EL-MINIA MED., BULL., VOL. 17, NO. 1, JAN., 2006
Aly et al
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OUTCOME OF ANATOMIC HEPATIC RESECTION IN PATIENTS WITH
SEVERE LIVER TRAUMA
By
Moatasem M. Aly, Zaghloul N.M., Tohamy A. T., Tarik Abdel Azeez Ahmed,
Khaled M. Mahran, Abou-Bakr Mohei El-Din.
Department of Surgery, El-Minia Faculty of Medicine
ABSTRACT:
Background: The liver is the organ most commonly injured during abdominal trauma.
The use of anatomic resection for liver trauma is advocated a conservative surgical
approach when operative intervention is required.
Objective: To assess the results of anatomic liver resection for severe liver trauma.
Patients and Methods: During the period 2003 to 2005, among 100 patients with
abdominal trauma and different types of liver injury admitted at El-Minia University
Hospital, 20 patients had severe liver injuries and underwent anatomical hepatic resection.
All patients had grade IV injury. Pringle maneuver was applied to control hemorrhage.
The resections performed included, bi-segmentectomy of segment 6 and segment 7 (n =
8), left lateral segment resection (n = 6), right lobectomy (n = 4) and segmental resection
of segment 6 (n = 2).
Results: The mortality rate was 5%, as one patient died postoperatively due to major
hepatic vein injury, while the morbidity rate was 25%. Postoperatively, there was a
statistically significant improvement in hemodynamic status. One month after surgery,
there was statistically non significant minimal change in liver functions.
Conclusion: An anatomic resection of the liver for trauma in appropriate situations may
be a useful, safe procedure today.
KEYWORDS:
Anatomic resection
Severe liver trauma.
operative measures to the use of
extensive surgical techniques3. Surgical
strategy for liver trauma is based on the
extent and localization of the injury, the
patient's overall status and severity of
associated injuries. Resection of the
injured parenchyma is indicated when
laceration of a hepatic lobe occurs4.
Progress of diagnostic human’s liver
imaging (ultrasound,
computerized
tomography, magnetic nuclear resonance,
etc.) stimulates development of modern
liver surgery. Therefore, before and
during the operation, surgeons and
INTRODUCTION:
The liver is the organ most
commonly injured during abdominal
trauma1. Liver trauma is the main cause
of death in patients suffering abdominal
injury, and remains an unresolved
problem, especially in its most severe
forms. Liver trauma, the main cause of
death in patients suffering abdominal
injury, remains an unresolved problem,
especially in its most severe forms2.
Management of hepatic trauma
has been refined and ranges from non-
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radiologists can determine the site and
extent of liver damage, its relationship
with blood vessels and ascertain which
part of the liver should be resected5.
PATIENTS AND METHODS:
During the period 2003 to 2005,
among 100 patients with abdominal
trauma and different types of liver injury
admitted at
El-Minia University
Hospital, 20 patients had severe liver
injuries and underwent anatomical
hepatic resection. The admission hemodynamic data and physical examination
findings included the initial emergency
evaluation based on the Glasgow Coma
Scale (GCS), systolic blood pressure,
pulse, and the presence of abdominal
pain and tenderness. Hemodynamically
stable patients were submitted for
abdominal ultrasound, CT abdomen, and
laboratory investigation particularly
hematocrite
measurement.
Hepatic
injury was graded either operatively or
by CT according to the Hepatic Injury
Scale established by the American
Association for the Surgery of Trauma13.
All patients had grade IV injury in
whom there was an evidence of ruptured
intraparenchymal hematoma with active
bleeding and parenchymal disruption
involving 25–50% of the hepatic lobe.
A single, worldwide-accepted
classification of the liver still does not
exist. Clinicians use Couinaud’s
segmentation system for the smallest
parts of the liver. It is important to
localize small lesions before a segmentectomy with preservation of undamaged
liver parenchyma, for example, in a
setting of cirrhosis. However, some
opine that Bismuth’s classification offers
a sufficiently detailed level for
description of anatomy involved in
modern hepatic surgery and radiology6.
