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Khomenko I, Tsema I, Humeniuk K, Makarov H, Rahushyn D, Yarynych Y, Sotnikov A, Slobodianyk V, Shypilov S, Dubenko D, Barabanchyk O, Dinets A. Application of Damage Control Tactics and Transpapillary Biliary Decompression for Organ-Preserving Surgical Management of Liver Injury in Combat Patient. Mil Med 2021; 187:e781-e786. [PMID: 33861850 DOI: 10.1093/milmed/usab139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 02/16/2021] [Accepted: 04/05/2021] [Indexed: 11/14/2022] Open
Abstract
The combat penetrating gunshot injury is frequently associated with damage to the liver. Bile leak and external biliary fistula (EBF) are common complications. Biliary decompression is commonly applied for the management of EBF. Also, little is known about the features of combat trauma and its management in ongoing hybrid warfare in East Ukraine. A 23-year-old male was diagnosed with thoracoabdominal penetrating gunshot wound (GSW) by a high-energy multiple metal projectile. Damage control tactics were applied at all four levels of military medical care. Biliary decompression was achieved by endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and the placement of biliary stents. Occlusion of the stent was treated by stent replacement, and scheduled ERCP was performed. Partial EBF was diagnosed from the main wound defect of the liver and closed without surgical interventions on the 34th day after the injury. A combination of operative and nonoperative techniques for the management of the combat GSW to the liver is effective along with the application of damage control tactics. A scheduled ERCP application is an effective approach for the management of EBF, and liver resection could be avoided. A successful biliary decompression was achieved by the transpapillary intervention with the installation of stents. Stent occlusion could be diagnosed in the early post-traumatic period, which is effectively managed by scheduled ERCP as well as stent replacement with a large diameter as close as possible to the place of bile leak.
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Affiliation(s)
- Igor Khomenko
- Department of Abdominal Surgery, National Military Medical Teaching Center of Ministry of Defense of Ukraine, Kyiv 01133, Ukraine
| | - Ievgen Tsema
- Department of Abdominal Surgery, National Military Medical Teaching Center of Ministry of Defense of Ukraine, Kyiv 01133, Ukraine
- Department of Surgery, Bogomolets National Medical University, Kyiv 01601, Ukraine
| | - Kostiantyn Humeniuk
- Department of Abdominal Surgery, National Military Medical Teaching Center of Ministry of Defense of Ukraine, Kyiv 01133, Ukraine
| | - Heorhii Makarov
- Department of Abdominal Surgery, National Military Medical Teaching Center of Ministry of Defense of Ukraine, Kyiv 01133, Ukraine
| | - Dmytro Rahushyn
- Department of Abdominal Surgery, National Military Medical Teaching Center of Ministry of Defense of Ukraine, Kyiv 01133, Ukraine
| | - Yurii Yarynych
- Department of Surgery, Bogomolets National Medical University, Kyiv 01601, Ukraine
| | - Artur Sotnikov
- Department of Abdominal Surgery, National Military Medical Teaching Center of Ministry of Defense of Ukraine, Kyiv 01133, Ukraine
| | - Viktor Slobodianyk
- Department of Abdominal Surgery, National Military Medical Teaching Center of Ministry of Defense of Ukraine, Kyiv 01133, Ukraine
| | - Serhii Shypilov
- Department of Thoraco-Abdominal Surgery, Military Medical Teaching Center of the Northern Region of Ministry of Defense of Ukraine, Kharkiv 61000, Ukraine
| | - Dmytro Dubenko
- Department of Surgery, Bogomolets National Medical University, Kyiv 01601, Ukraine
| | - Olena Barabanchyk
- Department of Internal Medicine, Taras Shevchenko National University of Kyiv, Kyiv 03022, Ukraine
| | - Andrii Dinets
- Department of Surgery, Taras Shevchenko National University of Kyiv, Kyiv 03022, Ukraine
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Oo J, Smith M, Ban EJ, Clements W, Tagkalidis P, Fitzgerald M, Pilgrim CHC. Management of bile leak following blunt liver injury: a proposed guideline. ANZ J Surg 2021; 91:1164-1169. [PMID: 33459492 DOI: 10.1111/ans.16552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/19/2020] [Accepted: 12/19/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bile leak following blunt liver trauma is uncommon. Management is difficult due to complex vasculo-biliary and liver parenchymal injury and lack of consensus on optimal care compared with bile leak following elective hepatectomy especially in regards to endoscopic retrograde pancreaticocholangiography (ERCP) timing and patient selection. METHODS This is a retrospective cohort study from a level 1-trauma centre of patients with bile leak following blunt liver injury between July 2010 and December 2019 identified from the trauma registry. Clinical data retrieved include patient demographics, injury severity score, liver injury grading and its associated complications and treatment. This was supplemented by surgical audit database and patients' electronic medical record. RESULTS There were 31 bile leaks amongst 639 patients with blunt liver trauma (4.9%). Bile leak was associated with higher liver injury grade (odds ratio (OR) 36, P = 0.001), hepatic embolization (OR 16, P = 0.003) and need for trauma laparotomy (OR 14, P = 0.024). ERCP was performed in 58.1% (n = 18). This was complicated in 27.7% (n = 5) by mild pancreatitis (n = 1) and intra-abdominal sepsis (n = 4) requiring surgical drainage of abscess (n = 2) and liver resection (n = 1). Bile leak settled conservatively (including percutaneous drainage) without ERCP in the remaining patients (41.9%). Overall mortality was not increased in those with bile leak (P = 0.998). CONCLUSION Bile leaks resolved conservatively in 41.9% of patients. Complications following ERCP were seen in 27.7%, frequently requiring intervention. Failure of conservative management was more likely in patients with hepatic embolization, in whom early ERCP remains appropriate. ERCP should otherwise be reserved for those who fail conservative management to minimize infective complications.
