Endoscopic retrograde cholangiography in the nonsurgical management of blunt liver injury

Endoscopic Coil Embolization for Refractory Intrahepatic Biliary Duct Leak

Bile leaks may be seen after blunt and penetrating trauma, as well as iatrogenic injury from surgical procedures. There are many articles on endoscopic treatment options for the management of biliary leaks, including sphincterotomy, endoscopic stent, or nasobiliary drain placement. Data, however, are scarce regarding the management of persistent biliary leaks after the initial intervention. We present a case of endoscopic coil embolization to treat a refractory bile leak after initial endoscopic sphincterotomy and stent placement in a patient with a grade IV liver laceration due to a gunshot wound.

Biliovascuar complications: a price to pay for non-operative management of major liver trauma

BACKGROUND

With non-operative management of major liver trauma, there has been an increased incidence of biliovascular complications which are reported variably.

METHODS

Fifty-six patients with age of 29.79±11.40 years and M:F 8.3:1, with grade III or more liver trauma were evaluated after stabilization for the development of liver related complications. Patients with active contrast extravasation at admission were managed with immediate angioembolization. Patients with prolonged hospital stay underwent repeat CT prior to discharge. Radiological, endoscopic and surgical interventions were carried out as appropriate.

RESULTS

Ninety-eight percent had blunt abdominal injury. Mean injury severity score was 25.68±10.389. Four (7%) required damage control laparotomy. CECT showed grade III injuries in 52%, grade IV in 30.4%, and grade V in 18%. 11% had laceration extending to porta. Seventeen patients had 21 liver-related complications: 4 biliary, 12 vascular and 1 combined biliary and vascular. Liver related complications were- 3.5% in grade III, 52% in grade IV and 70% in grade V. One patient with active arterio-portal fistula required urgent angioembolization while other arterial pseudoaneurysms were detected 7.23±5.14 days after trauma. Angioembolization was successful in 83% patients. On univariate and multivariate analysis, PRBC requirement and injury grade were the predictors of bilivascular complications. Laceration extending to porta was a predictor for biliary complications and not vascular. Repeat CT picked up 13 complications in 10 patients.

CONCLUSIONS

Biliovascular complications are managed by multidisciplinary approach. Lacerations extending to porta and grade IV/V injuries have a higher chance of developing biliovascular complications and should be observed closely.

Management of Traumatic Liver and Bile Duct Laceration

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.

Delayed bile leak in a patient with grade IV blunt liver trauma: A case report and review of the literature

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A case with delayed bile leak in a young male patient who presented with grade IV blunt liver injury following a motor vehicle collision.

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In addition to a high grade injury; centrally located liver injury is a significant risk factor for major bile duct injury.

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For such patients, early MRCP and ERCP may be warranted to rule out a significant bile leak.

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Patients with high grade liver injury are at risk of serious complications.

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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.

Isolated hepatic artery injury in blunt abdominal trauma presenting as upper gastrointestinal bleeding: treatment with transcatheter embolisation

Liver injury in blunt abdominal trauma is common. However, not often does blunt trauma cause injury to the anatomical structures of the porta hepatis. Isolated injury of the hepatic artery has been rarely reported in the literature. Such injury may be lethal and requires immediate diagnosis and management. This report describes an unusual case of blunt abdominal trauma resulting in hepatic and gastroduodenal artery dissection, with pseudoaneurysm formation complicated by active upper gastrointestinal bleeding. The injury was managed by transcatheter embolisation. Awareness of this diagnosis should facilitate management of similar trauma cases.

Bile duct leaks from the intrahepatic biliary tree: a review of its etiology, incidence, and management

Bile leaks from the intrahepatic biliary tree are an important cause of morbidity following hepatic surgery and trauma. Despite reduction in mortality for hepatic surgery in the last 2 decades, bile leaks rates have not changed significantly. In addition to posted operative bile leaks, leaks may occur following drainage of liver abscess and tumor ablation. Most bile leaks from the intrahepatic biliary tree are transient and managed conservatively by drainage alone or endoscopic biliary decompression. Selected cases may require reoperation and enteric drainage or liver resection for management.

Complications of high grade liver injuries: management and outcomewith focus on bile leaks

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.

Management of blunt hepatic trauma

Management of blunt liver trauma has progressed over the last 20 years with the adoption of conservative non-operative management (CM) as the gold standard in 80-90% of patients. Clinical and hemodynamic changes, and CT imaging guide the conservative attitude or pose an indication for urgent surgical intervention in unstable patients. The adoption of CM for blunt liver trauma has resulted in an increased incidence of late complications. These consist principally of persistent hemorrhage, fistulas and bile leaks, the abdominal compartment syndrome, and hepatic necrosis or abscess. These late complications can be managed secondarily by planned interventions via laparotomy or laparoscopy, interventional radiology and/or endoscopic techniques in a non-emergency setting as indicated by circumstances and with the benefit of multidisciplinary consultation. These secondary interventions should not be considered a failure of conservative treatment, but rather as an anticipated eventuality in the management of these patients.

Endoscopic management of bile leaks after blunt abdominal trauma

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.

Blunt Left Extrahepatic Bile Duct Injury: Case Report and Literature Review

BACKGROUND

Extrahepatic biliary tract injuries following blunt abdominal trauma are very rare and pose a diagnostic and therapeutic challenge.

