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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 2  |  Page : 58-61

Closed circuit refeeding biliary drainage in a complex blunt hepatobiliary trauma: A novel technique


Department of Pediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana, India

Date of Web Publication9-Aug-2017

Correspondence Address:
Jyoti M Bothra
Department of Pediatric Surgery, Rainbow Children's Hospital, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajt.ajt_5_17

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  Abstract 

Blunt trauma to the abdomen is common in children causing injuries of varying severity. We present a complex case of hepatobiliary, gastrointestinal, and renal artery injuries needing a tailored management strategy and a novel technique of nutrition for the best possible outcome for the patient. Our patient in this case report had extensive hepatobiliary trauma with complete biliary duct and duodenal transection and renal artery thrombosis. He was managed by staged surgeries comprising biliary diversion and duodenal repair in the first stage and undiversion of the system in the second surgery. This is a novel technique as the nutrition was maintained by a closed circuit of bile redrainage into the jejunostomy tube achieving a physiological drainage pattern and circumventing the need of parental nutrition.

Keywords: Biliary diversion, biliary fistula, duodenopancreatic injury


How to cite this article:
Jayaram H, Poddutoor P, Bothra JM, Kumar K L. Closed circuit refeeding biliary drainage in a complex blunt hepatobiliary trauma: A novel technique. Afr J Trauma 2016;5:58-61

How to cite this URL:
Jayaram H, Poddutoor P, Bothra JM, Kumar K L. Closed circuit refeeding biliary drainage in a complex blunt hepatobiliary trauma: A novel technique. Afr J Trauma [serial online] 2016 [cited 2021 Dec 5];5:58-61. Available from: https://www.afrjtrauma.com/text.asp?2016/5/2/58/212633


  Introduction Top


Blunt trauma to the abdomen is commonly seen in pediatric trauma centers and the management is tailored as per the patient's condition and severity of the trauma. The management varies from conservative to aggressive surgical management. A duodenal transection always needs exploration. However, the management of renal artery thrombosis varies from observation only, especially in unstable patient to immediate revascularisation surgeries depending on the surgeon's experience and preference. This has been discussed in detail later.


  Case Report Top


A 7-year-old boy presented with acute abdominal pain, distention, hematemesis and hemodynamic shock following an accidental fall of television on his abdomen. Computed tomography (CT) scan showed gross pneumohemoperitoneum, pancreatic head injury with hepatic contusions [Figure 1]. A right retroperitoneal hematoma along with right renal artery thrombosis with a partially perfused kidney was noted. The patient was explored after optimization. There was a total transection of the first part of the duodenum [Figure 2] along with complete common bile duct (CBD) transection 1 cm distal to the confluence of cystic duct and common hepatic duct. This was associated with pancreatic head laceration but did not involve the pancreatic duct. A primary duodenal anastomosis was done and the CBD was ligated proximal to the transection. A tube cholecystostomy and a feeding jejunostomy were concurrently performed and the peritoneum was drained. Endovascular or surgical intervention for the right renal vascular injury was ruled out in view of the persistent hemodynamic instability. Jejunostomy feeds were started on postoperative day 3 (POD3). The oral contrast study conducted on POD7 showed a healed duodenal anastomosis and oral feeds were initiated which were well tolerated. A closed-circuit drainage was established between the cholecystostomy and feeding jejunostomy tubes to maintain physiological bile drainage and nutrition [Figure 3]. In the early postoperative period, patient developed hypertension requiring antihypertensives. Doppler study showed a partial obstruction of the right renal artery. Subsequent recovery was uneventful and the parents were taught catheter care before discharge.
Figure 1: Preoperative contrast-enhanced computed tomography showing pnuemohemoperitoneum and right renal vessel stenosis

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Figure 2: Intraoperative photograph with near complete transection of the 2nd part of the duodenum

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Figure 3: The novel technique of the refeeding closed circuit between cholecystostomy and jejunostomy tubes

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Three months later, the patient was asymptomatic and nutritionally well preserved. The closed circuit between the jejunostomy and the cholecystostomy tubes was draining well with a marginal elevation of the serum bilirubin (2.4 mg/dl). The patient was clinically anicteric passing normal yellow stools. The patient had persistent hypertension requiring antihypertensives. The ultrasound showed minimal dilatation of the pancreatic duct. A contrast study through the cholecystostomy tube revealed a 10 mm dilated CBD with mild intrahepatic biliary radical dilatation [Figure 4]. Dimercaptosuccinic acid scan showed nonfunctional right kidney with CT evidence of complete stricture of the renal artery up to the renal hilum. He underwent hepaticoduodenostomy and right nephrectomy. Patient had an uneventful recovery and became normotensive after surgery and was weaned off from all antihypertensives. After re-establishment of full oral feeds, the jejunostomy tube was removed on the POD10. At 1-year follow-up, he has gained weight and is asymptomatic.
Figure 4: Postoperative contrast study