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Affiliation(s)
- June Oo
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Marty Smith
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Hepatopancreaticobiliary Surgery, Western Hospital, Melbourne, Victoria, Australia
| | - Ee Jun Ban
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Trauma, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Peter Tagkalidis
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Department of Trauma, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Charles H C Pilgrim
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Hepatopancreaticobiliary Surgery, Frankston Hospital, Melbourne, Victoria, Australia
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Tiwari C, Shah H, Waghmare M, Khedkar K, Dwivedi P. Management of Traumatic Liver and Bile Duct Laceration. Euroasian J Hepatogastroenterol 2017; 7:188-190. [PMID: 29201808 PMCID: PMC5670269 DOI: 10.5005/jp-journals-10018-1247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/03/2017] [Indexed: 11/23/2022] Open
Abstract
Posttraumatic major bile leak in children is uncommon, with few cases reported in the literature. These injuries are seen in high-grade liver trauma and are difficult to diagnose and manage. We describe a 7-year-old boy with grade IV hepatic trauma and bile leak following blunt abdominal trauma. The leak was successfully managed by percutaneous drainage and endoscopic retrograde cholangiopancreatography (ERCP) stenting of the injured hepatic duct. How to cite this article: Tiwari C, Shah H, Waghmare M, Khedkar K, Dwivedi P. Management of Traumatic Liver and Bile Duct Laceration. Euroasian J Hepato-Gastroenterol 2017;7(2):188-190.
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Affiliation(s)
- Charu Tiwari
- Department of Paediatric Surgery, Topiwala National Medical College & BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Hemanshi Shah
- Department of Paediatric Surgery, Topiwala National Medical College & BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Mukta Waghmare
- Department of Paediatric Surgery, Topiwala National Medical College & BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Kiran Khedkar
- Department of Paediatric Surgery, Topiwala National Medical College & BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Pankaj Dwivedi
- Department of Paediatric Surgery, Topiwala National Medical College & BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
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Kam J, Hugh TJ, Joseph A. Delayed biloma formation in a patient with blunt liver injury after low velocity trauma. Br J Hosp Med (Lond) 2017; 78:110-111. [PMID: 28165778 DOI: 10.12968/hmed.2017.78.2.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jonathan Kam
- Senior Resident Medical Officer, Royal North Shore Hospital, St Leonards, NSW, Australia, and Conjoint Fellow, Faculty of Medicine, University of Newcastle, Australia
| | - Thomas J Hugh
- Head of Department, Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St Leonards, NSW, Australia, and Discipline of Surgery, University of Sydney, Australia
| | - Anthony Joseph
- Head of Department, Trauma Unit, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia, and Discipline of Emergency Medicine, University of Sydney, 2006, Australia
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Outcomes of Endoscopic Stenting for Traumatic Biliary and Pancreatic Fistulae. Am Surg 2016. [DOI: 10.1177/000313481608200723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The role of endoscopic retrograde cholangiopancreatography (ERCP) in the trauma patient is limited. Therefore, reporting of outcomes is sparse in the literature. The purpose of this study was to review outcomes of patients who underwent ERCP for traumatic biliopancreatic injury. We retrospectively reviewed 1550 ERCPs, from a prospectively maintained database, performed by a single surgical endoscopist consulted by the trauma surgical service for the management of traumatic fistulae. Referral was made for patients with high output (greater than 200 mL/d) and/or persistent (failure to resolve within 30 days) fistulae and traumatic biliary stricture. Primary end point was postprocedural complications. Secondary end points included patient characteristics, stents placed, and duration of stenting. Seventeen patients underwent a total of 31 ERCPs for biliary and/or pancreatic injury resulting from abdominal trauma (eight penetrating, nine blunt). Fourteen patients had ERCP after laparotomy, with a mean interval to ERCP of 74 days. In three patients, ERCP was the only intervention required. Fourteen biliary stents were placed, seven of which were metallic. Ten pancreatic stents were placed; one proximally migrated but was successfully retrieved. Four patients had both ducts simultaneously stented. The mean duration of stenting was 158 days. All fistulae resolved after stenting. There were no serious complications.