CASE REPORT

We report a case of blunt liver injury with left extrahepatic duct transection following a motor vehicle collision. Technetium 99m dimethyliminodiacetic acid scan confirmed a bile leak and endoscopic retrograde cholangiopancreatography (ERCP) diagnosed the injury of the left extrahepatic duct. Management was initially conservative, consisting of external drainage along with trials of stent placement. Ultimately, partial left hepatectomy was required to definitively treat the injury.

CONCLUSION

In the setting of suspected biliary tract injury, early ERCP is essential to localize a leak and guide management decisions. In the event of a confirmed bile leak, a trial of nonoperative management consisting of endoscopic ductal decompression along with percutaneous drainage may initially be warranted although is not always successful.

Evolving role of endoscopic retrograde cholangiopancreatography in management of extrahepatic hepatic ductal injuries due to blunt trauma: diagnostic and treatment algorithms

Extrahepatic hepatic ductal injuries (EHDIs) due to blunt abdominal trauma are rare. Given the rarity of these injuries and the insidious onset of symptoms, EHDI are commonly missed during the initial trauma evaluation, making their diagnosis difficult and frequently delayed. Diagnostic modalities useful in the setting of EHDI include computed tomography (CT), abdominal ultrasonography (AUS), nuclear imaging (HIDA scan), and cholangiography. Traditional options in management of EHDI include primary ductal repair with or without a T-tube, biliary-enteric anastomosis, ductal ligation, stenting, and drainage. Simple drainage and biliary decompression is often the most appropriate treatment in unstable patients. More recently, endoscopic retrograde cholangiopancreatography (ERCP) allowed for diagnosis and potential treatment of these injuries via stenting and/or papillotomy. Our review of 53 cases of EHDI reported in the English-language literature has focused on the evolving role of ERCP in diagnosis and treatment of these injuries. Diagnostic and treatment algorithms incorporating ERCP have been designed to help systematize and simplify the management of EHDI. An illustrative case is reported of blunt traumatic injury involving both the extrahepatic portion of the left hepatic duct and its confluence with the right hepatic duct. This injury was successfully diagnosed and treated using ERCP.

Complex Hepatic Injuries: an Audit from a Tertiary Center

BACKGROUND

Nonoperative management is being increasingly employed in the management of blunt hepatic injuries.

PATIENTS AND METHODS

We analyzed patients with complex hepatic injuries over a period of 10 years (1996-2006).

RESULTS

Two hundred and ten patients with blunt hepatic injury were admitted and 103 patients had complex liver injuries. The predominant mode of injury was road traffic accidents in 91.2%. The grade distribution of liver injuries was grade III (72.8%), grade IV (23.3%) and grade V (4.9%). Twenty-four patients (23.3%) underwent surgery for persistent hemodynamic instability, persistent fall in hemoglobin level, bile leaks and intra-abdominal collection with sepsis. Associated intra-abdominal injuries were present in 19.4%, and 58.4% had associated extra-abdominal injuries. The operative procedures included hepatectomy (1), suture hepatorraphy (12), T-tube drainage for bile duct injuries (5), perihepatic sponge and gel foam packing (9), liver abscess drainage (3), and resection and debridement of liver tissue in six patients. The mortality and morbidity in this series was 10.7 and 56.4%, respectively. Multiorgan failure was present in 5, single organ failure in 37, sepsis in 24, biliary complications in 16 and intra-abdominal collection in 17 patients. Endoscopic management for bile leaks was performed in five patients, image-guided pig-tail drainage for abscesses in 11 patients, while angioembolization was done in two patients for right hepatic artery bleed. The mortality was not significantly different in surgical and nonoperative groups but operated patients had significantly higher morbidity.

CONCLUSIONS

Complex liver injuries can be managed successfully with conservative treatment in majority, with low mortality and acceptable morbidity. Surgery is reserved for selected indications.

Endoscopic management of traumatic hepatobiliary injuries

BACKGROUND

Non-surgical treatment has become the therapeutic method of choice in hemodynamically stable patients with liver trauma. There are a few reports of endoscopic management of traumatic hepatobiliary injuries in such patients; however, the optimal intervention is not known.

METHODS

Twenty patients with traumatic hepatobiliary injuries from May 1997 to November 2005 were retrospectively evaluated.

RESULTS

There were 18 male and two female patients with a mean age of 21.45 +/- 10.17 years (range 7-42 years). Seven patients were children. Patients presented 19.4 +/- 17.04 days following trauma. Computed tomography (CT) revealed hepatic laceration in right lobe in 14 (70%) and in left lobe in six (30%) patients. Endoscopic retrograde cholangiopancreatography (ERCP) revealed biliary leak in right duct in 14 (70%) and in left duct in six (30%) patients. Five patients also had bilhemia and one had hemobilia. Thirteen patients (65%) were treated by endoscopic sphincterotomy with nasobiliary drainage and seven (35%) were treated by nasobiliary drainage alone, which enabled fistula closure in 15.76 +/- 4.22 days and 12.14 +/- 3.93 days, respectively (P > 0.05). One patient in sphincterotomy group died due to multiple bony injuries and fat embolism. Two patients developed fever following ERCP, which responded to antibiotic treatment.

CONCLUSIONS

Endoscopic treatment with nasobiliary drainage without sphincterotomy is the optimal method of management of traumatic hepatobiliary injuries in hemodynamically stable patients.

Complications of nonoperative management of pediatric blunt hepatic injury: Diagnosis, management, and outcomes

BACKGROUND

Nonoperative management (NOM) of blunt hepatic injury is the standard of care in the hemodynamically stable pediatric patient, but it is not without pitfalls. The purpose of this study is to assess the incidence and types of complications associated with NOM in terms of diagnosis, management, and outcomes.

