严重肝后静脉创伤填塞治疗

目的采用肝周填塞以改善肝后静脉损伤手术的治疗效果。方法4年间15例严重肝后静脉损伤（Ⅲ－Ⅴ级）,手术采用Pringle法阻断肝蒂后肝内止血或清创切除,或加选择性肝动脉结扎。肝周填塞是处理昨后静脉损伤的主要手段。结果12例严重肝后静脉损伤获救,最大输血量12000毫升;死亡3例,主要死因为合并伤、大失血或并凝血障碍。结论正确操作的肝后填塞和适当的综合措施,对肝后静脉损伤具有明显疗效。     

肝脏损伤的诊断治疗策略

肝脏损伤手术治疗有较高的并发症发生率和死亡率,其治疗策略在过去几十年发生了转变,非手术治疗越来越多地被接受。但对创伤超声重点评估法(FAST)评估腹腔积血并伴有血流动力学状态不稳定、有明显腹膜炎症状的患者需行急诊剖腹探查术。非手术治疗肝脏损伤分级在Ⅳ~Ⅴ级的患者有较高的并发症发生率,需及早地发现并相应处理。手术治疗严重肝脏损伤成功的关键在于合理选择手术方式和及时运用损害控制理念和策略。肝后静脉损伤的主要对策是全肝血流阻断或转流下肝切除或肝切开显露和修补肝后静脉;难以耐受此术式时,肝周填塞是明智的选择。     

185例肝脏损伤综合手术治疗体会

目的探讨肝脏损伤的治疗方法,改善肝脏损伤手术的疗效。方法对2006年1月~2015年12月重庆市急救医疗中心创伤科收治的185例肝脏损伤手术患者的处理原则、手术方式及治疗结果进行总结,其中男性149例,女性36例;年龄15~79岁,平均37岁。按美国创伤外科学会(AAST)制订的肝损伤分级标准:Ⅰ级19例,Ⅱ级31例,Ⅲ级59例,Ⅳ级48例,Ⅴ级28例(其中合并肝后静脉损伤17例)。肝损伤AIS评分平均为(3.19±1.19)分。多发伤患者ISS评分平均为(18.76±6.64)分。以肝修补、大网膜填塞修补、Pringle法阻断肝蒂后肝内止血或清创切除、肝周填塞或加选择性肝动脉结扎作为处理肝脏损伤的主要手段。结果本组存活163例,死亡22例,死亡率11.89%。其中17例合并肝后静脉损伤者存活9例。死亡患者中除死于严重合并伤外,大失血或合并凝血障碍为主要死因。结论依据肝脏损伤的分级选择手术方案,肝后静脉损伤进行确切的肝后填塞和适当的辅助措施可提高救治成功率。     

严重肝脏损伤大出血5例行肝周填塞法的治疗体会

目的观察严重肝脏损伤行肝周填塞法的治疗效果。方法对本院2000年1月—2005年7月行肝周填塞法处理的5例严重肝脏损伤的资料进行回顾分析。结果5例患者均痊愈出院,除1例出院时伴有右侧胸腔积液,无1例发生胆瘘、胆道出血或肝脓肿。结论肝周填塞法是处理严重肝脏损伤的一种行之有效的方法。     

常温下全肝血流阻断处理严重肝外伤

目的 探讨常温下全肝血流阻断切肝术治疗严重肝外伤合并肝静脉和（或）下腔静脉损伤,以期提高严重肝损伤病人的抢救成功率,减少术后并发症。方法 采用常温下全肝血流 术切除肝叶,修复肝静脉和（或）下腔静脉处理８例严重肝外伤患者。结果 ８例合并肝静脉和（或）下腔静脉损伤的严重肝外伤病人,均采用全肝血流阻断处理,除１例合并其他损伤死亡外,其余均治愈。结论 常温下全肝血流阻断在处理合并肝静脉和（或）下腔静脉损伤     

肝外伤伴肝后静脉损伤的处理

目的 探讨肝外伤伴肝后静脉损伤的处理方法，以提高肝外伤伴肝后静脉损伤的外科治疗水平。方法 采用分步全肝血流阻断下显露修补、直接压迫下显露修补、缝扎肝静脉、缝合修补肝组织、纱布填塞等5种方法处理肝外伤伴肝后静脉损伤23例。结果 治愈18例(78．3％)，死亡5例(21．7％)。结论 术前合理的急救复苏、术中正确的综合手术治疗，是提高肝外伤伴肝后静脉损伤疗效的关键。     

