Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_725_Библиотеки_им_академика_М_И_Перельмана
.pdf
Figure25.3.“Sir,youhave33pointsontheMELDscore.Weneed…tofindanewliverfor
you.PerhapsfromChina?”Patient:“Actually,Iwouldlikeanotherpieceofchicken.And
getmesomebetterwine.Thisonesucks!”
Typically,youarecalledbecauseaChildBpatienthasanincarcerated
inguinal hernia and his internist wants it fixed. Makesure you explain
that the hernia repair might easily kill him, get an experienced
anesthetistinvolvedand,ifyoucan,performtherepairunderlocal
anesthesia.Correctingcoagulopathywith freshfrozen plasma (FFP) is
difficultandfrequentlydoesnot help;vitaminKshouldbeobligatorybut
frequently doesn’t help either in improving coagulopathy in cirrhotic
patients.
Bytheway,whatyoulearnwhenyoudolivertransplantsisthata
liverpatientwithanINRof2.5isnotnecessarilycoagulopathiclike
apatientwhotakescoumadinandhasanINRof2.5.Whilecorrecting
the INR with FFP in anticoagulated patients is indicated and effective,
mostsurgeonsdealing with cirrhotic patients do not attempt this before
theoperation.Givingpeople6unitsofFFPupfrontwillvolume-overload
them,causeascitesandmorebleedingfromvenouscongestion.Inever
doit—except occasionally to control postoperative bleeding. Now you
willaskmeabouttheevidence…(“Definition ofa modernsurgeon: one
whoseignoranceis due to lack ofexperience,but evidence-based.”)…,
butitisanareawhereitisdifficulttoperformaclinicaltrialaswetryto
avoidoperatingonthesepatientsanyway.
Obsessive hemostasis and meticulous respect for peritoneal
integrity to avoid postoperative leak of ascites (leading to its
infection) are the mainstays of successful surgical management.
These patients have a tendency to develop postoperative hematomas,
infectious complications, ascites and renal failure. Fluid management
shouldbe restrictive;lowdoses ofperi-operative diuretics arehelpful to
correct the volume retention physiology of chronic liver disease. Make
sure your residents are well instructed to avoid volume overloading at
night when called by the nurses about oliguria. Unlike in the routine
postopsurgicalpatient,oliguriahereusuallymeans‘Lasix®’rather
than‘lactatedRinger’s’…
Child C patients have a short life expectancy (unless
transplanted…) and theyshould only be operated on if thereis no
other option and should be clearly informed about their high
mortalityrisk.
Typically, due to the large-volume ascites, they have umbilical
hernia emergencies, that require emergency surgery. I have spent
manyhoursatthe bedside of patients high on the transplant list slowly
reducing a few loops of bowel that had incarcerated, but were not
strangulated,to spare them the umbilicalherniarepair that could easily
bringthemtotheICUwitha20MELDpointgainwithin24hours.Atthe
same time I have seen courageous (reckless? inexperienced?) young
transplantsurgeonstakingChildCpatientstotheORarguingthatinthe
eventofdecompensation“theyarealreadylistedfortransplantation”.Itis
importanttonoteherethattheoutcomeforpatientswhoaretransplanted
afterdecompensationisdramaticallyworse.
Another typical emergency for a jaundiced Child C patient with
massiveascitesisasprinklinglittlefountainofascitesatathinnedoutskinulcerationatthebaseofalargeumbilicalherniafilledwith
ascites. I strongly recommend that you do not perform a conventional
umbilical hernia repair here, but just cover the defect with normal
surrounding skin under local anesthesia. Whether you excise the
ulcerated skin and suture over the clean margins, or only approximate
the edges of the ulcer with big ‘bites’, or even just ‘fold over’ the
surroundingskin, dependson thecondition ofthe tissues.Thenputthe
patientonantibioticstopreventbacterialperitonitis.Thedermishasalot
ofmechanicalstabilityandultimatelytheselesionsmayheal.
Onoccasion,however,youwillhavenochoicebuttobitethebulletas
inarecentcaseofcolonoscopyperforationduringthework-upforaliver
transplant.Whenyoutakethese patientsto theoperatingroom,dissect
very carefully and beaware ofthe venouscollaterals of the abdominal
wall and the retroperitoneum. Among the many energydevice gadgets
yougetofferedinamodernhospital,theLigaSure®isreallyhelpfulinthis
situation.
