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Complex Hepatic Injuries

Tanya L. Zakrison Ryder Trauma Center University of Miami Miller School of Medicine Sept . 20 th , 2014. Complex Hepatic Injuries. Case. 18 male helmeted patient, high speed motorcycle collision Thrown off motorcycle hits barrier EMS arrives

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Complex Hepatic Injuries

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  1. Tanya L. Zakrison Ryder Trauma Center University of Miami Miller School of Medicine Sept. 20th, 2014 Complex Hepatic Injuries

  2. Case • 18 male helmeted patient, high speed motorcycle collision • Thrown off motorcycle hits barrier • EMS arrives • Patient is unresponsive, significant blunt trauma to right torso, blood pressure 80/50 mmHg

  3. What do you do next?

  4. Pre-Hospital Care / Paramedics • Pre-hospital care • most important is prompt transportation to a trauma center • SCOOP AND RUN • A - Intubate (possibly) • B - Needle decompression for any concern about a tension pneumothorax • Circulation – IV access, hypotensive resuscitation? • D – TBI with spinal cord injury – probable • Exposure

  5. Nurses • ATLS protocol in the trauma bay • Work as a team, excellent communication • Repeat the ABCDEs • Verify ETT placement • Help the surgeons place a tube thoracostomy on decompressed side • Contralateral side too if still hypotensive • Verify that the IV sites are in place, 20 cc/kg crystalloid • Blood (massive transfusion protocol) • ED thoracotomy? • FAST & CXR • Do we need to operate or not?

  6. Ahmadi-noorbakhsh S, Hyperpressureintraperitoneal fluid administration for control of bleeding after liver injury. J Surg Res. 2012 Aug;176(2):559-66. • Diasylate fluid is infused intraperitoneally to increase intra-abdominal pressure to reduce bleeding in the pre-hospital phase • Compared to previous models of abdominal hypertension using CO2 insufflation • Animal model demonstrated efficacy in animal models of liver injury • Abdominal pressure of 15 mmHg achieved • Mean arterial pressure, hematocrit and glucose concentration higher in dialysate group • Adjunct to increase survival in the pre-hospital phase

  7. Outline – management options • Hemodynamically stable • Blunt • Penetrating • Hemodynamically unstable • Blunt • Penetrating • Specific injuries: • Parenchymal injuries • Grade V juxtahepatic venous injuries • Portal triad • Complications

  8. Anatomy – Couinaud’s Segments There are 4 sources of bleeding in the liver

  9. Anatomy – Hepatic Suspensory Ligaments • Falciform ligament • Ligamentum teres • Coronary ligaments • Triangular ligaments • Hematomas may be contained within suspensory ligaments

  10. Liver Injury • May injure: • Blood vessels: • Retrohepatic IVC • Hepatic veins • Portal veins • Hepatic arteries • Biliary radicles • Parenchyma • Perihepatic structures • Management options: • Packing • Direct suture • Finger fracture • Omental packing • Penetrating tract • Open it (tractotomy) • Pack it (multiple adjuncts) • Hemostatic agents • Liver bag • Vascular isolation • Atriocaval shunting • Resection & tranplantation • Veno-veno bypass Bleeding & Air embolism

  11. AAST Organ Injury Scale

  12. Blunt Hepatic Injury - Stable • 85% of pts. with blunt liver injury are stable • 89% of these are managed non-operatively • Majority venous blood supply to liver (low pressure) • Non-operative management (NOM) leads to: • Less transfusions of blood products • Decreased length of stay • Decreased infectious complications • Few contraindications to NOM • Must be hemodynamically stable • Failure in 14% grade IV injuries, 23% grade V

  13. Penetrating Hepatic Injury - Stable • Role for non-operative management • Renz et al. (1994): • NOM in 13 pts. with TA GSWs • Follow with serial PE’s, contrast-enhanced CT scans • Demetriades et al. (1999): • NOM in 16 pts. with TA GSWs • Failure of NOM 33% • Omoshoro-Jones et al. (2005): • NOM in 31/33, including pts. with grade V liver injuries • Most complications also treated non-operatively • Ultimately only 30% of penetrating hepatic trauma will be eligible for NOM • Pt. selection important: • HD stability no peritonitis • GCS = 15 no active bleed on CT • AAST grade does not determine eligibility for NOM

  14. Multimodality Approach in Hepatic Injuries – Angioembolization • Angioembolization (AE): • Pseudoaneurysm, blush, active extravasation • May be used in NOM, pre-op. or post-op. • Asensio et al. (2003 & 2007) • Early hepatic AE in all pts. with grades IV, V injuries • Improved survival with • Immediate surgery • Early hepatic packing • Direct pt. transport from OR to angio suite