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Al-Hassani A, Jabbour G, ElLabib M, Kanbar A, El-Menyar A, Al-Thani H. Delayed bile leak in a patient with grade IV blunt liver trauma: A case report and review of the literature. Int J Surg Case Rep 2015; 14:156-9. [PMID: 26279258 PMCID: PMC4573864 DOI: 10.1016/j.ijscr.2015.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 07/29/2015] [Accepted: 08/04/2015] [Indexed: 11/20/2022] Open
Abstract
A case with delayed bile leak in a young male patient who presented with grade IV blunt liver injury following a motor vehicle collision. In addition to a high grade injury; centrally located liver injury is a significant risk factor for major bile duct injury. For such patients, early MRCP and ERCP may be warranted to rule out a significant bile leak. Patients with high grade liver injury are at risk of serious complications. There is a need for prompt diagnosis and treatment of delayed bile leak in blunt liver injuries.
Introduction Delayed bile leak following blunt liver trauma is not common. Presentation of case We presented a case report and literature review of delayed bile leak in a young male patient who presented with grade IV blunt liver injury following a motor vehicle collision; he was a restrained driver who hit a fixed object. Physical examination was unremarkable except for revelaed tachycardia, right upper quadrant abdominal tenderness, and open left knee fracture. A diagnosis of grade IV multiple liver lacerations with large hemo-peritoneum was made and urgent exploratory laparotomy was performed. The patient developed a biloma collection post- operatively. He underwent endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct stenting. His recovery was uneventful, and he was discharged home after 1 month. Discussion This is a rare case with no intra or extra hepatic biliary radicle injury seen on magnetic resonance cholangiopancreatography (MRCP) and no evidence of leak by ERCP. A review of the literature to highlight the incidence of delayed bile leak revealed only few reported cases. Conclusion Our findings demonstrate the need for prompt diagnosis and treatment of delayed bile leak in blunt liver injuries. When these principles are followed, a successful outcome is possible.
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Affiliation(s)
- Ammar Al-Hassani
- Department of surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Gaby Jabbour
- Department of Surgery, HGH, Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Mohammad ElLabib
- Department of surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Ahad Kanbar
- Department of surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, HGH, Doha, Qatar; Clinical Research, Trauma Surgery, HGH, Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Hassan Al-Thani
- Department of surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
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Affiliation(s)
- J M L Williamson
- Speciality Training Registrar in the Department of Hepato-Pancreato-Biliary Surgery, Bristol Royal Infirmary, Bristol BS2 8HW
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Day LW, Lin L, Somsouk M. Adverse events in older patients undergoing ERCP: a systematic review and meta-analysis. Endosc Int Open 2014; 2:E28-36. [PMID: 26134610 PMCID: PMC4423280 DOI: 10.1055/s-0034-1365281] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/20/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Biliary and pancreatic diseases are common in the elderly; however, few studies have addressed the occurrence of adverse events in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Our objective was to determine the incidence rates of specific adverse events in this group and calculate incidence rate ratios (IRRs) for selected comparison groups. PATIENTS AND METHODS Bibliographical searches were conducted in Medline, EMBASE, and Cochrane library databases. The studies included documented the incidence of adverse events (perforation, pancreatitis, bleeding, cholangitis, cardiopulmonary adverse events, mortality) in patients aged ≥ 65 who underwent ERCP. Pooled incidence rates were calculated for each reported adverse event and IRRs were determined for available comparison groups. A parallel analysis was performed in patients aged ≥ 80 and ≥ 90. RESULTS Our literature search yielded 7429 articles, of which 69 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 ERCPs) in patients aged ≥ 65 were as follows: perforation 3.8 (95 %CI 1.8 - 7.0), pancreatitis 13.1 (95 %CI 11.0 - 15.5), bleeding 7.7 (95 %CI 5.7 - 10.1), cholangitis 16.1 (95 %CI 11.7 - 21.7), cardiopulmonary events 3.7 (95 %CI 1.5 - 7.6), and death 7.1 (95 %CI 5.2 - 9.4). Patients ≥ 65 had lower rates of pancreatitis (IRR 0.3, 95 %CI 0.3 - 0.4) compared with younger patients. Octogenarians had higher rates of death (IRR 2.4, 95 %CI 1.3 - 4.5) compared with younger patients, whereas nonagenarians had increased rates of bleeding (IRR 2.4, 95 %CI 1.1 - 5.2), cardiopulmonary events (IRR 3.7, 95 %CI 1.0 - 13.9), and death (IRR 3.8, 95 %CI 1.0 - 14.4). Conclusions ERCP appears to be safe in elderly patients, except in the very elderly who are at higher risk of some adverse events. These data on adverse event rates can help to inform clinical decision-making, the consent process, and comparative effectiveness analyses.
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Affiliation(s)
- Lukejohn W. Day
- Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, California, United States
- GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, California, United States
| | - Lisa Lin
- Department of Medicine, Mount Sinai School of Medicine, New York, New York, United States
| | - Ma Somsouk
- Division of Gastroenterology, San Francisco General Hospital and Trauma Center, San Francisco, California, United States
- GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, California, United States
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Hasaniya NW, Premaratne S, Premaratne ID, McNamara JJ. A rare case of hepatic duct injury from blunt abdominal trauma. AMERICAN JOURNAL OF CASE REPORTS 2013; 14:106-8. [PMID: 23826446 PMCID: PMC3700485 DOI: 10.12659/ajcr.883881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 02/08/2013] [Indexed: 11/25/2022]
Abstract
Background: A 25 year-old male was brought to the emergency room following an apparent suicide attempt by jumping from the fourth floor. Case Report: Patient had a large abdominal laceration in the right upper quadrant (RUQ). CT scan showed a sub-scapular hematoma of the liver. Due to the repeated episodes of hypotension, a laporotomy was performed and the left hepatic artery was ligated while the ductal injury was managed with a Roux-en-Y left hepatic jejunostomy and stent. Bile leakage was resolved post-operatively by day 5 and the patient was discharged home on day 13 after clearance from psychiatry. Conclusions: While non-iatrogenic extrahepatic biliary trauma is rare, a high degree of suspicion is essential, especially in cases like the one discussed in this report. Diagnosis can be difficult in patients undergoing observation.
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Affiliation(s)
- Nahidh W Hasaniya
- Department of Surgery, School of Medicine, Loma Linda University, Loma Linda, CA, U.S.A. ; Department of Surgery, John A. Burns School of Medicine, University of Hawaii and Research Laboratory at the Queen's Medical Center, Honolulu, HI, U.S.A
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Affiliation(s)
- JML Williamson
- Department of Hepato-Pancreato-Biliary Surgery, Bristol Royal Infirmary, Bristol BS2 8HW
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11
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Abstract
Traumatic bile leaks often result in high morbidity and prolonged hospital stay that requires multimodality management. Data on endoscopic management of traumatic bile leaks are scarce. Our study objective was to evaluate the efficacy of the endoscopic management of a traumatic bile leak. We performed a retrospective case review of patients who were referred for endoscopic retrograde cholangiopancreatography (ERCP) after traumatic bile duct injury secondary to blunt (motor vehicle accident) or penetrating (gunshot) trauma for management of bile leaks at our tertiary academic referral center. Fourteen patients underwent ERCP for the management of a traumatic bile leak over a 5-year period. The etiology included blunt trauma from motor vehicle accident in 8 patients, motorcycle accident in 3 patients and penetrating injury from a gunshot wound in 3 patients. Liver injuries were grade III in 1 patient, grade IV in 10 patients, and grade V in 3 patients. All patients were treated by biliary stent placement, and the outcome was successful in 14 of 14 cases (100%). The mean duration of follow-up was 85.6 days (range 54–175 days). There were no ERCP-related complications. In our case review, endoscopic management with endobiliary stent placement was found to be successful and resulted in resolution of the bile leak in all 14 patients. Based on our study results, ERCP should be considered as first-line therapy in the management of traumatic bile leaks.
