# Evolving Role of Endoscopic Retrograde Cholangiopancreatography in Management of Extrahepatic Hepatic Ductal Injuries due to Blunt Trauma: Diagnostic and Treatment Algorithms

Authors: Nikhil P. Jaik; Brian A. Hoey; S. Peter Stawicki
Journal: HPB Surgery
 (2008)

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## Abstract

Extrahepatic hepatic ductal injuries (EHDIs) due to blunt abdominal trauma are rare. Given the rarity of these injuries and the insidious onset of symptoms, EHDI are commonly missed during the initial trauma evaluation, making their diagnosis difficult and frequently delayed. Diagnostic modalities useful in the setting of EHDI include computed tomography (CT), abdominal ultrasonography (AUS), nuclear imaging (HIDA scan), and cholangiography. Traditional options in management of EHDI include primary ductal repair with or without a T-tube, biliary-enteric anastomosis, ductal ligation, stenting, and drainage. Simple drainage and biliary decompression is often the most appropriate treatment in unstable patients. More recently, endoscopic retrograde cholangiopancreatography (ERCP) allowed for diagnosis and potential treatment of these injuries via stenting and/or papillotomy. Our review of 53 cases of EHDI reported in the English-language literature has focused on the evolving role of ERCP in diagnosis and treatment of these injuries. Diagnostic and treatment algorithms incorporating ERCP have been designed to help systematize and simplify the management of EHDI. An illustrative case is reported of blunt traumatic injury involving both the extrahepatic portion of the left hepatic duct and its confluence with the right hepatic duct. This injury was successfully diagnosed and treated using ERCP.


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## Body

## 1. Introduction

Injuries to the extrahepatic biliary system in blunt abdominal trauma are uncommon
[1–7].
Extrahepatic hepatic ductal injuries (EHDIs) occur even
less frequently [1–8]. Because of their rarity and the frequently insidious onset of symptoms, EHDIs
are commonly missed during the initial trauma evaluation, and debate continues
regarding the best way to diagnose and treat them [2, 9]. Diagnostic tools useful in EHDIs include computed tomography (CT), abdominal ultrasound (AUS), nuclear imaging (HIDA), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP).Traditional management options in EHDI include primary repair with or without a T-tube,
biliary-enteric anastomosis, ductal ligation, stenting, and drainage.
Simple drainage and biliary decompression is often the most appropriate treatment
option in unstable patients [2, 3]. More recently, ERCP has allowed trauma surgeons to diagnose and potentially treat EHDIs via stenting and/or
papillotomy, even in the face of previous abdominal surgical procedures [4, 10, 11].A comprehensive review of 53 cases of EHDIs reported in the English-language
literature was conducted, focusing on the evolving role or ERCP in diagnosis
and treatment of these injuries. We also report an illustrative case of blunt
traumatic injury involving the extrahepatic portion of the left hepatic duct
(LHD) and the confluence of the LHD and the right hepatic duct (RHD).
Diagnostic and treatment algorithms that incorporate ERCP are presented in
order to help systematize and simplify the management of EHDIs.


