纱布填塞压迫治疗严重肝外伤3例

目的 总结纱布填塞压迫治疗严重肝外伤体会。方法 回顾性分析3例严重肝挫裂伤,用纱布填塞压迫,术后经全身止血药、抗生素和营养支持治疗,5～7 d开始逐渐拔除纱布,共12～14 d拔完,伤口无出血、逐渐愈合。结果 3例严重肝外伤,转入我院时,病情平稳、血压正常、体温和血象稍高,伤口无出血,患者一般情况恢复,加强治疗,拔除纱布或绷带,已再无出血和感染等。3例严重肝挫裂伤经纱布填塞治愈,无并发症及后遗症。结论 纱布填塞治疗肝严重损伤,既是一种治疗方法,又可填塞压迫暂时止血,再送往上级医院彻底处理。纱布填塞对严重肝挫裂伤是一种简单、有效方法,最适合基层医院,值得推荐。     

半肝血流阻断及止血包填塞缝合术在严重肝外伤中的应用

目的：探讨应用止血包填塞缝合术,半肝血流阻断术及S－20型吸引治疗仪低负压持续吸引流技术,对严重肝外伤的手术治疗价值。方法：回顾总结1990年6月至2000年6月间我院收治严重肝外伤66例,按不同治疗方法分为两组,A组：1997年7月至2000年6月间应用止血包填塞缝合术,半肝血流阻断术及S－20型吸引治疗仪低负压持续吸引引流技术治疗严重肝外伤31例。B组：1990年6月至1997年7月间应用pringle法阻断第一肝门,明胶海绵或大网膜填塞术及双套管（弹簧式负压引流器）间断负压引流技术治疗严重肝外伤35例。结果：A组病死率为0,术后早期并发症共发生19例次（占61．3％）,B组病死率为2．9％,术后早期并发症共发生45例次（占128．6％）,两线比较有显著差异（P＜0．05）。结论：联合应用止血包填塞缝合术,半胖血流阻断术及S－20型吸引治疗仪低负压持续吸引流术,是治疗严重肝外伤较好的手术方法。具有良好的止血效果,术后早期并发症少,其术后肝功能恢复快。     

严重肝外伤术后并发症的防治

目的:探讨严重肝外伤术后并发症的防治。方法:采用深层褥式缝合。大网膜填塞,选择性肝动脉结扎,肝后纱布填塞及清创性肝部分切除,作为处理严重肝外伤的手术方式,共手术治疗53例严重肝外伤患者,同时治疗合并伤。结果:本后发生并发症16例(占30.2％),死亡10例(占18.9％),术后并发症是死亡的主要原因。结论:术中彻底止血,清创、引流,术后抗感染,严防MOF发生,是防治严重肝外伤术后并发症的根本措施。     

纱布条填塞在重症肝挫裂伤中的止血作用

作者报道闭合性肝挫裂伤40例,轻症20例,重症17例,肝静脉或肝后腔静脉破裂3例。在20例严重病例中,用纱布填塞作为止血、辅助止血或临时止血7例,其中基层医院纱布填塞临时止血转院1例,肝内血肿大网膜填塞外加纱布垫填塞止血2例,挫裂伤肝叶切除止血后,在复盖的大网膜上用阴道纱布条填塞止血3例,肝右静脉破裂纱垫填塞临时止血1例,都达到止血目的。认为这是一种有效的临时止血措施。     

严重肝外伤手术治疗的几种术式的选择与评价

目的探讨严重肝外伤手术治疗术式的选择与评价。方法分析自1982-2003年松花江流域8所医院手术治疗严重肝外伤100例的临床资料。结果100例严重肝外伤根据损伤部位及AAST分级标准、损伤程度，分别选用：清创止血加带蒂大网膜填塞缝合术：清创、止血、带蒂大网膜缝合加肝动脉结扎术或肝动脉栓塞术；肝切除和清创性肝切除术；肝切开术；肝脏网片包裹术；单纯纱布填塞术；网膜填塞缝合加肝后腔静脉修补术等。全组治愈率为91％(91/100)，病死率为9％(9/100)。结论严重肝外伤治疗困难，死亡率高；但合理选择术式是成功的关键措施。     

