Management of injuries to the porta hepatis.

The management of injuries to the porta hepatis is challenging and controversial. Although definitive, anatomic reconstruction of injured ductal or vascular structures is optimal, porta hepatis injuries are universally accompanied by injuries to other organs (3.6 in this series), which often precludes initial repair. Moreover, frequent injury to the inferior vena cava, aorta, or other major blood vessels in addition to the structures of the porta hepatis results in these injuries being treated in conjunction with exsanguinating hemorrhage. For that reason, control of hemorrhage is the initial management priority, with the initial operation requiring expeditious, if less than anatomically exact, operations. Eighteen of 31 patients survived porta hepatis injury. Hepatic artery injuries were treated by ligation. Complex injuries to bile ducts frequently required enteric-ductal anastomoses as secondary procedures. Of 29 patients with portal vein injuries, six were treated by ligation, 22 by lateral repair, and one with splenic vein interposition graft. As in earlier reports, the structure of the porta hepatis associated with the highest morbidity and mortality rates when injured was the portal vein.     

Traumatic injuries to the portal vein: case study

BACKGROUND: Injuries to the portal vein are rare but devastating. Contemporary studies have debated the most effective management for this injury. The purpose of this case study was to provide an update on portal vein injury and add information regarding its management. METHODS: A retrospective review investigated the 10-year experience with portal vein injury in a level 1 trauma center. RESULTS: Of the 18,900 trauma patients (0.08%) evaluated during a 10-year period, 15 sustained injuries to the portal vein. All the injuries resulted from penetrating trauma, and the overall survival rate was 60% (9 of the 15 patients). Four patients died of exsanguination and two patients died later as a result of multisystem organ failure. Postoperative complications were common. Sepsis and wound infection were the most common postoperative complications, occurring in seven (78%) of the nine survivors. All the patients had associated nonvascular injuries, whereas 9 (60%) of the 15 had associated vascular injuries. Associated injuries to the other structures in the portal triad occurred in 7 (47%) of the 15 patients, and 5 (71%) of these patients survived. Survival rates by procedure were 86% for venorrhaphy and 67% for ligation. CONCLUSIONS: Injuries to the portal vein are rare. In this study, exsanguination was the main cause of death. The key to a favorable outcome is prompt control of hemorrhage with an early decision to proceed with either venorrhaphy or ligation. Ligation can be effective for the management of hemodynamically unstable patients.     

Portal vein injuries.

Wounds of the portal vein are caused most commonly by penetrating trauma and carry a very high mortality rate. Most deaths are caused by exsanguination, occurring intraoperatively as surgeons struggle to control the hemorrhage from the portal vein and associated vascular injuries. A thorough knowledge of the anatomy of the area and of the likely patterns of wounding is important. At surgery, surgeons must be prepared to deal with multiple vessel wounding. Although most investigators have advocated lateral repair of the portal vein when it can be accomplished, portal ligation seems to be a safe alternative. Complex repairs are justified only when a contraindication to ligation exists. Postoperative care must recognize the need for extraordinary fluid replacement and the small risk for postoperative bowel infarction after repair or ligation of the portal vein.     

Therapeutic strategies of iatrogenic portal vein injury after cholecystectomy

Background

The incidence of vascular injury after a cholecystectomy is often underestimated. Although injuries to the portal vein are rare, they are devastating. The aim of the present study was to analyze suitable therapeutic strategies regarding portal vein injury in the absence of biliary injury.

Materials and methods

Eleven patients with portal vein injuries after laparoscopic or open cholecystectomy were referred to our hospital between 2004 and 2010. The clinical presentation, diagnosis, and management of patients with severe portal vein injuries were reviewed. All the patients were discharged without outstanding clinical conditions. During retrospective analysis, these patients were divided into early, middle, and late stages.

Results

All the 11 patients had a portal vein and/or right hepatic artery injury, but no biliary injuries were observed. Among these patients, different management strategies were managed according to the stage of the injury. Eight patients received a direct suture at the time of injury by an experienced hepatobiliary surgeon. Two patients received thrombolytic and anticoagulation therapy after cholecystectomy, without additional surgery. One patient received a liver transplant 3 mo after the injury. After long-term follow-up, these patients had no clinical conditions.

Conclusions

Direct repair or suture is important during the early stage of portal vein injury. Conservative thrombolytic and anticoagulation therapy may serve an important role in the treatment of acute massive thrombus in portal vein injury during the middle stage. Liver transplantation is a salvage therapy that should be used during the late stage.     

Portal vein injuries. Noninvasive follow-up of venorrhaphy.

