Significant Trends in the Treatment of Hepatic Trauma Experience With 411 Injuries

Abstract

Several significant advances in the treatment of hepatic injuries have evolved over the past decade. These trends have been incorporated into the overall treatment strategy of hepatic injuries and are reflected in experiences with 411 consecutive patients. Two hundred fifty-eight patients (63%) with minor injuries (grades I to II) were treated by simple suture or hemostatic agents with a mortality rate of 6%. One hundred twenty-eight patients (31%) sustained complex hepatic injuries (grades III to V). One hundred seven patients (83.5%) with grades III or IV injury underwent portal triad occlusion and finger fracture of hepatic parenchyma alone. Seventy-three surviving patients (73%) required portal triad occlusion, with ischemia times varying from 10 to 75 minutes (mean, 30 minutes). The mortality rate in this group was 6.5% (seven patients) and was accompanied by a morbidity rate of 15%. Fourteen patients (11%) with grade V injury (retrohepatic cava or hepatic veins) were managed by prolonged protal triad occlusion (mean cross-clamp time, 46 minutes) and extensive finger fracture to the site of injury. In four of these patients an atrial caval shunt was additionally used. Two of these patients survived, whereas six of the 10 patients managed without a shunt survived, for an overall mortality rate of 43%. Over the past 4 years, six patients (4.7%) with ongoing coagulopathies were managed by packing and planned re-exploration, with four patients (67%) surviving and one (25%) developing an intra-abdominal abscess. One additional patient (0.8%) was managed by resectional debridement alone and survived. During the past 5 years, 25 hemodynamically stable and alert adult patients (6%) sustaining blunt trauma were evaluated by computed tomography scan and found to have grade I to III injuries. All were managed nonoperatively with uniform success. The combination of portal triad occlusion (up to 75 minutes), finger fracture technique, and the use of a viable omental pack is a safe, reliable, and effective method of managing complex hepatic injuries (grade III to IV). Juxtahepatic venous injuries continue to carry a prohibitive mortality rate, but nonshunting approaches seem to result in the lowest cumulative mortality rate. Packing and planned reexploration has a definitive life-saving role when used adjunctively in the presence of a coagulopathy. Nonoperative management of select hemodynamically stable adult patients, identified by serial computed tomography scans after sustaining blunt trauma is highly successful (95-97%).

Methylene blue as an antioxidant agent in experimentally-induced injury in rat liver

“…ALT Liver injury may lead to death as a result of uncontrolled bleeding or sepsis (5,20). Non-operative management of stable liver trauma patients is associated with reduced mortality (21,22). However, it is important to recognize traumatic liver devascularization since an initially stable patient may decompensate due to septic complications.…”

Hepatic trauma management and outcome; Our experience

“…The line of management of isolated liver trauma is primarily guided by the hemo-dynamic status of the patient at the time of presentation in emergency department and response to the initial fluid challenge. Surgery is considered for isolated liver injury if the volume of replacement is more than 40ml/kg during first few hours [8][9]. A surgeon performed ultrasound using a 3.5 MHz transducer is an effective techniques for rapid imaging in hepatic injury [10].…”

Evaluation of the mortality rate caused by different periods of selective portal vein occlusion in rats

“…6 In humans, 30 minutes of PTO has been accepted as a safe procedure, and is usually employed in liver surgery. 7 More recently, Fontelles et al 8 demonstrated a clear correlation among hemodynamic and metabolic variables in rats subjected to hemorrhagic shock followed by 15 minutes of PTO; although not focused on mortality, the study points out the continued relevance of PTO in the surgery of trauma. On the other hand, selective portal vein occlusion (SPVO) may be achieved by means or ligation of the vein 1 .…”