H. Bismuth suggests dividing the liver
into left and right livers (hemilivers). A
right portal scissura divides the right
liver into two sectors. Each sector has
two segments: right anteromedial sector
– segment V anteriorly and segment VIII
posteriorly; right posterolateral sector –
segment VI anteriorly and VII
posteriorly. This is simple and practical
for imaging studies of the liver (ultrasound, computed tomography or
magnetic nuclear resonance)7,8.
Laparotomy was done with Jshaped right subcostal incision, which
was extended to midline when needed.
The extent of hepatic injury was
assessed Mobilization of the liver was
done by dividing the falciform ligament,
triangular and coronary ligaments. This
to deliver the liver down. started by
forceps fracture technique. To control
hepatic hemorrhage, Pringle maneuver
was applied, which includes 15 minutes
clamping of portal triad followed by 5
minutes reperfusion. The resections
performed included, bi-segmentectomy
of segment 6 and segment 7 (n = 8), left
lateral segment resection (n=6), right
lobectomy
(n=4)
and
segmental
resection of segment 6 (n = 2), (Fig. 1).
Segmental resections have been
developed thanks to a better knowledge
of hepatic anatomy and the increased use
of intraoperative ultrasound9. Anatomic
hepatic resection for trauma is associated
with low mortality and liver-related
morbidity rates and successfully
addressed bleeding, devitalized parenchyma, and intrahepatic bile duct
injuries when performed by experienced
hepatobiliary surgeons1,10,11,12.
The
purpose of this study was to assess the
results of anatomic liver resection for
severe liver trauma.
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After resection and hemostasis, tubal
drains were inserted followed by wound
closure. Postoperative assessment of
liver functions was done for all patients.
mean ± SD (standard deviation), while
discrete variables were expressed as
number and percent (%). Statistical
analyses were performed using t-student
test for continuous variables. Analysis
was done using Stat-view software SAS
Institute Inc., Cary, NC). P-value was
considered significant if <0.05, and
highly significant if <0.001.
Demographic, clinical, operative,
and postoperative data were collected
and analyzed. Continuous variables were
expressed as data are presented as the
Segemtecomy of
segment 6
10%
Right lobectomy
20%
Bi-segmentectomy
40%
Left lateral
segmentectomy
30%
Fig 1. Operative procedures in the studied patients.
Postoperatively, there was a
statistically significant improvement in
hemodynamic status; systolic blood
pressure (SBP), diastolic blood pressure
(DBP),
serum
hemoglobin,
and
hematoctrit percent, when compared to
preoperative values, (Table 4). Mean
values of postoperative liver functions
including levels of ALT, AST, bilirubin
(direct and total), serum albumin were
within normal values in most of the
studied patients. One month after
surgery, there was statistically non
significant minimal change in liver
functions (p-value >0.05), (Table 5).
RESULTS:
The twenty patients underwent
anatomical hepatic resection, had mean
age of 35.5±18.5 years, mean ISS of
21±8, and mean GCS of 12.2±3, (Table
1). Regarding operative data (Table 2),
mean operative time was 75.2±28.5
minutes, and mean blood loss was
650±310 cm3. The mortality rate was
5%, as one patient died postoperatively
due to major hepatic vein injury, while
the morbidity rate was 25%, which
included pneumonia in 2 patients (10%),
abdominal wound infection in another 2
patients (10%), and subphrenic abscess
in one patient (5%), (Table 3).
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Table 1: Demographic and clinical data of the study population.
Parameter
Age (years)
Mean ± SD
35.5±18.5
GCS
12.2±3
SD: standard deviation, GCS: Glasgow Coma Scale.
Table 2: Operative data.
Parameter
Operative time (min.)
Blood loss (mL)
SD: standard deviation.
Mean ± SD
75.2±28.5
650±310
Table 3: Postoperative outcome.
Parameter
Mortality rate
Morbidity rate:
- Pneumonia
- Abdominal wound infection
- Subphrenic abscess
No.(%)
1 (5%)
5 (25%)
2 (10%)
2 (10%)
1 (5%)
Table 4: Baseline versus postoperative vital signs, serum hemoglobin and hematocrit value.
Parameter
Pulse (beat/min.)
