COMPLEX HEPATIC INJURIES - 11/09/11

Doi : 10.1016/S0039-6109(05)70479-5

H. Leon Pachter, MD ^a, David V. Feliciano, MD ^b

^a Department of Surgery, New York University School of Medicine; Trauma and Shock Unit, Bellevue Hospital, New York, New York

^b Department of Surgery, Emory University School of Medicine; and Department of Surgery, Grady Memorial Hospital, Atlanta, Georgia

Résumé

The overall mortality incurred by civilians sustaining hepatic injuries remains in the vicinity of 10%, as 70% to 90% of all hepatic injuries are, fortunately, minor. Complex hepatic injuries, which account for the remaining 10% to 30% of hepatic trauma, remain formidable challenges even for the most experienced trauma surgeons. Until recently, these complex hepatic injuries were associated with mortality rates often in excess of 50%.^{11 Cogbill T.H., Moore E.E., Jurkovich G.J. , et al. Severe hepatic trauma: A multi-center experience with 1,335 liver injuries J Trauma 1988 ; 28 : 1433 [cross-ref]

Cliquez ici pour aller à la section Références, 23 Feliciano D.V., Mattox K.L., Jordan G.L. , et al. Management of 1000 consecutive cases of hepatic trauma (1979–1984) Ann Surg 1986 ; 204 : 438 [cross-ref]

Cliquez ici pour aller à la section Références, 24 Feliciano D.V., Pachter H.L. Hepatic trauma revisited Curr Probl Surg 1989 ; 26 : 453

Cliquez ici pour aller à la section Références, 52 Pachter H.L., Spencer F.C., Hofstetter S.R. Experience with the finger fracture technique to achieve intra-hepatic hemostasis in 75 patients with severe injuries to the liver Ann Surg 1983 ; 197 : 771 [cross-ref]

Cliquez ici pour aller à la section Références} The last decade, however, has witnessed a number of major changes in the way complex hepatic injuries are managed. These changing approaches have been responsible for lowering the mortality of grade III and IV hepatic injuries to under 10%.^{54 Pachter H.L., Spencer F.C., Hofstetter S.R. , et al. Significant trends in the treatment of hepatic trauma: Experience with 411 injuries Ann Surg 1992 ; 215 : 492 [cross-ref]

Cliquez ici pour aller à la section Références} Some of the most significant changes have been identified as follows: (1) the influence of CT scanning on the nonoperative management of adult blunt hepatic trauma ^{48 Pachter H.L., Hofstetter S.R. The current status of nonoperative management of adult blunt hepatic injuries Am J Surg 1995 ; 169 : 442

Cliquez ici pour aller à la section Références}; (2) the Pringle maneuver (occlusion of the portal triad), topical hypothermia isolated to the liver only, and hepatorrhaphy with intrahepatic hemostasis achieved by the finger fracture technique of Lin ^{52 Pachter H.L., Spencer F.C., Hofstetter S.R. Experience with the finger fracture technique to achieve intra-hepatic hemostasis in 75 patients with severe injuries to the liver Ann Surg 1983 ; 197 : 771 [cross-ref]

Cliquez ici pour aller à la section Références, 54 Pachter H.L., Spencer F.C., Hofstetter S.R. , et al. Significant trends in the treatment of hepatic trauma: Experience with 411 injuries Ann Surg 1992 ; 215 : 492 [cross-ref]

Cliquez ici pour aller à la section Références}; (3) perihepatic packing and planned re-exploration as part of the “damage control” concept whereby surgery must be terminated under circumstances of hemodynamic instability or coagulopathy^{9 Burch J.M., Ortiz V.B., Richardson R.J. , et al. Abbreviated laparotomy and planned reoperation for critically injured patients Ann Surg 1992 ; 215 : 416

Cliquez ici pour aller à la section Références}; and (4) the management of juxtahepatic venous injuries with or without various intracaval shunts. The purpose of this article is to give in-depth analysis of each of the aforementioned advances.