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.     

The Efficacy of Gauze Packing in Liver Trauma: an Evaluation of the Management and Treatment of Liver Trauma

Background: This study evaluates the management and treatment of liver trauma with emphasis on the efficacy of gauze packing. Material and Methods: 92 patients, diagnosed with liver trauma between 01/1992 and 01/2000, were evaluated retrospectively. For clinical management reasons, a distinction was made between hemodynamically stable and unstable patients. Results: 42 patients were clinically diagnosed as hemodynamically stable and had an average Injury Severity Score (ISS) of 24. 15 of them underwent abdominal surgery. In ten of these patients additional liver treatment was performed. The mortality among the 42 patients was two, both non-liver-related (sepsis and neurologic injury). 50 patients were considered to be hemodynamically unstable and had an average ISS of 35. All patients needed abdominal surgery. The mortality was 22 out of 50, of which seven were liver-related. In 38 of all 92 patients only gauze packing was used as initial therapy. In twelve patients the bleeding was controlled by the first tamponade, and ten patients needed a second tamponade after an average of 2 days. Additional surgery was performed in nine patients, and seven patients died shortly after the first laparotomy. The mortality was 16, of which nine were directly liver-related. Conclusion: Gauze packing as the initial treatment of liver trauma is considered a safe and quick method for controlling ongoing hemorrhage. Nevertheless, severe liver trauma goes with a high mortality rate.     

闭合性腘动脉损伤11例

目的总结闭合性动脉损伤的诊治经验.方法1983～2000年共11例闭合性动脉损伤患者.肢体血循环重建时间最短3.5h,最长27h,平均9h.结果8h以内重建血循环5例肢体循环功能恢复功能,8～10h2例遗有小腿缺血性挛缩,超过10h 4例中有1例小腿肌肉坏死,3例截肢.截肢率为27%,总病残率达55%.结论 动脉损伤应在6～8h内进行修复,超过这一时限病残率及截肢率均明显上升.延误诊断是导致闭合性动脉损伤后截肢率居高不下的主要因素.     

Management of Liver Trauma

Background  

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.     

Classification of Liver Trauma

The classification of liver injuries is important for clinical practice, clinical research and quality assurance activities. The Organ Injury Scaling (OIS) Committee of the American Association for the Surgery of Trauma proposed the OIS for liver trauma in 1989. The purpose ofthe present study was to apply this scale to a cohort ofliver trauma patients managed at a single Canadian trauma centre from January 1987 to June 1992.170 study patients were identified and reviewed. The mean age was 30, with 69% male and a mean ISS of 33.90% had a blunt mechanism ofinjury. The 170 patients were categorized into the 60IS grades ofliver injury. The number of units of blood transfused, the magnitude of the operative treatment required, the liver-related complications and the liver-related mortality correlated well with the OIS grade. The OIS grade was unable to predict the need for laparotomy or the length of stay in hospital. We conclude that the OIS is a useful, practical and important tool for the categorization of liver injuries, and it may prove to be the universally accepted classification scheme in liver trauma.     

Liver Transplantation following Blunt Liver Trauma

Due to developing medical technology worldwide, an increasing number of liver transplantations are performed for various indications. Liver transplantation has a limited but important role in specific life-threatening liver trauma cases, when initial therapeutic options fail to control the bleeding or when liver failure ensues. Herein we have reported a patient who required liver transplantation at 18 days after blunt liver trauma with acute liver failure. This case report suggested that liver transplantation is a potential treatment modality for a selected group of patients including pedratric cases who experience acute or subacute liver failure secondary to blunt trauma.     

Hepatic Artery Thrombosis After Orthotopic Liver Transplant: Experience in the Last 10 Years

BackgroundHepatic artery thrombosis (HAT) is the second cause of graft failure, after primary disfunction. It has a significant morbidity, with a retransplant and mortality rate in early hepatic artery thrombosis of 50%. The incidence of this event goes from 2% to 9% in the adult population.MethodsThe objective is to assess the incidence of HAT in a third-level hospital. The study design is an observational retrospective study, collecting data of the transplant recipient from 2010 to 2020.ResultsIncidence of HAT was 5.33% (39/732). A statistical difference was found with the blood intraoperative administration (P = .002) and with the presence of anatomic abnormalities in the hepatic artery between the HAT and the non-HAT group. We did not find any statistical difference with portal thrombosis (P = .73) between the groups.ConclusionsHAT is a fatal complication after an orthotopic liver transplant, which can lead to graft loss and even recipient death. For these reasons, we should early identify risk factors associated with this event early and try to minimize them to avoid the devastating consequences.     

