Management of bile leak following blunt liver injury: a proposed guideline

Abstract

Background Bile leak following blunt liver trauma is uncommon. Management is difficult due to complex vasculo‐biliary and liver parenchymal injury and lack of consensus on optimal care compared with bile leak following elective hepatectomy especially in regards to endoscopic retrograde pancreaticocholangiography (ERCP) timing and patient selection. Methods This is a retrospective cohort study from a level 1‐trauma centre of patients with bile leak following blunt liver injury between July 2010 and December 2019 identified from the trauma registry. Clinical data retrieved include patient demographics, injury severity score, liver injury grading and its associated complications and treatment. This was supplemented by surgical audit database and patients' electronic medical record. Results There were 31 bile leaks amongst 639 patients with blunt liver trauma (4.9%). Bile leak was associated with higher liver injury grade (odds ratio (OR) 36, P = 0.001), hepatic embolization (OR 16, P = 0.003) and need for trauma laparotomy (OR 14, P = 0.024). ERCP was performed in 58.1% (n = 18). This was complicated in 27.7% (n = 5) by mild pancreatitis (n = 1) and intra‐abdominal sepsis (n = 4) requiring surgical drainage of abscess (n = 2) and liver resection (n = 1). Bile leak settled conservatively (including percutaneous drainage) without ERCP in the remaining patients (41.9%). Overall mortality was not increased in those with bile leak (P = 0.998). Conclusion Bile leaks resolved conservatively in 41.9% of patients. Complications following ERCP were seen in 27.7%, frequently requiring intervention. Failure of conservative management was more likely in patients with hepatic embolization, in whom early ERCP remains appropriate. ERCP should otherwise be reserved for those who fail conservative management to minimize infective complications.

Diagnosis and Management of Bile Leaks after Severe Liver Injury: A Trauma Association of Canada (TAC) Multicenter Study

“…Overall, our multicenter study data validate several smaller, single-center studies 10,11 that encourage the pursuit of ERCP for bile leaks that exceed 300 to 400 mL/24 hours of bilious drain output at the time of diagnosis, with lower volume leaks managed with percutaneous drainage alone. One third of our bile leaks were managed with external drainage alone, a rate that is comparable with existing single-center studies 15,17 . Therefore, we propose that bile leaks with an initial output of <300 mL/24 hours be managed with close clinical observation, with reservation of ERCP for higher volume leaks.…”

“…Patients undergoing intervention for bile leak had significantly higher drain output on the day of diagnosis than did patients who were managed with drainage alone (320 [180-720] vs. 138 [85-330] mL, p = 0.010). Patients who underwent intervention had longer hospital LOS (29 vs. 17 [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] days, p = 0.007) but similar ICU LOS and ventilator days ( p > 0.05).…”

“…In terms of bile leak management, ERCP was the most frequent management strategy (n = 59 [55%]), followed by drain placement alone (n = 32 [30%]), operative intervention via exploratory laparotomy (n = 16 [15%]), and PTBD (n = 1 [<1%]) (Table 3). The ERCP was typically performed on hospital day 13 [8][9][10][11][12][13][14][15][16][17][18] and involved both stent placement and sphincterotomy (n = 33 [56%]). The ERCP failed to resolve the bile leak in 15 patients (25%), with at least 1 additional intervention pursued.…”

Outcomes and management of delayed complication after severe blunt liver injury

“…In the current study, all BL with peripheral bile duct injury could be managed without additional surgical procedures. Previous studies have reported BL, even in sever liver injury, can be managed by conservative treatment such as ERC and internal stenting [ 6 – 8 , 15 , 16 ], however the appropriate timing for and the choice of ERC have not been established and are controversial. Patients with severe liver trauma sometimes have severe traumatic injuries to other organs, such as the brain or multiple bone fractures.…”

An Unusual Recurrent Bile Leak Following High Grade Liver Trauma

“…Few reports have discussed the risks or pitfalls to ERCPs [16]. In a retrospective study of blunt liver trauma in 639 patients (July 2010 to December 2019) at the Alfred Health, Department of General Surgery, Melbourne, bile leaks accounted for almost 5% of cases, and the resolution of bile leakage without the need for intervention was successful in 42% of those patients (n = 31), compared with major morbidity related to ERCPs (28%, n = 18) [17]. Therefore, ERCPs at the Alfred Health are typically performed in patients who fail conservative management of bile leaks following blunt liver trauma.…”