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Surgical injury of the biliary tract in children
A O Ciftci1, I Karnak, M E Senocak
1Department of Pediatric Surgery, Hacettepe University Medical Faculty, Ankara, Turkey.
Insights
Surgical biliary tract injuries in children are rare but require prompt diagnosis and surgical management. Early intervention and specialized reconstructive techniques are crucial for successful outcomes and preventing long-term complications.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Surgical Oncology
Background:
- Operative biliary tract injuries are uncommon in pediatric patients.
- These injuries can lead to significant morbidity if not managed appropriately.
Purpose of the Study:
- To evaluate the etiology, incidence, diagnosis, management, and outcomes of surgical injuries to the biliary tract in children.
- To highlight the importance of prevention and specialized surgical management.
Main Methods:
- Retrospective clinical study of 4 pediatric patients treated for operative biliary tract injuries between 1970 and 1997.
- Inclusion of diagnostic methods (ultrasonography, percutaneous transhepatic cholangiography) and surgical procedures (Roux-en-Y hepaticojejunostomy, choledochoduodenostomy).
Main Results:
- Injuries were caused by accidental ligation, vascular insult, or formalin toxicity.
- Patients presented with jaundice, obstructive cholangitis, or biliocutaneous fistula.
- All patients required surgical treatment, with successful short- and long-term follow-up after reconstructive surgery.
Conclusions:
- Surgical biliary tract injuries in children necessitate specialized diagnostic and management approaches.
- Preventive measures during surgery and prompt, expert reconstructive surgery are vital for optimal patient outcomes.
- Delayed treatment can lead to severe complications such as biliary cirrhosis and hepatic failure.
Abstract:
A retrospective clinical study was performed to evaluate the etiology, incidence, diagnosis, management and outcome of patients presenting with surgical injury to the biliary tract. 4 boys were treated for operative biliary tract injuries between 1970 and 1997. This number represents less than 0.03% of all patients who underwent laparotomy in our unit during the same period. The mean age of the patients at presentation was 7.5 +/- 3 (range, 4 to 10 years). Accidental ligation of choledochus (n = 2), vascular insult of the biliary tract (n = 1) and formalin toxicity (n = 1) were the causes of injuries. The latter presented with caustic sclerosing cholangitis and biliocutaneous fistula while obstructive cholangitis (n = 2) and jaundice (n = 1) were noted in the remaining patients. The duration between surgical injury and presentation ranged from 6 to 125 days. All patients presented with elevated levels of transaminases, alkaline phosphatase and bilirubin. Ultrasonography, percutaneous transhepatic cholangiography and biliary drainage catheter placement were performed in all patients to visualize the extent of injury and to provide better patient status for operation. Biliary stent application provided temporary relief of obstruction in one patient, but all patients required surgical treatment subsequently. Roux-en-Y hepaticojejunostomy (n = 3), and choledochoduodenostomy (n = 1) were the operative procedures. No complications were encountered in the short and long-term follow-up. Our experience revealed that surgical biliary tract injuries have special features that warrant consideration with respect to prevention and management in children. They may be caused by partial or complete transection, suture ligation, clip application or vascular insult and can be avoided by adequate exposure, accurate gentle dissection, use of hemostatic clips rather than clamps and ties, and the liberal use of operative cholangiography. The presenting clinical picture depends on the cause, extent and duration of the injuries. Preoperative detailed evaluation of the hepatobiliary system by radiological and endoscopic means is mandatory for successful treatment. Percutaneous and/or endoscopic techniques can be employed in selected cases, but if these fail or can not be done, open surgical techniques should be performed without hesitation as delayed treatment results in biliary cirrhosis and hepatic failure. Excision of excessive scar tissue at the biliary tract and portal hilus, constructing the widest possible stoma, obtaining mucosa to mucosa approximation around 360 degrees, enduring a good blood supply to the anastomotic line and avoiding tension on the anastomosis are mainstays of successful surgery. Thus, reconstructive biliary tract surgery should be considered as a specialized procedure and should be performed by skillful and experienced hands.