肝后静脉损伤如何判断和处理？

Pringle法不能控制来自肝后的涌血，则表明有肝后静脉伤。此时若试图查找血管破口而盲目翻起肝脏是致命的。如果患者状况和手术者技术条件允许，可迅速实施全肝血流阻断，随即切除毁损的半肝，显露并修复损伤的肝后静脉。否则，肝周填塞为可选择的止血手段。操作要点：（1）明胶海绵浸泡血管收缩药或凝血药，填入肝伤处和第二肝门周围；（2）大网膜在横结肠左半的连接断开并作延展剪切，牵至膈下覆盖肝创面，须超过肝顶并包绕第二肝门；（3）纱垫2—3层逐一平铺在网膜下，压迫出血的肝伤并将网膜推向肝后腔静脉，垫尾留切口外，引流管置外侧以保证肝膈问压力均匀。2—3天后拔除纱垫，此时网膜已与肝创面和第二肝门周围愈着，较少复发出血。     

肝脏损伤肝叶切除术的适应证是什么?

解答:肝脏损伤肝叶切除术的适应证为:(1)局部毁损伤,切除损伤的肝组织有利于修复;(2)肝后静脉伤,需要切除部分肝组织以利显露;(3)肝损伤出血,用各种方法难以止血;(4)肝左外叶严重损伤。     

西宁地区常温下肝门阻断切肝术的临床研究

目的研究西宁地区常温下肝切除术中阻断入肝血流方式、阻断时间对“安全切肝”,尤其是肝癌合并有乙肝、肝硬化者的临床意义。方法选择临床和病理确诊的肝脏肿瘤及肝包虫病人共10例行手术治疗。结果本组10例肝脏手术均获成功(1例术后7天因肝衰死亡),根据病例的不同情况采用了三种肝血流阻断方法。结论采取常温下阻断肝血流的方法,减少肝脏切除术中大出血,同时尽可能减少入肝血流阻断的时间以减少和避免术后发生衰竭,为“安全切肝”提供了有力的技术保障。     

在持续肝门阻断时保留肝动脉血液供应对肝细胞的保护作用

 目的 研究在持续肝门阻断时保留肝动脉血液供应的安全性及其对肝细胞的保护作用.方法 设立对照组(SO组)、完全肝门阻断组(OPT组)和保留肝动脉持续阻断门静脉组(OPV组),通过测量3组肝断面出血量、安全时限、对肝脏的缺血再灌注损伤程度、对肝细胞能量代谢的影响以及病理学改变来评价肝门阻断时保留肝动脉血供对肝细胞的保护程度.结果 OPT组和OPV组相比肝断面出血量无统计学差异,耐受肝门阻断的安全时限OPV组为110 min,比OPT组平均延长20 min,复流后1 h和复流24 h,OPT组和OPV组的ALT、AST和MDA值对比有明显统计学差异(P<0.01);Na+-K+ATP酶的活性复流后1 h,OPT组和OPV组对比有明显统计学差异(P<0.01);复流后24 h,对比无统计学差异(P>0.05),病理组织学OPV组肝细胞损伤程度明显较OPT组轻.结论 在持续肝门阻断时保留肝动脉血液供应可以减轻对肝细胞缺血再灌注损伤,延长由于阻断肝门血流而引起的肝细胞能量衰减时间,使大鼠能够耐受更长时间的持续阻断,且不会增加肝断面的失血量,是值得推广的肝门阻断方法.     

Nonoperative management of hepatic trauma

In an attempt to determine whether selective, nonoperative management of hepatic trauma might be efficacious, a retrospective review of liver injuries was undertaken. Of the 48 patients with liver injuries identified, there were 34 men and 14 women with an average age of 28.5 years. Mechanism of injury consisted of blunt trauma in 23 patients, stab wounds in 14 patients, and 11 patients had gunshot wounds. There were 12 grade I injuries, 15 grade II injuries, 17 grade III injuries, 2 grade IV injuries, and 1 grade V injury. Diagnosis of liver trauma was made at the time of exploratory laparotomy in 15 patients and suggested by abdominal computed tomography (CT) scan in 18 patients; the remaining 15 patients had a positive peritoneal lavage which led to exploratory laparotomy. Following blunt trauma, 14 patients, all of whom underwent diagnostic abdominal CT scans which confirmed hepatic injury, had nonoperative treatment. All patients who received nonoperative management maintained stable vital signs and only five required transfusion. None of the patients who were treated nonoperatively developed complications or required delayed laparotomy. There were no deaths in this group. Of the 34 patients undergoing exploratory laparotomy, 19 required either no treatment or minor hepatorrhaphy. However, 17 of 25 patients with penetrating wounds had associated abdominal injuries which required operative treatment. Based on the information obtained in this review, it is recommended that stable patients with isolated hepatic injuries, secondary to blunt trauma confirmed by CT scan, may be managed nonoperatively. Due to the high frequency of associated injuries found in patients with penetrating trauma, nonoperative therapy is not advised.     

