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Demonstration of a traumatic biliary fistula by ERCP
layer to reach the submucosa (Fig. 2). This means that an arterial site proximal or upstream from the bleeding point often lies at a greater depth below the ulcer base than it occupies more distally. Therefore, hemostatic agents which typically are applied circumferentially to the bleeding point (monopolar electrocoagulation/ fulguration, YAG laser, argon laser) will be dealing with a deeper target than a device which can be applied directly to the bleeding point (e.g., heater probe or BICAP probe). In the example noted in Figure 2, YAG laser applied circumferentially to the sentinel clot failed to achieve coagulation at the deeper target site. The bleeding model for most experimental work with promising hemostatic instruments has been an acute factitial ulcer. 8 The Seattle ulcer maker removes a I-cm plug of mucosa, creating bleeding from many tiny mucosal and submucosal veins and arteries. Most thermal modalities were found to have similar effectiveness with this bleeding model. 9 Unfortunately, however, this ulcer model has little resemblance to single vessel arterial bleeding seen clinically. In our recent experiments using a single arterial bleeding canine model, striking differences in efficacy were seen with different instruments. 1o We found that direct vessel compression and thermal sealing with the heater probe and BICAP probe were much more effective, as well as safer, in coagulating medium size arteries than were YAG laser, argon laser, or monopolar electrocautery. It is anticipated that experimental work with a single arterial model will provide information which relates more directly to clinical peptic ulcer hemorrhage. The peptic ulcer with sentinel clot constitutes a warning sign of further major hemorrhage. Thorough understanding of the pathologic anatomy of this bleeding lesion with its underlying "invisible" vessel is important in designing effective endoscopic therapy. James H. Johnston, MD Jackson, Mississippi
REFERENCES 1. Johnston J. Natural history of gastrointestinal bleeding and
2. 3. 4. 5. 6. 7.
determinants of outcome. In: Fleisher D, Jensen D, BrightAsare P, eds. Therapeutic laser endoscopy in gastrointestinal disease. Boston: Martinus Nijhoff, 1983:29-37. Griffiths WJ, Neumann DA, Welsh JD. The visible vessel as an indicator of uncontrolled or recurrent gastrointestinal hemorrhage. N Engl J Med 1979;300:1411-3. Storey DW, Bown SG, Swain CP, et al. Endoscopic prediction of recurrent bleeding in peptic ulcers. N Engl J Med 1981;305:915-6. Vallon AG, Cotton PB, Laurence BH, et al. Randomized trial of endoscopic argon laser photocoagulation in bleeding peptic ulcers. Gut 1981;22:228-33. Hasson J. The visible vessel and gastrointestinal hemorrhage (letter). N Engl J Med 1979;301:892-3. Swain CP, Bown SG, Salmon PR, et al. Nature of the bleeding point in massively bleeding gastric ulcers. Gut 1982;23:A888-9. Beckley DE, Casebow MP. Preliminary clinical experience with an endoscopic Doppler ultrasound device in GI haemorrhage. Gut 1983;24:A968.
VOLUME 30, NO.5, 1984
8. Protell RL, Silverstein FE, Pierce J, et al. A reproducible animal model of acute bleeding ulcer-the "ulcer maker." Gastroenterology 1976;71:961-4. 9. Jensen DM. Endoscopic control of gastrointestinal bleeding. In: Berk JE, ed. Developments in digestive diseases, vol. 3. Philadelphia: Lea & Febiger, 1980:1-27. 10. Johnston J, Jensen D, Auth D. Comparison of endoscopic lasers, electrosurgery and the heater probe in coagulation of canine arteries. Gastrointest Endosc 1984;30:105.
