At this present no previous studyreviewed and compared grade of clinical liver trauma and CT imagesand the early result of surgery after liver trauma injury have beenreviewed.. “The corr
Trang 1Abdominal trauma in general and liver injury in special areconsidered intensive emergency which is increased nowadays Theliver is one of the most commonly injured organs inabdominal trauma It is together with the urbanization, developedtransportation and the development of civilization
Most of liver trauma was indicated surgery many years ago Surgery
of liver required advanced knowledge of anatomy, physiology of liver aswell as good technique of recovery and surgeon However thecomplication in surgery and post opereation is in high rate
Recent advancements in imaging studies and enhanced criticalcare monitoring strategies have shifted the paradigm for themanagement of liver injuries and the advent of damage control surgeryhave all improved outcomes in the hemodynamically unstable patientpopulation
The precise indication for liver trauma would guide clinicianclassify the grade of liver injury At this present no previous studyreviewed and compared grade of clinical liver trauma and CT imagesand the early result of surgery after liver trauma injury have beenreviewed
“The correlation between clinical and CT imaging features of liver trauma and evaluation of surgical management of liver trauma” Purposes:
1.Correlate clinical and CT grading features of liver trauma
2 Evaluate of surgical management of liver trauma
- Coded study was approval, data was first presented
Layout of the thesis: The dissertation consists of 140 pages, 4 chapters,
46 tables, 14 charts, 45 figure, 159 references including 27 Vietnamesereferences, 130 English references , 2 French references
Trang 2CHAPTER 1: OVERVIEW 1.1 Liver anatomy:
1.1.1 The structures to maintain hepatic fixed status:
* Porta hepatis and components of porta hepatis:
Porta hepatis or Glisson pedicle includes 3 components: portalvein (PV), hepatic artery (HA), biliary tract
+ Right pedicle: including the posterior hepatic segment with 2
branches sub-segment (SS) VI, VII and anterior segment pedicle with
SS V, VIII
+ Left pedicle: there are 3 branchs: SS IV, SS II and SS III
* Hepatic veins
+ Median hepatic vein: receives blood from lobe IV, anterior
segment and pour into IVC
+ Right hepatic vein: received blood from posterior segment and
+ The minor right hepatic vein (Makuuchi vein) guides blood
directly from the right liver sections (V, VI, VII, VIII) poured straightinto the side of IVC If there is severe injury, these positions could betorn violently, ensuing excessive bleeding
1.1.2 Application in hepatic resection surgery
* According to British-American authors: In 1953, Healey and
Schroy divided liver into 2 lobes – left and right 4 segments include:
medial, lateral, posterior, anterior segments Caudate segment is also
known as back segment Each segment is divided into 2 smaller parts:
Trang 3superior and inferior Caudate segment has 3 sections: right, left andcaudate.
* According to French authors: Couinaud in 1957 divided into 2
halves: right and left 4 parts include: right, right portal and left portal, left.Caudate lobe makes the back segment 8 segments are numbered clockwise
on the diaphragmatic surface
* Vietnam school: In 1963, Tôn Thất Tùng the combined 2 views of
British-American and French with experiences of Vietnam to suggest aparticular uniform view of Vietnam As dividing 2 halves of liver, 8subsegments is based on Couinaud theory and 4 segment followingBritish-American authors In our study, we use Ton That Tung’s school
In 2000, at Brisbane (Australia), the liver surgery conference come
to an agreement on liver operation and hepatic resesction surgery
1.2 The methods of diagnostic imaging of liver injury
1.2.1 The visual probe methods
* Abdominal radiograph: provide indirect signs of liver rupture
* Ultrasound: detecting peritoneal fluid with a very high
sensitivity, detecting which organ is damaged, plays important role inguiding and monitoring of lesion progression
* Magnetic resonance imaging: MRCP can be used to assess
biliary lesions
* Scintigraphy: questioning bile leak into the abdominal cavity.
* Angiography: usually for treatment through endovascular
intervention and can also be used in cases of biliary tract bleeding
* Liver computerized tomography
+ Anatomy of liver in CT: based on hepatic veins and the left and
right branches of the PV, virtual planes cut through the blood vesselshelping distinguishing location of lobes and segments of the liver
+ Classification of the grade of liver injury on CT: In 1994,
American Association for the Surgery of Trauma (AAST) divided liverlesions into 6 levels
1.2.2 The situation of computerized tomography studies in the diagnosis
of liver injury
* Around the world: Researches throughout the world from the 80s
and 90s so far suggests that CTis enormously valuable in detecting hepatictrauma, allowing surgeons to be comfortable and confident in the treatment
of conservation
* In domestic regions: In 2007, local authors had high opinions of the
Trang 4diagnostic ability of CT in hepatic trauma with the absolute level ofsensitivity up to 100%, accuracy 94.8%, positive predictive value 94.8%.
