bile leaks can result from penetrating injury , such as gunshot ( gsw ) or knife wounds , or from blunt trauma , such as motor vehicle ( mva ) or motorcycle accidents ( mca ) .
the incidence of bile leaks following hepatobiliary trauma ranges from 0.5 to 21% depending on the criteria and methods used to diagnose the bile leak [ 1 , 2 , 3 ] . following blunt or penetrating abdominal trauma
, there can be significant damage to the biliary tract with severe injuries ( grades iii 
vi ) leading to an intrahepatic biloma , intraperitoneal leakage of bile , hemobilia and bilhemia , and intra - abdominal abscess .
there is no consensus on the treatment of traumatic bile leaks and decisions are often based on extent and mechanisms of injury , associated organ injuries and local expertise . regardless of the etiology , bile leaks can be a considerable cause of morbidity in afflicted patients .
unstable patients , as well as those with a penetrating injury , require laparotomy in conjunction with less invasive techniques .
hemodynamically stable patients with blunt hepatic trauma can be managed nonoperatively which has become the treatment of choice over the past two decades . in earlier years ,
however , the treatment of bile leaks has evolved with improvements in technology and procedural techniques .
the management of surgical bile leaks with therapeutic endoscopic retrograde cholangiopancreatography ( ercp ) is well - established [ 5 , 6 ] .
however , the diagnosis of traumatic bile leaks can often be delayed and difficult . it has been suggested that posttraumatic bile leaks require more therapeutic procedures , patients have longer hospital courses , and higher hospital charges .
ercp has been found to be a useful tool for the diagnosis and treatment of posttraumatic bile leaks , but data on outcome after therapeutic ercp for traumatic bile leaks is limited [ 1 , 3 , 8 , 9 ] .
several case reports and a case series in the surgical literature report that ercp can be useful in the management of traumatic bile leaks . a variety of endoscopic techniques have been used to manage bile leaks .
these include biliary sphincterotomy alone , biliary stenting with or without sphincterotomy , and nasobiliary drainage with or without sphincterotomy .
these methods share the common goal of decreasing or eliminating the pressure gradient between the bile duct and duodenum , allowing preferential flow of bile from the duct into the duodenum instead of bile exiting the leak site .
the absence of ongoing bile flow through the leak site allows the defect to heal [ 1 , 8 ] .
we conducted a retrospective case review to evaluate the role of ercp in the management of patients who present with a bile leak after blunt or penetrating abdominal trauma .
the prospectively recorded endoscopy database at the university of texas health science center , houston , tex .
, usa , was reviewed to identify all patients who underwent ercp for the management of traumatic bile leaks between january 2004 and march 2009 .
all patients who developed a posttraumatic bile leak were included , regardless of the mechanism of injury ( blunt vs. penetrating ) or the initial method of management ( operative vs. nonoperative ) .
all patients were admitted to the trauma service and were initially managed in the surgical intensive care unit .
two of the 14 patients were initially managed conservatively with 1 of these 2 patients eventually undergoing interventional radiology computed tomographic - assisted aspiration of biloma and drain placement .
a bile leak was suspected when there was persistent drainage of bile via the surgical wound or through an intra - abdominal drain placed at surgery , after percutaneous drainage of a perihepatic fluid collection , or a positive hepatoiminodiacetic acid scan or when a computed tomography ( ct ) scan revealed a subhepatic fluid collection .
ercp was performed with standard therapeutic duodenoscopes ( olympus tjf-100/130/140/160 ; olympus america corporation , inc . ,
patients underwent ercp in the endoscopy unit with the assistance of anesthesia , using a combination of diprivan , meperidine , and midazolam or in the operating room if patient remained intubated . once
a bile leak was demonstrated on cholangiogram , a 7.0- , 8.5- or 10-f transpapillary biliary stent ( cook endoscopy , winston - salem , n.c . , usa ) was placed .
after the ercp , surgically or percutaneously placed drains were removed after there was decreased or absent output from the drains .
a repeat ercp was performed 416 weeks later to evaluate for resolution of a bile leak .
the time interval between ercps varied among patients because most of them had other associated injuries , were critically ill , and required other interventions . on repeat ercp ,
the patients were monitored daily after ercp for 48 h to asses for any complications and again in clinic 12 weeks after discharge .
endoscopic therapy was considered successful if the bile leak had resolved at the time of repeat ercp .
