Evoluția abordării leziunilor traumatice hepatice – experiența CNŞPMU

Abstract

Material şi metode. Evaluarea retrospectivă şi prospectivă a 271 traumatizați cu leziuni hepatice tratați în Clinica Chirurgie CNŞPMU în 1998-2010. Au fost 222(81,9%) bărbați şi 49(18,1%) femei, cu vârsta medie de 36,04±0,89(18-78). Leziunea hepatică a fost element asociat politraumatismului în 99,3%: TCC – 173(63,8%), toracic – 215(79,3%); locomotor – 102(37,6%). ISS mediu de 38,94±0,94 (5-75). Diagnosticul s-a bazat pe examenul clinic relevant şi LPD –196(73,3%); USG –150(55,4%); TC – la 46(16,97%); laparoscopie – 74(27,3%). Criterii de selectare a metodei curative: parametrii hemodinamici, gradul leziunii organice, datele USG şi TC. Rezultate. Conform severității leziunii hepatice pacienții s-au repartizat: gr.I – 18(6,6%); gr.II – 89(32,8%); gr.III – 111(40,9%); gr.IV – 36(13,3%); gr.V – 17(6,3%). Au fost operați 213(78,6%) pacienți. În 13(4,8%) cazuri leziunea hepatică s-a depistat la necropsie, decesul fiind determinat de politraumatismul sever. În leziunile nesevere s-au practicat metode conservative de tratament (TNO, aplicații hemostatice) şi hepatorafia solitară, iar în cele severe – hepatorafia asociată cu bioplombaj cu oment, meşaj hepatic (p<0,001). În 4(1,5%) cazuri debridarea chirurgicală a leziunii gr.V s-a soldat cu rezecție hepatică atipică(2), ligaturarea selectivă a vaselor sangvine şi ducturilor biliare(2). La 23(8,5%) pacienți cu hemoragie activă din leziunea gr.III-V s-a utilizat manevra Pringle în regim intermitent. Perioada postoperatorie a evoluat cu complicații la 135(49,5%) pacienți, mortalitatea generală constituind 29,5%. Concluzii. Abordarea pacienților cu leziuni traumatice ale ficatului necesită individualizare de vast diapazon privind amploarea operației determinată de parametrii hemodinamici şi severitatea leziunii organice. Rata tratamentului nonoperator a crescut progresiv, eforturile concentrându-se la scăderea mortalității şi morbidității la aceşti pacienți. Material and methods. Retrospective and prospective evaluation of 271 patients with traumatic liver injuries treated in surgical department of NSPCEM during 1998- 2010 was performed. There were 222 (81,9%) male and 49 (18,1%) female patients, median age was 36,04±0,89(18-78). Liver injury was a part of polytrauma in 99,3%: cranial trauma - 173(63,8%), thoracic -215(79,3%); locomotor – 102(37,6%). Median ISS was 38,94±0,94 (5-75). Diagnosis was based on relevant clinical data and DPL –196(73,3%); USG –150(55,4%); CT –46(16,97%); laparoscopy – 74(27,3%). Criteria for selection the treatment option were: hemodynamical parameters, grade of injury, USG and CT data. Results. The patients were divided according to liver injury severity as follows: gr.I – 18(6,6%); gr.II – 89(32,8%); gr.III – 111(40,9%); gr.IV – 36(13,3%); gr.V – 17(6,3%). Surgery was performed in 213(78,6%) patients. Liver injury was found at autopsy in 13(4,8%) cases, the cause of death being severe polytrauma. In non- severe injuries we applied conservative treatment (NOM, local hemostatics) and solitary hepatorrhaphy, while in severe injuries – hepatorrhaphy with omental patching, hepatic packing (p<0,001). In 4(1,5%) cases surgery for gr.V injury consisted of atypical liver resection(2), selective ligation of blood vessels and biliary ducts(2). In 23(8,5%) patients with active bleeding from gr.III-V injury we used intermittent Pringle maneuver. Postoperative morbidity was noted in 135(49,5%) patients, general mortality rate was 29,5%. Conclusion. The management of patients with traumatic liver injuries should be individualized in a wide range, the volume of surgery being determined by the injury severity and hemodynamic parameters. The rate of nonoperative treatment increased progressively, the efforts aiming the decrease of morbidity and mortality rates in these patients.

Material and methods. Retrospective and prospective evaluation of 271 patients with traumatic liver injuries treated in surgical department of NSPCEM during 1998- 2010 was performed. There were 222 (81,9%) male and 49 (18,1%) female patients, median age was 36,04±0,89(18-78). Liver injury was a part of polytrauma in 99,3%: cranial trauma - 173(63,8%), thoracic -215(79,3%); locomotor – 102(37,6%). Median ISS was 38,94±0,94 (5-75). Diagnosis was based on relevant clinical data and DPL –196(73,3%); USG –150(55,4%); CT –46(16,97%); laparoscopy – 74(27,3%). Criteria for selection the treatment option were: hemodynamical parameters, grade of injury, USG and CT data. Results. The patients were divided according to liver injury severity as follows: gr.I – 18(6,6%); gr.II – 89(32,8%); gr.III – 111(40,9%); gr.IV – 36(13,3%); gr.V – 17(6,3%). Surgery was performed in 213(78,6%) patients. Liver injury was found at autopsy in 13(4,8%) cases, the cause of death being severe polytrauma. In non- severe injuries we applied conservative treatment (NOM, local hemostatics) and solitary hepatorrhaphy, while in severe injuries – hepatorrhaphy with omental patching, hepatic packing (p<0,001). In 4(1,5%) cases surgery for gr.V injury consisted of atypical liver resection(2), selective ligation of blood vessels and biliary ducts(2). In 23(8,5%) patients with active bleeding from gr.III-V injury we used intermittent Pringle maneuver. Postoperative morbidity was noted in 135(49,5%) patients, general mortality rate was 29,5%. Conclusion. The management of patients with traumatic liver injuries should be individualized in a wide range, the volume of surgery being determined by the injury severity and hemodynamic parameters. The rate of nonoperative treatment increased progressively, the efforts aiming the decrease of morbidity and mortality rates in these patients.