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Massive hepatic resection in the treatment of severe liver trauma
Massive Hepatic Resection in the Treatment of Severe Liver Trauma FREDERICK W. ACKROYD, M.D., Boston, Massachusetts JAMES POLLARD, M.D., Boston, Massachusetts WILLIAM V. MCDERMOTT, JR., M.D., Boston, Massachusetts
The incidence of severe liver trauma is rising. Violence in the cities and high speed highway accidents are the most important contributing factors in civilian cases whereas penetrating, high velocity missile wounds account for the largest part of the military experience. Management of severe liver injury has traditionally been directed toward controlling exsanguinating hemorrhage and has been characterized by large isolating mattress stitches, packing with gauze or absorbent materials, and drainage. The mortality has been high (between 40 and 60 per cent) and the rate of serious complications approximately 50 per cent in the survivors [I$]. Most of the postoperative complications can be attributed to (1) continued bleeding, (2) necrosis of devitalized liver, and (3) subphrenic collections of blood and bile which become septic [3,4]. The increasing experience with elective liver resections for malignancy, both primary and metastatic, and the conviction that in many instances extensive damage to the liver from trauma may best be treated by formal hepatic resection rather than by attempts to reconstruct a badly fragmented lobe, have resulted in a growing body of clinical material which supports the concept of resection of devitalized tissues, drainage of injured areas, and vigorous postoperative metabolic support [6,6].
Clinical Material Interest at the Sears Laboratory in massive liver injury has evolved from the recent combined military and civilian experience of twenty-three From the Department of Surgery, Harvard Medical School, Fifth (Harvard) Surgical Service, Sears Surgical Laboratory, Boston City Hospital, and the Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts. Presented at the annual meeting of the New England Surgical Society, West Harwich, Massachusetts, September 26-28. 1968. 442
cases resulting from abdominal trauma.
Civilian
either
penetrating
or blunt
Experience
Blunt Nonpenetratirhg Trauma. Injury to the liver in civilian life may be the result of stab or gunshot wounds, but the interesting contrast to war injuries can be made mainly through the increasing numbers of fragmenting wounds of the liver suffered as a consequence of blunt trauma from highway accidents. The following selective case histories illustrate the problem and indicate how emergency resection by planned anatomic approaches can be utilized successfully. CASE I. The patient (R. G., MGH No. 1465738), a forty-seven year old man, suffered severe blunt abdominal trauma in an automobile accident four weeks prior to admission producing severe, deep liver lacerations which were treated elsewhere with suture of the hepatic capsule. Ten days prior to transfer, the patient began to run a septic course, and referral for emergency management was necessitated by massive hemorrhage and septicemia. Angiography demonstrated a large intrahepatic abscess with multiple arteriovenous fistulas (Fig. 1.) The patient underwent an emergency right hepatic lobectomy through a thoracoabdominal incision with insertion of a common duct T tube and appropriate drains. The postoperative course was complicated by a lung abscess in the right lower lobe and homologous serum jaundice both of which eventually cleared on conservative management over a three month period. He is now alive and in good health. Comment: This case illustrates the complications of recurrent hemorrhage and sepsis which may attend suture and packing in extensive liver injury, and points up t,he importance of anatomic resection when indicated by the extent of devitalized tissue. CASE II. The patient (T. E., Quincy City Hospital No. 43596%3), an eighteen year old gid, suffered The American
Journal
of Surgery
Hepatic
A Fig. 1.
Angiogram
for Liver Trauma
8
revealing dye in abscess
source
cavity indicates
of hemobilia
A
(case I).
i3 Fig. 2.
Stellate
laceration
blunt abdominal trauma in an automobile accident and u-as admitted to the accident room in shock. Exploratory laparotomy revealed a deep laceration of the dome of the right lobe of the liver (Fig. 2), which was initially packed, drains were placed, and the abdomen was closed. Two hours after exploration the abdomen became distended and the patient became hypotensive; it became apparent t.hat intraperitoneal hemorrhage had recurred. The abdomen was reexplored and right hepatic lobectomy was carried out through a thoracoabdominal approach. The patient tolerated the procedure well, requiring a total of 13 units of blood. A T tube was placed in the common duct, and sump drains were placed in the operative area. Pleural effusions developed on the right side which were tapped and proved to be sterile. A 20 per cent pneumothorax of the right side was noted, but this gradually re-expanded. The patient was discharged in good condition one month after hepatic resection. Vol.117.April1969
Resection
of liver (case II).
Comment: hemorrhage
The after
rapid mattress
sizes the role of emergency procedure
in selected
recurrence suture
of
massive
control
empha-
resection
as an initial
cases of liver trauma.
CASE III. The patient (A, B., Quincy City Hospital No. 434207-7), a nineteen year old boy, suffered blunt abdominal trauma in an automobile accident and was admitted to the accident room in shock. Exploratory laparotomy revealed complete fracture of the entire right lobe of the liver, and right hepatic lobectomy was carried out through a thoracoabdominal incision. Postoperatively, pneumothorax developed which necessitated reinsertion of a thoracostomy tube and wound dehiscence required resuture. A subphrenic abscess became apparent on the twelfth postoperative day and drainage through a subcostal incision was carried out. He is at present still hospitalized but is improving steadily. 443
Ackroyd,
Pollard,
and McDermott
Comment: Although emergency resection may also be attended by postoperative complications, complete fracture of the right lobe of the liver could not have been managed successfully by any procedure short, of right hepatic lobectomy.
drainage or local suture. Severe hemorrhage was not a factor in these cases and these less extensive liver injuries were treated by limited reconstructive procedures [7].
