Factores asociados a falla en el manejo no operatorio de lesiones hepáticas o esplénicas secundarias a trauma abdominal cerrado en niños / Associated factors to non-operative management failure of hepatic and splenic lesions secondary to blunt abdominal trauma in children

Introducción: El manejo no operatorio (MNO) es el manejo estándar del trauma cerrado esplénico y hepático en el paciente pediátrico. Se han identificado como fallas a este manejo inestabilidad hemodinámica y transfusiones masivas. Pocos trabajos evalúan si existen factores que permitan una anticipación a estos eventos. El objetivo fue determinar la existencia de factores asociados a la falla en MNO de las lesiones esplénicas y/o hepáticas secundarias al trauma abdominal cerrado. Pacientes y Método: Análisis retrospectivo 2007 a 2015 de los pacientes que ingresaron al servicio de Cirugía infantil del Hospital Universitario San Vicente Fundación con trauma hepático y/o esplénico cerrado. Resultados: Ingresaron 70 pacientes con trauma cerrado de abdomen, 3 fueron excluidos por cirugía inmediata (2 inestabilidad hemodinámica y 1 irritación peritoneal). De 67 pacientes que recibieron MNO, 58 tuvieron éxito y 9 presentaron falla (8 inestabilidad hemodinámica y 1 lesión de víscera hueca). Encontramos 3 factores asociados a la falla MNO: presión arterial (PAS) < 90 mmHg al ingreso (p=0,0126; RR =5,19), caída de la Hemoglobina (Hb) > 2 g/dl en las primeras 24 h (p=0,0009; RR= 15,3), y transfusión de 3 o más unidades de glóbulos rojos (UGR) (0,00001; RR= 17,1). Mecanismo del trauma, severidad e Índice de Trauma Pediátrico no se asociaron con fallo MNO. Conclusiones: Los niños con trauma cerrado hepático o esplénico responden al MNO. Los factores como PA menor de 90 al ingreso, caída de la Hb >2 g/dl en las primeras 24 h y la transfusión de 3 o más UGR pueden asociarse con la falla en el MNO.

Introduction: The non operative management (NOM) is the standard management of splenic and liver blunt trauma in pediatric patients.Hemodynamic instability and massive transfusions have been identified as management failures. Few studies evaluate whether there exist factors allowing anticipation of these events. The objective was to identify factors associated with the failure of NOM in splenic and liver injuries for blunt abdominal trauma. Patients and Method: Retrospective analysis between 2007-2015 of patients admitted to the pediatric surgery at University Hospital Saint Vincent Foundation with liver trauma and/or closed Spleen. Results: 70 patients were admitted with blunt abdominal trauma, 3 were excluded for immediate surgery (2 hemodynamic instability, 1 peritoneal irritation). Of 67 patients who received NOM, 58 were successful and 9 showed failure (8 hemodynamic instability, 1 hollow viscera injury). We found 3 factors associated with failure NOM: blood pressure (BP) < 90 mmHg at admission (p = 0.0126; RR = 5.19), drop in hemoglobin (Hb) > 2 g/dl in the first 24 hours (p = 0.0009; RR = 15.3), and transfusion of 3 or more units of red blood cells (RBC) (0.00001; RR = 17.1). Mechanism and severity of trauma and Pediatric Trauma Index were not associated with failure NOM. Conclusions: Children with blunted hepatic or splenic trauma respond to NOM. Factors such as BP < 90 mmHg at admission, an Hb fall > 2 g/dl in the first 24 hours and transfusion of 3 or more units of RBC were associated with the failure in NOM.

