A retrospective clinical study was performed to evaluate the etiology, incidence, diagnosis, management and outcome of patients presenting with
surgical injury to the biliary tract. 4 boys were treated for operative biliary tract
injuries between 1970 and 1997. This number represents less than 0.03% of all patients who underwent
laparotomy in our unit during the same period. The mean age of the patients at presentation was 7.5 +/- 3 (range, 4 to 10 years). Accidental
ligation of choledochus (n = 2), vascular insult of the biliary tract (n = 1) and
formalin toxicity (n = 1) were the causes of
injuries. The latter presented with
caustic sclerosing cholangitis and biliocutaneous
fistula while obstructive
cholangitis (n = 2) and
jaundice (n = 1) were noted in the remaining patients. The duration between
surgical injury and presentation ranged from 6 to 125 days. All patients presented with elevated levels of
transaminases,
alkaline phosphatase and
bilirubin. Ultrasonography, percutaneous transhepatic cholangiography and biliary drainage
catheter placement were performed in all patients to visualize the extent of injury and to provide better patient status for operation. Biliary
stent application provided temporary relief of obstruction in one patient, but all patients required surgical treatment subsequently. Roux-en-Y hepaticojejunostomy (n = 3), and
choledochoduodenostomy (n = 1) were the operative procedures. No complications were encountered in the short and long-term follow-up. Our experience revealed that surgical biliary tract
injuries have special features that warrant consideration with respect to prevention and management in children. They may be caused by partial or complete transection,
suture ligation,
clip application or vascular insult and can be avoided by adequate exposure, accurate gentle dissection, use of
hemostatic clips rather than clamps and ties, and the liberal use of operative cholangiography. The presenting clinical picture depends on the cause, extent and duration of the
injuries. Preoperative detailed evaluation of the hepatobiliary system by radiological and endoscopic means is mandatory for successful treatment. Percutaneous and/or endoscopic techniques can be employed in selected cases, but if these fail or can not be done, open surgical techniques should be performed without hesitation as
delayed treatment results in
biliary cirrhosis and
hepatic failure. Excision of excessive
scar tissue at the biliary tract and portal hilus, constructing the widest possible stoma, obtaining mucosa to mucosa approximation around 360 degrees, enduring a good blood supply to the anastomotic line and avoiding tension on the anastomosis are mainstays of successful surgery. Thus, reconstructive biliary tract surgery should be considered as a specialized procedure and should be performed by skillful and experienced hands.