Traumatic bile duct injury

　　First, etiology

　　Traumatic bile duct injuries caused by external trauma are relatively rare, and the causes of injury are mostly blunt traumas such as crushing injuries, kicks, and blows to the upper abdomen, or penetrating injuries caused by sharp instruments such as stab wounds and bullet wounds. Bile duct injuries often accompany other organ injuries, especially liver rupture or injury to other structures in the porta hepatis, and may also be accompanied by injuries to the stomach and duodenum, pancreas, right kidney, and other organs. In particular, the complex injury at the junction of the bile duct and pancreatic duct behind the pancreatic head with the duodenum is extremely concealed, and careful exploration must be made during surgery. Occasionally, bile duct injuries may be caused by fractured ribs, and may not be accompanied by other organ injuries.

　　Second, pathogenesis

　　In traumatic bile duct injuries, the gallbladder is more likely to be affected than the bile duct, and most of the injuries are sharp penetrating injuries, while blunt injuries are rare. Extracorporeal bile duct injuries are generally divided into gallbladder injuries and bile duct injuries.

　　1. Injury to the gallbladder

　　(1) Rupture of the gallbladder: This is the most common injury, often caused by direct trauma. Such as gunshot wounds, stab wounds, traffic accidents, or direct blows, manifested as perforation and laceration of the gallbladder wall. The gallbladder filled with bile is more prone to rupture.

　　(2) Rupture of the gallbladder: Rapid deceleration injuries can produce strong shearing forces, to the extent that the gallbladder filled with bile is torn away from the gallbladder bed of the liver. If completely torn off, the gallbladder will be suspended on the gallbladder bed by the cystic duct and the cystic artery.

　　(3) Gallbladder contusion: Direct blunt compression can cause contusions of the gallbladder wall, manifested as ecchymosis, or the blood produced fills the entire sac. Minor lacerations can heal spontaneously, but severe traumatic hematomas of the gallbladder wall can affect local blood supply, leading to delayed gallbladder rupture.

　　(4) Cholecystitis: Hemorrhage accumulated in the gallbladder can block the cystic duct, thereby causing acute cholecystitis.

　　2, Bile duct injury

　　Data shows that the incidence of extrahepatic bile duct injury is in the order of common bile duct, right hepatic duct, and left hepatic duct. Since the common bile duct at the porta hepatis is curved and elastic, once there is a deceleration injury or compression injury in the upper right abdomen, it can cause the liver to suddenly move within the abdomen, generating a shearing force above the relatively fixed pancreas, making the rupture of the bile duct at the junction of the pancreas and duodenum the most common in blunt injuries.

　　According to the degree of injury, it is divided into the following types:

　　(1) Bile duct contusion: non-penetrating injury, without bile leakage.

　　(2) Simple bile duct injury: tangential injuries with wound length less than 50% of the circumference of the duct wall.

　　(3) Complex bile duct injury: including tangential injuries with wound length greater than 50% of the circumference of the duct wall, segmental defects in the bile duct wall, and complete贯通 injuries of the bile duct.

　　1, Gallbladder rupture:This is the most common injury, often caused by direct trauma. Such as gunshot wounds, stab wounds, traffic accidents, or direct blows, manifested as perforations and lacerations of the gallbladder wall. The gallbladder filled with bile is more prone to rupture.

　　2, Gallbladder tear:Rapid deceleration injuries can produce strong shearing forces, to the extent that the gallbladder filled with bile is torn off from the gallbladder bed of the liver. If completely torn off, the gallbladder will be suspended on the gallbladder bed by the cystic duct and cystic artery.

　　3, Gallbladder contusion:Direct blunt compression can cause contusions of the gallbladder wall, manifested as ecchymosis, or the blood produced fills the entire sac. Minor lacerations can heal spontaneously, but severe traumatic hematomas of the gallbladder wall can affect local blood supply, leading to delayed gallbladder rupture.

　　4, Cholecystitis:Hemorrhage accumulated in the gallbladder can block the cystic duct, thereby causing acute cholecystitis.

　　The main manifestation of bile duct rupture is the overflow of bile, which can be seen in the early stage of injury as the leakage of bile from the wound or cholecystitis, both of which are signs of bile duct injury. However, trauma is often a composite injury, especially in closed abdominal contusions, where the manifestation of bile duct injury is often concealed by significant symptoms such as shock, intra-abdominal hemorrhage, peritonitis, or fractures. Sometimes, when the bile duct pancreas segment is injured, bile may overflow into the peritoneum, and there is no free bile in the abdominal cavity, making it more likely to be missed during exploratory surgery. David reported that in cases of closed extrahepatic bile duct injury, more than 50% had missed diagnoses during surgery, even causing multiple operations. Therefore, in abdominal trauma surgery, when exploring the injury of intrahepatic and extrahepatic bile ducts, or even small tears in extrahepatic bile ducts or duodenal posterior wall tears, in complex situations with multiple injuries, as long as the condition allows, a thorough examination should be conducted.