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  Discussion Top


Blunt abdominal trauma in children can lead to injuries ranging from trivial to the most complex nature requiring multidisciplinary team management and accounting for significant mortality and morbidity. Complex hepatico, duodenopancreatic, and biliary tract injuries are rare areas of involvement accounting for 0.2% of all blunt abdominal trauma.[1] Management options for such injuries are varied and depend on multiple factors such as time of presentation, relative stability of the child, degree of traumatic damage, and the vascularity of the structures involved. However, in view of small number of patients being reported in several centers, no definitive recommendations are available.

Duodenal injuries are usually managed by primary anastomosis, pyloric exclusion with gastrojejunostomy, and rarely the Whipple's procedure. A healthy margin of duodenal injury and early presentation allowed us to perform a primary anastomosis of duodenal injury. Pancreatic injuries range from contusion, partial to complete transection to stellate fragmentation. Recent studies have varied results with operative versus nonoperative management protocols. Some favor a conservative approach for all children with all grades of pancreatic injuries with good results.[2] Whereas, others advocate aggressive debridement or resection for severe ductal injuries with compelling data.[3] Our child with partial transection of the head of the pancreas was managed without pancreatic manipulation and had very minimal narrowing of the pancreatic duct at the junction of the head and body at follow-up scans.

There is little controversy in the management of renal blunt trauma in children with conservative management being the standard of care in the most centers with success rates of 98%.[4] However, there are only a few cases reported on renal artery occlusion in children. The ultimate goal of managing pediatric renal trauma is preservation of the renal tissue and minimizing the patient morbidity. About 90% of pediatric renal trauma are self-limiting.[5] Traumatic renal artery occlusion is rare with an incidence of 0.005%–0.1%.[6],[7],[8] Cass et al. have reported an average of 3.7 associated injuries per patient with 85% requiring laparotomy for the other intra-abdominal injuries as in our case.[9]

Treatment options for complex high-grade renal injuries are controversial ranging from immediate surgical revascularization, nephrectomy to nonoperative treatment.[5] Apart from bilateral renal vessel injury or injury in a solitary kidney, the consensus is of conservative approach in a unilateral renal artery injury, especially in a hemodynamically unstable child. A long-term follow-up is mandatory in these children to look for renovascular hypertension as 25%–50% may develop hypertension in 1st year posttrauma and may need delayed nephrectomy.[10] The true incidence is underreported though it is about 0.6%–6.6%.[5],[11] Percutaneous endovascular stenting is another treatment modality, however, its feasibility and effectiveness are yet to be confirmed.[5],[12]

Extrahepatic bile duct (EHBD) injury is extremely rare, especially those resulting in complete transection of the bile duct and is mostly reported in adults. Eighty-five percent of all EHBD injuries involve the gallbladder.[13] Isolated EHBD injuries usually present late with abdominal pain and biliary ascites or with delayed biliary strictures.[14],[15] The options in the management include ERCP and biliary stenting for isolated partial tears with the good results.[16] Initial external biliary diversion in the form of T-tube drainage, cannulation of choledochus stump, or cholecystojejunostomy followed by a definitive biliary-enteric anastomosis is the most commonly practiced.[17] Primary end-to-end anastomosis has a high rate of stenosis (55%) and primary hepaticojejunostomy is technically demanding in a nondilated bile duct with a risk of stenosis.[18] Primary cholecystojejunostomy as a permanent biliary diversion is not an option as bile drainage across the cystic duct is with resistance and will lead to biliary tract dilatation. A temporary cholecystostomy or a cholecystojejunostomy provided the cystic duct is patent, allows the bile ducts to dilate, and then can be followed by hepaticojejunostomy or hepaticoduodenostomy.[17]

Management of external biliary drainage is always a cause of concern due to the loss of bile salts and electrolytes. Various options of refeeding have been described including replacement through the nasogastric tube or reinfusion of collected intestinal secretions through the jejunostomy tube or gastrostomy tubes with jejunal extensions.[19] A novel way of replacement of bile continuously into the jejunum through the feeding jejunostomy tube as a closed circuit has been successfully demonstrated in our management of this child. Reinfusion of intestinal secretions has been described only in adults in palliative care for inoperable malignancies.[19] To the best of our knowledge, this has never been described in a child in literature. This can prevent the problems related to the external drainage and the trouble of periodic reinfusion of bile into the distal gut thus making the patient ambulatory with no external bags and decreasing the risk of cholangitis.


