Damage Control in Penetrating Liver Trauma: Fear of the Unknown / Control de Daños en Trauma Hepático Penetrante: El Miedo a Lo Desconocido

Abstract The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.

Resumen El hígado es el órgano solido más comúnmente lesionado en casos de trauma abdominal. El manejo del trauma penetrante hepático es un dilema para los cirujanos. Sin embargo, con la introducción del concepto de la cirugía de control de daños y los avances tecnológicos en imagenología y técnicas endovasculares han permitido que el enfoque del tratamiento cambie. La disponibilidad inmediata de la tomografía computarizada permite estadificar el grado de la lesión e incrementar la posibilidad de un manejo conservador en pacientes hemodinámicamente estables con trauma hepático. El trauma hepático severo que se asocia con inestabilidad hemodinámica tiene una alta mortalidad debido a la hemorragia activa. El objetivo de este artículo es proponer un algoritmo de manejo producto de un consenso de expertos acerca del abordaje de los pacientes hemodinámicamente inestables con trauma hepático penetrante. El manejo debe ser por parte de un equipo multidisciplinario que comienza desde la evaluación inicial de los pacientes, la activación temprana de protocolo de transfusión masiva y el control temprano de la hemorragia, siendo estos aspectos esenciales para disminuir la mortalidad. El miedo a lo desconocido es el dilema quirúrgico donde existen pocas opciones y es imperante decisiones rápidas y oportunas; por esta razón, se propone dar una luz de guía sobre lo desconocido respecto al manejo del paciente con trauma hepático severo.

Complication rates in managing hepatic trauma: a cross-sectional study stratifying their outcomes

Background: Liver trauma is the most commonly observed injured organ in abdominal trauma. The objectives of this study was to determine and evaluate the rates of complication in the management of liver traumaMethods: This cross-sectional observational study using non-probability convenient sampling technique was done at surgical unit of Liaquat University of Medical and Health Sciences, Jamshoro, for 06 months. After ethical approval from Institute’s Institutional Review Board (IRB), patients presenting to surgical emergency of the hospital between ages 16 to 60 years having blunt or penetrating liver trauma within 04 hours of incident, either road traffic accident, sustaining a fall, sporting injury, knife or stab wound were include while patients of liver trauma conservatively managed or had severe co-morbid, not fit for anesthesia, with multiple organs lesions (polytrauma) and all hepatic injury patients that were hemo-dynamically stable were excluded. SPSS version 23 was used for data analysis keeping p-value <0.05 as significant.Results: Among 136 patients with mean age 32.33±11.23 years, 120(88.2%) were males. 122(89.7%) of the patients were admitted due to liver trauma of blunt variety while 14(10%) with penetrating liver injury. Overall mean duration of hospital stay was 13.1±4.58 days. 41(30%) patients reported intra-abdominal sepsis, followed by recurrent hemorrhage in 33(24%) of patients while in 22(16%) of patients, biliary leakage was observed. An insignificant difference persisted in either surgical intervention in terms of the complication rates.Conclusions: Higher complication rates were observed in patients with peri-hepatic packing, however outcome of both surgical techniques in terms of complication rates were found to be insignificant. Further studies are needed to shed light upon the findings or this study.

Outcomes of surgical management of liver trauma at LUMHS Jamshoro

Background: Mortality from liver trauma remains high despite surgical advancements. The objective of this study was to determine the outcomes of surgical management of liver trauma at LUMHS Jamshoro.Methods: A cross-sectional observational study using non-probability convenient sampling technique was done at department of surgery LUMHS Jamshoro for 18 months. Patients between 14 to 50 years with blunt hepatic trauma presenting to the E.R. within 04 hours of incident were included and hepatic trauma patients managed conservatively, having multiple trauma and hemo-dynamically stable were excluded. SPSS version 20 was used for data analysis with mean and SD reported for qualitative and frequency and percentages for quantitative variables. Chi-square test was applied keeping p-value of < 0.05 as statistically significant.Results: From 136 patients with mean age of 32.33±1.23 years, 120 (88%) were male. 122 (89.7%) were admitted due to blunt trauma and 14 (10.3%) due to penetrating trauma. Peri-hepatic packing was performed in 116 (85.2%) and suture hepatorrhaphy in 20 (14.8%). Intra-abdominal sepsis was seen in 41 (30%) of patients followed by recurrent hemorrhage in 33 (24%) while 30 (22%) of patients died. Substantial differences (p < 0.001) were observed in terms of surgical technique and each of the complication i.e. sepsis, bile leak and recurrent hemorrhage among alive patientsConclusions: The most common post-operative complication was intra-abdominal sepsis followed by recurrent haemorrhage and bile leak. Significant mortality was observed in between type of complication as well as surgical technique.

