emphasis. In this twenty-two month oId chiId with the Iongitudinal spIit in the common hepatic duct it was not possibIe for us to put an anterior and posterior row of sutures in this tiny ducta structure, so we just Ieft
the poIyethyIene as a trough with the mucous membrane united in front of this trough, with an exceIIent result. The probIem of the best method of reconstitution of the common duct when severed remains unsoIved. Dr. Longmire’s paper before this Society casts some doubt upon the long term effectiveness without stricture of end to end ducta anastomosis It is possibIe that a Roux-en-Y is the best method.
156
Injuries to the Biliary System in Children*
SHERMAN W. HARTMAN, M.D. AND E. M. GREANEY, JR., M.D., Los Angeles, From tbe Department of Surgery, Cbildrens Hospital of Los Angeles, Los Angeles, California.
HE MANAGEMENT of abdomina1 trauma is a growing concern to the surgeon. A number of recent reports indicate an increasing incidence of these injuries [6,11,15,18]. BIunt trauma accounts for a high percentage of the cases encountered. In the pediatric age group, nonpenetrating injuries account for aImost a11 of the patients treated [2,4]. The genera1 principIes of management of these patients have been frequentIy reviewed and are fairIy uniformIy appIied in areas where this problem is often encountered [4,6, I I, 15,181, Injuries to the biliary tract, however, are rare and onIy sporadic reports of isoIated cases appear [I,4,5,8,g]. The cIinica1 course in these cases is often confusing, and deIay in diagnosis and treatment seems to be a recurring diffrcuIty. It appears necessary to re-emphasize the benign nature of biIe peritonitis and the necessity for accurateIy defining the type of
T
FIG. I.
Case
I.
injury invoIved. We have encountered five cases of injury to the biIiary tract due to bIunt trauma in the period from 1954 through 1963. The experience in these cases emphasizes the diff&Ities in diagnosis and the varied nature of the type of injury encountered. CASE REPORTS CASE I. M. P., a three and a haIf year oId white boy was admitted to the ChiIdrens HospitaI on January 5, 1955. Four days prior to admission he was thrown from a moving car after he reIeased the brake. He was observed at a IocaI hospita1 for two days and then discharged. At home he deveIoped increasing abdomina1 pain and weakness and was admitted to the ChiIdrens Hospital of Los Angeles. Admission temperature was IOO.~“F., puIse Izo/minute and respirations go/minute. The abdomen was distended, tender and doughy. Recta1 examination reveaIed nothing abnorma1. Laboratory studies reveaIed hemoglobin of 8.6 gm./Ioo cc., white blood celIs g,3oo/cu. mm. with
72 per cent poIymorphonucIear Ieukocytes, IO of which were band forms. Roentgenograms of the abdomen reveaIed free air over the Iiver and were reported as pneumoperitoneum and probabIe hemoperitoneum. A Iaparotomy was performed under genera1 anesthesia. The Ieft lobe of the Iiver was compIeteIy severed and suspended from the diaphragm by the trianguIar Iigament. (Fig. I.) The Iine of transection was at the Iigamentum teres of the Iiver. The major biIiary and vascuIar structure had been transected. There were approximateIy 500 cc. of bIood free in the peritonea1 cavity. There was no evidence of perforation of the gastrointestina tract and no evidence of active bIeeding at the time of expIoration. The Ieft Iobe of the Iiver was removed and the area of the cut surface of the remaining Iiver tissue was drained with Iarge Penrose drains. The patient made an uneventfu1 recovery and was discharged on January 18, 1955.
* Presented at the annual meeting of the Pacific Coast SurgicaI Association, February g-12, 1964. American Journal of Surgery. Volume IO& August 1964
150
Culi;fornia
San Francisco,
California,
Injuries
FIG.
2.
to RiIiary System
Case II.
