Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
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Lucknow
On Sep 2018




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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Case report
Year : 2012 | Month : August | Volume : 6 | Issue : 6 | Page : 1054 - 1055

Avulsion of the Common Bile Duct from the Duodenum: A Case Report

S.N. Shirbur, B.V. Goudar, Vrushab Patil, Md. Muzamil Pasha, Chethan V.N.

1. Professor 2. Associate Professor 3. Assistant Professor 4. Post Graduate Student 5. Post Graduate Student

Correspondence Address :
Dr. S.N. Shirbur
Dept of Surgery, SN Medical College & HSK Hospital,
Navanagar, Bagalkot, India - 587102.
Phone: 9448972509; E-mail: dr.shirbur.s@gmail.com

Abstract

Rupture of the extrahepatic bile duct due to blunt trauma abdomen is an infrequently encountered condition which will tax ingenuity of the surgeon. Our aim here is to highlight one such unique injury to common bile duct and outline appropriate method of management. The complexity of injury is increased by the degree of involvement of duodenal wall, pancreatic duct and pancreas. Injuries that include ampullary area are rare, therefore require special consideration. Case report demonstrates specific injury to common bile duct and duodenal wall without injury to pancreatic duct.

Keywords

Traumatic rupture of the common bile duct, Avulsion of the common bile duct

How to cite this article :

S.N. Shirbur, B.V. Goudar, Vrushab Patil, Md. Muzamil Pasha, Chethan V.N.. AVULSION OF THE COMMON BILE DUCT FROM THE DUODENUM: A CASE REPORT. Journal of Clinical and Diagnostic Research [serial online] 2012 August [cited: 2018 Oct 22 ]; 6:1054-1055. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2012&month=August&volume=6&issue=6&page=1054-1055&id=2339

Introduction
The rupture of the extra hepatic ducts by blunt trauma is an infrequent and serious lesion. Mason (1), in an excellent review article in 1954, noted that there were “less than 100 cases which were recorded in the last century”. Hicken (2), in 1948 stated, “the traumatic rupture of the common bile duct occurs very infrequently and it is usually fatal”. Numerous individual case reports of laceration of either or both the hepatic ducts or the common bile duct have appeared (3),(4),(5),(6),(7),(8),(9). A careful search in the literature has however revealed only one case report on the complete severance of the common bile duct (CBD). The complexity of these injuries is increased by the degree of involvement of the duodenal wall and the main pancreatic duct. The injuries that include the ampullary area are rare, and they therefore require special consideration.

Case Report

A 46-year old male agriculturist was admitted with a history of pain abdomen and vomiting, following blunt trauma abdomen. He was attacked by a wild boar while he was working in the field. As a result of this, he sustained blunt trauma in the upper abdomen. On examination, he was found to be febrile (99.4ºF), his pulse was 100/min and he had a systolic blood pressure of 90 mm/hg. He had generalized tenderness over the abdomen with guarding, rigidity and sluggish bowel sounds which were suggestive of generalised peritonitis. Following resuscitation, the patient was subjected to investigations. The initial laboratory data showed Hb-12.9%, TLC-7600/cu.mm with 80% PMNLs and RBC-4.3 million/cu.mm. He had raised serum bilirubin-4mg% and raised SGOT and SGPT values. The serum amylase value was 542 mg%. His renal function tests were normal. His CT scan showed an intra-peritoneal collection (haemoperitonium) without any injury to the liver, spleen or gut. On exploratory laparotomy, his peritoneal cavity was found to contain bile stained fluid and blood. Since the presence of bilious fluid in the peritoneal cavity points to injury to the biliary system or gut, a thorough search for an injury to the gall bladder or the CBD was carried out by mobilizing the transverse colon and by kocherizing the duodenum. The patient had an avulsion injury to the CBD which was detected, as there was bile leak from the CBD and theduodenal opening. Without much effort, the CBD was mobilized and an end to end anastomosis was performed to the duodenum after keeping a No.5 infant feeding tube as a stent. However, the contrast study was not performed due to the emergency situation. The patient made a remarkable improvement post-surgery. He did not show any evidence of pancreatitis in the post-operative period. He was discharged with an advice to return back after 6 weeks for the removal of the stent, but he refused the stent removal and was investigated with an MRCP, which revealed a stent in the CBD and that the CBD and the pancreatic duct had two separate openings in the duodenum. However, the patient came after 9 months of surgery with cholangitis and cholecystitis. He underwent removal of the stent endoscopically and was subjected to cholecystectomy. Till today, he is asymptomatic and healthy. As this was an interesting case to us and as it was planned for publication, an informed consent was obtained from the patient.

Discussion

The rupture of the extra hepatic bile duct which is caused by a blunt trauma is rare. The cause of the rupture of the bile duct is merely always a crushing trauma to the right hypochondrial region and especially to the costal margins. This syndrome was first recognized by Mason et al., (1), Fizeau (4). Fletcher et al., (10) and Hinshaw et al., (2). Although injuries to both the common bile duct and the pancreatic ducts had been mentioned by Maingot (11), White and Sanderson (12), Ehrlick and Howard (13), no case report which had described this as an isolated injury which was caused by blunt trauma had been previously reported.

The total transection of the duct can be repaired by a primary end to end anastomosis, primary choledocoduodenostomy or by Roux-en-Y choledocojejunostomy. The injuries to the common bile duct, together with or in the vicinity of the main pancreatic duct, are the most severe ones and they present the most challenging clinical problems. A search of the literature revealed 12 previously reported cases of complete transection of the common duct at the junction with the duodenum which had been caused by blunt trauma (1),(2),(3),(5),(7),(10),(14),(15),(16). Lysaght (6) performed a cholecystogastrostomy and Mast and Oz (15) performed acholedocoduodenostomy, while Hinshaw, Turner and Carter (2) performed a loop choledocojejunostomy and a jejunojejunostomy for this lesion. Tolins (16) located the distal severed common duct through duodenostomy with retrograde probing through the ampulla of Vater and thus was able to perform a direct duct to duct anastomosis.

