liver traumatic injury

Liver traumatic injury

Ri 周鈺翔

92-7-7

IntroductionThe liver is the most commonly injured abdominal organ after penetrating and blunt trauma

Blunt abdominal trauma-- most common cause of injuries, 95 % secondary to vehicle accident

Anatomy

Mechanism of injury(1)

Deceleration injury --producing a laceration of its relatively

thin capsule and parenchyma at the sites of attachment to the diaphragm

--usually tears between the post. sector(segments VI, VII ) and the ant. sectors(segments V,VIII ) of the R’t lobe

Mechanism of injury(2)

Crush injury

--direct blow to the abdomen

--damage to the central portion of the liver (segments IV, V, VIII)

Grading system(1)American Association for the surgery of trauma organ injury scale:liver

*Advance one grade for multiple injuries, up to grade III.

Grading system(2)

Grade I,II ---minor injuries, represent 80-90% of all

injuries, require minimal or no operative treatmentGrade III-V

-- severe,require surgical interventionGrade IV

--incompatible with survival

Assessment and initial investigation

A conscious p’t, hemodynamically unstable with generalized peritonism

→laparotomy without investigation Neurologically impaired or physical sign are equivocal →Diagnostic peritoneal lavage(DPL) and laparotomy performed if the test is positiveHemodynamically stable →further radiological assessment

Diagnosis of liver injuryDPL

--fast, sensitive, accurate and simple to perform --invasive, cannot diagnose retroperitoneal injury

X-ray --nonspecific, but useful in showing the extent of ass

ociated skeletal traumaUltrasonography

--fast, accurate, noninvasive, a good initial screening test

--sensitivity 88%, specificity 99%, accuracy 97%

Ultrosonography

Computed tomography(1)The standard evaluation method for stable p’t

Performed with Dilute water soluble oral contrast agent and intravenous contrast

Computed tomography(2)

Computed tomography(3)

Non-operative management

86% of liver injuries stopped bleeding by the time of surgical exploration67% of operations performed are nontherapeuticStandard method of pediatric p’t for the past 20 years, with a success rate of 90%For 50-82% of adult p’tmore serious injuries (Grade III,IV) have been successfully managed without surgery

Non-operative managementCriteria

--hemodynamically stable --simple hepatic parenchyma laceration of inrahepatic he

matoma --absence of active hemorrhage --hemoperitoneum of less than 500ml --limited need for liver related blood transfusions (12U) --absence of peritoneal sign --absence of other peritoneal injuries that would otherwis

e require an operation


Criteria --good quality CT scans --experienced radiologist --intensive care setting

Currently believe that ultimate decisive factor should be the hemodynamic stability at presentation or after initial resuscitation, irrespective of the grade of injury on CT or the amount of hemoperitoneum

Non-operative managementAbdominal CT F/U

--not necessary to F/U by CT and no alteration in management is indicated unless there is change in patient’s clinical course

Resumption of normal activities

--avoid delayed hemorrhage

--avoid contact sports or heavy physical activity for 8 wks after liver injury of grades III-VI (3wks-6months)

Non-operative managementRole of interventional radiology in blunt liver injury

--to document active haemorrhage in subcapsular haematomas,

--as a salvage alternative to surgery in the face of continuous haemorrhage in patients who remain haemody

namically stable --in the diagnosis and treatment of haemobilia --in the treatment of retained collections or perihepatic sep

sis (using percutaneous techniques).

Non-operative management--Arteriography is useful in selected patients after operative perihepatic packing who have postoperative evidence of ongoing haemorrhage.--Biliary endoscopy may be helpful in the diagnosis

and treatment of complications secondary to complex liver injury

Complication --delayed hemorrhage, biliary fistula and liver absc

ess, hemobilia and bilhemia, extrahepatic bile duct stricture

Non-operative managementMorbidity and death

--the incidence of associated abdominal injury ranges from 13% to 35%

--the incidence of truly missed injury ranges from 0.5% to 12%

--the incidence of missed injury was 0.2% when strict guidelines for conservative treatment were followed and CT was used routinely.