　　The late symptoms of bile duct injury vary depending on the location, severity, and associated injuries of the bile duct injury, but the general manifestation is bile duct infection, bile duct stenosis obstructive jaundice, or bile duct fistula, etc. After other injuries are treated, the symptoms of bile duct trauma are relatively apparent and prominent, and the diagnosis is relatively clear.

　　Prevention:Traumatic bile duct injury is actually rare, and the causes of injury are mostly blunt trauma such as crushing, kicking, and beating in the upper abdomen, or piercing injuries such as stab wounds and bullet wounds. Therefore, avoiding the above external causes is the main way to prevent it.

　　1, There may be elevated serum bilirubin, hypoalbuminemia, and increased white blood cell count.

　　2, Timely abdominal trial puncture should be performed for closed abdominal injuries, and if bile is found mixed in the peritoneal fluid, it has diagnostic significance. Preoperative imaging examinations, especially ultrasound and CT scans, show abnormalities in the liver and biliary system, peritoneal fluid around the gallbladder and bile ducts, selective angiography, and 99mTcIDA radionuclide scanning have high value for diagnosing liver injury and bile leakage.

　　Firstly, what foods are good for the body for traumatic bile duct injury:

　　1, It is recommended to eat lean meat and freshwater fish, as fish is low in fat but contains high-quality protein. In addition, meats that are low in fat and high in protein include: freshwater shrimps, chicken, and rabbit meat.

　　2, It is best to cook with vegetable oil, such as corn oil, peanut oil, etc. The main cooking methods are stewing, braising, and steaming, with lightness as the main route. It is best to drink skim milk for dairy drinks.

　　3, Fruits are best consumed with vitamin A: oranges, almonds, bananas, apples, walnuts, peanuts, hawthorn, and umeboshi. Apple juice, pear juice, and beetroot juice can be consumed.

　　4, Whole grains, fresh vegetables, garlic, onions, mushrooms, black fungus, corn silk, and bran can lower cholesterol and are recommended for consumption. Eat vegetables rich in vitamin A or vitamin K: such as broccoli, which is rich in vitamin K. Vegetables rich in vitamin A include: carrots, tomatoes, spinach, lettuce, soybeans, and green peas.

　　Secondly, what foods should be avoided for traumatic bile duct injury:

　　1, Do not eat foods with high cholesterol, such as animal hearts, livers, brains, intestines, as well as yolks, salted eggs, fish roe, and crab roe. It is recommended to eat less high-fat meats: such as fatty meat. At the same time, seafood should be eaten less.

　　2, Avoid eating fruits that have not been cleaned thoroughly to prevent ingesting worm eggs. Fried potato chips, fried bananas, and other fried fruits should not be eaten.

　　3, Do not eat vegetables that are not clean, contain pesticide residues, or have worm eggs, and eat less刺激性 vegetables: such as rapeseed. It is recommended to eat less: such as soy milk, bean cakes, etc.

　　First, treatment

　　The primary and direct goal of surgical treatment for traumatic extrahepatic bile duct injury is to stop bleeding caused by concurrent abdominal injuries, followed by repairing the damaged bile duct. Once bleeding during exploration is controlled, the gallbladder and common bile duct should be carefully explored. Subcutaneous hematomas, small blood clots, and other hematomas under the serosa of the porta hepatis, para-duodenal, and hepatoduodenal ligament should be considered as possible extrahepatic bile duct injuries. The hematomas should be incised, and the accumulated blood should be aspirated before further exploration. Sometimes, to facilitate exploration, the lateral peritoneum of the duodenum needs to be incised to turn the pancreatic head medially and inferiorly. If bile contamination of the hepatoduodenal ligament is found, it often indicates extrahepatic bile duct injury. If no injury is found during exploration, water-soluble contrast agent can be used for intraoperative bile duct imaging. After confirming the diagnosis, the treatment method is determined based on the location and nature of the injury.

