A 21-Year-Old Man with Previous History of Gastrectomy, Cholecystectomy, and Biliary Stenting with Failed Non-Operative Management of Blunt Trauma to the Liver Due to Traumatic Stent Perforation

Background

Management of blunt solid organ injury is based on patient hemodynamic condition and the presence of other associated injuries. Patients who are stable without any other lesions that require surgical intervention can be managed initially in a monitored setting with close clinical follow-up and serial hemoglobin checks, in order to identify those that require further interventions [1–3]. Hepatic trauma is one of the most common abdominal lesions in severely injured patients. Until about 30 years ago, most of these lesions were managed surgically. With damage control resuscitation strategies, advanced endovascular interventions, and high-resolution imaging, non-operative management (NOM) for select patients is being employed with increasing success, independent of the grade of the injury. The rate of failure for NOM for blunt liver trauma correlates with the severity of the injury is 3–15% [4]. According to Brooks et al [5], one of the main reasons for the increasing success of NOM is related to the use of whole-body CT scans that currently have a reduced rate of missing injuries as low as 2.4%, increasing the capacity to define which patients will benefit from angiography and embolizations. High-grade injuries (IV and V) and blood transfusion of more than 4 units are considered risk factors for NOM failure [5]. Barbier et al [6] reported a success rate of 96% for blunt liver trauma and recommended the use of CT scans for follow-up, especially for lesions greater than grade 3, considering that the majority of the cases who developed complications presented with high-grade injuries. They found that liver segments I, IV, and IX were most affected by biliary complications (eg, biloma, biliary peritonitis, and gallbladder injuries). We report the case of a 21-year-old man with a previous history of gastrectomy, cholecystectomy, and biliary stenting with failed non-operative management of blunt trauma to the liver, following a motor vehicle crash, due to traumatic stent perforation.

Case Report

A 21-year-old man was transported by Emergency Medical Services (EMS) to our facility 30 minutes after a frontal impact motor vehicle crash with airbag deployment. The patient reported driving at low speed (30 km/h) and was wearing a seat belt. He presented with a main concern of chest and abdominal pain and reported no loss of consciousness. On primary survey, he was hemodynamically normal and only had abdominal pain. His abdomen was non-distended, without peritonitis, and a Focused-Assessment Sonography in Trauma (FAST) scan was positive for fluid in the right hepatorenal space. A secondary survey revealed tenderness to the right chest wall, right flank, and right upper quadrant, without guarding.

Trauma whole-body computed tomography (CT) showed the following: grade 3 liver injury with lacerations to segments 1 and 4 without contrast pooling or extravasation; a common bile duct (CBD) stent; minimal perihepatic and subhepatic fluid; evidence of gastric sleeve surgery; soft-tissue fullness between the stomach and liver suggestive of hematoma; minimal perisplenic fluid with no obvious splenic injury; and relatively dense free fluid in the pelvic cavity (Figure 1). Initial laboratorial results revealed Hb / Ht 141 g/L / 0.41 L/L (132–173 / 0.39–0.49), arterial blood gas normal, lactate 1.9 mmol/L, base excess −1.2 mmol/L, PT 14.4 s, INR 1.11, APTT 28.3 (28.6–38.2), and fibrinogen 3.93 g/L.

According to the patient, he had a sleeve gastrectomy in 2021, and laparoscopic cholecystectomy with subsequent endoscopic retrograde cholangio-pancreatography (ERCP) and plastic stent placement in 2022 due to a residual stone in the common bile duct (CBD) in another institution. He did not follow up for biliary stent removal.

The patient was admitted to the Surgical Intensive Care Unit (SICU) for close hemodynamic monitoring and serial hemoglobin checks. On serial abdominal exams, approximately 18 hours after admission, the patient was noted to have progressively worsening abdominal pain and increasing heart rate with tachycardia not responding to fluid resuscitation, but was normotensive. A repeat CT abdomen confirmed the previous findings, but also noted the presence of an extraluminal gas bubble in the paraduodenal area (Figure 2). Based on the clinical changes and the CT imaging result, he was taken for exploratory laparotomy.