Liver Trauma Diagnosis and Surgical Management

Background: Liver trauma is one of the most common affected organs in blunt abdominal trauma. It is associatedwith a high rate of morbidity and mortality. Therefore, choosing the best modality for diagnosis and managingsuch high-risk patients is crucial. Objectives: In this study, we aim to review the literature focused on mechanismof liver trauma, pathophysiology, risk factors, diagnosis, and management with a focus on surgical approach.Methodology: PubMed database was used for articles selection using the following keywords: liver injury, andits management, and evaluation. Conclusion: Management of liver trauma patients depends on their status duringthe general assessment of the case. In hemodynamically unstable patients and those with gun-shot wounds, thefirst line is surgery. However, non-operative management remains the mainstay of therapy in blunt liver injury.The main rule dictating this decision is hemodynamic stability. Certain factors increase the risk of failedconservative therapy, and these should alert the surgeon to the possibility of conversion to the surgicalintervention.

Posttraumatic biloma formation: diagnosis and management

One of the rarest complications of the hepatic trauma is a biloma, defined as an abnormal bile collection outside the biliary tree, with intra or extrahepatic localization. Patients with biloma do not present with specific clinical features, which demands a challenging radiological diagnosis. In this report, we present a case of biloma due to blunt hepatic trauma, in which the patient experienced a changing symptomatic spectrum after surgery and had an interesting radiological investigation. The clinical course, imaging features, and management of this case are discussed. (AU)

Profils clinico-évolutifs de 45 patients opérés pour traumatisme hépatique / Clinical-evolutionary profiles of 45 patients operated for liver trauma

Introduction - La prise en charge des traumatismes hépatiques a considérablement évolué ces dernières années et les attitudes thérapeutiques sont de plus en plus conservatrices. L'objectif de notre étude était d'identifier les différents critères diagnostiques ayant posé l'indication opératoire ainsi que les aspects thérapeutiques et évolutifs des patients opérés pour lésion hépatique faisant suite à un traumatisme. Matériel et méthode - Il s'agit d'une étude descriptive rétrospective qui s'étale sur 4 années (du 01/01/2016 au 31/12/2019) qui a colligé 127 cas de traumatismes de l'abdomen (contusions et plaies pénétrantes de l'abdomen) opérés au service des urgences chirurgicales du CHU d'Oran - Algérie. Sur un total de 127 laparotomies effectuées pour traumatisme de l'abdomen, le foie était atteint dans 45 cas. Résultats - La moyenne d'âge des opérés était de 30,63 ans avec des extrêmes de 16 à 89. On note une nette prédominance masculine avec 89% des cas. Les traumatismes fermés de l'abdomen (TFA) sont retrouvés dans 64,4% des cas et les plaies pénétrantes de l'abdomen dans 35,6% des cas. L'instabilité hémodynamique d'emblée avec administration de supports hémodynamiques était présente dans 37,7 % des cas et ayant nécessité une exploration chirurgicale. Les lésions extra abdominales associées étaient fréquentes avec 26,6% de cas de traumatismes crâniens, 17,7% de cas d'hémopneumothorax, un cas d'hémo-médiastin, 11,1% de cas de traumatisme du rachis et 17,7% de cas de fractures du fémur. Discussion - La persistance de l'instabilité hémodynamique malgré les mesures de remplissage conditionne la prise de décision du traitement chirurgical. Tout retard à la réalisation de la laparotomie représente une perte de chance et impacte le taux de mortalité. Conclusion - Le pronostic des lésions hépatiques au cours des traumatismes de l'abdomen diffère selon la gravité lésionnelle et son caractère hémorragique. L'existence d'un choc hémorragique et l'association de lésions intra et/ou extra abdominales conditionnent le pronostic de ce type de traumatisme.

