Liver trauma: What current management?

Background: The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years.Methods: The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed.Results: The study involved 83 patients, with a mean age of 33 years and a marked male predominance(85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries(81.9%) were of low severity(grades Ⅰ,Ⅱ,Ⅲ), while 15(18.1%) were of high severity(grade Ⅳ or greater). Fifty-six patients(67.5%) had multiple injuries. Surgical treatment was performed in 26(31.3%) patients. Non-operative management was undertaken in 57 cases(68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group.Conclusions: Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.

Outcome analysis of management of liver trauma: A 10-year experience at a trauma center

AIM: To review the outcomes of liver trauma in patients with hepatic injuries only and in patients with associated injuries outside the liver.METHODS: Data of liver trauma patients presented to our center from January 2003 to October 2013 were reviewed. The patients were divided into two groups. Group 1 consisted of patients who had hepatic injuries only. Group 2 consisted of patients who also had associated injuries outside the liver.RESULTS: Seven(30.4%) patients in group 1 and 10(28.6%) patients in group 2 received non-operative management; the rest underwent operation. Blunt trauma occurred in 82.8%(48/58) of the patients and penetrative trauma in 17.2%(10/58). A higher injury severity score(ISS) was observed in group 2(median 45 vs 25, P < 0.0001). More patients in group 1 were hemodynamically stable(65.2% vs 37.1%, P = 0.036). Other parameters were comparable between groups. Group 1 had better 30-d survival(91.3% vs 71.4%, P = 0.045). On multivariate analysis using the logistic regression model, ISS was found to be associated with mortality(P = 0.004, hazard ratio = 1.035, 95%CI:CONCLUSION: Liver trauma patients with multiple injuries are relatively unstable on presentation. Despite a higher ISS in group 2, non-operative management was possible for selected patients. Associated injuries outside the liver usually account for morbidity and mortality.

Non-operative management of isolated liver trauma

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, nonoperative management（NOM） is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma.Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2%（70/72）. The success rates of NOM in the patients with grade I-III, IV and V liver trauma were100%, 94.4% and 83.3%. The complication rates were 10.0%and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived.NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.

Liver transplantation for severe hepatic trauma:Experience from a single center

Liver transplantation has been reported in the literature as an extreme intervention in cases of severe and complicated hepatic trauma.The main indications for liver transplant in such cases were uncontrollable bleeding and postoperative hepatic insufficiency.We here describe four cases of orthotopic liver transplantation after penetrating or blunt liver trauma.The indications were liver failure,extended liver necrosis,liver gangrene and multiple episodes of gastrointestinal bleeding related to portal hypertension,respectively.One patient died due to postoperative cerebral edema.The other three patients recovered well and remain on immunosuppression.Liver transplantation should be considered as a saving procedure in severe hepatic trauma,when all other treatment modalities fail.

Emergency strategies and trends in the management of liver trauma

The liver is the most frequently injured organ during abdominal trauma.The management of hepatic trauma has undergone a paradigm shift over the past several decades,with mandatory operation giving way to nonoperative treatment.Better understanding of the mechanisms and grade of liver injury aids in the initial assessment and establishment of a management strategy.Hemodynamically unstable patients should undergo focused abdominal sonography for trauma,whereas stable patients may undergo computed tomography,the standard examination protocol.The grade of liver injury alone does not accurately predict the need for operation,and nonoperative management is rapidly becoming popular for high-grade injuries.Hemodynamic instability with positive focused abdominal sonography for trauma and peritonitis is an indicator of the need for emergent operative intervention.The damage control concept is appropriate for the treatment of major liver injuries and is associated with significant survival advantages compared with traditional prolonged surgical techniques.Although surgical intervention for hepatic trauma is not as common now as it was in the past,current trauma surgeons should be familiar with the emergency surgical skills necessary to manage complex hepatic injuries,such as packing,Pringle maneuver,selective vessel ligation,resectional debridement,and parenchymal sutures.The present review presents emergency strategies and trends in the management of liver trauma.

Right Post-Traumatic Diaphragmatic Hernia with Liver Dislocation

Diaphragmatic hernia is a rare consequence of thoraco-abdominal trauma. It may be associated with high morbidity and mortality, particularly if surgical intervention is delayed. We report a case of a right diaphragmatic hernia in a 75-year-old woman. The patient was referred to our hospital with mild dyspnea. Chest radiograph showed an overtly elevated right hemi-diaphragm. Thoracic and abdominal computed tomographic scan was requested and showed a defect of the right diaphragmatic muscle wall with intrathoracic ascension of the liver. During the postoperative course, the patient was still on mechanical ventilation, hemodynamically unstable. She developped urinary peritonitis and an extensive bowel ischemia worsening. We report this case to show that the prognosis is related to associated injuries and possible complications. The possibility of a diaphragmatic rupture should be kept in mind and surgery is mandatory in order to avoid complications.

