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_992_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 17
converting the incision into a ‘T’ by adding a right
transverse component or to a ‘Y’ by adding a right lateral thoracotomy, although extension of the incision
into the chest is exceptional. In situations where an
operation is being carried out after initial conservative management, for example to treat bile leakage or
perform delayed resectional debridement, a subcostal
incision with fixed costal margin retraction affords excellent access to the liver.
Intraoperative assessment
Once the abdomen has been entered, blood and
clots should be removed and packs inserted into
each quadrant of the abdomen. A thorough laparotomy is performed in a systematic manner to identify
all intra-abdominal injuries. Any perforations in the
bowel should be sutured immediately to minimise
contamination. Significant liver haemorrhage can
usually be controlled initially by direct pressure using packs, although additional techniques that may
be employed include: temporary digital compression of the free edge of the lesser omentum (Pringle
manoeuvre; Fig. 17.2); bimanual compression of the
liver; or manual compression of the aorta above
the coeliac trunk. At this point, further evaluation
of the extent of liver injury should be delayed until the anaesthetist has replenished adequately the
intravascular volume and stabilised the blood pressure. Attempts to evaluate the liver injury before
adequate resuscitation may result in further blood
loss, with worsening hypotension and acidosis.
The packs can subsequently be gently removed to
allow a detailed evaluation of the type and extent
of the liver injury. It should be borne in mind that a
subcapsular haematoma may cover an area of ischaemic tissue and that parenchymal lacerations may
be associated with damage to segmental bile ducts.
Many liver injuries will have stopped bleeding spontaneously by the time of surgery. However, if there
is active bleeding, a Pringle manoeuvre can be used
diagnostically and compression can be maintained
with an atraumatic vascular clamp if haemorrhage
decreases (Fig. 17.3). The clamp should be occluded
only to the degree necessary to compress the blood
vessels and not to injure the common bile duct.
A normal liver can tolerate inflow occlusion for up
to 1 hour; however, the ability of a damaged liver to
tolerate ischaemia may be impaired. If haemorrhage
Figure17.2 • Manual occlusion of the structures of the portal triad – the Pringle manoeuvre.
310
Hepatobiliary and pancreatic trauma
Figure17.3 • Occlusion of the structures in the portal triad using a soft non-crushing clamp.
is unaffected by portal triad occlusion, major vena
cava injury or atypical vascular anatomy should
be suspected. Hepatic outflow control may also be
required. Access to the suprahepatic cava can be
gained by an experienced liver surgeon, and slings
may be placed around the hepatic veins following
mobilisation of the liver from its peritoneal attachments. Total vascular occlusion of the liver requires
control of the inferior vena cava below the liver in
addition to the suprahepatic cava but is likely to be
poorly tolerated by an injured liver.
control surgery – rapid perihepatic packing, closure
of the abdominal incision with or without a Bogota
bag and transferring the patient to ICU as soon as
possible for continued resuscitation and rewarming.
When the metabolic derangements have been corrected or improved, the patient can be taken back
to theatre or transferred to a specialist centre for
re-exploration and definitive treatment.
As packing is thus a widely applicable procedure,
some attention should be devoted to technical considerations. The packs should not be inserted into
the liver substance itself, as this will tend to distract
Perihepatic packing
In situations where it is thought that definitive control of haemorrhage cannot be obtained, or patients
are deemed critically unstable, coagulopathic or acidotic and therefore would not tolerate a prolonged
operative procedure, perihepatic packing can be
employed. This has led to the concept of damage
the edges of the parenchymal tear and encourage
continued bleeding. Rather, the technique of packing involves manual closure or approximation of
the parenchyma, followed by sequential placing of
dry abdominal packs or a single rolled gauze around
the liver and directly over the injury in an attempt to
provide tamponade to a bleeding wound (Fig. 17.4).
41
311
Chapter 17
a
b
Figure17.4 • (a) Placement of gauze packs around the liver to compress the fracture. (b) Closure of the incision
provides additional compression. Reproduced from Berne TV, Donovan AJ. Section 10. Injury and haemorrhage. In:
Blumgart LH, Fong Y (eds) Surgery of the liver and biliary tract, 3rd edn, Vol. 2. Edinburgh: Churchill Livingstone, 1994.