failure of endoscopic therapy was defined as persistence of a bile leak at follow - up ercp , persistence of biliary drainage through the percutaneous drain or persistence of biloma on ct that necessitated additional interventions to manage the bile leak . to assess the long - term outcome ,
follow - up data were obtained by telephone contact with the patients , who were questioned specifically about any evaluation or treatment of a recurrent bile leak , as well as complications , subsequent to their last endoscopic treatment .
a total of 14 patients ( 9 men , age range 1661 years ; 5 women , age range 1145 years ) , between january 2004 and march 2009 , underwent ercp for a bile leak secondary to traumatic injury to the abdomen .
eleven cases were because of blunt trauma : mva in 8 , and mca in 3 ; the remaining 3 were because of penetrating trauma from a gsw .
injuries were graded according to predefined criteria   and were grade iii ( <3 cm parenchymal laceration ) in 1 patient , grade iv ( 2575% parenchymal disruption ) in 10 patients , and grade v ( > 75% parenchymal disruption with or without involvement of major hepatic vasculature ) in 3 patients .
bile leaks were located in the common bile duct ( cbd ) in 1 patient , right ductal system in 8 patients , and in the left ductal system in 5 .
other associated injuries included lacerations to the spleen , diaphragm , kidney or major abdominal vessels , and hemothorax .
details on patient demographics and the nature of bile duct injury with location , interventions , and outcomes are shown in table 1 .
two patients were managed conservatively until bile leak was suspected based on ct scan findings .
one of these 2 patients subsequently underwent ct - guided biloma drainage and percutaneous drain placement .
all 8 patients eventually underwent ercp with a bile leak found in the right hepatic system in 4 and in the left hepatic system in 3 .
of the 3 patients with mca , all were initially managed with surgery with subsequent ercp with endobiliary stent placement .
follow - up ercp done in all patients with blunt trauma revealed resolution of the bile leak and the stent was removed .
three patients had a penetrating injury ( grade v in all 3 ) from a gsw and required emergent surgery .
all 3 patients underwent ercp because of continued bilious output from the surgically placed drain .
two of the 3 patients were found to have a bile leak from the left ductal system on cholangiogram , the third patient was found to have a bile leak from the right ductal system .
all 3 patients had endobiliary stents placed . of note , 2 of the 3 patients had delayed presentation of the bile leak .
one of the 2 patients developed bilious output from the surgically placed drain on postoperative day 11 .
the other patient developed fever and pain on postoperative day 18 and ct scan revealed a perihepatic fluid collection which prompted the referral for ercp . at follow - up ercp , all 3 patients had resolution of the bile leak and the endobiliary stents were removed .
this study showed that ercp with sphincterotomy and endobiliary stent placement is effective in the treatment of patients with major bile duct damage after hepatobiliary trauma . in our series ,
the resolution of a bile leak was seen in 100% of patients who underwent endobiliary stent placement and sphincterotomy .
this data is supported by a recent study reported by lubezky et al . , where ercp with biliary sphincterotomy and stent placement was found to be effective in all 11 patients who developed a traumatic bile leak .
also , in a study by bridges et al . , resolution of a traumatic bile leak was seen in 90% of patients who underwent endobiliary stent placement .
biliary ductal injuries may not be seen on initial imaging or laparotomy and can therefore have an insidious presentation .
the biliary injuries that result from hepatic trauma may be simple bile leaks into the lacerated liver , peritoneal cavity or pleural cavity or may result in biliary - vascular fistulas .
bile leaks usually present several days after the initial trauma , with the patient complaining of abdominal pain , increasing abdominal distention , and ascites . in the setting of penetrating abdominal trauma such as gsw , presentation of bile leak can be delayed up to two weeks as was reported previously .
the biliary injury can be intrahepatic , extrahepatic or both . in our series , 13 of 14 patients had injuries to the intrahepatic ductal system .
the other 4 cases involved the left intrahepatic ductal system and 1 involved the cbd . in previous series , the right intrahepatic ducts were the predominant sites of bile leaks following abdominal trauma [ 1 , 9 , 12 ] . whether or not the location of the bile leak can predict treatment outcome is still unclear and can not be elicited from our study or others .
surgery has been the conventional treatment for posttraumatic bile leaks but can be difficult to perform due to a combination of adhesions , inflammation , damaged liver parenchyma or the patient being a poor surgical risk .
the most important factors that influence survival in these patients are the associated injuries and the nature and the extent of liver injury .
it has been shown that liver - related complications appear to be less frequent in patients managed without surgery than in those managed surgically [ 8 , 9 , 10 ] .
nonoperative management of bile duct injury is effective with success rate ranging from 90 to 94% . in our series
the success rate of therapeutic endoscopic intervention ranges from 90 to 100% [ 1 , 8 , 9 , 12 ] .
reported healing of bile leaks in 5 of 6 patients after therapeutic ercp . in a series by bajaj et al .
