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Actualización del Manejo del Traumatismo Hepático en la Era
de la Radiología Vascular
Valladolid, 29 Octubre 2015
Juan Carlos Meneu Diaz
juancarlosmeneu.blogspot.com
@juancarlosmeneu
www.oncocir.com
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE
SYMPOSIUM TRAUMA HURH 2015
Cirugía General Aparato Digestivo.
Hospital 12 de Octubre
Unidad de Cirugía Hepática Biliar
Pancreática. Clínica Ruber
Madrid
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE
SYMPOSIUM TRAUMA HURH 2015
MacKenzie S, Kortbeek JB, Mulloy R, Hameed SM. Recent experience with multidisciplinary approach to complex hepatic
trauma. Injury. 2004;35:869–77.
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE
SYMPOSIUM TRAUMA HURH 2015
http://ec.europa.eu/transport/road_safety/specialist/statistics/index_en.htm
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE
SYMPOSIUM TRAUMA HURH 2015
Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg.2005;200:648–69.
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE
SYMPOSIUM TRAUMA HURH 2015
Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg.2005;200:648–69.
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE
SYMPOSIUM TRAUMA HURH 2015
Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg.2005;200:648–69.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Evolution. Liver trauma
● During last 3 decades, liver injury increased.
This could be actual or artificial due to better
diagnostic modalities
● Mortality
○ W 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.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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;200:648–69.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
Juan Carlos Meneu Diaz
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
From a surgical point of view
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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;35:869–77.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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).
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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 organs
○ Free fluid and Amount
○ Pneumothorax
● CT 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
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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;66:332–6.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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;66:332–6.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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.
Cuff RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: The value of follow-up abdominal
computed tomography scans. Am Surg. 2000;66:332–6.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Cuff RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: The value of follow-up abdominal
computed tomography scans. Am Surg. 2000;66:332–6.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
LIVER TRAUMA
STABLE PATIENT UNSTABLE PATIENT or PERITONITIS
GRADING CT SCAN
with IV contrast
OPERATING ROOM
MANAGE ACCORDING TO GRADE and
additional information. Re SCAN if
needed Laparotomy Laparoscopy
Nonoperative 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 S288–S293
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
Juan Carlos Meneu Diaz
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Initial management is done according to ATLS protocol
Criteria 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
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
H. Leon Pachter
George David Stewart Professor of Surgery, Chair of the Department of Surgery at
NYU Langone Medical Center
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Non OPerative Management (NOPM)
80% of patients with hepatic injuries can now be managed conservatively
Interventional techniques such as:
● endoscopic retrograde cholangiopancreatography,
● angiography
● laparoscopy, 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: 606–611
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Non OPerative Management (NOPM)
- 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 complications
- If HS; no longer considered absolute contraindications
- Severity of hepatic injury (CT grade or degree of hemoperitoneum)
- neurologic status
- presence of a “blush” on CT scan
- age greater than 55 years, and/or
- the 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: 475–480; discussion 480–481.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
Juan Carlos Meneu Diaz
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Initial management is done according to ATLS protocol
Criteria for Non OPerative Management (NOPM) (II)
Key points:
● Good quality CT scans
● Experienced radiologist
● Intensive care setting and expertised
● Quickly 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;66:332–6.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Non OPerative Management (NOPM)
Non-operative management (NOPM) consists of
● close observation of the patient complemented with
● angio-embolization, if necessary.
Observational management involves
● admission to a unit and the monitoring of vital signs,
● strict bed rest,
● frequent monitoring of hemoglobin concentration
● serial abdominal examinations
Cuff RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: The value of follow-up abdominal
computed tomography scans. Am Surg. 2000;66:332–6.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Non OPerative Management (NOPM)
Not enough literature to recommend
● Frequency of hemoglobin measurements
● Time to reinitiating oral intake
● Duration 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.
