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Wed Jan 14 05:30:48 GMT 2009

I would NOT put in either biliary stents, do an ERCP, nor transcutaneous  
biliary drainage via the liver.     The drainage will STOP  with time, IF there 
is not distal obstruction.       Slowly tweek the drains, but do not remove.   
The drains themselves  might be helping to keep the volume of the fistula  
open.      I would wait a long long time before  reoperating, especially just for 
biliary drainage into the abdomen.    If the drainage is into the chest and 
manifest by bilous chest tube drainage or  coughing up bile, I would do a 
thoracotomy, lobectomy and close the diaphragm  over the liver with BIG sutures via 
the  chest.        

k

In a message dated 1/13/2009 11:26:11 P.M. Central Standard Time,  
errington at erringtonthompson.com writes:

...and I  thought that I had problems.  Would wait about 12 weeks after
injury  and restudy.  Then consider operating.  As you know, the problem  is
you would rather operate in the first couple of days before inflammation  has
set in.  Now, it clearly has.  

I very interested in  what others have to say on this. 

Errington C. Thompson,  MD
Trauma/Surgical Critical Care
Talk Show Host -  WPEK
www.whereistheoutrage.net
Asheville, NC

-----Original  Message-----
From: trauma-list-bounces at trauma.org  [mailto:trauma-list-bounces at trauma.org]
On Behalf Of  moore677 at aol.com
Sent: Tuesday, January 13, 2009 2:22 PM
To:  trauma-list at trauma.org
Subject: GRADE V LIVER INJURIES

I have 2  patients in the hospital with grade V liver injuries after GSW's.?
Both  with prolonged hospital courses.? 
Both have persistent bile leaks 4 and 6  weeks after injury.? The first
patient had a stent placed in his RHD, bile  down to about 200mL/day.? The
second had both a failed ERCP (very  experienced endoscopist who does 4-6
ERCP's per week) and PTC for what  appears to be (intraop eval) a leak from a
branch of the LHD.? He drain's  about 800mL/day.? The first patient I
anticipate will close.? The second I  am seriously doubting will.??What else
might I try to get the fistula to  close?? If all conservative measures fail,
when would be the optimum time  to take him back to the OR for possible  liver
resection??

Dell.........

Forrest "Dell" Moore,  MD

Trauma Critical Care Surgery

St. Joseph's Hospital and  Medical Center

Phoenix, AZ
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GRADE V LIVER INJURIES