LIVER TRANSPLANTATION AFTER SEVERE HEPATIC TRAUMA: CURRENT INDICATIONS AND RESULTS / TRANSPLANTE DE FÍGADO APÓS TRAUMA HEPÁTICO GRAVE: INDICAÇÕES ATUAIS E RESULTADOS

Background : The liver is the most injured organ in abdominal trauma. Currently, the treatment in most cases is non-operative, but surgery may be necessary in severe abdominal trauma with blunt liver damage, especially those that cause uncontrollable bleeding. Despite the damage control approaches in order to achieve hemodynamic stability, many patients develop hypovolemic shock, acute liver failure, multiple organ failure and death. In this context, liver transplantation appears as the lifesaving last resource Aim : Analyze the use of liver transplantation as a treatment option for severe liver trauma. Methods : Were reviewed 14 articles in the PubMed, Medline and Lilacs databases, selected between 2008-2014 and 10 for this study. Results : Were identified 46 cases undergoing liver transplant after liver trauma; the main trauma mechanism was closed/blunt abdominal trauma in 83%, and severe trauma (>grade IV) in 81 %. The transplant can be done, in this context, performing one-stage procedure (damaged organ removed with immediate transplantation), used in 72% of cases. When the two-stage approach is performed, end-to-side temporary portacaval shunt is provided, until new organ becomes available to be transplanted. If two different periods are considered - from 1980 to 2000 and from 2000 to 2014 - the survival rate increased significantly, from 48% to 76%, while the mortality decreased from 52% to 24%. Conclusion : Despite with quite restricted indications, liver transplantation in hepatic injury is a therapeutic modality viable and feasible today, and can be used in cases when other therapeutic modalities in short and long term, do not provide the patient survival chances.

Introdução : O fígado é um dos órgãos mais afetados nos traumas abdominais. Atualmente, o tratamento de escolha na maioria dos casos é o não operatório; porém, a intervenção cirúrgica pode ser necessária nos traumas abdominais severos com lesão hepática grave, principalmente naqueles que provocam hemorragias de difícil controle. Apesar das abordagens de controle de danos visando a estabilidade hemodinâmica, muitos pacientes evoluem para choque hipovolêmico, insuficiência hepática aguda, falência múltipla de órgãos e óbito. Nesse contexto, o transplante hepático surge como última opção de tratamento. Objetivo : Analisar a utilização do transplante hepático como modalidade terapêutica em traumas hepáticos graves. Método : Foram revisados 14 artigos obtidos nas bases de dados Pubmed, Medline e Lilacs entre 2008-2014, sendo selecionados 10 para o presente estudo. Resultados : Foram identificados 46 relatos de casos de pacientes submetidos à transplante de fígado após trauma hepático; o principal mecanismo de trauma foi o fechado/contuso com 83%, e traumas graves (>grau IV) em 81%. O transplante pôde ser realizado em uma etapa (paciente com órgão lesado removido e imediatamente recebia o enxerto), utilizado em 72% dos casos. Nos procedimentos em duas etapas realizava-se shunt temporário portocava até que um órgão fosse disponibilizado. Na análise de dois períodos distintos - 1980 a 2000 e 2000 a 2014 -, taxa de sobrevida aumentou significativamente, passando de 48% para 76% e a mortalidade caiu de 52% para 24%. Conclusão : O transplante hepático apesar de ter indicações bastante restritas no cenário do trauma hepático, representa modalidade terapêutica nos dias de hoje viável e factível, podendo ser empregada em casos onde o tratamento cirúrgico, assim como outras modalidades terapêuticas, não ofereçam ao paciente chances de sobrevida a curto e longo prazo.

Hemobilia após trauma abdominal: relato de 3 casos / Hemobilia after abdominal trauma: report of 3 cases

Hemobilia é rara e potencialmente fatal. A suspeita de sangramento em trato biliar é maior em casos recentes de trauma hepático ou cirurgia hepatobiliar. Ruptura de pseudoaneurisma de artéria hepática é causa comum de hemobilia. Relatamos 3 casos de hemobilia em indivíduos jovens, acometidos por trauma abdominal, que evoluíram com ruptura de pseudoaneurisma e necessidade de embolização angiográfica de vaso sangrante.