Duringcolonsurgeryinliverpatientswithascites,thequestionof
primaryintestinal anastomosis versus stoma formation comesup.
While I would do an elective colonic anastomosis in the presence of
ascites,theemergencysituationcallsfordiversionorexteriorization
—especiallyifthepatientishypoalbuminemic.Makesure,however,
thatthe ascites is meticulouslycontrolledwith drains when youleavea
patientwithasciteswithanostomy—toallowhealingoftheostomyand
avoid bacterial peritonitis.Keep thedrains in situ until thestoma is
well healed. The protein losses of prolonged drainage in patients with
ascites are prohibitive and I would not drain a standard colon
anastomosis otherwise, but rather intermittently and regularly tap the
ascites (every day or every 2 days) to prevent leakage through the
incision and allow early recognition of anastomotic leaks via infected
ascites. This holds true for many other operations, including partial
hepatectomies,inliverpatientswithascites.
At any rate, ifyour ChildC patient survives thefirst fewweeks after
surgery, you and theyhave beenvery lucky. You should presentthese
patientsonyourweeklyM&MasS&S(‘SurvivalandSuccess’…).
The decompensated patient with cirrhosis and portal
hypertensionwhoneedstobetransferredtoatransplant
center
There are quite a few patients who present to emergency rooms
across the world with elevated liver function tests and unexplained
jaundice.Whoshouldbesenttoahepatologistforafurtherwork-upnext
weekandwhoshouldbequicklyreferredtoatransplantcenter?Hereare
the criteria which have been proposed for an immediate referral to a
transplantcenters2:
•
Extreme hyperbilirubinemia (>10mg/ml). Exclude, however,
obstructivejaundice.
•
Metabolic acidosis (pH <7.3). This should be very rare after
adequateresuscitation.
•
Drug use or overdose of toxic substances (e.g. mushrooms
ingested)whichcouldhavedamagedtheliver.
•
Marked decreased synthetic liver function (INR >3, or any
progressiveincreaseafteradmission).
•
Encephalopathy.
•
Compromised renal function (new onset, progressive — despite
adequatehydration).
Chronicliverpatientswithanyoftheaboveshouldbeevaluated
in atransplant center as soon as possible. Let them worry about
when and if to transplant — just make sure that you give the
patientsthatchance.
Theliverpatientemergencyontheward
Usually liver patients are admitted to internal medicine wards with a
gazillion of consultations: to hepatology to give recommendations
concerning the work-up and need for transplantation; to nephrology to
deal with compromised renal function; to infectious disease to give a
differentialdiagnosisfortheunexplainedfever;tonutritiontoaddressthe
lowalbumin; to dermatologyto explain theirrashand scratch marks;to
gastroenterology when patients develop GI bleeding; to psychiatry for
delirium;andofcourse—everybodywritesabill.
Surgeonsmaybecalledtoo,foraveryspecificemergency—GI
bleedingin patients withcirrhosisandanileostomy or colostomy.
SinceIhaveseenafewpatientsalmostdiefromthis,Ithinkitisworth
talkingabout.Thesituationisoulinedinthecaseboxopposite.
A patient had to undergo a colon resection in the presence of liver disease and portal
hypertension.Whileitisknownthatthe patient has varices, there has neverbeenaproblem
withGIbleedinguptonow.However,thedaypriortoconsultationtheresuddenlywereseveral
litersofbloodinthestomabag. At upper endoscopy asourceofbleedingwasnotidentified.
Nextyou hear thatthe patient becameunstable with another few liters of bloodloss but the
sourceremainsmysterious.‘Bleeding scans’arebeingperformed, trans-stomaenteroscopies
scheduledandacapsuleendoscopyisplanned—whichisexactlythetimepointatwhichyou
decidetojustgoupthereandseethepatientyourself.
