In the past, the failure of nonoperative management, either bleeding or bile leak, required operative management. More recently, it has become clear that many of these complications can be managed nonoperatively as well. Angiography with selective embolization is an effective means of treating even delayed blood loss from hepatic injuries. Percutaneous drainage can treat "bilomas" and can be used for hepatic abscesses. Endoscopic retrograde cholangiopancreatography (ERCP) with or without biliary stenting can be extremely helpful in decompressing clots from the biliary tree and definitively treating intraparenchymal hepatic ductal injury. Recently, Carrillo and colleagues reviewed 135 patients managed nonoperatively.19 Thirty-two patients developed complications requiring intervention, with most of these patients having higher-grade injuries. A combination of the aforementioned techniques was successful in managing these complications nonoperatively 85 percent of the time.
Finally, nonoperative techniques can be combined with operation. Laparotomy and temporary packing to control hepatic injury ("damage control") are now commonplace. This can be followed by angiographic embolization to control arterial injuries deep within the substance of the liver. Other techniques can then be used once the patient has stabilized.
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