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: 1.011-1.060).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.     

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.     

Surgical treatment of hepatic injury: morbidity and mortality analysis of 109 cases

BACKGROUND/AIMS: We aimed to determine the factors that affect morbidity and mortality in patients that underwent surgery for hepatic injury. METHODOLOGY: Records of 109 blunt or penetrating hepatic trauma patients that underwent surgery in the Third Surgical Clinic of Izmir Atattürk Training and Research Hospital between 1994 and 2004 were reviewed retrospectively. Evaluated parameters were: age, gender, cause of injury, diagnostic procedures, preoperative blood pressure (BP), hemoglobin (Hb) level, amount of intraabdominal blood, associated injuries, the number of involved hepatic segments and anatomic distribution, severity of injury, abdominal trauma index (ATI), amount of blood transfusions, type of surgery, hospital stay, and rates of morbidity and mortality. RESULTS: Median age of the patients was 29 years. The injury was penetrating in 53.2% of the patients and blunt in 46.8%. Abdominal blood was 500cc or less in 70 (64.2%) patients. Isolated hepatic injury was encountered in 29 (26.6%) cases. 22.9% of the patients had major injuries. Hemostasis was achieved by electrocautery, sponge-gel, primary suturing, hepatic resection or perihepatic packing. Morbidity and mortality rates were 40.4% and 14.6% respectively. CONCLUSIONS: Age, type of the injury, BP and Hb levels, amount of intraabdominal blood, degree of injury, ATI, and accompanying organ injuries significantly affect morbidity and/or mortality.     

Non-operative management of isolated liver trauma

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative 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 were 100%, 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.     

Hepatic resection in cirrhotic liver for treatment of hepatocellular carcinoma in Egyptian patients. Experience with 140 cases in a single center

BACKGROUND/AIMS: In many centers hepatic resection is still the treatment of choice for hepatocellular carcinoma in cirrhotic liver. Several factors affect the prognosis; one of them is the extent of resection. This study retrospectively evaluates outcome after different types of hepatic resection in cirrhotic liver. METHODOLOGY: Hepatectomy was performed in 245 patients. From them, 140 patients were subjected to hepatic resection for hepatocellular carcinoma in cirrhotic liver. According to the type of resection the patients were divided into three groups (A, B and C), major resection (group A) in 79 (56.3%), segmental resection (group B) 31 (22.1%) and localized resection (group C) in 30 (21.4%). Early postoperative mortality and morbidity as well as long-term survival and recurrence were assessed. RESULTS: The overall hospital mortality rate was (8.6%) with total complications 26%, recurrence rate 32.8% and median survival was 24 months (3-120). Group A showed high incidence rate of hospital mortality, total complications and hepatic cell failure than the other two types (p>0.05). On the other hand, group C patients showed high incidence of wound infection and recurrence rate after hepatic resection than the other two types (p>0.05). At the end of the study, the median survival was 18 months (4-120), 24 months (3-48) and 24 months (3-120) for the three groups respectively without significant difference. The overall 5-year survival rate was 20%, 0% and 15.3% for the three groups respectively (p>0.05). CONCLUSIONS: Although major liver resection in cirrhotic liver has high incidence of early mortality and morbidity, it gives low incidence of recurrence and better survival in comparison with segmental and localized resection. However it has to be reserved for large tumor in good liver and early cirrhosis.     

Clinical significance of liver biopsy in chronic hepatitis B patients with persistently normal transaminase

OBJECTIVE: The aim of this study was to study the clinical significance of liver biopsy for individuals who had chronic hepatitis B virus infection and persistently normal serum transaminases for more than 6 months. METHODS: A total of 452 patients with positive hepatitis B surface antigen for over 6 months underwent percutaneous liver biopsy. All liver biopsy specimens were assessed by experienced liver pathologists blinded to the liver biochemistry, and were scored according to the modified criteria of grade and stage of chronic hepatitis. Patients were divided into four groups: group A and group C patients had normal transaminases, and were hepatitis B e antigen (HBeAg) positive and HBeAg negative, respectively; group B and group D patients had elevated transaminases, and were HBeAg positive and HBeAg negative, respectively. RESULTS: All patients had necrosis and inflammation in the liver. Patients with increased serum transaminases had a significantly higher grade (G) of hepatic necrosis and inflammation and more severe (S) fibrosis compared with patients with normal transaminases (P < 0.05). However, in the latter patients, G3 was seen in 10 (5.5%) and 13 cases (9.1%), S3 in seven (3.8%) and 16 cases (11.1%), and S4 in three (1.6%) and seven cases (4.9%) in Group A and Group C, respectively. Moreover, in patients with normal transaminases, the HBeAg‐negative group had more severe fibrosis than the HBeAg‐positive group (P < 0.05). CONCLUSION: Although more severe pathological changes were more frequent in patients with elevated transaminases, significant hepatic pathology could still be found in cases with persistently normal transaminases. Liver biopsy in cases of chronic hepatitis B virus infection is helpful to accurately assess both the activity of the disease and the degree of fibrosis, and to estimate if antiviral therapy is justifiable. Patients with normal transaminases and serious hepatic necrosis, inflammation and fibrosis need proper management.     