At laparotomy, 1.5 L of hemoperitoneum was evacuated. Liver injuries were examined, and no active bleeding was identified. We observed minimal bile leaking (approximately 20 mL) from segment 1. The site of leakage was closed with 3-0 polypropylene sutures and Surgicel® was applied. We also noted bile surrounding the distal part of the stomach, with no obvious perforation of the stomach or duodenum. Intraoperative gastroduodenoscopy was done and no mucosal defects were identified, but a biliary stent was noted exiting the papilla (Figure 3). The biliary stent was palpated in the main biliary duct, and at the level of the hilum it was traced towards the left hepatic duct, where the distal stent tip was found exiting the left hepatic duct with a mature fibrous tract around the stent (Figure 4). The stent was retracted from the left hepatic duct about 2.5 cm, divided, and the intraluminal portion was allowed to retract (Figure 5). The anterior wall of the tract was closed with a single figure-eight 3-0 polypropylene suture (Figure 6). A multi-channel drain was placed next to segment 1 and the abdomen was closed.

The patient recovered in the ICU postoperatively, and on postoperative day #1 required no vasoactive medications, was extubated, and diet was started. On post operative day #5, he underwent ERCP for removal of the remaining stent; cholangiogram showed no extravasation and normal caliber of the bile ducts (Figure 7). Based on these findings, the stent was not replaced.

The postoperative course was complicated by bacteremia, surgical site infections (deep and superficial), fascial dehiscence, and urinary tract infection. The following sites and organisms were cultured: Intraperitoneal fluid from first laparotomy - Aeromonas jandaei and Citrobacter freundii; wound - Aeromonas hydrophila, Aeromonas sobria, Enterobacter cloacae, Enterococcus faecalis, Klebsiella oxytoca, Klebsiella pneumoniae, and Pseudomonas aeruginosa; blood – Aeromonas hydrophila; urine – Candida tropicalis. Infectious Disease was consulted and antibiotics were tailored to culture and sensitivity data. The deep-space abscess was managed by placement of 2 percutaneous drains, and the surgical wound infection and subsequent fascial dehiscence were managed operatively with interrupted suture fascial closure and application of negative-pressure wound therapy. The patient was discharged home in good condition after 37 days.

Discussion

In treating this uncommon case, we learned that it is essential for surgeons to know the previous medical history of patients when the case is managed, at least initially, as a non-operative case. The presence of biliary stents, which can result in traumatic biliary perforation with an intact liver, must always be considered, and a high index of suspicious must be present whenever there is free fluid and/or air in the cavity. The liver is the most commonly injured organ in blunt trauma, with an estimated incidence of about 13.9 per 100 000 population [7]. In the last 2 decades, management of liver injury has trended toward NOM. Proliferation and improvement in CT imaging allowed proper classification of liver injuries and development of modern treatment algorithms [8]. While the majority of patients admitted with minor or moderate liver injuries (World Society of Emergency Surgery -WSES and American Association for the Surgery of Trauma -AAST-OIS I, II, and III) are successfully treated by NOM, some patients, like the one presented in this report with a grade III injury, may still have treatment failure, and the decision to convert from NOM to a more aggressive approach must be based on the clinical parameters, patient stability, and available imaging. NOM in patients sustaining more severe injuries (WSES and AAST-OIS IV and V) should be considered only in select settings with immediate availability of trained trauma surgeons, operating rooms, ICU, access to intervention radiology, and robust blood banking [2,9].

Failure of NOM is usually defined as the need for surgical exploration due to hemodynamic instability, progressive fall of hemoglobin levels despite angioembolization, peritonitis, or missed abdominal injuries requiring surgical intervention. In our case, NOM was abandoned due to abdominal distension, worsening diffuse abdominal pain, and tachycardia refractory to proper volume replacement. According to the literature, the main causes of conversion to operative treatment are related to concomitant bowel and splenic injuries; only one-third are related to the liver injury. Although the success rates for high-grade liver injuries will be lower, it is well-established that NOM of stable patients is a reasonable option in well-organized trauma centers [7,9].

Ghosh et al [10] recently reported a case of extrahepatic duct injury after blunt trauma that failed to respond to NOM after 2 days in the ICU due to peritonitis. The patient underwent laparotomy and the injury to the main bile duct was not identified during the procedure. The patient was treated by ERCP and stent placement within the common hepatic duct and the right hepatic duct. In 2012, Balzarotti et al [11] described a patient with isolated extrahepatic bile duct rupture due to blunt trauma who presented with progressive abdominal pain, who after 7 days of NOM underwent a diagnostic laparoscopy that was negative for bile duct injuries, and after 11 days of admission was re-explored laparoscopically due to clinical deterioration. At the second procedure, about 1 L of bile was identified, surgery was converted to open, intraoperative cholangiogram was performed combined with cholecystectomy, and, again, no fistulas were identified. The patient’s bile was drained and due to deterioration of her clinical status was transferred to a specialized hepatobiliary unit. During her third operation after a transcystic cholangiogram, a fistula was identified at the left posterolateral aspect of the common bile duct, and a T-tube was placed combined with a subhepatic drainage. After 30 days, the T-tube was removed and the patient recovered from the procedure. These 2 rare cases clearly demonstrate that isolated extrahepatic bile duct injuries are not only uncommon, but also can be potentially dangerous for the patients. All these cases had a late presentation, as in our patient, demonstrating that extravasation of bile to the cavity does not provide an early clinical alert regarding the physical exam and the location of the trauma as well as its mechanism, and should lead the surgical team to have a high index of suspicion, especially in upper-right quadrant impact due to blunt trauma.