CASE IV. The patient (B. G., BCH No. 5482502), a twenty-eight year old woman, was stabbed in the right upper quadrant with multiple thrusts of a long hunting knife. At laparotomy several deep transverse lacerations involving both the right and left lobes of the liver were noted. Profuse hemorrhage did not respond to the usual measures and resection was at first avoided because of the obvious involvement of both lobes. In the presence of exsanguinating hemorrhage a right lobectomy was carried out in the hope of controlling major vein damage in the course of resection. A 3 cm. laceration of the vena cava in the region of the take-off of the superior hepatic vein was encountered and repaired, but the patient became profoundly hypothermic from large volume replacement with refrigerated blood. Arrhythmias and finally cardiac arrest occurred.
In a series of twenty-three cases of severe live1 injury representing civilian and combat experience, five of six patients who were managed conservatively with packing and suture died. In a subsequent group of sixteen patients with severe liver trauma treated with excisional therapy using anatomic lobectomy technics, only one of sixteen died.
Comment: Injuries involving both lobes or in the midplane between the lobes frequently result in laceration of the vena cava or avulsion of the hepatic veins from the vena cava at their point of origin. Venous bleeding of this type is well recognized as a formidable problem and represents an early indication for aggressive resectional therapy. Patient temperature monitoring and blood warming before infusion in massive replacement are also an essential part of therapy.
Military
Experience
Penetrating, High Velocity Nissile Wounds. All cases included in this portion of the report were caused by penetrating, high velocity missile wounds which resulted in severe implosion injury of the liver with devastating destruction of the architecture. The six initial patients admitted for emergency surgery were managed with packing and mattress sutures through the fracture lines, and five died of recurrent hemorrhage or sepsis. In view of the prohibitive mortality the decision was made to attempt excisional treatment using anatomic lobectomy technics. All of the subsequent thirteen patients with severe liver injuries treated by the excisional approach survived. It should be noted that numerous combat casualties not included in this report were noted to have liver injuries from shrapnel or other low velocity missiles which presented as hemoperitoneum or as incidental findings at laparotomy for other intraabdominal injuries and were treated with simple 444
Results
Comments The first reported successful limited hepatic resection for treatment of a gunshot wound was that reported by Bruns in 1870 [8]. The first presented series of liver injury treated by anatomic hepatic resection was that of McClelland, Shires, and Poulos in which they reported an over-all mortality of only 20 per cent and a relatively low complication rate [9]. Since that time a number of investigators have documented their experiences in the treatment of a variety of hepatic trauma with different technics [4,10-I%‘]. In general, incisive injury of the liver from simple penetrating trauma such as a knife wound or low velocity missile wound is easily treated with low risk, and hemorrhage is usually not a problem. However, high energy penetrating or nonpenetrating trauma t,o the liver with extensive destruction of hepatic parenchyma is attended by interruption of numerous vascular pathways in a very vascular organ, and frequent involvement of the major vessels including the hepatic veins and vena cava is seen. There is a growing body of evidence that these major hepatic injuries are best treated by aggressive excisional therapy utilizing anatomic lobectomy technics [15-161. The objectives of treatment of massive hepatic injury are usually considered to be (1) control of exsanguinating hemorrhage, (2) removal of devitalized tissue, (3) prevention of bile leakage either by adequate ligation of the bile ducts in the triads on the resected liver margin or employment of T tube drainage of the common duct, (4) establishment of adequate subhepatic and subphrenic drainage to eliminate collections of blood and bile which invariably became septic, and (5) administration of antibiotics guided by culture and sensitivity data combined with aggressive secondary drainage of abscess as needed. The American
Journal of Surgery
Hepatic
TABLE
Case
I
Survey
Type of Accident
of Twenty-Three
Resection
for Liver Trauma
Patients
Postoperative Complications
Operation
Injury of Major Vessels
Extent of Liver Injury
Civilian __.R. G.
Automobile
Right lobectomy
T. E.
Automobile
Right lobectomy
A. 6.
Automobile
Right lobectomy
B. G.
Knife
Right lobectomy
Subphrenic abscess and pneumothorax Dehiscence, subphrenic abscess, and pneumothorax Subphrenic abscess and pneumothorax Death, shock, and hemorrhage
~~~ .-
Shattered
right lobe
No
Shattered
right lobe
No
Shattered
right lobe
No
Shattered
right lobe
Yes (right and left hepatic veins)
~~
~~~_______
_-..-.
Military
L. S.
HVM
Packing
T. K.
HVM
Suture
Packing
R. L.
HVM
Suture
Packing
T. P.
HVM
Suture
Packing
B. L. M.Q. J. B. A. N.
HVM HVM HVM HVM
Right lobectomy Right lobectomy Right lobectomy Left Iobectomy
Death, shock, and hemorrhage Death, shock, and hemorrhage Death, shock, and hemorrhage Death, shock, and hemorrhage Subphrenic abscess Subphrenic abscess None None