  Conclusion Top


Management of a complex multiorgan trauma in a child needs to be tailored as per the patient condition. Establishing the nutrition of the child, especially in the developing countries where economic constraints play a major role, is a challenge for the treating physician. The closed-circuit bile drainage from cholecystostomy to jejunostomy is an effective, almost physiological, and infection-free way of maintaining the nutrition in the most economical fashion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ballard RB, Badellino MM, Eynon CA, Spott MA, Staz CF, Buckman RF Jr. Blunt duodenal rupture: A 6-year statewide experience. J Trauma 1997;43:229-32.  Back to cited text no. 1
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2.
Shilyansky J, Sena LM, Kreller M, Chait P, Babyn PS, Filler RM, et al. Nonoperative management of pancreatic injuries in children. J Pediatr Surg 1998;33:343-9.  Back to cited text no. 2
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3.
Canty TG Sr., Weinman D. Management of major pancreatic duct injuries in children. J Trauma 2001;50:1001-7.  Back to cited text no. 3
    
4.
Buckley JC, McAninch JW. Pediatric renal injuries: Management guidelines from a 25-year experience. J Urol 2004;172:687-90.  Back to cited text no. 4
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5.
Yokoyama S, Sekioka A, Utsunomiya H, Shimada K, Traumatic renal artery occlusion associated with a grade III hepatic injury in an 11-year-old boy: A case report. J Pediatr Surg Case Rep 2014;2:126-9.  Back to cited text no. 5
    
6.
Sangthong B, Demetriades D, Martin M, Salim A, Brown C, Inaba K, et al. Management and hospital outcomes of blunt renal artery injuries: Analysis of 517 patients from the National Trauma Data Bank. J Am Coll Surg 2006;203:612-7.  Back to cited text no. 6
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7.
Bruce LM, Croce MA, Santaniello JM, Miller PR, Lyden SP, Fabian TC. Blunt renal artery injury: Incidence, diagnosis, and management. Am Surg 2001;67:550-4.  Back to cited text no. 7
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8.
Jawas A, Abu-Zidan FM. Management algorithm for complete blunt renal artery occlusion in multiple trauma patients: Case series. Int J Surg 2008;6:317-22.  Back to cited text no. 8
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9.
Cass AS, Bubrick M, Luxenberg M, Gleich P, Smith C. Renal pedicle injury in patients with multiple injuries. J Trauma 1985;25:892-6.  Back to cited text no. 9
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10.
Haas CA, Dinchman KH, Nasrallah PF, Spirnak JP. Traumatic renal artery occlusion: A 15-year review. J Trauma 1998;45:557-61.  Back to cited text no. 10
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11.
Nance ML, Lutz N, Carr MC, Canning DA, Stafford PW. Blunt renal injuries in children can be managed nonoperatively: Outcome in a consecutive series of patients. J Trauma 2004;57:474-8.  Back to cited text no. 11
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12.
Dowling JM, Lube MW, Smith CP, Andriole J. Traumatic renal artery occlusion in a patient with a solitary kidney: Case report of treatment with endovascular stent and review of the literature. Am Surg 2007;73:351-3.  Back to cited text no. 12
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13.
Melton SM, McGwin G Jr., Cross JM, Davidson J, Waller H, Doss MW, et al. Common bile duct transection in blunt abdominal trauma: Case report emphasizing mechanism of injury and therapeutic management. J Trauma 2003;54:781-5.  Back to cited text no. 13
    
14.
Jain S, Jain A, Shrivastava SK. Isolated common bile duct avulsion following blunt abdominal trauma. Indian J Surg 2013;75 Suppl 1:199-200.  Back to cited text no. 14
    
15.
Bourque MD, Spigland N, Bensoussan AL, Garel L, Blanchard H. Isolated complete transection of the common bile duct due to blunt trauma in a child, and review of the literature. J Pediatr Surg 1989;24:1068-70.  Back to cited text no. 15
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16.
Sharma BC, Mishra SR, Kumar R, Sarin SK. Endoscopic management of bile leaks after blunt abdominal trauma. J Gastroenterol Hepatol 2009;24:757-61.  Back to cited text no. 16
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17.
Nagem RG, Abrantes WL. Avulsion of common bile duct-case report. Rev Col Bras Cir 2013;40:261-2.  Back to cited text no. 17
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18.
Jurkovich GJ, Hoyt DB, Moore FA, Ney AL, Morris JA Jr., Scalea TM, et al. Portal triad injuries. J Trauma 1995;39:426-34.  Back to cited text no. 18
    
19.
Parrish CR, Quatrara B. The art of reinfusing intestinal secretions. J Support Oncol 2010;8:92-6.  Back to cited text no. 19
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    Figures

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