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Penetrating liver War injury: a report on 676 cases, after Baghdad invasion and Iraqi civilian war April 2003.

Introduction

The liver is the largest intra-abdominal solid organ and is enclosed anteriorly and laterally by the rib cage. The large size of the liver, its friable parenchyma, its thin capsule, and its relatively fixed position in relation to the spine make the liver particularly prone to injury [1]. As a result of its larger size and proximity to the ribs, the right lobe is injured more commonly than the left [2]. Abdominal organ injuries appear frequently during war operations and can be found in approximately 20% of all injured persons. [3] Almost one-half of them die rapidly as a result of massive bleeding from the major abdominal vessels or concomitant injuries of the head and chest. Because of its size, the liver is the most commonly injured solid intra-abdominal organ. Traffic accidents and falls from heights are the main cause of blunt liver injuries during peacetime [4]. However, under war conditions, penetrating injuries predominate. High-velocity projectiles (bullets and shrapnel from mortar shells and grenades) cause fragmentation of the hepatic parenchyma with laceration of vessels and massive intraperitoneal hemorrhage. [5] Solitary liver injuries are fairly rare. They are usually combined with the injury of other abdominal and extra-abdominal organs, making an already severe prognosis even worse. Some basic surgical principles of the liver trauma treatment are not completely applicable under war conditions because of the lack of experienced surgical staff, instruments, materials , and contemporary diagnostic procedures. Furthermore, wounds are primarily contaminated, and injuries of different vital organs coexist [6].

Materials and Methods

This is a study of all patients with penetrating war injury of the liver admitted into the accident and emergency centre of the Mousl, Kirkok and Erbil University Teaching Hospital, between April 2003 and April 2007 .Based on patient's medical records of three surgical teams, we have analyzed a total of 676 (8.5%) patients with penetrating war injury of the liver. We focused on the type of injury, concomitant injuries of other organ systems, operative procedures, complications, and outcome. For the classification of the liver trauma, we have used the Liver Injury Scale that distinguishes six grades of injury. [4]

Surgical staff of the emergency North Hospitals (Mousl,Kikok and Erbil governorates) has covered the Western and North East parts of Iraq region (hot areas) in which most of causalities were transferred to the above governorates hospitals since the civilian and military conflict in Iraq from April. 2003 to April 2007. They were moved into a combat zone and performed first Aid measures by junior sub-staffs and junior doctors there in field portable medical units. That made it possible to start operative treatment within few hours from the moment of injury. All injured received standard life support measures available at the scene. These measures included maintenance of a clear airway, urgent volume replacement, analgesics, and bleeding control. After a short physical examination revealed a penetrating injury of the abdomen, patients were transported to the operating room. Immediately before the surgery, they received triple prophylactic antibiotic therapy (Ampiclox, gentamycin, metronidazol, or cefatox and metronidazol) and in some indicated cases antitetanic prophylaxis. The standard operative approach was extensive midline laparotomy, when indicated combined with the right subcostal incision extension to afford good access to the liver. After primary treatment in the emergency hospitals, when general conditions stable patients were transported to remote hospitals in side the cities for further treatment. That usually occurred 5 to 7 days after the surgery.

Results and Discussions

Results

In this 4-year period, 7,929 war casualties were treated at the mentioned emergency hospitals. From that total, 1216 (7.7%) sustained penetrating abdominal injuries. This study concentrates on 676 (8.5%) of them with liver injury. Isolated liver trauma was revealed in only 52 (7.6%) patients. A total of 624 or 92.3% had associated injuries of other abdominal and extra-abdominal organs, (Table 2). There were 572 (84.6%) men and 104(15.4%) women with a mean age of 27.7 years. In 568 (82.6%) cases, causes of liver injuries were fragments of various detonating devices. At the same time, 116 persons (16.8%) had shotgun injuries and 2 (0.6%) had a stab injury. A total of 624 or 92.3% had liver injuries associated with other injuries of abdominal organs (Table 2)

Although most victims of blunt abdominal injuries are classified as grade I or II, our patients mainly had grades III (142 or 42%) and IV (118 or 34.9%) injuries, which may explain poor outcome in many cases. The most severe grade VI injury was recorded in 8 patients (1.2%) with detrimental liver avulsion. The right liver lobe was damaged in 492 (72.7%), the left liver lobe was damaged in 128(19%) cases, and 68 patients (10%) had both lobes injured.