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Affiliation(s)
- Matthew P Spinn
- Division of Gastroenterology, University of Texas Health Science Center, Houston, Tex., Jacksonville, Fla., USA
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Bala M, Gazalla SA, Faroja M, Bloom AI, Zamir G, Rivkind AI, Almogy G. Complications of high grade liver injuries: management and outcomewith focus on bile leaks. Scand J Trauma Resusc Emerg Med 2012; 20:20. [PMID: 22444252 PMCID: PMC3352307 DOI: 10.1186/1757-7241-20-20] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 03/23/2012] [Indexed: 12/30/2022] Open
Abstract
Background Although liver injury scale does not predict need for surgical intervention, a high-grade complex liver injury should alert the physician to expect an increased risk of hepatic complications following trauma. The aim of the current study was to define hepatic related morbidity in patients sustaining high-grade hepatic injuries that could be safely managed non-operatively. Patients and methods This is a retrospective study of patients with liver injury admitted to Hadassah-Hebrew University Medical Centre over a 10-year period. Grade 3-5 injuries were considered to be high grade. Collected data included the number and types of liver-related complications. Interventions which were required for these complications in patients who survived longer than 24 hours were analysed. Results Of 398 patients with liver trauma, 64 (16%) were found to have high-grade liver injuries. Mechanism of injury was blunt trauma in 43 cases, and penetrating in 21. Forty patients (62%) required operative treatment. Among survivors 22 patients (47.8%) developed liver-related complications which required additional interventional treatment. Bilomas and bile leaks were diagnosed in 16 cases post-injury. The diagnosis of bile leaks was suspected with abdominal CT scan, which revealed intraabdominal collections (n = 6), and ascites (n = 2). Three patients had continuous biliary leak from intraabdominal drains left after laparotomy. Nine patients required ERCP with biliary stent placement, and 2 required percutaneous transhepatic biliary drainage. ERCP failed in one case. Four angioembolizations (AE) were performed in 3 patients for rebleeding. Surgical treatment was found to be associated with higher complication rate. AE at admission was associated with a significantly higher rate of biliary complications. There were 24 deaths (37%), the majority from uncontrolled haemorrhage (18 patients). There were only 2 hepatic-related mortalities due to liver failure. Conclusions A high complication rate following high-grade liver injuries should be anticipated. In patients with clinical evidence of biliary complications, CT scan is a useful diagnostic and therapeutic tool. AE, ERCP and temporary internal stenting, together with percutaneous drainage of intra-abdominal or intrahepatic bile collections, represents a safe and effective strategy for the management of complications following both blunt and penetrating hepatic trauma.
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Affiliation(s)
- Miklosh Bala
- Department of General Surgery and Trauma Unit, Hadassah-Hebrew University Medical Centre, Kiriat Hadassah, POB 12000, Jerusalem 91120, Israel.
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Szabó KG, Csiszkó A, Sasi-Szabó L, Bányai S, Szentkereszty Z, Varga Z, Fekete K, Sápy P, Damjanovich L, Szentkereszty Z. [Successful treatment of retrohepatic inferior vena cava injury: report of two cases]. Magy Seb 2011; 64:242-5. [PMID: 21997529 DOI: 10.1556/maseb.64.2011.5.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED Authors present two cases of successfully operated patients with retrohepatic inferior vena cava (IVC) injury. In the first case a 79 year old female patient suffered from multiple stab wounds in the area of the 4th segment of the right lung as well as in the retrohepatic region in close proximity to the IVC. At the time of the first surgery the IVC injury was not identified. During a second operation, however, the IVC was isolated from the liver using an anterior dissection of the parenchyma with finger-fracture technique and the injury was oversawn finally. Successful haemostasis of the liver was achieved by packing of the perihepatic space, which was removed three days later. In the second case a 25 year-old male patient had suffered blunt abdominal trauma. He underwent laparotomy and packing on the site of the hepatic injury, which had to be repeated seven more times. Later on, another urgent laparotomy was carried out for recurring intraabdominal bleeding and bile leakage, and cholecystectomy was performed due to gallbladder perforation. Another two days later a further emergency laparotomy was indicated for ongoing intraabdominal bleeding, when the bleeding source - an injury (3 mm in diameter) of the retrohepatic IVC - was oversawn. After relatively long postoperative stay both patients were fully recovered and discharged from hospital. CONCLUSIONS penetrating injuries of the IVC are associated with high mortality rate of approximately 78%. Proper management of these injuries requires experience in both vascular and liver surgery. Retrohepatic IVC injury needs to be considered in the differential diagnosis of ongoing bleeding in penetrating or blunt liver trauma. Packing of the liver is a reliable haemostatic method if bleeding persists due to division of the liver parenchyma.