CASE II. M. T., a six year oId white boy was admitted to the Childrens HospitaI on ApriI 30, 1955. Twenty-eight days prior to admission he was involved in an automobile accident and admitted to another hospita1 for observation. He was discharged after three days. He remained at home for three or four days and then was taken to another hospita1 where a Iaparotomy was performed. A biIe duct injury was found but no repair attempted. A large Penrose drain was pIaced in the region of the site of injury and the abdomen closed. He was discharged on the ninth postoperative day after the drain had been removed. WhiIe at home he did poorIy, his weight dropped to 37 pounds from the preaccident weight of 52 pounds. He became progressiveIy distended and jaundiced and was admitted to the Childrens HospitaI on advice of consuItant. On admission the temperature was IOI’F., the puIse Iqo/minute, bIood pressure 105/7o mm. Hg, and the respiration 35/minute. He was cachectic with a hugeIy distended abdomen and grossly jaundiced. Laboratory examination reveaIed a hemogIobin of 50.1 gm./Ioo cc., a white bIood count of Ig,8oo/cu. mm. with 88 per cent poIymorphonucIear forms. Roentgenograms reveaIed diffuse greyness compatibIe with free fluid in the abdomina1 cavity. The patient was prepared for surgery and just prior to transfer to the operating room, paracentesis was performed and 5,150 of biIe removed. At Iaparotomy the Ieft hepatic duct was found severed from the common duct at the point of junction. (Fig. 2.) This was repaired over a T tube pIaced from the common duct. His postoperative course was reIativeIy uneventfu1 and he was discharged on June IO, 1955, after satisfactory T tube choIangiogram x-rays.
FIG. 3. Case III. abdomina1 hemorrhage. He was given three units of bIood and the bIeeding was controlled. His postoperative course was fairIy good unti1 the tweIfth day when jaundice was noted. This increased unti1 admission to the ChiIdrens HospitaI. He continued ora intake during this period. On admission, temperature was IO~.I’F., the bIood pressure I 18/70 mm. Hg, the puIse 12a/minute and the respiration 32/minute. He was miIdIy icteric and the abdomen was distended and tympanic. Recta1 examination reveaIed a browngrey soft stoo1. Laboratory studies reveaIed the hemogIobin of 16.3 gm./Ioo cc. and the white bIood count of 28,ooo/cu. mm. of which 75 per cent were poIymorphonucIear forms. Roentgenograms revealed iIeus and fluid in the abdomen. An abdomina1 tap was performed and 15 cc. of yellowgoId fluid obtained. He was prepared with intravenous fluids and coIIoid and operated upon December 29, 1954. A Iaparotomy was performed and transection of the common duct at the head of the pancreas discovered. The open end of the duct was ligated and a Ioop choIecystojejunostomy carried out. (Fig. 3.) The postoperative course was uneventfu1 and he was discharged on January 22, 1955. CASE IV. J. H., a twenty-two month old white gir1 was admitted to the hospita1 on December 17, 1957, shortIy after being struck by a sIow-moving car.* There was no other history. PhysieaI examination reveaIed a temperature of IO~“F., the bIood pressure of o/o mm. Hg, the puIse 16a/minute and respiration 36/minute. There were muItipIe abrasions of the skin and the abdomen was distended and tender in the upper half. Rectal examination was noncontributory. Roentgenograms reveaIed the chest to be clear. There was abdomina1 iIeus. Voiding cystograms were normal. The hemogIobin was 8.5 gm./roo cc. The patient was vigor-
CASE III. G. L., a three year old white boy was admitted to Childrens HospitaI on December 27, 1954. Fifteen days prior to admission he had sustained bIunt trauma to the abdomen by tipping a cement bird bath onto his abdomen. He was taken to another hospita1 where paracentesis reveaIed bIood, and a Iaparotomy was performed which reveaIed Iacerations of the liver with intra-
* Treated at St. Joseph fornia by E. M. G., Jr. 151
Hospital,
Burbank,
Cali-
Hartman
and Greaney
FIG. 4. Case IV. FIG. 5. Case v.