After a brief exploration of the abdomen, we found that sources of massive bleeding in twelve patients were tears of the abdominal aorta and inferior vena cava (12 or 1.8%) and those dictated order of action. Hemostatic sutures of injured vessels allowed further precise exploration and treatment of the liver injury in patients that survived aortal and caval lesions. In all cases with bowel perforation, we first put some protective sutures at the spot of perforation to prevent major contamination of the abdominal cavity and separated injured gut with several sterile gauzes. While waiting for repair, the liver was packed with gauze pads held by an assistant.

A total of 536 (79.2%) liver injuries were treated with debridement of necrotic parenchyma and hemostatic sutures. In all cases with uncontrollable bleeding, we used temporary clamping of hepatic artery and portal vein to allow an accurate identification of the site of bleeding. Atypical resections (96 or 14.2%) were reserved for massive injuries of grades IV and V. When bleeding persisted after all reasonable attempts of hemostasis as well as in cases of huge intraparenchymal hematomas and disruptions of both lobes, we used liver packing (56 patients or 8.2%). In advance, we resected perihepatic ligaments to free the liver and placed sterile gauze pads all around the organ to get a firm compression. Pads were removed 72 hours later at the second-look surgery. Drains placed in subhepatic and Douglas spaces were used in all patients except in those with grade I liver trauma with no injury of other abdominal organs.

A total of 628 (92.8%) patients have survived the surgery. Of that total, 204 (30%) developed different complications, mostly multiple, with postoperative hemorrhage (124 or 19.3%) and disseminated intravascular coagulopathy (36 or 5.6%) being the most serious. Rebleeding from the injury and infected fluid collections were treated operatively and by an ultrasound-guided needle aspiration, respectively. All other complications were managed conservatively

A total of 196 patients (28.9%) did not survive. Of that total, 44 (22.4%) died on the operating table, 8 (4%) with grade VI liver injury and 36 (18.3%) because of associated injuries (brain, heart, and aorta injuries). The other 104(53%) injured died postoperatively, 54 (27.5%) as a consequence of liver injury and 50 (25.5%) of associated injuries.

Discussion

Before the Second World War, the overall mortality from liver injuries was over 60% [7]. The progress made in elective hepatic surgery backed by modern anesthesia and reanimation techniques have had a positive effect also on traumatological liver surgery, reducing mortality rates down to 10 to 15% [8]. However, despite this improvement, the mortality rate for severe lesions remains high, with hypovolemic shock being the prime cause [9].

War injuries with all their complexity make a decisive contribution in keeping that number high. These injuries are mostly penetrating and primarily infected by shrapnel and bullets [10].

Among 338 cases with liver injuries in only 26 (7.6%) patients had isolated liver trauma alone. A total of 312 or 92.3% had associated injuries of other abdominal and extra-abdominal organs; that sometimes mask the liver trauma [9] (table 2).

Because of non-organized transportation, our patients arrived at hospitals after few hours from the time of injury. After a physical examination and receiving some basic laboratory tests, patients were taken to the operating room without further examination. Ultrasound and X-ray examinations were performed only in those in a relatively good general condition and CT scanning, particularly contrast-enhanced CT, were done for few suspicious cases with relatively stable general condition, and it was accurate in localizing the site and extent of liver and associated injuries, providing vital information for treatment in patients [11,12] (figures 1, 2,3). Still, for most persons with abdominal trauma, explorative laparotomy was not only curative but also the most important diagnostic procedure in our area because of severe facilities limitations prior to surgery. The protocol of management and the priorities of surgery were to stop the hemorrhage, remove dead or devitalized liver tissue, and ligate or repair damaged blood vessels and bile ducts.