选择性肝动脉结扎加肝周填塞在严重肝外伤手术中的应用

目的:探讨选择性肝动脉结扎加肝周填塞在严重肝外伤手术中的应用价值.方法:选取2007年1月-2012年12月严重肝外伤行手术治疗患者80例进行回顾性分析,其中以2010-2012年的43例作为观察组,2007-2009年的37例作为对照组.观察组采用选择性肝动脉结扎、肝裂伤创面缝合加肝周填塞治疗,对照组采用肝裂伤创面致密缝合治疗,观察两组手术情况和治疗效果.结果:观察组在手术时间、术中出血量、术后3d腹腔引流量和住院时间上明显少于对照组(P＜0.05);观察组治愈率明显高于对照组(P＜0.05),并发症发生率和病死率明显低于对照组(P＜0.05).两组均未出现肝功能衰竭表现.结论:选择性肝动脉结扎加肝周填塞应用于严重肝外伤手术是安全有效的,能够减少术中术后出血量,缩短手术及住院时间,提高患者治愈率,减少并发症的发生,减少临床用血量,效果显著,值得临床推广.     

带蒂大网膜在肝外科中的应用体会：附242例分析

本文总结该院外科近２０年对２４２例肝外科病人应用带蒂大网膜治疗的情况。术后发生感染、脓肿及血肿等并发症１２例，占５％，均经再手术处理。通过分析作者认为：轻度肝外伤不需用大网膜填塞，严重肝外，尤其特殊类型严重肝外伤必须大网膜填塞才能消灭难以缝合的死腔；肝叶切除后断面的处理及肝脓肿的填塞，只要应用得当效果同样很好。     

严重肝外伤术后并发症防治体会

目的:总结严重肝外伤术后并发症的防治经验.方法:回顾分析近10年经手术治疗的56例严重肝外伤患者,15例伴合并伤(占26.8%),采用深层褥式缝合、大网膜填塞、选择性肝动脉结扎、肝后纱布填塞及清创性肝切除,作为处理严重肝外伤的手术方式,同时治疗合并伤.结果:术后17例发生并发症(占30.3%),9例死亡(占16.1%).因失血性休克术中死亡1例.术后并发症是死亡的主要原因,术后死亡原因:术后出血2例、MOF4例、严重腹腔感染并胆瘘1例、脑疝1例.其中伴合并伤死亡4例(占26.7%).结论:彻底止血、清创、引流,严防MOF发生,是防治严重肝外伤术后并发症的根本措施.     

严重肝外伤术后并发症的防治

目的总结严重肝外伤术后并发症的防治经验。方法回顾性分析1994年1月～2003年12月45例严重肝外伤病例行手术治疗的临床资料，包括损伤程度、手术方式、治疗效果及手术并发症。结果肝外伤Ⅲ级24例，Ⅳ级16例，Ⅴ级5例。行肝缝合修补术21例，大网膜填塞缝合4例，肝血肿清除3例，清创性肝切除14例，规则性肝切除3例。术后发生并发症17例次(38．6％)，并发多器官功能衰竭4例次，术后再出血3例次，胆漏3例次，膈下脓肿3例次，切口感染2例次，败血症1例次，肺部感染1例次；死亡7例(15．6％)，术中出血死亡1例，术后再出血死亡2例，术后多器官功能衰竭死亡4例。结论术后多器官功能衰竭、再出血、胆漏和膈下脓肿是严重肝外伤术后常见并发症。术中彻底止血，充分引流，预防多器官功能衰竭，可降低严重肝外伤术后并发症和死亡率。     

