Management of External Biliary Fistula?
This question is regarding a biliary tract injury. I have a patient with a gunshot would at the 6th intercostal space PAL on the right. The bullet hit the 6th rib, lungs, diaphragm, superior portion of the right lobe of the liver, and the thoracic vertebrae. Bleeding from the liver was not controlled and packing was done. After 2 days, the packing was removed and a drain was inserted in the subdiaphragmatic and subhepatic areas. On the second day after the packing was removed an external biliary fistula was noted, producing about 200 cc/day. It has been almost 2 weeks and the drainage has not decreased. What are your suggestions?
As noted in the present case, bile duct injuries from blunt or penetrating hepatic trauma are frequently overlooked during the initial resuscitation because of massive parenchymal damage and/or torrential hemorrhage. A delayed diagnosis is relatively common and may finally be suggested by the presence of subhepatic collections of bile (bilomas), generalized peritonitis, or a controlled fistula.
The natural history of a bile leak depends primarily on the location and size of the ductal disruption. Leaks from small, intrahepatic ducts will spontaneously resolve within several weeks once adequately drained. In contrast, lesions of larger intrahepatic and extrahepatic ducts may cause persistent, relatively high-volume drainage; in such cases, specific therapeutic interventions are usually required to achieve closure.
Management of a suspected ductal disruption should begin with an adequate imaging study of the entire biliary tract. Such noninvasive approaches as radionuclide scanning or helical computerized tomography cholangiography can reliably detect and localize most responsible lesions. These studies may be particularly helpful when used as the initial investigation in problematic cases. Endoscopic retrograde cholangiography can also be useful in localizing biliary leaks, and it has the additional advantage of providing the opportunity to place an endoluminal stent across the papilla of Vater.
Limited laboratory and clinical studies have documented that decompression of the intrabiliary pressure with such a stent promotes rapid healing of most ductal disruptions. Typically, the stent can then be removed endoscopically after 6-8 weeks. This minimally invasive approach should obviate the need for operative therapy in nearly all cases of partial duct disruption. However, when the duct is completely severed, as occasionally occurs at the junction of the common bile duct and the superior border of the pancreas, surgical control is considerably more demanding and risky. In this instance, the primary repair requires a choledochal anastomosis with either the duodenum or a Roux-en-Y limb of jejunum.
This question is regarding a biliary tract injury. I have a patient with a gunshot would at the 6th intercostal space PAL on the right. The bullet hit the 6th rib, lungs, diaphragm, superior portion of the right lobe of the liver, and the thoracic vertebrae. Bleeding from the liver was not controlled and packing was done. After 2 days, the packing was removed and a drain was inserted in the subdiaphragmatic and subhepatic areas. On the second day after the packing was removed an external biliary fistula was noted, producing about 200 cc/day. It has been almost 2 weeks and the drainage has not decreased. What are your suggestions?
As noted in the present case, bile duct injuries from blunt or penetrating hepatic trauma are frequently overlooked during the initial resuscitation because of massive parenchymal damage and/or torrential hemorrhage. A delayed diagnosis is relatively common and may finally be suggested by the presence of subhepatic collections of bile (bilomas), generalized peritonitis, or a controlled fistula.
The natural history of a bile leak depends primarily on the location and size of the ductal disruption. Leaks from small, intrahepatic ducts will spontaneously resolve within several weeks once adequately drained. In contrast, lesions of larger intrahepatic and extrahepatic ducts may cause persistent, relatively high-volume drainage; in such cases, specific therapeutic interventions are usually required to achieve closure.
Management of a suspected ductal disruption should begin with an adequate imaging study of the entire biliary tract. Such noninvasive approaches as radionuclide scanning or helical computerized tomography cholangiography can reliably detect and localize most responsible lesions. These studies may be particularly helpful when used as the initial investigation in problematic cases. Endoscopic retrograde cholangiography can also be useful in localizing biliary leaks, and it has the additional advantage of providing the opportunity to place an endoluminal stent across the papilla of Vater.
Limited laboratory and clinical studies have documented that decompression of the intrabiliary pressure with such a stent promotes rapid healing of most ductal disruptions. Typically, the stent can then be removed endoscopically after 6-8 weeks. This minimally invasive approach should obviate the need for operative therapy in nearly all cases of partial duct disruption. However, when the duct is completely severed, as occasionally occurs at the junction of the common bile duct and the superior border of the pancreas, surgical control is considerably more demanding and risky. In this instance, the primary repair requires a choledochal anastomosis with either the duodenum or a Roux-en-Y limb of jejunum.