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.     

Traumatic injuries of the portal vein. The role of acute ligation.

Injuries to the portal vein are rare but have a high risk with a mortality of 50--70% secondary to exsanguinating hemorrhage. When managing injuries to the portal vein, lateral venorrhaphy, end to end anastomosis, or an interposition graft should be attempted whenever possible. However, in a hemodynamically unstable patient or when confronted with a nonreconstructable injury, acute portal vein ligation may be the procedure of choice as it is safely tolerated in some 80% of patients. Of eleven reported patients in whom the portal vein was ligated acutely for traumatic injury, six survived. Four of the nonsurvivors died of massive associated injuries. Of the six surviving patients, five tolerated acute ligation of the portal vein without complication. Should portal vein ligation be performed a "second look" operation is essential in 24 hours to examine the bowel for viability. A portosystemic shunt with its inherent complications should not be done as a primary procedure when attempts at reconstruction of the portal vein have failed. Shunting should be reserved for those few patients who develop stigmata of portal hypertension or impending infarction of the bowel.     

Traumatic injury to the superior mesenteric artery.

BACKGROUND: Superior mesenteric artery (SMA) injuries are rare and devastating injuries incurring very high mortality rates. It is the purpose of this study to review our experience with these injuries, to analyze Fullen's classification based on anatomical zone and injury grade for its predictive value, and to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality. METHODS: Retrospective study was made over a 65-month period of all patients sustaining SMA injuries in an urban level I trauma center. RESULTS: Thirty-five patients, mean age 31, had a mean Revised Trauma Score of 5.86 and a mean Injurity Severity Score of 23. Mechanisms of injury were penetrating 27 (77%) and blunt 8 (23%). Mean admission systolic blood pressure was 85 mm Hg. Mean estimated blood loss was 8,500 mL and mean total fluid replacement 17,000 mL. Operating room findings were retroperitoneal hematoma in 34 (97%) and "black bowel" in 2 (6%). Number of associated injuries was nonvascular, mean 4.2, and vascular, mean 1.5. Surgical management consisted of ligation in 18 (51%), primary repair in 14 (40%), and interposition graft in 2 (6%). Overall mortality was 19 of 35 (54%). Mortality versus Fullen's zones was zone I, 100%, zone II, 43%, and zones III and IV, 25%. Mortality versus Fullen's ischemia grade was grade 1, 89%, grade 2, 58%, grade 3, 100%, and grade 4, 19%. Mortality versus AAST-OIS: was grade 1, 0%, grade II, 20%, grade III, 0%, grade IV, 59%, and grade V, 88%. CONCLUSIONS: SMA injuries are highly lethal. Most deaths are due to exsanguination. A higher number of associated vascular injuries increases mortality. "Black bowel" is an uncommon finding. Both Fullen's anatomical zones and the AAST-OIS for abdominal vascular injuries correlate with mortality. Fullen's ischemia grade does not.     

腹腔镜肝切除术中肝门大血管意外损伤的处理

目的探讨腹腔镜肝切除手术中肝门大血管意外损伤腹腔镜下修复的可行性。方法回顾性分析2005年11月至2009年12月144例腹腔镜肝切除术的临床资料,发生肝门大血管意外3例,其中门静脉主干损伤1例,门静脉右支损伤1例,肝左静脉损伤1例,均行腹腔镜手术修复损伤。结果 3例血管损伤都在腹腔镜下修复,手术时间240～330min,平均290min,术中出血量800～1200ml,平均1000ml,输血400～800ml,平均666.6ml,无死亡及再次手术病例,随访13～15个月,平均13.3个月,未见门静脉血栓形成。结论腹腔镜手术中肝门大血管意外损伤的腔镜下修复是可行的。     

医源性门静脉和肠系膜上静脉损伤的紧急处理

目的 探讨医源性门静脉和肠系膜上静脉损伤的紧急处理和预防.方法 回顾性分析医源性门静脉和肠系膜上静脉损伤的致伤原因及术中治疗经过,并就预防进行了探讨.结果 该组7例,其中门静脉损伤2例,肠系膜上静脉损伤5例.5例采用pringle手法暂时压迫止血后,用5-0血管缝线缝合修补破口,出血控制;2例因操作粗暴,胡乱钳夹,最终死亡.结论 预防上述血管损伤及预先游离周围组织至关重要,一旦损伤,应冷静沉着,暂时压迫止血后,用血管缝线缝合修补破口,止血效果好,是确实有效的方法.禁止胡乱钳夹止血.     

医源性门静脉和肠系膜上静脉损伤的紧急处理

目的 探讨医源性门静脉和肠系膜上静脉损伤的紧急处理和预防.方法 回顾性分析医源性门静脉和肠系膜上静脉损伤的致伤原因及术中治疗经过,并就预防进行了探讨.结果 该组7例,其中门静脉损伤2例,肠系膜上静脉损伤5例.5例采用pringle手法暂时压迫止血后,用5-0血管缝线缝合修补破口,出血控制;2例因操作粗暴,胡乱钳夹,最终死亡.结论 预防上述血管损伤及预先游离周围组织至关重要,一旦损伤,应冷静沉着,暂时压迫止血后,用血管缝线缝合修补破口,止血效果好,是确实有效的方法.禁止胡乱钳夹止血.     

Traumatic injury to the oesophagus

This contribution focuses on perforation of the oesophagus and foreign bodies within the oesophagus.     

Liver infarction after laparoscopic cholecystectomy injury to the right hepatic artery and portal vein

A 66-year-old woman presented with fever and right upper quadrant pain 5 weeks after laparoscopic cholecystectomy. Angiogram revealed occlusion of the right hepatic artery and right portal vein which necessitated a right hepatic lobectomy. To our knowledge this has not been previously reported. The patient recovered uneventfully.     

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.     

Congenital absence of the portal vein.

A 14-year-old girl presented at the hospital after discovering an abdominal tumor. CT scan and ultrasonography indicated a hepatic tumor and also revealed the absence of the portal vein. The patient was admitted to excise the hepatic tumor. It was found that the venous blood from the small intestines flowed into the left renal vein and then emptied directly into the inferior vena cava. A tumor extending from the right lobe through the middle portion of the liver was excised. The postoperative course was satisfactory and marked regeneration of the residual hepatic tissue was observed. Also the blood level of ammonia in the superior mesenteric vein was low, approximately 120 micrograms/dl, compared to the normal value of 350 micrograms/dl in the portal vein. This low blood level may indicate the presence of some homeostatic control mechanism.     

��ʮ��ָ���г������ž�������7������

目的 总结７例胰十二发除术中门静脉损伤临床处理经验。方法 对７例十二指肠切除术中门静脉损伤的病人进行分析。结果 ７例病人中５例恢复良好,切口感染１例。结论 加强胰十二指肠切除术中门静脉损伤的预防,根据不同情况正确修复,严格掌握门静脉血流阻断时限等是直接影响手术效果的关键环节。     

Management of portal vein injuries.

Injuries to the portal vein are associated with a high mortality because of a high incidence of concomitant injury to surrounding structures and refractory shock. Repair of the portal vein injury is often difficult or impossible because of massive hemorrhage. The key to successful management of a portal vein injury is rapid blood volume resuscitation and obtaining rapid and adequate exposure. The optimal exposure for repair consists of reflection of the hepatic flexure of the colon with mobilization of the root of the mesentery, pancreas, and duodenum. Lateral venorrhaphy is the preferred method of management, but in hemodynamically unstable patients, ligation of the portal vein is an acceptable method of treatment.