Almost nearly about 75% of patients were treated by simple elimination of necrotic parenchyma and suturing. In all patients with significant bleeding, we have used the Pringles maneuver, which is a temporary occlusion of blood input. Twenty to thirty minutes of clamping was safe in all patients, and we did not have any consequent tissue necrosis. Resections are not favorable options under mentioned septic conditions and we performed them when massive peripheral injury of the liver lobe was the source of uncontrollable bleeding. The management of major liver injury with uncontrollable hemorrhage remains controversial. During World War II perihepatic packing was the major surgical treatment but post-operative morbidity and mortality were significant. [13,14,15] we have used packing in the case of diffuse bleeding due to coagulopathy and in desperation when all other more selective methods failed In 32 (9.9%) of cases This approach has resulted in improved survival and fewer infectious complications compared with hepatic resection in the acute post-injury setting. Fifty percent of these patients survived. Packs were removed between 36 and 72 hours, and we did not have recurrent bleeding. Despite the extensive lavage at a second-look operation and prophylactic use of broad-spectrum antibiotics, we have noticed septic complications in 49% of patients that survived perihepatic packing in the form of the principal outcome measures were liver-related complications such as biliary leak, abscess, and rebleeding, No one died from those complications. The mortality was seen in 16 (50%) of cases with detrimental bleeding with liver packing. these patients have died because of a high incidence of septic complications, as well as numerous heavy injuries of the liver combined with associated trauma of other vital organs are responsible for the high mortality rate , The overall mortality was 28.9% (98 patients) Death was directly attributable to the liver injury in 76(77.5%) patients the commonest cause of death being uncontrollable hemorrhage compared with similar studies done in West Europe and United Status which is 10 to 15% [16].

[FIGURE 1 OMITTED]

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Probably the cause of this high mortality rate in this study is multifactorial like non-organized transportation, limited experienced medical personnel's in the field of traumata, lack of advanced resuscitation facilities , destruction of infrastructures in Iraq because of frequent unnecessary Wars within few years and lastly on the contrary to the traumatized person who arrives in peacetime to the trauma center where educated trauma specialists with all their equipment are waiting, soldiers from battlefield are brought to improvised field hospitals with scarce personal and equipment resources. Some types of complex liver injuries that have little chance to be repaired in modern trauma centers unfortunately have no chance at all in war hospitals.

Conclusion

* In complex liver injuries control of major hemorrhage is vital and perihepatic packing may be life saving before undertaking definitive surgical repair of the injury.

* Removing packs 36 to 72 hours after the initial operation reduced the risk of rebleeding without increasing the risk of liver associated with complications.

* Death rate is markedly influenced by prehospital hypotension, exsanguination, and arrest in the field or on presentation, acidosis with an initial pH less than 7, lactate level greater than 20 mmol/L, or base deficit more negative than -15 mEq HCO3.

Acknowledgments

We thank Professor Tareq AL-Hadethe and Dr Namir G.AL-Tawil of the Department of Community Medicine College of Medicine, Hawler Medical University, for statistical advice. We would like to thank the administration of Erbil, Kirkok and Mousl Emergency and causality Hospitals for their kind help. Also we are grateful to surgeon consultants, nurses and resident doctors of the Teaching Hospitals Departments of Surgery (Mousl, Kirkok, and Erbil governorates), for their participation in the management of these patients.

References

[1.] Beckingham, I.J. and J.E. Krige, 2001. ABC of diseases of liver, pancreas and biliary system: liver and pancreatic trauma. BMJ, 322: 783-5.

[2.] Carrillo, E.H., C. Wohltmann, J.D. Richardson and Polk H.C. Jr, 2001. Evolution in the treatment of complex blunt liver injuries. Curr Probl Surg, Jan, 38(1): 1-60.

[3.] McPherson, S. and L.H. Blumgart. 1985. Liver trauma. Surgery, 16: 369-73.

[4.] Ali Nawaz Khan, Sumaira Macdonald, 2005. CT criteria for staging liver trauma based on the AAST liver injury scale, Liver Trauma Radiology, 9: 122

[5.] Fang, J.F., R.J. Chen and Y.C. Wong, et al, 2000. Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma. J Trauma, Dec, 49(6): 1083-8.

