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Thelessonhereisthatarterialbleedingfromaliverinjurycannot
easilybefixedbypackingalone.
Thatistrueandthereforemanycentersroutinelyperformangiographyandembolization—as
needed—inallpatientsundergoingperihepaticpacking.However,perihepaticpackingusually
stops bleeding from low pressure venous injuries and is the preferred method especially for
surgeonsnotexperiencedinliversurgery.Andthekeyisalways:packearly!Ari
In complex liver injuries,suture ligationof thebleeding source is the
key to achieving a good outcome for patients. Similarly, resectional
debridement minimizes the amount of necrotic liver tissue that might
serve as a source of bile leaks and infections. Packing liver injuries
frequently serves as damage control in patients who are
hypothermicand coagulopathic. It isnotamistaketo then get the
surgeonswhohavethemostexperiencewithliversurgeryinvolved
inre-exploration.Orshipout!
Bleedingthatyoucannotstopbypackingandsutureligationisrarein
livertrauma; however,itdoes occur. Thereisa commonmisconception
that the hepatic artery may be ligated when bleeding does not stop; I
have even heard chief residents teach thisto their juniors. Historically,
occlusion of the common hepatic artery has been described, because
collateral flow is maintained throughthe gastroduodenal artery, thereby
bleedingcanbeslowedorstoppedwithoutcompletelyabolishingarterial
inflow. This sounds great in theory but every time I have seen the
commonhepaticarteryinjuredandnotreconstructed,theoutcome
wasdismal.
Herearesomegeneralrulesaboutthevascularsupplyoftheliver
intrauma:
•
Vascular inflow into the liver cannot be occluded with impunity in
trauma,neitherontheportalvenous,noronthearterialside.
•
Completeocclusionofthecommonhepaticarterymaywellresultin
postoperative liver failure, intrahepatic cholangiopathy, cholangitis
andabscesses.
•
Completeandsuddenocclusionofportalvenousflowwillresultin
massivelivernecrosiswithhemodynamicinstabilityandsepsis.
Indesperatesituations,theportalveincanbeligatedtostopmassivebleeding,butithasabout
a50%mortalityrate.Ari
Penetratinglivertrauma
Penetrating liver trauma occurs because the liver is the largest
parenchymatousorganandislocatedinthemid-portionofthetorsoinan
area which is frequently targeted. Injuries to the parenchyma are only
problematic when high-velocity missiles are involved due to the large
amountofenergydepositedandtheensuingcavitywithalotofnecrosis.
Usually packing as immediate damage control, hemodynamic
resuscitationandthenresectionaldebridementarethewaytogo.
Resectionaldebridementisseldomneeded—mostlyinhigh-velocitygunshotwounds.Ari
Low-velocitygunshotwoundsrarelyresultinproblemsespeciallywhen
they penetrate through and through, except for hematomas. The
associatedchest trauma,however,shouldnot beunderestimated; while
thishasalreadybeenpickedupbythepneumothoraxfoundonthechest
X-ray (and treated), remember that gunshot wounds through the liver
typicallytraversethediaphragmaswell.
There are three major scares even to the experienced trauma
surgeonwhoalsoisanoccasionalliversurgeon:
•
Hepatic artery and bile duct injuries may cause extensive
bleeding and make visualizationof not-pre-dissectedporta hepatis
extremelydifficult.
•
Portal vein injuries may be difficult to visualize and repair,
especiallyiftheyarebehindthepancreatichead.(“Idoknowthatit
is harder to control bleeding from the back side of the portal vein
thanitistolanda737withanengineonfire.”RichardC.Karl.)
•
Retrohepaticvenacavainjuriesmayresultinmassivebleedingif
theydonotremaincontainedintheretroperitoneum.
For management of these situations you have to have a decent
amountofexperiencewiththreemaneuvers.Ifyoudon’t—gethelpearly
enough.Ifsuchhelpisnotavailable—callthePriestortheRabbi(orthe
Imam—Editors):
•
Pringlemaneuver:rapidplacementofanumbilicaltapearoundthe
porta hepatis to stop vascular inflow and allow the dissection of
portalstructures.Limitclampingto15minutesifyoucanandisolate
injuredstructuresassoonasyoucan,toavoidglobalischemia.
•
Cattell-Braaschmaneuver:toexposeinjuriestotheportalveinand
thepancreaticheadyouhavebeabletorapidlyperformacomplete
medialvisceralrotation ontherightsideof theabdomen.The right
colonismobilizedandanextendedKochermaneuverperformedto
mobilize the duodenum.The root of the small bowel mesentery is
mobilizeduptothesuperiormesentericarteryandinferiorborderof
the pancreas. Now you may control the portal vein with finger
compressionand exposethe inferiorvena cavawhich isfrequently
injuredaswell.