With permission from Elsevier.
312
Hepatobiliary and pancreatic trauma
Most surgeons employ skin closure only, leaving the
fascia for primary closure at the subsequent procedure for pack removal. The presence of packs,
combined with massive oedema of the bowel, may
lead to difficulties in wound closure. If this is encountered, a mesh can be inserted to prevent further
compromise of ventilation and bowel viability, and
to avoid pressure necrosis of the liver.
42
The principal complications and limitations of
perihepatic packing can be considered as ‘early’ or
‘late’. Early complications include failure to control haemorrhage. However, this is relatively uncommon as even in patients with caval or hepatic
venous injuries, packing may control haemorrhage.
Concerns may also be raised about the potential
for compromise of caval blood flow by packing,
although this may be avoided by monitoring caval
pressure if this technique is available. The principal late complications of packing are infection
and multiple organ dysfunction. The risk of septic
complications has led to the recommendation that
liver packs should be removed as soon as possible.
However, Nicol et al. reported in a series of 93 patients requiring liver packing that an early re-look
laparotomy at 24 hours rather than at 48 hours
or later was associated with a higher incidence of
re-bleeding necessitating re-packing, without any
difference in the incidence of liver-related complications or intra-abdominal collections.43 Perihepatic
packing is an indication for intravenous antibiotic
administration.
The first re-look laparotomy following packing
for a liver injury should only be performed after
48 hours, when hypotension, hypothermia,
coagulopathy and acidosis have been corrected.
Techniques for surgical haemostasis
Exposed bleeding vessels can be suture-ligated,
clipped or repaired to achieve haemostasis. The
ultrasonic dissector is useful in removing damaged
and non-viable hepatic parenchyma whilst exposing
blood vessels. Diathermy coagulation can also be
used and in this context the argon beam coagulator,
which ‘sprays’ the diathermy current on an argon
beam, is invaluable as it produces surface eschar
without the diathermy probe becoming adherent to
the liver surface. The argon beam coagulator also
has the advantage of producing less hepatic tissue
necrosis than conventional diathermy, which is an
advantage in a potentially contaminated operative
field. Fibrin glue has been used as an adjunctive measure in some centres; however, there are concerns
regarding the use of fibrin glue in humans. Fatal
hypotension following application of fibrin glue
into a deep hepatic laceration has been reported.44
Recently, recombinant factor VIIa has been reported as a potential adjunct in the management of
liver injuries;45 however, further controlled studies
are warranted to evaluate the safety and efficiency
of this drug.
Liver sutures are absorbable sutures on a large
curved blunt-tipped needle often used in conjunction with a bolster of haemostatic material. These
can be used to approximate a fissured parenchymal
injury and thus control haemorrhage as an alternative to exploration of the depths of the injury. The
disadvantages of this technique are that vessels may
continue to bleed, resulting in a cavitating haematoma, bile duct injuries may not be detected, and the
suture itself may cause further bleeding, ischaemia
or intrahepatic bile duct injury (Fig. 17.5).
Stone and Lamb reported that the greater omentum could be employed as a pedicled flap to fill a
defect in the liver parenchyma and may help stop
oozing from the low-pressure venous system of
the liver parenchyma.46 The use of an absorbable
polyglactin perihepatic mesh, particularly for major
parenchymal disruptions, has also been reported.47
This technique is not indicated where juxtacaval or
hepatic vein injury is suspected. Advocates of mesh
wrapping claim that it can provide the benefits of
packing without the disadvantages. In particular, a
second laparotomy is not required routinely and, as
mesh wrapping does not increase intra-abdominal
volume or pressure, abdominal closure is much
easier and respiratory or renal function is less compromised. However, there is some concern about
the amount of time needed to apply the mesh wrap
in a haemodynamically unstable patient who might
be best treated with rapid insertion of perihepatic
packs, and as yet there is insufficient general experience with this technique.
Figure17.5 • Operative photograph demonstrating a
liver injury with necrosis at the site of previously inserted
liver sutures that had been applied in an attempt to arrest
haemorrhage.
