Spontaneous perforation of the bile duct

We present a classic but rare case of spontaneous perforation of the bile d uct in infancy and a previously undescribed treatment technique. The patien t, a male age 5 weeks, was admitted with abdominal distention, ascites, and conjugated hyperbilirubinemia. Ultrasound revealed ascites but did not pro vide visualization of the gallbladder. Although hepatobiliary scintigraphy with technetium [dimethyl iminodiacetic acid (HIDA scan)] showed normal upt ake peritoneal excretion suggested perforation of the common bile duct (CBD ). Exploratory laparotomy revealed 200 cm(3) dark amber ascitic fluid in th e peritoneal cavity and cholestasis of the liver. Intraoperative cholangiog ram performed via the gallbladder showed a large perforation at the cystic duct/CBD junction. The perforation was large and leakage of contrast preven ted demonstration of the distal CBD despite our attempt to primarily repair the perforation. The CBD was explored; a T-tube was placed. T-tube cholang iogram demonstrated flow of contrast into the duodenum. A large leak remain ed at the cystic CBD junction. A cholecystectomy was performed and a vascul arized flap of the gallbladder wall was used to repair the CBD over the T-t ube. The T-tube was clamped intermittently beginning 3 weeks postoperativel y. T-tube cholangiogram performed 6 weeks postoperatively revealed no extra vasation and normal intra- and extrahepatic biliary tree. The T-tube was su bsequently discontinued and liver function tests remained normal at 6 month s follow-up.