S. N.
HVM
Right lobectomy
Subphrenic
H. S.
HVM
Right lobectomy
None
L. 6.
HVM
None
L. N.
HVM
Exploration Right lobectomy Suture Packing
Death
A. R.
HVM
Suture
Death
N. J.
HVM
Right lobectomy
Wound
L. T.
HVM
Right lobectomy
Subphrenic
P. B.
HVM
Right lobectomy
Wound
J. M. N. Z.
HVM HVM
Left lobectomy Left lobectomy
None None
M. B.
HVM
Left lateral lobectomy
Left subphrenic
Vol. 117, April 1969
Packing
abscess
Shattered right and left lobe Shattered right and left lobe Shattered right lobe
Yes (right hepatic vein) Yes (right hepatic vein) Yes
Shattered right lobe, segmented left lobe Shattered right lobe Shattered right lobe Shattered right lobe Shattered lateral segmented left lobe Shattered right lobe
Yes
Shattered lateral aspect of right lobe Shattered lateral aspect of right lobe Shattered right lobe Shattered right lobe, Med. segment left lobe Shattered right lobe
sepsis abscess
dehiscence
abscess
Shattered lateral aspect of right lobe Shattered lateral aspect of right lobe Shattered left lobe Shattered lateral segment of left lobe Shattered lateral segment of left lobe
Yes No No No Yes (right hepatic vein No No Yes (right hepatic vein) Yes (hepatic veins) Yes (hepatic veins) Yes (right hepatic vein) Yes (right hepatic vein) No No No
445
Ackroyd, Pollard, and McDermott
Injury to the vena cava or one of the main hepatic veins was noted in several cases in this series, and it was apparent that control of hemorrhage could not have been achieved except by an aggressive approach and vascular suture of the patent vessels. The risk of air embolism from the open hepatic veins is a real one and must be guarded against. Only in recent years has the importance of resection of all devitalized liver tissues, through hemostasis, and adequate abdominal drainage been fully appreciated and employed
rupture. In fact, since angiography shows the inner hepatic architecture, it often gives a better idea of the extent of intrahepatic destruction than does a look at the surface of the liver at laparotomy. Metabolic requirements after extensive hepatic resection have been well defined and focus upon early maintenance of blood sugar levels and generous supportive therapy with intravenous human serum albumin [16,19,90].
1’4. Merendino, Dillard, and Cammock [II] have strongly advocated biliary drainage in the past. This has the theoretic advantage of reduction of leakage from the injured liver tissue and reduced intraductal pressure which might produce new leaks from the cut surface of the liver [11]. Equally important is accurate ligation of the appropriate branches of the portal triad during transection of hepatic parenchyma and either injection of colored material such as methylene blue into the common duct or an operative cholangiogram to check for extravasation from unrecognized open branches of the ductal system on the cut surface of the liver. (Fig. 3.) The decision between reconstructiou and resection is a difficult one and depends on surgical judgment as to the actual rather than apparent of damage to liver tissue. Often digital exploration seemingly minor surface lacerations will reveal extensive intrahepatic destruction. If the rondit’ion of the patient permits, we [17] and others [18] have found selective hepatic angiography of great help in establishing t,he diagnosis and extent of hepatic
1. Severe fracture injuries of the liver with extensive parenchymal destruction should be resected along anatomic planes for control of hemorrhage and limitation of po&traumatic and abscess formation. necrosis, bile leakage, Minor liver injuries can successfully be treated by ligation and suture reconstruction without wide resection. Preoperative angiography is helpful in defining the extent of injury. 2. Operative cholangiography or injection of dye into the common duct to check completeness of bile duct ligation in the parenchymal portal triads greatly reduces postoperative problems of subphrenic bile collections and sepsis. 3. Intravenous supplements of glucose for the first twenty-four hours and albumin for seven to ten days are essential until the residual liver tissue can keep pace with convalescent requirements. 4. The use of T tube decompression of the common duct is useful and may offer protection from parenchymal bile leakage unless contraindicated by a duct of small caliber. 5. Generous use of drains and sumps to remove subphrenic collections of bile, plasma, and blood markedly reduces postoperative morbidity.
Conclusions
References 1. HELLSTROM, G. Closed injury of the liver: analysis of a series of 300 cases. Acta chir. scandinav., 122: 490, 1961.
Fig. 3. Operative cholangiogram cut surface of the liver. 446
revealing no leaks from
2. MIKAL, S. and PAPEN, G. Morbidity and mortality in ruptured liver. Surgery, 27: 520, 1950. 3. SPARKMAN, R. S. and FOGELMAN, M. J. Wounds of the liver: review of 100 cases. Ann. Burg., 139: 690, 1954. 4. MIKESKY, W. E., HOWARD, J. M., and DEBAKEY, M. E. Injuries to the liver in 300 consecutive patients. Internat. Abstr. Surg., 103: 323, 1956. 5. FOSTER, J. H., LAWLER, M. R., WELBORN, M. B., HOLCOMB, G. W., and SAWYERS, J. L. Recent experience with major hepatic resection. Ann. Surg., 167: 651, 1968. 6. ARONSEN, K. F., BENGMARK, S., DAHLGREN, S., ENGEVIK, L., ERICSSON, B., and THOREU, L. The American
Journal of Surgery
Hepatic Resection for Liver Trauma
7.
8. 9.
10.
11.
12.
13.
Liver resection in the treatment of blunt injuries to the liver. Surgery, 63: 236, 1968. PERRY, J. F., ROOT, H. D., HANSER,C. W., and KEISER, P. J. Treatment of hepatic injuries. Surgery, 62: 853, 1967. GARRE, C. Beitrage zur leber Chirurgie. Be&. klin. Chir., 4: 181, 1888. MCCLELLAND,R., SHIRES, T., and POULOS,E. Hepatic resection for massive trauma. 1. Trauma, 4: 282, 1964. BAKER, R. J., TAXMAN,P., and FREEARK,R. J. An assessment of the management of nonpenetrating liver injuries. Arch. Surg., 93: 84, 1966. MERENDINO,K. A., DILLARD,D. H., and CAMMOCK,E. E. Surgical biliary decompression in the management of liver trauma. Surg. Gynec. & Obst., 177: 285, 1963. MCCLELLAND,R. and SHIRES, T. Management of liver trauma in 259 consecutive patients. Ann. Surg., 161: 248, 1965. LORTAT-JACOB,U. L. and ROBEKT, H. G. Hepatectomie droite reglce. Presw m&d., 60: 549, 1952.
14. QUATTLEBAUM, J. K. and QUATTLEBAUM, J. II., JR. Technique of hepatic lobectomy. Ann. Burg., 149: 648, 1959.
15. PACK, G. T. and ISLAMI,A. H. Operative treatment of hepatic tumors. C&n. Symposium, 16: 35, 1964. 16. WILLIAMS,L. F. and BYRNE,J. J. Trauma to the liver at the Boston City Hospital from 1955 to 1965. Am. J. Surg., 112: 368, 1966. 17. POLLARD,J. J., NEBESAR,R. A., and FLEISCHLI, D. J. Angiography in abdominal trauma. In preparation. 18. BOIJSEN, E., JUDKINS, M. P., and SIMAY, A. Angiographic diagnosis of hepatic rupture. Radiology, 86: 66, 1966. 19. STONE,F. A., SIDERINS,M. J., GOODMAN, J. ;Ll., ZICK, H. R., BLAHUT,R. J., and DYESS, N. H. Treatment of exsanguinating rupture of the right lobe of the liver by ligation of the main hepatic artery. Ann. Surg., 162: 933, 1965. 20. MONACO, A. P., HALLGRIMSSON, J., and McDERMOTT,W. V., JR. Multiple adenoma (hamartoma) of the liver treated by subtotal (99%) resection: morphological and functional studies of regeneration. Ann. Surg., 159: 513, 1964.