The authors report their experience with 14 patients with portal vein injuries (1976-1986) treated at a level I trauma center. Seven patients (50%) survived and included six of 10 patients (60%) who had venorrhaphy and one in whom the portal vein was ligated. Associated injuries were present in all the patients (mean Abdominal Trauma Index: 39.5) and accounted for the high mortality rate. Follow-up data after repair or ligation of the portal vein seldom are reported in the literature. The authors studied all three patients who survived portal venorrhaphy since 1982 by real-time ultrasonography. Patency of the repair could be established in two patients. In the third patient postvenorrhaphy thrombosis was diagnosed by ultrasonographic examination. Sequential ultrasonographic examinations demonstrated resolution of the thrombus on anticoagulant therapy. Ultrasonography provides a noninvasive and easily reproducible method of studying the portal vein after repair.     

Recent Concepts in the Treatment of Hepatic Trauma: Facts and Fallacies

Experience with 85 consecutive patients treated at Bellevue Hospital for hepatic trauma over the past two years has established the importance of several principles of management. Simple liver injuries can be treated by superficial suture and drainage. Using this approach in 57 patients there were no deaths and no postoperative abscesses. Among 28 other patients with complex liver injuries, the first six patients (Group 1) were treated by lobectomy alone (1 patient), lobectomy and intracaval shunt (3 patients), hepatic artery ligation (1 patient), and left lateral segmentectomy (1 patient). Only one of the six survived. In the next 22 consecutive patients managed by the Pringle maneuver combined with finger fracture technique of the hepatic parenchyma and a viable omental pack there was only one death (4.5%). An intracaval shunt was used successfully once in this group, in a patient with a lacerated middle hepatic vein. Only one patient developed a postoperative subphrenic abscess (4.5%), and no patients required reoperation for bleeding. Eighty-two per cent of these 22 patients safely tolerated inflow occlusion of greater than 20 minutes with steroid protection. Hepatic artery ligation is superfluous in the majority of liver injuries. In complex injuries involving lobar branches of the portal vein, the retrohepatic cava or hepatic veins hepatic artery ligation is probably ineffective. Hepatic resection is rarely required and carries a prohibitive mortality. The finger fracture technique provides a direct approach to the source of heniorrhage and is probably the procedure of choice.     

Ligation of a branch of the portal vein for carcinoma of the liver.

Portal branch ligation, a new surgical treatment for unresectable carcinoma of the liver, was performed in twenty patients. All the patients tolerated the procedure, and morbidity and mortality were minimal, even in patients in poor general condition. The responses to ligation differed considerably, but significant palliation was attained in some patients and one survived six years. The effect of portal branch ligation on the tumor appears to be closely related to the degree of tumor vascularity, tumor malignancy, and portal circulatory disturbances such as cirrhosis, portal hypertension, or portal thrombosis. We believe that the present procedure can be recommended for clinical application in some patients with unresectable carcinoma of the liver.     

Injuries to the portal triad

We reviewed the management and clinical course of 21 patients with extrahepatic injuries to the portal triad seen over the past 11 years at a Level I trauma center. These represented only 0.21% of patients with multiple trauma admitted during this time. Portal triad injury was never specifically diagnosed preoperatively. Extrahepatic bile duct injury occurred in 4 patients, portal vein injury in 14, and hepatic artery injury in 7; 3 patients had combined injuries. Eleven patients (52%) died, all due to uncontrolled hemorrhage from either an injured portal vein or associated intra-abdominal injuries. Management of the bile duct injuries included drainage alone, bile duct ligation, and Roux-Y hepaticojejunostomy. Survivors of portal vein injury were managed with lateral venorrhaphy. Ligation of the hepatic artery appeared to be optimal for injuries incurred by this vessel. Complications necessitating reoperation or percutaneous drainage procedures were encountered in 8 of 10 surviving patients (80%). Injuries to the portal triad are uncommon, difficult to diagnose, and technically challenging. Mortality is most directly related to uncontrolled intraabdominal hemorrhage, and salvage requires rapid control of bleeding as the first treatment priority.     

