Minimally invasive management of bile leaks after blunt liver trauma in children.
BACKGROUND
Management of bile leaks after blunt abdominal trauma remains controversial. Conventionally, open surgery has been considered necessary, but new modalities of treatment, including endoscopic biliary stenting and laparoscopy, offer a minimally invasive alternative.


METHODS
A retrospective review of all cases of blunt liver trauma in children treated at our institution between May 2002 and October 2004 was performed looking for possible biliary injury.


RESULTS
Five children (3 boys), median age 13 years (range, 10-15 years), were referred to our institution at a median time of 4 days (1-15 days) after the initial trauma. Mechanism of injury was motor vehicle accident (n = 3), fall from a motorbike/Quad bike (n = 2), and a scooter handlebar injury (n = 1). Two, who were hemodynamically unstable, required laparotomy within 24 hours, although their subsequent management was minimally invasive. Endoscopic retrograde cholangiopancreatography, performed at a median time of 15 days (2-28 days), demonstrated an intrahepatic biliary leak in all 5 patients. Biliary stenting was performed in each case, with 2 also having a sphincterotomy. One subsequently developed a bile duct stricture that was managed by endoscopic dilatation. Four required additional percutaneous external drainage of intraabdominal collections. Two underwent laparoscopy to facilitate peritoneal lavage and rule out bowel injuries. No child required open surgery to treat the bile leak. Median hospital stay was 43 days (range, 15-58 days).


CONCLUSIONS
A minimally invasive, multidisciplinary approach to traumatic bile leaks, as an alternative to open surgery, is practical and safe. It requires flexibility, particularly if the diagnosis has been delayed, and may still involve a prolonged hospital stay.
Castagnetti
Marco
M
Department of Paediatric Surgery, King's College Hospital, SE5 9RS London, UK.
Houben
Christopher
C
Patel
Shailesh
S
Devlin
John
J
Harrison
Philip
P
Karani
John
J
Heaton
Nigel
N
Davenport
Mark
M
D000007:Abdominal Injuries / Q000175:diagnosis* / Q000628:therapy; D000063:Accidents, Traffic; D000293:Adolescent; D001646:Bile; D001652:Bile Ducts / Q000293:injuries*; D002648:Child; D002760:Cholangiopancreatography, Endoscopic Retrograde; D004322:Drainage; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008099:Liver / Q000293:injuries*; D008297:Male; D015607:Stents; D014949:Wounds, Nonpenetrating / Q000175:diagnosis / Q000628:therapy