Discussion of Papers by Drs. Taylor and Ackroyd A. BIRTCH(Boston, Mass.) : I would like to address my remarks to Dr. Filler. We tend to learn more from the few failures in such a study than from the many successes you have presented. On the problem of air Vol. 117,April 1969
embolus occurring during use of the abdominal approach, were there other cases in which operation was performed via the abdomen without air embolism? The failure of the liver to regenerate after resection and immediate therapy with actinomycin C and radiation is of considerable interest. In liver transplantation in which the antimetabolite aeathioprine (Imuran@) has been used for immunosuppression, one wonders whether a similar inhibition of regenerative power may be acting. A. D. CALLOW (Boston, Mass.): I wish to extend my thanks for this most interesting and helpful paper and to ask a single question. Can the authors give us any additional guidelines beyond liver scan and hepatic arteriograms concerning the differentiation after partial hepatic resection between the abdominal mass which may represent recurrent malignancy or regenerating normal liver? W. H. HENDREN(Boston, Mass.): I would like to comment on the excellent paper concerning liver resection in children. It is a sizable series of cases and the results are certainly impressive. Our own experience on the Children’s Service at the Massachusetts General Hospital with a somewhat smaller group of similar cases is in complete agreement that these tumors, which are sometimes enormous, can often be removed. We agree that success in this requires not only aggressive surgery but also great operative support. In these cases, and in fact in any major operation in which we anticipate considerable blood loss, we routinely monitor constantly the venous pressure, radial artery pressure, body temperature, and electrocardiogram. In removing these large tumors blood loss can exceed one or two times the child’s blood volume. Replacement with ordinary bank blood preserved in acid citrate solution in past years sometimes resulted in cardiac arrest during the operation because acute metabolic acidosis can result from sudden infusion of blood preserved in this way. The potassium content of bank blood can also be rather high, an additional danger to the child. By contrast, children tolerate sudden massive blood replacement very well with fresh, warm blood drawn in heparin. We, therefore, have available an ample supply of this type of blood for all cases in which we anticipate great blood loss. Protamine is given to reverse the heparin, checking the child’s clotting time. A disadvantage of fresh hepariniaed blood is that it must be discarded if not used, which is wasteful. We believe, however, that this is justifiable when its availability provides additional safety for the child. We have used Dr. Charles Huggins’ frozen blood in about ten cases and have had quite a favorable experience with it. This consists of frozen red cells given together with a 5 per cent solution of albumin and saline. Up to the point of giving one blood volume of frozen blood to a child we have noted no labile blood factor changes, but beyond that point there is 447
Ackroyd, Pollard, and McDermott reduction in platelet count and fibrinogen concentration, which can be corrected by using platelet concentrates or fresh frozen plasma. We have avoided administering fibrinogen because this carries a very high risk of hepatitis. In addition, we believe that it is important to have two anesthesiologists for these cases, one to give anesthesia and the other to watch the monitors and supervise administration of blood and fluids. We think it is an invitation to disaster to undertake one of these cases without all of the aforementioned ancillary aids. R. M. FILLER (Boston, Mass.): In reference to Dr. Birtch’s question, early in our experience transabdominal guillotine resections were employed; in most recent cases anatomic lobectomies have been performed. There were two transabdominal left lohectomies and one additional right lobectomy. In terms of the studies which may bc a guide to recurrence of tumor, this is a difficult question to answer. In one of our cases, a boy who required two lobectomies, an abdominal mass developed after right hepatectomy which did not function on scan and was separate from the functioning liver tissue. In addition, an arteriogram made the diagnosis because of the presence of tumor vessels and tumor stain. One usually palpates a mass in the epigastrium after lobectomy even when there is no recurrence of tumor. This is due to regenerating liver tissue and can be differentiated from a large tumor by scan and arteriography. W. V. MCDERMOTT, JR. (closing) : Since the technic of hepatic resection has become standardized during the past decade and can be carried out with a very acceptable mortality, the question arises increasingly as to when major hepatic resection is indicated in the treatment of severe trauma. May I show some slides which I think illustrate the problem and indicate
448
why we should consider initial resection in selected instances of injury to the liver. This was a young girl (slide) who was brought into the hospital after an automobile accident. Abdominal exploration was carried out because of intraperitoneal hemorrhage which proved to be from a laceration of the liver. Mattress ligatures apparently controlled this hemorrhage; however, within a few hours after the conclusion of the procedure, massive intraabdominal hemorrhage recurred and we were asked to see the patient. It was clear that immediate resection would be required as a life-saving procedure, and this was carried out through a thoracoabdominal approach. Here we see a photograph (slide) of the result of blunt injury to the liver, and the stellate laceration does not seem very extensive. Once the liver was removed, however, one could see in the resected specimen of the right lobe (slide) what extensive damage had occurred within the liver without too much in the way of external evidence. A section through the specimen (slide) re-emphasizes the amount of necrotic devitalized tissue which may exist as a result of blunt trauma with apparently only superficial laceration through the liver capsule. This is not an uncommon experience, and other similar instances have been reported in our manuscript. If the amount of bleeding from the liver is not such that immediate exploration is required, preliminary arteriography will be of great help in defining the extent of disruption of the hepatic architecture. If this is not possible, digital examination through the lacerated surface of the liver may give some indication as to how much of the liver tissue has been turned into “mush” by the impact. As emphasized in Dr. Ackroyd’s presentation, I am sure that we can improve our results over the coming years by resorting to planned resection in selected cases of massive hepatic injury.