METHODS

A retrospective study of pediatric patients with blunt hepatic injuries admitted from 1991 through 1997 to a Level I pediatric trauma center was conducted. All stable patients were initially managed nonoperatively according to the Isolated Liver Laceration Critical Pathway. Surveillance was performed by physical examination and tracking of hematocrit and liver function test (LFT) results. Follow-up ultrasound (US) or computed tomography (CT) were performed as clinically indicated.

RESULTS

In all, 185 patients with nonoperatively managed blunt hepatic injuries were identified during a 7-year period. Over 90% (168/185) were successfully managed nonoperatively without adverse sequelae. Ten patients (5.4%) died: seven as a result of head injury; three as a result of multisystem organ failure; none directly attributable to their hepatic injuries. Complications occurred in seven patients (3.8%) with Grades III or IV right lobe liver lacerations and included biloma (5), hepatic artery pseudoaneurysm with hemobilia (1), and necrotic gallbladder (1). All seven patients (100%) had fever, persistent or worsening right upper quadrant pain, feeding intolerance, and persistently elevated LFTs. Complications were diagnosed by CT or US. Nonoperative treatment of complications was successful in four of the seven patients (57.1%) and consisted of percutaneous drain placement only (1), percutaneous drain placement and endoscopic retrograde cholangiopancreatography (ERCP)-guided stent placement (2) and angioembolization (1). Three patients (42.9%) required laparotomy, one for management of a concomitant pancreatic pseudocyst.

CONCLUSION

Complications of NOM of pediatric blunt hepatic injury are rare, but may include biloma, hepatic artery pseudoaneurysm, and necrotic gallbladder. Complications occur only with Grade III or greater injuries and are accompanied by fever, right upper quadrant pain, feeding intolerance, and persistently elevated LFTs. The clinician must maintain a high index of suspicion for the development of complications and have a low threshold for obtaining a CT or US for diagnosis. Interventional radiology techniques, angiography, and ERCP are useful adjuncts to nonoperative management, but some patients may still require laparotomy for management of complications.

Postoperative management of noniatrogenic traumatic bile duct injuries: role of endoscopic retrograde cholangiopancreaticography

BACKGROUND

Endoscopic therapy for iatrogenic bile duct injuries is well established. Abdominal trauma-related biliary injuries, however, are complex in nature. The role of endoscopic therapy for these patients needs further evaluation.

METHODS

A retrospective study investigated nine patients who had surgery for abdominal trauma (4 gunshot, 4 crush, and 1 stab injury), presented postoperatively with noniatrogenic biliary injuries, and underwent endoscopic retrograde cholangiopancreaticography (ERCP).

RESULTS

The ERCP was successful for all the patients. Eight patients had significant bile leak at intra- or extra-hepatic sites, and one patient was discovered to have complete cutoff of the common hepatic duct. All bile leaks were treated successfully using biliary sphincterotomy with or without transpapillary stenting. No complications of ERCP were observed.

CONCLUSIONS

In this case series, ERCP was found to be useful as a diagnostic and therapeutic method for managing noniatrogenic traumatic biliary injuries in patients who had undergone previous surgery for abdominal trauma. The ERCP results were similar to those for iatrogenic bile duct injuries.

Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention

BACKGROUND

Nonoperative management of blunt pediatric liver injuries has become the standard of care in the absence of hemodynamic instability. However, associated bile duct injuries remain as difficult challenges. Few case reports have demonstrated the benefits of conservative approaches, but others have found better outcomes with surgical intervention. In this study, we report on our experience with interventional endoscopic and radiologic management of 5 pediatric patients with bile duct injuries who underwent unsuccessful surgical interventions.

METHODS

We conducted a retrospective review of medical records of all pediatric patients who were admitted with major blunt liver trauma and bile duct injuries over a period of 5 years.

RESULTS

There were 5 patients (4 boys and 1 girl) whose ages range from 3 to 11 years in this study. All patients had major liver laceration and bilomas. Two had intrahepatic and 3 had extra hepatic bile duct injuries (2 right hepatic ducts and 1 junction of cystic duct with common bile duct). All of them underwent previous laparotomies, once in 2 patients, twice in 2 patients, and thrice in 1 patient. All 5 patients were eventually treated successfully with interventional endoscopic and radiologic techniques. Three underwent endoscopic retrograde cholangiopancreatography stenting with percutaneous drainage. Two patients were managed with percutaneous drainage alone. The follow-up is up to 2.5 years with normal liver function test and bile duct ultrasound.

CONCLUSION

With the current advancement in endoscopic retrograde cholangiopancreatography and intervention radiology techniques, we believe that interventional endoscopic and radiologic management of bile duct injuries caused by blunt trauma in children is successful and efficacious even after multiple laparotomies.

