Severe liver trauma with complex portal and common bile duct avulsion: A case report and review of the literature.

BACKGROUND: Given its size and location, the liver is the third most injured organ by abdominal trauma. Thanks to recent advances, it is unanimously accepted that the non-operative management is the current mainstay of treatment for hemodynamically stable patients. However, those patients with hemodynamic instability that generally present with severe liver trauma associated with major vascular lesions will require surgical management. Moreover, an associated injury of the main bile ducts makes surgery compulsory even in the case of hemodynamic stability, thereby imposing therapeutic challenges in the tertiary referral hepato-bilio-pancreatic centers' setting.

CASE SUMMARY: We present the case of a 38-year-old male patient with The American Association for the Surgery of Trauma grade V liver injury and an associated right branch of portal vein and common bile duct avulsion, due to a crush polytrauma. The patient was referred to the nearest emergency hospital and because of the hemorrhagic shock, damage control surgery was performed by means of ligation of the right portal vein branch and right hepatic artery, and hemostatic packing. Afterwards, the patient was referred immediately to our tertiary hepato-bilio-pancreatic center. We performed depacking, a right hepatectomy and Roux-en-Y hepaticojejunostomy. On the 9th postoperative day, the patient developed a high output anastomotic bile leak that required a redo of the cholangiojejunostomy. The postoperative period was marked by a surgical incision site of incomplete evisceration that was managed non-operatively by negative wound pressure. The follow-up was optimal, with no complications at 55 mo.

CONCLUSION: In conclusion, the current case clearly supports that a favorable outcome in severe liver trauma with associated vascular and biliary injuries is achieved thru proper therapeutic management, conducted in a tertiary referral hepato-bilio-pancreatic center, where a stepwise and complex surgical approach is mandatory.