ousIy transfused and taken to the operating room immediateIy where a Iaparotomy was performed. There were 650 cc. of blood in the peritonea1 cavity as a resuIt of a fracture of the caudate Iobe of the liver. ExpIoration of the porta triad reveaIed a rent in the common duct at the point where the right and left hepatic ducts joined. (Fig. 4.) The anterior portion of the rent was cIosed with interrupted catgut sutures and a poIyethyIene Y-shaped spIint inserted and threaded through the ampuIIa of Vater and brought out through a stab wound in the duodenum. A choIecystostomy was aIso performed. The postoperative course was stormy but the recovery was rapid. The choIecystostomy tube was removed on January 7, 1958, and the poIyethyIene spIint was removed on January 20, 1958. The patient continued to do we11 and was discharged on January 23, 1958.
Serum amyIase was 54 p. Serum protein was 6.4 gm./Ioo cc. of which 2.4 was albumin and 4.0 gIobuIin. Roentgenograms reveaIed a distended abdomen containing ffuid. AbdominaI paracentesis was carried out and 1,350 cc. of reddish-bIack-yeIIow-tinged fluid aspirated. After suitabIe preparation he was taken to the operating room and a Iaparotomy performed which reveaIed approximateIy 3 L. of fluid in the abdomen, a Iarge portion of which was a coIIection of biIe in the right upper quadrant. There was a I cm. perforation in the gaIIbIadder which was freeIy communicating with the peritonea1 cavity. (Fig. 5,) The tube was inserted in the gaIIbIadder and the choIangiogram made which demonstrated integrity of the remainder of the biIiary tract. ChoIecystectomy was performed. The postoperative course was somewhat stormy but the patient made rapid progress and was discharged approximateIy one month after admission.
CASE v. J. L., a seven and one haIf year oId Mexican boy was admitted to the ChiIdrens Hospita1 on March 2, 1963. On January 17, 1963, he was struck by a truck near his home in a smaI1 Mexican border community. He was examined by a physician and no serious injuries were noted. After four days abdomina1 distention deveIoped which became progressiveIy severe unti1 fourteen days prior to admission. He was hospitaIized in a IocaI hospita1. SeveraI abdomina1 taps were done but no other diagnostic or therapeutic measures were instituted, and the patient was discharged after four days in a near moribund condition. Transfer to this hospital was recommended by a consuItant after reviewing roentgenograms. On admission, the bIood pressure was r4o/g5 mm. Hg, puIse Izo/minute, respiration 36/minute, and temperature I 02’F. The patient was a cachectic maIe with an enormousIy distended abdomen containing Auid. Laboratory examination reveaIed hemogIobin of 8.1 gm./Ioo cc., white bIood count of 10,300/cu. mm., with 57 per cent poIymorphonucIear forms and 6 band forms. Serum biIirubin was 3.0 mg./Ioo ml. with 1.3 direct and 1.7 indirect.
COMMENT
The most striking feature of the cIinica1 course in these cases was the deIay in diagnosis and treatment of the biIe peritonitis. As much as six weeks eIapsed before the free escape of biIe into the peritonea1 cavity was corrected. The benign nature of biIe peritonitis has been observed for many years, but this fact apparently needs periodic re-emphasis. WangenSteen’s exhaustive review documents reports as earIy as 1844 which describe surviva1 for weeks with biIe peritonitis [r4]. In a recent report by Santschi there was Iong deIay in treatment of three patients with operative injury to the common duct. The nature of the IethaI factors in biIe peritonitis has been the subject of considerabIe investigation [JJ, 141. The factors impIicated are the toxicity of biIe 152
Injuries
to BiIiary
System
6. GLENN, F. and injuries to the IOI: 176, 1961. 7. HARKINS, H. N., LethaI factors
Saks, ffuid and eIectroIyte Ioss, and bacterial infection. No entireIy satisfactory evidence has yet been produced which indicates which of these factors is most important. Despite the proIonged peritonitis in severa of our cases as we11 as in many of the others reported, successfu1 repair resuIted in compIete recovery. Our experience demonstrates the varied nature of the biIiary tract injuries. In the surgica1 treatment of bIunt abdomina1 trauma evidence of the integrity of the biIiary system must be obtained. At times, operative choIangiogram may be the onIy way to estabIish this. Preparation for this procedure shouId be a part of the operative management. The actua1 repair of the injury requires improvisation. In generaI, restoration of the integrity of the tree, spIinting and drainage are required. The postoperative management presents no specia1 probIems. Accurate diagnosis and correction of the Iesion converts a IethaI situation to one that usuaIIy resuIts in compIete recovery.