SBP (mmHg)
DBP (mmHg)
At admission
108.3±19.4
88.2  15.1
60.5  16.09
Postoperative
76±8.2 **
110  11.47 **
72.25  8.02 *
9.2±3.4
32±6.8
12.1±4.6 *
43.1±7.4 **
Serum hemoglobin (g/dl)
Hematocrit (%)
*: p-value <0.05. **: p-value <0.001.
Table 5: Follow-up of liver functions after anatomic resection of the liver.
Parameter
One month after
operation (N=19)
AST (U/L)
ALT (U/L)
Total bilirubin (mg/dl)
Immediately
postoperative
(n=20)
26.40±3.92
23.26±9.17
1.24±0.66
Direct bilirubin (mg/dl)
Serum albumin (g/dl)
0.60±0.24
3.64±0.71
0.67±0.33
3.86±0.92
216
27±4.2
28±6.4
1.31±0.45
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left lobe resection
segment VI, VII resection
Hepatic resection plays a major
role in the treatment of severe liver
contusion, especially for patients with
severe contusions in multiple places, and
injuries in bile ducts, hepatic veins, and
the inferior vena cava in combination
with extensive parenchymal damage22.
The anatomic resection has two main
goals: (1) eradicating the source of
bleeding; and (2) removing the site of
necrosis. It leaves a smooth resected
surface, with a viable liver and a low
propensity for septic complications.
However, it is not optimal treatment for
all liver injuries and should never be
used when simpler methods can achieve
a successful outcome. The surgical
procedure chosen must be appropriate
for the individual injury, the patient, and
the surgeon in attendance. Broad
condemnation of an anatomic resection
as a useful treatment modality has
resulted in less than adequate surgery for
the shattered-liver injury 1.
DISCUSSION:
The common frequency of liver
injuries in modem society is a reflection
of the transition to mechanized
transportation as well as a progressive
increase in violent behavior14. Severe
liver injuries carry high morbidity and
mortality ranging between 40 and 80%15.
Non-operative therapy of liver injuries
has become an acceptable approach to
management of hemodynamically stable
patients without associated injury
requiring laparotomy, and the indication
is extended16–20. However, Parks and
some other surgeons recommend that
nonoperative management should be
initiated only for injuries below grade III
in patients with stable hemodynamics;
grade III to grade V injuries usually
require surgical intervention21. Strong et
al.,11 have an active attitude and
recommend anatomic resection for
severe liver trauma. We agree with the
viewpoints of Parks and Strong; in our
opinion, vital signs of patients (pulse,
blood pressure, etc.) are critical in
deciding whether nonoperative management can be applied. In other words,
surgical intervention is mainly indicated
by unstable hemodynamics.
In the present study, we used
Hepatic Injury Scale established by the
American Association for the Surgery of
Trauma13, to select patients with severe
liver injury for anatomic resection. This
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scoring system for liver injuries
represents a logical synthesis of prior
scaling systems predominantly that
originally described by Moore and coworkers23. Grades III through VI are
generally considered severe liver
injuries. The utility and validity of this
scale was addressed in clinical studies24.
mortality and morbidity rates are agreed
with more recent studies as reported
Strong et al.,11 who reported that an
anatomic hepatic resection for trauma is
associated with low mortality and liver
related morbidity rates when performed
by experienced hepatobiliary surgeons,
and that its role in the management of
severe hepatic trauma should be
reevaluated. Those authors reported the
overall mortality rate of 8.1%11. Also, in
the study by Tsugawa et al.,1 the
mortality rate was 21.1% among young
patients and 27.6% among elderly. The
better results obtained in our study and
the studies by Strong et al.,11 and
Tsugawa et al.,1 may be explained by the
better understanding of the anatomy and
physiology of the liver, improved
anesthetics and postoperative care, and
advances in operative techniques in the
last two decades.
We used Pringles' manoeuvre
(temporary occlusion of the hepatic
artery and portal vein) to control hepatic
hemorrhage. Various protocols have
been recommended using periods of
inflow occlusion for 10 to 30 minutes
followed by 5 to 15 minutes of
reperfusion. Elias et al.,25 demonstrated
that the intermittent Pringle maneuver
results in less blood loss and better
preservation of liver function and
permits a total ischemia time of up to
120 minutes. A randomized clinical
study of patients undergoing liver
resection by Belghiti et al.,26 showed that
intermittent clamping using multiple
cycles of 15 minutes of ischemia and 5
minutes of reperfusion was associated
with decreased injury compared with
similar periods of continuous inflow
occlusion.
