Hepatic vein and retrohepatic vena caval injuries in children. Sternotomy first?

Systematic Review of the Management of Retro-Hepatic Inferior Vena Cava Injuries

Background

Retro-hepatic inferior vena cava (RHIVC) injuries resulting from blunt or penetrating abdominal trauma are rare but devastating events that remain a considerable challenge to even the most experienced doctors, which continue to carry a considerable mortality.

Aim

To establish a better understanding of the management of RHIVC injuries and to identify any adjuncts or operative methods that were associated with an increased survival.

Methods

A systematic review of the MEDLINE database was conducted using Medical Search Headings and exploded keywords and phrases. Studies were screened and subjected to inclusion/exclusion criteria. Data were extracted in a methodical manner collecting population demographics, morbidity, mortality and operative intervention, where provided. Operative strategies were compared and discussed.

Results

An initial search identified 483 articles. Following duplicate removal and abstract screening, 85 full-text articles were assessed with 25 meeting the desired criteria and were, therefore, included in the systematic review. Key operative strategies and complications were identified and discussed.

Conclusion

The wide variety of operative interventions in the management of RHIVC liver injuries described attest to the increased efforts to improve outcomes. The overall improvement in mortality can be noted since the earlier descriptions reported mortality approaching 100% compared to the 52% reported in this review. An algorithm has been proposed based on these findings and our experiences for the management of RHIVC injuries.

Mechanisms of blunt liver trauma patterns: An analysis of 53 cases

Blunt liver trauma is the most dangerous and the second most frequent solid organ trauma that occurs in the abdominal cavity. Management of this life-threatening situation remains a significant challenge. The present study identified that the patterns of blunt liver trauma were closely correlated with the characteristics of the blunt force. Illustrations of findings from this study have been included in the hope that they may aid surgeons in improving the management of this emergency. In total, 53 cases of blunt liver trauma that underwent laparotomy in the First Affiliated Hospital of Wenzhou Medical College between 1999 and 2009 were retrospectively studied. The cause of the injury, the direction and site of the blunt force, surgical records and CT films were carefully studied to obtain information on the patterns and severity of the liver injury and the correlation with blunt forces. Trauma in the right lobe of the liver was mainly caused by acceleration, deceleration and compression of the liver, while in the left lobe of the liver, acceleration was the main cause of the trauma. Liver lacerations were always located close to the attachment sites of the ligaments which bore the majority of the shearing stress. The characteristics of the blunt force play a key role in the different patterns of blunt liver trauma. A thorough understanding of the mechanisms of blunt liver trauma may aid doctors in the management of patients with this condition.

Management of pediatric liver injuries: a 13-year experience at a pediatric trauma center

PURPOSE

This study of traumatic liver injuries (LI) in children reviews the authors' management and identifies the indications for surgical intervention.

METHODS

A total of 11,761 admissions over 13 years to a regional pediatric trauma center were surveyed.

RESULTS

LI were identified in 328 children. Mechanisms included 39% pedestrians struck by a vehicle, 34% motor vehicle occupants, 13% falls or discrete blows to the abdomen, 5% bicycle injuries, 5% child abuse, and 4% penetrating injuries. Eighty-seven of patients with LI were treated nonoperatively with a mortality rate of 17%. Six percent of deaths were attributed to the LI and massive hemorrhage, all of which presented with cardiopulmonary resuscitation (CPR) in progress, with the remainder of deaths attributed to massive head, neck, or chest injuries (HNCI, 90%) and sepsis (4%). Surgery was performed in 13% of all LI and included major hepatic vascular injury (MHVI) repairs (34%), hepatorrhaphies (34%), lobectomies (27%), and biliary repairs (4%). Excluding the nonoperative group deaths, the need for blood transfusion of more than 25 mL/kg in the first 2 hours as an indicator of surgical necessity or a MHVI had, respectively, a sensitivity of 34% and 67%, specificity of 98% and 97%, positive predictive value of 79% and 53%, negative predictive value of 89% and 98%, and prediction accuracy of 88% and 95%. In the surgical management group, the mortality rate was 23% with 40% of deaths attributed to MHVI, 30% a combination of MHVI and HNCI, 20% massive HNCI, and 10% sepsis.

CONCLUSIONS

The majority of pediatric LI are not associated with hemodynamic instability and can be successfully managed nonoperatively (72%). Hemodynamic instability, as defined by the need for blood transfusion in excess of 25 mL/kg within the first 2 hours, was a strong indicator of a MHVI, which was often a lethal injury (70%).

Abdominal packing for severe hemorrhage

BACKGROUND

Diffuse abdominal or retroperitoneal hemorrhage is potentially lethal particularly when associated with coagulopathy, hypothermia, and acidosis. Temporary abdominal packing (PACKS) can control hemorrhage and provide crucial time to correct these physiological and metabolic derangements.

METHODS

The author reviewed the combined experience of pediatric surgeons at 13 institutions to determine the efficacy of this technique.

