1
|
Martins PN, Buchwald JE, Movahedi B, Torres U, Emhoff T, Walker J, DeBusk MG, Bozorgzadeh A. Successful treatment of complete traumatic transection of the suprahepatic inferior vena cava with veno-venous and cardiopulmonary bypass with hypothermic circulatory arrest. Hepatobiliary Pancreat Dis Int 2021; 20:601-610. [PMID: 33468417 DOI: 10.1016/j.hbpd.2020.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 12/23/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Paulo N Martins
- Department of Surgery, Division of Transplantation, University of Massachusetts, Worcester, MA 01655, USA
| | - Julianna E Buchwald
- Department of Surgery, Division of Transplantation, University of Massachusetts, Worcester, MA 01655, USA
| | - Babak Movahedi
- Department of Surgery, Division of Transplantation, University of Massachusetts, Worcester, MA 01655, USA
| | - Ulises Torres
- Department of Surgery, Division of Trauma, University of Massachusetts, Worcester, MA 01655, USA
| | - Timothy Emhoff
- Department of Surgery, Division of Trauma, University of Massachusetts, Worcester, MA 01655, USA
| | - Jennifer Walker
- Department of Surgery, Division of Cardiac Surgery, University of Massachusetts, Worcester, MA 01655, USA
| | - Michael G DeBusk
- Department of Surgery, Division of Trauma, University of Massachusetts, Worcester, MA 01655, USA
| | - Adel Bozorgzadeh
- Department of Surgery, Division of Transplantation, University of Massachusetts, Worcester, MA 01655, USA.
| |
Collapse
|
2
|
Wikström MB, Smårs M, Karlsson C, Stene Hurtsén A, Hörer TM, Nilsson KF. A randomized porcine study of the hemodynamic and metabolic effects of combined endovascular occlusion of the vena cava and the aorta in normovolemia and in hemorrhagic shock. J Trauma Acute Care Surg 2021; 90:817-826. [PMID: 33496552 PMCID: PMC8081444 DOI: 10.1097/ta.0000000000003098] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mortality from traumatic retrohepatic venous injuries is high and methods for temporary circulatory stabilization are needed. We investigated survival and hemodynamic and metabolic effects of resuscitative endovascular balloon occlusion of the aorta (REBOA) and vena cava inferior (REBOVC) in anesthetized pigs. METHODS Twenty-five anesthetized pigs in normovolemia or severe hemorrhagic shock (controlled arterial bleeding in blood bags targeting systolic arterial pressure of 50 mm Hg, corresponding to 40-50% of the blood volume) were randomized to REBOA zone 1 or REBOA+REBOVC zone 1 (n = 6-7/group) for 45 minutes occlusion, followed by 3-hour resuscitation and reperfusion. Hemodynamic and metabolic variables and markers of end-organ damage were measured regularly. RESULTS During occlusion, both the REBOA groups had higher systemic mean arterial pressure (MAP) and cardiac output (p < 0.05) compared with the two REBOA+REBOVC groups. After 60 minutes reperfusion, there were no statistically significant differences between the two REBOA groups and the two REBOA+REBOVC groups in MAP and cardiac output. The two REBOA+REBOVC groups had higher arterial lactate and potassium concentrations during reperfusion, compared with the two REBOA groups (p < 0.05). There was no major difference in end-organ damage markers between REBOA and REBOA+REBOVC. Survival after 1-hour reperfusion was 86% and 100%, respectively, in the normovolemic REBOA and REBOA+REBOVC groups, and 67% and 83%, respectively, in the corresponding hemorrhagic shock REBOA and REBOA+REBOVC groups. CONCLUSION Acceptable hemodynamic stability during occlusion and short-term survival can be achieved by REBOA+REBOVC with adequate resuscitation; however, the more severe hemodynamic and metabolic impacts of REBOA+REBOVC compared with REBOA must be considered. LEVEL OF EVIDENCE Prospective, randomized, experimental animal study. Basic science study, therapeutic.