Therefore, an anatomic resection
for trauma in appropriate situations may
thus be a useful, safe procedure today, as
surgeons now have a better understanding of the anatomy and physiology
of the liver and can use improved
anesthetics postoperative care, and the
advances in operative techniques.
The present study revealed an
acceptable morbidity and mortality rates,
without major deterioration of liver
function immediately, and one month
after surgery. Our mortality rate was 5%,
and the morbidity rate was 25%.
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‫دراسة نتائج االستئصال الجزئي‬
‫للكبد في مرض تهتك الكبد الناتج عن الحوادث‬
‫معتصم محمد علي ‪ ،‬ناصر محمد زغلول ‪ ،‬تهامي عبدهللا ‪،‬‬
‫طارق عبدالعزيز أحمد ‪ ،‬خالد مهران ‪ ،‬أبو بكر محي الدين‬
‫قسم الجراحة العامة – كلية طب المنيا‬
‫إن الكبد بين األعضاء المعرضة لإلصابة أثناء التعرض إلصابات البعض في الحوادث وإن‬
‫استخدام األسلوب التشريحي لتقسيم الكبد إلي وحدات واستئصال الكبد بناء عليه قد أدخل فكرة‬
‫الجراحة التحفظية للكبد عند الحاجة لذلك ‪ ،‬لهذا تم عمل هذا البحث لتقييم نتائج استخدام هذا‬
‫األسلوب في حاالت الحوادث ‪.‬‬
‫وقد أجريت هذه الدراسة في الفترة من يناير ‪ – 2003‬يناير ‪ ، 2005‬في قسم االستقبال والحوادث‬
‫بمستشفي المنيا الجامعي‪ ،‬وشملت هذه الدراسة ( ‪ ) 100‬مريض يعانون من إصابات البطن‬
‫وإصابات مختلفة للكبد ‪ ،‬وتم تحديد ‪ 20‬مريضا ً يعانون من تهتك شديد بأحد فصوص الكبد‬
‫ويحتاجون لجراحة وهؤالء المرضي يصنفون من الدرجة ‪ ، IV‬حيث تضيف الجمعية األمريكية‬
‫لجراحة الكبد ‪.‬‬
‫ويتم إدراج المرض للجراحة بعد عمل الفحوص المعملية الالزمة وتقييم الحالة العامة للمريض‬
‫وكذلك أجزاء أشعة تليفزيونية ومقطعية للكبد لتحديد مدي اإلصابة في الكبد وتم استخدام طريقة‬
‫برنجل للسيطرة علي تيار الدم الداخل للكبد أثناء إجراء القطع لألنسجة ‪ ،‬وتم إجراء استئصال‬
‫الوحدة ‪ 7 ، 6‬من الكبد في عدد (‪ )8‬مرض‪ ،‬الجزء الخارجي للفص األيسر وحده ‪ 3 ، 2‬في عدد‬
‫(‪ )6‬مرضي واستعمال الفص األيمن في عدد (‪ )4‬مرضي واستئصال وحدة واحدة رقم ‪ 6‬في عدد‬
‫(‪ )2‬مرضي‪.‬‬
‫وتمت الجراحة بنجاح في ‪ % 95‬ممن المرضي مع حدوث حالة وفاة واحدة ناتجة عن تهتك شديد‬
‫في أوردة الكبد الرئيسية ‪ ،‬وحدوث مضاعفات مرضية شديدة في الدورة الدموية بعد إجراء‬
‫الجراحة ‪.‬‬
‫ولذلك لم يحدث أي تغيير ملحوظ في وظائف الكبد عن طريق متابعتها لمدة شهر بعد الجراحة ‪.‬‬
‫لذلك يعتبر االستئصال المبني علي أسس تشريحية للكبد في حاالت الحوادث وسيلة آمنة وسريعة‬
‫ويسهل استخدامها في الظروف الطارئة‬
‫‪.‬‬
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