Pigmented Villonodular Synovitis of the Foot and Ankle: Forty Years of Experience from the Scottish Bone Tumor Registry

Fourteen cases of pigmented villonodular synovitis (PVNS) of the foot and ankle accrued from the Scottish Bone Tumor Registry are presented with an average follow-up of 4.6 years. This study analyzed the clinical, radiological, and histopathological features and investigated their clinical behavior and the factors influencing recurrence. The mean age of the patients was 26.4 years (range, 8-52 years). There were 8 women and 6 men. The mean delay in presentation was 10.3 months. The anatomical sites were phalanges (n = 2), tarso-metatarsal area (n = 3), and hindfoot (n = 9) (6 extraarticular soft tissue swellings around the ankle, 2 ankle, 1 subtalar joint). Eight (57.1%) cases presented with a painless lump, 5 (35.7%) patients had painful masses, and 1 case had a lump associated with toe deformity. Peri-articular tissue invasion and cortical infiltration were found in one third on plain films. Magnetic resonance imaging findings were suggestive of synovial sarcoma in 2 cases because of extensive low-signal soft tissue hypertrophy and bone erosion. Excision of the lump was performed in 4 cases with a complete recovery. Phalangeal lesions were treated with toe amputation through the metatarsophalangeal joint, and no cases had recurrence. There were 2 recurrences affecting the ankle and the subtalar joint. There was a 14.3% recurrence rate, while complete recovery was achieved in 85.7% cases (12/14). A high index of suspicion for PVNS should be observed for cases presenting with a painless or painful mass in the foot and ankle region. Complete recovery can be achieved in the majority by complete excision. Toe amputation may be considered for foot phalangeal PVNS.     

Review of 9 Cases of Diaphragmatic Injury Following Blunt Trauma Chest; 3 Years Experience

Diaphragmatic injuries can occur with both blunt and penetrating trauma which can be associated with herniation of abdominal viscera into the thoracic cavity. Diaphragmatic injuries can occur with blunt trauma chest in 1–7 % of patients. Retrospectively for last 3 years all cases blunt trauma chest admitted to surgery were reviewed and a study of cases of diaphragmatic rupture was done. We analysed 496 patients of blunt trauma chest retrospectively for period of three years. Nine patients have diaphragmatic injuries, all were males, six presented acutely three were chronic. In six patients laparotomy was done, four subcostal and two midline incisions were preferred. In chronic cases thoracotomy was done. Left sided injury predominates and rib fractures are most common associated finding. Diagnosis in majority of cases is made by Computerised tomography scan. Subcostal incision may be used in patients with isolated diaphragmatic injury in acute presentation while thoracotomy is preferred in late cases. Most common morbidity is pulmonary complications     

Civilian Airway Trauma: A Single-Institution Experience

Background

Injuries to the airway in the neck and thorax are uncommon, but may be potentially life threatening. The objective of this study is to determine the clinical characteristics and outcomes for patients with airway injury.

Methods

From 1974 to 2014, a prospectively entered trauma database at a Level 1 trauma center was accessed to identify patients with injuries to the larynx, cervical trachea, or thoracic airway. Hospital charts were reviewed to obtain data on demographics, presentation, injury management, in-hospital and long-term morbidity and in-hospital mortality. Multivariate logistic regression was used to estimate predictors of mortality and long-term vocal cord morbidity. Data are expressed as N (%).

Results

One hundred and twenty patients were included (median injury severity score: 19 [interquartile range: 10–27]). There were 65 (54 %) blunt and 55 (46 %) penetrating injuries, with 90 (75 %) suffering multiple injuries. Sixteen (13 %) patients died from associated injuries (7: in ER; 9: after admission). Injuries were located in the cervical airway [101 (84 %)], thoracic airway [21 (18 %)], or both [2 (2 %)]. Eighty-six (72 %) patients were managed surgically. Predictors of in-hospital mortality included hemodynamic instability (OR 6.54, 95 % CI 1.11–37.14), GCS < 8 upon presentation (OR 4.35, 95 % CI 3.24–5.41), and head trauma (OR 4.10, 95 % CI 1.91–6.30). Fracture of cricoid or thyroid cartilages was a strong predictor of long-term vocal cord injury (OR 3.93, 95 % CI 1.25–12.59).

Conclusions

Airway trauma remains a major challenge for early diagnosis, airway control, and management of both acute life-threatening injury and long-term morbidity.

     

Trends in Trauma: A Rural Experience

In last 20 years a progressive increase in the cases of road traffic accidents is seen in the institution. In this study efforts have been made to study epidemiology of trauma & how to help the trauma victims in a better way. To study the changing trends in incidence & presentation of trauma victims. To recommend preventive measures based on the analysis. The present study was carried out in MGIMS, Sewagram, Wardha from 2001 to 2003. For this study which is retrospective and prospective, a total of 986 cases of surgical trauma were studied. Present study showed that in this rural area accidents account for maximum trauma admissions & major trauma only in 20 %. Out of 986 patients, 78.8 % required repair of wounds, 3.8 % required exploratory laparotomy and 16.3 % had orthopedic interventions. Overall mortality rate was 2.9 %. It was found that general care in wards was good in terms of trauma results of rural areas. These results may vary when compared with specialized trauma centers in cities; however after a period of few years cost effectiveness of trauma centers in terms of benefits needs an assessment*.     