The American
Journal
of Surgery
The incidence of severe liver trauma is rising. Violence in the cities and high speed highway accidents are the most important contributing factors in civilian cases whereas penetrating, high velocity missile wounds account for the largest part of the military experience. Management of severe liver injury has traditionally been directed toward controlling exsanguinating hemorrhage and has been characterized by large isolating mattress stitches, packing with gauze or absorbent materials, and drainage. The mortality has been high (between 40 and 60 per cent) and the rate of serious complications approximately 50 per cent in the survivors [I$]. Most of the postoperative complications can be attributed to (1) continued bleeding, (2) necrosis of devitalized liver, and (3) subphrenic collections of blood and bile which become septic [3,4]. The increasing experience with elective liver resections for malignancy, both primary and metastatic, and the conviction that in many instances extensive damage to the liver from trauma may best be treated by formal hepatic resection rather than by attempts to reconstruct a badly fragmented lobe, have resulted in a growing body of clinical material which supports the concept of resection of devitalized tissues, drainage of injured areas, and vigorous postoperative metabolic support [6,6].
Clinical Material Interest at the Sears Laboratory in massive liver injury has evolved from the recent combined military and civilian experience of twenty-three From the Department of Surgery, Harvard Medical School, Fifth (Harvard) Surgical Service, Sears Surgical Laboratory, Boston City Hospital, and the Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts. Presented at the annual meeting of the New England Surgical Society, West Harwich, Massachusetts, September 26-28. 1968. 442
cases resulting from abdominal trauma.
Civilian
either
penetrating
or blunt
Experience
Blunt Nonpenetratirhg Trauma. Injury to the liver in civilian life may be the result of stab or gunshot wounds, but the interesting contrast to war injuries can be made mainly through the increasing numbers of fragmenting wounds of the liver suffered as a consequence of blunt trauma from highway accidents. The following selective case histories illustrate the problem and indicate how emergency resection by planned anatomic approaches can be utilized successfully. CASE I. The patient (R. G., MGH No. 1465738), a forty-seven year old man, suffered severe blunt abdominal trauma in an automobile accident four weeks prior to admission producing severe, deep liver lacerations which were treated elsewhere with suture of the hepatic capsule. Ten days prior to transfer, the patient began to run a septic course, and referral for emergency management was necessitated by massive hemorrhage and septicemia. Angiography demonstrated a large intrahepatic abscess with multiple arteriovenous fistulas (Fig. 1.) The patient underwent an emergency right hepatic lobectomy through a thoracoabdominal incision with insertion of a common duct T tube and appropriate drains. The postoperative course was complicated by a lung abscess in the right lower lobe and homologous serum jaundice both of which eventually cleared on conservative management over a three month period. He is now alive and in good health. Comment: This case illustrates the complications of recurrent hemorrhage and sepsis which may attend suture and packing in extensive liver injury, and points up t,he importance of anatomic resection when indicated by the extent of devitalized tissue. CASE II. The patient (T. E., Quincy City Hospital No. 43596%3), an eighteen year old gid, suffered The American
Journal
of Surgery
Hepatic
A Fig. 1.
Angiogram
for Liver Trauma
8
revealing dye in abscess
source
cavity indicates
of hemobilia
A
(case I).
i3 Fig. 2.
Stellate
laceration
blunt abdominal trauma in an automobile accident and u-as admitted to the accident room in shock. Exploratory laparotomy revealed a deep laceration of the dome of the right lobe of the liver (Fig. 2), which was initially packed, drains were placed, and the abdomen was closed. Two hours after exploration the abdomen became distended and the patient became hypotensive; it became apparent t.hat intraperitoneal hemorrhage had recurred. The abdomen was reexplored and right hepatic lobectomy was carried out through a thoracoabdominal approach. The patient tolerated the procedure well, requiring a total of 13 units of blood. A T tube was placed in the common duct, and sump drains were placed in the operative area. Pleural effusions developed on the right side which were tapped and proved to be sterile. A 20 per cent pneumothorax of the right side was noted, but this gradually re-expanded. The patient was discharged in good condition one month after hepatic resection. Vol.117.April1969
Resection
of liver (case II).
Comment: hemorrhage
The after
rapid mattress
sizes the role of emergency procedure
in selected
recurrence suture
of
massive
control
empha-
resection
as an initial
cases of liver trauma.
CASE III. The patient (A, B., Quincy City Hospital No. 434207-7), a nineteen year old boy, suffered blunt abdominal trauma in an automobile accident and was admitted to the accident room in shock. Exploratory laparotomy revealed complete fracture of the entire right lobe of the liver, and right hepatic lobectomy was carried out through a thoracoabdominal incision. Postoperatively, pneumothorax developed which necessitated reinsertion of a thoracostomy tube and wound dehiscence required resuture. A subphrenic abscess became apparent on the twelfth postoperative day and drainage through a subcostal incision was carried out. He is at present still hospitalized but is improving steadily. 443
Ackroyd,
Pollard,
and McDermott
Comment: Although emergency resection may also be attended by postoperative complications, complete fracture of the right lobe of the liver could not have been managed successfully by any procedure short, of right hepatic lobectomy.
drainage or local suture. Severe hemorrhage was not a factor in these cases and these less extensive liver injuries were treated by limited reconstructive procedures [7].
CASE IV. The patient (B. G., BCH No. 5482502), a twenty-eight year old woman, was stabbed in the right upper quadrant with multiple thrusts of a long hunting knife. At laparotomy several deep transverse lacerations involving both the right and left lobes of the liver were noted. Profuse hemorrhage did not respond to the usual measures and resection was at first avoided because of the obvious involvement of both lobes. In the presence of exsanguinating hemorrhage a right lobectomy was carried out in the hope of controlling major vein damage in the course of resection. A 3 cm. laceration of the vena cava in the region of the take-off of the superior hepatic vein was encountered and repaired, but the patient became profoundly hypothermic from large volume replacement with refrigerated blood. Arrhythmias and finally cardiac arrest occurred.
