A. Nicol

Packing for Control of Hemorrhage in Major Liver Trauma

BackgroundPacking for complex liver injuries has been associated with an increased risk of abdominal sepsis and bile leaks. The aim of the present study was to determine the optimum timing of pack removal and to assess whether the total duration of packing increases the incidence of these complications.MethodsThe study was based on a retrospective review of all patients requiring liver packing over an 8-year period in a level 1 trauma center.ResultsNinety-three (17%) of 534 liver injuries identified at laparotomy required perihepatic packing. Penetrating and blunt trauma occurred in 72 (77%) and 21 (23%), respectively. The mean total duration of packing was 2.4 days (range: 0.5–6.0 days). There was no association between the total duration of packing and the development of liver-related complications (P = 0.284) or septic complications (P = 0.155). Early removal of packs at 24 h was associated with a higher rate of re-bleeding than removal of packs at 48 h (P = 0.006).ConclusionsThe total duration of liver packing does not result in an increase in septic complications or bile leaks. The first re-look laparotomy should only be performed after 48 h. An early re-look at 24 h is associated with re-bleeding and does not lead to early removal of liver packs.

Endoscopic treatment of persistent thoracobiliary fistulae after penetrating liver trauma

BACKGROUND This study evaluated the outcomes of patients with complex or persistent thoracobiliary fistulae following penetrating liver trauma, who underwent endoscopic biliary intervention at a tertiary referral centre. METHODS All patients who underwent endoscopic retrograde cholangiography (ERC) and endoscopic biliary intervention for traumatic thoracobiliary fistulae between 1992 and 2008 were evaluated. Bile duct injuries were classified according to their biliary anatomic location on cholangiography and type of pulmonary communication. RESULTS Twenty-two patients had thoracobiliary (pleurobiliary, n = 19; bronchobiliary, n = 3) fistulae. The site of the bile duct injury was identified in 20 patients on cholangiography. These 20 patients underwent either sphincterotomy and biliary stenting (n = 18) or sphincterotomy alone (n = 2). In 17 patients the fistulae resolved after the initial endoscopic intervention. Three patients required secondary stenting with replacement of the initial stent. Three patients developed mild pancreatitis after stenting and one stent migrated and was replaced. All fistulae healed after endoscopic treatment. In 18 patients the stents were removed 4 weeks after bile drainage ceased. Three of the 22 patients required a thoracotomy for infected loculated pleural collections after initial catheter drainage. CONCLUSIONS Endoscopic retrograde cholangiography is an accurate and reliable method of demonstrating post-traumatic thoracobiliary fistulae and endoscopic biliary intervention with sphincterotomy and stenting in this situation is safe and effective. Surgery in patients with thoracobiliary fistulae should be reserved for fistulae which do not heal after endoscopic biliary stenting or for patients who have unresolved pulmonary or intra-abdominal sepsis as a result of bile leak.