  15. Unstable Hepatic Injuries:Penetrating or Blunt • Classic teaching is operative management • Operative principles: • Hemostasis Adequate exposure • Debridement Drainage • Results poor with severe, high grade injuries (V) • Traditional operative approach being revised • Multidisciplinary approach also advocated by some in unstable patients

  16. Basic Operative Approach • Diagnostic & therapeutic maneuvres • Pack – what is bleeding? • Pringle maneuver (1908) • Hepatic arterial bleeding • Portal venous bleeding • May use safely for up to 75 minutes

  17. Basic Operative Approach • If ongoing venous bleeding with pringlemaneuvre • Retrohepatic IVC • Major hepatic veins • Direct visualization of bleeding vessels to suture ligate • Even if need to divide uninjured parenchyma • Tractotomy • Finger fracture

  18. Basic Operative Approach • In severe injuries, vascular exclusion / isolation techniques may be used • Atriocaval shunt • Complete vascular inflow occlusion • Pringle • Aorta • Infrahepatic IVC • Suprahepatic IVC

  19. When Things Are Really Bad… • May resort to veno-veno bypass • Allows for direct repair of injuries • juxtahepatic venous injuries

  20. Who, When & How to Pack? • Onset of triad of death • Extensive bilobar injuries • Large, expanding or ruptured hematomas • Failure of other maneuvers • Pts. who require transfer to a level I trauma center • Juxtahepatic venous injuries • Watch IVC with packing • Remove < 72 hrs

  21. “Much has been written on the topic of hepatic venous injuries and there are possibly more authors on the subject than survivors of the procedures described” A. Walt, 1978

  22. Management of Juxtahepatic Venous Injuries (V)

  23. Anatomy – Juxtahepatic Veins • Retrohepatic IVC • 7 cms in length • Phrenic & right adrenal vein • Completely circumscribed by hepatic suspensory ligaments • Major hepatic veins • Right, middle, left • Supernumerary veins • Typically 7, additional smaller veins • Drain right and caudate lobes • RIVC & MHVs are resistant to collapse or compression

  24. Juxtahepatic Venous Injuries – Buchman R. et al, Juxtahepatic Venous Injuries: A Critical Review of reported Management Strategies, J Trauma, 48 (5), 2000 • Most deadly form of liver trauma • Non-compressible, do not collapse • Surgically inaccessible • Injury causes • Life-threatening exsanguination • Fatal air embolism • Poor outcomes may be due to • Lack of familiarity with anatomy • Limited surgical experience • Current management strategies are flawed

  25. Juxtahepatic Venous Injuries – Buchman R. et al, Juxtahepatic Venous Injuries: A Critical Review of reported Management Strategies, J Trauma, 48 (5), 2000 • Elements of injury include: • Direct injury to vein • Intraparenchymal • Extraparenchymal • Injury to surrounding tamponading tissues • Parenchyma & capsule (intraparenchymal) • Areolar tissue, diaphragm, hepatic suspensory ligaments • Free bleeding occurs IFF there is a breach in the containing tissues in association with a venous injury • These breaches may occur with surgical decompression which can lead to massive, uncontrollable free bleeding

  26. Juxtahepatic Venous Injuries – Patterns of Injury: Type A • Hepatic venous injury is intraparenchymal • Associated disrupted liver parenchyma and capsule • Injuries bleed directly through disrupted liver parenchyma • May have associated injury to portal veins or hepatic arteries

  27. Juxtahepatic Venous Injuries – Patterns of Injury: Type B • Venous wound is extraparenchymal • Associated disruption of suspensory ligaments, diaphragm or both • Bleeding mainly • Around the liver • Into chest • Much less common than type A

  28. Determinants of Hemorrhage & Treatment Strategies • Amount of free bleeding depends on: • Extent of venous laceration • Severity of injury of associated structures • Operative strategies: • Direct suture repair +/- vascular isolation • Lobar resection for bleeding control • Tamponade / containment of venous bleeding