THOKBJARNSON, B. Traumatic abdominal organs. Am. J. Surg., HARMON, P. H. and HUDSON, J. in biIe peritonitis. Arch. Surg.,
33: 576, ‘936. 8. HICKS. J. H. A case of traumatic oerforation of the gaIlbladder in a chiId of three years. Brit. J. I
Surg., 3 1: 305, 1944. 9. HICKEN, N. F. and STEVENSON,V. L. Traumatic rupture of the choIedochus associated with acute hemorrhagic pancreatitis and biIe peritonitis. Ann. Surg., 128: 1178, 1948. IO. LADD, W. E. and GROSS, R. E. AbdominaI Surgery in Infancy and ChiIdhood, p. 295. PhiIadeIphia, 1941. W. B. Saunders Co. I I. MORTON, J. H., HINSHAW, J. R. and MORTOK,J. J. BIunt trauma to the abdomen. Ann. Surg., 145: 699, 1957. 12. SANTSCHI, D. R., HUIZENGA, K. A., SCUDAMORI, H. H.. DEARING. W. H. and WAUGH. J. M. Bile ascites. Arch. S&g., 87: 851, 1963. ’ 13. THOMPSON, J. The diagnosis and management of cIosed injuries of the extra-hepatic biIiary tract. J. Roy. Army, M. Corps, 106: 1o7, 1960. 14. WANGENSTEEN, 0. H. On the significance of the escape of steriIe biIe into the peritonea1 cavity. Ann. Surg., 84: 691, 1926. 15. WATKINS, G. L. BIunt trauma to the abdomen. Arch. Surg., 80: 187, 1960. 16. WAUGH, G. E. Traumatic rupture of the common biIe duct in a boy six years old. Brit. J. Surg., 3: 685, 1916. 17. WESTLAND, J. C., GREANEY, E. M., JR. and SNYDER, W. H.. JR. Exnerience with abdomina1 trauma in chiIdhood. *est. J. Surg., 63: 609, 1955. 18. WILLIAMS, R. D. and ZOLLINGER, R. M. Diagnostic and prognostic factors in abdomina1 trauma. Am. J. Surg., 97: 575, 1959. 19. WILLARD, W. Traumatic rupture of the gaI1 bIadder without injury of the liver. New York J. Med.,
SUMMARY
I. BIunt abdomina1 trauma is an increasing probIem. 2. BiIiary tract injury due to bIunt trauma is rare but does occur at any point in the biIiary tree. 3. There is often Iong deIay in diagnosis and treatment due to the indoIent nature of biIe peritonitis. 4. Facilities for operative ChoIangiography shouId be avaiIabIe in expIoration for bIunt trauma. 5. The site of injury must be identified and repair improvised to suit each case. 6. Diagnosis and treatment usuaIIy resuIt in recovery.