1.3 The method of treating liver injury
1.3.1 Inoperable conservation Treatment
* Clinical: closely monitoring whole body condition,
hemodynamic and abdomen status
* Paraclinical: monitoring indicators of blood counts, biochemical
and images-particularly CT
* Treatment: intensive care, estate resting in hospital bed ward
* During the follow-up, detecting complications so as to have
management on intervention or surgical procedure:
1.3.2 Embolization treatment
* Indication: From hepatic trauma grade III or beyond, there is vein damage,stable hemodynamic
* Contra-indication: blood pressure decrease shock and there is
vein damage in which surgery is inevitable
*Intra-vesel intervention for treatment of hepatic artery damage:
Using the material to cause embolism, according to damage
1.3.3 The methods of surgery treatment
* Surgical indication: fatal shock and failed conservation treatment
* Surgical rules: processing vessels, biliary tract, cut off dead hepatic
+ Simple hepatic draining tube: rarely applied
+ Hepatic venous repair
- Repairing venous lesion without using shunt: includes the method
of Ton That Bach, Heaney’s method and method of Dale coln
- Repairing venous lesion using shunt: includes the Buckberg’smethod, method of Albert E.Yellin and method of Pilcher
- Repairing using out of body circulation: exactly assess lesions,
Trang 5exactly and ensuring hemostatic, do not have risk of empty heart pulsation,embolism or hepatic anemia.
+ Repairing bile duct lesion: hemostatic sewing is simple in smalllesion in outer region of liver, liver cutting need to be considered in bileduct or segment injury, on-sonde sewing in common bile duct injury, bileduct-plasty, choledo-jejunum stomy Cholescystis-stomy or common bileduct drainage to reduce pressure in bile duct
+ Liver implant: in cases of complex and serious lesion
+ Liver resection: includes the method of Ton That Tung, Lortat Jacob and Bismuth Method of Ton That Tung has a lot of pros and iscurrently widely used
-* Treatment of post-operative complications:
+ Post-operative hemorrhage: depend on particular cases, bloodtransfer, scintigraphy or emergency operation
+ Bile duct hemorrhage: intervened embolization is considered avaluable treatment
+ Abscess inside and outside of liver: ultrasound guided puncture anddrainage give good result
+ Biliary peritonitis: immediate emergency operation
1.3.4 Status of research on domestic and world
* Status of research on the world
+ The first stage: not paying attention to the anatomical boundaries,focus only on hemostatic treatment
+ Modern Period of liver cutting: a deep understanding of liveranatomy to improve liver cutting techniques with the aim of reducingbleeding when cut liver parenchyma
The advancement of CT helped to accurately assess the degree ofliver damage, alter attitudes in patients treated hepatic trauma, treatmentrate increased non-operative conservation
* Status of Research domestic:
Ton That Tung’s liver cutting method was first published in 1962 inBerlin Trinh Hong Son’s study of hepatic trauma in Vietnam-GermanyHospital for 6 years from 1990 to 1995, emphasized the hemodynamicstatus when patient come in hospital have prognostic significance andsummarize the accompanying lesions, method of treatment andpostoperative complication rate Most recently, Nguyen Ngoc Hung’sstudy showed that treatment of liver preservation injury is applied to the84.4%, 89% achieved good results
Trang 6Chapter 2: SUBJECTS AND METHODS
2.1 Research Subjects
* For Objective 1: To compare the clinical presentation and liverinjury grade in CT of simple liver trauma
* For objective 2: Results of surgical treatment of simple liver trauma
2.2 Methodology of research: descriptive study with prospective analysis.
During the period from January 2009 to the end of December 2011
Research’s Steps:
+ Diagnosis and management of simple hepatic trauma comply with auniform regimen of treatment indications, assessment of liver injury on CTand in operation
+ The level of hepatic trauma was assessed by CT
+ Decide between non-operative conservation management oremergency surgery
The content of research:
* Compare hepatic trauma grade in CT with the general characteristics of the study groups: including the causes, mechanism of
injury, age, gender, occupational status prior to hospitalization and timefrom the accident until hospital
* Reconciliation of hepatic trauma grade with clinical presentation + Systemic symptoms: breathing and hemodynamic changes, signs of
severe blood loss, shock condition, coma, decreased consciousness
+ Functional symptoms: right hypochondrium abdominal pain,
stomach aches or no symptoms
+ Physical symptoms:
- Crash in lower region of right chest and hypochondrium
- Abdominal bloating: abdominal distension, bloating, moderate, mild
or no stumbling block
- Response to localized or diffuse abdominal wall
- Abdominal wall tetanus, peritoneum touch
* Compare hepatic trauma grade with laboratory studies:
+ The blood tests include: red blood cells, white blood cells,hemoglobin, hematocrit were grouped into 3 levels of blood loss
+ The tests include the coagulation rate Prothromobine, Fibrinogene,platelet counts to assess clotting function
+ Quantification of liver enzymes: SGOT, SGPT ; blood bilirubin,albumin and blood protein, urea quantification, blood creatinine
* Compare hepatic trauma grade with diagnostic imaging:
+ Abdominal ultrasound: Find free fluid in the abdomen, locate andnature of liver damage
+ Abdominal CT: locate, nature liver damage, grade according to
Trang 7Association USA (American Association for the Surgery of Trauma AAST, 1994)
-Table 2.1: Classification of traumatic hepatic of AAST 1994
Grade
*
Type of Injury Description of injury
I Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1cm
parenchymal depth
II Hematoma Subcapsular, 10% to 50% surface area
intraparenchymal <10 cm in diameterLaceration Capsular tear 1-3 parenchymal depth, <10
cm in lengthIII Hematoma Subcapsular, >50% surface area of
ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >
10 cm or expandingLaceration >3 cm parenchymal depth
IV Laceration Parenchymal disruption involving 25% to
75% hepatic lobe or1-3 Couinaud’s segments
V Laceration Parenchymal disruption involving >75%
of hepatic lobe or >3Couinaud’s segments within a single lobeVascular Juxtahepatic venous injuries; ie,
retrohepatic venacava/central major hepatic veins
VI Vascular Hepatic avulsion
+ Machine: single - receiver array CT in diagnostic imaging departments ofVietnam-Germany Hospital Slice thickness can vary 1mm - 10mm
+ Technique: patient supine, hands raised to the top Slices were takenfrom the top of the diaphragmatic dome to the ischium joint with 10mmthickness, if small lesions is suspicious conduct shooting 3 - 5mm thinlayer on the damaged area Slices were taken before and after contrastagent injection
+ Read the result: Location of lesions (Ton That Tung) Hepatic traumasigns: rupture; parenchymal contusion; parenchymal hematoma ;subcapsular hematoma ; parenchymal anemia; Escape of contrast agent.Classification of hepatic trauma in CT according to AAST grading of 1994
Trang 8* Evaluation of abdominal fluid: On ultrasound and CT, based on the
number of abdominal cavities with fluid
* Diagnosis of hepatic trauma: Based on the results of CT.
* Evaluate the severity of hepatic trauma: the classification of AAST 1994.
* Assess the level of blood loss: based on the level of blood loss to estimate
the amount of fluid, blood must be compensated
+ Open surgery or laparoscopy
+ Abdominal incision: midline, hypochondrium, line of Mercedes or Kehr.+ To assess the extent of liver damage: liver damage location based onthe anatomy of the liver of Ton That Tung, distribution of liver damage inthe operation according to Moore
+ The treatment of liver damage
- Electro-burning: Using monopolar or bipolar electrocoagulation knife
- Sewing hemostatic: slow absorbable suture, perform a U stitches takenout depth break lines
- Liver cutting according to damage region: Just take away the regionwhich is loss of nourishing and not really interested in the circuitry of thisregion
- Cut the liver according anatomy (Ton That Tung method) includingleft liver, right liver, left lobe, right lobe, segments cutting
- Packing:
- Handle the hepatic artery lesions: Sewing HA or selective ligation
- The handling of surgical lesions hepatic veins, portal vein, IVC: Fixdirect venous injury using shunt and circulation outside the body
- The surgical drainage of the bile ducts, the processing techniques ofbiliary lesions: drainage of common bile duct, cholecystis stomy, hepaticduct on-sonde sewing, choledo-jejunum stomy, or liver cutting
* Subscribe to detect postoperative complications: postoperative
hemorrhage, biliary duct hemorrhage, biliary peritonitis, bilioma, liverabscess, abscess under the diaphragm, bile leakage after surgery,complications in the lungs and pleura, liver failure, multi-organ failure
* Treatment of complications: indication of surgery or procedure is
Trang 9depended on developments, complications.
* Number of days in hospital
* Results of surgical treatment soon after
+ Good: No complication present or minor complications present buthave been treated without intervention
+ Average: patients with complications were stably handling
+ Bad: Death, serious complications
2.2.5 Gathering and processing data
All selected patients have complete individual profile with all necessaryparameters mentioned Data processing program according to medicalstatistics software SPSS 15.0
CHAPTER 3: RESEARCH RESULTS 3.1 General Characteristics
From January 2009 to the end of December 2011, there are 176 patients
on hepatic trauma in Viet-Duc hospital in which 166 patients weredesignated to assess liver CT capture and classify of hepatic trauma oncomputerized tomography scans 142 patients received conservativetreatment no-surgery accounting for 78.1% 24 patients (accounting for15%) of the patients after taken CT to detect liver damage wereemergency surgery 10 patients (6.9% percentage) was hospitalized incondition hemorrhagic shock, that is indicated emergency surgery toassess liver injury without CT
3.2 Group of patients diagnosed liver injury simply by taking CT
Table 3.5: Comparing the grade of hepatic trauma to cause injury
Kind of trauma
Grade
Traffic Accidents
Labor Accidents
Accidents activities
Trang 11Table 3:12: Comparing abdominal distention status on admission
Table 3.14: Comparing the degree of hepatic trauma and blood loss
Trang 12Table 3:15: Comparing the grade of hepatic trauma with blood
biochemical tests (SGOT) SGO
Table 3:16: Comparing the grade of hepatic trauma with blood
biochemical tests (SGPT) SGP
Trang 13P < 0,001 < 0,001 < 0,05
Table 3:20: Comparing the grade of hepatic trauma with
abdominal fluid on CT Abdominal