CT in blunt liver trauma

Nonsurgical treatment has become the standard of care in hemodynamically stable patients with blunt liver trauma. The use of helical computed tomography (CT) in the diagnosis and management of blunt liver trauma is mainly responsible for the notable shift during the past decade from routine surgical to nonsurgical management of blunt liver injuries. CT is the diagnostic modality of choice for the evaluation of blunt liver trauma in hemodynamically stable patients and can accurately help identify hepatic parenchymal injuries, help quantify the degree of hemoperitoneum, and reveal associated injuries in other abdominal organs, retroperitoneal structures, and the gastrointestinal tract. The CT features of blunt liver trauma include lacerations, subcapsular or parenchymal hematomas, active hemorrhage, juxtahepatic venous injuries, periportal low attenuation, and a flat inferior vena cava. It is important that radiologists be familiar with the liver injury grading system based on these CT features that was established by the American Association for the Surgery of Trauma. CT is also useful in the assessment of delayed complications in blunt liver trauma, including delayed hemorrhage, hepatic or perihepatic abscess, posttraumatic pseudoaneurysm and hemobilia, and biliary complications such as biloma and bile peritonitis. Follow-up CT is needed in patients with high-grade liver injuries to identify potential complications that require early intervention.

Complications of Nonoperative Management of High-Grade Blunt Hepatic Injuries

BACKGROUND

Nonoperative management of blunt hepatic injuries is highly successful. Complications associated with high-grade injuries, however, have not been well characterized. The purpose of the present study was therefore to define hepatic-related complications and associated treatment modalities in patients undergoing nonoperative management of high-grade blunt hepatic injuries.

METHODS

Three hundred thirty-seven patients from two regional Level I trauma centers with grade 3 to 5 blunt hepatic injuries during a 40-month period were reviewed. Complications and treatment of hepatic-related complications in patients not requiring laparotomy in the first 24 hours were identified.

RESULTS

Of 337 patients with a grade 3 to 5 injury, 230 (68%) were managed nonoperatively. There were 37 hepatic-related complications in 25 patients (11%); 63% (5 of 8) of patients with grade 5 injuries developed complications, 21% (19 of 92) of patients with grade 4 injuries, but only 1% (1 of 130) of patients with grade 3 injuries. Complications included bleeding in 13 patients managed by angioembolization (n = 12) and laparotomy (n = 1), liver abscesses in 2 patients managed with computed tomography-guided drainage (n = 2) and subsequent laparotomy (n = 1). In one patient with bleeding, hepatic necrosis followed surgical ligation of the right hepatic artery and required delayed hepatic lobectomy. Sixteen biliary complications were managed with endoscopic retrograde cholangiopancreatography and stenting (n = 7), drainage (n = 5), and laparoscopy (n = 4). Three patients had suspected abdominal sepsis and underwent a negative laparotomy, whereas an additional three patients underwent laparotomy for abdominal compartment syndrome.

CONCLUSION

Nonoperative management of high-grade liver injuries can be safely accomplished. Mortality is low; however, complications in grade 4 and 5 injuries should be anticipated and may require a combination of operative and nonoperative management strategies.

Mangafodipir-enhanced magnetic resonance cholangiography for the diagnosis of bile duct leaks

BACKGROUND

The purpose of this prospective study was to assess the value of contrast-enhanced magnetic resonance cholangiography with mangafodipir trisodium perfusion for detection and localization of trauma-induced and postoperative bile duct leaks.

METHODS

Eleven patients with suspected bile duct leaks after trauma (n=5) or surgery (n=6) were included. Patients with suspected leaks after cholecystectomy were excluded. All patients underwent contrast-enhanced magnetic resonance cholangiography with two-dimensional axial and three-dimensional coronal gradient-echo images acquired 1 to 3 hours after intravenous administration of mangafodipir trisodium perfusion. Contrast-enhanced magnetic resonance cholangiography findings were correlated with direct cholangiography obtained in all patients, including endoscopic retrograde (n=7) and percutaneous transhepatic cholangiography (n=4).

RESULTS

Biliary tract enhancement was identified in all patients on contrast-enhanced magnetic resonance cholangiography. Peritoneal cavity fluid and bile collections that contained extravasated mangafodipir trisodium (increased signal intensity on gradient-echo sequences) were demonstrated in 6 patients. Direct cholangiography confirmed the presence of bile duct leaks in these 6 patients and the absence of bile duct leaks in 5 patients. There was no false-negative or false-positive contrast-enhanced magnetic resonance cholangiography.

CONCLUSIONS

Mangafodipir-enhanced magnetic resonance cholangiography is a noninvasive technique that can provide functional biliary information with excellent depiction of bile duct leaks.

Benefits of early diagnosis and preemptive treatment of biliary tract complications after major blunt liver trauma in children

BACKGROUND/PURPOSE

Nonoperative management of blunt liver trauma may delay diagnosis of related biliary complications leading to delayed surgical intervention and related morbidity. The aim of this study was to see whether technetium (tc) 99 trimethylbromo-im-indolacetic acid (TBIDA) nuclear scan would allow noninvasive early diagnosis of bile leak and pre-emptive management.

METHODS

Retrospective analysis of the patient records and radiologic investigations of 7 patients admitted between April 1998 and December 2000 with "major" blunt liver trauma (parenchymal fracture of less than 4 cm on computed tomography [CT] scan or involving porta hepatis) and various types of biliary complications. Patients with or without early TBIDA diagnosis were compared.

RESULTS

There were 7 patients. The first 2 patients were treated conventionally without TBIDA, and late diagnosis was associated with further related problems (sepsis, life-threatening hemorrhage in both cases) and prolonged hospital stay. The subsequent 5 consecutive patients benefited from early diagnosis (TBIDA scan, 2 to 4 days after trauma), and preemptive management was done (tailored to each case). There was no further or related morbidity. All 7 patients currently are alive and well.