EVALUATION ON FACTORS INFLUENCING LIVER CANCER METASTASIS AFTER LIVER SURGERY BY A MOUSE MODEL

Objective: To evaluate the influence of surgical trauma on liver cancer metastasis. Methods: A mouse model of experimental liver cancer metastasis was established by subcapsule injecting hepatoma ascites tumor cells (H22) into spleen of NIH mice. Simple intrasplenic inoculation, with sham operation, partial hepatectomy, total occlusion of hepatic blood inflow and blood loss and re-perfusion were performed and metastatic effects were observed. Results: There were significant higher metastasis-augmenting effects in sham operation and partial hepatectomy groups. Compared with no-blood transfusion, blood transfusion group was found to be potent to increase intrahepatic metastases. But, neither inhibition nor enhancement with total occlusion of hepatic blood inflow for 20 and 30 minutes was seen. Conclusions: Surgical trauma, especially partial hepatectomy and blood transfusion, are involved in enhancing metastasis, but total occlusion of hepatic blood inflow is not responsible for enhanced liver metastasis in the experimental metastasis model.

基于损伤控制理论的救治管理对肝脏与胆管外伤患者救治效果的影响

目的 探究基于损伤控制理论的救治管理在肝脏与胆管外伤患者救治中的应用效果。方法 回顾性分析2022年8月—2023年3月收治的肝脏与胆管外伤102例的临床资料,根据临床处理方案分为观察组52例和对照组50例,对照组实施常规急诊救治,观察组实施基于损伤控制理论的救治管理。观察2组救治相关指标、并发症及干预前后损伤严重程度、氧化应激指标[髓过氧化物酶(MPO)、丙二醛(MDA)、超氧化物歧化酶(SOD)]变化情况。结果 观察组手术时间、术后肛门首次排气时间及住院时间均短于对照组,术中出血量少于对照组(P<0.01);干预后,观察组损伤严重程度轻于对照组(P<0.05);干预后,观察组血清MPO、MDA水平低于对照组,血清SOD水平高于对照组(P<0.05);观察组多器官功能障碍综合征、失血性休克发生率分别为3.85%(3/52)、1.92%(1/52),低于对照组的18.00%(9/50)、16.00%(8/50),差异有统计学意义(P<0.05)。结论 基于损伤控制理论的救治管理可降低肝脏与胆管外伤患者应激及损伤程度,加速康复进程,改善临床结局。

创伤失血性休克继发肝损伤机制的研究进展

近年来,随着地震灾难、道路交通事故、高空坠落等频发,创伤失血性休克临床发生率较高。创伤失血性休克导致各种脏器继发性损伤,肝损伤是其最常见的损伤。继发性肝损伤机制涉及内质网应激、肝脏纤维化、线粒体损伤、氧化应激和炎症反应等。本文就创伤失血性休克后继发性肝损伤病理生理特点结合机制研究的相关文献进行回顾并作综述,为进一步的研究提供理论指导。

颅脑外伤合并肝挫裂伤急诊手术患儿的麻醉护理1例

总结1例急诊颅脑外伤导致颅内出血同时伴有严重肝挫裂伤、有肝包膜破裂出血风险患儿的急诊手术麻醉护理经验。麻醉护理要点:麻醉前评估患儿的生命体征、治疗现状;监测凝血功能,关注腹腔脏器损伤,预防并发症发生;强化气管导管护理;配合麻醉诱导,加强液体管理,维持循环血压,中心静脉压稳定,促进围手术期麻醉平稳;关注患儿凝血功能,降低术中肝包膜破裂风险;制定个性化麻醉护理方案,预防低体温,配合医生摆放手术体位。患儿围手术期麻醉平稳,手术顺利,术中未发生血肿破裂出血,术后转回外科监护室继续治疗。

经导管栓塞治疗肝脏外伤出血

目的探讨经导管栓塞治疗肝脏外伤出血的疗效、适应证、并发症等。方法回顾性分析我院从1996年5月到2006年5月收治肝脏外伤出血患者33例,其中24例行肝动脉造影证实为肝动脉假性动脉瘤形成,再超选择插管至病变部位,根据载瘤动脉受损情况,予明胶海绵和(或)弹簧圈栓塞。结果24例28枚假性动脉瘤栓塞技术上均一次成功。2例分别在栓塞后48h、72h再次出血。再次栓塞后1例康复,1例在第2次栓塞后1周因再出血和严重腹腔感染死亡。发热9例,均与栓塞无直接相关。结论经导管栓塞治疗肝脏外伤出血安全、迅速、有效。

