Suganthan, T (2020) An Observational study on Management and Outcome of Liver Trauma, Based on World Society of Emergency Surgery (WSES) Guidelines in Rajiv Gandhi Government General Hospital. Masters thesis, Madras Medical College, Chennai.
|
Text
220100120suganthan.pdf Download (8MB) | Preview |
Abstract
BACKGROUND : The severity of liver injuries is universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale . The majority of patients admitted for liver injuries have grade I, II or III and are successfully treated with nonoperative management (NOM). In contrast, almost two-thirds of grade IV or V injuries require laparotomy (operative management, OM) . However in many cases there is no correlation between AAST grade and patient physiologic status. Moreover the management of liver trauma has markedly changed through the last three decades with a significant improvement in outcomes, especially in blunt trauma, due to improvements in diagnostic and therapeutic tools. In determining the optimal treatment strategy, the AAST classification should be supplemented by hemodynamic status and associated injuries. The anatomical description of liver lesions is fundamental in the management algorithm but not definitive. In fact, in clinical practice the decision whether patients need to be managed operatively or undergo NOM is based mainly on the clinical conditions and the associated injuries, and less on the AAST liver injury grade. Moreover, in some situations patients conditions lead to an emergent transfer to the operating room (OR) without the opportunity to define the grade of liver lesions before the surgical exploration; thus confirming the primary importance of the patient’s overall clinical condition.Ultimately, the management of trauma requires an assessment of the anatomical injury and its physiologic effects. AIMS AND OBJECTIVES : ➢ To find the efficacy of WSES guidelines in classifying liver trauma and determining optimal treatment strategy. ➢ To study the clinical course of non-operatively managed patients ➢ To find out appropriate monitoring methods and frequency of monitoring of non-operatively managed patients. ➢ To study the profile of various other associated injuries in liver trauma. MATERIALS AND METHODS : Study Centre Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai Duration of Study September 2017 to September 2019 Study Design Observational study (Prospective) Sample Size Approximately Inclusion Criteria All trauma victims sustaining blunt and penetrating trauma to the liver with or without associated injuries Exclusion Criteria Abdominal trauma with isolated injury to the extra hepatic biliary tree or other visceral structures without liver trauma Ethics Clearance Approved Methodology All Patients who fit the inclusion criteria will be observed and following data collected 1.Routine blood investigations -Hemoglobin - Hematocrit -Liver Function Test All these will be done serially 2. USG Abdomen 3. CECT Abdomen (i.v. contrast) for all cases 4. AAST grading system will be used to assess anatomy of liver injury 5.WSES classification will be the standard methodology used to assess the severity of liver injury 6. Management of liver injury will be based on WSES guidelines 7. Patients managed conservatively will be followed up prospectively and till discharge or death 8. Serial Abdominal examination 9. Time of reinitiating oral intake 10. Duration and intensity of restricted activity 11. Conclusions will be drawn based on the above parameters and all efforts to decide effectiveness of WSES guidelines in management of liver trauma and appropriate monitoring of NOM patients. All collected data will be analyzed and conclusions derived RESULTS : ❖ This study involving 50 patients was conducted in RAJIV GANDHI GOVERNMENT GENERAL HOSPITAL CHENNAI over a time span of 18 months approximately ( February 2018 - September 2019 ) recording all the patients admitted in trauma ward who were fitting the inclusion criteria. ❖ Patients admitted with liver injury having hemodynamic instability inspite of resuscitation , suspected peritonitis, suspected bowel injury and penetrating injury were taken for laparotomy. ❖ 6 patients were operated . The following were the indications: ➢ NUMBER OF PATIENTS HEMODYNAMIC INSTABILITY : 6 ( including 2 bowel injuries ) ➢ SUSPECTED BOWEL INJURY: 2 ➢ SUSPECTED PERITONITIS : 0 ➢ PENETRATING INJURY: 0 ❖ Out of the 6 patients operated, all were having WSES grade 4. ❖ Out of the 6 patients operated , 3 were having AAST grade 3 liver injury , 2 were having AAST grade 4 injury and 1 patient had AAST grade 5 injury OPERATIVE METHODS AND FINDINGS OPERATIVE METHOD NUMBER OF PATIENTS Peri hepatic packing 2 Hepatorrhaphy 3 Non anatomical debridement 1 OPERATIVE PROTOCOL : ❖ Patients blood grouping and typing was done along with on table availability of cross matched packed red blood cells and fresh frozen plasma. ❖ Abdomen opened by midline laparotomy in all cases and horizontal extension to right side was made in one case for good exposure. ❖ Falciform ligament was divided for good mobilisation of the liver. ❖ Hemoperitoneum was drained. Rapid evisceration of small bowel followed by identification of foramen of Winslow and PRINGLES maneuver was done using a umbilical tape brought out via the gastro hepatic ligament. ❖ In cases where bleeding was minimal and patient was hemodynamically stable after these initial steps, careful identification of the bleeders over the laceration was made and diathermy coagulated following which Hepatorraphy was done using 2-0 chromic catgut and to prevent cut through gel foam was kept before taking the bite. ❖ This was possible in 3 cases but in 2 cases where the hemodynamic status did not return to normalcy inspite of Pringles maneuver Perihepatic packing was done using abdominal pads in multiple layers to provide an adequate tamponade. ❖ After the packing hemodynamic status returned to normalcy and there were no soakage of the pads after a waiting period of fifteen minutes during which through laparotomy was done to identify other injuries. ❖ Rectus was closed using 1 prolene intermittently in some cases and skin alone was closed using 1-0 ethilon in few cases. ❖ There was no difference in outcome of closing either the skin alone or the rectus intermittently and no patients developed abdominal compartment syndrome . ❖ Planned relaparotomy was done after 48 hours for cases in which packing was done . ❖ The removal of the pads was done slowly after adequate irrigation with saline. ❖ Out of the two cases none had further bleeding and gel foam was kept over the laceration and abdomen was closed with 1 prolene and skin with 1-0 ethilon. ❖ 2 Cases where hepatorraphy was done had associated jejunal perforation and ascending colon perforation respectively. ❖ Jejunal resection and anastomosis was done as the hemodynamic status of the patient normalised after hepatorraphy and there was very minimal soiling intraperitoneally. ❖ Another case had ascending colon perforation but the soiling was too much for an anastomosis and hence limited resection with proximal ileostomy and transverse colostomy was done. ❖ Both patients were alive. ❖ One patient with AAST grade 5 and WSES grade 4 liver injury with associated splenic injury in whom non anatomical debridement of liver for necrosis of liver and splenectomy done, expired in 24 hours because of the initial insult due to hypovolemic shock and sepsis. ❖ Parenchymal dissection was carried out with crush clamp technique and the tip of the segment 7 necrosed area was resected. ❖ All operated patients were shifted to intensive surgical care unit and good ventilatory care for needy patients were given. CONSERVATIVE MANAGEMENT PROTOCOL : ❖ All patients with hemodynamic stability were subjected to all investigations in trauma ward and shifted to intensive surgical care unit. ❖ These patients were monitored periodically with : ➢ Abdomen girth chart ➢ Serial clinical examination periodically like new onset of liver tenderness or enlargement of liver marked ➢ Intake - output chart ➢ CBC 6th hourly for first 48 hours and then every day. ➢ LFT, RFT and coagulation profile were done daily ➢ Transfusion if there were low Haemoglobin levels ➢ Injection vitamin k and albumin. ➢ Strict bed rest ➢ ICD care ➢ Chest physiotherapy and incentive spirometry ➢ Higher antibiotics, analgesics and bronchodilators ➢ Check ultrasound on 4th day and near discharge after the patient starts mobilising. ❖ Only one patient with AAST grade 4 and WSES grade 3 on conservative management had sudden fall in haemoglobin level and developed hemodynamic instability during the course of treatment on day 2 and planned for emergency laparotomy but expired before proceeding to surgery. CONSERVATIVE VS OPERATIVE RESPIRATORY COMPLICATIONS OPERATIVE GROUP PACKING - 2 HEPATORRHAPHY - 3 RESECTION - 1 Lung injury - 0 Lung injury - 0 Lung injury - o No lung injury - 2 No lung injury - 3 No lung injury - 1 ❖ No patient in operative group had lung injury and all patients who underwent hepatorrhaphy and packing were extubated successfully . ❖ Only one patient with AAST grade 5 and WSES grade 4 could not be extubated due to severe hypoxia caused by associated splenic injury . CONSERVATIVE GROUP NO LUNG INJURY - 31 LUNG INJURY - 13 Associated splenic injury- 1 Associated splenic injury - 3 Associated kidney injury - 1 Associated kidney injury - 1 Other injuries- nil Other injuries- nil ❖ Only one patient patient who developed hemodynamic instability during the