23 15-year single-centre experience of biliary complications in liver trauma patients - evolution in the management of post-traumatic bile leak
Stephen Stonelake, Evelyn Ong, Ravindar Anbarasan, Simon McGuirk, Darius Mirza, Paolo Muiesan, Khalid Sharif
Birmingham Children's Hospital, Birmingham, United Kingdom

Abstract

Aim of the study
Management of post-traumatic bile leak has evolved over time in our unit from endoscopic retrograde cholangiopancreatogram stenting (ERCP) to intraperitoneal drainage alone (IPD) as first line treatment in the past 5 years.  Data is reviewed to recommend the best practice. 

Methods
Retrospective review of liver trauma patients from 2002-2017. Demographics, grading of injury, time of diagnosis of bile leak, type of bile leak ,management, morbidity, outcome  and  follow-up were examined.

Main Results
In 117 patients there were 28 traumatic bile leaks. Eighteen and 10 were free intraperitoneal and localised bilomas respectively. The median time of diagnosis was 6 days following injury. The most common mode of diagnosis was hepatobiliary scintigraphy (16), computerised tomography (5), laparotomy (3), other (4). All 10 localised bilomas resolved without intervention. Eleven, 3, 2 and 2 of the free intraperitoneal biliary leaks were managed with IPD alone, IPD plus ERCP, IPD plus transcystic biliary stent (TBS), and no intervention respectively. Median time of IPD duration was 7 days (4-95) and 14 days (6-40) in IPD alone versus IPD+ERCP/TBS respectively (P=0.3). Median inpatient length of stay was 13 days (8-44) and 12 days (8-22) in IPD alone versus IPD+ERCP/TBS respectively (P= 0.4). There were 3 failed attempts to cannulate the common bile duct at ERCP in 2 of the 11 patients managed with IPD alone. There was one failed attempt to remove a stent at ERCP resulting in prolonged inpatient stay due to concerns over duodenal perforation. There were 4 pseudoaneursyms managed with embolisation. There was no difference in outcome for both groups.  

Conclusion
Placement of IPD alone is safe and effective in the management of intraperitoneal bile leaks, as first line, avoiding the costs and complications of invasive ERCP procedure.


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