75: 369. 1902. DISCUSSION
HARRY E. PETERS. JR. (OakIand. Calif.): AIthough traumatic rupture of the liver is not uncommon, the four chiIdren presented by the authors with injury to the extrahepatic biliary
REFERENCES
system is one of the Iargest personal series on record. Injuries to the liver are legend, and there is no time in this discussion to review the probIems and modaIities of therapy concerned therein. The protection of the rib cage, location of the Iiver and kidney and the recessed Iocation of the gaIIbIadder and major biIe ducts wouId suggest that injury to the extrahepatic biliary system wouId be uncommon without concomitant injury to adjacent viscera. That such does occur is we11 attested by the cases reported by the authors and by numerous isoIated reports in the Iiterature. Injury to the gaIIbIadder is manifested by contusion, Iaceration or avuIsion. AIthough simpIe
I. BENSON, C. D. and PREIST, F. W. Traumatic injuries of the liver, gallbIadder and bitiary tract in infants and chiIdren. S. Clin. Nortb America, 33 : 1187, 1953. 2. BENSON, C. D., MUSTARD, W. T., RAVITCH, M. M., SNYDER. W. H.. JR. and WELCH. K. J. Pediatric Surgery, vol. I, p. 601. Traumatic Lesions of the Abdomen. Chicago, Year Book Pub- 1962. _ Iishers, Inc. 3. COHN, I., JR., COLTAR, A. M. ATIK, M., LUMPKIN, W. M., HUDSON, T. C. and WERNETTE. G. J. BiIe peritonitis. Ann. Surg., 152: 827, I&. A. DRYSDALE. T. M. Case of ruoture of the common duct of the Iiver. Am. J. h?f. SC., 41: 339, 1861. 5. GARRETT, R. W. Traumatic rupture of the bile duct. Ann. Surg., 31: 227, ~goo.
‘53
Hartman and Greaney suture is permissibIe with smaI1 cIean Iacerations, choIecystostomy is an effective form of therapy. With extensive injury to the gaIIbIadder, choIecystectomy shouId be performed. With Iaceration of the major bile ducts, meticuIous cIosure over a T tube, as advocated by the authors, is the treatment of choice. With transection of the common duct, end to end anastomosis over a T tube is to be preferred. If this is not feasibIe, then a shortcircuiting procedure shouId be performed, using the gaIIbIadder with or without a Roux-en-Y hook-up. The cIinica1 picture of the sIow Ieakage of noncontaminated biIe in children is characterized by the nonacute, gradua1 and reIativeIy benign onset of biIiary ascites, jaundice, achoIic stooIs and anorexia. This is we11 demonstrated in the cases presented by the authors and in numerous case reports in the Iiterature, in which not infrequentIy these chiIdren are observed after bIunt trauma, discharged as apparentIy we& onIy to be readmitted at a later date with the cIassica1 findings aIready mentioned. We have had just one patient with injury to the extrahepatic biliary system. This was a three and a haIf year oId child that was invoIved in an automobiIe accident, was hospitalized eIsewhere for a period of eight days and, then discharged as apparentIy weI1. The chiId was admitted to our hospita1 two and a haIf weeks Iater with a rather typica history of progressive enIargement of the abdomen, Iaboratory jaundice and achoIic stooIs. Examinations incIuded a norma upper gastrointestina1 series and intravenous pyeIograms, norma Iiver function tests and normal serum amylase. VisuaIization of the gaIIbIadder was not possibIe with the oral dye. At surgery a Iaceration of the common hepatic duct was found and repaired over a T tube, and operative choIangiogram reveaIed a satisfactory repair. The chiId made a satisfactory recovery. I wouId agree with Drs. Hartman and Greaney that each case must be individuaIized as to therapy as long as it embodies the principIes mentioned. VERNON 0. LUNDMARK (Seattle, Wash.): I have had an experience with a smaI1 group of aduIts. Some have been extremely puzzIing and dramatic in the outcome of their cases. A young Iady compIeteIy severed her common duct and yet did not deveIop biIe peritonitis. She was a twenty-nine year oId airline stewardess whom I saw in March, 1957. She had been invoIved in an auto accident with her husband in Iate October, 1956, had sustained a skuI1 fracture, fractured ribs and two compression fractures of Iumbar vertebrae, in addition to muItipIe Iacerations. The husband, an airIine piIot, had a seat beIt properIy appIied and was totaIIy uninjured. The patient had her seat belt on Iike a young girl
