Management of Complications of First Instance of Hepatic Trauma in a Liver Surgery Unit: Portal Vein Ligation as a Conservative Therapeutic Strategy.

Aldo Rocca,Paolo Bianco,Anna Ginevra Immacolata Zamboli,Giuseppe Surfaro,Enrico Andolfi,Maurizio Amato,Domenico Tafuri,Bruno Amato,Barbara Frezza,Marta Scricciolo,Sergio Brongo,Antonio Giuliani,Gianluca Costa,Graziano Ceccarelli

doi:10.1515/med-2019-0038

Abstract

BackgroundAccording to the National Trauma Data Bank, the liver, after the spleen, is the first most injured organ in closed abdominal trauma.MethodsFrom June 2010 to December 2015 we observed in our department of Hepato-biliary Surgery and Liver Transplant Unit of the A.O.R.N. A. Cardarelli of Naples 40 patients affected by hepatic trauma. In our retrospective study, we review our experience and propose portal vein ligation (PVL) as a first – line strategy for damage control surgery (DCS) in liver trauma.Results26/40 patients (65%) which received gauze-packing represented our study group. In 10 cases out of 26 patients (38,4%) the abdominal packing was enough to control the damage. In 7 cases (18,4%) we performed a liver resection. In 7 cases, after de-packing, we adopted PVL to achieve DCS. Trans Arterial Embolization was chosen in 6 patients. 2 of them were discharged 14 days later without performing any other procedure.In 3 cases we had to perform a right epatectomy in second instance. Two hepatectomies were due to hemoperitoneum, and the other for coleperitoneum. Two patients were treated in first instance by only doing hemostasis on the bleeding site. We observed 6 patients in first instance. Five of them underwent surgery with hepatic resection and surgical hemostasis of the bleeding site. The other one underwent to conservative management. In summary we performed 15 hepatic resections, 8 of them were right hepatectomies, 1 left hepatectomy, 2 trisegmentectomies V-VI-VII. So in second instance we operated on 10 patients out of 34 (30%).ConclusionsThe improved knowledge of clinical physio-pathology and the improvement of diagnostic and instrumental techniques had a great impact on the prognosis of liver trauma. We think that a rigid diagnostic protocol should be applied as this allows timely pathological finding, and consists of three successive but perfectly integrated steps: 1) patient reception, in close collaboration with the resuscitator; 2) accurate but quick diagnostic framing 3) therapeutic decisional making. Selective portal vein ligation is a well-tolerated and safe manoeuvre, which could be effective, even if not definitive, in treating these subjects. That is why we believe that it can be a choice to keep in mind especially in post-depacking bleeding.

Highlights

According to the National Trauma Data Bank, the liver, after the spleen, is the first most injured organ in closed abdominal trauma
We review our experience and propose portal vein ligation (PVL) as a first – line strategy for damage control surgery (DCS) in liver trauma
The improved knowledge of clinical physiopathology and the improvement of diagnostic and instrumental techniques had a great impact on the prognosis of liver trauma

Summary

Introduction

According to the National Trauma Data Bank, the liver, after the spleen, is the first most injured organ in closed abdominal trauma. According to the National Trauma Data Bank, the liver, after the spleen, is the second most injured organ in closed abdominal trauma (78%), and one of the most injured organs like spleen, eye and others in penetrating wound [1,2,3]. Liver trauma is classified following the “Liver Injury Scale” edited by the American Association for the Surgery of Trauma (AAST) (Table 1) where the severity of the trauma is described in six progressive steps, where each one is linked to the depth of the wound, the volume of the hematoma and the vascular hilum involvement [4]. There are three key points of the DCS: 1. Short time surgery only to control bleedings and sepsis

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