## 2. Illustrative Case Report

A 26-year old motorcycle rider was struck on his right side by a mid-sized passenger car traveling at
approximately 30 miles per hour. He was hemodynamically unstable upon arrival
to the hospital (systolic blood pressure 60 mmHg, heart rate 120/min). Bedside
abdominal sonogram showed free peritoneal fluid. The patient remained
hypotensive despite aggressive fluid resuscitation and was promptly taken to the
operating room. He was found to have a large stellate laceration of the liver
involving medial segments of the right lobe. Liver was packed and hemostasis
was obtained. Splenectomy was performed secondary to splenic laceration that
extended into the hilum. A Jackson-Pratt drain was left in the left upper
quadrant (LUQ). After a damage control dressing was placed, the patient was
taken to interventional radiology where several branches of the right hepatic
artery were embolized.The patient's early hospital course was uneventful and his abdomen was definitively
closed on postoperative day two. However, he subsequently began draining
increasing amounts of bile from his abdominal drain, associated with concurrent
rise in serum bilirubin. Computed tomography (CT) of the abdomen demonstrated a
large fluid collection in the upper abdomen (Figure1). A percutaneous
drain was placed into this collection and drained approximately 500 ml of bile.
Due to continued drainage of several hundred milliliters of bile per day, an
ERCP was obtained. This demonstrated a proximal transection of the extrahepatic
portion of the LHD as well as a leak at the confluence of LHD and RHD (Figure
2(a)). Stenting across the transected LHD was attempted but the guidewire
could not be passed across the injury. A sphincterotomy was performed and the
common bile duct (CBD) was stented in order to decompress the biliary tree.Figure 1
Computed tomographic (CT) scan showing a high-grade liver injury along with large amount
of intraperitoneal fluid in the upper abdomen.(a) Initial ERCP study demonstrating (1) left hepatic duct transection; (2) wire across the
patent right hepatic duct; and (3) embolization coils. (b) Repeat ERCP study demonstrating (1) intact left hepatic duct; and (2) percutaneous drain.
(a)(b)Over the next several days, the drainage markedly decreased and the patient was discharged to home with drains in place. A repeat ERCP four months after patient's initial injury showed
filling of both the RHD and the LHD (Figure2(b)). His liver function
tests (LFTs) at the time were within normal limits. Both the stent and drain
were removed, with no subsequent problems reported. He is now four years out
from his original trauma, has normal LFTs, and a recent abdominal sonogram
showed normal CBD size.