Introduction - The management of hepatic trauma has evolved considerably in recent years and therapeutic attitudes are becoming more and more conservative. The objective of our study was to identify the different diagnostic criteria that established the operative indication as well as the therapeutic and evolutionary aspects of patients operated on for liver injury following a trauma. Results - The average age of operated patients was 30.63 years with extremes from 16 to 89. There is a clear male predominance with 89% of cases. Closed trauma to the abdomen (ASD) was found in 64.4% of cases and penetrating wounds in the abdomen in 35.6% of cases. Hemodynamic instability from the outset with administration of hemodynamic supports was present in 37.7% of the cases and required surgical exploration. Associated extra abdominal lesions were frequent with 26.6% of cases of head trauma, 17.7% of cases of hemopneumothorax, one case of hemo-mediastinum, 11.1% of cases of trauma to the spine and 17.7 % of femur fractures. Discussion - The persistence of hemodynamic instability despite the filling measures conditions the decision to take surgical treatment. Any delay in performing the laparotomy represents a loss of luck and impacts the mortality rate. Conclusion - The prognosis for liver damage during trauma to the abdomen differs depending on the severity of the injury and its haemorrhagic nature. The existence of a hemorrhagic shock and the association of intra and / or extra abdominal lesions condition the prognosis of this type of trauma.

Tratamiento no operatorio en traumatismo cerrado de abdomen en el Hospital Municipal Dr. Leónidas Lucero: nuestra experiencia / Nonoperative treatment of blunt abdominal trauma at the Municipal Hospital Dr. Leonidas Lucero

Antecedentes: existe una tendencia creciente hacia el tratamiento no operatorio (TNO) en el trauma-tismo cerrado de abdomen (TCA), en pacientes estables hemodinámicamente, sin abdomen agudo peritoneal. No hay consenso sobre: momento de inicio de la dieta, deambulación, proflaxis anttrom-bótica, seguimiento y control, y reinicio de la actividad fisica. Objetivo: describir los resultados del manejo de pacientes con TCA, admitidos en nuestro Servicio de Cirugía. Material y métodos: incluimos pacientes mayores de 15 años internados desde enero de 2011 hasta septembre de 2014, con TCA sometidos a TNO. Se recabaron las variables analizadas de una base de datos electrónica de fichaje prospectivo. Resultados: del total de pacientes 31 TCA, 15 se intervinieron quirúrgicamente al ingreso y 16 pacientes se someteron a TNO. El 73,3% presentó lesiones asociadas extraabdominales. A todos se les realizó ecografa abdominal, donde se encontró líquido libre en el 80% y se identificó lesión de órgano sólido en el 60%. En 11 pacientes se realizó TC confrmando lesión objetivada en la ecografa e iden-tificando 3 no evidenciadas previamente. Se diagnosticaron 5 traumatismos hepáticos, 2 asociados a traumatismo renal; 6 traumatismos esplénicos, 4 renales y un paciente con hemoperitoneo. En 7 pacientes se utlizó tromboproflaxis. El TNO fue exitoso en todos los casos. Tres pacientes presentaron complicaciones. No se registró mortalidad. Conclusiones: los pacientes sometidos a TNO en nuestro hospital fueron tratados exitosamente en todos los casos. No se registró mortalidad en la serie analizada.

