Dealing with liver trauma Leppäniemi, AK
Trauma (London, England),
04/2011, Letnik:
13, Številka:
2
Journal Article
Recenzirano
Bleeding from a traumatic liver injury often ceases spontaneously, which is the basis for non-operative management, currently used in about 80% of patients with blunt hepatic trauma. The selection of ...patients for non-operative management is based on the assessment of haemodynamic stability and the presence of associated organ injuries requiring surgical repair. In patients requiring surgery, definitive repair is preferred in stable patients with normal tissue perfusion and temperature, and ranges from the use of local haemostats and sutures to non-anatomic hepatic resection and direct repair of juxtahepatic venous injuries. In the most seriously injured patients with major bleeding causing severe physiological derangement, a damage control strategy including perihepatic packing is the treatment method of choice. Adjunctive procedures including hepatic angiography and embolisation are often needed in high-grade liver injuries whether undergoing surgical or non-operative management. The multidisciplinary approach also includes procedures performed for biliary complications, such as percutaneous or endoscopic drainage of bile leaks.
Missed diaphragmatic perforation caused by penetrating trauma can lead to subsequent strangulation of a hollow viscus, which has prompted the use of invasive diagnostic procedures to exclude occult ...diaphragmatic injuries in asymptomatic, high-risk patients. The objective of this study was to determine the incidence of occult diaphragmatic injuries caused by stab wounds of the lower chest and upper abdomen, and to examine the natural history and consequences of missed diaphragmatic injuries.
On the basis of patient data from two previous randomized studies from our institution, a retrospective analysis was performed on 97 patients treated for anterior stab wounds located between the nipple line, the umbilical level, and the posterior axillary lines not having indications for immediate surgical exploration. The patients were divided into two groups on the basis of their initial randomized management (open or laparoscopic exploration vs. expectant observation).
In the exploration group (n = 47), four diaphragmatic injuries (9%) were detected (three left-sided and one right-sided). Excluding patients with associated injuries requiring surgical repair, the incidence of occult diaphragmatic injuries was 3 of 43 (7%). In the observation group (n = 50), there were two patients (4%) with delayed presentation of missed left-sided diaphragmatic injury 2 and 23 months later, respectively. Both injuries resulted from stab wounds of the left flank and presented with herniation of the stomach or small bowel and colon. The overall incidence of occult diaphragmatic injuries in left-sided thoracoabdominal stab wounds was 4 of 24 (17%), and was much lower after stab wounds of left epigastrium (0%), right lower chest (0%), and right epigastrium (4%).
In asymptomatic patients with anterior or flank stab wounds of the lower chest or upper abdominal area, the risk of an occult diaphragmatic injury is approximately 7% which, if undetected, is associated with a high risk of subsequent hollow viscus herniation. Exclusion of an occult diaphragmatic injury with invasive diagnostic methods, such as laparoscopy or thoracoscopy, should be considered at least in left-sided stab wounds of the lower chest.
In a collective analysis of 11 reports with a total of 355 blunt abdominal trauma patients, the sensitivity and specificity of diagnostic laparoscopy in predicting the eventual need for therapeutic ...laparotomy were 94% and 98%, respectively, with an overall accuracy of 97%. Although fairly accurate and safe (morbidity rate about 1.2%), the invasiveness, cost and time-consuming nature of diagnostic laparoscopy limit its routine use in trauma patients. It could, however, be useful in selecting patients with minor or nonbleeding injuries for nonoperative management after positive peritoneal lavage or computed tomography, and in excluding occult bowel and diaphragmatic injuries in patients with equivocal findings, thereby reducing the number of unnecessary laparotomies. With the improvement of laparoscopic techniques and instrumentation, more injuries can probably be managed laparoscopically with all the benefits observed with the shift from open to laparoscopic procedures in other patient populations, and it is likely that laparoscopy will find its place as an integral part of evaluating and treating patients with blunt abdominal trauma. At present, however, laparoscopy cannot be recommended as a routine tool for evaluating patients with blunt abdominal trauma, except in controlled clinical trials.
Introduction: The purpose of this study is to present our experience in the management of patients with abdominal aortic aneurysms (AaA) and aneurysms in both the internal iliac arteries (IIA) at the ...same time. Methods: Between 2000 and 2005, a series of 13 patients with AAA and also aneurysms in both the IIA, were treated in our clinic. They were all men with a mean age of 74 years. The size of the IIA aneurysms (IIAA) ranged from 2.0 to 8.0 cm (mean, 3.4 cm). All patients underwent an aneurysmatectomy of the AAA and placement of a prosthetic bifurcated aorto-biiliac or-bifemoral bypass, by a transperitoneal approach. The management of one of the two IIAA was the aneurysmatectomy and the direct revascularization of the healthy peripheral portion of the remaining IIA with the ipsilateral leg of the aorto-biiliac bypass. The other IIAA was treated with proximal ligation of its neck and aneurys-morraphy.
Results: No patient died during the first 30 postoperative days. Morbidity was about 7.7% (one patient suffered from 'trash foot', which was treated successfully with conservative measures). Finally, the mean stay in hospital was 7 days and no patient clinically presented symptoms of pelvic or colonic ischaemia.
Conclusions: Simultaneous treatment of AAA and bilateral IIA aneurysms is a technically difficult, but safe procedure, if it is performed meticulously. Revascularization of at least one internal iliac artery is strongly recommended in order to avoid dangerous complications, such as pelvic or colonic ischaemia.
