Hepatic Vein Injury Research Articles

Therapeutic perihepatic packing in complex liver trauma

Packing for control of haemorrhage was used in 22 of 294 patients undergoing surgery for liver trauma over a 6-year period. The major indication for packing was transfusion-induced coagulopathy. Sixteen patients had blunt trauma and six penetrating trauma including five gunshot wounds; 19 patients had major right lobe injuries, three left lobe and five also had hepatic vein injuries. Packing provided definitive control of bleeding in 18 patients but four patients had recurrent bleeding due to hepatic artery injury (three) and hepatic vein injury (one); three required further surgery and bleeding was controlled in the fourth by selective hepatic artery embolization. Six patients died and in two of these recurrent bleeding, despite packs, was a contributing factor. Mean blood loss in the six patients who died was 18 (range 10-30) units, compared with 13.1 (range 8-30) units in survivors. Packs were removed from the 16 survivors at laparotomy at a mean of 3.1 days after insertion; six patients rebled during pack extraction and were successfully repacked. Major morbidity occurred in 12 of the 16 survivors. Seven patients developed intra-abdominal sepsis following packing, one of whom died. Therapeutic liver packing provides life-saving control of hepatic bleeding which is frequently aggravated by coagulopathy. This approach permits resuscitation in an intensive care unit and subsequent planned relaparotomy for retrieval of packs and further intervention as necessary.

Retrohepatic vena cava and hepatic vein injuries: a simplified experimental methods of treatment by balloon shunt.

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. 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. 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). The addition of a gastric injury to a colon injury has a synergistic effect on the rate of postoperative infection.

Ｉｎｔｒａｌｕｍｉｎａｌ ｂａｌｌｏｏｎ ｅｘｃｌｕｓｉｏｎ法にて救命し得た肝静脈損傷合併重症肝破裂の１例

We present a case of hepatic rupture with hepatic vein injury following blunt trauma treated surgically by the intraluminal balloon exclusion technique. A 29-year-old woman was struck on the upper abdomen in a traffic accident. After admission, CT and ultrasonography demonstrated intra-abdominal hemorrhage and typeIIIb liver injury (JAST classification). Laparotomy was performed about 2 hours after injury, and revealed massive hemorrhage, severe injury to the lateral and medial segments of the liver, and injury to the left hepatic vein. Resectional debridement was immediately carried out to access the injured vein. A balloon catheter was introduced through the completely transected left hepatic vein, and inflated to obtain control of bleeding, then the vein was repaired with 4-0 prolene sutures which were tied after removing the occluding catheter. The patient was discharged 25 days after operation with an uneventful recovery. We think that the intraluminal balloon exclusion technique is an effective procedure for transected left hepatic vein injury.

Laparoscopic hepatic resection for hepatocellular carcinoma

Despite recent progress in diagnostics for hepatocellular carcinoma, the rate of resectability remains low, mainly because of the advancement of the underlying liver disease. We report a case of a 54-year-old man with a hepatocellular carcinoma and poor liver function that was treated successfully with a laparoscopic hepatic resection. Laparoscopic hepatic resection is considered to be feasible with the aid of an ultrasonic dissector and a microwave coagulator; however, close attention should be paid to the development of air embolism and hepatic vein injury.

Surgical management of juxtahepatic venous injuries in blunt hepatic trauma.

The purpose of this analysis was to understand better the problems faced in the management of blunt juxtahepatic venous injuries and to try and simplify the controversies regarding the optimal surgical approach to these injuries. Charts of 92 blunt liver trauma patients treated between July 1, 1991 to June 30, 1993 were reviewed. Nineteen patients with blunt juxtahepatic venous injuries were identified. The isolated left hepatic vein injury group (five patients) were all treated using a nonshunting approach with no mortalities. Half of the isolated right hepatic vein injury group (ten patients) received an atriocaval shunt, and the other half did not. These two different approaches each produced one survivor, with a combined mortality rate of 80% (eight of ten patients). One of the combined injuries group (four patients) received a total hepatectomy followed by liver transplantation. Another received a shunt. The other two were treated without shunting, but all of them expired. The overall mortality rate was 63.2% (12 of 19 patients), with nine patients dying intraoperatively or immediately postoperatively from exsanguination. The other three died 10, 25, and 30 days postoperatively because of sepsis. Juxtahepatic venous injury should be suspected after failure of the Pringle maneuver to stop bleeding and the different venous injuries differentiated by palpation of the adjacent hepatic parenchymal injuries. If an isolated left hepatic vein injury is found and the liver parenchymal injury is limited to segments II, III, or IV, then a nonshunting approach will achieve the optimal outcome.

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.

Microwave tissue coagulator in liver resection for cirrhotic patients.

