Blunt hepatic injuries: incidence, evaluation and management in Zagazig University Hospitals

A prospective study including most of the patients, [374 patients] admitted to emergency department of Zagazig University hospitals as a blunt abdominal trauma during the period from January 1998 to December 2001. Liver injury was found in 86 of them [those patients represents the material of this study]. The age of liver injured patients ranged between 9 to 59 years [mean 35 years]. 67 males and 19 females. Motor vehicle accident was the cause of liver injury in 53 patients [61.6%], train accident in 4 patients [4.6%] and fall from a height in 29 patients [33.8%]. The liver injured patients had exra-abdominal injuries in the form of, head injuries in 15 patients [17.4%]; chest injuries in 21 patients [24.4%] and orthopedic injuries in 33 patients [38.3%]. After exploration of 77 patients with liver injury there were other abdominal injuries as the following: spleen in 16 patients [18.6%]; mesentery [haematoma and/or tears] in 7 patients [8.1%]; small intestine in 5 patients [5.8%]; colonic injury in 3 patients [3.4%]; retroperitoneal haematoma in 12 patients [13.9%]; pancreas in one patient [1.15%]; kidney in 2 patients [2.3%] and diaphragm in one patient [1.15%]. All liver injured patients were categorized according to the degree of injury to five grades. The following techniques were used in the management of our liver injured patients. 1-Non-operative treatment: [12 patients], proved grade I, II or III by CT scan with mild to moderate intraperitoneal haemorrhage in haemodynamically stable patients. Early operative intervention was required in two patients with evidence of continuing intra-abdominal bleeding, and in one patient with signs of other associated injury which necessitates laparotomy. 2-operative treatment: For [77 patients]. The procedures used were: abdominal drainage only when the liver injury was minimal without obvious blesding or non expanding haematoma; topical haemostatic agent, as gelfoam or fibrin glue and electrocautary for superficial ooze occurs from decapsulated liver and superficial bleeding fracture; suturing: when bleeding was occurred from within the liver substance without a visible vessels; suture ligation of visible bleeding intra-hepatic blood vessels and injured bile ducts using the finger fracture technique; resection debridement [non anatomical resection] of devitalized or almost detached segments of the liver and peri-hepatic packing, in multiple and complex liver injuries beyond the surgeon's ability to manage and used with other surgical procedures, particularty when hypothermia and coagulopathy promotes diffuse bleeding which is not possible to alleviate by other means. The packs were removed when the patients were haemodynamically stable and coagulopathy was corrected, usually 3-5 days after first exploration. Further debridement of liver necrotic tissue was performed and new peritoneal drains were applied. Thirteen patients [15.1% of liver injured patients] died, two in grade II, one in grade III and three in grade IV i.e. 6 patients died [46% of all deaths] due to associated chest and head injuries [i.e. deaths not related to liver injury]. Three patients in grade V died on table due to massive, uncontrollable bleeding from hepatic injury. One patient died as a result of massive postoperative haematemesis, one due to rebleeding and irreversible shock 24 hours postoperatively in ICU and two patients died due to hepato-renal failure postoperatively. The hospital stay for all liver injured patients ranged from 6 to 31 days [mean 11 days]

Endoscopic reterograde cholangio-pancreatography versus magenetic resonance cholangio-pancreatogrphy in diagnosis and managment of biliary and pancreatic diseases

This work aimed to compare the value of MRCP versus ERCP in diagnosis and management of patients with suspected biliary and pancreatic diseases. The study carried out on 20 patients [12 males and 8 females] with obstructive jaundice. Their ages ranged between 25- 66 years with a mean age 44.2-year. Every patient was examined clinically, laboratory and by different imaging modalities. MRCP and ERCP were done for all 20 patients. Both of these investigations diagnose the cases of obstruction in 19 patient out of 20 cases 95%. The level of obstruction was correctly identified in all 20 cases 100%. MRCP diagnose stone in CBD in 5 cases with accuracy of 95%. There is false negative case by MRCP [There is obstruction but the cause is unknown]. Also ERCP diagnose 6 cases of stone CBD with accuracy of 100% compared with final diagnosis [surgery]. During ERCP therapeutic intervention and stone extraction by Dormia basket were occurred. Also MRCP and ERCP diagnose 6 cases of malignant obstruction with false positive case with accuracy of 95%, 2 cases of cholangio-carcinoma of Rt, Lt. hepatic duct, 2cases of periampullary Carcinoma and 2 cases of cancer head pancreas, There is one case of cancer head found to be chronic pancreatitis during surgery. MRCP diagnose benign strictures of extrahepatic ducts in 4 cases with accuracy of 100% ERCP diagnose 3 cases with accuracy of 95%. It failed to diagnose one case of stricture of CHD and history of gastric tube and choledoduodenostomy. It failed because the tube was wide enough that made its filling with the dye infeasible, So MRCP is superior to ERCP in patients with history of biliary enteric, anastmosis where ERCP can not be done. Also MRCP and ERCP diagnose 4cases iatrogenic postcholecystectony ligation of CBD with similar accuracy of 100%. ERCP has complication during this study pancreatitis in 25%, fever in 10% bleeding in 10% also one patient with periampullary adenocarcinoma die before surgery because of cholangitis and hepatorenal syndrome. There is no complication occurrred after MRCP. We conclude that MRCP is evolving rapid, accurate and non-invasive means of evaluating the biliopancreatic ductal system that can provide nearly similar diagnostic information about biliary obstruction as provided with ERCP even in old and debeSlitated patients, Accordingly we can restrict the use of ERCP to cases in which therapeutic procedure are anticipated or MRCP findings are equivocal, wilh considerable saving time and risks to the patients