超声造影引导微波凝固治疗Ⅰ～Ⅲ级肝外伤的实验研究

目的探讨超声造影引导微波凝固治疗Ⅰ～Ⅲ级肝外伤伴活动性出血的应用价值。方法全麻开腹状态下10只肝素化小型猪共建立Ⅰ～Ⅲ级肝外伤伴活动性出血模型40处，超声造影引导下将微波电极植入肝内活动性出血部位进行微波凝固治疗。治疗后2h观察治疗区有无再出血和血肿，并行超声造影检查及组织病理学检查判断疗效。结果40处肝外伤伴活动性出血微波治疗后均成功控制出血，Ⅱ级和Ⅲ级肝外伤局部出血时间[（192．0±108．0）S和（443．4±63．5）s]均长于Ⅰ级肝外伤[（48．3±33．3）s]（P〈0．01），出血量[（24．8±6．5）g和（47．8±10．5）g]均大于Ⅰ级肝外伤[（6．6±4．3）g]（P〈0．01）。微波治疗后2小时局部肝被膜均未见活动性出血和血肿。灰阶超声造影显示9处Ⅱ级和5处Ⅲ级肝外伤治疗区仅周边部见少许走行规则的线状增强，余治疗区均未见增强，呈负性显影。组织病理学显示，Ⅰ～Ⅲ级肝外伤微波治疗区内肝细胞变性明显，肝小叶内见多个大小不等的腔隙；血管壁的退变以近针道区明显，而远离针道区变化不明显。结论超声造影引导微波凝固治疗对Ⅰ～Ⅲ级肝外伤伴活动性出血较好的治疗作用，有望成为临床上外科治疗的一种重要辅助方法。

胶原海绵止血功能的实验研究

目的 验证国产胶原海绵的止血性能。方法 选用健康成年 SD大鼠 2 0只 ,随机分为二组。行肝脏表浅切口 ,分别用胶原及明胶海绵止血 ,观察止血情况 ;切除肝左前叶造成标准肝创伤模型 ,分别用二种海绵止血 ,观察止血情况 ,并记录即时止血时间及出血量。术后 7、14及 2 0天剖腹观察腹腔内粘连、腹腔内感染及肝脏愈合情况 ,并切除部分再生肝组织进行组织学检查。结果 胶原海绵与肝创面粘附良好 ,即时止血时间及出血量均明显优于对照组 (P<0 .0 5 )。组织切片显示胶原海绵吸收、降解快 ,可诱导肝细胞再生。结论 胶原海绵止血性能良好 ,能有效诱导肝再生 ,吸收降解快 ,使用方便 ,有应用、推广价值。

损伤控制手术在治疗严重肝外伤中的临床意义

目的探讨损伤控制性手术（damage control surgery，DCS）在治疗严重肝外伤中的临床应用。方法通过回顾性分析在2000—04～2008—09间我院采用损伤控制性手术治疗出现血流动力学不稳定、低体温、代谢性酸中毒和凝血障碍等情况的26例严重肝外伤（Ⅲ～Ⅵ级）患者的临床资料，总结出严重肝外伤应用损伤控制性手术的适应证、并发症和死亡率。结果26例患者中痊愈21例（治愈率80．2％），死亡5例（死亡率为19．2％），术后共17例发生了各种并发症（占65．4％）。结论对于严重肝外伤出现血流动力学不稳、低体温、代谢性酸中毒和凝血障碍等情况时选择损伤控制性手术不失为比较安全的、稳妥的手术方法，可有效地降低严重肝外伤的死亡率和并发症发生率。

外伤性肝脏出血的血管造影诊断和栓塞治疗

目的探讨外伤性肝脏出血的DSA诊断与介入栓塞治疗的临床应用价值。方法对18例肝脏外伤出血患者行急诊动脉DSA检查和介入栓塞止血治疗,栓塞材料采用明胶海绵和(或)聚乙烯醇(PVA)微粒。结果18例DSA检查出血表现为造影剂外溢,均获得了明确诊断。18例栓塞治疗后出血均立即停止,1例在治疗后24h内出血复发,遂行二次栓塞止血成功。随访3个月,无复发出血。未见严重并发症发生。结论DSA能及时、准确的发现肝脏出血的部位,是诊断外伤性肝脏出血的可靠方法。介入栓塞术治疗外伤性肝脏出血安全、迅速、有效,并能最大限度保护肝脏功能。

损伤控制性手术在严重肝外伤中的应用

目的探讨损伤控制手术在救治严重肝脏外伤中的应用价值。方法回顾性分析2000年1月～2012年7月应用损伤控制手术救治46例严重肝脏外伤患者的临床资料及应用情况。结果 46例患者均采用损伤控制性手术治疗,其中痊愈40例,死亡6例,术后出现并发症17例。结论损伤控制性手术,采用简单、有效的操作,使患者获得复苏的时间,避免病情进一步加重并有机会再进行完整、合理的再次或分期手术。正确熟练掌握损伤控制性手术适应证是手术成功的关键,应用损伤控制性手术可有效降低严重肝外伤患者病死率。

