Current management of biliary leaks

Screening and management of major bile leak after blunt liver trauma: a retrospective single center study

BACKGROUND

Major bile leak after blunt liver trauma is rare but challenging. It usually requires endoscopic retrograde cholangiography (ERC) for management. However, there is still lack of specific indications. The aim of this study is to elucidate risk factors for major bile leak and indications for early ERC after blunt liver trauma.

METHODS

The trauma registry of a level I trauma center in Taiwan was queried, and all blunt liver trauma patients from June, 2008 to June, 2011 were selected for retrospective review. Data collected included demographic data, laboratory data, Injury Severity Score (ISS), liver injury grade and location, management of liver trauma, length of ICU, hospital stay and treatment result. ERC was used to confirm major bile leak.

RESULTS

288 blunt liver trauma patients were selected from 2,475 torso trauma patients. There were 214 (74.5%) male and 74 (25.7%) female patients. The mean ISS was 24.2. Most patients received conservative treatment. Transcatheter artery embolization (TAE) and operation were 15.6% and 10.8% respectively. Major bile leak occurred in 14 (4.9%) patients. Risk factors for bile leak include high-grade liver injury, centrally-located liver trauma and use of TAE. A bilirubin level greater than 43.6 μmol/L provides a sensitivity of 100% and specificity of 85.1% for predicting major bile leak.

CONCLUSIONS

High injury grade; centrally-located liver trauma; and use of TAE are risk factors for major bile leak after blunt liver trauma. ERC should be arranged early if the patient has risk factors and their plasma bilirubin level is greater than 43.6 μmol/L during admission.

Management of post-surgical biliary leakage with percutaneous transhepatic biliary drainage (PTBD) and occlusion balloon (OB) in patients without dilatation of the biliary tree: preliminary results

OBJECTIVE

To compare the outcome of patients affected by biliary leak after major biliary surgery and treated with percutaneous transhepatic biliary drainage (PTBD) alone with that of similar patients treated with PTBD and concurrent positioning of an occlusion balloon (PTBD-OB).

METHODS

We retrospectively reviewed the results of the use of PTBD or PTBD-OB performed at our institution from 2004 to 2008 in patients with post-surgical biliary leak. Sixteen patients entered the evaluation. PTDB alone was performed in 9 men (age 59.7 +/- 13.4 years [mean +/- standard deviation]; median 60 years), while PTBD-OB was performed in 7 patients (5 men, 2 women, age 71.3 +/- 9.3 years; median 68 years).

RESULTS

No significant difference between groups was found regarding age (p = 0.064) and sex (p = 0.175) distribution, number of procedures (3.1 +/- 1.62; 2 vs 1.7 +/- 1.1; 1, p = 0.151), and days of disease before recovery, death or modification of treatment (51.6 +/- 66.8; 23 vs 18.6 +/- 15.1; 14, p = 0.266). The number of patients treated with PTBD-OB who fully recovered (7/7, 100%) was significantly higher than that of patients treated with PTBD alone (4/9, 44%, p = 0.034).

CONCLUSION

This procedure appears to be clinically effective, being associated with a higher probability of recovery in patients treated for post-surgical biliary leak. Further studies are needed to confirm these preliminary results.

Endoscopic evaluation and therapies of biliary disorders

Biliary disorders were once only accessible by orthodox surgery but are now diagnosed and treated by multiple methods and specialists. Therapeutic endoscopic retrograde cholangiopancreatography has flourished and continues to grow after its introduction with the first biliary spincterotomies in 1974 in Germany and Japan. The therapeutic biliary endoscopist contributes to the management of all biliary disorders and in many cases endoscopy is the preferable approach. However, endoscopic retrograde cholangiopancreatography remains a risky procedure and risk is best reduced by strictly limiting its use.

Contrast-enhanced sonographic guidance for local injection of a hemostatic agent for management of blunt hepatic hemorrhage: a canine study

OBJECTIVE

The purpose of this study was to determine whether injection of hemostatic agents directly into an injury site under the guidance of contrast-enhanced sonography can effectively control hemorrhage due to hepatic trauma.

MATERIALS AND METHODS

Fifteen mixed-breed dogs 2-3 years old and weighing 17-20 kg were anesthetized with intramuscular pentobarbital sodium (30 mg/kg). A special impacting device was used to induce hepatic trauma with a mean force of 5.3 +/- 0.3 kN. Twelve of the 15 dogs had hepatic injuries with a grade of 3-4 or 4. The 12 dogs were divided into treatment and control groups. In the treatment group, hemocoagulase atrox (1 Klobusitzky unit) and alpha-cyanoacrylate (1 mL) were administered by transcutaneous injection into the injury site and the bleeding site, respectively, under the guidance of contrast-enhanced sonography. The control group received injections of 0.9% normal saline solution.

RESULTS

After injection into the treatment group, no active bleeding was observed at the liver injury site. In the control group, evidence of active bleeding was present on contrast-enhanced sonograms. Laparotomy of the treatment group showed that hepatic injuries had been covered and adhered by clots and the glue membrane of the hemostatic agents and that free intraperitoneal blood volume was significantly less than in the control group (p < 0.001). Bleeding did not stop in the control group.

CONCLUSION

In dogs, transcutaneous local injection of hemostatic agents can effectively reduce blood loss due to severe liver trauma. Because it is simple, convenient, and effective, the technique may be an alternative for bedside and battlefield management of hepatic hemorrhage due to trauma.