course of conservative management was intubated due to hypoxia caused by sudden fall in hemoglobin. ❖ No other patients required ventilatory care. ❖ ICD removal done in lung injury associated patients after serial chest x ray and lung expansion ❖ No respiratory infection encountered in conservative group ❖ Grade of liver injury had no association with respiratory complications. HENCE REGARDLESS OF THE GRADE OF INJURY CONSERVATIVE GROUP HAD LESSER RESPIRATORY COMPLICATIONS COMPARED TO THE OPERATIVE GROUP BLOOD TRANSFUSION : ➢ OPERATIVE GROUP: ❖ The on table requirement of transfusions and fresh frozen plasma were higher. ❖ On an average the operative group required 5 packed cell transfusions and 8 fresh frozen plasma transfusions per patient . ❖ The higher the grade , the higher the requirement of transfusions. ➢ CONSERVATIVE GROUP ❖ This group required on an average less than 2 packed red blood cells and less than 4 fresh frozen plasma per patient . ❖ The lower grades almost required no transfusions . HENCE CONSERVATIVE GROUP HAS LESSER RISK OF TRANSFUSION AND TRANSFUSION RELATED COMPLICATIONS WOUND COMPLICATIONS : ❖ In the operative group perihepatic group developed more wound site infection requiring secondary suturing. ❖ The hepatorrhaphy and debridement group fared well compared to the packing group suggesting re laparotomy delaying the wound healing and inducing higher wound infection. THERE IS NO WOUND COMPLICATION IN CONSERVATIVE GROUP DURATION OF HOSPITAL STAY : ❖ The average duration of hospital stay for conservative group is 14 days and for operative group is 24 days. ❖ Regardless of the grade of the injury the length of stay is less in conservative group adding a logistic advantage over operative group. HENCE CONSERVATIVE GROUP SCORES OVER OPERATIVE GROUP MORTALITY : ❖ One patient in operative group expired due to associated splenic injury causing severe hypoxia on post operative day 1. ❖ One patient in conservative group expired despite the best intensive care ❖ The probable cause of death could be an associated injury explaining the shortcoming of CT scan in few situations. Hence conservative approach is justified in all hemodynamically stable patients (WSES grade 1 , 2 and 3) irrespective of the AAST grade of the liver injury. FOLLOW UP : ❖ Three patients in the operative group developed moderate post operative intra abdominal collections and the collections were drained under ultrasound guidance. ❖ No patients in the conservative group developed complications like biloma, biliary fistula, liver abscess etc. ❖ Follow up USG/CT abdomen showed early resolution of lesion in lower grades when compared to higher grades. CONCLUSION : ❖ The management of trauma poses in definitive the attention in treating also the physiology and decision can be more effective when both anatomy of injury and its physiological effects are combined. ❖ So WSES classification and recommendations helps in choosing optimal management strategy and appropriate protocol for operative and non operative management, combining both anatomical and physiological status of the patient, when compared to AAST grade which does not incorporate the physiological status of the patient. ❖ NOM is the modality of choice in hemodynamically stable patients irrespective of AAST grade of liver injury. ❖ In incorporating NOM, consistent hemodynamic stability is required. ❖ If there are findings of sepsis like biloma, infected necrosis, liver abscess at any point of time the first option of intervention will be minimally invasive procedures like image guided drainage. ❖ If there are features of peritonitis or hemodynamic instability during the course of non operative management , then laparotomy must be considered without any delay. ❖ Operative management is employed for hemodynamically unstable patients. ❖ The first step will always be a Pringles maneuver to identify the possible source of bleeding which can be from either the portal vein or hepatic artery and hemostasis can be achieved by topical hemostatic agents like gel foam etc. ❖ If the patients hemodynamic status is in jeopardy then Perihepatic packing serves as the best operative intervention in reversing the patients hemodynamic status to normalcy.
| Item Type: | Thesis (Masters) |
|---|---|
| Additional Information: | 221711019 |
| Uncontrolled Keywords: | Liver trauma, Hemodynamic status, AAST grade, WSES classification, Follow up of conservatively managed patients, Associated injuries, Anatomical injury and physiological status. |
| Subjects: | MEDICAL > General Surgery |
| Depositing User: | Subramani R |
| Date Deposited: | 09 Feb 2021 00:48 |
| Last Modified: | 09 Feb 2021 00:48 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/13936 |
Actions (login required)
 |
View Item |