Outcome of Portal Injuries Following Bariatric Operations

Background: Portal vein thrombosis is rare following Roux-en-Y gastric bypass (RYGBP). Its natural history is dependent on the etiology of the thrombosis. Iatrogenic injuries at bariatric operations resulting in portal vein thrombosis are lethal complications typically necessitating a liver transplant, whereas postoperative portal vein thrombosis without an injury to the portal vein has a benign course. There are currently no data on management or prognostic factors of portal vein thrombosis after bariatric operations. Methods: 3 patients referred for liver transplantation secondary to portal vein injury following bariatric surgery between 2000 and 2003 are presented. Results: 2 super-obese (BMI ≥50 kg/m²) and 1 morbidly obese (BMI 44 kg/m²) patients sustained portal vein injuries during bariatric surgery (RYGBP 2, VBG 1) by experienced bariatric surgeons. In each case, the portal injury was identified and repaired. Thrombosis followed reconstruction in all 3 patients. All 3 underwent emergency liver transplantation, but died of sepsis and multi-organ failure following transplantation. Review of the literature found no cases of traumatic portal vein injuries following bariatric operations and 2 cases of postoperative portal vein thrombosis: 1 following LRYGBP (BMI 46) and one after a Lap-Band (BMI 41). Conclusion: Injury to the portal vein resulting from difficulty in discerning the anatomy of the intra-abdominal structures in the morbidly obese, is a lethal complication of bariatric surgery. Super-obese patients submitting to bariatic surgery should lose weight, undergo a two-stage bariatric procedure, or undergo laparoscopic RYGBP to minimize the risk of portal injury. Postoperative portal vein thrombosis has a benign course and can be managed conservatively.     

Laparoscopic bowel injury: incidence and clinical presentation

PURPOSE: Bowel injury is a potential complication of any abdominal or retroperitoneal surgical procedure. We determine the incidence and assess the sequelae of laparoscopic bowel injury, and identify signs and symptoms of an unrecognized injury. MATERIALS AND METHODS: Between July 1991 and June 1998 laparoscopic urological procedures were performed in 915 patients, of whom 8 had intraoperative bowel perforation or abrasion injuries. In addition, 2 cases of unrecognized bowel perforation referred from elsewhere were reviewed. A survey of the surgical and gynecological literature revealed 266 laparoscopic bowel perforation injuries in 205,969 laparoscopic cases. RESULTS: In our series laparoscopic bowel perforation occurred in 0.2% of cases (2) and bowel abrasion occurred in 0.6% (6). The 6 bowel abrasion injuries were recognized intraoperatively and 5 were repaired immediately. In 4 cases, including 2 referred from elsewhere, perforation injuries were not recognized intraoperatively and they had an unusual presentation postoperatively. These patients had severe, single trocar site pain, abdominal distention, diarrhea and leukopenia followed by acute cardiopulmonary collapse secondary to sepsis within 96 hours of surgery. The combined incidence of bowel complications in the literature was 1.3/1,000 cases. Most injuries (69%) were not recognized at surgery. Of the injuries 58% were of small bowel, 32% were of colon and 50% were caused by electrocautery. Of the patients 80% required laparotomy to repair the bowel injuries. CONCLUSIONS: Bowel injury following laparoscopic surgery is a rare complication that may have an unusual presentation and devastating sequelae. Any bowel injury, including serosal abrasions, should be treated at the time of recognition. Persistent focal pain in a trocar site with abdominal distention, diarrhea and leukopenia may be the first presenting signs and symptoms of an unrecognized laparoscopic bowel injury.     

Traumatic injury to the portal vein.

Traumatic injuries to the upper abdominal vasculature pose difficult management problems related to both exposure and associated injuries. Among those injuries that are more difficult to manage are those involving the portal vein. While occurring rarely, portal vein injuries require specific therapeutic considerations. Between January, 1968, and July, 1974, over 2000 patients were treated operatively for abdominal trauma at the Ben Taub General Hospital. Among these patients, 22 had injury to the portal vein. Seventeen portal vein injuries were secondary to gunshot wounds, 3 to stab wounds, and 2 to blunt trauma. Associated injuries to the inferior vena cava, pancreas, liver and bile ducts were common. Three patients had associated abdominal aortic injuries, two with acute aorto-caval fistulae. Nine patients died from from failure to control hemorrhage. Eleven were long-term survivors, including two who required pancreataico-duodenectomy as well as portal venorrhaphy. Late complications were rare. The operative approach to patients with traumatic injuries to multiple organs in the upper abdomen, including the portal vein, requires aggressive management and predetermined sequential methods of repair. In spite of innumerable associated injuries, portal vein injuries can be successfully managed in a significant number of patients using generally available surgical techniques and several adjunctive maneuvers.     

