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Wed Jan 14 18:21:22 GMT 2009

There you have it!

-----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 1:04 PM
To: Trauma &amp; Critical Care mailing list
Subject: Re: R: GRADE V LIVER INJURIES

It is unlikely that you can mobilize the colon to exterorize it.  Treat like a damage control abd with a fecal fistula.

K

Sent via BlackBerry by AT&T

-----Original Message-----
From: "Gross, Ronald" <Ronald.Gross at bhs.org>

Date: Wed, 14 Jan 2009 12:54:24
To: 'Trauma &amp; Critical Care mailing list'<trauma-list at trauma.org>
Subject: RE: R: GRADE V LIVER INJURIES

I would exteriorize the colon - he isn't going to close that with poor nutrition, and I am not sure that you can rest safely on the assumption that he is going to restrict his drainage to the outside!

Ronald I. Gross, MD, FACS
Chief of Trauma & Emergency Surgery Services
Baystate Medical Center
759 Chestnut Street
Springfield, MA  01199
413-794-4022  phone
413-794-0142  fax
ronald.gross at bhs.org

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of moore677 at aol.com
Sent: Wednesday, January 14, 2009 12:23 PM
To: trauma-list at trauma.org
Subject: Re: R: GRADE V LIVER INJURIES

 The patient with the stent has had two re-operations for undrainable peri-hepatic abscesses (infected necrotic liver with infected hematoma, as well as Bacteroides bacteremia and a second hit of CNS bacteremia).  At both operations, there were no obvious bile leaks identified and wide drainage was again done (our purpose was not to go after the bile leaks).  This last operation was this past Saturday.  During closure we noticed we had a serosal tear in SB.  Was repaired and the patient closed (he has had a RUQ incision both times).  Today I am called to his bedside for what is stool draining out of his wound).  It is not succus.  I should mention he had a RHC 6 weeks ago, first a damage-control lap then a RHC 2 days later.  His wbc is down to 14, he is afebrile, and he is clinically improving albeit his nutritional status is horrible.

What would you guys do with the colocutaneous fistula now?  Reoperate?  TPN?  We have kept him alive for 6 weeks and clinically he looks good...I would sure hate to lose him now!!  We are getting a CT today to see if there are any undrained collections and praying this fistula goes right to the wound

The second patient with the 800mL per day was discharged today after 5 weeks in the hospital.  His output was 800mL then it went to nothing.  I did a repeat CT which showed some fluid in the pelvis.  I repeated it 2 days ago for which the fluid was nearly gone.  do these fistula's=2
0close just like that, and so fast?

Your guys' help is much appreciated, esp. with these complex patients.

Dell...................

-----Original Message-----
From: Peter <taliente at tiscalinet.it>
To: 'Trauma & Critical Care mailing list' <trauma-list at trauma.org>
Sent: Wed, 14 Jan 2009 9:40 am
Subject: R: GRADE V LIVER INJURIES

For the first patient, where is the leak if the stent is in place and
functioning? For the second patient, if the leak is the major LHD you really
don't have much choice but to reoperate, Roux on Y bilioanastomosis or if
not possible hepatic resection. Seeing that it is not clear where the leak
is from, NMR may help you (in both cases).
Let us know! Thanks
Peter

-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
Per conto di Errington Thompson
Inviato: mercoledì 14 gennaio 2009 6.25
A: 'Trauma & Critical Care mailing list'
Oggetto: RE: GRADE V LIVER INJURIES

...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 Beh
alf 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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