## 3. Discussion

The first case of bile duct rupture due to blunt abdominal trauma was reported by Wainwright in 1799 [13]. Traumatic extrahepatic biliary tree injuries are rare and usually associated with penetrating mechanism [1]. The frequencies of injuries to the biliary tree, in decreasing order, are those of gallbladder, common bile duct (CBD), hepatic
ducts (HD) and junction of left hepatic duct (LHD), and right hepatic duct (RHD)
[1, 14]. Only 2% of patients with extrahepatic biliary injury have HD injury [1]. We will first discuss the demographics, anatomy, and pathophysiology of EHDIs, followed by a description of some traditional treatment methods and a detailed discussion of the emerging role of ERCP in the treatment of EHDIs,
along with diagnostic and treatment algorithms that incorporate ERCP.Extrahepatic hepatic ductal injuries (EHDIs) occur predominantly in men, and the male-to-female ratio increases with patient age [2, 12, 15]. Approximately 50% of EHDIs
are automobile-related, with the remaining half due to crush injuries,
motorcycle crashes, sports/recreational injuries, and falls [12]. The rarity of
EHDIs combined with over 50% frequency of severe associated injuries contributes
to an average diagnostic delay of about 2 weeks [12, 16]. The frequencies of EHDIs locations are shown in Figure 3.Figure 3
Diagram demonstrating the locations and frequencies of extrahepatic hepatic ductal
injuries. Source: [12].In EHDIs, the relative fixation of the proximal hepatic ducts to the liver can lead to a
shearing force, inducing intraductal hypertension and tearing, as seen with
high-speed deceleration [14, 17]. Another mechanism involves compression of the biliary system and gallbladder against the vertebral column and ductal blowout, which may be seen when the gallbladder rapidly empties into a short cystic duct
[2, 8, 16]. Ischemic necrosis of the ducts has also been proposed, perhaps
accounting for delayed injuries [18]. Extensive ductal dissection during
surgery can also produce an ischemic injury. A combination of mechanisms is
likely involved in each individual case.Abdominal ultrasound (AUS) and computed tomography (CT) constitute the initial diagnostic
workup. Ductal dilatation and/or periportal fluid collections raise the
suspicion of bile duct injury [8]. Percutaneous evacuation of bile can help
confirm the diagnosis [9]. In cases of persistent bile drainage, scintigraphy
may be useful, although it is poor in pinpointing the site of injury [6, 19]. Cholangiogram is the gold standard for defining a ductal injury [20]. More recently, ERCP has emerged as a valuable adjunct in treatment of EHDI, and can be both diagnostic and therapeutic [12, 21–23].One third of EHDIs are missed at initial laparotomy or investigation, and another 2% are
not recognized on repeat surgery [8, 12]. Over 50% of patients with EHDIs who do not undergo immediate trauma laparotomy typically have a diagnostic delay of more than 1 day, which can result in significant morbidity and mortality [2, 8]. Sterile bile causes minimal peritoneal reaction, with vague abdominal pain and distention, nausea, vomiting, and jaundice [8, 24]. Liver injury is the most common associated injury (55% of patients), followed by extremity (19%),  pelvic fractures (17%), and splenic and gallbladder injury [12]. Pneumothorax, rib fractures, and head injury are less frequent. Others report combined
injuries involving the duodenum, stomach, colon, pancreas, and non-EHDI biliary
duct injuries (5%) [12, 25].Mortality was reported in 3.8% to 12.7% cases of EHDI, with blunt injuries being
associated with higher mortality than penetrating injuries [1, 2, 12, 25, 26]. EHDIs are associated with long hospitalizations (average of 40 days) and many
potential complications [12]. Early complications include wound infection,
abscess, and biliary fistula [8, 27, 28]. Late complications include ductal stricture with or without cholangitis and posttraumatic hepatic atrophy [25, 29, 30].When the diagnosis of EHDIs occurs during an emergent celiotomy, the
primary focus should be on patient stabilization, hemostasis, temporizing stenting, ligation, and T-tube placement should be considered [1, 8, 31]. At the very least, the injured duct should be tagged and the area drained, with definitive repair performed later. Long-term stenting across injured hepatic ducts may be considered, even without suture repair [17, 32]. Choledochoenterostomy and hepaticoenterostomy
have been used for major ductal injuries, including
complete transections [1, 15, 33]. When performing biliary reconstruction,
the size of the duct and viability of its blood supply have to be considered,
and end-to-end ductal repair should be avoided in complete injury due to the
risk of stricture formation [8, 16, 25]. Other techniques include repair with vein, serosal or jejunal patch [33, 34]. Adequate operative drainage is
essential [3]. Bilioenteric anastomoses produce good long-term outcomes in
85–90% of cases [35–38]. Long-term
anastomotic stenting (6–9 months) has been supported by some authors [25, 36], while others stent for a shorter period of time or
not at all [35, 39]. Anastomotic stents decompress the biliary tree, allow postoperative radiographic followup, and there may be a correlation between outcome and the time stented as anastomotic catheters may limit the contraction
of collagen and stricturing [25]. Opponents of stenting argue that stents
contribute to complications (stent dislodgment, occlusion by biliary debris,
and cholangitis) [25, 40]. While many biliary strictures appear in the first 2 postoperative years, it may take up to 5 years for 80% of strictures to occur,
with approximately 20% of failures after that period, suggesting that a
long-term followup of 7–10 years may be optimal [25, 35, 41]. Tacking of the
Roux-en-Y jejunal loop marked with metallic clips to the abdominal wall can
help facilitate future biliary tree access [36].