Hemobilia is rare and potentially fatal. Suspect bleeding in the biliary tract is higher in recent cases of liver trauma or hepatobiliary surgery. Rupture of hepatic artery pseudoaneurysm is a common cause of hemobilia. We report 3 cases of hemobilia in young individuals suffering from abdominal trauma, who developed pseudoaneurysm rupture and need for angiographic embolization of bleeding vessel.

Estudo da morbimortalidade em pacientes com trauma hepático / Morbimortality in patients with hepatic trauma

O fígado é o órgão intra-abdominalmais comumente lesado em pacientes vítimas detrauma. A lesão ocorre mais frequentemente notrauma penetrante do que no trauma contuso

Fístula de alto gasto / High output fistula

Se presenta a un paciente de 37 años de edad que acude a nuestro Cuerpo de Guardia politraumatizado, con lesiones torácicas y abdominales, con síntomas y signos sugestivos de fracturas costales múltiples, con hemotórax derecho y hemoperitoneo, corroborado imaginológicamente y en la punción abdominal. Se realiza pleurostomía mínima intermedia y laparotomía exploratoria. Se le encuentran lesiones hepáticas de los segmentos VI, V, VIII y IV, con una profundidad mayor de 3 cm, además, deserosamientos en las asas delgadas intestinales y colon. Se realiza hepatorrafia y empaquetamiento hepático. Posteriormente van apareciendo complicaciones, por lo que tiene que ser reintervenido en máqs de 60 ocasiones. Entre ellas, la aparición de una fístula de alto gasto, que lo llevó a la desnutrición y a la permanencia con el abdomen expuesto durante 7 meses hasta el egreso. Se revisa la literatura correspondiente a estas entidades(AU)

A 37 years-old multi-traumatized male patient went to our emergency service. He had many injures in the thorax and the abdomen, together with symptoms and signs suggestive of multiple costal fractures, with right hemothorax and hemoperitoneum, all of which was confirmed by imaging techniques and by abdominal puncture. Minimal intermediate pleurostomy and exploratory laparoscopy were performed. We found hepatic lesions in the 6th, 5th, 8th and 4th segments, over 3 cm deep; additionally, the loss of serosa from the intestinal ansae and from the colon. Hepatorrhaphy and hepatic packing were also performed. Later on, more complications appeared, so he had to be re-operated more than 60 times. The occurrence of a high output fistula led him to malnutrition and his abdomen remained exposed for 7 months until he was finally discharged from hospital. This paper also presented a literature review on this topic(AU)

Embolização arterial no tratamento de hemobilia pós-trauma hepático: relato de caso / Arterial embolization in the treatment of hemobilia after hepatic trauma: a case report

Hemobilia é causa rara de hemorragia digestiva e complicação incomum no trauma hepático. Ocorre devido à comunicação entre ductos biliares e vasos intra-hepáticos. Os autores relatam um caso de paciente vítima de ferimento penetrante abdominal que evoluiu, após três meses da hepatorrafia, com dor, icterícia e hemorragia digestiva. Foi realizada angiografia, que demonstrou pseudoaneurisma de artéria hepática direita, e efetuada embolização com sucesso.

Hemobilia is a rare cause of gastrointestinal bleeding and uncommon complication in cases of liver trauma. It occurs due to communication between bile ducts and intrahepatic vessels. The authors describe the case of a patient victim of penetrating abdominal injury, who progressed after three months of liver suture with pain, jaundice and gastrointestinal bleeding. Angiography diagnosed right hepatic artery pseudoaneurysm, and embolization procedure was successfully performed.