To make the diagnosis, you have to do the unprecedented and
reallyexaminethepatientandtakeoffthestomabag—whichisa
huge effort and you may dirty your hands! You will find a
peristomal varicosity that is directly dripping blood into the
ostomybag. Now you ask the nurse for a needle holder and a Vicryl
®
suture and you
overrun, with deep locking bites, the bleeding area. Such varicosities may be familiar to the
stomanurses,buttheyarenotaroundwhenpatientsbleed.And—asweallknow—regular
wardnursesarenot generally changing stoma bags anymore.Thesurgical consult resident
longagolostthe habit to thoroughlyexaminethestomaandtheresident who takesoverthe
next shift never actually saw the patient and is only able to tell you that there is a capsule
endoscopyscheduledforthenextday.Theshiftmentality—hallelujah!
Theliverpatientemergencyintheoperatingroom
Wesometimesstumbleacrosspatientswithportalhypertensioninthe
operating room, either because wewere unaware of their liverdisease
and portal hypertension or because we were led awry by an error in
diagnosisorbecauseoneofourfellowsurgeonscallsusunpreparedand
gives us the honor of consulting the so-called ‘liver expert’ — which I,
humbly,am ;and Imust admit thatinsuch situationsitis good tobe
theliverexpert.
You should not miss the fact that a patient has cirrhosis with
portalhypertensionduringthepre-operativework-up.Therearetoo
manyredlightsalongtheway.Ifyourpatienthasnostigmataofliver
disease like spider naevi, ascites, encephalopathy, edema, cachexia
(when was the last time you have elicited flapping tremor?), he surely
musthave undergonesome routinelaboratory test likeaplatelet count,
INR,or bilirubin or creatinine level—which are abnormal. Remember:
whenthediagnosisofcirrhosisismissed,laboratoryabnormalities
aregenerallynotoverlooked,butmisattributed —thrombocytopenia
isduetoidiopathicthrombocytopenicpurpura(ITP);theINRishighdue
tooralanticoagulationforatrialfibrillation(oh,andthepatientmentioned
thatheonlyhadtotakecoumadinonceperweek);thepatienthasbeen
toldthatthehyperbilirubinemiaisduetoGilbertsyndromeandthereare
numerous reasons to have renal insufficiency. If despite this and other
things—theCTscanwithanenlargedspleen,thedysmorphicliverwith
anirregular surface andthe convolutes ofvaricesvisible evenona CT
scan without contrast — the alarm bell doesn’t ring in yourbrain, then
youshouldseriouslyconsiderapplyingforanearlyrecertificationexamor
becomeahospitalist.
However,theinterestingscenarioIfoundmyselfinseveraltimes
is the patient known to you as having cirrhosis but you
underestimatedtherisk(seethecasebelow).
YouhaveaChildApatientwhoneedsawedgeresectionofasinglehepatocelllularcarcinoma
lesion. According to the Barcelona Clinic Algorithm3, you diligently check portal wedge
pressuresand thegradientwiththeCVP.At 8mmHgthegradientisabsolutelynormalinyour
patients (up to 12mmHg); furthermore, it was done by the new interventional radiology
attendingwhowastrainedatthebigcenterdowntown.Uponenteringtheabdomenyoucome
across some slightly enlarged veins which are bleeding slightly more than they should.
Surprised,yougobacktotheCTscanonthecomputerscreenandyouseethatthespleenis
around12cm.Becausethevenous phase of the CT scan was not welltimed,thevaricesdo
notseemquiteasimpressiveastheyappearinreality.
Comforted by the ‘normal’ value of the pre-operative portocaval gradient, you decide to
continuewiththeexploration.Theomentalveinsareengorged as well and when you detach
theomentum from thegallbladder bed (years ago the patient underwenta cholecystectomy)
thereis some bleeding. Before you even start yourhepatic ultrasound tofind the lesionyou
wanttoresect,youhavelostaliterofblood.Despitetheseredlightsyoucontinueheroically.
At the end of the procedure, the patient, who could have had radiofrequency ablation or
transarterial chemoembolization, has lost 2Lof blood, develops ascites and temporary renal
failure,andspendsamonthinthehospitaldespitethebestperi-operativemanagement.Heis
luckytosurvive!
Remember: single testsmay be wrong.And it is not toolate to
stopaplannedoperationaftertheexploratorylaparotomy.