  29. Operative Strategy – Direct Suture Repair +/- Adjuncts • Direct repair done in accordance with historic beliefs, approach taken elsewhere in body • Ochsner (1961) & Starzl (1962) pioneers for repair of IVC injuries • Infrahepatic IVC injuries, none were retrohepatic • Technical difficulties lead to vascular exclusion / isolation techniques as adjuncts • Atriocaval shunt (Schrock – 1968) • First successful suture of JHVI Bricker, 1971 • Complete vascular exclusion (Waltuck – 1970, Yellin – 1971) • Clamps applied to the suprahepatic and infrahepatic IVC, portal vein, aorta • Prohibitively high rate of cardiac arrest if done while pt. severely hypovolemic • Need for venous suturing has never been questioned

  30. Operative Strategy – Anatomic Resection • McClelland & Shires (1965) • 80% survival in 25 pts. undergoing lobectomy for severe hepatic trauma • Unclear prevalence of JHVI • Other series demonstrate high mortality when done for bleeding or precise anatomic resection • Main success is with debridement for devitalized tissues • Not widely applied for treatment of acute hemorrhage from hepatic venous injury • Complete resection = hepatic transplantation • Few successes in case reports

  31. Operative Strategy – Tamponade & Containment • Deep parenchymal suturing to control venous bleeding ‘standard of care’ • Stone & Lamb (1975) • Omental inclusion with deep sutures • Near complete success in 37 pts. • Fabian & Stone (1980) • 104 pts. with blunt hepatic injury & venous bleeding • Hemostasis in 95%, 8% died • Repeat study in 1991 with JHVI • Survival 80% • Mortality 3x lower vs. direct venous repair +/- isolation • Ideal for type A injuries

  32. Operative Strategy – Tamponade & Containment • Beal (1990) • Perihepatic gauze packing in 35 pts. including JHVI • Mortality 14% vs. 70% with AC shunts & DVR • Balloon tamponade used in bilobar GSWs • Very few with actual hepatic venous injury

  33. Conclusion • Wide hepatic mobilization & direct venous ligation should be abandoned for JHVIs • Omental and gauze packing provide alternatives with lower mortality • Recurrence of bleeding or thrombosis are not major sources of mortality when veins are not repaired • Based on injury pattern, restoration of containment structures around disrupted veins may be a preferred approach

  34. Conclusion: What is New? • Can we improve how we pack? • Hemostatic agents prepacking? • Packing material itself? • New multimodality approaches • Endovascular stenting of IVC • Intraoperativepercutaneous deployment of venous balloons • Right femoral vein to infrahepatic IVC • Right internal jugular to retrohepatic IVC • Proceed with suture repair of venous injuries

  35. Options to Improve Packing? FloSeal effectively stopped hemorrhage in arterial & venous injuries (IV, V) in coagulopathic swine. Leixnering M., et al., J Trauma, 64 (2), 2008 FloSeal may be applied to actively bleeding vessels. Made of bovine gelatin & thrombin, hemostasis occurs in wet fields up to arterial pressure

  36. Options to Improve Packing? • Modified chitosan (N-acetyl glucosamine) used in an animal model of liver injury • Grade V major hepatic venous involvement • Animals also coagulopathic & hypothermic • MC group: • Higher MAP • Less total blood loss • All MC animals survived • 50% controls died Bochicchio G. et al, Use of a modified chitosan dressing in a hypothermic, coagulopathic grade V liver injury model, American Journal of Surgery (2009) 198, 617–622

  37. Injury to the Portal Triad • Portal vein • Mainly seen with penetrating injuries • May ligate portal vein • Fluid requirements massive • Second look laparotomy for small bowel viability • Splenectomy? • Proper hepatic artery • May ligate with impunity • Holds true for normotensive pts., pts. in shock may experience hepatic necrosis • Common bile duct • High rate of failure & stenosis with primary end-to-end anastomosis • Roux-en-Y hepaticojejunostomy preferred • Drain & refer to specialized hepatobiliary surgeon

  38. Post-Operative Complications • Abscesses • Bilomas • Necrosis • Pseudoaneurysms

  39. Post-Operative Complications: Fistulas • Hemobilia: blood (arterial) into bile • Quincke (1871): RUQ pain, jaundice, UGIB • Treat with ERCP, angioembolization or OR if fails • Bilhemia: bile into blood (venous) • Presence of hyperbilirubinemia, normal LFT’s • Treat with ERCP • Thoracobiliary fistula: bile into pleura • May progress to bronchobiliary fistula • Treat with chest tube & ERCP

  40. In Summary • Grade V hepatic injury? • Consider injury pattern • Consider a different approach • Consider new adjuncts • FloSeal (gelatin bovine & thrombin) • Modified chitosan packs • Angioembolization • Watch for complications

  41. tzakrison@med.miami.edu ¡Muito obrigado!

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