Collapse
|
3
|
Zargaran D, Zargaran A, Khan M. Systematic Review of the Management of Retro-Hepatic Inferior Vena Cava Injuries. Open Access Emerg Med 2020; 12:163-171. [PMID: 32617024 PMCID: PMC7326178 DOI: 10.2147/oaem.s247380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/19/2020] [Indexed: 11/23/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- David Zargaran
- Department of Medicine, Imperial College London, London, UK
| | | | - Mansoor Khan
- Brighton and Sussex University Hospitals, Brighton, UK
| |
Collapse
|
4
|
Rezende-Neto JB, Al-Kefeiri G, Strickland M, Prabhudesai V, Rizoli SB, Rotstein O. Three Sequential Balloon Catheters for Vascular Exclusion of the Liver and Aortic Control (one REBOA and two REBOVCs): A Hemorrhage Control Strategy in Suprahepatic Vena Cava Injuries. ACTA ACUST UNITED AC 2018. [DOI: 10.5005/jp-journals-10030-1214] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
5
|
Abstract
Nonoperative management has become the surgical treatment of choice in the hemodynamically stable patient with blunt hepatic trauma. The increased use and success of nonoperative management have been facilitated by the development of increasingly higher resolution computed tomography imaging, improved management of physiology and resuscitation (damage control), and routine availability of interventional procedures such as angiography and embolization, image-guided percutaneous drainage, and endoscopy. On the other hand, recognition of the patient who should proceed to immediate laparotomy is of utmost importance. A systematic and logical approach to the control of hemorrhage is required in the operating room. Thorough knowledge of the anatomy and surgical techniques, such as perihepatic packing, effective Pringle maneuver, hepatic mobilization, infrahepatic and suprahepatic control of the IVC, and stapled hepatectomy, is essential.
Collapse
Affiliation(s)
- J Ward
- Department of Surgery, University of Pittsburgh, F-1281, UPMC-Presbyterian, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | | | | |
Collapse
|
6
|
Latifi R, Khalaf H. Selective vascular isolation of the liver as part of initial damage control for grade 5 liver injuries: Shouldn't we use it more frequently? Int J Surg Case Rep 2014; 6C:292-5. [PMID: 25569195 PMCID: PMC4334949 DOI: 10.1016/j.ijscr.2014.12.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 12/11/2014] [Accepted: 12/13/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND 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. RESULTS 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, 36h later, the patient underwent a right hepatectomy. CONCLUSION 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.
Collapse
Affiliation(s)
- Rifat Latifi
- Department of Surgery, University of Arizona, Tucson, AZ, USA; Trauma Section, Hamad Medical Corporation, Doha, Qatar.
| | - Hatem Khalaf
- Hamad Medical Corporation, Transplant Section, Doha, Qatar
| |
Collapse
|
7
|
Kozar RA, Feliciano DV, Moore EE, Moore FA, Cocanour CS, West MA, Davis JW, Mcintyre RC. Western Trauma Association/Critical Decisions in Trauma: Operative Management of Adult Blunt Hepatic Trauma. ACTA ACUST UNITED AC 2011; 71:1-5. [DOI: 10.1097/ta.0b013e318220b192] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
8
|
Abstract
The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of the liver and use of atriocaval shunt are rarely indicated.
Collapse
Affiliation(s)
- Nasim Ahmed
- Department of Surgery & Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center 1945 State Rt. 33, Neptune, US
| | | |
Collapse
|
9
|
|
10
|
Abstract
BACKGROUND Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems. METHODS A literature review was undertaken to determine the current consensus on investigation and management strategies. RESULTS The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing. CONCLUSIONS Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.
Collapse
Affiliation(s)
- S A Badger
- Hepatobiliary Surgical Unit, Mater Hospital, Crumlin Road, Belfast, BT14 6AB Northern Ireland, UK.
| | | | | | | | | |
Collapse
|
11
|
Abstract
BACKGROUND Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems. METHODS A literature review was undertaken to determine the current consensus on investigation and management strategies. RESULTS The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing. CONCLUSIONS Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.