•
Heaneymaneuver:mobilizationoftheportahepatis, therightlobe
oftheliver,theinfrahepaticinferiorvenacavaandthesuprahepatic
inferiorvenacavatoperformtotalvascular exclusionof theliver in
extensivevascularinjuriesoftheliverandthevenacava.
Retrohepaticvenacavainjuries
If a hematoma behind the liver is not expanding, don’t mobilize,
justpack.If massivelybleeding,mobilizetherightlobeandthenpack.If unsuccessfuland
youareanexperiencedliversurgeon,attempthepaticvascularisolation(Pringleplusclamping
suprahepatic/infradiaphragmaticvenacavaandinfrahepatic/suprarenalvenacava),exposethe
retrohepaticvenacavaandrepair.Ifnot,packandcallforhelp.Atriocavalshuntsare
cumbersome, take too much time and seldom work, except in
publications of which there are more than survivors — usually
authoredbymoreauthorsthanreportedcases. I havetreatedonepatient
withananteriorstabwoundsplittingtheliverandtheanteriorwalloftheretrohepaticvenacava,
wherethecavawasalreadyexposed,managedtosutureitandcompletedthe(left)lobectomy,
andthepatientsurvived(madeanicecasereport).Ari
Patients with penetrating trauma requiring any of these
maneuversarerare…andsoarethesurvivors!
Emergenciesarisingfromhepaticlesions
Atrainedsurgeonknowshowtodoit;aneducatedsurgeon
knowswhyyoudoit.
RodneyPeyton
Theseareexceedinglyrarebutitisgoodtoknowthemwell.
‘Ruptured’hepaticcysts
Thisisoneofthemostcommonquestionsbypatientswhohavebeen
diagnosedwith incidental hepatic cysts:Willitrupture? Or rather: What
happens when it ruptures? The truth is, hepatic cysts almost never
rupture.
Soyouwillhearthequestionfromthepatientwithalargeincidentally
discovered asymptomatic cyst — whether he/she may continue taking
Taekwondoorkick-boxingclasses?Whilesomesurgeonsusescenarios
likethesetoscarepeopleintoperformingsurgeryonsimplecysts,Ihave
yettoseeahepaticcystrupturefromthepracticeofmartialarts.Iwould
avoid fear-mongering along these lines and tell patients they may
continueto do everything they have doneinthe past even after having
beendiagnosedwithahepaticcyst.
Despite the above, every 5 years or so, I see a patient with acute
abdominalpain whoisadmitted witha disintegrated hepaticcyst, some
freeabdominalfluid andathinmembranehanging fromtheliveronthe
CT scan. My recommendation: check serology for Echinococcus,
explore the liver laparoscopically, wash out the abdomen, culture
the fluid andresect the cyst wall. Because this is an extremely rare
event there are noreliable dataon this versus other approachesbut it
savesyoualotofheadaches.Rupturedechinococcalcystsmaypresent
inpatientswithanaphylacticshock.IsawitonceinmylifeinSwitzerland
whereEchinococcusisendemic.
Liverabscesses
ThediagnosisofanhepaticabscessismadebyultrasoundorCTina
patientwithfeversandabdominalpain.Asusualitisworthlookingat
theimagescarefullyasyourresidentsmaycallahepaticabscess
what is actually a ‘subphrenic’ or ‘subhepatic’ abscess. Spilled
stones after a previous cholecystectomy, cholecystitis, any source of
abdominal infection like appendicitis, deep surgical space infections,
visceralperforationsduetodiverticulitisandinflammatoryboweldisease
may cause subphrenic and subhepatic abscesses in the peritoneal
spacesaboveandbelowtheliverthataretightlysealedoffbythebulge
ofliverparenchyma.Athoroughwork-upofthehistoryofthepatientand
thelaboratoryandimagingdatashouldguideyoutothediagnosis.
Mosttrueliverabscessesinthewesternworldarepyogenicand
amoebic abscesses occur mostly in third world countries. While
amoebic abscesses almost always respond to antibiotic treatment (with
metronidazole), pyogenic abscesses are more tricky. While some may
simplybe aspiratedwith aneedle underUSguidance,andresolvewith
antibiotic therapy, very large ones and especially loculated ones
usuallyrequiretranscutaneousinterventionaldrainage.