RESULTS

Twenty-two patients with refractory hemorrhage (ages, 6 days to 20 years) were treated with PACKS. The etiology of hemorrhage was trauma in 13, solid organ tumor bed in four, liver bleeding during necrotizing enterocolitis surgery in two, hemorrhagic pancreatitis in one, iliac artery injury while on extracorporeal membrane oxygenation (ECMO) in one, and biliary reconstruction after liver transplant in one. The anatomic site of hemorrhage was the liver or hepatic veins in 14, retroperitoneum or pelvis in seven, and the pancreatic bed in one. Twenty patients (91%) were coagulopathic, hypothermic, and acidotic at the time of packing. Fifteen patients (68%) had PACKS inserted during a primary operative procedure, whereas seven patients (32%) had PACKS inserted during a reexploration for persistent hemorrhage. The mean volume of intraoperative transfusion before PACKS was 190 mL/kg (range, 50 to 600). Primary fascial closure was accomplished in 12 (55%) patients, and temporary skin closure or prosthetic material was used in the other ten. PACKS controlled hemorrhage in 21 of 22 (95%) patients. Removal of PACKS was possible within 72 hours in 18 (82%) patients. No patient experienced rebleeding after PACKS removal; however, two patients died with PACKS in place. An abdominal abscess developed in seven patients (32%); all were successfully drained. Eighteen patients (82%) survived after abdominal packing. Two deaths were caused by multisystem organ failure, one was caused by cardiac failure from uncorrectable cardiac anomalies, and one was from exsanguination after blunt traumatic liver injury. There were no differences in volume of intraoperative blood product transfusion, time to initiate PACKS, physiological status, or type of abdominal closure between survivors and nonsurvivors.

CONCLUSION

The author concludes that temporary abdominal packing can be life saving in children with refractory abdominal or retroperitoneal hemorrhage associated with coagulopathy, hypothermia, and acidosis.

Use of active shunt for surgical repair of intrapericardial inferior vena caval injury

We report a case of intrapericardial inferior vena caval disruption due to goring by a bull, and we describe the surgical repair of this uncommon penetrating cardiac injury. Review of the literature indicates that, as with other penetrating cardiac injuries, this rare lesion requires aggressive treatment involving an emergency thoracotomy. The use of an atrial caval active shunt was necessary for successful surgical management, and therefore we conclude that surgical treatment of this lesion is comparable with surgical repair of hepatic veins and retrohepatic vena caval injuries incurred during blunt vascular trauma or penetrating abdominal injuries.

Successful repair of major retrohepatic vascular injuries without the use of shunt or sternotomy

Injury to the retrohepatic veins and vena cava secondary to blunt abdominal trauma is often fatal. The purpose of this report is to describe the successful isolation and repair of retrohepatic vascular injuries without the use of median sternotomy or vena caval shunt. Two children with both hepatic vein and retrohepatic caval injuries from blunt trauma were treated by the following surgical approach: (1) bilateral subcostal incision with vertical midline extension; (2) packing of the liver and volume resuscitation with the Rapid Infusion System prior to vascular isolation; (3) isolation of the intrapericardial vena cava through a transdiaphragmatic pericardial window; (4) control of the suprarenal vena cava and porta hepatis; and (5) repair of vein lacerations with vascular occlusion and continuous saline irrigation for improved visualization despite continued venous bleeding. This approach was tolerated and allowed successful repair without shunting in these patients despite an average weight of 14 kg and the loss of 3 L and 23 L of blood, respectively. We attribute the success of this technique to rapid control of hemorrhage and volume resuscitation. This success suggests that the routine use of shunt or sternotomy is not necessary in these devastating injuries.

Operative intervention for pediatric liver injuries: avoiding delay in treatment

To identify the physiological and anatomic factors that characterize the need for operative management of blunt pediatric liver injuries, the case records of 106 pediatric trauma victims with liver injuries over a 6-year period were reviewed. Sixty-nine patients were managed without operation (nonoperative) and 37 underwent operation, 7 with penetrating and 30 with blunt liver injuries. Of these 30 patients, 21 underwent laparotomy due to blunt liver injuries (operative); the remaining 9 patients required operation due to associated intraabdominal injuries. Nine (45%) of the 21 operative patients had major hepatic vein or retrohepatic vena caval injuries, 7 of whom died. Overall mortality was 9.4% (10/106). When nonoperative and operative groups were compared, those who underwent laparotomy due to blunt liver injuries: (1) had significantly lower Champion and Pediatric Trauma Scores due to multisystem injury; (2) had 25% or greater lobar disruption with pelvic blood collections on computed tomography scan; (3) underwent early transfusion within 2 hours of admission (18/21); and (4) were frequently found to have a major hepatic vein or retrohepatic vena caval injury at the time of operation. Only one patient successfully managed without operation received greater than 30 mL/kg of blood products within 24 hours of admission. As selective nonoperative management of pediatric liver injuries gains widespread acceptance, the identification of factors that predict the need for operative intervention will limit the potential risks of delay in treatment.