Management of traumatic peripheral vein injuries: Primary repair or vein ligation

The management and outcome of 83 patients who had 86 venous injuries were retrospectively reviewed to identify optimal management techniques in patients with peripheral vein injuries. Venous injuries of the arms were associated with no long-term sequelae, and management with vein ligation appears safe. In patients with venous injuries of the legs, primary repair by lateral suture or primary end-to-end reanastomosis is recommended when technically easy. In patients who are unstable or in whom primary repair cannot be performed, vein ligation is recommended. Autogenous vein interposition grafting appears indicated only in the popliteal area when vein reconstitution should be aggressively sought. Vein ligation in peripheral vein injuries should be followed with aggressive postoperative management to prevent the development of distal edema. Limb elevation is effective in minimizing the development of adverse sequelae.     

Isolated iliac vascular injuries and outcome of repair versus ligation of isolated iliac vein injury

Objective

The incidence of morbidity and mortality for iliac vascular injuries in the literature are likely overestimated owing to associated injuries. Data for isolated iliac vascular injuries are very limited. No large studies have reported the incidence of morbidity for repair versus ligation of isolated iliac vein injuries.

四肢大血管损伤的救治

本文报告四肢大血管损伤２４例救治体会。刀伤１１例，四肢骨折伴大血管损伤１３例，分别采用动脉吻合、大隐静脉间位移植，静脉缝合修补和静脉缝扎术。作者认为：现场急救方法是否正确，直接关系到病人肢体和生命的存亡，而现场救治中以伤口压迫止血的方法最为简便，效果确实。闭合性血管损伤诊断有一定困难，积极手术探查是保存病人肢体和生命最有效的措施。股动脉损伤后至肢体血供恢复时间超过５ｈ者，应常规行小腿筋膜腔，尤其是胫前筋膜腔减压，以防肌肉坏死和肾功能衰竭。     

Management of Blunt and Penetrating Injuries to the Porta Hepatis

Injuries to the porta hepatis pose difficult problems in management, and transection of the bile ducts, portal vein and hepatic artery is among the most challenging. Twenty-one patients with severe injuries to the porta hepatis were treated over a ten-year period. Ages ranged from 13 to 56 years, and follow-up was up to nine years. Among the 14 patients with bile duct injury, eight were found to have complete transection, and five suffered a tangential laceration or incomplete disruption with a portion of a duct wall remaining intact. Five of the eight patients who had complete transection underwent primary end-to-end repair with T-tube splinting, while three were treated with primary Roux-en-Y choledocojejunostomy. All patients with incomplete disruption underwent primary repair with or without T-tube splinting. Of the five patients with complete disruption who were treated with primary end-to-end anastomosis of the bile duct in conjunction with T-tube splinting, all required secondary biliary tract reconstruction of some type. No patient with complete transection that was treated with primary Roux-en-Y biliary enteric anastomosis required reoperation. Partial transections were successfully treated with primary repair. Portal vein injury was encountered in ten patients. Injury was successfully managed by primary closure, interposition of a vein, or splenicmesenteric vein bypass. Associated injuries to liver, pancreas, kidney and duodenum were common. In four patients there was injury to the main or left or right hepatic artery which was managed successfully by repair or ligation, with or without hepatic lobectomy. By adhering to the principles of management to be outlined, many patients with injury to the porta hepatis will survive, and the long term outcome can be gratifying.     

Superior mesenteric venous injuries: to ligate or to repair remains the question

BACKGROUND: Superior mesenteric vein injuries are rare and incur high mortality. Given their low incidence, little data exist delineating indications for when to institute primary repair versus ligation. The purposes of this study are to review our institutional experience, to determine the additive effect on mortality of associated vascular injuries, to correlate mortality with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury and to examine and define the indications and outcomes for primary repair versus ligation. MATERIAL: Retrospective 156 months study (January 1992 through December 2004) in a large Level I urban trauma center of all patients admitted with superior mesenteric vein injuries. Patients were stratified, according to surgical technique employed to deal with their injuries, into those undergoing primary repair versus ligation to determine outcomes and define the surgical indications of these methods. The main outcome measure was overall survival. Cases of survival were stratified according to surgical method: primary repair versus ligation. RESULTS: There were 51 patients with a mean Injury Severity Score of 25 +/- 12. Mechanism of injury was penetrating for 38 (76%), blunt for 13 (24%), and patients undergoing emergency department thoracotomy for 4 (8%). Surgical management was ligation for 30 (59%), primary repair for 16 (31%), and 5 (10%) patients were exsanguinated before repair. The overall survival rate was 24/50 (47%). The survival rate excluding patients undergoing emergency department thoracotomy was 51%. The survival rate excluding patients that sustained greater than 3 to 4 associated vessels injured was 65%. The survival rates of patients with superior mesenteric vein and superior mesenteric artery was 55% and superior mesenteric vein and portal vein (PV) was 40%. The survival rate of patients with isolated superior mesenteric vein injuries was 55%. Mortality stratified to AAST-OIS grade III, 44%; grade IV, 42%; and grade V, 42%. Survival rates stratified to method of management consisted of primary repair (60%) versus ligation (40%). CONCLUSIONS: SMV injuries are highly lethal. Multiple associated vessel injuries increase mortality. Mortality correlates well with the American Association for the Surgery of Trauma-Organ Injury Scale for abdominal vascular injuries. Patients undergoing primary repair have higher survival rates (63%) and lesser numbers of associated vascular and nonvascular injuries; whereas those undergoing ligation have a smaller survival rate (40%) and higher number of associated vascular and nonvascular injuries. Ligation appears to be safe and should be selected for hemodynamically unstable patients with a large number of associated injuries.     