Collapse
Affiliation(s)
- S A Badger
- Hepatobiliary Surgical Unit, Mater Hospital, Crumlin Road, Belfast, BT14 6AB Northern Ireland, UK.
| | | | | | | | | |
Collapse
|
12
|
Aseni P, Lauterio A, Slim AO, Giacomoni A, Lamperti L, De Carlis L. Life-saving super-urgent liver transplantation with replacement of retrohepatic vena cava by dacron graft. HPB Surg. 2010;2010:pii: 828326. [PMID: 20811479 PMCID: PMC2926580 DOI: 10.1155/2010/828326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Revised: 05/31/2010] [Accepted: 06/26/2010] [Indexed: 02/07/2023]
Abstract
We describe a modified technique of side-to-side cavo-cavostomy by Dacron interposition prosthesis during a super urgent liver transplantation. A liver graft from a deceased donor was immediately requested on a top priority basis as a consequence of massive bleeding during extended left hepatectomy for a huge hepatic haemangioma arising from the caudate lobe. Veno-venous bypass was employed during anhepatic phase but it was disconnected due to severe fibrinolysis and hypothermia. A porto-caval shunt was performed and the inferior vena cava outflow was restored by a Dacron interposition prosthesis. A liver graft from a deceased donor was available 16 hours later. Due to the shortness of the vena cava of the donor liver graft, the removal of the Dacron graft was impossible and a modified side-to-side cavo-cavostomy between the Dacron interposition graft and the vena cava of the donor liver was than performed. Liver transplantation was uneventful and the patient is doing well 25 months after the surgical procedure. Although the use of synthetic vascular prosthesis should usually be discouraged during organ transplantation, its exceptional use during liver transplantation is possible with long-term good results.
Collapse
|
13
|
Stein DM, Scalea TM. Trauma to the Torso. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
14
|
Marino IR, di Francesco F, Doria C, Gruttadauria S, Lauro A, Scott VL. A new technique for successful management of a complete suprahepatic caval transection. J Am Coll Surg 2007; 206:190-4. [PMID: 18155588 DOI: 10.1016/j.jamcollsurg.2007.05.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Revised: 05/29/2007] [Accepted: 05/30/2007] [Indexed: 11/19/2022]
Affiliation(s)
- Ignazio R Marino
- Division of Transplantation, Department of Surgery, Jefferson Medical College, Thomas Jefferson University Hospital, Philadelphia, PA 19107-5083, USA.
| | | | | | | | | | | |
Collapse
|
15
|
Perdrizet GA, Giles DL, Dring R, Agarwal SK, Khwaja K, Gao YZ, Geary M, Cowell VL, Berman M, Brautigam R. Major hepatic trauma: warm ischemic tolerance of the liver after hemorrhagic shock. J Surg Res 2006; 136:70-7. [PMID: 17007881 DOI: 10.1016/j.jss.2006.06.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Revised: 04/28/2006] [Accepted: 06/27/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND The management of severe hepatic trauma frequently involves exposing the liver to varying periods of warm ischemia. The ischemic tolerance of the liver, in the setting of hemorrhagic shock (HS) and trauma, is presently unknown. We tested the hypothesis that warm ischemic tolerance of the porcine liver will be decreased following resuscitation from HS. MATERIALS AND METHODS Twenty-three Yorkshire pigs were divided into three groups: 1) hepatic ischemia alone (HI, n = 9); 2) hemorrhagic shock alone (HS, n = 3); and 3) hemorrhagic shock plus hepatic ischemia combined (HSHI, n = 11). Following reperfusion, a liver biopsy was obtained and serial blood chemistries were sampled. RESULTS Post-operative day 7 mortality was increased in the HSHI group (7/11) compared to the HI (0/9) group, P = 0.038. Notably, deaths did not result from acute liver failure, but rather from intra-operative hemodynamic collapse shortly following hepatic reperfusion. In addition, the HSHI group experienced significantly elevated lactic acid, serum creatinine and liver enzyme levels. Analysis of the liver biopsy samples is consistent with a more severe liver injury in the HSHI group. CONCLUSIONS The warm ischemic tolerance of the liver following resuscitation from HS is significantly decreased in this porcine model compared to HS or HI alone. Mortality was associated with acute intra-operative hemodynamic collapse occurring shortly after hepatic reperfusion.