　　1. The treatment of gallbladder injury generally involves cholecystectomy, and sometimes cholecystostomy or gallbladder repair may be performed. Regardless of the surgical method used, it is routine to place an abdominal drain below the liver. Sutures on the gallbladder wall may cause secondary gallstones, and bile leakage may occur at the suture site, therefore, cholecystectomy is the best treatment option. However, it should not be used in the following situations:

　　(1) Patients with multiple trauma who have severe coagulation mechanism disorders or liver cirrhosis.

　　(2) Gallbladder injury is small, but combined with multiple injuries leading to shock and unstable hemodynamics.

　　(3) Patients with mild gallbladder injury may not require surgical treatment or can be cured.

　　2. The treatment of bile duct injury primarily depends on the patient's overall condition. Repairing the damaged bile duct, internal support, and biliary decompression and drainage are the three key elements of successful treatment. Once damage is found, definitive surgical treatment can be performed in the operating room for patients with stable hemodynamics and clean surgical fields. For patients with poor general condition, long injury time, severe abdominal contamination, or insufficient technical strength to complete primary suture, it is best to perform proximal bile duct external drainage first and schedule a secondary operation. Forcing primary repair often leads to severe complications.

　　(1) Bile duct lacerations less than 50% of the circumference of the wall: Treatment should include suturing the damaged wall, placing a T-tube, and external drainage. When placing the T-tube, a new incision should be made above or below the injury site, with the long arm of the T-tube placed in the sutured area for support. The T-tube is generally placed for 6 months to 1 year. Although there is no definitive evidence that T-tube placement is necessary after bile duct injury repair, the T-tube can alleviate biliary pressure due to postoperative biliary edema. In addition, the T-tube can facilitate postoperative common bile duct imaging. Therefore, it is routine to place a T-tube in patients undergoing bile duct repair surgery. When encountering very thin bile ducts, a urinary catheter can be used instead of a T-tube.

　　(2) Partial or minor damage to the bile duct, with intact connections, may be treated with options such as umbilical vein, gallbladder, vascularized gastric serosal flap, or ileal segment repair, along with internal support. Due to the thin caliber of the bile duct, meticulous suture with fine needles and threads is required, and internal support is needed for 3 to 6 months. In cases with severe local infection and prolonged bile leakage, the support time may be extended.

　　(3) Complex bile duct injuries: Generally, bile-enteric anastomosis and external drainage are used. For patients with partial defects in the bile duct wall, penetrating wounds, and wall injuries greater than 50%, in-situ suture or in-situ anastomosis is performed, and the incidence of long-term bile duct stricture is only 5%, with good results. For bile-enteric anastomosis with external drainage, the surgery should follow the following basic principles:

　　① Thorough debridement;

　　② Thorough dissection;

　　③ Tension-free reconstruction;

　　④ Single-layer mucosal-to-mucosal anastomosis;

　　⑤ Placement of stent and drainage.

　　(4) There are generally 4 types of bile-enteric anastomosis:

　　① Hepatic duct jejunostomy and cholecystectomy: It is suitable for complex common hepatic duct injuries. If the common hepatic duct is widely injured, it is necessary to use a blunt technique to dissect and separate the liver parenchyma, expose and identify the left hepatic duct and the right hepatic duct. Suture the left and right hepatic ducts to form a common channel, and then anastomose with the jejunum.

　　② Common bile duct jejunostomy: It is suitable for complex common bile duct injuries and has a definite effect, and it is currently used the most. Whether it is common bile duct jejunostomy or hepatic duct jejunostomy, Roux-en-Y anastomosis is the best choice. Generally, 5-0 sutures are used for single-layer anastomosis. With the improvement of anastomotic technology, anastomotic fistula has become rare.

　　③ Common bile duct duodenal anastomosis: This is commonly used for distal common bile duct injuries, but this method is usually not recommended. Because if bile leakage occurs, it can cause serious duodenal wall leakage. Moreover, when the common bile duct is small or varies, the operation is more difficult.

　　④ Cholecystojejunostomy and common bile duct ligation: This can be applied when there is damage to the distal common bile duct, but it is not recommended. Because when ligating the common bile duct, it is sometimes careless to ligate the normal cystic duct, causing an anastomosis without function, and it is generally not easy to be discovered during surgery. When jaundice occurs after surgery and requires reoperation, the surgery will be more complex.

　　II. Prognosis

　　The mortality rate of extrahepatic bile duct injury is related to the type of associated injury. Patients with large vessel and nerve injuries have a high mortality rate. The greatest risk of bile duct injury is the missed diagnosis of bile duct injury and the attempt to perform primary in-situ repair for complex bile duct injuries.