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Fri Jan 4 17:57:45 GMT 2008

Interesting discussion, but maybe we should look at the experience of liver
surgery units and liver transplants. The biliary sutures are the ones most
at risk, but there has been no proponents for papillary stents and now even
placing stents or Kehr tubes is being discussed. The use of Octreotide is
mainly for pancreatic fistulae and tends to increase the pressure in Vater's
papilla, not the best solution if there is a bile leakage! But in medicine
everything may seem to work, but the evidence?
Just my reflections!
Peter

-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
Per conto di Dr. Haim Paran
Inviato: mercoledì 2 gennaio 2008 18.54
A: 'Trauma &amp; Critical Care mailing list'
Oggetto: RE: GSW to liver

I have a modest experience with 2 recent cases of penetrating injuries to
the liver with continuous bile leak. One of them had a leak through the
diaphragm into a chest tube and the other developed a bile leak after the
laparotomy when a JP drain was left near a non bleeding laceration. In both
cases an ERCP and stenting the papilla immediately decreased the output by
60% and the leak stopped spontaneously a week later. There were no
complications from the procedure.

P.S. Octreotide usually decreases the bile output by 30%

Good luck,

Haim Paran

Kfar-Sava

Israel

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Errington Thompson
Sent: Wednesday, January 02, 2008 1:03 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: GSW to liver

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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R: GSW to liver