Application of Damage Control Tactics and Transpapillary Biliary Decompression for Organ-Preserving Surgical Management of Liver Injury in Combat Patient.

The combat penetrating gunshot injury is frequently associated with damage to the liver. Bile leak and external biliary fistula (EBF) are common complications. Biliary decompression is commonly applied for the management of EBF. Also, little is known about the features of combat trauma and its management in ongoing hybrid warfare in East Ukraine. A 23-year-old male was diagnosed with thoracoabdominal penetrating gunshot wound (GSW) by a high-energy multiple metal projectile. Damage control tactics were applied at all four levels of military medical care. Biliary decompression was achieved by endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and the placement of biliary stents. Occlusion of the stent was treated by stent replacement, and scheduled ERCP was performed. Partial EBF was diagnosed from the main wound defect of the liver and closed without surgical interventions on the 34th day after the injury. A combination of operative and nonoperative techniques for the management of the combat GSW to the liver is effective along with the application of damage control tactics. A scheduled ERCP application is an effective approach for the management of EBF, and liver resection could be avoided. A successful biliary decompression was achieved by the transpapillary intervention with the installation of stents. Stent occlusion could be diagnosed in the early post-traumatic period, which is effectively managed by scheduled ERCP as well as stent replacement with a large diameter as close as possible to the place of bile leak.

Non-Operative Management of Bronchobiliary Fistula Due to Proximal Migration of Biliary Stent in a Patient With Unresectable Klatskin Tumor.

INTRODUCTION: One of the methods for the biliary tree decompression in the case of Klatskin tumor is transpapillary stenting, which could be completed by stent migration in 4% to 10% of cases. Approximately half of the stent migrations are in the proximal direction. In this study, we reported a rare case of proximal trans-diaphragmatic stent migration to the lower lobe of the right lung with the formation of a biliary-bronchial fistula (BBF). CASE PRESENTATION: A 60-year-old woman was diagnosed with hilar cholangiocarcinoma (type 3B by Bismuth-Corlette) complicated by posthepatic jaundice. To relieve jaundice there were performed endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy, endobiliary stent placement (10 Fr, 150 mm). A restenting (11.5 Fr, 130 mm) was performed in 2.5 months due to endobiliary tube occlusion. In the next 2 months, coughing attacks and biliptysis have appeared in the patient. A CT scan showed penetration of the liver, diaphragm, and lower lobe of the right lung with the proximal part of the stent and caused BBF formation. Anti-inflammatory and antibacterial therapy was administrated for 14 days and BBF was closed. Stent retrieval from the right hemithorax and endobiliary restenting was performed in 9 months after primary stenting. During follow-up, appropriate positioning and functioning of the stent were observed. CONCLUSION: BBF formation is a rare complication of endobiliary stenting, which can be successfully treated by anti-inflammatory and antibiotic therapy, followed by transpapillary stent retrieval.