Prevention of bile peritonitis by laparoscopic evacuation and lavage after nonoperative treatment of liver injuries. Discussion

One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, pa...

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Published inThe American surgeon Vol. 73; no. 6; pp. 611 - 617
Main Authors FRANKLIN, Glen A, RICHARDSON, J. David, MALHOTRA, Ajai, BROWN, Aaron L, BRITTON CHRISTMAS, A, MILLER, Frank B, HARBRECHT, Brian G, CARRILLO, Eddy H, LOTTENBERG, Lawrence, HAWKINS, Michael, BRANDT, Mary Margaret
Format Journal Article
LanguageEnglish
Published Atlanta, GA Southeastern Surgical Congress 01.06.2007
SAGE PUBLICATIONS, INC
Subjects
Biological and medical sciences
Blood
General aspects
Intensive care
Liver
Medical imaging
Medical sciences
Medical treatment
Mortality
Patients
Physical examinations
Prevention and actions
Public health. Hygiene
Public health. Hygiene-occupational medicine
Veins & arteries
Liver
Laparoscopy
Trauma
Medicine
Prevention
Treatment
Abdominal disease
Surgery
Evacuation
Endoscopy
Lesion
Discussion
Peritonitis
Bile
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Summary:One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2-18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic inflammatory response syndrome, respiratory compromise, or elevated bilirubin. The bile and retained hematoma was evacuated from around the liver and closed-suction drainage was placed. Twenty-eight patients underwent laparoscopic evacuation/lavage of bile collections (about 4% of total blunt liver injuries). The majority (75%) had Grade IV or V injury. The amount of evacuated fluid ranged from 300 to 3800 mL. Other adjunctive procedures (endoscopic retrograde pancreaticocholangiography, angiography, and laparotomy) were occasionally required. There were no complications related to the procedure. Most patients had a dramatic decline in tachycardia, temperature, white blood cell count, serum bilirubin, and pain. Respiratory failure also resolved in most patients. Large bile and/or blood accumulations are present in a subset of patients with severe liver injuries treated nonoperatively. Delayed laparoscopic evacuation of these collections prevents bile peritonitis and decreases inflammatory response and avoiding early operation, which has been implicated in increased death from hemorrhage. [PUBLICATION ABSTRACT]
ISSN:0003-1348
1555-9823