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Non OPerative Management (NOPM)
Indication for angiography if
● transfusion of 4 units of RBCs in 6 hours or
● 6 units of RBCs in 24 hours without hemodynamic
instability
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Non OPerative Management (NOPM)
Complications: Delayed hemorrhage
● most common, usual indication for a delayed operation
● under 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
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
DELAYED
HAEMORRHAGE
STABLE PATIENT UNSTABLE
PATIENT
CT SCAN
OPERATING ROOM
Pooling of contrast
Laparotomy Laparoscopy
Liver injury unchanged
Angiogram/embolization
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Operative Management (OPM)
● In hemodynamically unstable patient
● Grade IV, V and VI injuries
● Goal is to arrest Hemorrhage
Initial control of hemorrhage is attained by
Perihepatic packing
Mannual compression
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Operative Management (OPM)
4 Ps of operative management • Operative management can be
summarized as
1. PUSH
2. PRINGLE
3. PLUG
4. PACK
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Operative Management (OPM)
Summarized as
● Initial control of bleeding temporary tamponade
○ using packs
○ portal triad occlusion
○ bimanual compression of the liver or
○ compression abdominal aorta above celiac trunk
● If is unaffected major vena cava injury or atypical
vascular anatomy should be expected
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
● Right costal margin is elevated
● Additional pads should be placed between the
liver, diaphragm, and anterior chest
● Sometimes 10 to 15 pads may be required
● Removing packing when:
○ Body Tº > 36ºC
○ Base deficit > (-) 4
○ Lactate normal
○ No coagulopathy
○ Low dose vasoactive drugs
○ Sat 95% with FiO2< 50%
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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 repaired
● low incidence of rebleeding, necrosis and sepsis
● effectives following blunt liver trauma requires further
evaluation
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Operative Management (OPM)
Mesh rapping
● new technique for grade III,IV laceration
● especially when combined with ipsilateral ligation
of the bleeding vessel.
● tamponading large intrahepatic hematomas
● not indicated where juxtacaval or hepatic vein
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
Criteria for Operative Management (OPM)
Intrahepatic tamponade. Ballon tamponading
● Transhepatic penetrating wound
● Use of 2.5 cm Penrose
● Hollow catheter (Robinson Catheter)
● Inflated with soluble contrast agent
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
1. Nonoperative management: modality of choice in HS
2. Only in an environment that provides capabilities
3. H. Instability and peritonitis still warrant emergent surgery
4. Enhanced CT scan: of choice
5. Repeated imaging : patient’s clinical status
6. Adjunctive therapies ( angiography, percutaneous
drainage,ERCP laparoscopy)
Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular
II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
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Actualización del manejo del traumatismo hepático en la era de la radiología vascular

  • 1. Actualización del Manejo del Traumatismo Hepático en la Era de la Radiología Vascular Valladolid, 29 Octubre 2015 Juan Carlos Meneu Diaz juancarlosmeneu.blogspot.com @juancarlosmeneu www.oncocir.com II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Cirugía General Aparato Digestivo. Hospital 12 de Octubre Unidad de Cirugía Hepática Biliar Pancreática. Clínica Ruber Madrid
  • 2. II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 MacKenzie S, Kortbeek JB, Mulloy R, Hameed SM. Recent experience with multidisciplinary approach to complex hepatic trauma. Injury. 2004;35:869–77.
  • 3. II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 http://ec.europa.eu/transport/road_safety/specialist/statistics/index_en.htm
  • 4. II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg.2005;200:648–69.
  • 5. II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg.2005;200:648–69.
  • 6. II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Richardson JD. Changes in the management of injuries to the liver and spleen. J Am Coll Surg.2005;200:648–69.
  • 7. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Evolution. Liver trauma ● During last 3 decades, liver injury increased. This could be actual or artificial due to better diagnostic modalities ● Mortality ○ W 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.
  • 8. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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;200:648–69.
  • 9. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular Juan Carlos Meneu Diaz II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 From a surgical point of view
  • 10. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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;35:869–77.
  • 11. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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).
  • 12. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
  • 13. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
  • 14. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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
  • 15. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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 organs ○ Free fluid and Amount ○ Pneumothorax ● CT 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
  • 16. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
  • 17. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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;66:332–6.
  • 18. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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;66:332–6.
  • 19. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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. Cuff RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: The value of follow-up abdominal computed tomography scans. Am Surg. 2000;66:332–6.
  • 20. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Cuff RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: The value of follow-up abdominal computed tomography scans. Am Surg. 2000;66:332–6.
  • 21. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 LIVER TRAUMA STABLE PATIENT UNSTABLE PATIENT or PERITONITIS GRADING CT SCAN with IV contrast OPERATING ROOM MANAGE ACCORDING TO GRADE and additional information. Re SCAN if needed Laparotomy Laparoscopy Nonoperative 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 S288–S293
  • 22. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular Juan Carlos Meneu Diaz II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
  • 23. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Initial management is done according to ATLS protocol Criteria 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
  • 24. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 H. Leon Pachter George David Stewart Professor of Surgery, Chair of the Department of Surgery at NYU Langone Medical Center
  • 25. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Non OPerative Management (NOPM) 80% of patients with hepatic injuries can now be managed conservatively Interventional techniques such as: ● endoscopic retrograde cholangiopancreatography, ● angiography ● laparoscopy, 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: 606–611
  • 26. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Non OPerative Management (NOPM) - 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 complications - If HS; no longer considered absolute contraindications - Severity of hepatic injury (CT grade or degree of hemoperitoneum) - neurologic status - presence of a “blush” on CT scan - age greater than 55 years, and/or - the 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: 475–480; discussion 480–481.