Livertrauma(seealso Chapter32)
Happily enough, the majority of acutely injured livers have a normal
parenchyma, unless you work in the famous trauma center downtown
thatreceivesthe homeless alcoholic run over by a car while your posh
neighborlevel1traumacenterreceivestheMaserati-drivingphotomodel
withconcussion.
Bluntlivertrauma
Therearethreedifferentmechanismsofinjury:
•
Anterior/posteriorimpactinjurieslikethetypicalsteeringwheel‘bear
clawinjuries’.
•
T-bone impact injuriesgenerally resultin lateralserial ribfractures
and a transverse rupture of the liver along the division line of the
superiorandinferiorsegments, andmayresultinsevereinjuriesof
therightlobe.
•
Themostsignificantinjurytotheliverresultsfromanextreme
deceleration and vascular avulsion from the vena cava which
typicallyresultsinmassiveimmediateexsanguination.
Priortothe adventofCT, manypatientswithbloodin theirdiagnostic
peritoneallavageunderwentlaparotomy.Frequently,nomorewasfound
than a laceration of the liver or the spleen which would have stopped
bleeding spontaneously — the great majority of these laparotomies
endedupbeingnon-therapeuticasfarastheliverwasconcerned.
Nowadays,liverlacerationsaregradedbyaCTscan.GradeIorII
injuriesalmostalwayscanbemanagedconservatively(unlessthereisan
additional injury thatis non-liver-related), while injuries above Grade III
may require surgical intervention in a little more than half of patients.
Therefore,youhavetoknowhowtodistinguishaGradeIIIorhigher
injuryfromalesserinjury.
Whatisa≥GradeIIIliverinjurybyCT?
•
Subcapsularhematoma>50%orexpanding.
•
Intraparenchymalhematoma>10cm.
•
Laceration>3cmindepth.
Ifyouencountera≥GradeIIIinjury,butthepatientiswellandthereis
no other reason to take him to the operating room, you may safely
observe him. However, if the patient with a ≥Grade III liver injury
‘turnsa hair’,in terms ofhemodynamicstability,itissafer to take
himtotheoperatingroom.Ofcourse,if theabdomenisdistended
and there isa lot of bloodin the abdomenon CT, you willignore
your laceration grading and explore the patient. Remember that
injurygradingisaguideonlyandwhatmattersmostistheclinical
conditionofthepatient.
Now,whatarethesurgicalstepstoexploretheinjuredliver?
•
Packingtoobtainhemostasis.
•
Mobilizationoftheliverandopeningofthelessersac.
•
Surgicalcontrolofbleeding:
ifnecessaryresectionaldebridement;
if necessary controlof arterial and portal inflow and selective
clamping.
•
Re-explorationiftheviabilityoflivertissueisquestionable.
As straightforward as this sounds, a recipe like this can result in a
disastrousoutcomeinthehandsofsurgeonsinexperiencedwiththeliver.
Whathasmadepeopleunderestimatethevalueofpropertraininginliver
surgeryinthemanagementoftraumaisthemyththatanylivertrauma
canbefixedbypackingalone—seethecasebelow.
As a freshly graduated transplant surgeon I worked in Indochina with an American veteran
surgeon who had been to many theaters of war and humanitarian disasters, had graduated
fromseveralfellowships andmighteasilyhavebeen oneofthemostexperiencedsurgeonsI
have ever worked with. I was sure he would never have to summon me for help… but one
nighthecalledmein:a16-year-oldgirlhadbeeninvolvedinabusinjuryandwasbroughtin,
inanunstablecondition,toourlittle‘traumacenter’.On explorationshehada30cmruptured
subcapsular hematoma from a direct impact injury.My partner had packed the liver well by
carefullyplacinglaparotomypadsaroundit; relativeshaddonatedfull bloodtokeepheralive
butdespitethetransfusionoffourunitsshehadbecomeunstableintheearlymorninghours.
Were-exploredhertogether;theextensiveamountofarterialbleedingfromthelargecapsular
defect was obvious to somebody who had just learned how to transplant and resect lots of
livers,andalineofrunningsutureswithalargeMHneedlealongthearterialbleedersfixedthe
ongoing blood loss almost immediately. The girl recovered with one more exploration to
removethepacks.
Соседние файлы в папке Библиотека им академика М.И. Перельмана