TherearetwotypesofmistakesIhaveobservedwithliverabscesses:
oneistodrageverypatientwithaliverabscessintotheoperatingroom,
becauseofthemisguidedconceptthattheworldiswaitingforprofessorsurgeonstosolveallproblems;theotherisnottousesurgicalcommon
senseearlyenough—seethecasebelow.
Sometimeswereceiveaconsultationaboutapatientwithanon-resolvingliverabscess:alittle
9Frcatheterhasbeeninsertedbyaradiologistwhoneversawthepatientafterwardsandhas
sinceretired.A9Frdrainishangingfromthepatient’ssidewithoutbeingflushedregularly.Itis
obstructed half of the time and otherwise draining thick pus that has not changed in quality
overthelast10days.Oncethesurgicalservicereceivesaconsultationaboutsuchapatient,it
is good judgment to first recommend upsizing to a 12 or 15Fr catheter, frequent flushing to
address the source of the infection and to consider surgery if things don’t improve after the
lesionhasbeenwelldrained.
Surgeryis not quite indicatedunlessthepatient has reallybeen
treated non-surgically. Onthe other hand, there are situations where
surgical drainage of non-resolving hepatic and perihepatic abscesses
maysolveaproblemimmediatelythat,if notaddressed —especially in
older patients — may cost the patient’s life. Non-resolving perihepatic
abscesses nowadays are best addressed through a laparotomy with
adequateantibioticcoverage,careful debridementand drainplacement.
Theextraperitoneal approaches (plus/minusribresection) belong to the
skill set of a different generation of general surgeons and are not
practicedanymore.
When a hepatic abscess is drained surgically, I recommend
pokingastraightfingerintotheusuallyloculatedcollectiontobreak
itupandrefrainfromtearingapart theinnerwallsofthe loculated
collections with a curved finger, since this will invariable destroy
the Glissonian structures crossing the abscess and cause bile
leaks.
Hemobilia
Hemobiliaismostfrequentlyacomplicationofinterventionalradiology
procedures and is treated by interventional radiologists as well. As a
surgeon you simply have to recognize the entity, know how it is
diagnosedandpassitontothe specialtywhofixes it.Mostfrequently,
patients present with stigmata of GI bleeding like melena, anemia
and sometimes hemodynamic instability and a recent history of
instrumentation of the liver — either by transcutaneous biopsy,
endoscopic retrograde cholangiography or even a laparoscopic
cholecystectomy—seethecasebelow.
Doyourememberthelaparoscopiccholecystectomyyoudidinadiabeticpatientafewweeks
ago—theonewithabaked-inchronicallyinflamedgallbladder?Yougotintothewrongplane,
therewassomebleeding from thegallbladderbed,intheendyouasked for theargonbeam
coagulator. Ultimately it stopped. The patient did fine. Afew weeks later he presented with
melena, but a negative colonoscopy and a negative upper GI endoscopy. The
gastroenterologistdidnotvisualizethepapilla,buttheymighthavenotseenanythinganyway,
because hemobilia is intermittent. However, because you are smart, you order a CT
arteriogram and there it is: an intrahepatic aneurysmof the righthepatic
artery!
Thepathophysiologyisanarteriobiliaryshuntcausingbleedingintothe
biliary system and — therefore — GI bleeding. Embolization of the
pseudo-aneurysm is the treatment of choice. Only in scenarios of
tumors causing arteriobiliary fistulas and the non-availability of an
interventional radiologist, is a surgical resection of one liver lobe or
surgicalligationofeitherhepaticarteryrequired;thisisrare.
Hepatictumors
Liver tumors may present as an emergency because of intraabdominal bleeding. The “bleeding hepatic tumor” announced by the
emergencyroomcrewfrequentlyturnsouttobeatransferfromanother
hospital, because a liver lesion had been transcutaneously biopsied,
although imaging with three-phase contrast CTs or MRIs could have
established the diagnosis.Tobe fair,thereis a riskof spontaneous
bleeding in adenomas and hepatocellular carcinomas, but it
remainsanuncommonpresentation.
Bleedingofhepaticadenomasismorecommonspecificallyinpregnant
women. Bleeding hepatic tumors are nowadays managed by
transcatheter embolization to stop the bleeding. Convince your
interventional radiologist to embolize the bleeding as selectively as
possible and avoid embolizing the entire hemi-liver, because necrosis
andintrahepatic cholangiopathy mayensue,which ultimately requires a
moreextensiveresectionthaninitiallynecessarytoremovethetumor.It
should be rare that tumor bleeding cannot be controlled by an
angiographicintervention.