with a huIa-hoop, and consequentIy sustained severe injuries. About five weeks after this injury she deveIoped jaundice and at first the jaundice was ascribed to the Thorazine medication she had received. As the jaundice deepened extensive Iiver studies were performed. Her hepatogram was extremeIy confusing, aIthough the picture of obstruction with Iiver damage was quite suggestive. There was nothing to indicate serious intra-abdomina1 injury earIy in the course, because the patient had extreme paraIytic iIeus, due undoubtedIy to her compression fractures, it was thought. Examination of the abdomen some five or six weeks Iater was noncontributory. Her jaundice was extreme; her bIood choIestero1 was ZJOO, aIkaIine phosphatase 49 units/loo mI., and her bromsuIphaIein indicated extensive Iiver damage. After due preparation she was expIored. The gaIIbIadder was found to be grossIy enIarged, perhaps four to five times; the gastrohepatic Iigament was about 7 to 8 cm. in thickness, with a sandy fee1 to paIpation but otherwise intact and without biIe spiIIage. It was quite obvious that some extensive damage had been done in the biIiary tree, The common duct above the entry of the cystic duct was greatIy diIated and paIpation reveaIed nothing notabIe otherwise. An operative choIangiogram was made and a compIete break just beIow the take-off of the cystic duct was found. An attempt to fiI1 the Iower segment was not successfu1. Because of the poor condition of the patient a choIocystoduodenostomy was performed with a z cm. opening with the hope of bypassing the point of injury. She gained strength and weight over the next few months. The folIowing year she began to have occasiona bouts of chiIIs and fever, which responded very we11 to chIoromycetin. However, these bouts of chiIIs and fever became more and more frequent and severe, and as time went on it was beiieved a second expIoration was necessary. She was explored again in ApriI, 1960 and a cholecystojejunostomy was performed, this time using the Roux-en-Y technic. ExpIoration by way of the common duct at this time revealed compIete obstruction at the sites previousIy noted. The Iower duct was expIored and was found to be aImost compIeteIy obIiterated and cordIike. We were unabIe to get a probe up through the common duct from beIow through a duodenostomy. After this procedure she was very we11 for about three or four years. In the summer of 1963 she began to have jaundice again, and definite enIargement of the liver. The possibility of a stone was suggested. EXpIoration in June reveaIed this to be quite true and the stone was removed. There was no obstruction of the choIecystojejunostomy. Except for a
I54
Iniuries biliary 6stuJ.t of two weeks’ duration
to BiIiary System
she made an uneventful recovery foIlowing removal of the stone, and lo the present time she has been in excellent health. This case, I think, iIIustrates a few points, namely, that seat belts are undoubtedly a bhssing when properly worn, but certainly can be exceedingIg dangerous when not properly applied. AIso that one can have rather serious bile duct injury without bile peritonitis; that the management of jaundice, its diagnosis and basic pathologic features when concerned with trauma can stiI1 be very trying, and certainiy operative cholangiography at the time of surgery is of inestimabIe value. WERNER E. ZELLER (PortIand, Ore.): I wouId like to re-emphasize one point, and that is if there is any question about trauma within the abdomen, one shouId expIore instead of waiting to observe. I had one boy of seventeen about three years ago who was invofved in an accident in which his hot rod hit a teIephone post, and he was thrown forward so that the Iower haIf of the steering whee1 struck him in the abdomen. His condition on entrance to the hospital in the afternoon was not remarkabIe. He compIained of some abdomina1 pain, but there was no IocaIization of pain or tenderness and the abdomen was soft. His white bIood count was not eIevated and the hemogIobin had not dropped. We watched him overnight. The foIIowing morning his condition stiI1 did not Iook bad, but his purse remained a IittIe higher than it should have been so we decided to expIore him. What we found was exactIy what Dr. Hartman showed on his Iast case, a perforation about z cm. Iong right in the very tip of the gaIIbIadder. He had a biIe peritonitis without any other evidence of abdomina1 injury inside. There was no hematoma anywhere in the mesentery, nothing on the posterior walI; there was not even a IittIe tear in the liver. In trying to reconstruct the type of