Surgical injury of the biliary tract in children

A retrospective clinical study was performed to evaluate the etiology, inci dence, diagnosis, management and outcome of patients presenting with surgic al injury to the biliary tract. 4 boys were treated for operative biliary t ract injuries between 1970 and 1997. This number represents less than 0.03% of all patients who underwent laparotomy in our unit during the same perio d. 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 injuri es. The tatter presented with caustic sclerosing cholangitis and biliocutan eous fistula while obstructive cholangitis (n=2) and jaundice (n=1) were no ted in the remaining patients. The duration between surgical injury and pre sentation ranged from 6 to 125 days. All patients presented with elevated l evels of transaminases, alkaline phosphatase and bilirubin. Ultrasonography , percutaneous transhepatic cholangiography and biliary drainage catheter p lacement were performed in all patients to Visualize the extent of injury a nd to provide better patient status for operation. Biliary stent applicatio n 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 com plications were encountered in the short and long-term follow-up. Our exper ience revealed that surgical biliary tract injuries have special features t hat warrant consideration with respect to prevention and management in chil dren. They may be caused by partial or complete transection, suture ligatio n, clip application or vascular insult and can be avoided by adequate expos ure, accurate gentle dissection, use of hemostatic clips rather than clamps and ties, and the liberal use of operative cho[angiography. The presenting clinical picture depends on the cause, extent and duration of the injuries . Preoperative detailed evaluation of the hepatobiliary system by radiologi cal and endoscopic means is mandatory for successful treatment. Percutaneou s and/or endoscopic techniques can be employed in selected cases, but if th ese fail or can not be done, open surgical techniques should be performed w ithout hesitation as delayed treatment results in biliary cirrhosis and hep atic failure. Excision of excessive scar tissue at the biliary tract and po rtal hilus, constructing the widest possible stoma, obtaining mucosa to muc osa approximation around 360 degrees, enduring a good blood supply to the a nastomotic line and avoiding tension on the anastomosis are mainstays of su ccessful surgery. Thus, reconstructive biliary tract surgery should be cons idered as a specialized procedure and should be performed by skillful and e xperienced hands.