Collapse
Affiliation(s)
- George A Perdrizet
- Departments of EMS/Trauma, Surgery, and Pathology, Hartford Hospital, Hartford, Connecticut 06102, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Abstract
The aim of this population based study was to assess the incidence, mechanisms, management, and outcome of patients who sustained hepatic trauma in Scotland (population 5 million) over the period 1992-2002. The Scottish Trauma Audit Group database was searched for details of any patient with liver trauma. Data on identified patients were analyzed for demographic information, mechanisms of injury, associated injuries, hemodynamic stability on presentation, management, and outcome. A total of 783 patients were identified as having sustained liver trauma. The male-to-female ratio was 3:1 with a median age of 31 years. Blunt trauma (especially road traffic accidents) accounted for 69% of injuries. Liver trauma was associated with injuries to the chest, head, and abdominal injuries other than liver injury; most commonly spleen and kidneys. In all, 166 patients died in the emergency department, and a further 164 died in hospital. The mortality rate was higher in patients with increasing age (p < 0.001), hemodynamic instability (p < 0.001), blunt trauma (p < 0.001), and increasing severity of liver injury (p < 0.001). The incidence of liver trauma in Scotland is low, but it accounts for significant mortality. Associated injuries were common. Outcome was worse in patients with advanced age, blunt trauma, multiple injuries and those requiring an immediate laparotomy.
Collapse
Affiliation(s)
- John M Scollay
- Department of Clinical and Surgical Sciences (Surgery), The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, EH16 4SA, United Kingdom.
| | | | | | | | | | | |
Collapse
|
17
|
Liu PP, Chen CL, Cheng YF, Hsieh PM, Tan BL, Jawan B, Ko SF. Use of a Refined Operative Strategy in Combination with the Multidisciplinary Approach to Manage Blunt Juxtahepatic Venous Injuries. ACTA ACUST UNITED AC 2005; 59:940-5. [PMID: 16374285 DOI: 10.1097/01.ta.0000187814.30341.ca] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Despite continuous advances in traumatology, juxtahepatic venous injuries are still the most difficult and deadly form of liver trauma. Most deaths result from exsanguination, and reported mortality ranges from 50% to 80%. This is an evaluation on our experience with the management of this high mortality injury following a refined operative strategy. METHODS This is a retrospective study of consecutive patients sustaining blunt juxtahepatic venous injuries. The management for these patients was mainly a refined operative strategy combined with a multidisciplinary approach. Preoperative conditions and the patient demographics were gathered. In addition, the number and type of interventional procedures, overall complications, and operative procedures were collected and analyzed. RESULTS From January, 1996 to March, 2004, 19 patients (M:F = 13:6) with juxtahepatic venous injuries were included and all were managed operatively. The operative procedures included hepatectomy by finger fracture technique for direct repair (8), perihepatic packing (1), packing and hepatic artery embolization (1), packing and hepatic artery ligation (1), hepatorrhaphy and packing (5), packing followed by hepatectomy (2) and atriocaval shunt for direct repair (1). The survival rate for the packing group was higher than that of the direct repair group (75% versus 45%), but was not statistically significant (p = 0.352). Injury to the retrohepatic vena cava influenced the patient's survival significantly (p = 0.041). The overall survival was 58% (11/19). CONCLUSION A well-defined operative strategy helps surgeons deal with the problem of blunt juxtahepatic venous injury, and its combination with multidisciplinary management will improve patient outcomes.
Collapse
Affiliation(s)
- Po Ping Liu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
Diagnostic evaluation and treatment of blunt liver trauma in children have changed essentially over the last decades. In the period between January 1975 and December 2002, a total of 45 children, 18 girls and 27 boys, between the ages of 1 and 16 years (mean 8.19) were treated for liver rupture following blunt abdominal trauma. The most common causes of injury were traffic accidents (49%), followed by falls (22%), direct trauma due to impact (20%) and being run over by a vehicle (9%). A total of 26 patients had one or more concomitant injuries; the injury severity score was between 16 and 57 (mean 22.9), and 16 patients had additional injuries to other solid abdominal organs. Since we last used laparotomies to explore the abdomen and manage liver ruptures in 1984, we divided our patients into two groups with respect to the choice of diagnostic and treatment modalities: group I, consisting of children treated before 1984, and group II, consisting of children treated after 1985. In group I (n=12), a diagnosis was made in eight cases based on exploratory laparotomy, in two cases based on sonography and laparoscopy, in one case based on laparoscopy only, and in another case based on sonography only. In eight cases the rupture was treated operatively; there was one postsurgical sepsis and one ileus due to adhesions. One child hemorrhaged to death when the vena cava ruptured during surgery. In group II (n=33), sonography was sufficient for a diagnosis in 18 cases. In 12 cases an additional computed tomographic scan was performed following initial sonography, and in three cases a diagnostic laparotomy was done elsewhere. In five cases the rupture was treated operatively in other hospitals. Twenty-eight patients could be treated conservatively and without any complications. One child died 3 days after the accident as a result of a severe brain injury. Over the past 15 years we have seen a clear tendency toward conservative treatment of our patients, which is also in agreement with current literature. Initial sonography, supplemented by computed tomography when necessary, allows not only noninvasive initial diagnostic evaluation but is also helpful in the further course in hemodynamic stable patients. All patients who had been treated conservatively (n=30) had no complications related to the liver rupture.