Clinical study on surgical treatment for injury of liver and vascular approaching to liver with 35 Cases / 中国综合临床

ObjectiveTo explore the surgical approach and therapeutic efficacy of injury of liver and vascular approaching to liver.MethodsThe clinical data from January 1997 to May 2010 of 35 patients with injury of liver and vascular approaching to liver were retrospectively analyzed.Results Among 35 cases,32cases were cured by surgery ( cure rate 91.43％ ) and 3 cases died ( mortality rate 8.57％ ).Postoperative complications occurred in 5 patients ( complication rate 14.29％ ).There were 2 cases of pulmonary infection,1case of biliary fistula,1 case of multiple organ failure and 1 case of incision infection.Conclusion Urgent surgery need to be performed for injury of liver and vascular approaching to liver and effective recovery was important.In the operation,careful handling,complete dissociation and sufficient exposure were the key to successful repair.

Twenty-year experience in the diagnosis and treatment of hepatic trauma / 国际外科学杂志

Objective To summarize the experience in the diagnosis and treatment of hepatic trauma. Methods The clinical data of 260 patients with hepatic trauma admitted from January 1988 to December 2007 were retrospectively reviewed with regard to degree of trauma, treatment methods, therapeutical effects, complications and SO on. Results One hundred and fifty-three eases were treated by operative management,1 07 cases by nonoperative management.236 cases were cured,24 cases died,and the case fatality rate was 10.2%.There were no death among 139 patients with hepatic trauma grades Ⅰ～Ⅱ,22 death among 119 grades Ⅲ～Ⅴ patients, all death of 2 in grade VI, which demonstrated the correlation between death and hepatic trauma grade was statistically significant. Complications appeared in 82 eases, mainly including Secondary hemorrhage, abdominal infection and so on. Conclusions Nonoperative management is suitable for hepatic trauma with stable hemodynamics. Operative management is rapidly selected when the hemodynamics aren't stable. The cooperation of many specialities can enlarge the application of nonoperative management and decrease complications.

Diagnosis and treatment of hepatic trauma: a report of 55 cases / 国际外科学杂志

Objective To summarize the experiences of the diagnostic and therapeutiec approach of hepatic trauma.Methods Referencing to the literature of recent years,we retrospectively analyzed the clinieal data of 55 cases of liver trauma.Results Among the 55 cases.18 eases of stage Ⅰ～Ⅱ.1 5 cases of stage Ⅲ,17 eases of stage Ⅳ and 5 cases of stage V,Thirty-one cases received non-operative treatment.and 24 cases reeeived operative therapy.In non-operative treatment group,the cure rate was 100%.In operation Ireatmenl group the cure rate was 91.7%.Conclusions Focused abdominal sonography for trauma (FAST) and diagnostic peritoneal paraeentesis are the initial methods for diagnosis of liver trauma and are largely used nowadays.When the patient is hemodynamically stable,CT scan or simuhaneous contrast-enhanced scan are important to decide for conservative ur surgical treatment.Today.treatment of hepatic lesions takes in account mainly two aspects:hemodynamically stability and the mechanism for trauma(blunt or penetrating).Liver injmy score of patienlS is not as important as the hemodynamie status for determining conservative management.Nonoperative management under close continuous observation for the hemodynamically stable patients with stage Ⅰ and Ⅱ and some eases of stage Ⅲ blunt hepatic injury has become the stamlard of care.The decision for surgical intervention should be given in time according to the variance of hemodynamically stability and the presence of trauma (blunt or penetrating).Some cases of stage Ⅲ and all cases of stage Ⅳ to Ⅴ hepatic injury shouht preferably undergo surgieal treatment.The effective preventive measures to decrease mortality in patients with severe hepatic trauma include early remedy to henmrhagie shock.effective hemostasis,complete abdominal drainage and prevention of pnstoperative enmplieations.