## 4. Emerging Role of ERCP in Management of EHDI

Management of EHDIs depends on the patient's overall clinical status, associated injuries,
and the location and extent of the injury [8]. Patients who are hemodynamically
stable on initial presentation and do not require immediate surgical
intervention can safely undergo nonoperative management of bile duct injuries—an attractive therapeutic alternative [42, 43].
This is further supported by the use of ERCP in treatment of iatrogenic
extrahepatic bile duct injuries, which is well described and accepted [12, 22].More recently, ERCP has emerged as a valuable adjunct in treatment of EHDI, and has
been used to define the anatomy of the injury as well as to provide definitive
therapy [12, 21–23, 43]. In fact, a total of 19 cases in this review involved ERCP utilization in either diagnostic or therapeutic capacity (Table 1). The safety and efficacy of ERCP has been advocated in increasing number of publications, with excellent (>90%) ductal visualization success and low (<10%) morbidity [7, 43].Table 1
Collected summary of all reported cases of extrahepatic hepatic ductal injuries
from 1925 to present.
Date, Author, (Ref.) (chronological)Age (y.)GenderMechanism of injuryNature of ductal  injuryTreatmentERCP1925, Cope [44]10MMVCConfluence of R & LHDCholecystostomy drainsN1929, Long [45]40MCrushed between autosConfluence of R & LHDCholecystostomy drainsN1938, Lewis [27]49MMV versus PEDConfluence of R & LHDDrainage. Followed by re-drainageN1953, Walker [46]2MRun over by a tractorConfluence of R & LHDR-en-Y repair over stentsN1955, Baty [47]25MMVCLHD lacerationCommon duct T-tubeN1955, Schaer [48]50MStruck by a bullRHD lacerated anteriorly (0.5 cm)CBD stent, drainsN1956, Foman [49]34MMVCR & LHD near the confluenceCholecystostomy, drainN1961, Nikishin [50]3MRun over by an autoRHD lacerationDrainsN1964, Hartman [51]2FMV versus PEDConfluence of R & LHDCholecystostomy with drainageN6MMVC(1) Bile duct leak at unknown site (2) LHD transectionDrains, primary repair over catheters, common duct tube, cholecystostomy,
feeding jejunostomyN1967, Noone [52]8MBicyclist falling onto handle bars(1) Lacerated R liver lobe (2) R & LHD disruptionPrimary anastomosis over catheters, cholecystostomy, drainsN1967, Sewell [53]14FMVCLHD avulsionLHD ligation, T tubeN1968, Maier [26]37MMCCRHD laceration (lateral)Repair over T tubeN1969, Haynes [54]N/AN/ABlunt abdominal trauma(1) R hepatic lobe laceration (2) LHD lacerationDrains, Primary ductal repairN1969, Estrada [55]26MMVCLHD laceration, posteriorRepair over T-tubeN1972, Zollinger [32]21FMVCR & LHD lacerationRepair over catheters, drainN48MMVCLHD avulsionDrains, RHD anastomoses to R-en-Y, stent, T-tubeN1974, Williams [56]3MMV versus PEDLHD avulsionEnd-to end anastomosisN1980, McFadden [28]31MMVCCombined R & LHDHepaticojejunostomyN1985, Jones [21]37MMCCConfluence of R & LHDR & L hepaticojejunostomyN1985, Michelassi [2]9MPatient denied any traumaLHD partially severedSuture repair. Drains. T-tubeN1987, Salam [19]17FMVCRHD lacerationSuture repairN1991, Dawson [3]17MCrushed by a logLHD avulsion, 3 cm tear across the junction of CHD and RHDSuture repair of RHD & CHD, R-en-Y hepaticojejunostomyN1991, Monk [34]14MBicycle crashLHD disruption (noncircumferential)Vein patch cholangioplasty with stent & drainageN1992, Muin [24]45MHit by falling tree branchConfluence of R & LHD (superiorly)R-en-Y hepaticojejunostomyN1993, Hills [30]18FMVCLHD injuryPercutaneous stentN15FMVCLHD injuryCholecystectomy, omental plugN16MMCCLHD injuryPartial liver resectionN1993, Moulton [10]5FMV versus PEDLHD tearStent placed via ERCPY1994, Brenneman [57]36MMCCLHD injuryRepair over T-tubeN1995, Gerndt [8]20MMVCL & RHD injuryPrimary repair. Drains.Y19MMVCLHD transectionDrains, R-en-Y hepaticojejunostomyN21MMVC(1) L & RHD injury near bifurcation (2) Transected lateral LHDERCP