Nowadays, with the advancements in resuscitation anesthesia, surgical techniques, the trend of non-operative management for patients with grade I, II and III and stable hemodynamics is i
Trang 1108 INSTITUTE OF CLINICAL MEDICAL SCIENCE RESEARCH
PHAM TIEN BIEN
DIAGNOSIS AND TREATMENT
LIVER TRAUMA AT THE NORTHERN
Trang 2STUDY ARE COMPLETED AT
108 INSTITUTE OF CLINIC MEDICAL SCIENCE RESEARCH
Science instructor: Prof Trinh Hong Son
Trang 3LIST OF PUBLISHED RESEARCH ARTICLES
RELATED TO THE THESIS
1 Pham Tien Bien, Nguyen Hoang Dieu, Trinh Hong Son (2020),
“Diagnosis of liver trauma in northern mountain hospitals”, VietNam medical Journal, 3 (2): 13-16
2 Pham Tien Bien, Nguyen Hoang Dieu, Trinh Hong Son (2020),
“Treatment of liver trauma in northern mountain hospitals”, VietNam medical Journal 3 (2): 29-32
Trang 4INTRODUCTION
Liver trauma (LT) is a solid organ trauma that is common in closed abdominal trauma (15-20%) According to statistics, 31% cases (TH) of multiple traumas had closed abdominal trauma, of which 16% were recorded with LT
Today, with knowledge about anatomy, physiology, traumatic mechanisms, and the development of computerized tomography made a breakthrough in LT diagnosis and treatment
In terms of treatment, previously surgery was indicated for LT popularly Nowadays, with the advancements in resuscitation anesthesia, surgical techniques, the trend of non-operative management for patients with grade I, II and III and stable hemodynamics is increasing and achieving good results Many recent studies show that about 70-90% of LT is treated with non-operative management and successfullyrate is 85-94%
The Northern mountainous provinces have underdeveloped economies, difficult life, inadequately developed health systems, inadequate human resources, limited and uneven qualifications, and lack of modern medical equipment, making it difficult to diagnose and treat surgical diseases, including LT
Trinh Hong Son's study found that the diagnostic protocol and indications for treatment were inconsistent due to the lack of diagnostic equipment, the lack of diagnostic doctors, many surgeons who had no experience in assessing and difiniting lesions that lead to wrong indications, some hemostatic and resectiontechniques of liver rupture are not proficient, increasing the rate of complications In order to improving the effectiveness of LT diagnosis and treatment in Northern mountainous hospitals, we carry out the project with two objectives:
1 To study about LT diagnosing at Northern mountainous hospitals
2 To evaluate early results of LT treatment at Northern
mountainous hospitals
NEW CONTRIBUTIONS OF THE THESIS
The study was conducted on 124 patients (BN) diagnosed LT, treated at 11 Northern mountainous hospitals from November 2009 to the end of May 2013
Trang 5- Regarding diagnosis of LT: 60.5% patients had stable hemodynamics upon admission 96.8% patients had abdominal ultrasound, 85% found liver lesions, 40.3% patients had computerized tomography Patients who had computerized tomography had a higher rate of non-operative treatment than the group didn’t have CT (69.4% versus 11.3%) The accuracy of computerized tomography detecting abdominal fluid is 93.33%, detecting liver lesions is 100%
- Regarding treatment results: 50% patients were given operative treatment and 50% were given emergency surgery 74.2% were treated with non-operative management and then 25.8% failed The reason for changing to surgery in the non-operative management group was mainly due to increased abdominal distention, increased pain level, accounting for 43.75% During surgery, a grade IV liver rupture was observed (47.43%) Liver suturing accounted for 92.3% The rate
non-of complications related to surgery is 24.4% Four patients(3.23%) died during treatment coursewere in the surgical group
- Evaluation of early results:
+ Non-operative management group: Good results accounted for 74.2%
+ Surgery group: Goodresults(67.9%), averageresults(26.9%) and poorresults(5.2%)
These contributions expose reality and contribute to raising the status quo, thereby improving the efficiency of diagnosis and treatment
LT at Northern mountainous hospitals
STRUCTURE OF THE THESIS
The thesis consists of 133 pages: 2-page introduction, 36-page literature review, 23-page study subjects and research methods, 25-page research results, 43-page discussion, 2-page conclusions, 1-page recommendations 3 articles, 39 tables, 05 charts, 11 pictures 158 references
Trang 6Chapter 1 LITERATURE REVIEW 1.1 Liver surgery
1.1.1 Devices holding the liver’s place
1.1.2 Hepatic artery, ven and biliary tract
- Abdominal exam: Abdominal distention, abdominal skin scraping, abdominal wall reaction, abdominal puncture
- Comprehensive examination, avoiding missed coordination injuries
Trang 7- CT scan: For patients havestable survival signs, abdominal or systemic CT scan is a useful technique to quickly detect all possible lesions in one scan and allow the doctor to evaluateabdominal fluid and gas; lesions of solid organs, gastrointestinal tract, excretion route, timely detection of associated lesions with high sensitivity and accuracy, prognosis and thereby making decisions about non-operative management or surgical treatment in multiple traumapatients
Images of liver lesions caused by abdominal trauma on CT scan: Abdominal fluid, images of liver trauma (hematoma under the liver capsule, parenchymal tear or rupture, contusion and hematoma in the parenchyma)