Traumatic lesions of adrenal glands in paediatrics: about three cases

Pediatric adrenal injuries, in blunt thoracoabdominal trauma, are rare and usually associated with traumatic liver and kidney lesions. This paper aims to present imaging findings and possible adrenal involvement in blunt abdominal traumas in childhood. We report three cases of thoracoabdominal trauma with adrenal involvement. Two patients were polytraumatised in car accidents. The third case was unusual because of the mild trauma. The adrenals lesions were right-sided in all cases. Post-traumatic adrenal contusion/haematoma may arise not only because of a direct trauma but also as a consequence of a sudden increase in the pressure in the inferior vena cava system-adrenal veins. This is why adrenal haemorrhage is not directly proportional to the trauma: compression of the inferior vena cava leads to increased pressure in the adrenal venous circulation, which supports the parenchymal lesion. The right adrenal gland is more frequently injured than the left gland: it can be easily compressed between the liver, spine and kidney, and its venous drainage flows directly into the inferior vena cava.     

严重肝脏损伤并发凝血病32例救治分析

目的探讨严重肝脏损伤并发凝血病的救治方法。方法回顾性分析重庆市急救医疗中心2010年2月—2016年4月收治的32例严重肝脏损伤并发凝血病患者的临床资料。其中男性23例,女性9例;年龄15~84岁,平均37.4岁。致伤原因:道路交通伤17例(56.3%),坠落/跌倒10例(28.1%),压砸/掩埋伤3例,其他2例。分析其救治方法及治疗结果。结果 32例均为多发伤。入院后按"CRASH PLAN"原则,快速做出伤情评估,同时建立静脉通道及抽血做凝血功能、配血等检测,按照损害控制复苏(DCR)原则进行复苏。术前有凝血功能障碍19例。大量输血按新鲜冰冻血浆、悬浮红细胞各6~10U和10U冷沉淀配送22例。肝脏损伤Ⅳ级20例、Ⅴ级12例。手术包括清创性肝切除22例,改良肝周填塞13例;手术时间30~90min。本组共存活24例,死亡8例(25%),因肝脏损伤及其并发症死亡6例(18.8%,6/32)。结论Ⅳ、Ⅴ级肝脏损伤容易并发创伤性凝血病;DCR是严重肝脏损伤并发凝血病的救治策略;"改良肝周填塞法"和清创性肝切除是抢救严重肝脏损伤并发凝血病时的主要损害控制性手术措施。     

Liver trauma due to penetrating lesions: miscellanea, personal case series, clinical and CT findings

PURPOSE: Penetrating liver wounds are related to many causes and rank second after blunt abdominal and liver trauma. We will report the clinical and radiological findings of our personal series of patients with penetrating trauma, especially by firearms and stab and cut wounds. We will also try to define the diagnostic workup of these traumas, which is especially based on CT signs of liver damage and associated changes and which is of basic importance for following treatment, both surgical or conservative. MATERIAL AND METHODS: In the last seven years we retrospectively reviewed 31 cases of penetrating liver trauma. The patients were 19 men and 12 women, ranging in age 18 to 73 (mean 42), with penetrating liver injuries from firearms (16 patients) and stab (9 cases) wounds; 6 patients had injuries from different causes. Abdominal CT was carried out in emergency with the CT Angiography (CTA) technique in all patients. In the patients with suspected chest and abdomen involvement CT was performed from the mid-chest for accurate assessment of diaphragm and lung bases and to exclude associated pleuropulmonary damage. RESULTS: Penetrating liver wounds were caused by firearms in 70% of cases, by stabbing in 12% and, in the extant 18%, by other causes such as home accidents, road and work traumas, and liver biopsy. In our series, the liver was most frequently involved, especially by firearms wounds; in our 16 cases the most frequent injuries were hemorrhagic tears. We found bullets in the liver in 6 cases. In one case of home accident the patient wounded himself while slicing bread with a long knife, which cut into the anterior abdominal wall and tore the anterior liver capsule, as seen at CTA. DISCUSSION AND CONCLUSIONS: Penetrating wounds to liver and abdomen are less frequent than those to the chest. In the past decade the use of CT has changed the diagnostic and therapeutic approach to such injuries completely, decreasing the resort to explorative laparotomy and hepatorrhaphy. Indeed, CT provides a clear picture of the extent and severity of damage, which permits to choose a conservative treatment in case of intraparenchymal hematomas and lacerocontusive foci without hemoperitoneum, which can be followed-up with physical and CT examinations. Moreover, Helical CT could provide the early diagnosis of active bleeding in the peritoneum and of focal bleeding in the liver, thus permitting prompt hepatorrhaphy or targeted hepatectomy. A diaphragm injury suspected at CT should always prompt the surgeon to intervention, especially when hemothorax, lung base pneumothorax, large liver hematoma or tear of the liver dome are associated. Finally, subdiaphragmatic free gas indicates gut perforation associated with liver damage, in which case surgery is necessary too.     