B超检查在闭合性肝外伤诊断中的应用价值

目的探讨B超检查在闭合性肝外伤诊断中的应用价值及注意事项。方法选择2007年1月—2008年10月在我院应用西门子公司SEQUIOA512彩色超声诊断仪(探头频率2.0～5.0MHz)诊断且经术后证实的48例闭合性肝外伤患者,回顾性分析患者的B超检查结果。结果48例患者中,肝脏真性破裂33例,被膜下破裂10例,中央型破裂5例。(1)真性破裂:肝脏外形增大,形态不规则,轮廓线中断;包膜不完整、断离、缺损,断离口周围常伴有不规则混合性强回声区,边界模糊;肝实质内可见强弱不均的杂乱回声,与正常肝组织无明显分界,损伤早期表现为不规则模糊的絮状、云雾状或斑块状强回声,随着时间的延长,病灶密度逐渐变为低回声或无回声液性暗区。肝肾间隙探及不等量的无回声区。(2)被膜下破裂:肝脏大小、形态正常,内部回声均匀,肝包膜强回声亮线与肝实质间出现无回声区,呈棱形改变,随着时间的延长,血肿机化时呈较强回声。(3)中央型破裂:肝脏肿大,形态异常,但包膜完整,内部回声紊乱,肝实质内出现不规则的液性暗区及强弱不均的回声区,边界欠清晰。结论B超检查诊断肝脏外伤方便、快捷、准确性高,具有重要的临床价值;但应注意随诊动态观察,难以探查的部位应扩大扫描视野,对肝脏周围及腹腔全面扫查,并进行必要的鉴别。

外伤性肝损伤的MSCT诊断价值分析

目的探讨MSCT扫描检查在肝脏创伤中的诊断价值。方法选择我院诊治的106例肝脏创伤患者,全部患者在伤后20min至3d内进行了64排螺旋CT检查,其中62例患者行增强扫描,并按美国创伤外科学会(AAST)及我国王正国院士分级方法进行分级。结果肝脏创伤患者I级24例,II级25例,III级34例,IV级14例,V级7例。其中,肝包膜下血肿56例,肝挫伤61例,单发或多发肝脏撕裂伤45例,肝实质内血肿30例,肝破裂21例,肝门汇管区损伤8例。结论 MSCT扫描检查能明确肝创伤的范围、程度,对肝脏创伤的诊断和治疗方案的选择具有重要指导意义。

腹腔镜治疗肝外伤的临床体会

目的研究腹腔镜在肝外伤治疗的应用价值。方法该院于2010年01月～2010年12月应用腹腔镜治疗肝外伤11例,腹部闭合伤9例,其中交通事故5例,挤压伤3例,坠落伤1例;刀刺伤2例。合并其他脏器损伤4例,合并小肠破裂2例,脾破裂1例,横结肠挫伤1例。参照Moore分级标准:Ⅰ级2例,Ⅱ级7例,Ⅲ级1例,Ⅳ级1例。合并其他脏器损伤者,同时在腹腔镜下予以处理。结果用腹腔镜完成治疗10例(其中1例用手助器完成),1例中转开腹,所有病例均无严重并发症及死亡。手术时间为50～180 min,平均手术时间70min。1例患者出现胆漏,经治疗后痊愈出院。结论腹腔镜技术对肝脏外伤的诊治具有独到的价值,适时应用腹腔镜技术治疗肝外伤可以达到满意的效果。

冷循环式多极射频凝固治疗轻型肝外伤的实验研究

目的探讨冷循环式多极射频凝固治疗轻型肝外伤的可行性。方法10只健康家猪开腹直视下采用手术刀片切割肝脏,建立Ⅰ、Ⅱ级肝外伤各10处。Ⅰ、Ⅱ级再各自随机平均分为两组,均采用冷循环式多极射频进行凝固止血治疗。随机选一组将两根射频针置于肝破裂口内,另一组将射频针置于裂口两侧肝实质内。射频输出功率及其它射频参数相同。观测肝活动性出血中止的治疗时间及凝固范围。结果随着射频热量的提高,肝裂口周围肝实质逐渐被凝固并延伸至肝裂口处,活动性出血逐渐停止;Ⅱ级组治疗时间明显长于Ⅰ级组(P<0.05);射频针置于裂口两侧组治疗时间少于相同级别的将射频针置于裂口内治疗组,均具有统计学差异(P<0.05)。结论冷循环式多极射频针能有效治疗轻型肝外伤,合理布针可明显缩短治疗时间。