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Liver traumaLiver trauma
Introduction The liver is the most commonly injured
abdominal organ after penetrating and blunt trauma
Blunt abdominal trauma-- most common cause of injuries, 95 % secondary to vehicle accident
Anatomy
Mechanism of injury(1)
Deceleration injury --producing a laceration of its relatively thin
capsule and parenchyma at the sites of attachment to the diaphragm
--usually tears between the post. sector(segments VI, VII ) and the ant. sectors(segments V,VIII ) of the R’t lobe
Mechanism of injury(2)
Crush injury
--direct blow to the abdomen
--damage to the central portion of the liver (segments IV, V, VIII)
Grading system(1)American Association for the surgery of trauma organ injury scale:liver
*Advance one grade for multiple injuries, up to grade III.
Grading system(2)
Grade I,II ---minor injuries, represent 80-90% of all
injuries, require minimal or no operative treatment
Grade III-V -- severe,require surgical intervention Grade VI --incompatible with survival
Assessment and initial investigation
A conscious p’t, hemodynamically unstable with generalized peritonism
laparotomy without investigation Neurologically impaired or physical sign
are equivocal →Diagnostic peritoneal lavage(DPL) and laparotomy performed if the test is positive
Hemodynamically stable →further radiological assessment
Diagnosis of liver injury Diagnostic Peritoneal Lavage --fast, sensitive, accurate and simple to perform --invasive, cannot diagnose retroperitoneal injury X-ray --nonspecific, but useful in showing the extent of
associated skeletal trauma Ultrasonography --fast, accurate, noninvasive, a good initial screening test --sensitivity 88%, specificity 99%, accuracy 97%
Computed tomography(1) The standard evaluation method for stable
p’t Performed with Dilute water soluble oral
contrast agent and intravenous contrast
Non-operative management
86% of liver injuries stopped bleeding by the time of surgical exploration
67% of operations performed are nontherapeutic
Standard method of pediatric p’t and many adults
Non-operative management Criteria --hemodynamically stable --simple hepatic parenchyma laceration of inrahepatic
hematoma --absence of active hemorrhage --hemoperitoneum of less than 500ml --limited need for liver related blood transfusions (12U) --absence of peritoneal sign --absence of other peritoneal injuries that would otherwise
require an operation
Non-operative management
Criteria --good quality CT scans --experienced radiologist --intensive care setting Currently believe that ultimate decisive
factor should be the hemodynamic stability at presentation or after initial resuscitation
Non-operative management Abdominal CT --no alteration in management is indicated
unless there is change in patient’s clinical course
Resumption of normal activities --avoid delayed hemorrhage --avoid contact sports or heavy physical
activity for 8 wks after liver injury of grades III-VI (3wks-6months)
Non-operative management Role of interventional radiology in blunt liver injury --to document active haemorrhage in subcapsular
haematomas, --as a salvage alternative to surgery in the face of continuous haemorrhage in patients who remain
haemodynamically stable --in the diagnosis and treatment of haemobilia --in the treatment of retained collections or perihepatic
sepsis (using percutaneous techniques).
Non-operative management--Arteriography is useful in selected patients after operative perihepatic packing who have postoperative evidence of ongoing haemorrhage.--Biliary endoscopy may be helpful in the diagnosis
and treatment of complications secondary to complex liver injury
ComplicationComplication --delayed hemorrhage, biliary fistula and liver
abscess, hemobilia and bilhemia, extrahepatic bile duct stricture
Non-operative management Morbidity and death --the incidence of associated abdominal injury ranges from
13% to 35% --the incidence of truly missed injury ranges from 0.5% to 12% --the incidence of missed injury was 0.2% when strict
guidelines for conservative treatment were followed and CT was used routinely.