Collapse
Affiliation(s)
- Barbara Schmidt
- Department of Paediatric Surgery, University of Graz, Auenbruggerplatz 34, 8036 Graz, Austria.
| | | | | |
Collapse
|
19
|
Affiliation(s)
- Ian B Anderson
- Department of Surgery and Trauma Services, University of Calgary, Calgary, Alberta, Canada
| | | | | | | |
Collapse
|
20
|
Affiliation(s)
- Adam P Angeles
- Department of Surgery, York Hospital, York, Pennsylvania 17403, USA
| | | | | |
Collapse
|
21
|
Rosenthal D, Wellons ED, Shuler FW, Levitt AB, Henderson VJ. Retrohepatic vena cava and hepatic vein injuries: a simplified experimental methods of treatment by balloon shunt. ACTA ACUST UNITED AC 2004; 56:450-2. [PMID: 14960995 DOI: 10.1097/01.ta.0000100209.33919.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Fecal contamination from colon injury has been thought to be the most significant factor for the development of surgical site infection (SSI) after trauma. However, there are increasing data to suggest that other factors may play a role in the development of postinjury infection in patients after colon injury. The purpose of this study was to determine the impact of gastric wounding on the development of SSI and nonsurgical site infection (NSSI) in patients with colon injury. METHODS Post hoc analysis was performed on data prospectively collected for 317 patients presenting with penetrating hollow viscus injury. One hundred sixty-two patients with colon injury were subdivided into one of three groups: patients with isolated colon wounds (C), patients with colon and stomach wounds with or without other organ injury (C+S), and patients with colon and other organ injury but no stomach injury (C-S) and assessed for the development of SSI and NSSI. Infection rates were also determined for patients who sustained isolated gastric injury (S) and gastric injury in combination with organ injuries other than colon (S-C). Penetrating Abdominal Trauma Index, operative times, and transfusion were assessed. Discrete variables were analyzed by Cochran-Mantel-Haenszel chi2 test and Fisher's exact test. Risk factor analysis was performed by multivariate logistic regression. RESULTS C+S patients had a higher rate of SSI infection (31%) than C patients (3.6%) (p = 0.008) and C-S patients (13%) (p = 0.021). Similarly, the incidence of NSSI was also significantly greater in the C+S group (37%) compared with the C patients (7.5%) (p = 0.07) and the C-S patients (17%) (p = 0.019). There was no difference in the rate of SSI or NSSI between the C and C-S groups (p = 0.3 and p = 0.24, respectively). The rate of SSI was significantly greater in the C+S patients when compared with the S-C patients (31% vs. 10%, p = 0.008), but there was no statistical difference in the rate of NSSI in the C+S group and the S-C group (37% vs. 24%, p = 0.15). CONCLUSION The addition of a gastric injury to a colon injury has a synergistic effect on the rate of postoperative infection.
Collapse
Affiliation(s)
- David Rosenthal
- Departments of Vascular Surgery and Trauma Surgery, Atlanta Medical Center, Atlanta, Georgia 30312, USA.
| | | | | | | | | |
Collapse
|
22
|
Broering DC, Al-Shurafa HA, Mueller L, Pothmann W, Nierhaus A, Rogiers X. Total vascular isolation and in situ cold perfusion for management of severe liver trauma. J Trauma 2002; 53:564-7. [PMID: 12352498 DOI: 10.1097/00005373-200209000-00028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Dieter C Broering
- Department of Hepatobiliary Surgery, University Hospital of Hamburg-Eppendorf, University of Hamburg, Germany.