联合肝切除治疗肝内胆管结石并狭窄

目的探讨联合肝切除组合胆道手术治疗肝内胆管结石并狭窄的疗效。方法回顾性总结四年来联合肝切除组合胆道手术治疗肝内胆管结石并狭窄８２例,其中,肝左外叶切除６５例（７９．２７％）,左半肝切除１２例（１４．６３％）,右肝部分切除３例（３．６６％）,左肝外叶＋右前叶下段切除１例（１．２２％）。结果手术后结石取净７８例（９５．１２％）,术后纤维胆道镜取石３例,２例结石取净,总的结石取净率为９８．７８％（８０／８２）,手术并发症７例（８．５３％）,死亡１例（１．２２％）,８１例术后随访１个月～４年,肝内结石复发３例（３．７０％）。结论联合肝切除组合胆道手术是治疗肝内胆管结石并狭窄的有效方法、联合肝切除必须掌握适应证,急症肝切除的并发症多且较严重,术后纤维胆道镜检查与治疗对诊治残余结石有重要意义。     

Severe hepatic trauma：surgical strategies

Objective:To probe into effective surgical procedures and improve the outcome of treatment for patients with severe hepatic injury.Methods:A retrospective study involving 113 patients with severe hepatic trauma(AAST grade IV and V) during the past 12 years was carried out.Ninety-eight patients underwent surgical treatment.Surgical interventions including hepatectomy or direct control of bleeding vessels by finger fracture technique with Pringle maneuver, selective ligation of hepatic artery,retrohepatic caval repair with total hepatic vascular occlusion,and perihepatic packing were mainly used.Results:In the 98 patients treated operatively,the survival rate was 69.4%(68/98).Among 40 patients with juxtahepatic venous injury(JHVI),15 were cured with the maximum blood transfusion of 12 000 ml.Eight cases of Grade IV injury treated nonoperatively were cured.The percentage of failure of nonoperative management was 42.9%(6/14).The overall mortality rate was 32.7%(37/113),and 57% of the deaths were due to exsanguinations.Conclusions:Reasonable surgical procedures based on classification of hepatic injuries can increase the survival rate of severe liver trauma.Accurate perlihepatic packing is effective in dealing with JHVI.     

Recent experiences with a multidisciplinary approach to complex hepatic trauma

BACKGROUND: The selection of an appropriate time to terminate damage control efforts when faced with haemorrhagic shock from severe hepatic trauma can be challenging. At our centre, trauma surgeons have increasingly been favouring an operative approach simply involving early perihepatic packing (without extensive use of intraoperative measures aimed at achieving definitive haemostasis) and temporary abdominal closure. This is often followed by hepatic arteriography with angioembolization, resuscitation, and early re-exploration under more optimal physiological conditions. This study describes the initial outcomes of this approach. MATERIALS AND METHODS: All patients with high-grade liver injury requiring operative intervention due to refractory haemodynamic instability, presenting to our trauma centre between 1995 and 2001 were reviewed. Two treatment groups: definitive laparotomy (DL), and early packing (EP) with angioembolization and re-exploration were compared, using a retrospective audit. RESULTS: Thirty-seven patients were identified with severe liver injuries requiring operative intervention (DL 30, EP 7). Patient demographics between groups were similar. The EP group was found to have lower mortality (0% versus 36.7%), but increased length of hospital stay, transfusion requirements, and complication rates. CONCLUSIONS: A multidisciplinary approach to complex hepatic trauma involving brief damage control laparotomy with perihepatic packing only, followed by angioembolization, and early re-exploration may confer a survival benefit over early operative attempts at definitive haemostasis but is associated with complications.     

Transplantation of a severely lacerated liver – a case report with review of the literature

Abstract:  Using lacerated livers for liver transplantation (LTx) can add an option to the extended donor criteria. We present an LTx case using a severely lacerated liver and review of the literature for reported cases. We used a high-grade lacerated liver from a 19-yr-old brain-dead patient caused by traffic accident. The liver had grade IV and II lacerations in the right and left lobe, respectively. Lacerations were managed by sealants, stitching and perihepatic packing. The liver was transplanted to a 49-yr-old man suffering from hepatocellular carcinoma on hepatitis C-induced liver cirrhosis. The two-yr follow-up was uneventful. All published LTx cases using traumatized livers (n = 18) were analyzed. The liver injury ranged from subcapsular hematoma to deep ruptures. Most reported lacerations were in the right lobe, which were managed by digital compression, suturing, electrocautery, and perihepatic packing. The reported complications were primary non- (18%), or poor function, liver abscess, bilioma, and subhepatic hematoma each in one case (5.5%). Six-month graft and patient survival were 71% and 88%, respectively. With meticulous management lacerated livers can be transplanted successfully. Because of complexity of the management, procurement and transplantation should be done by experienced liver surgeons. These organs are marginal grafts and should be offered to selected patients.     