--Wrong interpretation and poor quality of the initial scan is the most common cause
--A radiologist and the attending trauma surgeon read the initial CT scan, which must be of excellent quality were recommended
Non-operative management Complication --Delayed hemorrhage ‧ most common, usual indication for a delayed operation ‧under strict guidelines, the incidence ranges from 0-5%, and blood transfusions were required in fewer than 20% ‧ common errors:(1)assuming that the hemorrhage is not related to the liver (2)multiple(more than four)blood transfusions in the hope that it will stop (3)misreading CT and underestimating hemoperitoneum and active bleeding
Non-operative management
Non-operative management Complication --biliary fistula and liver abscess --Hemobilia ‧1%,iatrogenic causes most common ‧injury causes communication between the biliary tract and blood vessels ‧abdominal trauma, jaundice, RUQ colicky pain and blood in vomitus or stool point to this diagnosis ‧managed by percutaneous selective hepatic a. embolization or surgical intervention
Non-operative management Complication --bilihemia ‧rare complication of severe decelerationon injury, in which the
hepatic venules and the intrahepatic bile ducts rupture ‧excessive bilirubin level ‧endoscopic sphincterotomy and biliary endostenting --Extrahepatic bile duct stricture ‧ the incidence is higher than the past ‧no uniformity of treatment criteria
Non-operative management
Mortality rate
--7-13% with most resulting from associated injuries
--0-0.4% resulting from liver itself
Non-operative managementindications
In haemodynamically stable patients with blunt hepatic injury, an expeditious abdominal CT scan
haemodynamic stability rather than findings on CT determines which patients should be managed conservatively
in haemodynamically stable patients less treatment is probably the best treatment
most blunt hepatic injuries can be managed without operation with minimal morbidity and mortality rates
Operative management
Initial control of bleeding achieved with temporary tamponade using packs, portal triad occlusion(Pringle manoeuvre), bimanual compression of the liver or even manual compression abdominal aorta above celiac trunk
If hemorrhage is unaffected by portal triad occlusion(Pringle manoeuvre) by digital compression or vascular clamp, major vena cava injury or atypical vascular anatomy should be expected
Operative management
Hepatotomy with direct suture ligation --using the finger fracture technique,
electrocautery or an ultrasonic dissector to expose damaged vessels and hepatic duct which ligated , clipped or repaired
--low incidence of rebleeding, necrosis and sepsis --effectives following blunt liver trauma requires
further evaluation
Operative management
Resection debridement
--removal devitalized tissue
--rapid compared with standard anatomical resection, which are more time consuming and remove more normal liver parenchyma
--reduced risk of post-op sepsis secondary hemorrhage and bile leakage
Operative management
Anatomical resection --reserved for deep laceration
Perihepatic packing --Indication:coagulopathy, irreversible shock from
blood loss (10u), hypothermia(32C), acidosis(PH7.2), bilobar injury,large nonexpanding hematoma, capsular avulsion, vena cava or hepatic vein injuries
Perihepatic packing
Operative management
Mesh rapping
--new technique for grade III,IV laceration, tamponading large intrahepatic hematomas
--not indicated where juxtacaval or hepatic vein injury is suspected
Mesh rapping
Operative management
Omental packing Intrahepatic tamponade with penrose drains Fibrin glue Retrohepatic venous injuries
--Total vascular exclusion
--venovenous bypass
--Atriocaval shunting
--Liver transplantation
Operative management Complication --Hemorrhage,sepsis --Biliary fistula --Respiratory problems --Liver failure --Hyperpyrexia --Acalculous cholecystitis --Pancreatic, duodenal of small bowel fistula --Drainage of intra-abdominal abscess or bilioma under
ultrasonography or CT guidance and embolization of AV fistula and deep bleeding vessels
Conclusion Optium results need a specialist team -experienced liver surgeon, and anaesthetist used to dealing
with the coagulopathyof liver disease -interventional hepatobiliary radiologist and endoscpoist to
manage post-op complication -rapid infusers, cell savers and venovenous bypass to deal
with massive blood loss -Appropriate intensive care facilities -perihepatic packs to control hemorrhage -hepatotomy with direct suture ligation or resection
debridement was preferred
Hydatid cyst of the liverHydatid cyst of the liver
ETHIOLOGY
Taenia echinoccocus (cel mai frecvent)Taenia echnoccocus granularis – more
severe due to exogenous vesiculation Multiple localisation: lung, brain, muscles
PATHOLOGY Types of cysts:
unic vs.multiple Structure
proligerous membrane - inside the mebrane: CUTICULA is the germinative strata, producing new daughter cysts
Adventiceal layer – compression and metaplazia of normal liver tiussue, forms the percyst which may impregnated with calcium salts.
content – typical transparent fluid, but may become stayne dwith bile
SYMPTOMSPRETUMORAL
No symptoms Alergic reactions and eosinophylia
PSEUDOTUMORAL – may become evident on liver surface and produce tumoral effect on adjacent organs:
- post-superior – sdr. BUDD-CHIARI
- ant-inferior duodenal compression
- post-inferior – lombar expasnion may mimick renal problems, IVC compression
SYMPTOMS
- centralc – may compress IVC or portal vein –portal hypertension
- left lobe –may compress the splenic vein: segmentary portal hypertension
COMPLICATIONS
COMPLICATIONS
A. SISTEMIC
1. Alergic reactions – may produce even anaphylactic shock when suddenly ruptures
2. Septic complications – may become infected and behaves like liver abscess with billiary communications.
COMPLICATIONSB. LOCAL1. Fissure: cyst may be evacuated in the billiary tree, main step to many
comlpications
2. Rupture Peritoneal cavity
- usually with anaphylactic shock
- may be symptom-less
- during the operation
Peritoneal echinoccocosis Pleural cavity or pericardium Bronchial tree: sudden pseudo-vomitus with salty taste, +/- alergic
reactions. Risk to seed the opposite lung
TRATAMENT
No treatment- when the parasite is dead and cyst completely encapsulated
Medical treatment – antiparasitic, if the parasit may be accessed, as well as postoperative
Surgical treatment – most cases
STEPS TO FOLLOW
1. Parasite inactivation - injection in the cyst of a parasitic substance
2. Evacuation of the cyst
3. Extraction of the germinal membrane and daughter cysts
4. Manage the cavity.- care for billiary fistulas
5. LIVER RESECTION may be required
TREATMENT - alternatives
1. LIVER RESECTION may be required
2. Ideal cystectomy3. Percutaneous treatment – US control4. Laparoscopic treatment5. Albendazole
TOTAL CYSTECTOMY
TYPICAL EVOLUTION
Slow growth but no complications Local complications – typical with billairy
fistulas Calcification of the membrane – associated
with parasitic death
ECHINOCCOCUS MULTILOCULARIS
PATHOLOGY - multiple cavities in liver parenchim, similar to
a honey comb
SYMPTOMS - hepato-splenomegaly associated with jaundice
TREATMENT - parasitic inactivation with intracystic injection
-liver transplantation
LIVER ABSCESSLIVER ABSCESS
LIVER ABSCESSESLIVER ABSCESSESClassificationClassificationTiming: - primary Timing: - primary
-secondary -secondary
Evolution: -acuteEvolution: -acute-chronic-chronic
EtEthhiologiologyy - parasitic (amoebiene)- parasitic (amoebiene)- nonparasitic- nonparasitic
Parasitic abscesses (amoebiene)Parasitic abscesses (amoebiene)
EthiologyEthiology: : Entamoeba histoliticaEntamoeba histolitica (A(Africafrica))
SignsSigns: -: - painful hepatomegaly painful hepatomegaly
-- feverfever
Lab workLab work: - US, CT, imunofluorescence : - US, CT, imunofluorescence (A(Acc anti-amoeba) anti-amoeba)
Liver abscess Liver abscess (non parasitic)(non parasitic)
• After abdominal sepsis – apendicitisAfter abdominal sepsis – apendicitishighhigh fever, chils fever, chils
hepatomegaly, hepatomegaly, jaundice jaundice pleural effusion, pleural effusion, US thrombosis or air in portal systemUS thrombosis or air in portal system
• After billiary septic complicationsAfter billiary septic complications• After septicemic seedingAfter septicemic seeding
LAB WORKLAB WORKLaborator:Laborator:- High WBC, very high levels or very low High WBC, very high levels or very low
levels levels - ESR ESR - Plain abdominal X-Ray, Plain abdominal X-Ray, - US, CTUS, CT
Tratament: SOURCE +Tratament: SOURCE +
-- antibyotics, antibyotics,
- - Percutaneous approach to evacuate and drain Percutaneous approach to evacuate and drain
- - Surgical drainageSurgical drainage
CLICK
Surgical treatmentSurgical treatment
LIVER TUMORSLIVER TUMORS
CLASSIFICATION
BENIGN
MALIGNANANT
BENING LIVER BENING LIVER TUMORSTUMORS
HEPATOCYTIC ADENOMA
Well demarcated small, dark brown, with a clear tumoral wall
It may develop into a malignant tumor
Easy to confuse with a hepatoma which has to be ruled out
ADENOMA ADENOMA
Billiary adenoma Originates in cells lining the billiary
canaliculi Small yellow tumor, but can also develop
cystic In superficial forms, metastasis must be
ruled out
HEMANGIOMA
Capillary Cavernous Vascular tumor, very frequent encountered Small to large tumors located anywhere in the
liver Smooth surface, soft, dark-brown or violet in
cavernous form (lakes of blood) Symptoms generated by the size of tumor
LESION THAT MIMICK LIVER TUMORS
1. Focal nodular hyperplasia
Frequent in women 40-50, associated with hormonal supplements and anti-baby pills
Usual single lesion but may be multiple
2 pathological forms - solid type – the most frequent. Solid small tumor of hyperplastic hepatocytes. Scar like capsule that enteres and separates the tumor - telangiectatic form
2. Inflamatory pseudotumors