Background: there is a growing trend towards non-operative management (NOM) in the blunt abdominal trauma (BAT) in hemodynamically stable patentis without peritoneal acute abdomen. However, there is stll no consensus on: tme of onset of diet, ambulaton, antthrombotic prophylaxis, follow-up, and resumpton of physical activity. Objective: to describe the management of patentis with BAT, admited to the Department of Surgery of our insttuton. Material and methods: we included patentis age 15 and older admited from January 2011 to Sept-ember 2014, with BAT who underwent NOM. The variables analyzed were collected from an electronic database of prospective signing. Resultis: 31 TCA were identifed, 15 were operated on at admission and 16 patentis underwent NOM. 75% were men; mean age of 29 (range 18-58). In 100% abdominal ultrasound was performed, finding free fuid in 80% and identifying organ damage in 60% of the total. In 11 patentis CT scan was perfor-med confrming identifed organ injury on ultrasound and diagnosing three not evidenced previously. We included 5 patentis with liver trauma, 2 associated renal trauma; 6 splenic trauma; 4 kidney trauma and 1 patent with hemoperitoneum. Thromboprophylaxis was used in 7 patentis. NOM was successful in all cases. Three patentis presented complicatons, not associated with trauma. No mortality was recorded. Conclusions: patentis undergoing NOT in our hospital were successfully treated in all cases. There were no complicatons associated with management of the NOT. No mortality was recorded.

Diagnosis and treatment of grade Ⅴ liver trauma combined with hilar bile duct transection injury / 中华消化外科杂志

According to the Organ Injury Scale Grading System of the American Association for the Surgery of Trauma (AAST-OIS),grade Ⅴ liver trauma is always complicated with retrohepatic inferior vena cava injury and less bile duct injury,and it is extremely severe and difficult to be treated.Timely and fast judgment,emergent exploration and effective repair of the injured bile duct are the key points for the treatment of bile duct injury.One patient with grade Ⅴ liver trauma combined with hilar bile duct transection injury was admitted to the Fuzhou General Hospital of Nanjing Military Command on August 30,2013.The rupture of left and right liver junction was detected by preoperative multidisciplinary consultation and emergency open surgery at admission hour 4.There was left and right hepatic duct bifurcation rupture at the first hepatic hilum.Non-functional liver tissues were excised.Breakage left and middle hepatic vein were sutured by polymer suture line.Liver traumatic bleeding and bile duct were sutured and ligatured individually.Left and right hepatic duct laceration was sutured by 6-0 PDS suture line.A hole in the stomach wall was opened fist,and then most part of the gastric contents was removed and the gastric wall was reparied by stapler.Patient received the postoperative symptomatic treatment with gradual recovery,and was discharged from hospital at admission day 26.The patient was readmitted to the hospital at 31 days of discharge due to outflow of purulent fluid from abdominal cavity drainage tube,and was treated by ceftriaxone sodium and tazobactam sodium according to the results of drug sensitive test and continuous peritoneal lavage.The abdominal cavity drainage tube and left and right hepatic duct drainage tube were removed at postoperative day 83.The patient was discharged from hospital at readmission day 28,and was followed up till December 2014 with good recovery and without complication.

Clinical efficacy of interventional treatment in blunt liver trauma (in 32 cases report) / 国际外科学杂志

Objective Compared with surgical operation,to investigate the clinical efficacy and advantages of interventional treatment in blunt liver traum.Methods 32 patients from July 2010 to October 2012,who were diagnosed as blunt liver trauma,received super selective hepatic artery embolization in Chinese People's Liberation Army in 98th Hospital.Another 27 ones received operation at the same time in Peolies's Liberation Army 98th (AAST grade Ⅱ to Ⅳ).Retrospective analysis of related cases was presented.The results were analyzed by t test.Results All of 32 patients that received super selective hepatic artery embolization were stanched bleeding successfully.All patients were followed up for 3 to 18 months,the mean follow-up time was 10 months,with no severe complications occurred or no lost cases.Conclusions Compared with surgical operation,interventional treatment had advantage that included eliable hemostasis,less operation time,minimally invasive and less hospitalization time.Interventional treatment had good effects on blunt liver trauma which were AAST grade Ⅱ to Ⅲ.