trauma which could give this type of Iocalized injury to the gaIlbladder, one must consider the basic Iaw in physics, which states that in a cIosed ffuid system, a force exerted at one point is transmitted equahy in a11 portions of the system. With a tense galIbIadder, the sudden increased intra-abdomina1 pressure may have been sufficient to cause rupture without any direct bIow. HENRY N. HARKINS (SeattIe, Wash.): We have been interested in biIe peritonitis for a number of years. It was just thirty years ago with the Iate Edmund Andrews and with PauI Harmon that we demonstrated the importance of the irritating action of biIe, particuIarIy biIe saIts, in causing pIasma IOSS, hemoconcentration and shock. We recognize now, as Dr. Hartman has said, that this is not the only expIanation. On the other hand it
stiJ1 is a factor about which something can be done Therefore, I re-emphasize that after thirty years this factor stiI1 pIays a role. It is quite possibIe that in some of the cases presented herein, as we described, the diIute liver biIe, which is not so irritating, may be partIy the explanation as to why these patients Iived so Iong. Second, I wouId Iike to speak briefly on something the authors mentioned but did not especialIy emphasize, nameIy, the importance of biliary tract decompression in these cases of trauma. We usuaIIy drain the common duct in aduIts. In children, when one is sure that the cystic duct is patent, we may drain the gaIIbIadder only, and I did this in my Iast case, a gir1, five years of age, with extensive Iiver damage. The advantage, of course, is earIy decompression; Iater one can use ChoIangiography. The method prevents Ieakage. In one long term case of fistuIa extending to the skin, the hstuIa closed as soon as we drained the common duct. The question often raised is, “Why do it, if it is not aIways necessary?” In eIective biIiary tract surgery it is quite possible to cIose the common duct after choIedochotomy and expIoration. In fact, at Hopkins, VanderbiIt and a few other pIaces this is more or Iess the preferred method. On the other hand, most surgeons advise drainage because of possibIe leakage. The same men question the need for drainage in cases of trauma in which the Ieakage is not onIy possibIe but aIso probabIe, and I believe there is a much higher yieId in draining the biIiary tract in these cases than there is in the eIective. EDWARD M. GREANEY, JR. (cIosing): The purpose of this paper, as given by Dr. Hartman, was to re-emphasize the indoIent nature of biIe peritonitis and the diffrcmties of diagnosis and treatment. The IethaI factor in biIe peritonitis has been the basis of discussion for many, many years. Perhaps Dr. Wangensteen was the foremost proponent of the toxic factor of biIe sa1t.s; Dr. Harkins the ffuid Ioss and the setting up of the third space. RecentIy, Dr. Isidore Cohn has written a briIIiant paper on experimenta biIe peritonitis, the roIe of bacteria1 invasion and of antibiotic prophylaxis, and the IethaI factor in biIiary peritonitis. AI1 of our patients did receive preoperative and postoperative broad spectrum antibiotic therapy, a point that we think needs emphasis. In concIusion, the principIes of management of bihary tract trauma remain as outIined. In bIunt trauma of the abdomen, when the abdomen is opened, preparation for operative cholangiography shouId be made. Operative choIangiography shouId be utilized whenever the integrity of the extrahepatic biIiary system is in question. This is true whether or not there is Ieakage of biIe. Hematoma of the hepatoduodena1 Iigament might be the onIy objective finding.
Hartman
and Greaney
Drainage and decompression of the biIiary tree with reconstitution of the biIiary tree are extremeIy important factors. In the fourth case that Dr. Hartman presented, I think one factor needs re-emphasis. In this twenty-two month oId chiId with the Iongitudinal spIit in the common hepatic duct it was not possibIe for us to put an anterior and posterior row of sutures in this tiny ducta structure, so we just Ieft
the poIyethyIene as a trough with the mucous membrane united in front of this trough, with an exceIIent result. The probIem of the best method of reconstitution of the common duct when severed remains unsoIved. Dr. Longmire’s paper before this Society casts some doubt upon the long term effectiveness without stricture of end to end ducta anastomosis It is possibIe that a Roux-en-Y is the best method.
156