肝脏损伤并发腹腔感染的防治

目的探讨肝脏损伤并发腹腔感染的防治方法。方法回顾性分析2006年1月~2015年12月314例肝脏损伤患者的临床资料,男性221例,女性93例;年龄15~76岁,平均38岁。其中129例行非手术治疗,185例行手术治疗。结果 54例出现腹腔感染,均发生在手术组,感染率为29.2%。185例手术治疗患者中单纯性肝损伤73例[美国创伤外科学会(AAST)分级Ⅰ~Ⅱ级5例,发生腹腔感染0例;Ⅲ~Ⅴ级以上68例,发生腹腔感染14例],合并腹部其他脏器损伤或腹部外脏器损伤112例(AASTⅠ~Ⅱ级肝损伤45例,发生腹腔感染7例;Ⅲ~Ⅴ级肝损伤67例,发生腹腔感染33例)。54例腹腔感染中,49例治愈,治愈率为90.7%。结论严重肝脏损伤或合并腹部其他脏器损伤较易并发腹腔感染,根据肝脏损伤级别采取合理术式、保证充分引流、重视综合预防治疗措施可有效减少感染发生率和死亡率。     

Pediatric blunt abdominal trauma: periportal tracking at CT.

Periportal zones of decreased attenuation at computed tomography (CT) have been described in a variety of disorders. In the setting of blunt abdominal trauma, the zones have been attributed to dissection of blood along the portal tracts. Because of the observation of isolated periportal tracking (PPT) in children after blunt trauma, the authors retrospectively reviewed CT scans of the abdomen obtained in 114 children to determine the frequency of PPT, liver injury, and peritoneal fluid. PPT was present in 22% of patients (25 of 114); it was associated with liver injury in 10 and was the only liver abnormality in 15. Pathologic correlation was available in two patients: In one it revealed marked periportal lymphedema and in the other, PPT of blood. This study indicates that both hemorrhage and lymphatic edema may be represented as PPT in children after blunt abdominal injury.     

Penetrating liver war injury: a report on 172 cases

During the 4-year military conflict in Croatia, we treated operatively 7,928 casualties. Of those casualties, 172 (2.2%) had penetrating liver injury, mostly sustained by explosive devices. Of these injuries, 90.7% were associated with the trauma of other abdominal and extra-abdominal organs. Seventy-five percent of injuries belonged to grades III and IV on the Liver Injury Scale. The main method of treatment was debridement with ligation of severed vessels and bile ducts. In 8.1% of cases with detrimental bleeding, we used liver packing. Fifty percent of these patients have survived but with a high incidence of septic complications. This method was proven salutary in the most detrimental injuries that could not be treated in any other way. Postoperative hemorrhage and intra-abdominal abscesses were complications that needed surgical and ultrasound-guided aspiration, respectively. Numerous heavy injuries of the liver combined with associated trauma of other vital organs are responsible for the high mortality rate of 28.5%.     

胸外伤后急性呼吸衰竭的防治与病因分类

本文分析了55例胸外伤后急性呼吸衰竭(ARF),发生率为13％(55/423)。伴有休克或(和)心电图异常31例,昏迷14例,肾功能障碍13例和肝功能障碍9例,死亡7例,死亡率12.7％。ARF随着合并功能障碍脏器数目的增多,死亡的危险性明显增加。在总结临床经验的基础上作者指出,及早预防和处理ARF和脏器功能障碍,是降低胸外伤死亡率的关键,并提出了按照主要病因和发病机理将胸外伤后ARF分为:(1)外呼吸障碍,(2)肺挫伤,(3)继发性病因所致三类呼衰的分类方法。第(3)类ARF的死亡率最高。     

Liver trauma grading and biochemistry tests

Among solid organ blunt traumas, the liver and spleen are mostly subject to injury. In addition, the liver is also commonly injured in penetrating traumas because of its size, location, and the ease of injury to the “Glisson Capsule”. Several enzymes are known to be elevated following trauma. In our study, we evaluated the correlation between the levels of serum aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, and gamma-glutamyl transpeptidase in 57 patients with blunt trauma to the liver and compared these values to the American Association for the Surgery of Trauma trauma grading system. Additionally, we compared the enzyme level elevations in these patients to the enzyme levels of 29 healthy subjects. As expected, we found significant elevations in enzyme levels of trauma patients compared to the control group. The calculated point estimates were not significantly different between grades 1 and 2 trauma. However, grade 3 trauma group showed a significant increase in enzyme levels.