In a series of twenty-three cases of severe live1 injury representing civilian and combat experience, five of six patients who were managed conservatively with packing and suture died. In a subsequent group of sixteen patients with severe liver trauma treated with excisional therapy using anatomic lobectomy technics, only one of sixteen died.
Comment: Injuries involving both lobes or in the midplane between the lobes frequently result in laceration of the vena cava or avulsion of the hepatic veins from the vena cava at their point of origin. Venous bleeding of this type is well recognized as a formidable problem and represents an early indication for aggressive resectional therapy. Patient temperature monitoring and blood warming before infusion in massive replacement are also an essential part of therapy.
Military
Experience
Penetrating, High Velocity Nissile Wounds. All cases included in this portion of the report were caused by penetrating, high velocity missile wounds which resulted in severe implosion injury of the liver with devastating destruction of the architecture. The six initial patients admitted for emergency surgery were managed with packing and mattress sutures through the fracture lines, and five died of recurrent hemorrhage or sepsis. In view of the prohibitive mortality the decision was made to attempt excisional treatment using anatomic lobectomy technics. All of the subsequent thirteen patients with severe liver injuries treated by the excisional approach survived. It should be noted that numerous combat casualties not included in this report were noted to have liver injuries from shrapnel or other low velocity missiles which presented as hemoperitoneum or as incidental findings at laparotomy for other intraabdominal injuries and were treated with simple 444
Results
Comments The first reported successful limited hepatic resection for treatment of a gunshot wound was that reported by Bruns in 1870 [8]. The first presented series of liver injury treated by anatomic hepatic resection was that of McClelland, Shires, and Poulos in which they reported an over-all mortality of only 20 per cent and a relatively low complication rate [9]. Since that time a number of investigators have documented their experiences in the treatment of a variety of hepatic trauma with different technics [4,10-I%‘]. In general, incisive injury of the liver from simple penetrating trauma such as a knife wound or low velocity missile wound is easily treated with low risk, and hemorrhage is usually not a problem. However, high energy penetrating or nonpenetrating trauma t,o the liver with extensive destruction of hepatic parenchyma is attended by interruption of numerous vascular pathways in a very vascular organ, and frequent involvement of the major vessels including the hepatic veins and vena cava is seen. There is a growing body of evidence that these major hepatic injuries are best treated by aggressive excisional therapy utilizing anatomic lobectomy technics [15-161. The objectives of treatment of massive hepatic injury are usually considered to be (1) control of exsanguinating hemorrhage, (2) removal of devitalized tissue, (3) prevention of bile leakage either by adequate ligation of the bile ducts in the triads on the resected liver margin or employment of T tube drainage of the common duct, (4) establishment of adequate subhepatic and subphrenic drainage to eliminate collections of blood and bile which invariably became septic, and (5) administration of antibiotics guided by culture and sensitivity data combined with aggressive secondary drainage of abscess as needed. The American
Journal of Surgery
Hepatic
TABLE
Case
I
Survey
Type of Accident
of Twenty-Three
Resection
for Liver Trauma
Patients
Postoperative Complications
Operation
Injury of Major Vessels
Extent of Liver Injury
Civilian __.R. G.
Automobile
Right lobectomy
T. E.
Automobile
Right lobectomy
A. 6.
Automobile
Right lobectomy
B. G.
Knife
Right lobectomy
Subphrenic abscess and pneumothorax Dehiscence, subphrenic abscess, and pneumothorax Subphrenic abscess and pneumothorax Death, shock, and hemorrhage
~~~ .-
Shattered
right lobe
No
Shattered
right lobe
No
Shattered
right lobe
No
Shattered
right lobe
Yes (right and left hepatic veins)
~~
~~~_______
_-..-.
Military
L. S.
HVM
Packing
T. K.
HVM
Suture
Packing
R. L.
HVM
Suture
Packing
T. P.
HVM
Suture
Packing
B. L. M.Q. J. B. A. N.
HVM HVM HVM HVM
Right lobectomy Right lobectomy Right lobectomy Left Iobectomy
Death, shock, and hemorrhage Death, shock, and hemorrhage Death, shock, and hemorrhage Death, shock, and hemorrhage Subphrenic abscess Subphrenic abscess None None
S. N.
HVM
Right lobectomy
Subphrenic
H. S.
HVM
Right lobectomy
None
L. 6.
HVM
None
L. N.
HVM
Exploration Right lobectomy Suture Packing
Death
A. R.
HVM
Suture
Death
N. J.
HVM
Right lobectomy
Wound
L. T.
HVM
Right lobectomy
Subphrenic
P. B.
HVM
Right lobectomy
Wound
J. M. N. Z.
HVM HVM
Left lobectomy Left lobectomy
None None
M. B.
HVM
Left lateral lobectomy
Left subphrenic
Vol. 117, April 1969
Packing
abscess
Shattered right and left lobe Shattered right and left lobe Shattered right lobe
Yes (right hepatic vein) Yes (right hepatic vein) Yes
Shattered right lobe, segmented left lobe Shattered right lobe Shattered right lobe Shattered right lobe Shattered lateral segmented left lobe Shattered right lobe
Yes
Shattered lateral aspect of right lobe Shattered lateral aspect of right lobe Shattered right lobe Shattered right lobe, Med. segment left lobe Shattered right lobe
sepsis abscess
dehiscence
abscess
Shattered lateral aspect of right lobe Shattered lateral aspect of right lobe Shattered left lobe Shattered lateral segment of left lobe Shattered lateral segment of left lobe
Yes No No No Yes (right hepatic vein No No Yes (right hepatic vein) Yes (hepatic veins) Yes (hepatic veins) Yes (right hepatic vein) Yes (right hepatic vein) No No No
445
Ackroyd, Pollard, and McDermott
Injury to the vena cava or one of the main hepatic veins was noted in several cases in this series, and it was apparent that control of hemorrhage could not have been achieved except by an aggressive approach and vascular suture of the patent vessels. The risk of air embolism from the open hepatic veins is a real one and must be guarded against. Only in recent years has the importance of resection of all devitalized liver tissues, through hemostasis, and adequate abdominal drainage been fully appreciated and employed
rupture. In fact, since angiography shows the inner hepatic architecture, it often gives a better idea of the extent of intrahepatic destruction than does a look at the surface of the liver at laparotomy. Metabolic requirements after extensive hepatic resection have been well defined and focus upon early maintenance of blood sugar levels and generous supportive therapy with intravenous human serum albumin [16,19,90].