Classification of liver rupture according to CLVT: There are many ways to classify liver damage in closed abdominal trauma Nowadays, the grading system LT of American Association for the Surgery of Trauma (AAST) in 1994 is most applicable This classification system
is based only on anatomical damage of the liver According to
AAST-1994, LT is classified into 6 degrees, based on the type of liver injury, lesion site, surface area of injury and other related lesions
- Angiography
- Biliary cholangiopathoscopy (ERCP)
- Magnetic resonance imaging (MRI)
- Indication of surgery due to associated injuries such as hollow organ perforation or in some multiple traumatic cases with accompanying abdominal trauma
- Indication of non-operative treatment but through monitoring, bleeding or rupture of the liver was not controlled and/or peritonitis Management of surgical lesions
Trang 8- Temporarily hemostasis: Manually squeezing the liver, Pringle procedure, inserting hemostatic gauze, clamping the aorta or blocking the aorta below the diaphragm
- Complete hemostasis: electro-surgery or hemostatic suture, selective hepatic artery ligaturing, liver resection
1.3.3 Non-operative treatment
Most of the authors believe that non-operative treatment can only
be used for patients with stable hemodynamics, patients who are hospitalized in a state of shock have a very high rate of emergency surgery In addition, it is necessary to exclude coordinated lesions in the abdominal cavity requiring emergency surgery, especially perforation lesions, hollow organ rupture Some other conditions that are needed to decide on monitoring and non-operativetreatment:
+ Having conditions for close and continuous monitoring of clinicic, subclinicic, image diagnosis (ultrasound, CT, emergency angiography)
+ Facility have capable of surgery at any time, a team of surgeons have experience in liver surgery, including major liver resection
1.4 Current situation of LT diagnosis capability in northern
mountainous hospitals
1.4.1 The basic features of geography, economy and population
The Northern mountainous provinces still face many economic difficulties: they have a large area, quite complex topography, many high mountain ranges, large slopes, limited transportation,far distance from Hanoi capital and remote areas The main area is the mountainous forests have few advantages in natural resources and trading, people are mainly ethnic minorities, the main economy is agriculture, and the income is still very low This condition effect on diagnosis and treatment of LT and surgical diseases
socio-1.4.2 Human resources and LT diagnostic facilities
The lack of human resources as well as equipment systems limit the development of diagnostic techniques: CT scans, magnetic resonance imaging, endoscopic ultrasound, so that some diagnostic diseases are not adequate, especially multiple traumatic cases, closed abdominal trauma has many associated lesions
Trang 91.4.3 Situation of LT diagnosis in Northern mountainous provinces
Trinh Hong Son's study on 40 LT patients at 12 general hospitals
in the northern mountainous provinces: 47.5% of patients are ethnic minorities (H.Mong minority 20%) The main cause of LT is traffic accidents (35%), CT was performed on 9/40 (22.5%) patients, abdominal lavage was performed on 5/40 (12.5%) patients
1.5 Current situation of LT treatment in Northern mountainous hospitals
Due to the lack of gastrointestinal surgical specialists and image diagnostic equipments The techniques of measuring liver volume or imaging intervention have not been transferred and applied in the Northern mountainous hospitals, lead to a high rate of LT surgery Most hospitals have implemented basic techniques such as hemostatic swab inserting, hemostatic suturing, but liver resection in LT surgery is still difficult, not widely applied
Trinh Hong Son's study had 2.5% of patients were indicated to non-operative treatment, 39 patients (97.5%) were indicated to surgery Indications for emergency surgery were shock (23.0%), abdominal distention increased (51.3%), peritonitis (7.7%); 7 patients (18%) had stable hemodynamics but the reason for surgery was only due to the detection of liver lesion There were 7 LT patients (18%) of grade I and
II alone and 22 LT patients (56.4%) of grade III ordered surgery 19 patients (51.4%) had an intra-abdominal blood volume <500ml Management of liver lesion in surgery: liver rupture suturing is the main procedure (84.4%), liver resection was performed on 4 patients (10.4%) Complications after surgery: bleeding 5.2%, 3 patients had infected surgical incisions (7.7%), 1 patient have abscess under the diaphragm (2.6%) and 1 patient have bile leakage (2.6%); The death rate is 7.7%
Trang 10Chapter 2 STUDY SUBJECTS AND RESEARCH METHODS
2.1 Study subjects
All patients were diagnosed LT and treated at 11 northern mountainous hospitals (Lai Chau, Dien Bien, Son La, Ha Giang, Cao Bang, Lao Cai, Tuyen Quang, Bac Kan, Lang Son, Bac Giang and Quang Ninh), from November 2009 to May 2013
2.1.1 Selection criteria
- Patient was diagnosed liver rupture due to abdominal trauma and treated at 11 northern mountainous hospitals Including patients were treated by surgical or non-operative treatment
- Full medical records, patients agree to participate in the study
2.1.2 Exclusion criteria
- LT Patients due to abdominal stab wounds or death before hospitalization; Patients with a history of pre-existing hepatobiliary diseases such as liver tumors, cirrhosis, cysts, gallstones; Patients disagree to participate in the study, whose medical records are insufficient information