CONCLUSIONS

A TBIDA nuclear medicine scan was efficient in providing an early diagnosis of biliary leakage, thus, allowing adequate preemptive management. In turn, this may have helped avoid related added morbidity compared with cases of late diagnosis. Early TBIDA scan should be performed routinely when the initial CT scan confirms liver trauma graded as "major."

A minimally invasive approach to bile duct injury after blunt liver trauma in pediatric patients

A 12-year-old boy presented with a large liver laceration after blunt abdominal trauma. He was treated nonoperatively and subsequently had bile peritonitis from a bile leak. Endoscopic retrograde cholangiopancreatography (ERCP) visualized the bile duct injury and allowed decompression of the biliary tree with an endoscopically placed biliary stent. A drain also was placed over the laceration through a small subcostal incision. The patient recovered rapidly after this minimally invasive procedure and went home 9 days later.

Biliary Complications After Liver Transplantation

The incidence of biliary complications after liver transplant is estimated to be 8% to 20%. Post-liver transplant biliary complications may lead to acute and chronic liver injury. The early recognition and prompt treatment of such complications improves the long-term survival of the patient and graft. An understanding of the type of biliary reconstruction, the rationale for creating a particular anastomosis, and the technical difficulties in reconstructing the biliary tract are important in assessing and managing complications after liver transplant. Because the clinical presentation of these patients may be subtle, the physician must be aggressive and thoughtful in ordering and interpreting the diagnostic tests. Important points to remember are 1) that noninvasive examinations may fail to detect small obstructions or leaks, 2) a liver biopsy often is performed prior to cholangiography to exclude rejection and ischemia, and 3) the liver biopsy can miss an extrahepatic obstruction by misinterpreting portal inflammation as rejection. Biliary leaks and strictures are the most common biliary complications following liver transplant. Less common complications include ampullary dysfunction and stone/sludge formation. The effective management of biliary complications following a liver transplant depends on understanding the natural history, the prognosis, and the available therapeutic options for each type of complication.

Haemobilia

BACKGROUND

This review aims to establish whether increased use of invasive procedures and the trend toward conservative management of major trauma has resulted in an increased incidence of haemobilia.

METHOD

A Medline (http://igm.nlm.nih.gov/)-based search of the English language literature from January 1996 to December 1999 inclusive was performed using the keywords haemobilia, hemobilia, haematobilia and hematobilia. The presentation, aetiology, investigation, management and outcome of 222 cases were reviewed.

RESULTS

Two-thirds of cases were iatrogenic while accidental trauma accounted for 5 per cent. Haemobilia may be major, constituting life-threatening haemorrhage, or minor; it may present many weeks after the initial injury. Diagnosis is most commonly confirmed by angiography. Management is aimed at stopping bleeding and relieving biliary obstruction; 43 per cent of cases were managed conservatively and 36 per cent were managed by transarterial embolization (TAE). Surgery was indicated when laparotomy was performed for other reasons and for failed TAE. The mortality rate was 5 per cent.

CONCLUSIONS

Although the incidence of iatrogenic haemobilia has risen considerably, the bleeding is often minor and can be managed conservatively. When more urgent intervention is required, TAE is usually the treatment of choice. There is no evidence that the conservative management of accidental liver trauma increases the risk of haemobilia.

Major intrahepatic bile duct injuries detected after laparotomy: selective nonoperative management

BACKGROUND

Abdominal trauma causing major intrahepatic bile duct injury is a relatively uncommon occurrence. Most authorities recommend operative, usually resectional, management of these injuries when recognized, citing increased risks of complications and mortality with nonoperative management. However, very few data have been published to document the optimal management of these challenging injuries.

METHODS

We present a series of five patients with significant hepatic injury and documented major bile duct injury managed at a single provincial trauma center. All of these patients had first- or second-order bile duct injuries diagnosed using endoscopic retrograde cholangiopancreatography and had developed complications caused by the ductal injury.

RESULTS

In all patients, the bile duct injury and resulting complication were successfully managed by a combination of endoscopic drainage procedures and interventional radiology techniques. Average length of hospital stay for these patients was 45 days. All patients eventually attained preinjury functional status.

CONCLUSION

Nonoperative techniques can be used to successfully manage selected patients and represent a reasonable alternative to operative intervention and resectional therapy, especially in the compromised patient. Extended length of stay is to be expected, but good outcomes can be achieved.

Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma

BACKGROUND

Pooling of contrast material on computed tomographic (CT) scan represents free extravasation of blood as a result of active bleeding. For patients with blunt hepatic injury, aggressive management such as angiography or celiotomy is usually indicated if this sign is detected. The purposes of this study were to further categorize this CT scan finding and to correlate its characteristics with clinical outcomes. This CT scan classification might be helpful for the selection of appropriate management.

METHODS

During a 42-month period, 276 patients with blunt hepatic injury were treated. Two hundred twelve of them were hemodynamically stable after initial resuscitation and underwent abdominal CT scan examination. Pooling of contrast material was detected on the CT scans of 15 patients. The CT scans and medical records were reviewed. Special attention was paid to the presence, location, and character of the extravasated contrast material.

RESULTS

The finding of pooling of contrast material on CT scan was categorized into three types according to its location and character. Type I showed extravasation and pooling of contrast material in the peritoneal cavity (six patients). All patients with type I CT scan findings became hemodynamically unstable soon after CT scan examination and required emergent laparotomy. Type II findings showed simultaneous presence of hemoperitoneum and intraparenchymal contrast material pooling (six patients). Four patients with type II CT scan findings required laparotomy for hemostasis. Type III findings showed intraparenchymal contrast material pooling without hemoperitoneum (three patients). All patients with type III CT scan signs remained hemodynamically stable.