Expression of Hedgehog Signaling Pathway after Different Liver Damage / 中国中医药信息杂志

Objective To preliminarily explore the expresssion of the Hedgehog signaling pathway (HH) after different liver trauma, and provide basis for the blockaded effection of HH and the potentiality of new traditional Chinese medicine exploition. Methods After adaptive breeding for one week, a cohort of 140 male SPF Fisher 344 rats were randomly divided into Retrorsine injection (R) indicated the toxical of chemical damage of liver, partial hepatectomy (PH) indicated the acute liver trauma, retrorsine/partial hepatectomy (R/PH) for the hepatic stem cells regeneration, and normal control (N) groups. The administering of retrorsine or placebo, and PH or sham operation were performed as Gordon’s matheds. RT-PCR, real-time PCR and immunohistochemistry were performed to detect the expression of the constituents related to HH after liver damage. Results RT-PCR demonstrated that the mRNA expression of IHH, PTCH, Smo, Gli1, Gli2, Gli3 were all activated in primary liver cells after different kinds of liver damage. The results of real-time PCR analysis indicated an interaction effect existing between the treatment and the time in 3 Hedgehog-related constituents (signaling molecule IHH, indicators of the HH activation Ptc, Gli1) (all P<0.001). The protein expression of PTCH in liver tissue section was confirmed by immunohistochemistry, which differed in the duration in PH and R/PH groups. Conclusion The HH was abnormally activated during the different liver trauma. It’s maybe an important signaling pathway during the liver’s reaction after damage.

The advances and trends in the management of liver trauma / 中华肝胆外科杂志

Liver is the largest parenchymal organ in human body and the most commonly injured organ in abdomen,accounting for 20％ of all abdominal traumas.Traumatic liver rupture can bring about intra-abdominal hemorrhage,peritoneal irritation and hemorrhagic shock.If the liver trauma takes place in peri-hepatic veins or multiple-organ injury,mortality rate is increased.In recent years,with more studies on liver injury and the rapid development of modern surgical techniques as well as the equipments,the strategies and means of liver trauma treatment have greatly changed.These changes include liver trauma cases with nonoperative treatment have been increased gradually,the improvement of damage control packing,the application of fast-track surgery concept in liver trauma,etc.

Characteristics and choice of surgical treatments for severe liver trauma / 中华肝胆外科杂志

Objective To analyze characteristics of severe liver trauma and efficacy of different surgical procedures. Methods Clinical data of 109 patients with severe liver trauma treated in the recent 10 years were retrospectively analyzed. Debriding suture was performed in 32 patients, gauze tamponade in 5, debridement hepatectomy in 59 and anatomical hepatectomy in 13 patients. Results In all the 109 patients, 92 were cured and 17 died. The dead patients included 3 with grade Ⅲ trauma,9 with grade Ⅳ trauma, and 5 with grade V trauma. Among the dead patients, there were 3 patients with simple liver injury (17.6%) and 14 with associated injury (82.4%). Conclusion Right hepatic serious damage is the main type of severe liver trauma and is always complicated with associated injury and needs emergency treatment. Application of the most appropriate surgical approach according to the traumatic condition is important to promote the successful rate of treatment.

Pseudoaneurisma da artéria hepática: relato de dois casos / Hepatic artery pseudoaneurysm: report on two cases

O pseudoaneurisma de artéria hepática é complicação rara do trauma abdominal fechado. Ocorre quando há ruptura da parede arterial com extravasamento de sangue para um hematoma intraparenquimatoso, onde uma cápsula de tecido fibroso é formada. Relatam-se dois casos de pseudoaneurisma de artéria hepática pós-trauma. Achados por tomografia computadorizada e arteriografia confirmaram o diagnóstico. Em ambos os casos, o tratamento consistiu em embolização. Neste relato de caso, enfatiza-se a importância desse diagnóstico porque mesmo os pseudoaneurismas assintomáticos devem ser tratados. Há elevado risco de ruptura, associada a elevada morbidade.

Hepatic artery pseudoaneurysm is a rare complication of blunt abdominal trauma. It originates from a disruption of arterial wall with extravasation of blood and forming of an intraparenchymal hematoma, where a fibrous tissue capsule is formed. This paper aims at describing two cases studies of post-traumatic hepatic artery pseudoaneurysm. Computed tomography and arteriography findings confirmed the diagnosis. Treatment on both patients consisted in embolization. This case report emphasizes the importance of this diagnosis because even asymptomatic pseudoaneurysms should be treated. They have a high risk of rupture, associated with high morbidity.