Inflammatory granulomas – due to infections propagated through the portal vein
More frequent in children and young male adolescents
Simptoms: fever, weight loss, billiary obstructions
Pathology-inflammatory lesion progressively developing in association in pileflebitis
Differential diagnostic : liver malignancies (biopsy)
Treatament – antiinflamatory drugs Prognostic good
3. Bening cystic tumor
**Non – parasitic cystsNon – parasitic cysts-- solitarysolitary : billiary / serosal; : billiary / serosal;
-- multiplemultiple: polycystic disease : polycystic disease
- - dg. US, CTdg. US, CT
TratamentTratament
- nothing- nothing
- surgical unroofing- surgical unroofing
- percutaneous evacuation- percutaneous evacuation
Polycystic disease
Laparoscopic approachLaparoscopic approach
Malignant liver Malignant liver tumorstumors
•Primary liver tumors•Secondary liver tumors
Malignant liver tumorsMalignant liver tumors
IncidenceIncidence: more : more frequent in africa frequent in africa and far East, male and far East, male patientspatients
Path:Path:- Single tumorSingle tumor- Multiple tumors Multiple tumors
(liver cancer in (liver cancer in chirotic livers)chirotic livers)
HISTOLOGY
ORIGIN
hepatocyt: – hepatocelular carcinoma– hepatoblastoma
Billiary canaliculi: cholangiocarcinoma Mixt forms Sarcomas
HEPATOCELULAR CARCINOMA
Adenocarcinoma developed from hepatocytes
More often unique tumor, brownish, soft Centrifugal development produces
compression of adjacent liver structures = pseudocapsule
May also develop bilobar and multicentric but diferentiation from metastasis
CLASIFICATION
1. INFILTRATING – develops on a normal liver without demarcation between tumor and normal tissue
2. EXPANDING– well encapsulated tumors, developed on chirrhotic liver
3. MIXT
4. DIFUSE – multiple nodule in liver chirrosis, nodules having no tendency to become confluent.
infiltratinginfiltrating
multifocalmultifocal
pedunculated tumorpedunculated tumor
Spreading
Centrifugal – compressing adjecent liver tissue
Venos – anterograd şi retrograd Limphatic – regional lymphnodes Direct invasion of diaphragm
Hepatocelular Hepatocelular carcinoma with carcinoma with satelite lesions satelite lesions
CLINICAL SIGNSSUBIECTIV Discomfort in RUQ, but no pain anorexia, weight loss Low grade fever
OBIECTIV Hard hepatomegaly jaundice Sings of UGI bleeding Ascites
LAB WORK Anemia and increased ESR High levels of AFP Ultrasound imaging CECT cu substanţă de contrast MRI – indicaţii limitate Angiography (CT angiography) –
abnormal type o vascularisation Laparoscopy +/- biopsy
PROGNOSTIC Not very good in large tumors With surgical treatment <10% survivaal at
5 y MTS pleuropulmonary, bones, LN
COMPLICATIONS
Intraperitoneal rupture and hemoperitoneum
Necrosis + infections followed by septic complications
Compression of intra- or extrahepatic bile ducts and joundice
Hemobilia
TREATMENT
Systemic chemotherapy Chemoembolisation Arterial emolisation Distruction with alchool injection,
radofrequency, heat, etc Radiotherapy Cryosurgery Surgical resection
TREATMENT
NEW DEVELOPMENTS– Radiotherapy using intratissular irradiation– Photodynamic therapy– Inteligent molecules: Anti VEGF
Cholangiocarcinoma Origine: epithelium form billiary canaliculi Ethiology:
– Sclerosis cholangitis– Clonorchis sinensis
Pathology: glandular proliferation with mucin secretion, surrounded by dens stroma
Differential diagnostic with hepatoma: immunohystochemistry
CLINICAL DIAGNOSTIC Non-specific symptoms
LAB US scan CT AFP, CEA, CA 19-9 Ac anti mytochondrial FAlc
Cholangiocarcinoma
HEPATOMA ON CIRRHOTIC LIVER
Patients with high risk for hepatoma (B and C hepatitis)
Screenign:– AFP– US scan CT scan
TREATMENT
Destruction within oncologic limits (RF, Cryo, Heat)
Resection of tumor with free margins Maintain enough liver tissue for sufficient
liver function ***methods to increase the volume of the liver
Metastatic liver cancerMetastatic liver cancer
second most common site for MTS
Primary tumors
Stomach Pancreas
Genital (prostate, ovary, uterus) Skin (malignant melanoma)
Breast
SYMPTOMS
May be asymptomatic Symptoms generated by the primary Symptoms generated by products
produced by tumor or MTS
PLUS– Liver enlargment– Liver failure
LAB WORK
All imagistic evaluations work in different degrees
Monitoring programs after control of primary tumors
Tumoral markers PET CT FIND the primary
CT spiral:
TREATMENT and PROGNOSIS
DEPEND ON THE PRIMARY TUMOR
TREATMENT
Surgical – usually addressed to single tumors. If adjacent hepatectomy – care for liver function
Destruction Chemoembolisation Systemic chemotherapy + inteligent
molecules