Operative and nonoperative management of blunt hepatic trauma in adults: a single-center report

Background/Purpose

Liver trauma, especially that as result of road traffic accidents, still remains a complicated problem in severely injured patients. The aim of this study was to extract useful conclusions from the management in order to improve the final outcome of such patients.

Methods

Details for 86 patients with blunt hepatic trauma who were examined and treated in our department during a 6-year period were analyzed. We retrospectively reviewed the severity of liver injury, associated injuries, treatment, and outcome.

Results

Forty-nine liver injuries (57%) were of low severity (grades I and II), while 37 (43%) were of high severity (grades III, IV, and V). Liver trauma with associated injury of other organs was noted in 62 (72.1%) patients. Forty-three (50%) patients underwent an exploratory laparotomy within the first 24?h of admission. Thirty-five (71.4%) of the 49 patients with low-grade hepatic injuries were managed conservatively; no mortality occurred. Six (14%) of forty-three patients with liver trauma initially considered for conservative management required surgery due to hemodynamic instability. Five (13.5%) of 37 patients who were finally managed nonoperatively required adjunctive treatment for biloma, hematoma, or biliary leakage; no mortality occurred. The overall mortality rate was 9.3%; mortality rates of 5.8% and 3.5% were due to liver injuries and concomitant injuries, respectively.

Conclusions

Severe hepatic injuries require surgical intervention due to hemodynamic instability. Low-grade injuries can be managed nonoperatively with excellent results, while patients with hepatic trauma with associated organ injuries require surgery, because they continue to have significantly higher mortality.

     

Monitoring and management of antituberculosis drug induced hepatotoxicity

BACKGROUND: Hepatotoxicity to antituberculosis therapy (ATT) poses a major challenge. This often results in inadequate therapy. The risk of fulminant hepatic failure and mortality is high once icteric hepatitis develops. There is no consensus on monitoring protocols and for the reintroduction of ATT. METHODS: All patients (from the Department of Internal Medicine and Gastroenterology, Jagjivanram Hospital and the Department of Gastroenterology, Bombay Hospital, Mumbai, India) with a diagnosis of tuberculosis, who were to receive ATT during the study period, were included in the present study for prospective periodic laboratory monitoring for the development of hepatotoxicity. Those patients who developed hepatotoxicity formed Group A (n = 21), whereas those who did not develop hepatotoxicity were included in Group C (n = 179). For the purpose of comparison with Group A, all the patients who presented directly with ATT induced hepatotoxicity during the study period were categorized as Group B (n = 24). Group A and B were further studied after normalization of liver functions for sequential reintroduction with therapeutic doses at a weekly interval. RESULTS: In Group A, 66.6% (14 patients) of the patients were diagnosed in the asymptomatic period. Seven patients had symptomatic hepatitis, but none had icteric illness. There were no mortalities in Group A. In contrast, all the patients in Group B had symptomatic hepatitis (75% icteric hepatitis). There was a mortality rate of 16.6% (four patients). Of the 41 patients from Groups A and B who survived, reintroduction was successful in 38/39 (97.4%). In the remaining two patients who were in Group B, reintroduction was not attempted because of decompensated liver disease. CONCLUSIONS: Periodic laboratory monitoring is important in detecting hepatotoxicity at an early stage, thereby preventing mortality. Sequential reintroduction is often successful.     