313
Chapter 17
Resectional debridement
This technique involves removal of devitalised liver
tissue down to normal parenchyma using the lines
of the injury, rather than anatomical planes, as the
boundaries of the resection.48 The optimum timing
may be to combine debridement with pack removal,
as necrotic tissue will be well demarcated at 48 h
post-injury. Resectional debridement is by definition ‘non-anatomical’ and may expose segmental
bile ducts (Fig. 17.6). Disrupted bile ducts exposed
in the periphery of the liver should be sutured or ligated in order to prevent postoperative bile leaks,
as this troublesome complication will not necessarily be treatable by endoscopic transampullary biliary stenting. It is better to anticipate and avoid this
complication.
Anatomical liver resection
The practical difficulties of undertaking formal anatomical liver resection in a patient with a significant
liver injury, who will frequently have associated
shock, coagulopathy and concomitant injury, are
such that this type of treatment is not used widely.
It is generally accepted that anatomical resections
should be reserved for situations in which no other
procedure adequately achieves haemostasis, such as
with deep liver lacerations involving major vessels
and/or bile ducts, where there is extensive devascularisation or if there is major hepatic venous bleeding.
Strong et al. reported a single-centre series of 37
patients that underwent anatomical resection for
liver trauma from an institutional experience of
287 patients with liver injury treated over a 13-year
period.49 Twenty-seven of these patients underwent
right hemihepatectomy and overall there were three
postoperative deaths (8% mortality rate). However,
these excellent results achieved by a technically
skilled liver surgeon and his unit may not be reproduced if the technique were more widely used.
Figure17.6 • Debridement of a liver injury managed
3 days before by packing has left the branches of the
right portal pedicle exposed.
Selective ligation of the hepatic artery
Selective ligation of the hepatic artery is no longer
a commonly used technique and is not mentioned
frequently in contemporary reports. It may be used
when intrahepatic manoeuvres have failed and
when persistent re-bleeding occurs on unclamping the hepatic pedicle. In a series of 60 patients,50
Mays reported ligation of the right hepatic artery in
36 patients, the left hepatic artery in 15 patients and
the main hepatic artery in the remaining nine patients. No cases of liver failure or necrosis were observed but it seems likely that modern liver surgical
approaches have rendered ligation an uncommon
manoeuvre in liver injury. Hepatic arterial ligation
to control haemorrhage should only be performed
when other manoeuvres have failed, when selective
ligation has failed and when pedicle clamping has
been demonstrated to arrest haemorrhage. Acute
gangrenous cholecystitis is a well-recognised complication of hepatic artery ligation, and cholecystectomy should be performed if the main hepatic artery
or right hepatic artery is ligated.
Management of hepatic venous and retrohepatic caval injury
Suspicion that one of these serious injuries is present should be raised if the Pringle manoeuvre fails to
arrest haemorrhage. In this situation it is vital that
a systematic approach be adopted. Injudicious mobilisation of the liver can cause exsanguination or
embolisation of air or detached fragments of liver
parenchyma. Therefore it is important to exclude
anatomical vascular variants as a source of persistent bleeding. For example, there may be bleeding
from the left liver due to the presence of a left hepatic artery arising from the left gastric artery or
there may be bleeding from the right liver due to an
aberrant right hepatic artery. The commonest anatomical variation in the origin of the right hepatic
artery (occurring in approximately 15% of cases) is
the persistence of the right primordial hepatic artery
where the right hepatic artery arises from the superior mesenteric artery and runs just to the right and
slightly posterior to the structures in the porta hepatis. These anatomical variants should be considered
and excluded. During this process, active bleeding
can be reduced or arrested by perihepatic packing.
Persistent bleeding despite exclusion of anatomical
variants may then indicate the presence of hepatic
venous or retrohepatic caval injury. These injuries
account for about 10% of liver trauma cases, and
there is no clear consensus on an optimal management strategy. Total vascular exclusion (clamping
of the inferior vena cava and suprahepatic cava in
addition to the Pringle manoeuvre) may be used.