CONCLUSION

With the use of a high-speed spiral CT scanner, it is possible to predict the necessity of operative management or angiography for patients with blunt hepatic injury before deterioration of hemodynamic status. The presence of pooling of contrast material within the peritoneal cavity indicates active and massive bleeding. Patients with this CT scan finding show rapid deterioration of hemodynamic status. Most of these patients might require emergent surgery. Pooling of contrast material in a ruptured hepatic parenchyma indicates active bleeding. Close monitoring and emergent angiography should be performed. Deterioration of hemodynamic status in these patients usually requires prompt surgical intervention. Intraparenchymal pooling of contrast material with unruptured liver capsule often indicates a self-limited hemorrhage. Patients with this CT scan finding have a high possibility of successful nonoperative treatment.

Blunt hepatic injury: minimal intervention is the policy of treatment

BACKGROUND

Many publications recommend nonoperative treatment for stable blunt hepatic injury patients. Unstable hemodynamic status is the only indication for surgery. When operation is indicated, controversies exist regarding which operative procedure will be more beneficial to the patients. The purposes of this study are to compare the results of operative and nonoperative management of patients with blunt hepatic injuries and to identify the optimal surgical approach when surgery is indicated.

METHODS

Different prospective protocols of treating adult blunt hepatic injuries were conducted. From 1992 to 1993 (group I), urgent surgery would be performed in the presence of hemoperitoneum. The policy shifted to aggressive nonoperative approach between 1996 and 1997 (group II). The patients from each period were divided into three subgroups. Group A included the patients who received nonoperative treatment in either period. Group B consisted of the patients who received surgery in the first period and nonoperative management in the second period. Group C included the patients who were operated on in either group. Comparisons were made between matched groups.

RESULTS

Groups IA and IIA patients had minor injuries and could be successfully treated nonoperatively. The results of groups IB and IIB were similar concerning hospital stay, morbidity, and mortality. Transfusion requirements of group IIB patients were significantly higher (2.2 vs. 1.1 units,p = 0.01) than those of group IB. However, 25 (58%) celiotomies of group IB patients were nontherapeutic. When surgery was indicated, group IC patients had significantly higher liver-related mortality (14 of 49 vs. 3 of 55, p = 0.002). Anatomic resection was performed more frequently in that period.

CONCLUSION

Nonoperative treatment significantly decreased the rate of nontherapeutic laparotomy but carried the risks of higher transfusion requirements and delaying operation. When surgery was indicated, the policy of minimal intervention positively affected the patients' outcomes. The goal of surgery should be hemorrhage control rather than resection of the injured liver tissues.

Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s

OBJECTIVE

To analyze the outcome of hemodynamically stable patients with blunt hepatic injury managed nonoperatively, and to examine the impact of this approach on the outcome of all patients with blunt hepatic injury.

SUMMARY BACKGROUND DATA

Until recently, operative management has been the standard for liver injury. A prospective trial from the authors' institution had shown that nonoperative management could safely be applied to hemodynamically stable patients with blunt hepatic injury. The present study reviewed the authors' institutional experience with blunt hepatic trauma since that trial and compared the results with prior institutional experience.

METHODS

Six hundred sixty-one patients with blunt hepatic trauma during the 5-year period ending December 1998 were reviewed (NONOP2). The outcomes were compared with two previous studies from this institution: operative 1985 to 1990 (OP) and nonoperative 1993 to 1994 (NONOP1).

RESULTS

All 168 OP patients were managed operatively. Twenty-four (18%) of 136 NONOP1 patients and 101 (15%) of the 661 NONOP2 patients required immediate exploration for hemodynamic instability. Forty-two (7%) patients failed nonoperative management; 20 were liver-related. Liver-related failures of nonoperative management were associated with higher-grade injuries and with larger amounts of hemoperitoneum on computed tomography scanning. Twenty-four-hour transfusions, abdominal infections, and hospital length of stay were all significantly lower in the NONOP1 and NONOP2 groups versus the OP cohort. The liver-related death rate was constant at 4% in the three cohorts over the three time periods.

CONCLUSIONS

Although urgent surgery continues to be the standard for hemodynamically compromised patients with blunt hepatic trauma, there has been a paradigm shift in the management of hemodynamically stable patients. Approximately 85% of all patients with blunt hepatic trauma are stable. In this group, nonoperative management significantly improves outcomes over operative management in terms of decreased abdominal infections, decreased transfusions, and decreased lengths of hospital stay.

A Minimally Invasive Approach to Bile Peritonitis after Blunt Liver Injury

The advent of nonoperative management of liver injuries has made it imperative that surgeons be familiar with the potential delayed complications of this approach. In this report, we describe a minimally invasive strategy for the management of bile peritonitis following nonoperative management of blunt liver injuries. Two cases are presented in which bile peritonitis with massive bile ascites was managed with laparoscopic localization and drainage of the bile leak, irrigation of the peritoneal cavity, and postoperative endoscopic retrograde cholangiography with bile duct stenting. In both cases the bile leak ceased, and the patients recovered without adverse sequelae. The combination of laparoscopic surgery and endoscopic stenting provides a minimally invasive approach to this entity.

Endoscopic biliary stenting for treatment of persistent biliary fistula after blunt hepatic injury

BACKGROUND

Surgical treatment for persistent biliary fistula after blunt hepatic injury is often technically difficult. Endoscopic treatment for such fistulas has been described only infrequently.