1’4. Merendino, Dillard, and Cammock [II] have strongly advocated biliary drainage in the past. This has the theoretic advantage of reduction of leakage from the injured liver tissue and reduced intraductal pressure which might produce new leaks from the cut surface of the liver [11]. Equally important is accurate ligation of the appropriate branches of the portal triad during transection of hepatic parenchyma and either injection of colored material such as methylene blue into the common duct or an operative cholangiogram to check for extravasation from unrecognized open branches of the ductal system on the cut surface of the liver. (Fig. 3.) The decision between reconstructiou and resection is a difficult one and depends on surgical judgment as to the actual rather than apparent of damage to liver tissue. Often digital exploration seemingly minor surface lacerations will reveal extensive intrahepatic destruction. If the rondit’ion of the patient permits, we [17] and others [18] have found selective hepatic angiography of great help in establishing t,he diagnosis and extent of hepatic
1. Severe fracture injuries of the liver with extensive parenchymal destruction should be resected along anatomic planes for control of hemorrhage and limitation of po&traumatic and abscess formation. necrosis, bile leakage, Minor liver injuries can successfully be treated by ligation and suture reconstruction without wide resection. Preoperative angiography is helpful in defining the extent of injury. 2. Operative cholangiography or injection of dye into the common duct to check completeness of bile duct ligation in the parenchymal portal triads greatly reduces postoperative problems of subphrenic bile collections and sepsis. 3. Intravenous supplements of glucose for the first twenty-four hours and albumin for seven to ten days are essential until the residual liver tissue can keep pace with convalescent requirements. 4. The use of T tube decompression of the common duct is useful and may offer protection from parenchymal bile leakage unless contraindicated by a duct of small caliber. 5. Generous use of drains and sumps to remove subphrenic collections of bile, plasma, and blood markedly reduces postoperative morbidity.
Conclusions
References 1. HELLSTROM, G. Closed injury of the liver: analysis of a series of 300 cases. Acta chir. scandinav., 122: 490, 1961.
Fig. 3. Operative cholangiogram cut surface of the liver. 446
revealing no leaks from
2. MIKAL, S. and PAPEN, G. Morbidity and mortality in ruptured liver. Surgery, 27: 520, 1950. 3. SPARKMAN, R. S. and FOGELMAN, M. J. Wounds of the liver: review of 100 cases. Ann. Burg., 139: 690, 1954. 4. MIKESKY, W. E., HOWARD, J. M., and DEBAKEY, M. E. Injuries to the liver in 300 consecutive patients. Internat. Abstr. Surg., 103: 323, 1956. 5. FOSTER, J. H., LAWLER, M. R., WELBORN, M. B., HOLCOMB, G. W., and SAWYERS, J. L. Recent experience with major hepatic resection. Ann. Surg., 167: 651, 1968. 6. ARONSEN, K. F., BENGMARK, S., DAHLGREN, S., ENGEVIK, L., ERICSSON, B., and THOREU, L. The American
Journal of Surgery
Hepatic Resection for Liver Trauma
7.
8. 9.
10.
11.
12.
13.
Liver resection in the treatment of blunt injuries to the liver. Surgery, 63: 236, 1968. PERRY, J. F., ROOT, H. D., HANSER,C. W., and KEISER, P. J. Treatment of hepatic injuries. Surgery, 62: 853, 1967. GARRE, C. Beitrage zur leber Chirurgie. Be&. klin. Chir., 4: 181, 1888. MCCLELLAND,R., SHIRES, T., and POULOS,E. Hepatic resection for massive trauma. 1. Trauma, 4: 282, 1964. BAKER, R. J., TAXMAN,P., and FREEARK,R. J. An assessment of the management of nonpenetrating liver injuries. Arch. Surg., 93: 84, 1966. MERENDINO,K. A., DILLARD,D. H., and CAMMOCK,E. E. Surgical biliary decompression in the management of liver trauma. Surg. Gynec. & Obst., 177: 285, 1963. MCCLELLAND,R. and SHIRES, T. Management of liver trauma in 259 consecutive patients. Ann. Surg., 161: 248, 1965. LORTAT-JACOB,U. L. and ROBEKT, H. G. Hepatectomie droite reglce. Presw m&d., 60: 549, 1952.
14. QUATTLEBAUM, J. K. and QUATTLEBAUM, J. II., JR. Technique of hepatic lobectomy. Ann. Burg., 149: 648, 1959.
15. PACK, G. T. and ISLAMI,A. H. Operative treatment of hepatic tumors. C&n. Symposium, 16: 35, 1964. 16. WILLIAMS,L. F. and BYRNE,J. J. Trauma to the liver at the Boston City Hospital from 1955 to 1965. Am. J. Surg., 112: 368, 1966. 17. POLLARD,J. J., NEBESAR,R. A., and FLEISCHLI, D. J. Angiography in abdominal trauma. In preparation. 18. BOIJSEN, E., JUDKINS, M. P., and SIMAY, A. Angiographic diagnosis of hepatic rupture. Radiology, 86: 66, 1966. 19. STONE,F. A., SIDERINS,M. J., GOODMAN, J. ;Ll., ZICK, H. R., BLAHUT,R. J., and DYESS, N. H. Treatment of exsanguinating rupture of the right lobe of the liver by ligation of the main hepatic artery. Ann. Surg., 162: 933, 1965. 20. MONACO, A. P., HALLGRIMSSON, J., and McDERMOTT,W. V., JR. Multiple adenoma (hamartoma) of the liver treated by subtotal (99%) resection: morphological and functional studies of regeneration. Ann. Surg., 159: 513, 1964.