Liver Trauma: Experience in 348 Cases

Liver trauma, the main cause of death in patients suffering abdominal injury, remains an unresolved problem, especially in its most severe forms. The objective of this study was to probe effective surgical procedures and improve the outcome for patients with severe hepatic injury. A retrospective study of 348 patients with hepatic trauma seen in our institution during the past 12 years was carried out. Of these 348 patients, 259 (74.4%) underwent surgery. To manage severe liver trauma (American Association for the Surgery of Trauma grade III to grade V), procedures such as packing of the laceration with omentum, hepatectomy or direct control of bleeding vessels within the liver substance by means of the Pringle maneuver, selective hepatic artery ligation, retrohepatic caval repair with total hepatic vascular occlusion, and perihepatic packing were selected and combined based on the specific injury. In the 259 patients treated operatively, the survival rate was 86.9% (225/259); and 15 of 40 with retrohepatic venous injury (RHVI) were cured with the maximum blood transfusion of 60 units. In 42 patients treated by perihepatic packing, the bleeding was stopped in 20 of 25 (80%) with RHVI and in 14 of 17 (82%) without such injury (p > 0.75). The percentage of failure of nonoperative management was 17.2% (17/99); and it was 46.7% (14/30) in patients with grade III–V injury. Death occurred in 3 (50%) of 6 failures of grade IV–V injury. The overall mortality rate was 11.8% (41/348), and 51% of the deaths were due to exsanguination. The results suggest that severe hepatic injuries, especially grade IV–V injuries, usually require surgical intervention; reasonable surgical procedures based on classification of liver trauma and combined application of techniques can increase the survival rate; and perihepatic packing is effective in dealing with RHVI.     

Continuing evolution in the approach to severe liver trauma.

Surgical and radiologic techniques from computed tomography (CT) scanning and embolization to temporary gauze packing and mesh hepatorrhaphy have been developed to make the management of severe liver injuries more effective. Surgical approaches for severe liver trauma have been oriented to two major consequences of these injuries: hemorrhage and infection. Early attempts at hemorrhagic control found benefit only in temporary intrahepatic gauze packing. The subsequent recognition of complications after liver injury blamed the practice of packing, which then remained unused for more than 30 years. Yet more aggressive attempts at controlling hemorrhage without temporary packing failed to improve results. Temporary perihepatic gauze packing therefore has been reintroduced, but this is probably an imperfect solution. Mesh hepatorrhaphy may control bleeding without many of the adverse effects of packing. Fourteen patients are reported with severe liver injuries who have undergone mesh hepatorrhaphy, bringing the current reported experience with mesh hepatorrhaphy to 24, with a combined mortality rate of 37.5%. Thus far, it appears that only juxtacaval injuries fail to have their hemorrhage controlled with mesh hepatorrhaphy, but many believe that these injuries may be controlled by perihepatic packing. Prophylactic drainage of severe liver injuries is a concept for which there is little evidence of benefit. Furthermore, recent radiologic developments appear capable of draining those collections that do occasionally develop in the postoperative period. The ultimate challenge of liver transplantation for trauma has been attempted, but the experience is thus far very limited.     