However, clamping the vena cava will seriously
314
Hepatobiliary and pancreatic trauma
compromise venous return in a situation of major
trauma and seems unwise. Veno-venous bypass
(shunt from common femoral vein to left internal
jugular or axillary vein) has the advantage of preserving venous return. Atriocaval shunting has also
been described and, combined with a Pringle manoeuvre, allows total vascular isolation of the liver.
Chen et al. reported on a series of 19 patients with
blunt juxtahepatic venous injury from a group of 92
patients with blunt liver trauma over a 2-year period.51 Five patients with isolated left hepatic vein
injuries were treated with the use of veno-venous bypass with no mortality. Ten of the 20 patients with
isolated right hepatic vein injury were treated using
an atriocaval shunt but the mortality in these 20 patients was 18 (80%), with one survivor in both the
shunted and non-shunted groups. Of four patients
with combined right and left hepatic vein injury, one
was treated by liver transplantation but all four patients in this group died. The overall mortality rate
in patients with juxtahepatic vein injury was 63%.
The opportunity to optimise the outcome in patients
with these serious injuries probably lies in packing
followed by transfer to a specialist liver surgery unit.
Ex vivo surgery and liver transplantation
Ringe and Pichlmayr52 reported a consecutive series
of eight patients with severe liver trauma treated by
total hepatectomy followed by liver transplantation.
These patients had all undergone prior surgery for
trauma, which had been followed by severe complications – uncontrollable bleeding in four and massive
necrosis in four. Where a donor liver was not immediately available a temporary portacaval shunt was
used as a bridging procedure. There was a high mortality in this group, with six out of eight patients dying from multiple organ failure or sepsis. The authors
conclude that total hepatectomy can be a potentially
life-saving procedure in exceptional emergencies in
patients with major liver injuries. Heparinised coated
tubes such as the Gott shunt can be used to bridge
caval defects if total hepatectomy and excision of a
caval segment is required in order to obtain haemostasis.53 The shunt acts as a temporary bridge during
the anhepatic phase and has been reported to remain
patent over an 18-h period. Whilst experience of this
sort of surgery is extremely infrequent, awareness of
the therapeutic potential is useful and small series
continue to report encouraging results.
54
Complications of liver trauma
Complications of non-operative management
Complications of non-operative management
of liver trauma can be considered in three main
categories. First, it should be borne in mind that
complications can arise as a result of inappropriate selection of a patient for conservative management. If a patient has continued bleeding this may
present as episodes of hypotension requiring fluid
and blood replacement, impaired renal function,
impaired respiratory function (due to diaphragmatic splinting by intra-abdominal haematoma)
and there may be evidence of coagulopathy. These
features represent not so much a ‘complication’ as
the natural progression of a patient with continued active intra-abdominal bleeding, and in such a
case the policy of non-operative intervention will
require reappraisal.
The second group of complications are those
relating to coexisting injuries that have not been
recognised at the time of initial presentation or
become apparent after initial delay. Bile leaks may
manifest as biliary peritonitis or as a localised bile
collection. ERCP is useful in diagnosing the source
of a bile leak in patients with liver trauma treated
non-operatively and also in postoperative patients.
Perforations of the intestine are also at risk of being
missed as the signs of abdominal tenderness may be
attributed to intra-abdominal blood from the liver
injury. The risk of missing this type of injury can be
minimised by regular careful clinical observation.
Intestinal perforation may become apparent on
serial ultrasound or CT by the presence of free intraperitoneal fluid or gas. In Sherman et al.'s series of
patients with liver trauma treated non-operatively,
4 of 30 (13%) patients initially treated without operation required subsequent laparotomy.32 These
were due to splenic injury in three patients and renal
injury in one patient. Although the grade of injury
to these organs is not specified, in all cases the injuries became apparent after a period of clinical observation. However, the authors concluded that this
risk of missed solid-organ injury does not obviate
the benefits of initial non-operative management.
The third category of complication relates to the
late complications of liver injury. Liver injury may
give rise to a transient increase in liver transaminase
enzymes. Their persistent elevation suggests significant liver injury. Septic complications such as intraabdominal abscess and bile leak are recognised late
complications and may require radiological, endoscopic or surgical intervention.