Discussion of Papers by Drs. Taylor and Ackroyd A. BIRTCH(Boston, Mass.) : I would like to address my remarks to Dr. Filler. We tend to learn more from the few failures in such a study than from the many successes you have presented. On the problem of air Vol. 117,April 1969
embolus occurring during use of the abdominal approach, were there other cases in which operation was performed via the abdomen without air embolism? The failure of the liver to regenerate after resection and immediate therapy with actinomycin C and radiation is of considerable interest. In liver transplantation in which the antimetabolite aeathioprine (Imuran@) has been used for immunosuppression, one wonders whether a similar inhibition of regenerative power may be acting. A. D. CALLOW (Boston, Mass.): I wish to extend my thanks for this most interesting and helpful paper and to ask a single question. Can the authors give us any additional guidelines beyond liver scan and hepatic arteriograms concerning the differentiation after partial hepatic resection between the abdominal mass which may represent recurrent malignancy or regenerating normal liver? W. H. HENDREN(Boston, Mass.): I would like to comment on the excellent paper concerning liver resection in children. It is a sizable series of cases and the results are certainly impressive. Our own experience on the Children’s Service at the Massachusetts General Hospital with a somewhat smaller group of similar cases is in complete agreement that these tumors, which are sometimes enormous, can often be removed. We agree that success in this requires not only aggressive surgery but also great operative support. In these cases, and in fact in any major operation in which we anticipate considerable blood loss, we routinely monitor constantly the venous pressure, radial artery pressure, body temperature, and electrocardiogram. In removing these large tumors blood loss can exceed one or two times the child’s blood volume. Replacement with ordinary bank blood preserved in acid citrate solution in past years sometimes resulted in cardiac arrest during the operation because acute metabolic acidosis can result from sudden infusion of blood preserved in this way. The potassium content of bank blood can also be rather high, an additional danger to the child. By contrast, children tolerate sudden massive blood replacement very well with fresh, warm blood drawn in heparin. We, therefore, have available an ample supply of this type of blood for all cases in which we anticipate great blood loss. Protamine is given to reverse the heparin, checking the child’s clotting time. A disadvantage of fresh hepariniaed blood is that it must be discarded if not used, which is wasteful. We believe, however, that this is justifiable when its availability provides additional safety for the child. We have used Dr. Charles Huggins’ frozen blood in about ten cases and have had quite a favorable experience with it. This consists of frozen red cells given together with a 5 per cent solution of albumin and saline. Up to the point of giving one blood volume of frozen blood to a child we have noted no labile blood factor changes, but beyond that point there is 447
Ackroyd, Pollard, and McDermott reduction in platelet count and fibrinogen concentration, which can be corrected by using platelet concentrates or fresh frozen plasma. We have avoided administering fibrinogen because this carries a very high risk of hepatitis. In addition, we believe that it is important to have two anesthesiologists for these cases, one to give anesthesia and the other to watch the monitors and supervise administration of blood and fluids. We think it is an invitation to disaster to undertake one of these cases without all of the aforementioned ancillary aids. R. M. FILLER (Boston, Mass.): In reference to Dr. Birtch’s question, early in our experience transabdominal guillotine resections were employed; in most recent cases anatomic lobectomies have been performed. There were two transabdominal left lohectomies and one additional right lobectomy. In terms of the studies which may bc a guide to recurrence of tumor, this is a difficult question to answer. In one of our cases, a boy who required two lobectomies, an abdominal mass developed after right hepatectomy which did not function on scan and was separate from the functioning liver tissue. In addition, an arteriogram made the diagnosis because of the presence of tumor vessels and tumor stain. One usually palpates a mass in the epigastrium after lobectomy even when there is no recurrence of tumor. This is due to regenerating liver tissue and can be differentiated from a large tumor by scan and arteriography. W. V. MCDERMOTT, JR. (closing) : Since the technic of hepatic resection has become standardized during the past decade and can be carried out with a very acceptable mortality, the question arises increasingly as to when major hepatic resection is indicated in the treatment of severe trauma. May I show some slides which I think illustrate the problem and indicate
448
why we should consider initial resection in selected instances of injury to the liver. This was a young girl (slide) who was brought into the hospital after an automobile accident. Abdominal exploration was carried out because of intraperitoneal hemorrhage which proved to be from a laceration of the liver. Mattress ligatures apparently controlled this hemorrhage; however, within a few hours after the conclusion of the procedure, massive intraabdominal hemorrhage recurred and we were asked to see the patient. It was clear that immediate resection would be required as a life-saving procedure, and this was carried out through a thoracoabdominal approach. Here we see a photograph (slide) of the result of blunt injury to the liver, and the stellate laceration does not seem very extensive. Once the liver was removed, however, one could see in the resected specimen of the right lobe (slide) what extensive damage had occurred within the liver without too much in the way of external evidence. A section through the specimen (slide) re-emphasizes the amount of necrotic devitalized tissue which may exist as a result of blunt trauma with apparently only superficial laceration through the liver capsule. This is not an uncommon experience, and other similar instances have been reported in our manuscript. If the amount of bleeding from the liver is not such that immediate exploration is required, preliminary arteriography will be of great help in defining the extent of disruption of the hepatic architecture. If this is not possible, digital examination through the lacerated surface of the liver may give some indication as to how much of the liver tissue has been turned into “mush” by the impact. As emphasized in Dr. Ackroyd’s presentation, I am sure that we can improve our results over the coming years by resorting to planned resection in selected cases of massive hepatic injury.
The American
Journal
of Surgery