Hepatic trauma \ufffd?determinants to treatment attitude in Viet Duc hospital

Background: Hepatic trauma is the second injury of closed abdominal injury, but it is the leading cause of death. The most of hepatic trauma due to closed abdominal injury caused by traffic accident. Objectives: To assess determinants to treatment attitude of hepatic trauma patients treated in Viet Duc hospital. Subjects and method: A cross-section descriptive study was conducted on 157 patients with closed abdominal injury (118 male, 39 female), was diagnosed with hepatic trauma, treated in Viet Duc hospital from January, 2004 to April, 2006. Results: The average age of patients were 28.9\xb113 for male, 28.8\xb112 for female. The common occupations were farmers (35.7%), workers (14.6%), no professional 14.6% and other jobs (35.1%). Combined injuries included: cranial trauma (9.6%), facial trauma (10.2%), chest trauma (17.2%), major bone trauma (7.6%). 19.7% patients with combined injuries were operated. 130 patients with hepatic trauma (82.2%) was detected by ultrasound, 1 patient with splenic trauma combined hepatic repture. The differences between shock of admission, level of hepatic trauma and the amount of blood in abdominal CT scans to treatment attitude were having a statistically significant with p<0.001, p<0.001 and p=0.005, respective. Conclusion: Recently, the treatment attitudes with hepatic trauma patients have more changed. Hemodynamic stability, clinical close monitoring, excluding combined injuries required surgery and assessing injuries by CT scans are important factors to indicate conservation therapy for hepatic trauma. Conservation therapy is safe and effective in the treatment of hepatic trauma in Viet Duc hospital.

The value of computerized tomography in diagnosis of hepatic trauma

Background: Hepatic trauma is a common disease in surgical emergency. Nowadays, there are many means of diagnostic imaging such as ultrasound, computerized tomography, magnetic resonance imaging.. but computerized tomography is more valuable in the diagnosis and treatment decisions. Objectives: To assess the value of computerized tomography in diagnosis of hepatic trauma. Subjects and method: To conduct computerized tomography on 36 patients with hepatic trauma (28 male, 8 female, aged 5-70 year olds), was diagnosed by ultrasound in Viet Duc hospital from January, 2005-June, 2005. Results: Major cause of the trauma was still due to traffic accidents (77.8%), followed by living and occupational accidents (61.5%). Using computerized tomography, there were only 12 patients undergoing surgery, the remainders were conservative treated. The common signs were: fluids in abdominal cavity: 33/36 patients (91.7%), without fluids in abdominal cavity: 3 patients. Parenchyma crush: 28/36 patients (77.8%). The most common lesion site was right liver. Diagnostic CT scans at 4 or more degrees was necessary during considering surgical indication for cases of having combined injuries, which can lead to hemodynamic dysfunction. Therefore, clinicians tend to use conservative therapy in hepatic trauma. Conclusion: CT scans was chosen as major examination to determine exactly level of lesions and to decide procedures.

Hepatic injury / Trauma hepático

Hepatic trauma occurs in approximately 5 percent of all admissions in emergency rooms. The anatomic location and the size of the liver make the organ even more susceptible to trauma and frequently in penetrating injuries. The American Association for the Surgery of Trauma established a detailed classification system that provides for uniform comparisons of hepatic injury. Diagnosis of hepatic injury can be sometimes easy; however the use diagnostic modalities as diagnostic peritoneal lavage, ultrasound and computed tomography allow faster and more accurate diagnosis. Nonoperative management of the hemodynamically stable patient with blunt injury has become the standard of care in most trauma centers. Few penetrating abdominal lesions allow conservative management; exceptions can be some penetrating wounds to right upper abdominal quadrant. Operative treatment of minor liver injuries requires no fixation or can only be managed with eletrocautery or little sutures. Major liver injuries continue, despite technical advances, a challenge to surgeons. Many procedures can be done as direct repair, debridement associated to resections, or even in more severe lesions, packing. This constitutes a damage control which can allow time to recovery of patient and decreasing mortality shortly after trauma.

