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.     

Liver abscess after non-operative management of blunt liver injury

BACKGROUND: The non-operative management of blunt liver trauma can be applied in almost 80% of patients with this type of injury, with the advantages of the need for fewer blood transfusions, less intra-abdominal sepsis, and a better survival rate, than with the operative approach. However, liver abscess, as a known complication of the non-operative management of blunt liver trauma, is discussed infrequently. Therefore, we herein review our experience and describe this complication in detail. MATERIALS AND METHODS: From 1995 to 2001, 674 patients were admitted to our hospital due to blunt hepatic trauma. Among these patients, 279 underwent laparotomy and the remaining 395 patients were treated non-operatively. Twenty-two patients were identified as having liver abscess, with 16 of them belonging to the operative group, and six to the non-operative group. A retrospective review of these six patients and their characteristics, as well as pathogenesis, diagnosis, and the management of the liver abscesses, was conducted. RESULTS: These six patients were all male, with a median age of 19.5 years (range 3-24). The median injury severity score was 16.5 (range 9-25); three patients sustained grade-3 hepatic injury, and the other three were grade 4. The main diagnostic tool was abdominal computed tomography, and the abscesses took a median of 6 days (range 1-12) to form and be diagnosed. The abscesses were usually caused by infection from mixed organisms, and an abscess resulting from Clostridium infection developed within 1 day after injury. These abscesses were treated with antibiotics and drainage, and the median length of hospital stay was 26 days (range 8-44), without mortality or long-term morbidity. CONCLUSION: Liver abscess as a complication of the non-operative management of blunt hepatic trauma is a rare entity, with an incidence of 1.5% (6/395). It is usually seen in severe liver injury (grade 3 and above), but all our patients were all treated successfully, with no mortality. However, prolonged hospitalization may be required in this patient group.     

Diagnosis and management of bile leaks after blunt liver injury

BACKGROUND: Nonoperative management (NOM) of blunt liver injuries (BLIs) is common, but little data exist on the management of complications related to NOM. Furthermore, bile leaks are emerging as frequent complications of NOM. The goal of this study was to determine which BLI patients are at greatest risk for bile leaks and how to manage this complication. METHODS: Patients treated with NOM, including angiographic embolization (AE) and observation, were compared with those undergoing operation (OR). Mortality, hospital length of stay, liver-related complications, and severity of liver injury were compared among the groups. RESULTS: Two hundred eighty-one patients sustained a BLI from 1997 through 2004. The Injury Severity Score and age of the groups were similar. The mortality rate of the OR patients was higher (P = .02). All bile leaks occurred in patients with a liver Abbreviated Injury Score (AIS) of > or = 4. For survivors of more than 4 days, 71% of OR, 50% of AE, and 17% of observed patients developed bile leaks. For the OR and AE groups, HIDA scanning detected all leaks, leading to earlier drainage procedures. Detection of a bile leak in NOM patients before 5 days of hospitalization led to shorter HLOS, P = .02. No patient with a negative HIDA scan developed a subsequent bile leak. CONCLUSIONS: NOM of BLIs is associated with lower mortality, but significant complications. Bile leaks are more common in patients with higher liver AIS, and in this study presented in only those with liver AIS > or = 4. HIDA scanning successfully diagnosed all patients with bile leaks and led to less invasive drainage procedures over time and shorter HLOS.     

Early-onset liver abscess after blunt liver trauma: report of a case

A 23-year-old male patient underwent nonoperative management for his blunt liver trauma as he was hemodynamically stable without any signs of peritonitis initially after injury. A fever of 39.5°C and severe right upper quadrant abdominal pain developed on the second day, and an abdominal computed tomography (CT) scan showed the formation of a gas-containing liver abscess in the traumatized liver. An emergency laparotomy revealed a foul-smelling liver abscess at the traumatized site, which was finally disclosed to be the result of a Clostridium species infection. A liver abscess is a rare complication following the nonoperative management of liver injury, and such an occurrence is even more rare within 1 day after injury. A Clostridium species infection is responsible for the fulminant progressing nature of the disease because the devitalized, ischemic liver parenchyma is ideal for such growth, and this is the first time that a such condition has been shown by CT images. Close observation with a high degree of suspicion is required for the successful treatment of such abscesses. Received: March 28, 2002 / Accepted: July 2, 2002 Reprint requests to: C.-H. Hsieh     

Chyloperitoneum after blunt abdominal injury

The objective of this study was to evaluate incidence of chylous injury in blunt trauma using a retrospective chart review. We present two patients who sustained chyle duct injury after blunt trauma. The first patient is a pedestrian struck by car. Abdominal CT scan revealed duodenal thickening and a moderate amount of paraduodenal fluid, which prompted surgical exploration. At laparotomy, the patient was found to have a disruption of his lymphatics at the level of the inferior vena cava (IVC) without duodenal injury treated with hemoclips, fibrin sealant and elemental gastrojejunal feeds. The second patient was involved in a high speed motor vehicle collision (MVC) resulting in transection of the mesentery of the transverse colon. Disrupted lacteals were treated intra-operatively with hemoclips and fibrin sealant decreasing the lymph leak. In both cases, the leak completely resolved with use of tube feedings with medium chain triglycerides. On literature review, six prior patients with spontaneous chylous retroperitoneum were described undergoing similar operative management. Chylous leakage due to blunt trauma is a rare finding. Mechanism of injury includes hyperextension or flexion resulting in stretching and shearing of the tethered lymphatics. Open ligation or clipping of the injured ducts seems effective. Tube feeds with medium chain triglycerides may enhance efficacy of operative treatment.     

