Blunt hepatic injuries: incidence, evaluation And management in zagazig university Hospitals
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A prospective study including most of the patients, (374 patients) admitted to emergency departments of Zagazig University hospitals (Zagazig and Banha*) as a blunt abdominal trauma during the period from January 1998 to December 2001. Liver injury was found in 86 of them (those patients represents the material of this study). The age of liver injured patients ranged between 9 to 69 years (mean 35 years). 67 males and 19 females. Motor vehicle accident was the cause of liver injury in 53 patients (61.6%), train accident in 4 patients (4.6%) and fall from a height in 29 patients (33.8%). The liver injured patients had exra-abdominal injuries in the form of, head injuries in 15 patients (17.4%); chest injuries in 21 patients (24.4%) and orthopedic injuries in 33 patients (38.3%). After exploration of 77 patients with liver injury there were other abdominal injuries as the following: spleen in 16 patients (18.6%); mesentery [haematoma and/or tears] in 7 patients (8.1%); small intestine in 5 patients (5.8%); colonic injury in 3 patients (3.4%); retroperitoneal haematoma in 12 patients (13.9%); pancreas in one patient (1.15%); kidney in 2 patients (2.3%) and diaphragm in one patient (1.15%). All liver injured patients were categorized according to the degree of injury to five grades. The following techniques were used in the management of our liver injured patients. 1-Nonoperative treatment: (12 patients), proved grade I, II or III by CT scan with mild to moderate intraperitoneal haemorrhage in haemodynamically stable patients. Early operative intervention was required in two patients with evidence of continuing intra-abdominal bleeding, and in one patient with signs of other a ssociated injury which necessitates laparotomy. 2-operative treatment: For (77 patients). The procedures used were: abdominal drainage only when the liver injury was minimal without obvious bleeding or non expanding haematoma; topical haemostatic agent, as gelfoam or fibrin glue and electrocautary for superficial ooze occurs from decapsulated liver and superficial bleeding fracture; suturing: when bleeding was occurred from within the liver substance without a visible vessels; suture ligation of visible bleeding intra-hepatic blood vessels and injured bile ducts using the finger fracture technique; resection debridement (non anatomical resection) of devitalized or almost detached segments of the liver and peri-hepatic packing, in multiple and complex liver injuries beyond the surgeon's ability to manage and used with other surgical procedures, particularly when hypothermia and coagulopathy promotes diffuse bleeding which is not possible to alleviate by other means. The packs were removed when the patients were haemodynamically stable and coagulopathy was corrected, usually 3-5 days after first exploration. Further debridement of liver necrotic tissue was performed and new peritoneal drains were applied. Thirteen patients (15.1% of liver injured patients) died, two in grade II, one in grade III and three in grade IV i.e. 6 patients died (46% of all deaths) due to associated chest and head injuries (i.e. deaths not related to liver injury). Three patients in grade V died on table due to massive, uncontrollable bleeding from hepatic injury. One patient died as a result of massive postoperative haematemesis, one due to rebleeding and irreversible shock 24 hours postoperatively in ICU and two patients died due to hepato-renal failure postoperatively. The hospital stay for all liver injured patients ranged from 6 to 31 days (mean 11 days).