Management of iatrogenous esophagus perforation

OBJECTIVES: The management of patients with iatrogenous, instrumentally caused esophageal disruptions is still a controversially discussed challenge for any physician. We reviewed indications, morbidity, and mortality of esophagectomy compared to less aggressive treatment schemes in the light of our single-unit experience. PATIENTS AND METHODS: We reviewed the cases of 38 consecutive patients suffering from iatrogenous esophageal disruption treated within the last 10 years at the University Medical School Graz. RESULTS: Severe sepsis was diagnosed in seventeen patients; fourteen of the seventeen patients were treated by esophagectomy followed by primary or secondary reconstruction at a mortality rate of 28.6 % (four of fourteen patients). All fourteen patients thus treated had major preexisting esophageal pathologies. In three of the total seventeen cases reviewed, conservative treatment modalities were used. The mortality rate in the non-septic group treated by direct suturing (n = 21) was 4.8 % (one of twenty-one patients). Major preexisting esophageal pathology was present in thirteen. The overall mortality was 13.2 % (five of thirty-eight patients). CONCLUSION: The strategy of primary repair for iatrogenous esophageal injury should only be adopted in patients with minor or without intrinsic esophageal disease, and in the absence of severe sepsis suggesting mediastinitis. Severe sepsis following iatrogenous esophageal trauma should prompt the decision for esophagectomy where anatomically and/or oncologically possible.     

早期强化辛伐他汀治疗急性冠状动脉综合征的研究

目的 :研究两组不同剂量辛伐他汀治疗急性冠状动脉综合征 (ACS)的近期心血管事件影响及安全性。方法 :15 2例ACS患者随机分成 3组。A组常规治疗 ;B组 :辛伐他汀 2 0mg/d ;C组 :辛伐他汀 4 0mg/d ,随访观察 3组患者首次入院后 1个月和 1年的终点事件发生率 (死亡、再发心绞痛或心肌梗死、再入院率 )以及血脂水平、肝肾功能和不良反应。结果 :B组、C组初始 1个月及 1年内的病死率、再发心绞痛、再发心肌梗死及再住院率均较A组明显降低 (均P <0 .0 5 )。B组 1个月、1年病死率下降分别为 3.92 %、7.84 % ,C组 1个月、1年病死率下降分别为 3.76 %、7.6 0 % ;C组与B组比较 ,初始 1个月内心绞痛、心肌梗死再发生率差异有统计学意义 (P<0 .0 5 )。但对 1年内病死率及心绞痛、心肌梗死的再发生率差异无统计学意义 (均P >0 .0 5 )。 2、6、12个月血脂监测显示B组、C组均能有效降低总胆固醇、低密度脂蛋白胆固醇、三酰甘油水平。B组 2例、C组 3例出现恶心、纳差等消化道症状 ;B组 1例、C组 2例出现转氨酶增高 1～ 3倍。结论 :辛伐他汀 2 0、4 0mg用于ACS早期治疗均安全有效 ,均能有效降低近期冠心病事件发生率和病死率 ,且提示疗效与剂量成正相关     

220例慢性乙型肝炎病毒携带者5年随访分析

目的 了解慢性乙型录肝炎病毒携带者的肝组织病理改变,乙型肝炎再激活率及血清学变化.方法 对无锡地区220例慢性乙型肝炎病毒携带者进行了为期5年的临床症状、肝功能、肝脏组织病理学、病毒学及血清病毒标志物等的动态观察研究.结果 5年间,220例中有35例出现乙型肝炎再激活,占15.9%(35/220).220例中肝脏组织有明显炎症者(≥G2),乙型肝炎再激活率为27.0%(33/122),而肝组织炎症为GO～G1者再激活率为2.0%(2/98),肝脏组织炎症≥G2者再激活率明显高于GO～G1者,两者比较,X2=25.41,P<0.01,差异有统计学意义.35例乙型肝炎再激活患者中≥40岁者27例(77.1%),显示年龄与乙型肝炎病毒携带者再激活率有明显相关性(X2=6.72,P<0.01),而性别与再激活率无相关性.抗-Hbe阳性组患者,肝组织炎症程度重于HBeAg阳性组患者,X2=8.68,P<0.01,差异有统计学意义;抗一Hbe阳性组患者肝组织纤维化程度重于HBeAg阳性组患者,X2=6.84,P<0.01,差异有统计学意义.按年龄分组,<40岁组及≥40岁组,两组间炎症活动度比,X2=0.62,P>0.05,差异无统计学意义;两组纤维化程度轻(S0～1)重(≥S2)比较,X2=7.37,P<0.01,差异有统计学意义,≥40岁组纤维化程度明显重于<40岁组.56例行2次肝活组织检查,23例行3次肝活组织检查,第一次肝活组织检查肝组织正常者几年内相对稳定,病理变化很少,原炎症程度较重者不易恢复,但可以在小范围内波动.17例HBsAg转阴,年转阴率为1.55%.其中168例HBeAg阳性者中45例发生HBeAg血清学转换,HBeAg年阴转率为5.4%.结论 55%慢性乙型肝炎病毒携带者肝脏组织有明显异常(炎症≥G2),乙型肝炎再激活率与肝脏炎症分级及年龄密切相关.     

