GSW to liver

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Errington,

I would have put the stent in via the ercp route for hepato-enteral
internal drainage when I discovered the collection with persistent
drainage.  We have done this frequently with excellent results.  And no
I never did write it up.......yet!  ;-)

Ron

>>> "Errington Thompson" <errington at erringtonthompson.com> 1/1/2008
6:03 PM >>>
Peter - 

You might be right but as I'm looking at a patient who is post-injury
day 32
(on going biliary drainage), I'm thinking a stent maybe helpful. 

Errington C. Thompson, MD, FACS, FCCM
Trauma/Surgical Critical Care
Mission Hospital
Asheville, NC
Author - A Letter to America
www.whereistheoutrage.net 

 
Everyone deserves to make an informed decision
                                - Errington Thompson, MD


-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] 
On Behalf Of Peter
Sent: Tuesday, January 01, 2008 5:02 PM
To: 'Trauma &amp; Critical Care mailing list'
Subject: R: GSW to liver

I think that the placement of a stent  does nothing to improve drainage
in
this case, but is an invasive procedure with a possibility of
increasing the
risk of infection. The biliary output will decrease spontaneously.
Peter

-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] 
Per conto di Tchaka Shepherd
Inviato: lunedì 31 dicembre 2007 6.27
A: Trauma &amp; Critical Care mailing list
Oggetto: RE: GSW to liver



If the patient remains stable. ERCP with stent placement should provide
a
path of least resistance and significantly decrease your drain output.
Isolated liver injuries with hemodynamic stability infrequently need
operative intervention.



----------------------------------------
> From: jamac at pacific.net.ph 
> To: trauma-list at trauma.org 
> Date: Thu, 11 Dec 2003 18:17:25 +0800
> Subject: Re: GSW to liver
> 
> Dr. Thompson,
> I will also take the patient to the OR. Seeing the extent of his
injury, I
> will place a balloon tamponade and drain.
> Thanks.
> Joel U. Macalino, MD
> Philippines
> ----- Original Message -----
> From: Errington Thompson 
> To: 'Trauma & Critical Care mailing list' 
> Sent: Sunday, December 30, 2007 1:06 PM
> Subject: GSW to liver
> 
> 
> I have a couple of questions on a recent case.  30 yo male was too
drunk
to
> have a gun but had one nonetheless.  He shot himself in the right
upper
> quadrant.  He was stable, awake and talking in the ER.  Entrance
wound
> easily seen just under the ribs and just lateral to the
mid-clavicular
line.
> The bullet was palpable just under the skin at about the 12th rib. 
No
SOB.
> 
> 
> 1) CT or not CT scan.  IF you do scan the patient and see a thru and
thru
> wound the liver, can you just watch him?
> 
> I take the patient to the OR.  He indeed has a thru and thru GSW to
the
> liver.  The wounds are not really bleeding.  There is no bile oozing
from
> either wound.
> 
> 2) Drain or no drain?
> 
> The patient develops an ileus and bile peritonitis.  He is
percutaneously
> drained.  On day 5 with his drain output still over 300 cc per day
the
> character of the drainage changes to a dark green.  CT scan revealed
an
> abscess posterior to the liver.  Percutaneous drainage was
performed.
> Enterococcus in the fluid.  Antibiotics were started.  Antiobiotics
stopped
> after 7 days.
> 
> Thoughts?
> 
> Errington C. Thompson, MD, FACS, FCCM
> Trauma/Surgical Critical Care
> Mission Hospital
> Asheville, NC
> Author - A Letter to America
> www.whereistheoutrage.net 
> 
> 
> Everyone deserves to make an informed decision
> - Errington Thompson, MD
> 
> 
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