O trauma hepático corresponde a aproximadamente 5 por cento das admissões das salas de urgência. A localização anatômica do fígado e o seu tamanho o tornam mais susceptível ao trauma contuso e freqüentemente às lesões penetrantes. A associação Americana para a Cirurgia do Trauma estabeleceu uma classificação detalhada, o que possibilita comparações uniformes do trauma hepático. O diagnóstico destas lesões pode ser muitas vezes fácil, contudo a utilização de modalidades diagnósticas como o lavado peritoneal, a ultrassonografia e a tomografia computadorizada, permite o diagnóstico mais rápido e acurado. O tratamento conservador não operatório do trauma hepático contuso em pacientes com estabilidade hemodinâmica tornou-se padrão na maioria dos centros de trauma. Poucas lesões penetrantes do abdome permitem o tratamento conservador. As exceções podem ser justamente aquelas localizadas no quadrante superior direito do abdome que atinjam apenas o fígado. O tratamento cirúrgico de pequenas lesões hepáticas geralmente necessita de nenhum reparo ou podem ser tratadas com cauterização ou pequenas suturas. As lesões mais graves, a despeito dos avanços tecnológicos, constituem ainda um desafio aos cirurgiões. Muitos procedimentos podem ser realizados como: simples suturas, ressecções associadas a desbridamentos ou mesmo em lesões ainda mais graves, o empacotamento. Este constitui o controle do dano, o qual pode permitir a recuperação do paciente com diminuição da mortalidade precoce após o trauma.

Liver injury in Siriraj Hospital.

Background : Liver injury is a challenging intraabdominal injury with a high morbidity and mortality rate. We describe details of this interesting injury that was treated at Siriraj Hospital. Objective : To review mechanism of injury, severity of injury, treatment and mortality rate of liver injury at Siriraj Hospital. Methods : A retrospective study of liver injuries that occurred during May 1997 and March 2000 was done. Analysis of the data was made be a simple statistical method using mean and percentage. Results : Sixty-eight patients with liver injury who were admitted of and had completely recorded data from Siriraj Hospital were analyzed, including 56 males and 12 females. Mean age was 28.6 yr. (4.60). Regarding mechanism of injury,39 (57.4%) were affected from blunt ingury,26 (38.2%) were had stab wounds, and 3 (4.4%) had gunshot wounds. Fifty-five patents with liver injury (80.9%) had at least one site of other organ injury (77 sites in 55 patents). The most common other injury was chest in injury (28 sites including 13 sites of diaphragmatic injury) This study included 23 (33.8%), 24 (35.3%), 18 (26.5%), 1 (1.5%) and2 (2.9%) patients who were classified as grade I, II, III, IV and V of liver injury respectively. Surgery was performed in 66 patients whereas only 2 patients were observed and CT scanning for successful nonoperative management. Cauterizaton and suture of injured liver were the two most common procedures that were performed in our hospital, 52.9% and 23.5% of cases respective, had they were limited to only grade I, II and III liver injury. The overall mortality rate was 11.8%, with only 8.5% being grade I and II but markedly increased to 19% in grades III, IV and V. Conclusion : More than half of the liver injuries in this study were from blunt injury, the other 42.6% were from penetrating injury. There was a high rate of associated injury. Most hepatic injuries were minor (69.2%) In this study surgery was per formed in 66 patients whereas only 2 patients were observed. Nonoperative management was not widely used, In case of an operation, one or more surgical procedures were used, including electrocautery, suturing of liver parenchyma or vessels, packing of the liver ligating the hepatic artery and repairing the vena cava. In complex hepatic injury, we prefer the conventional method by perihepatic packing. The overall mortality rate was 11.8%

Application of Hepatic Partial Resection for Hepatic Trauma:A Clinical Report of 36 Cases / 中国医师杂志

Objective The effect of hepatic partial resection for hepatic trauma.Methods Thirty-Six patients with hepatic trauma were operated on the bases of litertures,we elucidated the indication and method of operation and prevention of operative complications .Resuts Three cases died,a death rate of 8 33%,and a cure rate of 91 8%.Conclusion Hepatic partial resection is an effective method for treatment of hepatic trauma.