managing liver trauma - gest · managing liver trauma m. rodiere 1, f. thony , ... peritonitis...
TRANSCRIPT
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Managing Liver Trauma
M. Rodiere1, F. Thony1, C. Letoublon2, P. Bouzat3 , C. Sengel1
1- Radiology Department2- Digestive Surgery Department
3- Anesthesia Department
University hospital of Grenoble
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Mathieu Rodiere, M.D.
• No relevant financial relationship reported
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Introduction
• Liver = largest intra-abdominal solid organ• Liver = Organ most frequently affected by trauma
• Prevalence = 1% to 8%• Mortality rate = 4.1% to 11.7%
• CT scan = reference technique for lesion diagnosisand aid in initial management
•
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NOM
• NOM=Nonoperative management
• 86.3% of hepatic injuries are now managedwithout operative intervention
Tinkoff J Am Coll Surg. 2008
• Now the standard of care for hemodynamically stable patients with blunthepatic trauma
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Guidelines
• Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline - J Trauma Acute Care Surg-2012
• Level 1– Patients who are hemodynamically unstable or who have diffuse
peritonitis after blunt abdominal trauma should be taken urgently for laparotomy
= Damage control surgeryLiver packingvascular exclusion
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Guidelines
• Level 2– A routine laparotomy is not indicated in the
hemodynamically stable patient without peritonitis presenting with an isolated blunt hepatic injury.
– Angiography with embolization should be considered in a hemodynamically stable patient with evidence of active extravasation (a contrast blush) on abdominal CT scan.
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Guidelines
• Level 3
– Interventional modalities including endoscopicretrograde cholangiopancreatography, angiography, laparoscopy, or percutaneousdrainage may be required to manage complications (bile leak, biloma, bile peritonitis, hepatic abscess, bilious ascites, and hemobilia) that arise as a result of nonoperative management of blunt hepatic injury
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CT Scan
• A CT scan of the abdomen with intravenous contrastadministration is the optimal diagnostic modality for hemo- dynamically stable patients to aid in both the diagnosis and management of blunt hepatic trauma.
• Liver Lesions – Subcaps hematoma
– Intraparenchymal Hematoma
– Intraparenchymal laceration
– Active extravasation
– False aneurysm
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Active extravasation
Intraparenchymal hematoma
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Embolization principles
• Coeliac trunk must be analyse beforeembolization
• selective embolization = microcatheter
• Embolic material:
– Temporary or definitive
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Results
• NOM– Success rates ranging from 82% to 100%. (US trauma centers) – Complications including bile leaks, hemobilia, bile peritonitis,
bilious ascites, hemoperitoneum, abdominal compartmentsyndrome, missed injuries, hepatic necrosis, hepatic abscess, and delayed hemorrhage.
– The complication rate increases with the grade of injury
• Embolization– success rate is 95% 1
– Hepatic necrosis is rare– First complication is gallbladder necrosis
1- Monnin- Place of arterial embolization in severe blunt hepatic trauma- 2008
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For those patients who are hemodynamically unstable despite continuous re-suscitation, laparotomy followed by embolization if needed is likely a safer approach.
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Take home message
• Nonoperative management = the gold standard
• CT Scan = Help NOM and embolization
• Liver Embolization
– Propose when active hemorrhage in CT scan
– Good success rate