Postoperative complications after surgery for liver trauma
The complications after liver surgery for trauma
are similar to those encountered after any form
of hepatic surgery. Haemorrhage in the immediate
postoperative period may be due to coagulopathy related to large-volume transfusion and may
require correction with fresh frozen plasma and
315
Chapter 17
platelet concentrates. If there is no evidence of a
significant coagulopathy and bleeding continues,
CT angiography may provide diagnostic information. Selective mesenteric angiography may permit
therapeutic embolisation, but if this is unsuccessful, re-laparotomy will be indicated to assess and
control the source of bleeding and to remove retained blood and clot. Bleeding in the later postoperative period may be due to haemobilia or
bleeding from the biliary tree into the gut. It has
been reported to occur in 1.2% of patients with
liver trauma.
Postoperative sepsis may be due to infected collections of bile or blood, or related to devitalised
segments of liver parenchyma. Ultrasound and
CT are of value in diagnosis and these modalities may be used to guide placement of drains.
Bile leakage from a drain site is not uncommon
and usually ceases spontaneously; however, if it
persists, ERCP may be all that is required to define the site of the leak and allow temporary stent
placement. Arteriovenous fistula is not an uncommon complication after liver injury and can manifest as an arterioportal fistula resulting in portal
hypertension.
55
Outcome after liver injury
The outcome after liver trauma is related not
only to the severity of the injury but also to the
severity of any associated injury. Most series report mortality rates of approximately 10–15%;
however, the large variation in case mix between
different centres makes comparison difficult.
In a large series of 1000 cases of liver trauma
from Houston, an overall mortality of 10.5%
was reported.4 White and Cleveland documented
a similar mortality rate, with eight deaths occurring in a consecutive series of 126 patients
(6.3%).27 The results in the series reported by
Schweizer et al. recorded an overall mortality
rate of 12% (21 deaths in 175 patients), with
a progressively higher mortality rate associated
with an increasing grade of liver injury.8 In a series of 337 patients, Kozar et al. reported 37 hepatic-related complications in 25 patients; 63%
(5 of 8) of patients with grade V injuries developed complications, 21% (19 of 92) of patients
had grade IV injuries, but only 1% (1 of 130) of
patients had grade III injuries.56 The mechanism
of injury has an important bearing on the mortality rate, with blunt trauma carrying a higher
mortality rate (10–30%) than penetrating liver
trauma (0–10%). While most early deaths seem
to be due to uncontrolled haemorrhage and associated injuries, most late deaths result from head
injuries and sepsis with multiple organ failure.
Extrahepatic biliary tract trauma
Non-iatrogenic injury to the extrahepatic biliary
tract is uncommon and encountered only rarely
by surgeons outside specialist hepatobiliary centres. Most injuries are due to penetrating rather
than blunt abdominal trauma. Biliary tract injury
is diagnosed infrequently before operation and is
often only recognised incidentally at laparotomy.
Extrahepatic bile duct injury due to blunt trauma
is only rarely associated with injury to the portal
vein or hepatic artery. This may be explained by
the increased length, tortuosity and elasticity of the
vascular structures. Furthermore, a vascular injury,
especially portal vein rupture, is likely to be associated with a high immediate mortality.