METHODS

We reviewed 6 patients who underwent endoscopic biliary stent placement with (n = 1) or without (n = 5) sphincterotomy for persistent (12 to 138 days; mean 48 days) biliary fistula after blunt hepatic injury.

RESULTS

ERCP showed bile leakage from a second-order or more peripheral branch of the intrahepatic bile ducts in 5 patients but failed to reveal the fistula in 1. Stent placement was successful without complications in all patients. Bile leakage resolved within 1 to 3 days in 5 patients. After 36 to 86 days, the stent was removed and ERCP confirmed disappearance of the fistula. These patients have remained asymptomatic for a mean of 2.6 years since stent removal. In the patient in whom ERCP had not shown a fistula, bile leakage continued despite successful stent placement.

CONCLUSIONS

Endoscopic biliary stent placement is a rapid, safe and effective treatment for persistent post-traumatic biliary fistula demonstrated by ERCP.

Complete biliary avulsion from blunt compression injury

The liver is the solid organ most commonly injured as a result of blunt abdominal trauma. Complete avulsion of the common hepatic duct is a rare and devastating type of hepatobiliary trauma. Here the authors report the case of a 7-year-old child who had complete biliary disruption as a result of an abdominal crush injury that was not diagnosed correctly preoperatively. The intraoperative diagnosis and treatment of this injury is discussed.

Pooling of contrast material on computed tomography mandates aggressive management of blunt hepatic injury

BACKGROUND

Nonoperative management of blunt hepatic injury is currently a widely accepted treatment modality. Computed tomography (CT) is an important imaging study both for diagnosis and follow-up of these patients. There is, however, no reliable predictor of failure of nonoperative treatment other than the ultimate development of hemodynamic instability. Previous reports mostly were based on the data obtained from low-speed dynamic incremental scanners. The purpose of this study is to evaluate the value of a high-speed helical scanner in predicting the outcome of patients managed nonoperatively.

METHODS

During a 30-month period, 194 patients with blunt hepatic injury were treated, 150 of them were hemodynamically stable after initial resuscitation and underwent abdominal CT examination. All CT scans were performed with the High Speed Advantage Scanner. The CT scans and medical records were reviewed.

RESULTS

Nonoperative management was successfully applied to all patients with grade I and II, 93% of grade III, 87% of grade IV, and 67% of grade V liver injuries. Twelve patients required liver-related celiotomy. Pooling of contrast material was detected on the CT scans of 8 patients. Six (75%) of these patients developed hemodynamic instability and required liver-related celiotomy later. Pooling of contrast material can be detected in 50% of the patients receiving liver-related celiotomy.

CONCLUSION

The presence of pooling of contrast material within the hepatic parenchyma indicates free extravasation of blood as a result of active bleeding. In patients with blunt hepatic injury, if this sign is detected, nonoperative treatment should be terminated and angiography or celiotomy undertaken promptly. With the increasing use of high-speed spiral CT scanner and improvement in scanning technique, pooling of contrast material may become a sensitive sign for active bleeding and may be used as a guide for the selection of treatment modality.

Non-operative management of blunt hepatic trauma

BACKGROUND

Non-operative management is currently considered the treatment of choice in over 50 per cent of adult patients with blunt liver injury. This report reviews the criteria for non-operative management and its potential downside.

METHODS

English language publications were reviewed.

RESULTS

Most reports from major trauma centres in the USA support the non-operative treatment of patients with blunt liver injury if well established criteria are met. Using such criteria, non-operative treatment is successful in 50-80 per cent of cases. Adjunctive radiological techniques may be helpful in managing some complications of non-operative treatment.

CONCLUSION

Non-operative management is safe in haemodynamically stable patients with blunt liver injury. Computed tomography (CT) of the abdomen is extremely useful to document the extent of the damage and the presence of associated injuries, but it is not possible, based on CT alone, to predict failure; careful physiological monitoring in selected patients is indicated to avoid catastrophic complications.

A simple stenting method for management of hepatic ductal injury secondary to blunt abdominal trauma: two case reports

We report two cases of liver injury with hepatic ductal disruption after blunt abdominal trauma. The first case involves a 23-year-old male. Because the bifurcation of the hepatic duct was longitudinally torn, two stenting catheters were inserted toward the right and left hepatic ducts without suture closure of the tear. The patient is well 10 years after the injury. The second case involves a 22-year-old male who suffered an infarction of the inferior portion of the medial segment of the left hepatic lobe as well as a laceration of the left hepatic duct, a 50% circumferential tear. A stenting catheter was introduced into the left hepatic duct, but the defect was not sutured. The patient is well 1.5 years after the injury. The catheter stenting method without suture repair or defect plasty is a simple and effective way to manage hepatic ductal injury.

Nonoperative Management of Solid Abdominal Visceral Injury: Part II. Liver and Kidney

Only in recent years has it been recognized that the injured liver is not only capable of spontaneous hemostasis, but also that it can heal itself remarkably well without surgical intervention. Currently, the approach to stable patients with blunt liver trauma should be nonoperative, regardless of the age of the patient, the degree of liver injury, or the amount of blood in the peritoneal cavity. However, success with this method of management is highly dependent on selection of patients whose liver has ceased bleeding and who do not have an associated intra-abdominal injury in need of operative repair. Similarly, a nonoperative approach is appropriate in patients with blunt renal trauma if the injury is properly staged and if major urinary extravasation and vascular injuries are not present.