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.     

Phrenic nerve injury after blunt trauma

Phrenic nerve injury resulting from blunt trauma is unusual and may closely mimic diaphragmatic rupture. Diagnosis remains difficult and is often delayed. A prompt diagnosis requires a high index of suspicion. We describe one patient with phrenic nerve injury in whom the diagnosis was made late at the time of injury. Radiograph, ultrasonography, and computed tomography were helpful in the diagnosis. Video-assisted thoracic surgery was performed on our patient for diagnostic purposes. Left phrenic nerve injury and pericardial injury were found. Diaphragmatic plication was performed through a miniature left posterolateral thoracotomy. This case was presented to show the unusual nature of phrenic nerve injury.     

Cervical vessel injury after blunt trauma

Blunt trauma accounts for 3% to 10% of cervical vessel injuries. Death and severe neurologic impairment have been reported in more than 80% of blunt carotid injuries. In our recent experience, 10 patients sustained 18 blunt cervical arterial injuries: two internal carotid artery (ICA) dissections, three ICA transections with pseudoaneurysm, five ICA thromboses, two vertebral artery dissections, one vertebral artery transection with pseudoaneurysm, one vertebral artery thrombosis, one minimal vertebral artery injury, and three caroticocavernous fistulas. A delay of more than 12 hours in making the diagnosis occurred in seven of the 10 patients. The mental status was initially normal in seven patients. The subsequent development of focal neurologic findings incongruent with CT scanning of the head prompted four-vessel angiography. Treatment was individualized and included supportive management, intravenous heparin, ligation, extracranial-intracranial bypass, and radiologic embolization. We have developed an angiographic classification that may aid management. Early angiography in patients with neurologic findings incongruent with head CT scan or in whom a normal sensorium and hemiparesis are present may permit improved outcomes. We advocate direct operative repair for accessible lesions of recent onset. For surgically inaccessible lesions, those with delayed presentation or in some cases with a fixed neurologic deficit, intravenous heparin can be started and follow-up angiography, head CT scanning, and the patient's clinical status determine further therapy.     

Conservative management of hepatic duct injury after blunt trauma: a case report

Nonoperative management of solid organ injury in children with blunt abdominal trauma represents the standard of care. In rare cases, a major duct injury with persistent bile leakage may result from blunt trauma to the liver. This injury is of concern in patients treated nonoperatively because it generally must be treated with major abdominal surgery. The authors describe a case of hepatic duct injury from blunt trauma in which healing occurred without surgical repair or resection.     

Acute cholecystitis secondary to hemobilia after percutaneous liver biopsy.

A case of obstructive acute cholecystitis following percutaneous liver biopsy is presented. The patient complained of intense and continuous pain in the right upper quadrant of the abdomen 2 days after the liver biopsy. On abdominal examination, Murphy's sign was present. Hemogram revealed a fall in the hematocrit level from 44 to 38 because of hemobilia. Ultrasonography showed a dilated gallbladder with moderate thickness of the wall and a blood clot of 20 x 9 mm inside. The patient was subjected to laparoscopic cholecystectomy. The acute inflammation of the gallbladder was secondary to obstruction of the cystic duct by the blood clot. The postoperative period was uneventful.     

肝外伤术后血胆症的诊治体会(附4例报道)

目的探讨肝外伤术后血胆症的诊断及治疗。方法对我院1999年1月～2003年12月73例肝外伤术后并发血胆症4例进行回顾性分析。结果本组4例血胆症患者的手术是肝破裂缝合修补术后1例,肝脏清创不规则切除术后1例,填塞止血术后2例。术后发生胆道出血的时间均在术后1W～4W之内。4例均行了再次手术,其中1例再手术2次。治愈3例,死亡1例。结论血胆症是肝外伤术后的严重并发症,是一种非典型的胆道出血,以手术治疗为主。加深对血胆症的认识,对肝外伤创面进行彻底清创止血是防治本症的关键。     

Reimaging in pediatric blunt spleen and liver injury

Background

APSA guidelines do not recommend routine reimaging for pediatric blunt liver or spleen injury (BLSI). This study characterizes the symptoms, reimaging, and outcomes associated with a selective reimaging strategy for pediatric BLSI patients.