Letters to the Editor Demonstration of a traumatic biliary fistula by ERCP To the Editor: Although traumatic liver injury is a common clinical problem, complicating biliary fistulas are rare. I would like to report a patient whose biliary fistula was clearly demonstrated by ERCP. A 25-year-old man was brought to Bridgeport Hospital after sustaining gunshot wounds through the anterior chest wall and right upper quadrant. After initial evaluation and stabilization, the patient was taken for exploratory laparotomy. The bullet had tra,:ersed the posterior portion of the right lobe of the liver. Bleeding was controlled with cautery and clips, and multiple drains were placed. Eight days later fever and chills developed. Both a liver scan and ultrasound evaluation suggested a subphrenic collection, and antibiotics were started. The patient subsequently underwent drainage of a large bile collection. Because a septic course returned, 17 days after admission the right subphrenic space was drained under ultrasound guidance and the catheter was left in place. After 2 weeks of continuous drainage, an ERCP was performed. A fistula was readily demonstrated from the main right hepatic duct into the subphrenic space and out into the percutaneously placed catheter (Fig. 1). In spite of continuous drainage, spiking fevers recurred and the patient was returned to the operating room 6 weeks after admission. A wedge resection of the right lobe at the site of the bullet track was performed. The fistula was then directly closed with silver clips. The patient was discharged 7 days later. Biliary fistulas complicating liver trauma are quite unusual. In several large series of patients with liver injuries, the incidence of biliary fistulas varied between 0.44% and 2.6%.1,2 All cases in each ofthese large series were eventually closed with the patients receiving only conservative management. Prolonged drainage and hospitalization were often required. Recent reports have described a variety of surgical managements of patients with persistent biliary fistulas including lobectomy, fistulocholecystectomy and Roux-enY hepaticojejunostomy.3 There is little discussion of preoperative visualization and direct repair or ligation of the injured duct. The use of ERCP to demonstrate the presence and anatomy of other types of biliary fistulas, most frequently on the basis of calculous disease, has been previously reported! Although ERCP in this setting would seem a valuable di315
Figure 1. Endoscopic cholangiogram demonstrating a fistula from the right main hepatic duct into the subphrenic space and out into the percutaneous catheter.
agnostic tool, little attention has been given to its use in demonstrating traumatic biliary fistulas. Alan M. Nelson, MD Bridgeport Hospital Bridgeport, Connecticut
REFERENCES
1. Defore WW, Mattox KL, Jordon GL, Beall AC. Management of 1590 consecutive cases of liver trauma. Arch Surg 1976;111:493-7. 2. Trunkey DO, Shires GT, McClelland R. Management of liver trauma in 811 consecutive patients. Ann Surg 1974;179:722-8. 3. Smith EEJ, Bowley N, Allison OJ, Blumgart LH. The management of post traumatic intrahepatic cutaneous biliary fistulas. Br J Surg 1982;69:317-8. 4. Tytgat GN, Bartelsman J, Huibregtse K, Agenant D. Common duct complications of choledocholithiasis revealed by ERCP. Gastrointest Endosc 1979;25:63-66.
Emergency ERCP for the diagnosis of complications after cholecystectomy
and avoid excessive dissection in the operative field. We would like to alert endoscopists to this indication for ERCP by presenting a recent case. Two months after a normal delivery, a previously healthy 25-year-old woman had repeated attacks of right-sided abdominal pain. A nonfunctioning gallbladder was diagnosed by oral cholecystography. After a severe attack the woman was admitted to the hospital as an emergency patient with suspicion of an acute cholecystitis. The diagnosis was verified at the operation on the following day and a cholecystectomy was done. The operation was technically difficult. The cystic duct was thin, cannulation was unsuccessful, and operative cholangiography was not performed. The cystic duct was ligated as well as the cystic artery, and the gallbladder was removed. A silicone tube was inserted to drain the operative field. The gallbladder contained many small stones. Four days after the operation the patient complained of increasing abdominal pain, accompanied by a rise in temperature and signs of peritonitis. An intraabdominal bile leak was suspected, although the amount of bile coming through the drain had not increased. Bilirubin and transaminase levels had decreased since the day she was admitted; the amylase was normal. A common bile duct injury was considered as well as leakage from the cystic duct. Retained stones in the common bile duct causing obstruction was another possible cause. Intravenous cholangiography showed only the renal pelvis. Sonography questioned the presence of a stone in the common bile duct, but bowel gas made the interpretation uncertain. An emergency ERCP was done without difficulties, and the common bile duct and the cystic duct were visualized with no signs of damage or leakage. No stones were seen. The patient was re-explored and 700 ml of bile were found in the abdomen. Bile was leaking from an aberrant bile duct which was subsequently tied off. Because of the ERCP findings a further exploration of the common bile duct in order to perform a cholangiography was considered unnecessary. The postoperative course was quite normal. Although normally an easy operative procedure, cholecystectomy can in some cases be extremely difficult. In a review of 63,252 cholecystectomies, Hermann 2 noted 336 bile duct injuries, an incidence of approximately 0.5%. In cases without an operative cholangiogram and early signs of injury to the bile duct, an examination of the common bile duct is mandatory. By using ERCP in our emergency case, exploration of the common bile duct was avoided, as well as the risks of postoperative common bile duct drainage and other complications due to dissection in this area. Sam Smedberg, MD Lennart Ling, MD, PhD Department of Surgery Central Hospital Helsingborg, Sweden
To the Editor: Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable and well established method in the diagnosis of postoperative complications following bile duct surgery, such as stricture of the common bile duct.! In an emergency situation, ERCP could be even more valuable by enabling the surgeon to focus directly on the complication 316
REFERENCES
1. Smith I, Sherlock S. Surgery of the gall bladder and bile ducts, 2nd ed. London: Butterworth, 1981:363-5. 2. Hermann RE. A plea for a safer technique of cholecystectomy. Surgery 1976;79:609-11. GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Johnston J. Natural history of gastrointestinal bleeding and
2. 3. 4. 5. 6. 7.