Complex hepatic injuries

The most significant contribution to the management of hepatic injuries over the past 5 years has been the nonoperative management of blunt injuries in the adult patient. Recent data suggest that as many as 80% of all blunt hepatic injuries may be treated in this fashion, with a success rate exceeding 95%. The fear of missing hollow viscus injuries, as well as the risk of sudden hemorrhage in the observational period, leading to an increase in hepatic-related deaths, seems exaggerated. The intraoperative management of complex hepatic injuries revolves around strict adherence to resuscitation prior to addressing the lesion itself. At times, "damage control" with termination of surgery and "packing" the patient with planned re-exploration are critical, as these maneuvers are often lifesaving. The Pringle maneuver and intrahepatic hemostasis for grades III to IV injuries have resulted in a mortality rate under 10%. Juxtahepatic venous injuries continue to carry an inordinately high mortality rate. Intracaval shunts, when used, should be inserted early in the course of the operation before excess transfusions are given and acidosis and hypothermia develop.

Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients

INTRODUCTION

Nonoperative management is presently considered the treatment modality of choice in over 50% of adult patients sustaining blunt hepatic trauma who meet inclusion criteria. A multicenter study was retrospectively undertaken to assess whether the combined experiences at level I trauma centers could validate the currently reported high success rate, low morbidity, and virtually nonexistent mortality associated with this approach. Thirteen level I trauma centers accrued 404 adult patients sustaining blunt hepatic injuries managed nonoperatively over the last 5 years. Seventy-two percent of the injuries resulted from motor vehicle crashes. The mean injury severity score for the entire group was 20.2 (range, 4-75), and the American Association for the Surgery of Trauma-computerized axial tomography scan grading was as follows: grade I, 19% (n = 76); grade II, 31% (n = 124); grade III, 36% (n = 146); grade IV, 10% (n = 42); and grade V, 4% (n = 16). There were 27 deaths (7%) in the series, with 59% directly related to head trauma. Only two deaths (0.4%) could be attributed to hepatic injury. Twenty-one (5%) complications were documented, with the most common being hemorrhage, occurring in 14 (3.5%). Only 3 (0.7%) of these 14 patients required surgical intervention, 6 were treated by transfusions alone (0.5 to 5 U), 4 underwent angio-embolization, and 1 was further observed. Other complications included 2 bilomas and 3 perihepatic abscesses (all drained percutaneously). Two small bowel injuries were initially missed (0.5%), and diagnosed 2 and 3 days after admission. Overall, 6 patients required operative intervention: 3 for hemorrhage, 2 for missed enteric injuries, and 1 for persistent sepsis after unsuccessful percutaneous drainage. Average length of stay was 13 days. Nonoperative management of blunt hepatic injuries is clearly the treatment modality of choice in hemodynamically stable patients, irrespective of grade of injury or degree of hemoperitoneum. Current data would suggest that 50 to 80% (47% in this series) of all adult patients with blunt hepatic injuries are candidates for this form of therapy. Exactly 98.5% of patients analyzed in this study successfully avoided operative intervention. Bleeding complications are infrequently encountered (3.5%) and can often be managed nonoperatively. Although grades IV and V injuries composed 14% of the series, they represented 66.6% of the patients requiring operative intervention and thus merit constant re-evaluation and close observation in critical care units. The optimal time for follow-up computerized axial tomography scanning seems to be within 7 to 10 days after injury.

The current status of nonoperative management of adult blunt hepatic injuries

This review of 14 recent publications encompassing 495 patients highlights the current role of the nonoperative management of adult blunt hepatic injuries. When careful inclusion criteria were met, the most important of which is hemodynamic stability, a 94% success rate was achieved, clearly attesting to the safety and efficacy of this approach. A 0% liver-related mortality in these 495 patients was achieved, and there were no documented missed enteric injuries. Delayed hemorrhage that led to laparotomy occurred in 2.8% of patients. The mean length of hospital stay was 13 days, and the mean transfusion requirement was 1.9 units of blood per patient. Computed axial tomography scanning was essential and played an integral role in delineating the extent of the injury, identifying other intra-abdominal injuries that would mandate immediate laparotomy, and following the progress of injury resolution. Overall, 34% of blunt liver injuries were managed nonoperatively. As of 1993, however, available data confirms that 51% of adult reported blunt hepatic injuries have been treated nonoperatively. Rigid adherence to the described guidelines may allow the majority of blunt hepatic injuries to be treated nonoperatively. It should be stressed, however, that this method of patient management should only be undertaken at institutions where the appropriate resources necessary to deal with this patient population are readily available.

The role of angiography in the assessment of blunt liver injury

Angiography and therapeutic embolism (TE) were studied retrospectively in cases of blunt liver injury with regard to their indications and usefulness. The management of patients fell into three groups distinguished by the clinical evidence of the severity of the liver injuries. The most severe 42 cases (39.6 per cent) were managed surgically and promptly, the least severe 38 cases were not subjected to angiography and the intermediate group (26 cases; 24.5 per cent) underwent angiography and 12/26 cases underwent TE. However, haemodynamic stability on admission was not significantly different between these groups. In addition, all patients who underwent angiography and TE had more severe parenchymal injury on imaging studies while their haemodynamic instability was not identified on admission. Angiography and TE for blunt liver injury were most strongly indicated in patients with good haemodynamic responses to intravenous fluid administration during the acute phase and/or in cases of severe parenchymal injury on imaging.