Incidence of biliary injury
The reported incidence of injury to the extrahepatic
biliary system varies between 1% and 5% of patients
who sustain abdominal trauma.57 In a review of
5070 patients who sustained blunt and penetrating
abdominal trauma, Penn reported a 1.9% incidence
of gallbladder injury.58 Soderstrom et al. identified 31
patients (2.1%) with gallbladder injury in a group
of 1449 patients who sustained blunt abdominal
trauma and underwent exploratory laparotomy.59 In
a further review of 949 patients undergoing laparotomy for acute trauma, there were 32 injuries to the
gallbladder (3.4%) and five to the common bile duct
(0.5%).60 Burgess and Fulton reported that, over a
5-year period, 24 of 184 patients with abdominal
trauma had extrahepatic bile duct or gallbladder injury as well as liver injury.61 They reported that this
injury was often seen with severe hepatic trauma and
in association with multiple organ injury. Dawson
et al. reviewed the results of treatment of all patients
with porta hepatis injuries presenting to a level I
trauma centre in Seattle over an 11-year period.62 A
total of 21 patients (0.21% of 10 500 admissions)
had injuries to the portal triad, of whom 11 (52%)
died. Isolated extrahepatic bile duct injury occurred
in four of these patients. Injuries to the portal vein
or hepatic artery, either in isolation or in association
with extrahepatic bile duct injury, were associated
with the worst prognosis. Of note is the fact that in
none of the 21 cases was the diagnosis of the injury
made preoperatively. The male to female ratio is usually reported as approximately 5:1.63 However, Bade
et al. reported a male to female ratio of 25:1, which
may reflect the higher number of injuries from stab
wounds seen in a South African population.64 Most
series report a median age of approximately 30 years
and there are many reports in children.
316
Hepatobiliary and pancreatic trauma
Classification of biliary injury
The gallbladder is the most frequently injured
part of the extrahepatic biliary tract. The largest
reported series of extrahepatic biliary tract injuries consists of 53 patients, of whom 45 (85%)
sustained injury to the gallbladder and eight
(15%) had an injury to the bile duct.64 Kitahama
et al. reported the gallbladder to be involved in
32 (80%) of 40 patients, while ductal injury occurred in 12 (30%), some patients having multiple injuries.
Injury to the gallbladder resulting from blunt
trauma can be classified as contusion, avulsion
or perforation. In addition to these three main
types of injury, Penn added traumatic cholecystitis as a pathological entity.58 The most common type of gallbladder injury is perforation.
Avulsion of the gallbladder may refer to the organ being partially or completely torn from the
liver bed while still attached to the bile duct, or
it may signify complete separation from all attachments with the organ lying free in the abdomen. Contusion is probably under-reported,
as it will be recognised only if laparotomy is
performed. The natural course of an untreated
gallbladder contusion is not known, although it
is likely that the majority resolve without further complication. It has been speculated that
an intramural haematoma might result in necrosis of the gallbladder wall and result in a subsequent perforation. There have been a number
of reports of delayed rupture of the gallbladder,
and it is plausible that unrecognised contusion
of the gallbladder might lead to such a delayed
presentation.
Bile duct injury is classified according to the site of
injury and according to whether the transection is
partial or complete. Partial duct injuries are often referred to as ‘tangential’ wounds. Penetrating injuries
can affect any part of the extrahepatic biliary system; however, the commonest sites of injury due to
blunt trauma are at the point where the common bile
duct enters the pancreas and where the biliary confluence exits from the liver. These sites are at points
of maximum fixation, which accounts for their propensity to injury.
Isolated injury to the extrahepatic biliary tract
is very uncommon. The liver is the organ most
commonly injured in association with biliary tract
trauma (approximately 80% of cases), with the
duodenum, stomach, colon and pancreas being the
next most frequently reported. Associated vascular
injuries are relatively rare; however, inferior vena
cava and portal vein injuries are more commonly
reported than those to the hepatic artery, renal vessels or aorta.
63
Presentation and diagnosis of biliary injury
Clinical presentation of the vast majority of bile
duct injuries can be divided into two broad categories. The first contains patients in whom clinical
signs or associated injury lead to laparotomy with
early diagnosis and surgical management (early
presentation); these patients generally present with
hypovolaemic shock or signs of an acute abdomen.
The second category of patient has a delay (greater
than 24 h) in diagnosis and definitive therapy (delayed presentation). These patients comprised over
half the cases (53.2%) in a review of combined
series.65 In addition, a third category of patient,
representing a very small proportion of those who
sustain a bile duct injury, may present with obstructive jaundice months or even years after the initial
trauma (late presentation). In these patients, the bile
duct injury is always isolated. Compromise of the
blood supply to the duct may occur either at the
time of the primary injury or at operation during
the Pringle manoeuvre, and this may contribute to
the development of a late biliary stricture. Bourque
et al. reported that the delay between clinical presentation and surgical intervention for isolated bile
duct injury averaged 18 days, with a range from
several hours to 60 days.66 Michelassi and Ranson
reported that biliary injury was not recognised at
initial operation in 11 (12%) of 91 patients with extrahepatic biliary tract trauma,65 whereas Dawson
and Jurkovich reported that 41% of bile duct injuries were missed at initial laparotomy.
