Spontaneous perforation of the extrahepatic bile duct in infancy: report of two cases and literature review

Spontaneous biliary perforation in infancy: Management strategies and outcomes

PURPOSE

Infantile spontaneous biliary perforation is rare with variable management strategies ranging from nonoperative treatment to complex operations such as biliary-enteric reconstruction. Biliary fistula and portal vein thrombosis are known complications, though outcomes are poorly defined.

METHODS

We assessed the incidence of spontaneous biliary perforation in infants <1 year old using a population database. Next, we describe 4 patients treated at our institution and review all reported cases within the past 25 years.

RESULTS

The incidence of spontaneous biliary perforation is 1.5 in 1,000,000 live births. Over the past 25 years, 90 cases were reported, over half of which were initially managed with a surgical drainage procedure. The most common reason for failure of this strategy was CBD obstruction. Our 4 patients were successfully managed without biliary reconstruction despite 2 presenting with CBD obstruction. Reported complications occurred in 22% of patients, most frequently biliary fistula requiring delayed biliary reconstruction.

CONCLUSIONS

Surgical drainage is an effective method for treatment of infantile spontaneous biliary perforation; however a persistent biliary fistula should prompt evaluation for distal CBD obstruction. Though biliary-enteric anastomosis is the historic procedure of choice for persistent fistula, with improvements in endoscopic and percutaneous treatment, extensive biliary reconstruction may be avoided in the future.

Complex spontaneous bile duct perforation: an alternative approach to standard porta hepatis drainage therapy

INTRODUCTION

Spontaneous perforation of the bile duct (SPBD) is a rare abnormality of the extrahepatic biliary tree in infants. Limited porta hepatis exploration and drainage of the bile-soiled peritoneum are often sufficient treatment. Here, we describe three cases of SPBD, one of which required complex multi-disciplinary interventions for restoration of biliary continuity.

METHODS

Three infants with bilious ascites from spontaneous biliary perforation were reviewed. Metrics included age, presenting symptoms, diagnostic tests, interventions performed, and outcomes.

RESULTS

The presenting symptoms of all three infants were bilious ascites, sepsis, lethargy, anorexia, fever and persistent emesis. SPBD was confirmed pre-operatively by HIDA scan (hepatobiliary scintigraphy) in each case. Intra-operative, trans-cholecystic cholangiogram confirmed SBDP in two cases. Two of the infants were successfully treated with placement of a cholecystostomy tube and porta hepatis drains. The third infant, having failed multiple similar drainage procedures, required percutaneous transhepatic drainage of a persistent porta hepatis biloma. Ultimately percutaneous, transhepatic cannulation of the extra-hepatic biliary tree for prolonged stenting was required to successfully treat this biliary perforation.

CONCLUSION

Complex spontaneous biliary perforation may require extensive interventions if the perforation fails to resolve with standard porta hepatis drainage. Access of the biliary tree via Interventional Radiology procedures for complex biliary disease of this type is novel and presents an alternative to traditional open surgical treatment and control of spontaneous biliary perforations.