with stenting of R ductal systemY1995, Baer et al. [58]31MFell 10 metersLHD injuryDrainsN1995, Poli [9]12FKicked by a horseConfluence of R & LHD, CHD tearNasobiliary and percutaneous drainsY1996, Eid [4]21MCrushed by a containerERCP, LHD tearStenting via ERCPY1996, Hayakawa et al. [59]21MMCCLHD transectionPrimary repair over stentN1996, Sharma [5]35MFall from a heightRHD bile leakEndoscopic papillotomyY1997, Sakamoto [17]23MFall from ladderConfluence of R & LHDDrains at laparotomyN22MMV versus PEDLHD lacerationStent at laparotomyN1999, Arkovitz [6]7MMV versus PED(1) Complete avulsion of LHD (2) Attenuated RHDStenting, Drainage, L and R hepaticojejunostomiesY1999, Simstein [60]21MPinned under automobile(1) Injury at R & LHD confluence (2) RHD disruptionIntraoperative placement of drainsY1999, Bin Yahib et al. [14]3MMV versus PEDTorn R & LHDPrimary repair of R & LHD, R-en-Y hepaticojejunostomyY2000, Sanders [7]11MAll terrain vehicle accidentLHD injuryCholecystostomy tube, Jackson-Pratt™ drainsY2001, D'Amours [61]34MFall 9 metersR & LHD injuryERCP. Sphincterotomy and stentingY41MMVCLHD injuryDrains, ERCP with sphincterotomy and double pigtail stentY2001, Nuzzo [29]42FMVC(1) LHD transection (2) LHD strictureLHD end-to-end anastomosis. ERCP stenting and serial dilations
of LHD strictureY2001, Rodriguez-Montes [25]N/AN/AN/ARHD lacerationT-tube, RHD R-en-Y choledochojejunostomyNN/AMN/A(1) LHD transection (2) RHD stricture (delayed finding)Primary repair of LHD transection. Endoscopic stenting od RHD.Y2002, Sharpe [11]11MSledding accidentTransected LHDPercutaneous drainage of subhepatic space and transampullary stentY2003, Nathan [16]17MMVCConfluence of R & LHDIntraoperative placement of drains. ERCP with stent placementY2006, Almaramhi [43]6FMVCRHDERCP with stent placement and percutaneous drainageY6MMVCRHDERCP with stent placement and percutaneous drainageYCurrent case26MMCC(1) Confluence of R & LHD (2) LHD injuryExternal drainage, ERCP with sphincterotomy and CBD stentingYAbbreviations: N/A = Data Not Available; ERCP = Endoscopic retrograde cholangiopancreatography; CHD = Common hepatic duct; LHD = Left hepatic Duct; RHD = Right hepatic duct; R
& LHD = Right and Left Hepatic Ducts; R = Right; L = Left; R-en-Y =
Roux-en-Y; MVC = Motor vehicle crash; MV versus PED = Motor vehicle versus pedestrian.Endoscopic retrograde cholangiopancreatography has been successfully utilized in treatment
of hepatic ductal injuries both as a primary treatment modality and as an
adjunct to surgery, with some of the patients having previously undergone at
least one laparotomy [43]. Indeed, it may be that ERCP is the optimal choice
for treatment of bile duct injuries regardless of whether the patient underwent
recent surgery. One might speculate that performing a potentially therapeutic
ERCP for EHDIs in the setting of a recent laparotomy may actually constitute the
safest initial approach, given the possibility of postoperative adhesions and
the risk of bile duct devascularization due to surgical dissection. In fact, at
least one reported death was due to massive hepatic bleeding encountered during
an operative attempt at repair of RHD stricture [25].
The usefulness of ERCP in such setting is exemplified by the current
case, where the diagnosis of EHDI was not made until after the initial trauma
laparotomy, and reoperation to restore biliary continuity would have been very
difficult and risky. Not only did ERCP confirm the diagnosis of EHDIs and
facilitated definitive treatment of the injury, but also indirectly pointed to
the potential cause of surgical failure if operative management was attempted—small transected LHD that could not be traversed with the guidewire. Because surgical repair of small extrahepatic
bile ducts can be exceedingly difficult [62, 63], a topic beyond the scope of this discussion, ERCP may