| | | | | | | | | | | |
Collapse
|
23
|
Abstract
Injuries of the IVC, whether caused by blunt or penetrating mechanisms, are usually fatal. Patients who arrive in shock and fail to respond to initial resuscitative measures, those who are still actively bleeding at the time of laparotomy, and those with wounds of the retrohepatic vena cava have a low probability of survival. Death most commonly is caused by intraoperative exsanguination. Knowledge of the anatomy and exposure techniques for the five different segments of the intra-abdominal vena cava is very important to trauma surgeons. Although some wounds of the vena cava, especially those of the retrohepatic vena cava, are best left unexplored, most injuries inferior to this level can be exposed and repaired by lateral suture technique. Preservation of a lumen of at least 25% of normal is probably important in the suprarenal vena cava but is of no provable value inferior to the renal veins. No evidence supports the need to expose and repair vena caval wounds that have spontaneously stopped bleeding. Such wounds, especially in the retrohepatic area, may be managed expectantly provided that there is no strong suspicion of an associated injury to a major artery or hollow viscus.
Collapse
Affiliation(s)
- R F Buckman
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA
| | | | | | | |
Collapse
|
24
|
Carr JA, Kralovich KA, Patton JH, Horst HM. Primary Venorrhaphy for Traumatic Inferior Vena Cava Injuries. Am Surg 2001. [DOI: 10.1177/000313480106700302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Primary venorrhaphy for traumatic inferior vena cava (IVC) injury has been criticized because of the potential for stenosis, thrombosis, and embolism. A retrospective study was performed to evaluate the morbidity and outcome of this method. Thirty-eight patients at our institution had traumatic injuries to the IVC between 1994 and 1999. Thirty (79%) were from firearms, five (13%) from stab wounds, and three (8%) from blunt trauma. Six patients died in the emergency department. The remaining 32 patients underwent exploratory celiotomy with 23 survivors and nine intraoperative deaths for a mortality rate of 28 per cent (nine of 32). Vascular control was achieved by manual compression in 44 per cent and by local clamping directly above and below the injury in 38 per cent. All repairs were by primary venorrhaphy, and no patient was treated with patch angioplasty or venous reconstruction. Three patients had caval ligation. Follow-up IVC imaging in 11 patients revealed that the IVC was patent in eight, narrowed in two, and thrombosed below the renal veins in one. One patient developed a pulmonary embolus. The vast majority of traumatic injuries to the IVC can be managed by direct compression or local clamping and primary venorrhaphy. Direct repairs are associated with a low thrombosis and embolic complication rate.
Collapse
Affiliation(s)
- John Alfred Carr
- Department of Trauma Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Kurt A. Kralovich
- Department of Trauma Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Joe H. Patton
- Department of Trauma Surgery, Henry Ford Hospital, Detroit, Michigan
| | - H. Mathilda Horst
- Department of Trauma Surgery, Henry Ford Hospital, Detroit, Michigan
| |
Collapse
|
25
|
MESH Headings
- Hemorrhage/etiology
- Hepatectomy/methods
- Hepatic Veins/anatomy & histology
- Hepatic Veins/injuries
- Humans
- Risk Factors
- Suture Techniques
- Vascular Surgical Procedures/methods
- Vena Cava, Inferior/anatomy & histology
- Vena Cava, Inferior/injuries
- Wounds, Nonpenetrating/classification
- Wounds, Nonpenetrating/etiology
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/surgery
- Wounds, Penetrating/classification
- Wounds, Penetrating/etiology
- Wounds, Penetrating/mortality
- Wounds, Penetrating/surgery
Collapse
Affiliation(s)
- R F Buckman
- Department of Surgery, Temple University, Philadelphia, Pennsylvania 19140, USA
| | | | | |
Collapse
|
26
|
Abstract
BACKGROUND Although nonoperative treatment has been a major advance in the management of liver trauma, emergency surgery is still required for unstable patients. Severe hepatic lesions located in the right lobe, notably juxtahepatic venous injuries, are difficult to access and still carry a high mortality. METHODS We describe a surgical approach for severe blunt injury to the right liver by a combined midline-transverse incision. This techniques allows simple, easy, and rapid mobilization and compression of the liver to control bleeding. RESULTS This technique was used in 10 patients with blunt liver trauma, with grade III (n = 2), IV (n = 5), and V (n = 3) injuries. Mean intraoperative blood transfusion required was 21 units. Six patients underwent mandatory anatomic resection, three patients were treated by hepatic suture, and one patient was treated by packing. This patient developed brain death after surgery and was the only mortality. CONCLUSION This technique is efficient and less cumbersome than shunting approaches.