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Affiliation(s)
- Károly Gábor Szabó
- Debreceni Egyetem Orvos- és Egészségtudományi Centrum Sebészeti Intézet 4032 Debrecen Móricz Zs. krt. 22.
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Ulitsky A, Werlin S, Dua KS. Role of ERCP in the management of non-iatrogenic traumatic bile duct injuries in the pediatric population. Gastrointest Endosc 2011; 73:823-7. [PMID: 21295302 DOI: 10.1016/j.gie.2010.11.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 11/29/2010] [Indexed: 02/08/2023]
Affiliation(s)
- Alex Ulitsky
- Division of Gastroenterology and Hepatology, Froedtert Memorial Hospital, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Sharma BC, Mishra SR, Kumar R, Sarin SK. Endoscopic management of bile leaks after blunt abdominal trauma. J Gastroenterol Hepatol 2009; 24:757-61. [PMID: 19054254 DOI: 10.1111/j.1440-1746.2008.05703.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND STUDY AIMS Endoscopic retrograde cholangiopancreaticography (ERCP) has been found to be useful for the diagnosis and treatment of post-traumatic bile leaks, but data on outcome after therapeutic ERCP is limited. We performed a prospective study on evaluation of ERCP for diagnosis and treatment of bile leaks following blunt abdominal trauma. PATIENTS AND METHODS Ten patients of bile leaks following blunt abdominal trauma were evaluated for modes of injury, clinical presentations, investigations, ERCP findings, modes of therapy and outcome. The time interval between trauma and ERCP, ERCP and healing of bile leak and complications of ERCP were also recorded. RESULTS Ten patients (age 21.9 +/- 14.5 years, 6 males) presented 24.6 +/- 17.1 days following trauma. The modes of injury were motor vehicle accident (n = 6), and fall from height (n = 4). The ERCP revealed bile leak from the right hepatic duct (n = 7), both right and left hepatic ducts (n = 1), mid-common bile duct (n = 1), and peripheral branches of right hepatic duct (n = 1). Procedures for ERCP included endoscopic sphincterotomy (ES) with stenting in nine patients and ES with nasobiliary drainage in one patient. Bile leak resolved in all the patients in 8.5 +/- 8.2 days. Biliary stents and the nasobiliary drain were removed after 36.4 +/- 16.2 days of their insertion and all the patients remain asymptomatic for follow up of 33 +/- 20.8 months. CONCLUSIONS Therapeutic ERCP procedures like endoscopic sphincterotomy with stenting or nasobiliary drainage are effective in management of bile leaks following blunt abdominal trauma.
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Affiliation(s)
- B C Sharma
- Department of Gastroenterology, G B Pant Hospital, New Delhi, India.
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Shah JN. Endoscopic treatment of bile leaks: current standards and recent innovations. Gastrointest Endosc 2007; 65:1069-72. [PMID: 17531644 DOI: 10.1016/j.gie.2007.02.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Accepted: 02/09/2007] [Indexed: 12/13/2022]
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Abstract
Traumatic noniatrogenic biliary injuries, unlike iatrogenic injuries, are usually complex in nature and are frequently associated with other multiorgan trauma and infection. Bile leaks following these injuries are an important source of short- and long-term morbidity. Repeat surgery for primary repair of complex bile leaks is difficult and can be complicated by anastomotic leakage and biliary stricture formation. Endoscopic retrograde cholangiopancreatography (ERCP) was initially used only as a diagnostic technique to guide surgical repair in this setting. However, with the high success rates observed in treatment of iatrogenic bile leaks, ERCP has emerged as a nonoperative treatment option for noniatrogenic biliary leaks as well. Recent data show that ERCP is effective in managing bile leaks after blunt and sharp liver injuries, using transpapillary stenting, endoscopic sphincterotomy, or both, with greater than 80% healing rates. The evidence is not clear regarding which ERCP maneuver - endoscopic sphincterotomy, transpapillary stenting, or both - should be used.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA
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