Severe hepatic trauma: A multi-center experience with 1,335 liver injuries
Department of Surgery, Gundersen/Lutheran Medical Center, La Crosse, WI. The Journal of trauma
(Impact Factor: 2.96).
The experience of six regional trauma centers with severe hepatic trauma was reviewed to identify trends in management, mortality, and postoperative complications. During the 5-year period ending June 1987, 210 complex liver injuries were identified at laparotomy. There were 92 Class III, 59 Class IV, and 59 Class V injuries. Mechanism of injury was blunt in 101 (48%) patients and penetrating in 109 (52%). Shock was observed in 38%, 46%, and 85% of Class III, IV, and V patients, respectively. Emergency department thoracotomy was performed in 31 patients. There was only one (3%) survivor. Resuscitative operating room thoracotomy was performed in 34 patients with three (9%) survivors. Class III injuries were most frequently treated with hepatotomy and individual vessel ligation (41%) and deep liver suturing (25%). Class IV injuries were most often managed by resectional debridement (36%). Class V injuries required caval shunt placement in 38 (64%) patients. There were only four (10%) survivors after caval shunt placement. There were 20 (59%) survivors of 34 patients treated with packing placed as an adjunct after hepatic injury repair. There was no significant increase in the incidence of abscess formation after perihepatic packing. Routine peritoneal drainage was used in 94% of patients. Overall mortality rates for Class III, IV, and V injuries were 25%, 46%, and 80%, respectively (p less than 0.01). Death rates due to the liver injury in Class III, IV, and V patients were 7%, 30%, and 66%, respectively (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Available from: Rifat Latifi
- "Even patients with severe liver injuries (grades 4 and 5) do not require an exploratory laparotomy, as long as they are hemodinamically stable. With advances in the use of massive blood transfusion protocols , along with the ability of intervention radiologists to perform selective embolization of arterial bleeds of the liver , the need for major operative intervention in liver trauma has diminished significantly    . As trauma surgeons , most of us now rely on perihepatic packing, abbreviated surgery or damage control, and intervention radiology for the management of these important injuries. "
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Severe liver trauma (grade 4 and 5) carries mortality greater than 40%. It represents a major surgical challenge in patients with hemodynamic instability who require an immediate exploratory laparotomy. Perihepatic packing and damage control can sometimes work, but for severe liver injuries, adjunct maneuvers might be needed (such as early embolization or hepatic artery ligation). During a patient’s first operation for severe liver trauma, anatomic resection is rarely tolerated.
Materials and methods
We managed a 31 year-old male with a blunt grade 5 right-lobe liver injury in severe hypovolemic shock.
As part of the initial damage control operation, concurrently with intermittent Pringle maneuver, he underwent intra- and perihepatic packing; selective isolation and ligation of the right portal vein, right hepatic artery, and right hepatic vein; and repair of the retrohepatic inferior vena cava. Then, 36 h later, the patient underwent a right hepatectomy.
For patients with severe liver injuries, selective vascular isolation and ligation may be considered as part of damage control (in addition to intermittent Pringle maneuver) and might enable anatomic resection at a later stage.
International Journal of Surgery Case Reports 12/2014; 60. DOI:10.1016/j.ijscr.2014.12.021
Available from: Derek Manas
- "In a series of 31 patients treated using this technique Burch et al. describe an operative mortality of 81% with technical difficulties with shunt placement occurring in 7 patients . Similarly in a series of 34 patients treated by Cogbill et al. with caval shunting an operative mortality of 90% was reported . Total vascular exclusion of the liver i.e. application of a prolonged pringle manoeuvre combined with clamping of the infrahepatic and suprahepatic IVC has been proposed as an alternative strategy to the management of these injuries . "
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ABSTRACT: Injuries to the retrohepatic vena cava are extremely rare and are associated with an operative mortality of up to 50% even in high volume trauma centres. We present a patient with such an injury who underwent successful repair using cardiopulmonary bypass and deep hypothermic circulatory arrest.
A 23 year old male was transferred to our unit following laparotomy with packing of the abdomen after uncontrolled haemorrhage from the retrohepatic vena cava was experienced. The patient was placed on full cardiopulmonary bypass and cooled to 20 °C before clamping of the supracoeliac aorta and inferior vena cava. This facilitated exposure of the retrohepatic cava and allowed successful primary repair of a 5 cm laceration.
Other techniques to allow repair of these injuries, such as atriocaval shunts and total vascular exclusion of the liver, are associated with a high mortality. We believe the technique described in this case report is an alternative strategy that can be used successfully to manage life threatening from the retrohepatic vena cava.
Injury Extra 07/2014; 45(7). DOI:10.1016/j.injury.2014.03.013
Available from: Mohammad Reza Sharif
- "The high morbidity and mortality rates of liver injuries are attributed to too large volume of blood lost and extensive control of bleeding imposed to the patient (6). This has motivated many studies and led to the introduction of new techniques like intermittent clamping of the portal triad (7) for controlling liver bleeding, and the goal of these studies is to introduce a treatment method for liver bleeding control, that can prevent the complete resection of the bleeding part of the liver (8-11). Ferric chloride is a dark brown chemical agent with formula FeCl3 and acidic property. "
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ABSTRACT: Background:Controlling parenchymal hemorrhage especially in liver parenchyma, despite all the progress in surgical science, is still one of the challenges surgeons face saving patients’ lives and there is a research challenge among researchers in this field to introduce a more effective method.Objectives:This study attempts to determine the haemostatic effect of ferric chloride and compare it with that of the standard method (suturing technique) in controlling bleeding from liver parenchymal tissue.Materials and Methods:In this animal model study 60 male Wistar rats were used. An incision, two centimeters (cm) long and half a cm deep, was made on each rat’s liver and the hemostasis time was measured once using ferric chloride with different concentrations (5%, 10%, 15%, 25% and 50%) and then using the control method (i.e. controlling bleeding by suturing). The liver tissue was examined for pathological changes.Results:The hemostasis time of ferric chloride concentration groups was significantly less than that of the control group (P value < 0.001). The pathologic examination showed the highest frequency of low grade inflammation based on the defined pathological grading.Conclusions:Ferric chloride is an effective haemostatic agent in controlling liver parenchymal tissue hemorrhage in an animal model.
Hepatitis Monthly 06/2014; 14(6):e18652. DOI:10.5812/hepatmon.18652 · 1.93 Impact Factor
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