If a non-operative course of management for abdominal trauma is adopted, suspicion of an extrahepatic bile duct injury may be raised by CT evidence
of a central liver injury involving the porta hepatis
or the head of the pancreas, the presence of fluid
collections in the subhepatic space, or evidence of
periportal tracking of haematoma.16 The diagnostic procedure of choice is ERCP, and if a duct injury is identified this may be treated by endoscopic
stenting.
requires a high index of suspicion. The presence
of free bile in the peritoneal cavity, or the presence
of bile staining in the hepatoduodenal ligament or
retroperitoneum, is a sign of injury to the extrahepatic bilary tract. Biliary tract injury must also
be suspected if there is profuse bleeding from the
hepatic artery or portal vein, particularly following
blunt trauma, as the bile duct is also likely to be
injured. Penetrating wounds near the porta hepatis
require careful examination. If routine dissection
does not reveal the location of the injury, fine-needle
intraoperative cholangiography via the gallbladder
or common bile duct may identify the site. Cystic
68
Intraoperative recognition of biliary tract injury
67
317
Chapter 17
duct cholangiography should be considered after
cholecystectomy for traumatic gallbladder injury to
avoid missing an associated bile duct injury.
It is possible for a patient who has sustained blunt
abdominal trauma to be discharged from hospital
only to return days or weeks later with a combination of symptoms and signs, including jaundice,
abdominal distension, nausea, vomiting, anorexia,
abdominal pain, low-grade fever or weight loss – a
clinical picture similar to that seen in patients with
intraperitoneal bile leakage following cholecystectomy. When jaundice develops after abdominal
trauma, missed extrahepatic biliary injury must be
considered.
Operative management of biliary injury
Many patients with extrahepatic biliary tract injury
present in shock due to associated haemorrhage,
and the priority at laparotomy is to identify and
control haemorrhage. The report of Dawson et al.
demonstrates that these patients are at risk of exsanguinating on the operating table.62 Injuries to the
gallbladder are best treated by cholecystectomy.69
Primary repair of a clean and simple partial or
complete transection of the common duct using absorbable sutures such as 4/0 polydioxanone over a
T-tube inserted through a separate choledochotomy
has been described. However, this type of repair is
not appropriate if there is any evidence of duct contusion, loss of ductal tissue or possible injury to the
hepatic artery as this may increase the risk of late
development of an ischaemic stricture. In general,
it is therefore safer to recommend that most injuries should be managed by fashioning a Roux-en-Y
hepatico-jejunostomy as in the management of iatrogenic bile duct injuries.
Outcome after biliary injury
Trauma Register of the German Society of Trauma
Surgery, 9268 (18%) had documented abdominal injuries and 284 (3.1%) had a pancreatic injury.
70
Mechanisms of pancreatic injury
Deceleration injury and direct blunt trauma are major mechanisms of pancreatic trauma, with the neck
of the gland being at risk of transection across the
vertebral column. The deep location of the pancreas
means that considerable force is needed to cause an
injury and this level of force may often be sufficient
to damage other organs.
Diagnosis of pancreatic injury
Pancreatic injury should be suspected in any patient
with penetrating trauma to the trunk, particularly
if the entry site is between the nipples and the iliac
crest, and in any patient with blunt compression
trauma of the upper abdomen.
In an early study, Moretz et al. found that there
was no reliable correlation between serum amylase
and pancreatic injury.71 In a later report, Takashima
et al. retrospectively studied admission serum amylase values in a series of 73 patients with blunt pancreatic trauma treated in a single institution over a
16-year period.72 Sixty-one (84%) of these patients
had a raised serum amylase level. Of interest, the
serum amylase level was found to be abnormal in all
patients admitted more than 3 hours after trauma.