Only after embolization, are a thoughtful imaging work-up and
stagingindicatedtoestablishasurgicaltreatmentplan. Sometimes
anintervalofseveralweeksisrequireduntilthe hepatichematoma has
resolved to be able to establish a radiologic diagnosis by MRI. Do not
plan elective resectional surgery until the hematoma has completely
resolved.Alargecentralhematomacancompresshepaticveinscausing
aBudd-Chiari syndrome—operating insuchcircumstances mayprove
disastrous!
Ifnointerventionalradiologistisavailable,laparotomyandrapidinflow
control of the liver may be necessary. In older, frail patients with
comorbidities and limited reserves and a bleeding exophytic
hepatocellular carcinoma, I have used a hand-assisted laparoscopic
approachandstaplertumorectomytorapidlyremovethebleedingmass.
Should you encounter a bleeding liver tumor causing
hemodynamic instability with no local angiographic facilities, no
expertise in liver surgery, and no immediate options of rapid
transferal—dowhatyouwoulddowithlivertrauma:openupand
pack!
Another emergency scenario is the incidentally discovered liver
tumor,eitherduringanemergencyexploratorylaparotomyorduring
anelectivelaparoscopyorlaparotomy.Youmightask:shouldIexcise
thelesionorperformabiopsy?Ifthelesionissmallandperipheral,itis
nomistaketoexciseit,butIwouldn’ttakeanyrisks,sinceitisnoteasyto
exclude other lesions in the rest of the liver without cross-sectional
imaging by CT or MRI, unless you are avery goodultrasonographer.I
wouldstronglyadvise nottoperformadirect biopsyintoatumorvisible
ontheliversurface,butifyoudo,thenonlydoitbydrivingacoreneedle
through healthy livertissue and then carefully ablating the needle tract
afterwards. You just don’t want to spill tumor tissue throughout the
abdomen by performing a biopsy with a needle coming through the
abdominal cavity. Nowadays MRI diagnosis of liver tumors both in
healthy and diseased livers is excellent and tissue diagnosis is not
always necessary to decide on further treatment courses: don’t let
anybody talk you intoa biopsy; the work-up should be performed after
thesurgeryisover.
Tosumup…
The liver is a quiet organ and doesn’t cause many problems unless
chronically ill. Patients with chronic liver disease may present with
dramaticemergenciesanditisimportantforsurgeonsandendoscopists
tobewellpreparedforthose.Bluntlivertraumacanfrequentlybetreated
non-operatively;thisisalsotrueforhepaticstabwoundsandlow-velocity
gunshot wounds — unless associated with severe bleeding or other
injuries. In emergencies arising with hepaticlesions, itis goodto know
whennottooperate.Butisn’tthistrueforanythingelse?
“Liverismynumberonemosthatedfood.Oh,God,Iget
sicktalkingaboutit!”
GuyFieri
1
MELD—ModelofEndstageLiverDiseasebasedonthepatient’sage,bilirubin,creatinineandINRlevels.To
calculategoto:http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/
2
http://www.odt.nhs.uk/pdf/advisory_group_papers/LAG/referral_for_transplantation.pdf.
3
http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guidelines/hccupdate2010.pdf
Chapter26
Inflammatoryboweldiseaseandothertypesof
colitis
BasharSafarandJonathanEfron
1
Savethepatient,notthecolon.
JohnC.Goligher
Colitis refers to inflammation of the colon. It might affect the
entirecolon oritssegments.Ulcerativecolitisstartsin therectum
andmigratesproximallywhereasCrohn’scolitisaffectsanypartof
thecolon —aswell astheterminal smallintestine— buttendsto
present with generalized colitis. Some patients present acutely with
severedisease,butmoreoftenbothdiseasestatesprogressslowlywith
intermittentflaresleadingtotheneedforeventualsurgicaltreatment.
The patient and the gastroenterologists view surgery for
inflammatory bowel disease as a failureof medical therapy. Thus,
manyofthesepatientshavespentmuchoftheirlivesattemptingtoavoid
surgery at all costs. It is for this reason that most patients with
inflammatory bowel disease are on multiple immunosuppressive
medicationsandcanbeseverelydebilitatedbythetimea surgeon
isconsultedtoconsideranoperation.Itisimportanttorememberthat:
•
Crohn’sdisease(CD) is atransmural process, is not curable and
thatsurgicaltherapyisaimedatpalliatingthepatient’ssymptoms
andcontrollingactiveinfectionsandseveredisease.
Ulcerativecolitisontheotherhand,affectsthemucosaonlyandis
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