Selectivity in the Management of Hepatic Trauma

Abstract

Retrospective review of 178 consecutive patients who sustained hepatic injuries confirms that selective application of hepatic artery ligation is an efficient means of definitive hemostasis. Only two of 20 immediate deaths resulted from hepatic parenchymal hemorrhage. Over-all mortality (20%) was not significantly increased where hepatic artery ligation was used. Sepsis was the most frequent complication after severe hepatic trauma.

Hepatic trauma: experience with 135 consecutive liver injuries (1982?1989) and arguments for conservative surgery

“…It is difficult to compare this with the rates in other recent studies (6%-35%), as it is not always known whether global mortality, mortality due directly to the hepatic injury or to concomitant lesions, mortality on patient's arrival (35%) [16] before or immediately after the operation [4,10,16,20] is meant. The peculiarity of this series is the specific recruitment from spinal surgery and neurosurgery patients, which explains the high proportion of patients with severe hepatic injuries (classes IV and V: 25%) and concomitant lesions in often severe multisystern traumas (58% of those with blunt traumas).…”

“…An initial state of shock (systolic blood pressure lower than 80 mmHg) is considered a significant predictive factor [4,10,16,20]. In this series 21 deaths among 63 patients in shock means a significantly higher rate than given by the 12 deaths among 72 injured patients @ < 0.02).…”

“…On one occasion we succeeded in ligating the hepatic artery. Some workers advise this hepatic artery ligation if the parenchymal hemorrhage continues when the portal triad clamping is released, meaning a failure of the biliovascular elective ligations [10,16]. This could lead to necrosis of the dearterialized parenchyma requiring further resection.…”

“…The severity of hepatic lesions has been classified according to Moore into 5 grades [10,17] (Table 1). The postoperative mortality has been analyzed according to such potentially predictive factors as severity of the hepatic wound, concomitant extraabdominal lesions, initial shock, and the kind of surgical treatment performed.…”

The management of liver trauma

“…It should be remembered that anomalous origin ofeither hepatic artery is not uncommon. Although doing nothing to control bleeding from retrograde flow in hepatic veins, venous haemorrhage may often be subsequently controlled by tamponade (Mays et al, 1979), and this procedure has been widely used with good results (Foster et al, 1968;Flint et al, 1977). Rearterialization of the liver occurs rapidly via collaterals (Mays & Wheeler, 1974;Koehler et al, 1975), and hepatic necrosis is extremely rare (Lucas & Ledgerwood, 1978;Flint & Polk, 1979).…”