R. J. Miskimins1, A. A. Greenbaum1, P. Kilen2, R. Preda1, S. W. Lu1, T. R. Howdieshell1, S. D. West1 1University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 2University Of New Mexico HSC,School Of Medicine,Albuquerque, NM, USA
Introduction: Bile leak from the intrahepatic biliary tree is a major cause of morbidity after high grade liver injury. The rate of bile leak after hepatic trauma ranges from 0.5-21%. The risk of a bile leak increases with higher grade injury, however other risk factors have not been characterized. The aim of our study was to clarify the incidence, risk factors and management of intrahepatic bile leak following laparotomy for high grade liver injury.
Methods: A retrospective review of patients with complex liver injuries, defined as AAST grade III-V, who underwent laparotomy from Jan 2008 to July 2015 at an ACS-verified Level I trauma center was performed. Patients who died within 72 hours or under the age of 14 were excluded. Bile leak was defined as bilious output lasting more than 14 days from a surgically or interventional radiology percutaneous drain (IRPD). The grade of liver injury, number of laparotomies, operative techniques, use of hepatic angioembolization (HAE), placement of surgical drains, reason for laparotomy, number of readmissions, and interventions for management of bile leak were recorded. The institutional trauma database was used to obtain demographics, initial vital signs, ISS, length of stay (LOS), ICU LOS, and mechanism of injury (MOI). Statistical analyses were performed using Chi-squared and Fisher exact tests for categorical data, and the Mann–Whitney U-test for continuous variables. P-values < 0.05 were significant.
Results: 117 patients met inclusion criteria, 29 (25%) developed a bile leak (BLG) and 88 (75%) had no leak (NLG). There was no significant difference between the groups in age, sex, MOI, initial vitals, ISS, ICU LOS or reason for laparotomy. The BLG had higher grades of injury (Grade 5: 45% vs 10%, Grade 4: 41% vs 31%, Grade 3: 14% vs 60%, P <0.01), longer hospital LOS (29 vs 21 days, p <0.01) and were more likely to be readmitted (41% vs 15%, P<0.01). No significant difference in the rates of perihepatic packing, argon beam hepatorrhaphy, gelfoam packing, or suture hepatorrhaphy was observed. The BLG required more laparotomies (3.5 vs 2.2, p<0.01), were more likely to have excisional debridement (38% vs 9%, p<0.01), and HAE (38% vs 6%, P=0.03). Ninety-seven percent (n=28) in the BLG had perihepatic drains placed prior to abdominal closure, and 65% (n=19) of bile leaks were managed entirely with these drains. Seventeen percent (n=5) required IRPD, 14% (n=4) underwent ERCP and insertion of biliary stent in addition to the perihepatic surgical drains, and 3% (n=1) underwent both IRPD and ERCP.
Conclusion: In patients with AAST Grade III-V liver injury who require laparotomy, the grade of injury, use of hepatic embolization and excisional debridement are assoicated with development of bile leak.Those who develop a bile leak have longer hospital LOS and are more likely to be readmitted. The majority of bile leaks can be managed conservatively with perihepatic drain placement prior to definitive abdominal closure.