Prognostic risk factors of survival after resection of hepatocellular carcinoma

BACKGROUND/AIMS: Surgical resection is a standard treatment of hepatocellular carcinoma, but liver cirrhosis is known to be associated to a high tumor recurrence rate. METHODOLOGY: A retrospective study of 55 consecutive patients (37 males, 18 females) suffering from hepatocellular carcinoma having undergone surgical resection. Hepatocellular carcinoma developed in 29 patients with normal liver (group A) and in 26 patients with chronic liver disease (CLD) (group B). Patients were significantly older and at high-risk in Group B. RESULTS: Radical liver resection was achieved in 98% (100% in group A; 96% in group B). Overall 2-month mortality was 2% (0% in group A; 4% in group B). The 5-year overall and disease-free survival was respectively 55% and 35%. However, the 5-year overall and disease-free survival was significantly better in Group A (71% and 59%) compared to Group B (37% and 6%) (p < 0.001), respectively. Multivariate statistical analysis demonstrated that age > 50 years, poor tumor differentiation and presence of satellite nodules were significant independent adverse predictive factors of overall and disease-free survival. CONCLUSIONS: Resection of HCC is safe and effective with satisfactory overall and disease-free survival rates, except when underlying chronic liver disease and poor tumor differentiation are present.     

Mortality associated with traumatic injuries in the elderly: a population based study

Elderly trauma is increasing in incidence and is associated with significant morbidity and mortality. The primary objective of the study was to identify factors associated with survival or mortality in the elderly following trauma. The secondary objective was to compare the epidemiology of trauma in the elderly with younger patients. A retrospective analysis was performed of data that was obtained from a prospectively collected multi-centre trauma database maintained by The Scottish Trauma Audit Group (STAG) containing details of 52,887 trauma patients admitted to 25 participating Scottish Hospitals over an 11-year period. Elderly trauma patients (aged >80 years) were separately analyzed and compared to younger trauma patients (aged 13-80). Of 52,887 trauma patients identified, 4791 were elderly (9.1%). Elderly patients had a higher absolute mortality rate following traumatic injury (9.9% versus 4%, p<0.001). Mortality in the elderly was higher in males, following a high fall, with lower Glasgow Coma Scale (GCS), in those with higher Abbreviated Injury Scale (AIS)/Injury Severity Score (ISS), in those with concomitant injuries, hemodynamic compromise and following delayed presentation. Multiple logistic regression analysis confirmed an independent relationship between mortality and low GCS, male gender, higher ISS, higher AIS of spinal injury, hemodynamic compromise and concomitant minor leg/arm injury(ies) in the elderly. In conclusion, trauma in elderly patients is associated with significantly higher mortality. Low GCS, male gender, higher ISS, higher AIS of spinal injury, hemodynamic compromise and concomitant minor leg/arm injury(ies) have the strongest independent relationships with mortality after trauma in the elderly population.     

97例肝硬化患者胃镜结果分析

目的：通过97例肝硬化患者的胃镜检查,对上消化道黏膜病变程度与Child-Pugh分级的关系进行探讨。方法：将97例肝硬化患者根据Child．Pugh分级,分为A级、B级两组,观察其食管静脉曲张轻、中、重程度、门脉高压性胃病、溃疡、食管炎及十二指肠球炎发生率,并做统计学处理。结果：97例肝硬化患者食管静脉曲张检出率90．7％,门脉高压性胃病检出率54．6％,胃溃疡检出率17．5％,十二指肠溃疡检出率9．3％,十二指肠球炎检出率27．8％,反流性食管炎检出率10．3％。食管静脉曲张严重程度（x^2=10．95）和反流性食管炎发生率（X^2=6．12）与Child．Pugh级别呈正相关（P〈0．01）,而门脉高压性胃病、胃溃疡、十二指肠溃疡、十二指肠球炎发病率与之无明显关系（P均〉0．05）。结论：肝硬化患者食管静脉曲张严重程度和反流性食管炎发生率随Child·Pugh分级而上升,门脉高压性胃病、胃溃疡、十二指肠溃疡、十二指肠球炎发病率则与Child-Pugh分级无明显关系。     

Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study

BACKGROUND: The necessity for drainage of both liver lobes in tumors arising at the biliary bifurcation is controversial. The aim of this study was to compare the outcome of unilateral versus bilateral drainage in patients with biliary obstruction at the hilum. METHODS: One hundred fifty-seven consecutive patients with primary cholangiocarcinoma, gallbladder cancer, or periportal lymph node metastases were randomly allocated to unilateral (group A) or bilateral (group B) hepatic duct drainage. RESULTS: In intention-to treat analysis, group A had a significantly higher rate of successful endoscopic stent insertion than group B (88.6% vs. 76.9%, p = 0.041). Group B had a significantly higher rate of complications than group A (26.9% vs. 18.9%, p = 0.026) because of the higher rate of early cholangitis (16.6% vs. 8.8%, p = 0.013). In per-protocol analysis the rate of successful drainage, complications, and mortality did not differ between the two groups. Median survival did not differ between the two groups but was significantly different for patients with cholangiocarcinoma and those with gallbladder cancer versus patients with metastatic tumors (p = 0.0247). CONCLUSION: The insertion of more than one stent would not appear justified as a routine procedure in patients with biliary bifurcation tumors.     

Assessment of hepatic functional reserve by cirrhosis grading and liver volume measurement using CT

AIM： To explore a method for quantitative assessment of hepatic functional reserve by combining computed tomography （CT） volumetry with CT grading of liver cirrhosis before liver resection in patients with hepatocellular carcinoma.
METHODS： CT images of 55 patients undergoing liver resection were studied prospectively. The degree of liver cirrhosis was referred as ＂CT grade＂ and the percentage of remnant liver volume （PRLV） [PRLV = predicted RLV/predicted total liver volume （PTLV） × 100%; PTLV （mL） = 121.75 ＋ 16.49 × body mass （kg）] were calculated by adding slice by slice of CT liver images. The postoperative RLV, pathologic stages of liver fibrosis in non-tumor area and survival time in these cases were analyzed.
RESULTS： There was a significant difference in survival time between the group with PRLV ≤ 50% and the group with PRLV 〉 50% （X^2= 4.988, P = 0.026）, and between the group with CT grade 0/1 and the group with CT grade 2/3 （X^2= 5.429, P = 0.026）. With combination of the both parameters, an oblique line was identified according to the distribution of 32 survivors versus 23 deceased subjects. The mortality rate above the line was 7.1% （1/14）, and that below the line was 53.7% （22/41）, indicating a significant difference between the two rates （X^2 = 9.281, P = 0.002, P 〈 0.05）. CONCLUSION： PRLV and CT grades are significantly correlated with hepatic functional reserve. The predicted line using these two parameters is useful in candidates undergoing liver resection for judging hepatic functional reserve.     

Prehospital Index: a scoring system for field triage of trauma victims

The Prehospital Index (PHI) is a triage-oriented trauma severity scoring system comprising four components: systolic blood pressure, pulse, respiratory status, and level of consciousness, each scored 0 to 5. The PHI was developed after analysis of 313 cases to provide an objective prehospital scoring system for distinguishing less seriously injured patients (minor trauma) from those patients who are likely to die within 72 hours after injury or who require general or neurosurgical operative intervention within 24 hours (major trauma). A PHI of 0 to 3 indicated minor trauma, and a PHI of 4 to 20 signified major trauma. Retrospective analysis of an additional 465 consecutive trauma cases revealed that patients with a PHI of 0 to 3 (minor trauma) had a 0% mortality and a 2% rate of general or neurosurgical operative intervention. Those with a PHI of 4 to 20 (major trauma) carried a 16.4% mortality and an emergency operative rate of 49.1%. The PHI was applied prospectively to 388 consecutive trauma cases presenting to the Butterworth Hospital Emergency Department from October through December 1984. Of the 351 patients scored as minor trauma in the field, there was a 0% mortality and only a 0.3% operative rate. Those scored as major trauma in the field had a mortality of 27% (PHI 4 to 7, 0%; PHI 8 to 20, 53%) and an operative rate of 40.5% (PHI 4 to 7, 22%; PHI 8 to 20, 57.9%). These data demonstrate the ability of the PHI to predict mortality (P less than .001) and the need for emergency general or neurosurgical operative intervention (P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Managing injuries of hepatic duct confluence variants after major hepatobiliary surgery： An algorithmic approach

