Evaluation of experimental blunt and penetrating hepatobiliary trauma by sequential peritoneal lavage

Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile

INTRODUCTION

While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients' chest tube effluent.

PATIENTS AND METHODS

We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury.

RESULTS

Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3+/-4.1 mg/dL) and was always higher than both serum bilirubin (p<0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p<0.05). One RST injury patient died of line sepsis.

CONCLUSION

Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.

Diagnostic peritoneal lavage. Questions and answers

Peritoneal lavage is a useful adjunct to physical examination and to other traditional means of assessing the patient with potential intraabdominal injury. The procedure is safe in experienced hands and may be easily and rapidly performed with a minimum of equipment. The information that lavage provides may spare some patients an exploratory laparotomy and, more important, may identify those patients who appear to be in stable condition but who, in fact, need immediate lifesaving intervention.

Perforation of the gall bladder following blunt abdominal trauma

A 66-year-old man presented after having been involved in a motor vehicle accident. He was not wearing his seatbelt, and his vehicle had a deformed steering wheel after the incident. In the emergency department, his only complaint was mild right lower quadrant abdominal pain without signs of rebound or guarding. His laboratory and radiologic evaluations were unremarkable and he was observed in the intensive care unit. Nine hours after the accident, he developed an acute abdomen; exploratory laparotomy revealed a perforation of the gall bladder. Gall bladder injuries secondary to blunt trauma are infrequent events.