be the preferred treatment method in this scenario as well.In majority of reported cases, including the current report, ERCP-facilitated ductal
stenting was performed [8, 10, 16, 43]. In fact, ERCP with sphincterotomy and
drainage avoids surgery in 70–90% of iatrogenic ductal injuries by reducing the
biliary intraductal pressure gradient [42]. Percutaneous drainage of any bile
collections should be performed as well, with prophylactic drainage suggested
by some even in the absence of an active bile leak  [43]. In the current case,
while a CT scan revealed a fluid collection, it failed to fully delineate the
anatomic injury. Much like in other reports of both traumatic and nontraumatic
bile duct injuries, ERCP was used to define the anatomy of the injury and to
treat it definitively with biliary decompression and stenting  [12, 21–23]. It
is likely that endoscopic stenting provides similar effects to operative anastomotic
stenting via biliary decompression and by potentially decreasing stricturing
through limiting collagen contraction [25]. Failures of
endoscopic therapy are rare, and have been associated with leaks from noncommunicating or
anatomically “excluded” ductal injuries [42].A recent review of EHDIs with an average followup period of 26 months
reported an increasing use of ERCP in both diagnostic and therapeutic
capacities [12]. Among patients treated primarily with ERCP, 9/19 had followup studies [4, 8, 11, 12, 16, 43, 61]. Among these patients, 8/9 showed resolution of biliary leak and no evidence of biliary stricture [4, 8, 11, 16, 43, 61] and
1/9 showed nonvisualization of the previously injured LHD [11].
As more long-term followup data confirm good clinical results, the ERCP
will likely take the dominant position as the initial treatment of choice for EHDIs.Complication rates associated with ERCP use in the setting of bile duct injuries are low
(<10%) [7]. Reported post-ERCP complications include
pancreatitis and persistent hyperamylasemia [10, 14]. In addition, stent migration or clogging may occur [43]. In adult patients, stent migration has been noted in upto 5% of patients [10]. Stent clogging is more common, with upto 30% incidence
within 3 months of stent placement [10]. There is also a low risk of infection
and bleeding related to percutaneous catheter drainage of EHDI-associated bile
collections [43]. Ductal stenosis at the site of injury is an important late
complication of ERCP and stenting. It has been postulated that prolonged
stenting (up to 12 months), sometimes with multiple stents, may provide both
treatment and prevent further stricturing [42].After a literature search was conducted, Table1 was
constructed to summarize all known cases of EHDIs from 1952 to 2006. Based on our case as well as the
literature search, proposed diagnostic (Figure 4) and treatment
(Figure 5) algorithms were designed in order to systematize clinical
decision-making in the setting of EHDIs. These algorithms reflect the evolving role of ERCP in treatment EHDIs.Figure 4
Proposed diagnostic algorithm for extrahepatic hepatic ductal injuries. ERCP =
endoscopic retrograde cholangiopancreatography. HIDA = nuclear biliary scan.Figure 5
Proposed treatment algorithm for extrahepatic hepatic ductal injuries.


## 5. Conclusions

Because the clinical presentation is often insidious, EHDIs are
frequently missed on the initial clinical evaluation. The management of
EHDIs has changed over the last decade. Availability of ERCP presented
trauma surgeons with a new diagnostic and therapeutic alternative. With
good short-term results of ERCP being well established, a growing body of
data is demonstrating equally good results on long-term followup. We
recommend the use of diagnostic and treatment algorithms to standardize
care, decrease diagnostic delay, and potentially improve outcomes.



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