Venous injury: to repair or ligate, the dilemma

Surgical management of major venous injuries remains controversial. The medical records of 184 patients with major venous injury were reviewed. Forty-three patients had isolated venous injury; 31 of 43 patients (72%) underwent ligation to treat their vein injury. Another 141 patients had combined arterial and venous injury; 117 of these patients (83%) had ligation. Injured were the inferior vena cava, iliac, femoral, popliteal, distal leg, and arm veins; all patients underwent surgical exploration. Arterial injuries were repaired by standard techniques and venous injuries were either ligated or repaired by end-to-end or lateral phleborrhaphy. Adjunctive fasciotomy was used when clinically indicated. The patients were followed up for 1 month to 9 years. No permanent sequelae of venous ligation were identified. Transient extremity edema developed in up to 32% of patients, regardless of whether vein ligation or repair was performed. This edema resolved completely within 12 weeks of the injury. No extremity was lost after ligation of a venous injury. Although it may be ideal to repair all venous vascular injuries, selective management reflecting mechanism of injury, blood loss, anesthesia requirements, associated organ injury, and other concerns may mitigate against extensive venous repair.     

四肢主干血管急性损伤的诊治

目的 对３０８例四肢主干血管急性损伤进行回顾分析。方法 本组共３０８例,其中开放性损伤１８１例,闭合性损伤１２７例。男２９９例,女９例。年龄最大６２岁,最小６岁,平均２４．５岁。对该种损伤患者尽早施行手术清创、探查。具体修复方法为：（１）单纯修补缝合受损的血管。（２）血管端端吻合术。（３）血管移植。结果 ３例因吻合口血栓形成发现较晚而截肢。１例因肢体血循环重建时间较长,术后出现骨筋膜室综合征肾功能     

肝外伤选择不同术式意义的探讨

目的探讨不同术式综合应用对不同程度不同类型肝外伤的治疗效果。方法分析我院1998年1月至2004年11月经手术治疗肝外伤49例的手术方式:肝缝合修补术7例;肝修补加门静脉裂口修补1例;肝动脉结扎加肝缝合修补3例;肝切开缝扎术(应用手指折断技术即FFT肝造口选择性血管胆管缝扎,缝合肝裂口)17例;清创性肝切除18例,其中5例另行肝右静脉缝扎,3例另行肝右静脉缝扎加肝后下腔静脉修补;规则性肝切除3例(右半肝2例,左外叶1例),其中2例另行肝后下腔静脉修补。结果除3例术前因重度休克,术中出现不可逆DIC,术后因MODS死亡外,其他病例均抢救成功,死亡率6.12%,无严重术后并发症。结论正确的术式选择是提高严重肝外伤疗效的关键。手术过程不能局限于肝表面止血,肝内管道处理更为重要;肝切开缝扎术及清创性肝切除术适用于大宗肝外伤病例。     

Traumatic superior mesenteric artery—Portal vein fistula

An interesting and rare case of traumatic superior mesenteric artery-to-portal vein arteriovenous fistula is presented. Initial operative control of the bleeding superior mesenteric artery injury required ligation of the superior mesenteric artery at its origin to prevent exsanguination in an extremely unstable patient with multiple injuries. Early postoperative visceral arteriography documented ligation of the superior mesenteric artery with a proximal superior mesenteric artery-to-portal vein arteriovenous fistula. Percutaneous catheter embolization of the arteriovenous fistula was undertaken successfully at this time. Superior mesenteric artery ligation was surprisingly well tolerated. Major arterioportal fistulas require treatment to prevent long-term complications of intestinal ischemia, portal hypertension, and cirrhosis. Although traditional treatment involves ligation of the arteriovenous fistula and arterial bypass, percutaneous embolization is becoming a viable alternative. Arteriography remains the cornerstone of diagnosis and treatment planning.