Clinical Analysis on Patients with Traumatic Liver Injury

PURPOSE: The liver is one of the most commonly injured organs in abdominal trauma. Surgery has played a major role in treating traumatic liver injury. Recently, it was reported that conservative treatment could be the first-line management for hemodynamically stable patients without combined intraabdominal surgical problems. The aim of this study was to examine the prognostic factors in traumatic liver injury. METHODS: The medical records of 41 patients who were treated for traumatic liver injury at Seoul National University Bundang Hospital from March 2003 to October 2007 were retrospectively reviewed. RESULTS: Among the 41 patients, 34 cases (82.9%) were managed nonsurgically, and 7 cases (17.1%) were managed surgically. Out of the 5 (12.2%) mortalities, 2 were encountered in those who underwent surgery, and 3 were encountered in those who were treated nonsurgically. Univariate analysis showed that the initial systolic blood pressure, the initial hemoglobin level, and the grade of liver injury were significant prognostic factors for survival. Multivariate analysis indicated that initial low systolic blood pressure was the only independent risk factor. CONCLUSION: Patients with unstable vital signs initially have a poor prognosis. Aggressive management might be helpful for improving the survival rate in these patients.

Spiral CT Manifestations of Blunt Liver Trauma / 中国普外基础与临床杂志

Objective To investigate the spectrum of spiral CT imaging findings of blunt liver trauma.Methods Clinical data of 17 patients with blunt liver trauma were retrospectively collected. All patients underwent standardized spiral CT examination of the upper abdomen, which include plain scan, arterial phase and portal venous phase acquisition. The morphology, density and integrity of liver parenchyma and intrahepatic venous structures were carefully observed, as well as regions of porta hepatis, peritoneal cavity and retroperitoneal space.Results Twelve cases (70.6%) developed hepatic parenchymal laceration. There were 9 cases (52.9%) of traumatic hematoma, among which 5 were intraparenchymal and 4 were subcapsular. One case (5.9%) showed active bleeding within an intrahepatic hematoma, while two cases (11.8%) had injury (laceration) of hepatic veins. There were 7 patients (41.2%) who demonstrated the so-called “halo sign” around the intrahepatic portal branches. Thirteen patients were associated with peritoneal fluid (blood) collection, 3 with hematoma or hemorrhage of the right adrenal gland, 8 with plural effusion and 3 cases with rib fractures of right lower chest. Conclusion CT imaging findings of blunt liver trauma include parenchymal laceration, intraparenchymal and /or subcapsular hematomas, active hemorrhage, and tear of hepatic veins. Plain CT scan and contrast-enhanced dual-phase acquisition is very important for the comprehensive evaluation of patients with blunt liver trauma.

Prognostic Factors in Traumatic Liver Injury

PURPOSE: The liver is one of the most commonly injured organs in abdominal trauma. Surgery has played a major role in treating traumatic liver injury. Recently, it was reported that conservative treatment could be the first-line management for the hemodynamically stable patients without combined intraabdominal surgical problems. However, the risk of mortality remains high in this type of injury. The aim of this study was to examine the prognostic factors intraumatic liver injury. METHODS: The medical records of 132 patients who were treated for traumatic liver injury at Ewha Womans University, Mokdong Hospital from March 1994 to June 2001 were reviewed. The initial systolic blood pressure, prehospital transportation time, the number of associated organ injury, the level of initial hemoglobin, the grade of liver injury, the treatment method, the preoperative preparation time, the amount of estimated intraoperative blood loss, and the amount of intraoperative transfusion were analyzed with a univariate analysis and a multivariate analysis. RESULTS: Among the 132 patients, 76 cases (57.6%) were managed non-surgically, and 56 cases (42.4%) underwent surgery. Out of the 17 cases (12.9%) of mortality, 14 (82.4%) were encountered in those who underwent surgery and 3 cases (17.6%) were encountered in those who were treated nonsurgically. Univariate analysis revealed that the initial systolic blood pressure, prehospital transportation time, initial hemoglobin level, the number of associated organ injury, the surgical treatment, the grade of liver injury and the amount of intraoperative transfusion were significant prognostic factors for the survival. Multivariate analysis indicated that the initial systolic blood pressure and the extent of associated organ injury were the independent prognostic factors. CONCLUSION: The patients with unstable vital signs initially and multiple associated organ injuries have a poor prognosis. Aggressive management might be helpful for improving the survival rate in these patients.