The use of the microwave tissue coagulator was studied on 20 consecutive elective hepatic resections carried out for symptomatic hepatocellular carcinoma with liver cirrhosis. The mean operative blood loss (excluding one patient with hepatic vein injury) was 1132 mL. Five patients required no blood transfusion. The average time taken to coagulate the anticipated liver transection plane was less than 15 min. Apart from the complications similar to those occurring in hepatic resections for cirrhotic patients, higher incidences of intra-abdominal sepsis (20%), sympathetic pleural effusion in the absence of chest or intra-abdominal sepsis (20%), and persistent fever lasting more than 1 week (40%) were encountered. It was considered that these complications were related to the coagulated tissue present in the liver remnants (mean depth of tissue coagulation = 3.8 mm) and concluded that although the hospital mortality rate of 10% and the mean operative blood loss of 1132 mL were acceptably low, microwave liver surgery carried a high morbidity rate which is a drawback in major hepatic resectional surgery.

Hepatic Vein and Retrohepatic Vena Caval Injuries in Children

Major hepatic vein and retrohepatic vena caval injuries are often fatal because of massive uncontrollable hemorrhage. Children with these injuries can be identified by their unique and dramatic clinical presentation and the selective use of computed tomographic imaging. Volume resuscitation promotes abdominal wall tamponade and hemodynamic stability until the abdomen is opened, at which point there may be sudden exsanguination before vascular control can be obtained. An alternative approach is to open the sternum before opening the abdomen. Management in this sequence provides rapid vascular control and improves the efficiency of hepatic exclusion. To date, five children with major hepatic vascular injuries have been treated with the sternotomy-first approach and four have survived; an atriocaval shunt was used on two occasions. Although sternotomy before laparotomy improves the efficiency of hepatic exclusion and may offer improved survival, accurate preoperative case selection limits its routine use.

Packing and Planned Reexploration for Hepatic and Retroperitoneal Hemorrhage: Critical Refinements of a Useful Technique

We evaluated 35 consecutive patients treated with temporary intraabdominal packing for control of bleeding to determine factors that could improve hemorrhage control, morbidity from infection, and mortality. Twelve patients could not be resuscitated from hemorrhagic shock and died in the operating or recovery room. Bleeding was controlled in the remaining 23 patients; however, five (22%) died of complications other than hemorrhage. Intra-abdominal abscesses occurred in seven of the 21 patients who survived longer than 5 days and were more frequent in patients who had gastrointestinal perforation (50% versus 27%) and selective hepatic artery ligation (80% versus 19%). Four patients with either retrohepatic vena cava injury, hepatic vein injury, or both, were packed without attempted repair; three underwent delayed repair and survived. Coagulopathy occurred in 55% of patients who received greater than 15 units of blood before packing but in only 17% who received less than 15 units. The abdomens of ten patients were closed with a prosthetic mesh which did not prevent hemorrhage control, and only one patient developed a wound infection compared to 42% of patients with primary suture closure. We therefore conclude: 1) packing is more effective if instituted early (when less than 15 units of blood have been transfused) and is not contraindicated before either repair of retrohepatic vena cava injury, hepatic vein injury, or both; 2) selective hepatic artery ligation should be avoided if packing alone stops bleeding; 3) abdominal closure with a synthetic mesh decreases the incidence of wound infection; and 4) patients should be returned to the operating room for repacking if 24-hour postoperative blood requirements exceed 10 units.

Hepatic vein and retrohepatic vena caval injury

Retrohepatic venous injury presents as a rare but frequently lethal complication of trauma. The anatomic arrangement makes management of these injuries difficult at best. Operative exposure and isolation techniques ranging from cross-clamping the aorta, portal triad, suprarenal vena cava, and suprahepatic vena cava to the use of internal shunts are described in this report. Our experience from 1968 to 1987 with internal shunting techniques includes 27 patients. We have successfully resuscitated 12 patients for an acute mortality of 55%. We believe that this figure is high but compares favorably with published results. Late deaths from sepsis, disseminated intravascular coagulation, or multiple systems organ failure remain as significant causes of overall mortality. Many techniques have been successfully employed over the years in achieving vascular isolation of the liver. The methods all have their own merits, but the key factor in each is the recognition that they need to be employed. Conservative selection of patients is undoubtedly justified, but aggressive approaches should not be delayed until they are the methods of last resort.

The role of hepatic resection in the management of blunt liver trauma

Forty-two (14%) of 306 patients with liver injuries presenting to Westmead Hospital over a 10-year period required hepatic resection as their definitive treatment. Two types of resection were performed: Resectional debridement utilized the plane of injury as the line of resection while anatomical resection utilized anatomical planes. Resectional debridement was used in 35 patients. In 29, the major technical problem was bleeding and 21 of these patients had associated hepatic vein injuries. In 5, the major problem was devitalized parenchyma, and, in 1, it was an intrahepatic bile duct injury. Anatomical resection was performed in 7 patients: 3 with bleeding, 2 with devitalized parenchyma, and 2 with intrahepatic bile duct injuries. Overall, 15 patients died (36%). The most common cause of death was bleeding in 9 of the 15 patients. Survivors spent a median of 32 days in hospital (range: 11-162 days) and sustained a median of 2 complications (range: 0-6). The most common complications were respiratory infection and/or failure, coagulopathy, and sepsis. Resection successfully addressed bleeding, devitalized parenchyma, and intrahepatic bile duct injuries with an acceptable mortality in critically ill patients who would otherwise have died.