Background: Hydrocortisone (HC) has been reported to rapidly improve hemodynamics and reduce the time to vasopressor cessation in septic shock, but none has focused on this effect in acute ...pancreatitis. We therefore performed a study to assess the effects of hydrocortisone on catecholamine‐dependent shock among patients with severe acute pancreatitis.
Methods: A retrospective, case‐controlled study among 10 patients with severe acute pancreatitis and HC treatment for catecholamine‐dependent shock was performed. The control group comprised 11 conventionally treated patients with the same severity of pancreatitis and circulatory shock according to the norepinephrine support required. In focus were the first 48 h from the start of HC administration in the HC group and from the reference point in the control group, respectively. The reference point for the control group was the time point at which doses of norepinephrine exceeded 0.3 µg kg−1 min−1.
Results: Patients in the HC group were weaned off norepinephrine in a significantly shorter time (61 h in HC group vs. 141 h, P = 0.016). The HC group received significantly less norepinephrine (area under curve of norepinephrine dose, P = 0.041). The reduction in norepinephrine dose was comparable at 24 h, being −0.051 (−0.208–0.022) µg kg−1 min−1 in the HC group vs. −0.026 (−0.150–0.030) µg kg−1 min−1 in the controls (P = 0.307), and at 48 h with respective figures of −0.206 (−0.317 to −0.102) µg kg−1 min−1 and −0.103 (−0.178–0.029) µg kg−1 min−1 (P = 0.072), from the start of HC administration.
Conclusion: According to our data it seems reasonable to formulate a hypothesis that low doses of HC shorten the time to vasopressor cessation and rapidly reduce the need for norepinephrine support in patients with shock associated with severe acute pancreatitis without sepsis.
In connection with the Asian tsunami disaster on December 26, 2004, a specially equipped Finnair B-757 airplane capable of evacuating badly injured patients was remodeled into an ambulance airplane. ...The vehicle could take up to 22 severely injured or ill patients and intensive care and limited surgical procedures could be provided to the patients. The plane was manned with a civilian medical team of 37 physicians and nurses. The plane left for Thailand to evacuate the most severely injured Finnish citizens within 10 hours of the evacuation decision. A total of 14 patients including 4 critically ill (two on ventilator) were transferred to Helsinki within 32 hours of takeoff. The medical team included a general, an orthopedic and a plastic surgeon. Soft tissue wounds, some of them severely infected, were the most common injuries, followed by extremity fractures and head injuries. The surgical procedures that were performed midair included wound surgery, to remove necrotic tissue, and external fixation and fasciotomy for a lower extremity fracture. The facilities under these circumstances would allow performing life-saving procedures to maintain airway and breathing, and surgical procedures of the soft tissues, extremity and pelvic fractures. Cavitary surgery would require additional equipment and resources.
Significant visceral edema associated with massive fluid resuscitation, paralytic ileus and formation of pancreatic ascites in patients with severe acute pancreatitis (SAP) can lead to abdominal ...compartment syndrome (ACS) that can contribute to the early development of multiple organ dysfunction syndrome (MODS), especially in the early stages of the disease. The prevalence of intra-abdominal hypertension (IAH) in SAP is about 40% and a manifest ACS occurs in about 10% of the patients warranting close monitoring of intra-abdominal pressure (IAP) in all patients with the severe form of the disease. Although nonsurgical management utilizing percutaneous drainage of ascites or continuous hemodiafiltration may decrease IAP, most patients require decompressive laparostomy and temporary abdominal closure. The primary aim in managing the ensuing open abdomen is delayed fascial closure during initial hospitalization. On many occasions a planned hernia approach, either with early skin grafting over the exposed bowel or managing the ASC primarily with a subcutaneous linea alba fasciotomy, is the only available option. The development of ACS in patients with SAP seems to be associated with increased mortality.
To review the clinical features and results of surgical treatment of renal artery aneurysms from two large centers.
A retrospective analysis of 21 hypertensive patients with renal artery aneurysms ...operated in two centers during a 24-year period was performed.
The presenting symptom was subcostal or flank pain in 8 (38%) and hematuria in 5 (24%) cases. A ring-like calcification was seen on plain X-ray in 6 (29%) cases. All patients were evaluated with renal angiography showing a saccular aneurysm in 13 cases (62%), fusiform in 5 (24%) and dissecting in 3 (14%) cases. All saccular aneurysms were treated with resection followed by reconstruction with vein patch in 10 cases, and with and end-to-end anastomosis in 3 cases. All fusiform and dissecting aneurysms were managed with resection and reconstruction using aortorenal bypass. There was no hospital mortality or significant morbidity. During a follow-up ranging from 6 months to 23 years, there was definite cure of hypertension in 14 (67%) patients and improvement of blood pressure levels in 4 (19%) patients. Three patients continued to be hypertensive.
Surgery for renal artery aneurysms can be accomplished with good results and should be considered for patients with aneurysms greater than 2 cm, for aneurysms causing renovascular hypertension, significant stenosis, flank pain, or hematuria, for dissecting, expanding and thrombotic aneurysms, and in women with a potential for pregnancy. However, all aneurysms cannot and should not be treated surgically.
In the era of worldwide organ shortage for liver transplantation, every effort must be made to use all potentially available livers. In this case report, we present a liver graft with abnormal left ...hepatic vein draining directly to the right atrium of the donor heart, which was discovered during back table preparation of a liver graft. The vein was reconstructed and the subsequent liver transplantation was successful. Five years after the transplantation, no signs of complications have emerged.