Liver trauma and wounds: classification and severity, diagnosis and treatment (198 cases treated from 1990-1995

A retrospective study was conducted concerning the analysis of data. Trauma were classified according to Moore'standard and the locations of the wound were identified according to T«n ThÊt Tïng. To diagnose, ultrason was used commonly. Most of cases were treated surgically and the technique were described in details. Mortality was 13.13% and the complications comprised of hemorrhagia, under diaphragm abscess, bile perforation, pleuresia, infection of the wound and renal failure

Treatment of Retrohepatic Caval Injury using Total Hepatic Vascular Isolation and Venovenous Bypass / 한국간담췌외과학회지

Retrohepatic caval injuries are a difficult problem to surgeons as its mortality approaching 50~80%. Several bypass techniques was advocated to reduce operative bleeding and to improve the prognosis of the traumatized patients. We successfully managed a case of retro hepatic caval injury using venovenous bypass and total hepatic vascular isolation. A 28 year old female patients was admitted to Cheju Medical Center injured in a traffic accident. At exploration, a retrohepatic caval injury was suspected. So patient was emergently transferred to Seoul National University Hospital, after gauze packing. On arrival, vital signs were stable. Reexploration was undertaken. There was gush out of blood from retrohepatic space. After clamping suprahepatic and infrahepatic vena cava, venovenous bypass was introduced to left axillary vein and left femoral vein using Biomedicus pump. Systemic heparinization was not used. Avulsion between vena cava and common trunk of left and middle hepatic veins was repaired and left hepatectomy was done. Gauze packing was done due to ongoing oozing by coagulopathy from massive transfusion. Total venovenous bypass time was 30 min. On 10th operative day, reexploration was undertaken to assure hemostasis and to remove packed gauze. On 54th postoperative day patient discharged without any morbidity.

Delayed Complications of Hepatic Rupture:Imaging Diagnosis and Treatment / 实用放射学杂志

Objective To retrospectively evaluate the MR and CT features of delayed complications of hepatic rupture and clinical management.Methods Delayed complications developed in 8 of 20 patients with hepatic rupture 1～3 weeks after surgery.7 patients were managed with PTD and one with laparotomy.MRI and CT were followed-up before and after treatment.Results Delayed complications included 3 bilomas,3 recurrent bleedings and 2 abscess,which appeared characteristic bi-directional changes of the signal intensity on T 1-weighted image and were non-specific on T 2-weighted image(hyperintense)and CT (low-density).Conclusion T 1-weighted images appeared to be more effective than T 2-weighted images and CT in the differentiation of delayed complications from subacute intrahepatic hematoma.Followed-up MRI and CT are needed in patients with deeptype hepatic rupture in the first month after injury.PTD and laparotomy are helpful in management of biloma and abscess and nonuseful in patient with inactive recurrent bleeding.

Self—Made Fibrin Glue to treat Local Liver Trauma of Anticoagulated Rabbit / 中华创伤杂志

This experiment aims at exploring the prepared method of self—made fibrin glue (SMFG), its loeal hemostatic ways, curative effects and tissue reactions in the model of anticoagulated rabbits, to offer a experimental basis for clinical application. SMFG was made by a combination of swine thrombin and pyknotic fibrinogen extracted from fresh frozen plasma through double freezing, unfreezing, centrifugation—precipitation. Using SMFG in various liver wounds, local wounds were observed by gross, optical microscopic and electron microscopic ways. The results showed that SMFG had good hemostatic capacity in the model of heparinized liver trauma, without serious tissue reactions and cellular toxicity. It could satisfy the need of hemostasis in liver trauma, at the same time, it possesses some superiority of simple, safety and cheapness, and could be the best ideal alterative of commercial fibrin glue.