Liver Transplantation for Familial Amyloidotic Polyneuropathy (FAP): A Single-Center Experience Over 16 Years

Orthotopic liver transplantation (LTx) is currently the only available treatment that has been proven to halt the progress of familial amyloidotic polyneuropathy (FAP). The aim of this study was to assess mortality and symptomatic response to LTx for FAP. All 86 FAP patients transplanted at our hospital between April 1990 and November 2005 were included in the study. Five patients underwent retransplantation. The 1-, 3- and 5-year patient survival rates in patients transplanted during 1996-2005 were 94.6%, 92.3% and 92.3%, respectively, a significant difference from the rates of 76.7%, 66.7% and 66.7%, respectively, during 1990-1995 (p = 0.0003). Multivariate analysis revealed that the age at the time of LTx (>or=40 years), duration of the disease (>or=7 years) and modified body mass index (mBMI) (<600) were independent prognostic factors for patient survival. A halt in the progress of symptoms was noted in most patients, but only a minority experienced an improvement after LTx. To optimize the posttransplant prognosis, LTx should be performed in the early stages of the disease, and close post-LTx monitoring of heart function by echocardiography and of heart arrhythmia by Holter ECG is mandatory.     

Penetrating Liver Trauma in Pregnancy

Abstract Penetrating abdominal injury during pregnancy is extremely rare. The case of an 18-year-old primigravid woman at 29 weeks gestation is presented who sustained a low-velocity handgun penetrating liver injury. Due to her hemodynamic stability, absence of fetal distress and also absence of radiographic and clinical signs of hollow viscus injury, the patient was conservatively treated and discharged in perfect condition on the 10th day following admission.     

Polycystic Liver Disease and Liver Transplantation: Single-Institution Experience

Adult polycystic liver disease (PLD) can cause massive hepatomegaly leading to pain, caval obstruction, and hemorrhage. Many surgical techniques including aspiration, fenestration, and resection have been used to treat PLD. In addition to substantial morbidity and mortality, conservative surgery may have limited success, and palliation may be temporary. With improved results of liver transplantation, it has become the definitive treatment for PLD. We retrospectively reviewed our experience in patients with PLD between 1998 and 2007. Thirteen patients underwent liver only or liver-kidney transplantation. All surgical procedures were performed with preservation of the recipient inferior vena cava and without venovenous bypass (piggyback technique). Our patients experienced a high rate of perioperative morbidity. However, long-term patient and graft survival were excellent.     

The Hepatix Extracorporeal Liver Assist Device: Initial Clinical Experience

Abstract: Eleven patients were treated with the Hepatix extracorporeal liver assist device (ELAD) between June 1991 and August 1993. The first 2 patients were treated according to Food and Drug Administration guidelines ("Emergency Use of Unapproved Medical Devices," October 22, 1985), and the remaining 9 were treated according to an Investigational Device Exemption (IDE). The goal of the study was to establish the short-term safety of ELAD therapy, with a focus on acute medical complications such as hemodynamic instability, complement activation, and deterioration of vital organ function. As secondary goals, the metabolic capacity of ELAD cartridges and their clinical impact were assessed. Treatment was considered successful if the patient recovered sufficient liver function to survive weaning from the ELAD or was stabilized until orthotopic liver transplantation was performed. No short-term safety problems were associated with ELAD use. In addition, metabolic support was documented in 10 of the 11 patients, and 6 patients reached a successful end-point. The Hepatix ELAD is safe, and it provides measurable metabolic support in patients with late-stage liver failure. This pilot study provides the impetus to perform controlled trials of ELAD therapy in the treatment of various types of end-stage liver disease.     

Biliary Complications After Orthotopic Liver Transplantation: The Hungarian Experience

Biliary complications (BC) significantly affect morbidity and mortality after orthotopic liver transplantation (OLT). The aim of this study was to analyze the incidence and types of biliary complications after OLT in Hungary. We retrospectively analyzed data of 471 adult liver transplant recipients between 1995 and 2011. Biliary complications occurred in 28% of patients. The most frequent BCs were bile duct stricture, stenosis (19%), biliary leakage (12%), and necrosis (BN: 6.4%). Biliary complications were associated with the incidence of acute rejection (51% vs 31%; P = .003), hepatic artery thrombosis (43% vs 11%; P < .001), and hepatic artery stenosis (26% vs 11%; P = .002). When cold ischemic time was longer than 12 hours, leakage (10% vs 3%; P = .043), ischemic type biliary lesion (20% vs 3.4%; P = .05), and BN (12% vs 3%; P = .067) were more often diagnosed post-OLT. Most of the biliary complications were treated by radiologic interventions (70%). Bile duct necrosis was associated with lower graft and patient survival. In conclusion, acute rejection, hepatic artery thrombosis/stenosis and cold ischemic time longer than 12 hours increase the incidence of BCs. Successful management of these risk factors can reduce the incidence of biliary complications and improve mortality.     

In Search of Benchmarking for Mortality Following Multiple Trauma: A Swiss Trauma Center Experience

Background  

The manifestations associated with non-survival after multiple trauma may vary importantly between countries and institutions. The aim of the present study was to assess the quality of performance by comparing actual mortality rates to the literature.