determinants of outcome. In: Fleisher D, Jensen D, BrightAsare P, eds. Therapeutic laser endoscopy in gastrointestinal disease. Boston: Martinus Nijhoff, 1983:29-37. Griffiths WJ, Neumann DA, Welsh JD. The visible vessel as an indicator of uncontrolled or recurrent gastrointestinal hemorrhage. N Engl J Med 1979;300:1411-3. Storey DW, Bown SG, Swain CP, et al. Endoscopic prediction of recurrent bleeding in peptic ulcers. N Engl J Med 1981;305:915-6. Vallon AG, Cotton PB, Laurence BH, et al. Randomized trial of endoscopic argon laser photocoagulation in bleeding peptic ulcers. Gut 1981;22:228-33. Hasson J. The visible vessel and gastrointestinal hemorrhage (letter). N Engl J Med 1979;301:892-3. Swain CP, Bown SG, Salmon PR, et al. Nature of the bleeding point in massively bleeding gastric ulcers. Gut 1982;23:A888-9. Beckley DE, Casebow MP. Preliminary clinical experience with an endoscopic Doppler ultrasound device in GI haemorrhage. Gut 1983;24:A968.
VOLUME 30, NO.5, 1984
8. Protell RL, Silverstein FE, Pierce J, et al. A reproducible animal model of acute bleeding ulcer-the "ulcer maker." Gastroenterology 1976;71:961-4. 9. Jensen DM. Endoscopic control of gastrointestinal bleeding. In: Berk JE, ed. Developments in digestive diseases, vol. 3. Philadelphia: Lea & Febiger, 1980:1-27. 10. Johnston J, Jensen D, Auth D. Comparison of endoscopic lasers, electrosurgery and the heater probe in coagulation of canine arteries. Gastrointest Endosc 1984;30:105.
Letters to the Editor Demonstration of a traumatic biliary fistula by ERCP To the Editor: Although traumatic liver injury is a common clinical problem, complicating biliary fistulas are rare. I would like to report a patient whose biliary fistula was clearly demonstrated by ERCP. A 25-year-old man was brought to Bridgeport Hospital after sustaining gunshot wounds through the anterior chest wall and right upper quadrant. After initial evaluation and stabilization, the patient was taken for exploratory laparotomy. The bullet had tra,:ersed the posterior portion of the right lobe of the liver. Bleeding was controlled with cautery and clips, and multiple drains were placed. Eight days later fever and chills developed. Both a liver scan and ultrasound evaluation suggested a subphrenic collection, and antibiotics were started. The patient subsequently underwent drainage of a large bile collection. Because a septic course returned, 17 days after admission the right subphrenic space was drained under ultrasound guidance and the catheter was left in place. After 2 weeks of continuous drainage, an ERCP was performed. A fistula was readily demonstrated from the main right hepatic duct into the subphrenic space and out into the percutaneously placed catheter (Fig. 1). In spite of continuous drainage, spiking fevers recurred and the patient was returned to the operating room 6 weeks after admission. A wedge resection of the right lobe at the site of the bullet track was performed. The fistula was then directly closed with silver clips. The patient was discharged 7 days later. Biliary fistulas complicating liver trauma are quite unusual. In several large series of patients with liver injuries, the incidence of biliary fistulas varied between 0.44% and 2.6%.1,2 All cases in each ofthese large series were eventually closed with the patients receiving only conservative management. Prolonged drainage and hospitalization were often required. Recent reports have described a variety of surgical managements of patients with persistent biliary fistulas including lobectomy, fistulocholecystectomy and Roux-enY hepaticojejunostomy.3 There is little discussion of preoperative visualization and direct repair or ligation of the injured duct. The use of ERCP to demonstrate the presence and anatomy of other types of biliary fistulas, most frequently on the basis of calculous disease, has been previously reported! Although ERCP in this setting would seem a valuable di315
Figure 1. Endoscopic cholangiogram demonstrating a fistula from the right main hepatic duct into the subphrenic space and out into the percutaneous catheter.