Bile duct injuries are very rare. After laparoscopic cholecystectomies, bile duct injury is a well-known complication, with an incidence of around 0.1–0.6% [12]. Obstructive jaundice after laparoscopic cholecystectomy is usually related to retained stones in the common bile duct or bile duct injuries, and its treatment requires an endoscopic approach to remove the obstructive factor. In this case, we presumed that the patient had a retained stone, and a plastic biliary stent was placed in the CBD approximately 10 months prior to his motor vehicle crash. Biliary stents are made of plastic or metal, and for placement of plastic stents a biliary sphincterotomy is usually required. According to Meseeha et al [13], another potential indication for the placement of a plastic stent is biliary leaks after the surgical procedure. Our patient did not mention any complications related to the ERCP performed at the outside the hospital, but the why the stent was not removed was unclear to our team and the patient.

The most frequently reported complications related to biliary stents are stent fracture, migration, obstruction, tumor in-growth, sludge in the stent, biliary obstruction, cholecystitis, cholangitis, liver abscess, pancreatitis, hemorrhage, and perforation of the duodenum. Complications occur in approximately 5–10% of cases, producing morbidity and occasional mortality [14]. Sohn et al reported that the most common complication of retained long-term plastic biliary stents was acute cholangitis (94%) associated with CBD stones, which occurred in 92% of patients in a series of 38 patients with stents in place for more than 12 months [15].

According to Bagul et al [16], most complications related to perforations occur due to use of straight stents and usually perforates the small bowel with potential to injure the colon. Our patient had had perforation of the left hepatic duct without migration of the stent to the duodenum. The same authors reported that perforation of the biliary tree secondary to stent insertion is exceptionally rare. The cause of a perforation may be the phenomena of impaction, erosion, and perforation of the biliary tree after deployment of plastic biliary stents to treat CBD stones or bile duct injuries [16].

Sinha et al [17] described 3 cases of biliary perforation by stents identified during laparoscopic cholecystectomies 6 weeks, 3 months, and 5 months after endoscopic placement. It is possible that the observed phenomenon was related to the shape of the pigtail stent, with impaction of the proximal extremity against the CBD wall. Pigtail stents are purported to offer greater anchorage (and thus resistance to migration) within the CBD, although this advantage is offset by reduced bile flow rates compared with straight stents. In our case, the patient had a pigtail stent placed inside the bile ducts. We hypothesized that the patient did not present with symptoms of bile leak prior to laparoscopic cholecystectomy because of the combined effect of sphincterotomy and bile flow through the stent reduced outflow resistance through the CBD and into the duodenum [12]. The same rational can help to explain the fact that our patient remained asymptomatic after the stent placement and only presented with symptoms, likely after the blunt abdominal trauma disrupted adhesions around the tip of the catheter.

Endoscopic stenting has proven to be an effective temporary or definitive therapeutic option for both benign and malignant biliary obstructions and to manage bile duct injuries. Dundee et al [18] found that the most common plastic biliary stent complication is migration, and the possibility of perforations to the CBD must be kept in mind, as well as common hepatic duct and gallbladder injury. To the best of our knowledge, this is the first reported case of a perforation of the left hepatic duct by a stent after blunt abdominal trauma.

The removal of the stent and the surgical closure of its track are mandatory to fix the lesion and solve the problem. It can be achieved by a surgical procedure, as in the reported case, or by endoscopy if no formal indication to exploration is present. An endoscopic cholangiogram with or without placement of a new, properly positioned CBD stent are part of the treatment plan.

In retrospect, there may be a role for either magnetic resonance cholangio-pancreatography (MRCP) or a lower threshold for operative management in blunt injury trauma patients who present with biliary stents with associated findings of fluid near the portal structures.

Conclusions

Blunt trauma injury of the liver can be successfully managed conservatively. However, this case highlights the importance of knowledge of the patient’s medical history and the presence of biliary stents, which can result in traumatic biliary perforation with an intact liver, which requires treatment with a multidisciplinary approach.