Christopher F McNicoll, MD, MPH, MS1, Lindsay M Wenger, MD1, Krystle R Tuaño, MD1, Paul J Chestovich, MD1, Cory G Richardson, MD2, Charles R St. Hill, MD, MSc, FACS1, Matthew S Johnson, MD3, Nathan I Ozobia, MD, FACS4. 1Department of Surgery, University of Nevada School of Medicine, 2Northwest Institute for Digestive Surgery, Post Falls, Idaho, 3Desert Surgical Associates, Las Vegas, Nevada, 4University Medical Center of Southern Nevada
Hepatic angioembolization (HAE) of arteries with active extravasation following traumatic injury is routinely performed in trauma centers. Gallbladder necrosis, hepatic necrosis, abscess, and bile leak are some of the known complications of HAE. In approximately 75% of patients, the cystic artery divides into the superficial and deep branches, with several additional minor branches known as Calot’s arteries. Since the cystic artery is an anatomic end artery, the gallbladder is susceptible to ischemia and perforation if HAE occludes the artery. We describe the presentation and management of a delayed cholecystocutaneous fistula and bile leak following HAE for actively bleeding grade 4 liver lacerations.
This 23-year-old male presented to the level I trauma center with multi-system trauma following a motorcycle crash. He suffered cardiac arrest upon arrival and was resuscitated. Further workup revealed multiple fractures of the face, extremities, and spine, pulmonary contusions, traumatic brain injury with intracranial hemorrhage, two splenic lacerations, and a complex grade 4 liver laceration. The right hepatic lobe laceration extended centrally within segment 5 and exhibited active extravasation. On hospital day 1, an interventional radiologist performed embolization of the right and left hepatic arteries with injection of a gelatin hemostatic agent. The patient was then admitted to the trauma intensive care unit for critical care management and non-operative therapy of the liver and splenic lacerations.
The patient’s abdomen became clinically distended, and a CT scan on hospital day 22 showed a perihepatic fluid collection. A percutaneous drain was placed with bilious output, and a HIDA scan on day 37 confirmed the persistent biliary leak. On day 39, the trauma surgeon performed an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and common bile duct stent placement to facilitate internal bile drainage. Cholangiography demonstrated multiple biliary leaks from the laceration of the right hepatic lobe and gallbladder fundus. Open cholecystectomy, abdominal washout, and drain placement was performed, and the gallbladder fundus was noted to be necrotic and perforated. The external drain output gradually decreased, and the drain was removed on day 51. He was transferred to a rehabilitation facility, with follow-up in 4 weeks to remove the biliary stent.
Right hepatic artery angioembolization can lead to cystic artery occlusion and gallbladder infarction. Internal biliary drainage, facilitated by a trauma surgeon’s placement of a biliary stent via ERCP, can reduce biliary leakage by promoting antegrade biliary flow.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80329
Program Number: P159
Presentation Session: Poster (Non CME)
Presentation Type: Poster