actualización del manejo del traumatismo hepático en la era de la radiología vascular

Actualizacin del Manejo del Traumatismo Heptico en la Era de la Radiologa Vascular

Actualizacin del Manejo del Traumatismo Heptico en la Era de la Radiologa VascularValladolid, 29 Octubre 2015

Juan Carlos Meneu [email protected]

II JORNADA DE ACTUALIZACIN EN LA ATENCIN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015

Ciruga General Aparato Digestivo. Hospital 12 de Octubre

Unidad de Ciruga Heptica Biliar Pancretica. Clnica RuberMadrid


MacKenzie S, Kortbeek JB, Mulloy R, Hameed SM. Recent experience with multidisciplinary approach to complex hepatic trauma. Injury. 2004;35:86977.

II JORNADA DE ACTUALIZACIN EN LA ATENCIN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015http://ec.europa.eu/transport/road_safety/specialist/statistics/index_en.htm


Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg.2005;200:64869.





Actualizacin del Manejo del Traumatismo Heptico en la era de la Radiologa Vascular


Evolution. Liver trauma During last 3 decades, liver injury increased. This could be actual or artificial due to better diagnostic modalitiesMortalityW W 1: 66%W W 2 28%Vietnam 15% Currently 4%-15%Richardson JD. Ann Surg. 2000;232:324-330. Lucas CE. Am Surg. 2000;66:337-341.



Mechanism of injury Liver is particularly vulnerable to the ability of compressive abdominal blows to rupture its relatively thin capsule. Blunt trauma in a road traffic accident or fall from a height, may result in a deceleration injury as the liver continues to move on impact leads to tear at sites of fixation to the diaphragm and abdominal wall. Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg.2005;200:64869.


Juan Carlos Meneu Diaz


From a surgical point of view



A well-recognised deceleration injury involves a fracture between the posterior sector (segments VI and VII) and the anterior sector (segments V and VIII) of the right lobe

MacKenzie S, Kortbeek JB, Mulloy R, Hameed SM. Recent experience with multidisciplinary approach to complex hepatic trauma. Injury. 2004;35:86977.



In contrast, direct blow on right upper abdomen during vehicular accident or direct blow by a weapon or fist can lead to stellate type of injury to the central liver (segment IV, V and VIII).







Shock assessment from the static model of classification by percentage of blood volume loss to the dynamic model of monitoring the response to initial IVF resuscitation with division into Rapid, Transient & non-responders



Diagnostic modalities Serial Physical Examination (PE) (50% Sensitivity)Local Wound Exploration (LWE) Diagnostic Peritoneal Lavage (DPL) (Jansen has written the DPL Obituary (born 1965 & died 2005).Ultrasound (FAST) : (Sens 90%----Spec 95%).Not for organsFree fluid and AmountPneumothoraxCT Scan (For the hemodynamically unstable patients, CT scanning in a distant radiology suite posing hazards in transfer, monitoring & resuscitation can render the CT gantry as the tunnel to death.)Laparoscopy Laparotomy






Investigations are done if the patient is hemodynamically stable FAST is quick, readily available and non invasive can detect free fluid and blood in peritoneal cavity If FAST is positive and patient is stable then CT scan is the gold standard..

Cuff RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: The value of follow-up abdominal computed tomography scans. Am Surg. 2000;66:3326.



Grade I injury: small posterior capsular tear and small perihepatic hemorrhage. Grade II injury: posterior hepatic laceration < 3cm deep with adjacent hemorrhage.Grade III injury: hepatic lacerations greater than 3 cm in depth with a focus of active hemorrhage.Cuff RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: The value of follow-up abdominal computed tomography scans. Am Surg. 2000;66:3326.



Grade IV injury:

large ruptured intraparenchymal hematoma, active bleeding and large hemoperitoneum

Grade V injury:

deep hepatic laceration extending into the major hepatic veins with discontinuity of the left hepatic vein.







LIVER TRAUMA

STABLE PATIENTUNSTABLE PATIENT or PERITONITIS

GRADING CT SCAN with IV contrastOPERATING ROOMMANAGE ACCORDING TO GRADE and additional information. Re SCAN if needed

LaparotomyLaparoscopyNonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline.Volume 73(5) Supplement 4 EAST Practice Management Guidelines, November 2012, p S288S293






Initial management is done according to ATLS protocolCriteria for Non OPerative Management (NOPM)(I)

(1) haemodynamic stability, or stability achieved with minimal resuscitation (1-2 litres of crystalloid) (2) absence of other abdominal injuries requiring laparotomy (3) preserved consciousness allowing serial examination of abdomen (4) absence of peritonism (5) absence of ongoing bleeding on CT scan

Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline



H. Leon PachterGeorge David Stewart Professor of Surgery, Chair of the Department of Surgery at NYU Langone Medical Center



Criteria for Non OPerative Management (NOPM)

80% of patients with hepatic injuries can now be managed conservatively

Interventional techniques such as:endoscopic retrograde cholangiopancreatography,angiographylaparoscopy, or percutaneous drainage may be required to manage complications (bile leak, biloma, bile peritonitis, hepatic abscess, bilious ascites, and hemobilia...) Christmas AB, Wilson AK, Manning B, et al.. Selective management of blunt hepatic injuries including non-operative management is a safe and effective strategy. Surgery. 2005; 138: 606611




The standard of care for hemodynamically stable (HS) patients Reported success rates ranging from 82% to 100%Operative management of hepatic trauma leads to increased hepatic hemorrhage and other complicationsIf HS; no longer considered absolute contraindicationsSeverity of hepatic injury (CT grade or degree of hemoperitoneum)neurologic statuspresence of a blush on CT scanage greater than 55 years, and/orthe presence of associated injuries Velmahos GC, Toutouzas K, Radin R, et al.. High success with non-operative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg. 2003; 138: 475480; discussion 480481.




