Intrahepatic biliary lesions following blunt liver trauma in children--is nonoperative management or conservative operative treatment always safe?

Nonoperative management of blunt liver injuries has become standard care for children, in the absence of hemodynamic instability. However, attention has to be drawn to biliary complications which can manifest themselves after a latent period, even in the presence of rupture of main biliary ducts. Peripheral bile duct lesions are easily treated by wide drainage. However, the extremely rare intrahepatic main bile duct lesions require other treatments. We report 2 cases of severe liver trauma associated with intrahepatic bile duct lesions: the first, managed nonoperatively, developed biliary peritonitis on day 21. Lesions of the main right biliary ducts were discovered. Because the right liver vascularization was not compromised, an intrahepatic biliary reconstruction was performed through a large hepatotomy according to the functional anatomy. The second child, who had an emergency laparotomy on admission, suffered nevertheless from a bilioma, drained on day 38. Because of increasing daily bile flow through the drain a second laparotomy was performed that demonstrated a biliary leak from a main segmental duct. Resection of the segment cured the patient. These two cases illustrate the occurrence of intrahepatic main bile duct lesions, clinically apparent after a latent period, following blunt trauma of the liver treated by nonsurgical or conservative surgical management. Intrahepatic biliary reconstruction is an alternative to liver resection when viable vascularization of the involved sector justifies its preservation.