AIM：To investigate injuries of anatomy variants of hepatic duct confluence during hepatobiliary surgery and their impact on morbidity and mortality of these procedures. An algorithmic approach for the management of these injuries is proposed.
METHODS：During a 6-year period 234 patients who had undergone major hepatobiliary surgery were retrospectively reviewed in order to study postoperative bile leakage. Diagnostic workup included endoscopic and magnetic retrograde cholangiopancreatography （E/MRCP）, scintigraphy and fistulography.
RESULTS：Thirty （12.8%） patients who developed postoperative bile leaks were identified. Endoscopic stenting and percutaneous drainage were successful in 23 patients with bile leaks from the liver cut surface. In the rest seven patients with injuries of hepatic duct confluence, biliary variations were recognized and a stepwise therapeutic approach was considered. Conservative management was successful only in 2 patients. Volume of the liver remnant and functional liver reserve as well as local sepsis were used as criteria for either resection of the corresponding liver segment or construction of a biliary-enteric anastomosis. Two deaths occurred in this group of patients with hepatic duct confluence variants （mortality rate 28.5%）.
CONCLUSION：Management of major biliary fistulaethat are disconnected from the mainstream of the biliary tree and related to injury of variants of the hepatic duct confluence is extremely challenging. These patients have a grave prognosis and an early surgical procedure has to be considered.     

Clinical course of patients with hepatocellular carcinoma after surgical resection, with emphasis on the occurrence of hepatic failure]

Postoperative course including serial changes in values of liver function tests and occurrence of hepatic failure was investigated in 59 patients with hepatocellular carcinoma. Eleven cases out of 59 patients were associated with chronic hepatitis (CH group), while remained 48 cases were with liver cirrhosis (25 cases of group A and 23 of group B in Child's classification). There was no significant difference in survival rate or recurrence rate after operation among these three groups. Hepatic failure within one year after hepatectomy was observed in 9%, 28% and 91% of patients in groups CH, Child's A and Child's B, respectively, and the frequency of occurrence of hepatic failure in Child's B group was significantly higher than those of groups CH and Child's A. Hepaplastin test and serum albumin levels recovered from the decline after hepatectomy in groups CH and Child's A. On the other hand, no recovery was found in Child's B group as well as lower levels before operation and that was thought to be the major reason for the frequent occurrence of hepatic failure in Child's B group.     

Is resection for large hepatocellular carcinoma in cirrhotic patients beneficial? Study of 38 cases.

BACKGROUND/AIMS: Hepatocellular carcinoma in cirrhotic patients generally carries a poor prognosis either due to recurrence or to postoperative morbidity or both. Several factors affect the prognosis of hepatocellular carcinoma resection as presence of cirrhosis of the liver, tumor diameter and tumor capsulation. METHODOLOGY: Thirty-eight patients with large hepatocellular carcinoma greater than 5 cm with a background of cirrhotic liver were divided into two groups according to tumor diameter. Group A (n = 20) with tumors less than 10 cm in diameter, and group B (n = 18) with tumors larger than 10 cm. All patients underwent preoperative investigations including clinical laboratory tests, sonography, computed tomography, selective angiography and upper gastrointestinal endoscopy. All patients were subjected to different types of hepatic resection. RESULTS: A significant difference in tumor size, capsulation, and operation time were recorded between the two groups, of patients. No significant difference was detected between both groups regarding sex, age, viral markers, pathologic features, and Child classification. Hospital mortality occurred in 5% versus 11.1% of both groups, respectively. Postoperative jaundice and ascitis occurred in 30%, 35% versus 44.4%, 72.0%, respectively (P < 0.005, P < 0.04). Late mortality occurred in 65% of patients in group A and in 77% of group B. Recurrence was detected in 42% of group A and 62% in group B. Recurrence after resection in capsulated tumors was significantly lower than in noncapsulated tumors in group A (P < 0.01), but not significant in group B. Also, survival rate in patients with capsulated tumors was significantly better in both groups (P < 0.01) than that with noncapsulated tumors. CONCLUSIONS: Resection of hepatocellular carcinoma with diameter larger than 10 cm recorded bad prognosis regarding recurrence and mortality rates than tumors less than 10 cm. However, capsulated tumors gave better postoperative prognosis than noncapsulated ones.