[6.] Saccia, A., 1994. Major resection in severe hepatic trauma: technical indications and clinical considerations in a case of personal experience. Minerva Chir, 49: 705-15.

[7.] Kirby, R.M. and M. Braithwaite, 2000. Management of liver trauma. Br J Surg, Dec, 87(12): 1732.

[8.] Carillo, E.H. and J.D. Richardson, 2001. The current management of hepatic trauma. Adv Surg, 35: 39-59.

[9.] Parks, R.W., E. Chrysos and T. Diamond, 1999. Management of liver trauma. Br J Surg, Sep; 86(9): 1121-35.

[10.] Kirby, R.M. and M. Braithwaite, 2000. Management of liver trauma. Br J Surg, 87: 1732.

[11.] Udobi, K.F., A. Rodriguez, W.C. Chiu and T.M. Scalea, 2001. Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma, Mar, 50(3): 475-9.

[12.] Jurkovich, G.J. and C.J. Carrico, Trauma, 1997. management of the acutely injured patient. In Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 15: 317-20. Edited by Sabiston DC Jr. Philadelphia, PA, WB Saunders Company.

[13.] Feliciano, D., K. Mattox and J. Burch, 1986. Packing for control of hepatic hemmorhage. J Trauma, 26: 738.

[14.] Pachter, H., F. Spencer and S. Hofstetter, 1992. Significant trends in the treatment of hepatic trauma. Ann Surg, 215: 492.

[15.] Reed, R., R. Merrell and W. Meyers, 1992. Continuing evolution in the approach to severe liver trauma. Ann Surg, 216: 524.

[16.] Cogbill, T.H., E.E. Moore and G.J. Jurkovich, 1988. Severe hepatic trauma: a multicenter experience with 1,335 liver injuries. J Trauma, 28: 1312.

Abdulqadir Maghded Zangana

Department of surgery, College of Medicine, Hawler Medical University, P.O.Box. 178, Erbil, Iraq.

Corresponding Author

Abdulqadir Maghded Zangana, Department of surgery, College of Medicine, Hawler Medical University, P.O.Box. 178, Erbil, Iraq. E-mail:draqzangana@yahoo.com
Table 1: CT criteria for staging liver traum a based on the AAST
liver injury scale (the American Association for the Surgery of
Traum a (AAST)

Grade 1 Subcapsular hem atom a less than 1 cm in maximal
 thickness, capsular avulsion, superficial
 parenchymal laceration less than 1 cm deep, and
 isolated periportal blood tracking

Grade 2 Parenchym al laceration 1-3 cm deep and parenchymal/
 subcapsular hem atom as 1-3 cm thick

Grade 3 Parenchymal laceration m ore than 3 cm deep and
 parenchymal or subcapsular hem atom a m ore than
 3 cm in diameter

Grade 4 Parenchym al/subcapsular hem atom a m ore than 10
 cm in diameter, lobar destruction, or
 devascularization

Grade 5 Global destruction or devascularization of the
 liver

Grade 6 Hepatic avulsion

Table 2: Shows Distribution of samples by type of injury.

Organs n (%)
s

Small bowel 128 20.5
Colon 100 16.0
Stomach 92 14.7
Bladder 88 14.1
Diaphragm 84 13.4
Spleen 40 6.4
Kidney 28 4.4
Gallbladder 24 3.8
Rectum 20 3.2
Major vessel 12 1.92
Pancreas 8 1.3

Table 3: Organs injured vs. mortality rate Number of organs
injured

 Number of patients Number of deaths Mortality rate (%)

1 60 8 13.3
2 224 32 14.2
3 220 76 39.5
4 172 80 46.5

Total 676 196 28.9
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Title Annotation:Original Article
Author:Zangana, Abdulqadir Maghded
Publication:Advances in Medical and Dental Sciences
Article Type:Report
Geographic Code:7IRAQ
Date:Sep 1, 2007
Words:2767
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