Biliary Complications Following Hepatic Trauma: The Importance of ERCP

Abstract

Purpose: The purpose of the study was to describe our experience with traumatic biliary complications and in particular define the efficacy, safety and outcomes of ERCP in the management of bile leaks following liver injury. Methods: A prospective analysis of liver injuries from October, 2001 to April, 2006 was performed. Information recorded included demographic, radiologic and operative interventions. A bile leak was diagnosed if there was bile noted in a surgical wound, bile leakage from an intra-abdominal drain, or a leak noted on hepatobiliary scintigraphy (HIDA). ERCPs were performed in all patients with bile leaks. Characteristics of the leak and endoscopic treatment of the injury were assessed. Clinical outcomes measured included healing of the leak, post-treatment biliary anatomy, and associated complications. Results: 225 patients experienced major hepatic trauma (145 blunt and 80 penetrating). Twenty-eight patients (12.4%; 13 blunt, 15 penetrating) underwent ERCP for biliary injury diagnosed by HIDA (26 pts.) and/or by clinical suspicion from previously noted surgical findings or percutaneous biliary drainage (10 pts.). The average AAST liver injury grade was 3.25. The mean time to diagnosis of biliary injury was hospital day 7 (range 3-18). Laparotomy was performed in 18 (64%) and surgical or CT drainage of bilomas in 10 pts. (36%). All leaks identified on nuclear scintigraphy were confirmed at ERCP. However, HIDA scanning underestimated the extent of the injury in 8 patients where the leak was characterized as contained but found to be freely extravasating on ERCP. ERCP was performed at a mean of hospital day 7.5 (range 2-28). The total number of ERCPs performed was 50. Endoscopic therapy included biliary sphincterotomy (n = 6), stent placement (n = 16) or combined therapy (n = 6). All bile leaks resolved after ERCP. Cholangiography was normal in all 16 patients who received a follow-up ERCP. The average hospital length of stay was 25.8 days (range 3-70). There was one (3.5%) ERCP-related complication which was moderate pancreatitis. There were no deaths noted. Conclusion: Bile leaks commonly occur in individuals with liver trauma (12.4%). ERCP is a safe and effective strategy for diagnosing and managing biliary complications following blunt and penetrating hepatic trauma. Although biliary scintigraphy has a high positive predictive value for diagnosing biliary leaks, ERCP better distinguishes the extent of injury and eliminates the need for more invasive surgical treatment.