--Wrong interpretation and poor quality of the initial scan is the most common cause

--A radiologist and the attending trauma surgeon read the initial CT scan, which must be of excellent quality were recommended

Non-operative management Complication

--Delayed hemorrhage ‧ most common, usual indication for a delayed operation ‧under strict guidelines, the incidence ranges from 0-5%, and blood transfusions were required in fewer than 20% ‧ common errors:(1)assuming that the hemorrhage is not related to the liver (2)multiple(more than four)blood transfusions in the hope that it will stop (3)misreading CT and underestimating hemoperitoneum and active bleeding

Non-operative managementComplication

--biliary fistula and liver abscess ‧ranges from 0.5-20% ‧success rate 70% with percutaneous technique ‧more aggressive surgical treatment may be considered --Hemobilia ‧1%,iatrogenic causes most common ‧injury causes communication between the biliary tract and blood vessels ‧abdominal trauma, jaundice, RUQ colicky pain and blood in vomitus or stool point to this diagnosis ‧managed by percutaneous selective hepatic a. embolization or surgical intervention

Non-operative managementComplication

--bilihemia ‧rare complication of severe decelerationon injury, in whic

h the hepatic venules and the intrahepatic bile ducts rupture ‧excessive bilirubin level ‧endoscopic sphincterotomy and biliary endostenting --Extrahepatic bile duct stricture ‧ the incidence is higher than the past ‧no uniformity of treatment criteria


Mortality rate

--7-13% with most resulting from associated injuries

--0-0.4% resulting from liver itself

Non-operative managementIn haemodynamically stable patients with blunt hepatic injury, an expeditious abdominal CT scan and a proper classification using the AAST Organ Injury Scale will facilitate non-operative management and the development of protocols. haemodynamic stability rather than findings on CT determines which patients should be managed conservatively in haemodynamically stable patients less treatment is probably the best treatmentmost blunt hepatic injuries can be managed without operation with minimal morbidity and mortality rates

Non-operative managementincreasing transfusion requirements should be regarded with suspicionthe interventional radiologist should be part of the treatment teamwhen conservative management fails, abbreviated laparotomy and planned reoperation should be considered at an early point during surgerymost complications should be managed in a non-operative fashion unless clear surgical indications are present.

Operative management

Initial control of bleeding achieved with temporary tamponade using packs, portal triad occlusion(Pringle manoeuvre), bimanual compression of the liver or even manual compression abdominal aorta above celiac trunkIf hemorrhage is unaffected by portal triad occlusion(Pringle manoeuvre) by digital compression or vascular clamp, major vena cava injury or atypical vascular anatomy should be expected


Hepatotomy with direct suture ligation --using the finger fracture technique, electroca

utery or an ultrasonic dissector to expose damaged vessels and hepatic duct which ligated , clipped or repaired

--low incidence of rebleeding, necrosis and sepsis

--effectives following blunt liver trauma requires further evaluation


Resection debridement

--removal devitalized tissue

--rapid compared with standard anatomical resection, which are more time consuming and remove more normal liver parenchyma

--reduced risk of post-op sepsis secondary hemorrhage and bile leakage


Anatomical resection --reserved for deep laceration involving major

vessels or bile ducts, extensive devascularization and major hepatic venous bleeding

Perihepatic packing --Indication:coagulopathy, irreversible shock fr

om blood loss (10u), hypothermia(32C), acidosis(PH7.2), bilobar injury,large nonexpanding hematoma, capsular avulsion, vena cava or hepatic vein injuries

Perihepatic packing


Mesh rapping

--new technique for grade III,IV laceration, tamponading large intrahepatic hematomas

--not indicated where juxtacaval or hepatic vein injury is suspected

Mesh rapping


Omental packing

Intrahepatic tamponade with penrose drains

Fibrin glue

Retrohepatic venous injuries

--Total vascular exclusion

--venovenous bypass

--Atriocaval shunting

Liver transplantation

Operative managementComplication

--Hemorrhage,sepsis --Biliary fistula --Respiratory problems --Liver failure --Hyperpyrexia --Acalculous cholecystitis --Pancreatic, duodenal of small bowel fistula --Drainage of intra-abdominal abscess or bilioma under

ultrasonography or CT guidance and embolization of AV fistula and deep bleeding vessels

ConclusionOptium results need a specialist team

-experienced liver surgeon, and anaesthetist used to dealing with the coagulopathyof liver disease

-interventional hepatobiliary radiologist and endoscpoist to manage post-op complication

-rapid infusers, cell savers and venovenous bypass to deal with massive blood loss

-Appropriate intensive care facilities -perihepatic packs to control hemorrhage -hepatotomy with direct suture ligation or resection de

bridement was preferred

Reference --Management of liver trauma R.W. Parks, E. Chrysos and T. Diamond British Journal os Surgery 1999,86,112-1135

--Non-operative management of blunt hepatic trauma E. H. CARRILLO*, A. PLATZ†‡, F . B. MILLER*, J . D. RICHARDSON* and H. C. POLK JR

British Journal of Surgery 1998, 85, 461–468

--Liver, Trauma http://www.emedicine.com/radio/topic397.htm

Thank you for your attention

liver traumatic injury

Documents