Conservative approach in the management of isolated penetrating liver trauma

Damage to the liver is the most common cause of death after abdominal injury. The most common cause of liver injury is blunt abdominal trauma. In the case of penetrating injury, non-intervention management has not been adequately addressed. Selective non-operative management of stab wounds especially to the liver has been reported. This study was carried out from May 2006 to April 2011 at the Main Alexandria University Hospital, Faculty of Medicine, Alexandria, Egypt. This study consisted of 62 liver trauma patients and the following data were collected: demographics, mechanism of injury, pre-hospital care, hemodynamic status, grade of hepatic injury, associated injuries, failure of non-operative [NOP] management, hospital stay in intensive care unit [ICU] or in the ward and death. Patients were eligible for the study if they sustained isolated penetrating right hypochondrial injury. Assessment of hemodynamic stability was based on routine vital signs. Injury severity was determined from CT and classified by means of the Liver Injury Scale. This study was carried out for 62 consecutive patients with hepatic trauma in a five year period. Mean age was 33.6 years with a range of 16-54 years. The isolated penetrating liver injuries included knives, guns [gunshot and shotgun injuries] and other sharp objects. All patients were treated successfully via NOP management except five patients [8%] who failed NOP management. These five patients were hemodynamically unstable and were unresponsive to crystalloid and blood transfusion. The five patients underwent surgery [suturing, packing, and resectional debridement]. Two patients [3.2%] died because of high grade liver injury. The overall actuarial one-year survival in NOP management was 96.8%. Low grade penetrating hepatic injuries [G I-III] can be managed non-operatively with excellent results; even G IV penetrating liver injuries with hemodynamically stable patients can be managed safely non-operatively

Gastroenterology surgical unit experience in hepatic resection for liver tumors

Hepato-cellular carcinoma [HCC] is the fourth most common malignant tumor in the world and is responsible for an estimated one million deaths annually. This study was carried out on 35 patients with hepatic tumors. The aim was to study the impact of the underlying liver disease, tumor pathology, and extent of resection on the outcome of hepatic resection for liver tumors. All patients were subjected to complete history taking, thorough clinical examination, laboratory and imaging studies followed by hepatic resection based on the preoperative data. Follow up of patients was done to determine the perioperative complications, disease-free period, overall survival, tumor recurrence and tumor-related deaths in cases of malignant liver tumors. The indications for hepatic resection were haemangioma [in 2 patients], HCC [in 27 patients] and secondary malignancy [in 6 patients]. Hepatic resections were hemi-hepatectomy in 16, extended hepatectomy in 4 and left lateral lobectomy in 7. The remaining 8 cases included resections of one to three segments or consisted of non-anatomical wedge resections. 23 patients had no perioperative complications. Minor morbidity occurred in 8 patients and major morbidity in 4 patients. There were 2 perioperative deaths. The median survival in patients who underwent hepatic resection for HCC was 30.6 months [15.07-46.17] and the survival rates at 1, 3 and 5 years were 83.3, 63.6 and 34.1% respectively. There is now ample evidence that surgical resection, if possible, remains the best option for treating malignant liver tumors as it offers the best hope of cure in such patients

Anterior abdominal wall fistula: a clinicopathological challenge

Aim of the work was to study the anterior abdominal wall fistulae connected to the gut from etiological, clinical and therapeutic aspects regarding their incidence, presentations, response to conservative or surgical treatment and final outcome. This study was carried out on 30 patients with external fistulae connecting the anterior abdominal wall and Originating from the intestine, biliary radicles and the pancreas. All patients were admitted to Department of Surgery, Main Alexandria University Hospital There were 18 males and 12 females, the age ranged from 12 to 65 years with a mean value of 48.15 +/- 3.24 years. Eleven patients [36.7%] were of high output fistulae, 4 patients [13.3%] were of moderate output fistulae and 15 patients [50%] were of low output fistulae. The complications were sepsis in 10 patients [33. 3%], fever in 10 patients [33.3%], electrolyte depletion and weight loss in 4 patients [13.3%] and skin complications in 22 patients [73.3%]. Abdominal ultrasound and CT scans were done in all cases and revealed internal collection in 7 patients [23.3%], fistulogram was done in 7 cases [23.3%] and endoscopic retrograde cholangiopancreatography [ERCP] in one case. The origin of fistulae was the small intestine In 10 patients [33.3%], the colon in l6 patients [53.3%], from biliary- enteric anastomosis in 3 patients [10%] and from pancreatic duct in one patient [3.3%]. The etiological factors were gut carcinoma in 8 patients [26.7%], hernia repair in 10 patients [33.3%], neglected appendicitis in 3 patients [10%], post Whipple operation in 3 patients [10%], post pancreatic necrosectomy in one case [3.3%], iatrogenic trauma to sigmoid colon during gynaecological surgery in 2 cases [6.7%], rupture sigmoid diverticulitis in 2 patients [6.7%] and one case [3.3%] following typhoid perforation. Spontaneous closure was achieved in 25 patients [83.3%] by conservative treatment which included total parenteral nutrition, enteral nutrition, somatostatin analogue and antibiotics. Surgical intervention was required in spatients [16.7%] in the form of resection of the fistula- bearing segment and anastomosis of the two healthy ends. Five fistulae [16.7%] closed between 2 and 4 weeks, 8 fistulae [26.67%] between 4 and 8 weeks, 9 fistulae [30%] between 6 and 8 weeks and 8 fistulae [26.7%] closed after more than 8 weeks. Only one patient [3.3%] died from sepsis and multiple organ failure. spontaneous closure is depending on a number of factors which include anatomical site, distal obstruction, presence of inter current disease and whether or not the fistulous track is simple or complex. Sepsis in the peritoneal cavity is the major cause of mortality. The use of octreotide is highly recommended as It definitely converts high output to low output fistulae. The enterocutaneous fistulae that fail to resolve within 4 to 6 weeks under conservative treatment require surgical intervention