Collapse
Affiliation(s)
- T Berney
- Clinic of Digestive Surgery and Visceral Transplantation, Department of Surgery, Geneva University Hospital, Switzerland
| | | | | | | | | |
Collapse
|
27
|
Abstract
BACKGROUND AND METHODS Management of blunt or penetrating injuries to the liver remains a significant challenge. This review discusses the mechanisms of liver injury, grading system for severity, available diagnostic modalities and current management options. It is based on a Medline literature search and the authors' clinical experience. RESULTS Unstable patients require immediate laparotomy, but selected patients who are haemo- dynamically stable may be managed without operation. The preferred operative techniques include resectional debridement, hepatotomy with direct suture ligation and perihepatic packing; anatomical resection, hepatic artery ligation and various bypass techniques have a limited, more defined role for selected injuries. Major complications include haemorrhage, sepsis and bile leak. CONCLUSION Enhanced resuscitation, anaesthesia and intensive care have contributed to a significant reduction in mortality rates from liver trauma. Optimum results are obtained with a specialist team that includes an experienced liver surgeon, anaesthetist, endoscopist and interventional hepatobiliary radiologist with expertise in managing postoperative complications.
Collapse
Affiliation(s)
- R W Parks
- Surgical Unit, Mater Hospital, Belfast, UK
| | | | | |
Collapse
|
28
|
Miyazaki M, Ito H, Nakagawa K, Ambiru S, Shimizu H, Okuno A, Nukui Y, Yoshitomi H, Kusashio K, Furuya S, Nakajima N. Aggressive surgical resection for hepatic metastases involving the inferior vena cava. Am J Surg 1999; 177:294-8. [PMID: 10326846 DOI: 10.1016/s0002-9610(99)00044-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The implications of aggressive surgical approaches for hepatic metastases involving the inferior vena cava (IVC) have not been clarified yet. The aim of this study is to assess the preliminary results of aggressive surgical resection for hepatic metastases involving the IVC. METHODS Sixteen patients with hepatic metastases involving the IVC underwent surgical resections with the repair and reconstruction of the IVC: patch repair in 2 and ringed Goretex in 1, primary closure in 13 patients. Hepatic metastases were from colorectal cancer in 14, stomach cancer in 1, and uterine cancer in 1 patient. RESULTS Vascular control utilized for resecting the IVC were total hepatic vascular exclusion in 8, hypothermic isolated hepatic perfusion in 3, and side clamp in 5 patients. The combined IVC resection with hepatectomy in 16 patients brought about 25% and 6% surgical morbidity and mortality rates, respectively. Survival rates following surgical resections were 64%, 33%, 33%, 22%, 22% for 14 patients of colorectal metastases involving the IVC as compared with 82%, 58%, 41%, 37%, 27% at 1, 2, 3, 4, 5 years, respectively, for 154 patients of colorectal metastases not involving the IVC. CONCLUSION Hepatic metastases involving the IVC could be safely resected without an increase in surgical risk. Aggressive surgical approaches might bring about a favorable outcome in select patients with colorectal hepatic metastases involving the IVC.
Collapse
Affiliation(s)
- M Miyazaki
- First Department of Surgery, School of Medicine, Chiba University, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Biffl WL, Moore EE, Franciose RJ. Venovenous bypass and hepatic vascular isolation as adjuncts in the repair of destructive wounds to the retrohepatic inferior vena cava. J Trauma 1998; 45:400-3. [PMID: 9715205 DOI: 10.1097/00005373-199808000-00038] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- W L Biffl
- Department of Surgery, Denver Health Medical Center, Colorado 80204, USA
| | | | | |
Collapse
|
30
|
Rogers FB, Reese J, Shackford SR, Osler TM. The use of venovenous bypass and total vascular isolation of the liver in the surgical management of juxtahepatic venous injuries in blunt hepatic trauma. J Trauma 1997; 43:530-3. [PMID: 9314322 DOI: 10.1097/00005373-199709000-00026] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- F B Rogers
- College of Medicine, University of Vermont, Burlington 05405, USA
| | | | | | | |
Collapse
|