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Avulsion of the gallbladder from its liver bed, with detachment from both cystic artery and duct is an exceedingly rare consequence of blunt abdominal injury. A case of this injury in a 52-year-old man is reported from the University Hospital, Kuala Lumpur. Early recognition by diagnostic peritoneal lavage led to successful treatment.

During the period 1986-1994, 6250 patients were admitted to the Accident and Emergency Unit of the University Hospital, Kuala Lumpur, with 175 patients requiring hepatorrhaphy. Eleven of these 175 patients developed either a biloma, biliary fistula or both. The patients' ages ranged from 15 to 40 years, with a mean injury severity score of 23. Seven patients suffered penetrating injury and 4 were victims of blunt trauma. The right lobe was injured in 10 patients, with 1 patient sustaining left lobe injury. All liver injuries were either grade 3 (7 patients) or grade 4 (4 patients). No patient sustained extrahepatic biliary tract injury. Biloma and fistulas were diagnosed 14-30 days post-injury (mean, 24 days) by computed tomography (CT) or 99mTc-2,6-din~ethylacetanilideiminodiacetic acid (HIDA) scans. All were managed by CT-guided percutaneous drainage. One patient also required percutaneous transhepatic cholangiography with biliary stent placement, due to bile-stained ascites. Fistulas persisted for 5-120 days (mean, 44 days). No patient required further operative intervention and all fistulas closed spontaneously without complication.

Abstract:The benefit of total parenteral nutrition (TPN) for the non-operative treatment of acute pancreatic pseudocyst remains hypothetical benefit. We reviewed results for 40 patients with pancreatic pseudocyst treated with TPN who had had serial imaging studies. On presentation, mean cyst size was 7.4 cm and after non-operative treatment with TPN (mean 32.5 days) the cyst had decreased to 5.6cm. After the nonoperative period, 68% of the pseudocysts had regressed, completely in 14% and partially in 54% of the patients. Except for 1 patient with cyst-related obstructive jaundice, there were no complicated pseudocysts. Only 12 (28%) of the patients underwent cyst drainage. Fifteen patients (35%) sustained catheter-related complications, which included'sepsis (26%), pneumothorax (9%), hydropneumothorax (2%), and septic right atrial thrombosis (2%), during the course of hospitalization. Most of the patients treated with TPN showed both clinical and radiographic regression of their pseudocysts. However, the risk of catheter-related complications in this group suggests that this therapy should be limited to those patients who are unable to sustain enteral nutrition.