Initial management is done according to ATLS protocolCriteria for Non OPerative Management (NOPM) (II) Key points:Good quality CT scans Experienced radiologist Intensive care setting and expertisedQuickly available surgeons/operating room

Ultimate decisive factor hemodynamic stability irrespective of the grade Cuff RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: The value of follow-up abdominal computed tomography scans. Am Surg. 2000;66:3326.




Non-operative management (NOPM) consists of close observation of the patient complemented withangio-embolization, if necessary.

Observational management involvesadmission to a unit and the monitoring of vital signs,strict bed rest,frequent monitoring of hemoglobin concentrationserial abdominal examinationsCuff RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: The value of follow-up abdominal computed tomography scans. Am Surg. 2000;66:3326.




Not enough literature to recommend Frequency of hemoglobin measurements Time to reinitiating oral intakeDuration and intensity of restricted activity Optimum length of stay for both Timing of initiating chemical deep venous thrombosis (DVT) prophylaxis after hepatic injury

Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline.J Trauma Acute Care Surg. 2012 Nov;73(5 Suppl 4):S288-93.



Criteria for Non OPerative Management (NOPM)Indication for angiography if

transfusion of 4 units of RBCs in 6 hours or6 units of RBCs in 24 hours without hemodynamic instability




Complications: Delayed hemorrhagemost common, usual indication for a delayed operationunder strict guidelines, the incidence ranges from 0-5%, and blood transfusions are required in fewer than 20%

Common errors: assuming that the hemorrhage is not related to the liver multiple (more than four) blood transfusions in the hope that it will stop misreading CT and underestimating hemoperitoneum and active bleeding



DELAYED HAEMORRHAGE

STABLE PATIENTUNSTABLE PATIENT

CT SCANOPERATING ROOMPooling of contrast

LaparotomyLaparoscopyLiver injury unchanged

Angiogram/embolization



Criteria for Non OPerative Management (NOPM)Complications: Biliary fistula and liver abscess ranges from 0.5%-20% (Nasobiliary or percutaneous transhepatic drainage or endoprothesis insertion . If fails, then needs surgical resection of affected segment)

Hemobilia 1%, iatrogenic causes most common (injury causes communication between the biliary tract and blood vessels abdominal trauma, jaundice, RUQ colicky pain and blood in vomitus or stool point to this diagnosis)managed by percutaneous selective hepatic a. embolization or surgical intervention



Criteria for Non OPerative Management (NOPM)Complications: Bilihemia rare complication of severe decelerationon injury, in which the hepatic venules and the intrahepatic bile ducts rupture excessive bilirubin level endoscopic sphincterotomy and biliary endostenting

Extrahepatic bile duct stricture Endobiliary ballon dilatation or stenting usually require surgical correction using Roux-en-Y hepatodochojejunostomy Mortality rate --7-13% with most resulting from associated injuries --0-0.4% resulting from liver itself





Criteria for Operative Management (OPM)

(1) any patient who is haemodynamically unstable with suspected liver trauma (2) multiple transfusions required to maintain haemodynamic stability (3) signs of peritonism, or development of peritonism on serial abdominal examinations (4) active arterial blush on CT for which interventional techniques have failed and/or ongoing bleeding on CT scan with focal pooling of contrast (5) penetrating trauma




In hemodynamically unstable patientGrade IV, V and VI injuriesGoal is to arrest Hemorrhage

Initial control of hemorrhage is attained by Perihepatic packingMannual compression




4 Ps of operative management Operative management can be summarized asPUSHPRINGLEPLUGPACK



Criteria for Operative Management (OPM)Summarized asInitial control of bleeding temporary tamponade using packsportal triad occlusion bimanual compression of the liver or compression abdominal aorta above celiac trunkIf is unaffected major vena cava injury or atypical vascular anatomy should be expected



Right costal margin is elevatedAdditional pads should be placed between the liver, diaphragm, and anterior chest Sometimes 10 to 15 pads may be required Removing packing when:Body T > 36CBase deficit > (-) 4 Lactate normalNo coagulopathyLow dose vasoactive drugsSat 95% with FiO2< 50%



Criteria for Operative Management (OPM)Hepatotomy with direct suture ligation using the finger fracture technique, electrocautery ultrasonic dissector to expose damaged vessels and hepatic duct which ligated , clipped or repairedlow incidence of rebleeding, necrosis and sepsiseffectives following blunt liver trauma requires further evaluation



Criteria for Operative Management (OPM)Mesh rappingnew technique for grade III,IV laceration especially when combined with ipsilateral ligation of the bleeding vessel.tamponading large intrahepatic hematomasnot indicated where juxtacaval or hepatic vein



Criteria for Operative Management (OPM)Intrahepatic tamponade. Ballon tamponadingTranshepatic penetrating woundUse of 2.5 cm PenroseHollow catheter (Robinson Catheter)Inflated with soluble contrast agent



Nonoperative management: modality of choice in HS Only in an environment that provides capabilitiesH. Instability and peritonitis still warrant emergent surgery Enhanced CT scan: of choiceRepeated imaging : patients clinical statusAdjunctive therapies ( angiography, percutaneous drainage,ERCP laparoscopy)



Available at SLIDESHARE. Oncocir-Slideshare(http://es.slideshare.net/ruber12?utm_campaign=profiletracking&utm_medium=sssite&utm_source=ssslideview)

actualización del manejo del traumatismo hepático en la era de la radiología vascular

Health & Medicine