Department of Surgery, Division of Trauma, Critical Care and Acute Care Surgery, Sheikh Shakhbout Medical City - Mayo Clinic, Abu Dhabi, United Arab Emirates.
Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.
Am J Case Rep. 2023 Aug 31;24:e940984. doi: 10.12659/AJCR.940984.
BACKGROUND Conservative management of blunt trauma to the liver is commonly used when there are no immediate signs of rupture or hemorrhage, but requires patient monitoring. The rate of failure for non-operative management ranges is 3-15%. This report is of a 21-year-old man with a previous history of gastrectomy, cholecystectomy, and biliary stenting with failed non-operative management of blunt trauma to the liver following a motor vehicle crash, due to traumatic stent perforation. CASE REPORT The patient reported abdominal pain and had positive FAST for fluid in the hepatorenal space. CT abdomen showed grade 3 hepatic injury and a common bile duct stent. He was resuscitated and admitted to the ICU. He developed escalating abdominal pain and tachycardia without hypotension. Repeat CT demonstrated a paraduodenal gas bubble. He underwent exploratory laparotomy, during which the following were found: hemoperitoneum, no active bleeding, a 3-cm blue stent exiting the left hepatic duct surrounded by a fibrous tract, and bile spilling from around the stent. The protruding portion of the stent was resected, the was tract oversewn, and the abdomen was closed. Once stabilized, the patient underwent ERCP with removal of the remaining stent segment. The postoperative course was complicated by surgical wound infection and fascial dehiscence managed operatively and with local wound care, and deep-space infections managed by interventional radiology drainage. CONCLUSIONS Blunt trauma injury of the liver can be successfully managed conservatively. However, this case highlights the importance of knowledge of the patient's medical history and the presence of biliary stents, which can result in traumatic biliary perforation with an intact liver.
当没有肝破裂或出血的即时迹象时，通常采用保守治疗方法来处理钝性肝损伤，但需要对患者进行监测。非手术治疗的失败率为 3-15%。本报告介绍了一位 21 岁的男性患者，他有胃切除术、胆囊切除术和胆道支架置入术的病史，因外伤性支架穿孔，在机动车事故后未能成功进行非手术治疗，导致钝性肝损伤。
患者报告腹痛，超声检查显示肝肾间隙有液体，腹部 CT 显示 3 级肝损伤和胆总管支架。他接受了复苏治疗并收入 ICU。他出现了进行性腹痛和心动过速，但没有低血压。再次 CT 显示十二指肠旁气肿。他接受了剖腹探查术，术中发现：腹腔积血，无活动性出血，一根 3 厘米长的蓝色支架从左肝管穿出，周围有纤维通道，支架周围有胆汁溢出。切除突出的支架部分，缝合通道，关闭腹部。一旦病情稳定，患者接受了 ERCP 以取出剩余的支架段。术后病程复杂，包括手术切口感染和筋膜裂开，通过手术和局部伤口护理进行治疗，以及通过介入放射学引流治疗深部感染。
钝性肝损伤可以成功地进行保守治疗。然而，本病例强调了了解患者病史和存在胆道支架的重要性，这可能导致肝脏完整的外伤性胆道穿孔。
