Liver Trauma: New Management Trends

J M Little

doi:10.1155/1994/19580

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 and 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 and 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 (retro-hepatic cava or hepatic veins) were managed by prolonged portal 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 ?? cumulative mortality rate. Packing and planned reexploration has a definitive life-saving role when used adjunctively.

Highlights

And the use of a viable omental pack is a safe, reliable, and effective method of managing complex hepatic injuries
The authors have analysed their experience with 411 liver injuries. They use a grading system which extends from Grade I for the most minor haematoma or laceration to Grade VI which represents avulsion of the liver from the inferior vena cava
Grade V injuries represent more than 75% destruction of a hepatic lobe or a juxta-hepatic venous injury. 258 of the injuries encountered between 1977 and 1991 by the authors in New York were of Grade I or II severity

Summary

Introduction

And the use of a viable omental pack is a safe, reliable, and effective method of managing complex hepatic injuries (grade III to IV). The great majority of the more complex injuries (83%) were graded as either III or IV, and these injuries were usually dealt with by occlusion of the portal triad and finger fracture of liver parenchyma to allow access for haemostasis and drainage. Fourteen patients (3.4% of the total series) suffered Grade V injury to the juxtahepatic venous structures.

Results

Conclusion