, therapeutic ercp was successful in 8 of 9 ( 89% ) patients for managing posttraumatic bile leaks .
bridges et al .   reported healing of bile leaks in 9 of 10 ( 90% ) patients after biliary stenting .
hence , an ercp is both of diagnostic and therapeutic benefit in these patients . in the present series , resolution of bile leak
was documented on repeat ercp which was anywhere from 4 to 16 weeks after initial ercp .
sharma et al .   documented resolution of bile leak after 8.5 days ( range 330 days ) of endoscopic interventions . in a series by singh et al .
, bile leaks closed in 15.76 days in patients who had undergone sphincterotomy , and in 12.14 days in patients without sphincterotomy .
reported resolution of bile leaks in 67 days ( range 510 days ) after ercp .
bajaj et al .   reported time to resolution of bile leak after ercp as 7.4 days ( range 217 days ) .
we routinely perform biliary sphincterotomy and endobiliary stent placement for the management of a bile leak .
there are , however , several studies that clearly demonstrate the efficacy of biliary stent placement alone in this cohort of patients .
other series support our combined approach of endoscopic sphincterotomy and stenting for management of bile leaks following hepatic trauma [ 8 , 9 , 12 ] . in major leaks it is unlikely that sphincterotomy alone can seal the leak . the ideal length of time for stenting is not known .
follow - up in our patients ranged from 54 to 175 days ( mean of 85.6 days ) .
none of our patients showed evidence of post - ercp complications . in a study by sugiyama et al .   on long - term follow - up
, there were no late complications after endoscopic treatment . in the series by sharma et al .
, after a mean follow - up of 33 months , there were no complications and all the patients remained asymptomatic .
the limitations of this study include the retrospective case series design as well as the small number of subjects included in the series .
this particular cohort is small in the general population , and thus these procedures are rarely undertaken .
as was the case with previously published case series , the management of bile leaks was not standardized .
the follow - up was also short compared to other studies , and thus some long - term complications from ercp could have occurred . in summary , this study demonstrated the efficacy of ercp with sphincterotomy and endobiliary stent placement in the management of patients with extensive traumatic hepatic injury with intrahepatic bile leaks .
the severity of an injury and the site of a bile leak do not preclude endotherapy as a management option in these patients .
the results of our series and those of previously published series suggest that ercp should be considered as a first - line therapy for traumatic bile leaks .
matthew p. spinn and frank j. lukens have no conflicts of interest or financial ties to disclose .
 traumatic bile leaks often result in high morbidity and prolonged hospital stay that requires multimodality management . 
 data on endoscopic management of traumatic bile leaks are scarce . 
 our study objective was to evaluate the efficacy of the endoscopic management of a traumatic bile leak . 
 we performed a retrospective case review of patients who were referred for endoscopic retrograde cholangiopancreatography ( ercp ) after traumatic bile duct injury secondary to blunt ( motor vehicle accident ) or penetrating ( gunshot ) trauma for management of bile leaks at our tertiary academic referral center . 
 fourteen patients underwent ercp for the management of a traumatic bile leak over a 5-year period . 
 the etiology included blunt trauma from motor vehicle accident in 8 patients , motorcycle accident in 3 patients and penetrating injury from a gunshot wound in 3 patients . 
 liver injuries were grade iii in 1 patient , grade iv in 10 patients , and grade v in 3 patients . 
 all patients were treated by biliary stent placement , and the outcome was successful in 14 of 14 cases ( 100% ) . 
 the mean duration of follow - up was 85.6 days ( range 54175 days ) . 
 there were no ercp - related complications . in our case review , 
 endoscopic management with endobiliary stent placement was found to be successful and resulted in resolution of the bile leak in all 14 patients . based on our study results , 
 ercp should be considered as first - line therapy in the management of traumatic bile leaks . 
Introduction
Patients and Methods
Results
Discussion
Disclosure Statement