  • 27. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular Juan Carlos Meneu Diaz II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Initial management is done according to ATLS protocol Criteria for Non OPerative Management (NOPM) (II) Key points: ● Good quality CT scans ● Experienced radiologist ● Intensive care setting and expertised ● Quickly 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;66:332–6.
  • 28. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Non OPerative Management (NOPM) Non-operative management (NOPM) consists of ● close observation of the patient complemented with ● angio-embolization, if necessary. Observational management involves ● admission to a unit and the monitoring of vital signs, ● strict bed rest, ● frequent monitoring of hemoglobin concentration ● serial abdominal examinations Cuff RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: The value of follow-up abdominal computed tomography scans. Am Surg. 2000;66:332–6.
  • 29. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Non OPerative Management (NOPM) Not enough literature to recommend ● Frequency of hemoglobin measurements ● Time to reinitiating oral intake ● Duration 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.
  • 30. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Non OPerative Management (NOPM) Indication for angiography if ● transfusion of 4 units of RBCs in 6 hours or ● 6 units of RBCs in 24 hours without hemodynamic instability
  • 31. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Non OPerative Management (NOPM) Complications: Delayed hemorrhage ● most common, usual indication for a delayed operation ● under 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
  • 32. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 DELAYED HAEMORRHAGE STABLE PATIENT UNSTABLE PATIENT CT SCAN OPERATING ROOM Pooling of contrast Laparotomy Laparoscopy Liver injury unchanged Angiogram/embolization
  • 33. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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
  • 34. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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
  • 35. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015
  • 36. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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
  • 37. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Operative Management (OPM) ● In hemodynamically unstable patient ● Grade IV, V and VI injuries ● Goal is to arrest Hemorrhage Initial control of hemorrhage is attained by Perihepatic packing Mannual compression
  • 38. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Operative Management (OPM) 4 Ps of operative management • Operative management can be summarized as 1. PUSH 2. PRINGLE 3. PLUG 4. PACK
  • 39. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Operative Management (OPM) Summarized as ● Initial control of bleeding temporary tamponade ○ using packs ○ portal triad occlusion ○ bimanual compression of the liver or ○ compression abdominal aorta above celiac trunk ● If is unaffected major vena cava injury or atypical vascular anatomy should be expected
  • 40. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 ● Right costal margin is elevated ● Additional pads should be placed between the liver, diaphragm, and anterior chest ● Sometimes 10 to 15 pads may be required ● Removing packing when: ○ Body Tº > 36ºC ○ Base deficit > (-) 4 ○ Lactate normal ○ No coagulopathy ○ Low dose vasoactive drugs ○ Sat 95% with FiO2< 50%
  • 41. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 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 repaired ● low incidence of rebleeding, necrosis and sepsis ● effectives following blunt liver trauma requires further evaluation
  • 42. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Operative Management (OPM) Mesh rapping ● new technique for grade III,IV laceration ● especially when combined with ipsilateral ligation of the bleeding vessel. ● tamponading large intrahepatic hematomas ● not indicated where juxtacaval or hepatic vein
  • 43. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Criteria for Operative Management (OPM) Intrahepatic tamponade. Ballon tamponading ● Transhepatic penetrating wound ● Use of 2.5 cm Penrose ● Hollow catheter (Robinson Catheter) ● Inflated with soluble contrast agent
  • 44. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 1. Nonoperative management: modality of choice in HS 2. Only in an environment that provides capabilities 3. H. Instability and peritonitis still warrant emergent surgery 4. Enhanced CT scan: of choice 5. Repeated imaging : patient’s clinical status 6. Adjunctive therapies ( angiography, percutaneous drainage,ERCP laparoscopy)
  • 45. Actualización del Manejo del Traumatismo Hepático en la era de la Radiología Vascular II JORNADA DE ACTUALIZACIóN EN LA ATENCIóN AL PACIENTE CON TRAUMA GRAVE SYMPOSIUM TRAUMA HURH 2015 Available at SLIDESHARE. Oncocir-Slideshare (http://es.slideshare.net/ruber12?utm_campaign=profiletracking&utm_medium=sssite&utm_source=ssslideview)