Pancreatoduodenectomy has also been described as an option for the management of such cases, especially the ones which involve the distal CBD or the confluence. But in view of it as a time consuming procedure, it may not be a very viable option in an emergency situation. Also, the expertise of the young surgeon/ residents who handle such emergencies may also not permit the use of this procedure routinely. This can be used in selected, haemodynamically stable patients in the presence of a surgeon who is experienced in this procedure.

The authors feel strongly that insufficient attention has been given to the pancreatic duct in this injury. With complete intra-mural transection of the common bile duct as was presented in a case report, the identification of the pancreatic duct is imperative. A separate duodenotomy may be necessary on the anterior surface of the duodenum to identify the pancreatic duct orifice and to facilitate the debridement and closure of the duodenal wall at the site of the choledochal rupture. With the pancreatic duct being cannulated during the repair of the defect in the duodenal wall, the likelihood of an iatrogenic injury to the duct is minimized. When injuries to the main pancreatic duct occur and remain unrecognized, any of the grave complications of peritonitis, pancreatic abscess, subphrenic abscess, external pancreatic fistula or pseudocyst formation may follow.

Another case reported the total transection of both the common bile and the pancreatic ducts at the ampulla. The pulpy haematoma of the head of the pancreas made adequate identification of the main pancreatic duct difficult or impossible. Recent literature has indicated an increasing interest in the treatment in pancreaticoduodenal wounds by pancreatoduodenectomy (9),(17),(18). Under certain circumstances, this may be the best method for handling the problem, but alternative conservative approaches should be undertaken whenever they are feasible (8).

SUMMARY
With this rare case report, we would like to enlighten the surgical community about this rare and frequently not looked for injury in cases of blunt abdominal trauma. This has highlighted the distal CBD transections, especially the ones in the retro duodenal and the intrapancreatic portions. These are prone to be easily missed, in part, because of the emergency situation and the poor preparedness on the part of the surgeon who is handling the emergency. We wouldlike to suggest with our experience that, a thorough exploration of the region by a Kocher’s manoeuvre and a further duodenotomy is needed, especially in the cases which involve the confluence or the intra-pancreatic portion . Such cases need to be addressed with a discreet identification of both the ducts (pancreatic and CBD) and a repair after the cannulation of both, lest late strictures occur. In case the expertise is not available or in an emergency situation, a closed circuit drain can be placed and the patient can be referred to a high volume centre or he/she can be re-explored by a surgeon who is experienced in handling the same.

References

1.
Mason LB, Sidbury JB, Guiring S. Rupture of the extra-hepatic bile ducts due to a non penetrating trauma. Ann Surg 1954;140:234.
2.
Hinshaw DB, Turner GB, Carter R. Transection of the common bile duct which was caused by a nonpenetrating trauma. Am J Surg 1962;104.
3.
Donald J, Donald, John. Complete severance of the Common Duct Due to Nonpenetrating Trauma. Ann Surg 1958;148:855.
4.
Fizeau L. Observation sur une rupture du conduite choledoque avec d eponchment dans leventre suivie d autres observations analoques a des reflections sur Ia coulcar jauncdes icteriques. J Med Cbir Pbarmacol 1806;12:171.
5.
Lewis KM. Traumatic rupture of the bile ducts. Ann Surg 1938; 108: 237.
6.
Lysaght AC. A case of traumatic severance of the common bile duct. Brit J Surg 1939; 26:646.
7.
Mohardt J. Traumatic rupture of the common bile duct. Report of a case and review of the literature. 1956;30:16.
8.
Smith AD, Woolverton WC, Weichert RF, Drapanas T. Operative Management of Pancreatic and Duodenal Injuries. Presented at the Meeting of the American Association for the Surgery of Trauma. Chicago, Illinois 1970.
9.
Thal AP, Wilson RF. A pattern of severe blunt trauma to the region of the pancreas. Surg Gynaecol Obstet 1964;119:773.
10.
Fletcher W, Mohnke D, Dunphy JE. Complete division of the common bile duct due to blunt trauma. J Trauma 1961;1:87.
11.
Maingot R. Abdominal operations 5th Edition.
12.
White TW, Sanderson ER, Morgan A. Injury to the sphincter of oddi in the courses of gastric and duodenal surgeries. Am J of Surg 1967;114.
13.
Ehrlic EW, Howard JM. Ampullary disconnection during gastrectomy. Ann Surg 1969;171:6.
14.
Hartman SW, Greaney EM. Traumatic injuries to the biliary system in children. Am J Surg 1964;108:150.
15.
Mast WL, Oz M. Complete severance of the common bile duct due to external blunt trauma to the abdomen. J Internat Coll Surg 1960;34:726.
16.
Tolins SH. Complete severance of the common bile duct secondary to blunt trauma. Ann Surg 1959;149:61.
17.
Bach R, Frey C. The Management of Pancreatic Trauma. Presented at the Meeting of the Society for Surgery of the Alimentary Tract. Chicago, Illinois 1970.
18.
Wilson RF, Tagett JP, Pucelik JP, Walt AJ. Pancreatic Trauma. J Trauma 1967;7:643.

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ID: JCDR/2012/3979:2339

Date of Submission: Jan 13, 2012
Date of Peer Review: Apr 09, 2012
Date of Acceptance: Jun 28, 2012
Date of Publishing: Aug 10, 2012

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