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Wed Jan 14 16:12:27 GMT 2009

Yep, I like this idea better than my original post.  No distal obstruction.
Make sure your suction isn't keeping the fistula open and wait.  

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 Gross, Ronald
Sent: Wednesday, January 14, 2009 8:48 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: GRADE V LIVER INJURIES

One of my partners had an almost identical dilemma a couple of months
back...GSW to the abdomen with a Grade IV liver injury.  Needed operative
intervention for the other intra-abdominal injuries (duodenum, colon and
small bowel).  Damage control, RUQ packing, open abdomen, eventual abdominal
wall closure and subsequent huge RUQ biliary collection.  IR placed drains
that were placed on suction, GI stented Rt. Duct.  Drainage continued for
several weeks, slowed down and then ceased.  Drains removed with subsequent
recollection in RUQ 7 days later.  New drains placed and NO suction applied.
Drainage to leg bag only.  Took three weeks to stop, but it did without any
further GI intervention, and without reoperating on the fellow.

Bottom line, leave alone - it will stop all by itself!  (Most of the time)

Just my 2 cents.
Ron
-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of KMATTOX at aol.com
Sent: Wednesday, January 14, 2009 12:31 AM
To: trauma-list at trauma.org
Subject: Re: GRADE V LIVER INJURIES

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