[Current diagnostic and therapeutic approaches in liver injuries].
OBJECTIVE
The recent improvements in hospital care system (centralized specialized care) and the use of new imaging methods and modern technologies in surgical treatment have greatly enhanced successful outcomes of therapy in liver injury. The aim of the study was to evaluate the contribution of procedures included in the diagnostic-therapeutic algorithms to the treatment of blunt injury to the liver in our patient population.


METHODS
Our group consisted of 43 patients with blunt injury to the liver who were treated at the Emergency Department between 1998 and 2002. In 28 patients, blunt injury was part of polytrauma, in 7 patients it was associated with thoraco-abdominal injury and, in 8 patients, it was the only trauma sustained.


METHODS
The diagnosis and therapy were based on the algorithm currently used for treating liver injury at the Emergency Department. In addition to clinical examination and assessment of the actual status of hemodynamics, spinal computed tomography was carried out to establish the therapeutic procedure. Fourteen patients were treated conservatively according to the criteria of a non-surgical approach and 29 patients underwent urgent surgery. Indications for revision surgery included, apart from signs of ongoing abdominal bleeding related to liver injury, combined spleen and kidney trauma. All patients with thoraco-abdominal involvement had laparotomy; in addition, four underwent thoracotomy including repair of the lacerated lung by suturing and three patients required suturing of a rupture of the right part of the diaphragm.


RESULTS
In the patients treated conservatively, 10 showed spontaneous regression of parenchymal hematomas and four had to be treated by suction drainage. Out of 29 patients operated on, five died with signs of an irreversible hemorrhagic shock from multiple trauma and one died of multiple organ failure.


CONCLUSIONS
The principal criterion determining therapy in blunt liver injury is the patient's hemodynamic status; laparotomy is mandatory in intra-abdominal trauma with severe hemoperitoneum or when unstable hemodynamics is due to intraperitoneal bleeding. Non-surgical treatment of blunt liver injury, on condition that the established criteria are observed, has several advantages such as less stress for the patient, fewer intra-abdominal complications and fewer blood transfusions needed. The modern technologies used in the operative procedure are related to both a transient vascular occlusion and a strategy for selective care in liver trauma.


CONCLUSIONS
1. The treatment strategy in a patient with blunt liver trauma is determined by the patient's hemodynamic status; in a stable patient, spinal CT examination of the thorax and abdomen is mandatory. 2. Urgent laparotomy is indicated when the patient with blunt liver trauma is hemodynamically unstable due to diagnosed hemoperitoneum or suspected intraperitoneal bleeding. 3. Conservative therapy is applied when the criteria for non-surgical treatment are fulfilled. 4. Surgical strategy for blunt liver trauma is based on the extent and localization of the injury, the patient's overall status and severity of associated injuries. Resection of the injured parenchyma is indicated when laceration of a liver lobe occurs. 5. The prognosis of blunt liver injury is influenced, apart from hemorrhagic shock reversibility, by the severity of associated injuries in multiple trauma.
Traumatologické centrum, Chirurgická klinika 3. LF UK a FNKV, Praha.
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Vyhnánek
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Denemark
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Duchác
D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008099:Liver / Q000293:injuries*; D008297:Male; D008875:Middle Aged; D014949:Wounds, Nonpenetrating / Q000175:diagnosis* / Q000628:therapy*