Liver Transplantation for Post reperfusion Syndrome due to Surgical Packing of a Lacerated Liver

Abstract  The liver is the most frequently injured intra-abdominal organ and is the main cause of death in patients with abdominal injuries (mortality 10–15%). Grades III and IV liver injuries may present a complex problem to the surgeon. Several techniques to prevent exsanguination have been described including perihepatic packing, hepatic artery ligation, liver suturing or resection, and hepatectomy with transplantation. We report a case of a trauma patient who underwent perihepatic packing to control bleeding. Following pack removal, the patient developed severe cardiorespiratory depression resulting from postreperfusion syndrome requiring emergency total hepatectomy and liver transplantation. Types I–III hepatic injuries can safely be treated conservatively. Complex injuries (types IV and V) result in significant mortality, often requiring operative intervention. Indications of transplantion are uncontrollable hemorrhage or irreversible liver dysfunction. Literature reports describe liver transplantation as a second line treatment of complications following initial treatment. Our patient underwent liver transplantation as a second line treatment. The decision to transplant was based on two pathologic findings, ischemic changes of the liver and sudden cardio-respiratory decompensation following restoration of the blood supply to the liver. Both complications are emergencies, leading to death if not recognized and treated instantly. A total hepatectomy with temporary portocaval shunt followed by liver transplantation immediately or at a later stage is a life saving treatment for such cases.     

Can we evaluate the pressure of perihepatic packing? Results of a study on dogs.

The pressure of perihepatic packing can cause organ perfusion disturbances. The problem is to determine the pressure applied during the operative procedure. The objective of this animal study was to assess the perihepatic packing pressure and its effect on the pressure in the inferior vena cava (IVC). In order to assess the pressure in the IVC a catheter was introduced through the femoral vein. A rearranged tourniquet for blood pressure measurement was placed on the dog liver and with various perihepatic pressures the resulting pressures in the IVC were assessed. It was established, that by applying pressure of 30 mm Hg to the liver, the pressure in the IVC did not exceed 10 cm of water. Two clinical cases are reported where the method was shown to be crucial for the management. The first one is related to haemodynamic instability after successful perihepatic packing for grade V injury. In the second case, an otherwise stable patient had significantly elevated pressure in the IVC, which crucially influenced the treatment. The introduction of a catheter into the IVC to monitor the pressure in patients with liver injuries is useful.     

Predictive factors of morbidity and mortality in grade IV and V liver trauma undergoing perihepatic packing: Single institution 14 years experience at European trauma centre

PurposeMajor liver trauma in polytraumatic patients accounts for significant morbidity and mortality. We aimed to assess prognostic factors for morbidity and mortality in patients with severe liver trauma undergoing perihepatic packing.MethodsProspectively collected records of 293 consecutive polytrauma patients with liver injury admitted at a level I trauma centre between 1996 and 2008 were reviewed. 39 patients with grade IV–V AAST liver injury and treated with peri-hepatic packing were identified and included for analysis. Univariate and multivariate analyses were performed to assess prognostic factors for morbidity and mortality.ResultsMean age of patients was 41 years. 34 patients were haemodynamically unstable at initial presentation. Ten of 39 patients were treated with angiographic embolization in addition to perihepatic packing. The overall mortality rate was 51.3%. Liver-related death occurred in 23.1%. Overall and liver-related morbidity rates were 90% and 28%, respectively. Glasgow Coma Scale (GCS), respiratory rate, packed red blood cells (PRBC) transfusion, pH and Base Excess (BE), Revised Trauma Score (RTS) and Trauma Injury Severity Score (TRISS), need for angiographic embolization as well as early OR and ICU admission were associated with significant decrease of early mortality.ConclusionsRevised Trauma Score, haemodynamic instability, blood pH and BE are important prognostic factors influencing morbidity and mortality in polytrauma patients with grade IV/V liver injury. Furthermore, fast and effective surgical damage control procedure with perihepatic packing, followed by early ICU admission is associated with lower complication rate and shorter ICU stays in this patient population.     

Use of a refined operative strategy in combination with the multidisciplinary approach to manage blunt juxtahepatic venous injuries

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.     

肝周大静脉损伤救治策略的探讨

目的 探讨肝周大静脉损伤救治策略.方法 2001年6月至2011年6月,急诊收治肝外伤病人152例,根据术前CT检查和术中探查,18例诊断为肝周大静脉损伤.入院时行创伤严重度评分(ISS)和肝损伤严重度评分.按照损伤控制性外科的原则,分别采用肝脏缝合、损毁肝切除、血管直接修补、纱布填塞等治疗,分析手术并发症和临床疗效....