The Value of ERCP in the Management of Complex Liver Injuries

Introduction: Our objective is to evaluate the use of ERCP in the management of complex, traumatic biliary injuries in a case series. Grades I and II liver injuries are often amenable to expectant management and usually resolve without further intervention. More severe injuries may continue to hemorrhage, or develop further complications including bile leaks, biliary peritonitis, bilomas, and biliary fistulas.
In critically ill patients with multiorgan trauma “damage control” surgery is often performed in conjunction with less invasive modes of therapy in order to minimize the necessity of high-risk surgical interventions. In this setting biliary peritonitis can be a highly morbid if not fatal complication. Several series have recommended multimodal approaches to treatment of complex traumatic liver injury. ERCP has proved to be an important adjunct in this algorhythm for grades III – VI hepatic injuries as it proves to be diagnostic as well as therapeutic.
We have performed ERCP and endobiliary stenting on patients with evidence of biliary injury in order to define the extent of injury and decompress the biliary system in the acute setting to prevent further sequelae of these complications. Early treatment was made possible by performing the procedure in the supine position.

Methods: ERCP with associated papillotomy and insertion of a bile stent was performed on a number of patients with complex liver injuries. The procedure was performed early after diagnosis of biliary leak and biloma based on intraoperative findings or computed tomography results for diagnosis and management. Supine positioning was used in the operative suite with the patients under general anesthesia.

Results: One patient with biliary peritonitis, one with biliocutaneous fistula, and a third patient with an intrahepatic biloma were treated with ERCP, papillotomy and biliary stent placement. All resolved with endobiliary decompression within 6 weeks.
One complication of proximal stent migration was encountered. The stent was easily retrieved during the repeat ERCP performed to remove the stent and perform completion cholangiogram to evaluate resolution of biliary injury.

1. Complex liver injury can be managed effectively by surgical endoscopists using ERCP and biliary decompression with papillotomy and endobiliary stent placement.
2. Ability to perform ERCP in supine position is more challenging than standard prone or lateral decubitus positioning but may be required in critically ill patients or patients with open abdomen.
a. This approach allows early treatment of biliary peritonitis in critically ill patients who would not tolerate standard positioning in ERCP. It may minimize number of re-exploration, abdominal washouts and time to resolution of leaks.
3. Currently, a chief surgical resident and a senior resident are involved in this study and are performing these procedures under supervision.

Session: Poster

Program Number: P382

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