Biliary fistulas resulting from blunt hepatic injury treated by endoscopic diversion of the bile flow.
Biliary fistula is a fairly uncommon complication of blunt liver injury, but with more liberal use of a nonoperative approach to the treatment of hepatic injury, the incidence is rising. If present, it becomes evident with physical examination aided by common diagnostic modalities (ultrasonography, computed tomography, cholangiography). The treatment, though, still presents a significant dilemma and often results in high morbidity with prolonged hospital stay and unnecessary expenses. Information was collected prospectively on a group of 26 consecutive patients with blunt hepatic trauma. Three cases of biliary fistulas were diagnosed, all after bile peritonitis ensued, or after a continuous discharge of bile through a postoperative drain took place. In one case, the diagnosis was confirmed by ultrasonography and computed tomography. Endoscopic retrograde cholangiopancreatography was used in all cases for diagnostic work-up and therapy. Endoscopic placement of a nasobiliary catheter was the definitive treatment in all cases. In all three patients, abdominal drains were removed two days after placement of a nasobiliary catheter. Diversion of the bile flow was discontinued after 6-7 days with no recurrent bile leak. No mortality due to hepatic injury or its complications was observed.


CONCLUSIONS
Posttraumatic bile fistulas are relatively easy to diagnose and their management with endoscopic drainage of the biliary tree through a nasobiliary tube is safe and effective. Adequate perihepatic drainage prevents relaparotomy for bile peritonitis. The possibility of biliary leakage does not reduce the relative safety of non-operative treatment of injury to solid organs.
Grala
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Division of Trauma, Burns and Plastic Surgery, Poznań University of Medical Sciences, Poznań, Poland. pafciog@tlen.pl
Skrzywanek
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Sowier
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