R: GSW to liver
Ronald Gross
rgross at harthosp.org
Fri Jan 4 18:34:49 GMT 2008
You are comparing apples with oranges. Complications from liver
transplants are a different animal than the case we have been
discussing. We aren't talking about a suture line failure, but rather a
rather large hole in the parenchyma of the liver with markedly disrupted
intrahepatic ducts mixing with blood. A well placed stent will
facilitate biliary drainage - of that I am 100% certain.
Ron
>>> "Peter" <taliente at tiscalinet.it> 01/04/08 12:57 PM >>>
Interesting discussion, but maybe we should look at the experience of
liver
surgery units and liver transplants. The biliary sutures are the ones
most
at risk, but there has been no proponents for papillary stents and now
even
placing stents or Kehr tubes is being discussed. The use of Octreotide
is
mainly for pancreatic fistulae and tends to increase the pressure in
Vater's
papilla, not the best solution if there is a bile leakage! But in
medicine
everything may seem to work, but the evidence?
Just my reflections!
Peter
-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
Per conto di Dr. Haim Paran
Inviato: mercoledì 2 gennaio 2008 18.54
A: 'Trauma & Critical Care mailing list'
Oggetto: RE: GSW to liver
I have a modest experience with 2 recent cases of penetrating injuries
to
the liver with continuous bile leak. One of them had a leak through
the
diaphragm into a chest tube and the other developed a bile leak after
the
laparotomy when a JP drain was left near a non bleeding laceration. In
both
cases an ERCP and stenting the papilla immediately decreased the output
by
60% and the leak stopped spontaneously a week later. There were no
complications from the procedure.
P.S. Octreotide usually decreases the bile output by 30%
Good luck,
Haim Paran
Kfar-Sava
Israel
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Errington Thompson
Sent: Wednesday, January 02, 2008 1:03 AM
To: 'Trauma & Critical Care mailing list'
Subject: RE: GSW to liver
Peter -
You might be right but as I'm looking at a patient who is post-injury
day 32
(on going biliary drainage), I'm thinking a stent maybe helpful.
Errington C. Thompson, MD, FACS, FCCM
Trauma/Surgical Critical Care
Mission Hospital
Asheville, NC
Author - A Letter to America
www.whereistheoutrage.net
Everyone deserves to make an informed decision
- Errington Thompson, MD
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Peter
Sent: Tuesday, January 01, 2008 5:02 PM
To: 'Trauma & Critical Care mailing list'
Subject: R: GSW to liver
I think that the placement of a stent does nothing to improve drainage
in
this case, but is an invasive procedure with a possibility of
increasing the
risk of infection. The biliary output will decrease spontaneously.
Peter
-----Messaggio originale-----
Da: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
Per conto di Tchaka Shepherd
Inviato: lunedì 31 dicembre 2007 6.27
A: Trauma & Critical Care mailing list
Oggetto: RE: GSW to liver
If the patient remains stable. ERCP with stent placement should provide
a
path of least resistance and significantly decrease your drain output.
Isolated liver injuries with hemodynamic stability infrequently need
operative intervention.
----------------------------------------
> From: jamac at pacific.net.ph
> To: trauma-list at trauma.org
> Date: Thu, 11 Dec 2003 18:17:25 +0800
> Subject: Re: GSW to liver
>
> Dr. Thompson,
> I will also take the patient to the OR. Seeing the extent of his
injury, I
> will place a balloon tamponade and drain.
> Thanks.
>
Joel U. Macalino, MD
> Philippines
> ----- Original Message -----
> From: Errington Thompson
> To: 'Trauma & Critical Care mailing list'
> Sent: Sunday, December 30, 2007 1:06 PM
> Subject: GSW to liver
>
>
> I have a couple of questions on a recent case. 30 yo male was too
drunk
to
> have a gun but had one nonetheless. He shot himself in the right
upper
> quadrant. He was stable, awake and talking in the ER. Entrance
wound
> easily seen just under the ribs and just lateral to the
mid-clavicular
line.
> The bullet was palpable just under the skin at about the 12th rib.
No
SOB.
>
>
> 1) CT or not CT scan. IF you do scan the patient and see a thru and
thru
> wound the liver, can you just watch him?
>
> I take the patient to the OR. He indeed has a thru and thru GSW to
the
> liver. The wounds are not really bleeding. There is no bile oozing
from
> either wound.
>
> 2) Drain or no drain?
>
> The patient develops an ileus and bile peritonitis. He is
percutaneously
> drained. On day 5 with his drain output still over 300 cc per day
the
> character of the drainage changes to a dark green. CT scan revealed
an
> abscess posterior to the liver. Percutaneous drainage was
performed.
> Enterococcus in the fluid. Antibiotics were started. Antiobiotics
stopped
> after 7 days.
>
> Thoughts?
>
> Errington C. Thompson, MD, FACS, FCCM
> Trauma/Surgical Critical Care
> Mission Hospital
> Asheville, NC
> Author - A Letter to America
> www.whereistheoutrage.net
>
>
> Everyone deserves to make an informed decision
> - Errington Thompson, MD
>
>
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