Management of the traumatized liver: an appraisal of 63 cases.

A review of all patients with liver trauma admitted to the Royal Adelaide Hospital during the period 1983-86 was undertaken. Twelve of the 63 patients died. Liver trauma was responsible in eight (giving a mortality rate of 12.7%). The overall mortality rate was 19.0%. Most of the liver injuries (83%) were due to blunt trauma. All the deaths occurred in this group and were related directly or indirectly to blood loss. A high mortality (83%) was associated with hepatic vein injury. Right hepatectomy was unsuccessful in preventing death in any of these patients. The management of major venous injuries is discussed. A significant number of the liver injuries was minor. Analysis of these suggests that a more conservative approach to the management of haemodynamically stable patients might be appropriate.

Successful management of hepatic vein injury from blunt trauma in children

In children, the majority of deaths from blunt trauma to the liver are caused by large stellate fractures of the posterolateral aspect of the right lobe of the liver with extension into the hepatic veins. Four children with such injuries were successfully treated. Hypotension and abdominal tenderness are not early manifestations of this highly lethal injury in children. When an appropriate mechanism for liver injury exists, paracentesis or peritoneal lavage, followed by prompt laparotomy for hemoperitoneum, gives the best chance for early and successful treatment. Large cannulas in arm veins and cross matching for twice the patient's blood volume are used when there is a possibility of a liver injury. The important aspects of operative management are identification of the injury when the abdomen is first opened and prompt control of bleeding. The possibility of hepatic vein injury exists if the surgeon finds the coronary ligament disrupted by a large liver laceration on the posterolateral liver surface. Compressing the liver against the diaphragm will usually control the bleeding while blood replacement is accomplished. The hepatic vein entrance into the inferior vena cava is then exposed using a median sternotomy, if necessary. Partial occlusion of the inferior vena cava can usually be safely done with this direct approach if the blood volume has been restored. Frequently, valuable time and blood are lost if attempts are made to insert internal shunts.

Management of 1,590 consecutive cases of liver trauma.

Between 1939 and 1974, more than 1,500 patients have been treated for penetrating or blunt liver trauma at our institution. Gunshot wounds and major blunt trauma have increased, stab wounds decreased, as percent of total. In most cases techniques other than partial hepatic resection were used, although this was performed in 49 instances. Choledochostomy was infrequently employed. Intracaval shunts were useful in 15 selected patients with massive hepatic, concomitant suprarenal vena caval, or hepatic vein injuries. The overall mortality of this group was 13.1%. The improvement in mortality from liver injuries is attributable to (1) early exploration for suspected intra-abdominal traumatic injury, (2) a conservative approach to the liver injury, and (3) the limitation of lobar resection, vascular cannulae, and afferent vascular compression to highly selected cases.

Liver trauma: current method of management.

Two hundred eighty-five cases of liver trauma have been treated in the last five years at the San Francisco General Hospital. One hundred three resulted from blunt trauma and 182 from penetrating wounds. The average age was 29 years. Fifty-eight percent of the patients were treated with drainage, 28% by resectional debridement, and 14% by major resection. Associated injuries occurred in 212 patients (74%). Twenty-nine patients (10%) died in the operating room from exsanguination and 23 (9%) postoperatively from head injury, sepsis, and pulmonary insufficiency. The overall mortality was 18.8%. The indications for liver resection in trauma include the following: deep lacerations with involvement of major vascular structure or bile ducts, lacerations which produce nonviable liver segments, and lacerations with massive hemorrhage which are associated with vena cava or hepatic vein injury.

Management of blunt trauma to the liver and hepatic veins.

CURRENTLY accepted management of liver trauma outlined by Madding et al¹has reduced overall mortality from 60% prior to World War II^2,3to between 9% and 27%.^4-6To further reduce mortality the treatment of blunt liver injuries must be improved.⁷The mortality from penetrating wounds has been relatively low, ranging from 0.8% to 14.3%,^6,8but blunt trauma has been reported to be fatal in 25% to 55% of recent series.^8,9 Review of the experience at San Francisco General Hospital showed that hepatic vein injuries were a significant factor in the high mortality from blunt liver trauma. A new approach to management of hepatic vein injuries has been devised. <h3>Material</h3> From 1960 to 1966, 61 patients with liver injury were admitted to San Francisco General Hospital. Thirty-two patients had stab wounds, nine had gunshot wounds, and 20 had blunt trauma. The 47 males and 14