agnostic tool, little attention has been given to its use in demonstrating traumatic biliary fistulas. Alan M. Nelson, MD Bridgeport Hospital Bridgeport, Connecticut
REFERENCES
1. Defore WW, Mattox KL, Jordon GL, Beall AC. Management of 1590 consecutive cases of liver trauma. Arch Surg 1976;111:493-7. 2. Trunkey DO, Shires GT, McClelland R. Management of liver trauma in 811 consecutive patients. Ann Surg 1974;179:722-8. 3. Smith EEJ, Bowley N, Allison OJ, Blumgart LH. The management of post traumatic intrahepatic cutaneous biliary fistulas. Br J Surg 1982;69:317-8. 4. Tytgat GN, Bartelsman J, Huibregtse K, Agenant D. Common duct complications of choledocholithiasis revealed by ERCP. Gastrointest Endosc 1979;25:63-66.
Emergency ERCP for the diagnosis of complications after cholecystectomy
and avoid excessive dissection in the operative field. We would like to alert endoscopists to this indication for ERCP by presenting a recent case. Two months after a normal delivery, a previously healthy 25-year-old woman had repeated attacks of right-sided abdominal pain. A nonfunctioning gallbladder was diagnosed by oral cholecystography. After a severe attack the woman was admitted to the hospital as an emergency patient with suspicion of an acute cholecystitis. The diagnosis was verified at the operation on the following day and a cholecystectomy was done. The operation was technically difficult. The cystic duct was thin, cannulation was unsuccessful, and operative cholangiography was not performed. The cystic duct was ligated as well as the cystic artery, and the gallbladder was removed. A silicone tube was inserted to drain the operative field. The gallbladder contained many small stones. Four days after the operation the patient complained of increasing abdominal pain, accompanied by a rise in temperature and signs of peritonitis. An intraabdominal bile leak was suspected, although the amount of bile coming through the drain had not increased. Bilirubin and transaminase levels had decreased since the day she was admitted; the amylase was normal. A common bile duct injury was considered as well as leakage from the cystic duct. Retained stones in the common bile duct causing obstruction was another possible cause. Intravenous cholangiography showed only the renal pelvis. Sonography questioned the presence of a stone in the common bile duct, but bowel gas made the interpretation uncertain. An emergency ERCP was done without difficulties, and the common bile duct and the cystic duct were visualized with no signs of damage or leakage. No stones were seen. The patient was re-explored and 700 ml of bile were found in the abdomen. Bile was leaking from an aberrant bile duct which was subsequently tied off. Because of the ERCP findings a further exploration of the common bile duct in order to perform a cholangiography was considered unnecessary. The postoperative course was quite normal. Although normally an easy operative procedure, cholecystectomy can in some cases be extremely difficult. In a review of 63,252 cholecystectomies, Hermann 2 noted 336 bile duct injuries, an incidence of approximately 0.5%. In cases without an operative cholangiogram and early signs of injury to the bile duct, an examination of the common bile duct is mandatory. By using ERCP in our emergency case, exploration of the common bile duct was avoided, as well as the risks of postoperative common bile duct drainage and other complications due to dissection in this area. Sam Smedberg, MD Lennart Ling, MD, PhD Department of Surgery Central Hospital Helsingborg, Sweden
To the Editor: Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable and well established method in the diagnosis of postoperative complications following bile duct surgery, such as stricture of the common bile duct.! In an emergency situation, ERCP could be even more valuable by enabling the surgeon to focus directly on the complication 316
REFERENCES
1. Smith I, Sherlock S. Surgery of the gall bladder and bile ducts, 2nd ed. London: Butterworth, 1981:363-5. 2. Hermann RE. A plea for a safer technique of cholecystectomy. Surgery 1976;79:609-11. GASTROINTESTINAL ENDOSCOPY