2.2 Research Methods
2.2.1 Research design
Observational describing retrospective combined prospective studies
Research period: from November 2009 to the end of May 2013
- Retrospective: From November 2009 to the end of November
2011, there were 81 patients
- Research progress: From December 2011 to the end of May 2013, there were 43 patients
2.2.2 Sample size and sample selection: Convenient sample
selection
2.2.3 The protocol of diagnosis and treatment of liver trauma in research: according to the State-level Science and Technology project
have code ĐTĐL.2009G/49
Trang 112.2.3.1 Diagnostic protocol:
(1) Clinical diagnosis and identified diagnosis of LT (2) Determinated Diagnosis of LT level (3) Diagnosis of combined lesions (4) Diagnosis of treatment capacity
2.2.3.2 Original resuscitation
2.2.3.3 Non-operative treatment
Indication
+ Merely LT grade I, II, III (a small number of liver trauma grade
IV, V) according to CT, have stable hemodynamics For patients who
do not have CT scan, the indication of follow-up and non-operative treatment depends on the doctor's judgment, the hospital's monitoring and resuscitation conditions
+ Hemodynamic stability returned after resuscitation: rapid response to initial resuscitation or temporary response to initial resuscitation but hemodynamics remains stable after compensation of fluid and the blood needs to be estimated but not more than 4 units of blood in the first 24 hours
+ No detected organ damage in the abdominal cavity undergoing surgery (especially hollow organs)
+ Hematological indexes are stable or change within permitted limits + Soft belly, no reaction
+ Having adequate medical diagnostic facilities (ultrasound, CT scan) good monitor andresusciationconditions, a contingent of digestive surgeons and operating rooms at any times if non-operative treatment fails and require emergency surgery
Non-operative treatment follow-up procedure
- Patient is asked to rest in bed, closely monitored in the first 24 hours: + Hemodynamic status: pulse, blood pressure
+ Abdominal condition,combined injuries
+ Ultrasound and complete blood count tests may be repeated several times to monitor the progression of the lesion
- Compensation of fluid, blood, depending on the patient's condition and prophylactic antibiotics
Trang 12Monitoring and evaluating the results of non-operative
treatment
- Success: patients do not suffer from surgery (the time from admission to discharging to the hospital), complications are treated with less invasive intervention
- Failure: Patients are indicated non-operative treatment but then have to undergo surgery due to the following reasons: Continued bleeding, peritonitis due to hollow organ or combination organs lesions (pancreas, kidney , spleen)
2.2.3.4 Surgical treatment
Indication
+ Blood loss shock, no response or temporary response to initial resuscitation, after that hemodynamics is still unstable, even though after compensation of fluid and the blood needs
+ Abdominal bloating, increased abdominal pain level and fluid + There is a compromised lesion that needs intervention (hollow organs)
+ Hepatic liver damage spreads to the porta hepatis on CT scan + Non-operative treatment failure: Hepatic rupture, continuous bleeding, detection of hollow organ lesions requiring surgical intervention
Surgical methods of LT treatment: Burning electrolyte, liver suturing, inserting hemostatic gauze, resection liver If the surgery shows that the liver damage has stopped bleeding: Clean the abdomen, carefully examine other organs to avoid missing lesions, put backup drains
Dealing with combined injuries
Subclinic:
- Blood tests: Hematology, biochemistry (GOT, GPT)
Trang 13- Abdominal ultrasound: Determine liver damage, abdominal fluid
- Abdominal CT scan: Determine liver damage, abdominal fluid
- Accuracy of ultrasound, CT compared to surgery
- Diagnosis of combined lesions
2.2.4.2 Results of treatment
- Treatment indications: First-aid surgery, non-operative treatment (success/ failure to undergo surgery)
- Reason for emergency surgery
Results of surgery: surgical incision, grading of liver rupture, degree of blood loss, methods to resolve lesions
General results: Death, early complications, hospital stay time
- Evaluate results soon
Non-operative treatment group (According to author Nguyen Ngoc Hung):
+ Good: Patients who received successfully non-operative treatment, there were no complications during monitoring and treatment
+ Moderate: Patients have complications operativetreatment but have stable medical treatment or less invasive intervention, not undergo surgery
duringnon-+ Poor: Patients have failed non-operativetreatment then undergo surgery to management of liver and organs damage due to complications Surgical group (According to author Nguyen Hai Nam):
+ Good: Patients who have surgery and treatment of liver damage, postoperatively favorably without complications, discharged from hospital to good rehabilitate; Patients who received surgical treatment with mild complications were successfully treated by internal medicine without having to re-operate
+ Moderate: Patients have complications who have surgery or stable procedure intervention Restore normal function
+ Poor: Deaths during or after the surgery,having serious complications during or aftersurgery and/or poor clinical status
2.2.5 Data collection and analyzing
2.2.6 Research ethics