title: Traumatic bile leaks from blunt liver injury in children: a multidisciplinary and minimally invasive approach to management.
abstract: BACKGROUND
  Selective non-operative management (NOM) of hemodynamically stable pediatric patients with blunt hepatic trauma is the standard of care. Traumatic bile leaks (TBL) are a potential complication following liver injury. The use of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of TBL is described in adults, but limited in the pediatric literature. We report our experience with a multidisciplinary and minimally invasive approach to the management of TBL.
  
  
  METHODS
  This was an IRB-approved 13-year retrospective review (January 1999-December 2012) of an institutional pediatric trauma registry; 294 patients (≤ 17 years old) sustained blunt hepatic injury. Those with TBL were identified. Patient demographics, mechanism of injury, management strategy and outcomes were reviewed.
  
  
  RESULTS
  Eleven patients were identified with TBL. Hepatobiliary iminodiacetic scan (HIDA) was diagnostic. Combinations of peri-hepatic drain placement, ERCP with biliary stenting and/or sphincterotomy were performed with successful resolution of TBL in all cases. No child required surgical repair or reconstruction of the leak. Cholangitis developed in one child. There were no long-term complications.
  
  
  CONCLUSIONS
  A multidisciplinary and minimally invasive approach employing peri-hepatic external drainage catheters and ERCP with sphincterotomy and stenting of the ampulla is a safe and effective management strategy for TBL in children.
authors.affiliation: Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA.
authors.forename: Afif N
authors.initials: AN
authors.lastname: Kulaylat
authors.affiliation: Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA.
authors.forename: Audrey L
authors.initials: AL
authors.lastname: Stokes
authors.affiliation: Division of Pediatric Surgery, Penn State Hershey Children's Hospital, Hershey, PA 17033, USA.
authors.forename: Brett W
authors.initials: BW
authors.lastname: Engbrecht
authors.affiliation: Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA.
authors.forename: J Steele
authors.initials: JS
authors.lastname: McIntyre
authors.affiliation: Division of Pediatric Surgery, Penn State Hershey Children's Hospital, Hershey, PA 17033, USA.
authors.forename: Susan E
authors.initials: SE
authors.lastname: Rzucidlo
authors.affiliation: Division of Pediatric Surgery, Penn State Hershey Children's Hospital, Hershey, PA 17033, USA. Electronic address: rcilley@hmc.psu.edu.
authors.forename: Robert E
authors.initials: RE
authors.lastname: Cilley
mesh_terms: D000293:Adolescent; D014670:Ampulla of Vater; D001646:Bile; D001652:Bile Ducts / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D002760:Cholangiopancreatography, Endoscopic Retrograde; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008099:Liver / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic; D015607:Stents; D013396:Suction; D019780:Technetium Tc 99m Lidofenin; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*
chemical_list: D019275:Radiopharmaceuticals; D019780:Technetium Tc 99m Lidofenin
keywords: Bile leak/injury; Blunt trauma; Endoscopic retrograde cholangiopancreatography (ERCP); Liver trauma/injury; Non-operative management; Pediatric