Bearing in mind the practicality that patients with
pancreatic injury will simultaneously be undergoing
evaluation to exclude concomitant intra-abdominal
visceral injury, contrast-enhanced CT has been the
investigation of choice (Fig. 17.7). Reported CT features of pancreatic injury include free intraperitoneal
fluid, localised fluid in the lesser sac, retroperitoneal
fluid, pancreatic oedema or swelling and changes in
Injuries of this nature are associated with a mortality rate of 10% from concomitant injuries.63 Septic
complications and bile leakage account for most of
the early morbidity and may require operative intervention. Late morbidity after repair of a traumatic
biliary tract injury is unusual; however, jaundice or
episodes of ascending cholangitis suggest a stricture
of the ductal system.
Pancreatic trauma
Injuries to the pancreas are uncommon, accounting for
1–4% of severe abdominal injuries, and usually occur
in young men. In a report of 51 425 patients from the
318
Figure17.7 • CT image showing a complete transection
of the neck of the pancreas in an 8-year-old boy who had
fallen out of a tree.
Hepatobiliary and pancreatic trauma
the peripancreatic fat. The presence of fluid in the
lesser sac between the pancreas and the splenic vein
is reported by Lane et al. to be a reliable sign in blunt
pancreatic injury.73 However, Sivit and Eichelberger
reported that this radiological sign was rarely the
only abnormal CT finding in pancreatic injury.74 It
should be borne in mind that many of these CT features are also seen in acute pancreatitis (and furthermore that acute pancreatitis may occur as a result
of blunt abdominal trauma). There is also evidence
that CT tends to underdiagnose pancreatic injury.
Akhrass et al. evaluated the clinical course of 72
patients with pancreatic injury admitted over a 10year period.75 Seventeen of these patients underwent
CT as part of their initial assessment and this was
reported as normal in nine. Eight of these patients
underwent laparotomy (principally for suspected
associated splenic injury) and three were found to
have pancreatic injury requiring distal pancreatectomy. Newer, non-invasive imaging modalities such
as magnetic resonance pancreatography have been
reported in the assessment of patients with suspected
pancreatic trauma.76 Increased sophistication with
the use of this technique may allow for accurate assessment of pancreatic ductal integrity.
Classification of pancreatic injury
• gradeI–superficialcontusionwithminimal
damage;
• gradeII–deeplacerationortransectionofthe
left portion of the pancreas;
• gradeIII–injuryofthepancreatichead
(Fig. 17.8).
A more complex system of classification taking
into account the frequent coexistence of duodenal
and pancreatic injuries was proposed by Frey and
Wardell78 (Table 17.2). The most common site of
injury is the neck of the pancreas. The relative frequency of pancreatic injuries reported in collected
reviews is represented in Fig. 17.9.
Of the various proposed classification schemes,
Lucas suggested in an early report that appropriate
treatment be formulated according to the type of injury.77 This classification system divides pancreatic
injuries into three groups:
Table17.2 • Classification of pancreatic injury proposed by Frey and Wardell
Figure17.8 • Operative photograph of a transection
injury along the neck of the pancreas resulting from a
direct blow to the abdomen. This injury was managed by
distal pancreatectomy and splenectomy.
Pancreatic injury
Class I Capsular damage, minor gland damage (P1)
Class II Body or tail pancreatic duct transection, partial or complete (P2)
Class III Major duct injury involving the head of the pancreas or the intrapancreatic common bile duct (P3)
Duodenal injury
Class I Contusion, haematoma or partial-thickness injury (D1)
Class II Full-thickness duodenal injury (D2)
Class III Full-thickness injury with >75% circumference injury or full-thickness duodenal injury with injury to the
extrahepatic common bile duct (D3)
Combined pancreatico-duodenal injuries
Type I P1D1, P2D1 or D2P
Type II D2P
Type III D3P
Type IV D3P
Reproduced from Frey CF, Wardell JW. Injuries to the pancreas. In: Trede M, Carter DC (eds) Surgery of the pancreas. Edinburgh:
Churchill Livingstone, 1993. With permission from Elsevier.
2
1–2
3
or P3D
1
1–2
319