TRAUMA HEPATICO
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El documento resume la historia, epidemiología, clasificación, diagnóstico y manejo del trauma hepático. Describe las lesiones hepáticas desde lesiones leves (Grado I-II) hasta graves (Grado IV-V), y los enfoques de manejo que incluyen el manejo conservador, cirugía y técnicas quirúrgicas como empacado hepático, resecciones hepáticas y bypass venoso. Resalta factores predictivos de malos resultados como hipotensión, necesidad de transfusión y lesiones de alto grado.
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TRAUMA HEPATICO
- 1. Trauma Hepático Por: Humberto Juárez Rosario Médico Residente de Cirugía General
- 3. Historia
- 4. Historia Mitología.- Prometeo. En 1870 Burns describio un paciente que sobrevivio a una lesion en el higado por arma de fuego. Reseccion hepatica por tumores (1887 Carl Lagenbuch); (1891 William Keen).1902 se usa sutura absorbible en vez de seda 1908 maniobra de Pringle (Clampaje completo y en bloque del hilio hepático). Uso empacado descendio la mortalidad de 30 a 17% despues de la Segunda Guerra Mundial
- 5. Prometeo y el aguila
- 6. Anatomía
- 7. Anatomía
- 8. Anatomía
- 9. Anatomía
- 10. Anatomía
- 11. Anatomía
- 12. Anatomía
- 13. Anatomía
- 14. Anatomía
- 15. Anatomía
- 16. Anatomía
- 17. Epidemilogía Segundo Organo más afectado Primera Causa de Muerte Organo sólido mas voluminoso
- 18. Epidemiología
- 19. Trauma Contuso • Bazo ( 40 a 55%) • Hígado ( 35 a 45%) • Intestinal (1.5% a 5%) • Colon (0.5 a 1.5%)
- 20. Trauma Penetrante • Intestino Delgado ( 60-70%) • Colon ( 40-45%) • Estómago ( 10 a 15%) • Bazo ( 5 a 7%) • Hígado (15 a 25%)
- 21. Mecanismo Compresión Simple Presión del Hemitórax Derecho Desaceleración Trasmisión de Aumento de Presión Venosa
- 22. Lesiones Desgarro de la Cápsula Hematoma Fuga biliar Bilioma Fístula arteriobiliar Fístula venobiliar Hemoperitoneo
- 23. Lesión en Garra de Oso
- 24. Lesiones Asociados Lesión esplénica 45% Fracturas costales 33% Lesion de duodeno, pancreas asociado a lesion del lobulo derecho 15%. Lesion hepatica aislada <50%.
- 25. Clasficación Grado Descripción Mortalidad (%) I Hematoma Subcapsular menor 10%, Laceración menor 1 cm de profundidad ~ 0 II Hematoma Subcapsular de 10 a 50% o 10 cm, Laceración: 1 a 3 cm profuncdiada < 10 III Hematoma subcapsular mayor 50%, hemamotoma intraparenquimtoso de más de 10 cm de diametro o expasnsvios. Laceración mayor de 3cm 10 a 25 IV Hematomas intraparquimotosos con sangrado activo, disrrupcion de 25 a 75 % de un lobulo o 1-3 segmentos. 45% V Disrrupcion de mas 75% de un lóbulo o más de 3 segmentos. Lesiones suprahépaticas. 80% VI Avulsion de las venas suprahepaticas, grandes arterias o venas del parenquima hepatico ~100
- 26. Clínica Historia Clinica y Antecedentes Marca del Cinturón Irritacion peritoneal. Dolor en cuadrante superior derecho. Perdida de sangre Irritación Peritoneal. Laboratorio: Aumento de enzimas hepaticas.
- 27. Imagenes Rx de Tórax FAST Tomografía Computada Angiografía
- 29. Tomografía Computada Yi-Chieh Huang, M.D.a, Shih-Chi Wu, M.D.b Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury.jTh American Journal fo Surgery.2011.01.031
- 30. tomografía computada Yi-Chieh Huang, M.D.a, Shih-Chi Wu, M.D.b Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury.j.amjsurg.2011.01.031
- 31. Manejo
- 32. Lesiones Grado I-II Hb/Hcto seriados Reposo
- 35. Manejo Conservador 50% de las lesiones hepáticas ceden Paciente Pediatricos Capacidad de cicatrización Avances de Tomografía 88 a 99% de Exito 6 a 20% Biliomas o Fugas 5% 5
- 36. Hemobilias 3% de los casos Ventana de 4 meses Angiografía Embolización
- 37. Lesiones Grado IV-V 92% de la manejas conservadorarmente ameritan intervención
- 39. Grado V Las lesiones de las venas suprahepaticas requieren SOP Mortalidad de 50 a 80%
- 40. Lesiones Grado V
- 41. Malos Indicadores Hipotensión a la admisión Necesidad de Trasfusión Lesiones de Alto Grado Salida de contraste intraperitoneal Hemoperitoneo
- 42. Factores Comprobados Laceración Esplénica o Renal con FAST Positivo Liquido libre mayor de 300cc Transfusión de Sangre
- 43. Angiografía 80-90 % de exito Resangrado luego de empacamiento 8-28% de Mortalidad Yi-Chieh Huang, M.D.a, Shih-Chi Wu, M.D.b Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury.jTh American Journal fo Surgery.2011.01.031
- 44. Extravasación
- 45. Manejo Conservador Baleados Demetriades et al, Journal of American College of Surgeons Vol. 188 No 4 2000
- 46. Cirugía
- 47. Cirugía Preparar hemoderivados Agentes Hemostasticos Elevar la Temperatura del SOP >30 Grados Campo Quirúrgico Procedimiento de Urgencia
- 48. Objetivos de la Cirugía Control de la Hemorragia Controlar fuga biliar Debridar o resecar tejido desvitalizado Drenaje
- 49. Incisiones
- 50. Empacado 4 a 25% de las lesiones hepáticas que se operan Malla de Vycril Vendas
- 51. Empacado
- 52. Empacado
- 53. Empacado
- 54. Empacado Franco Baldoni, M.D.a, Salomone Di Saverio. Refinement in the technique of perihepatic packing: a safe and effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma American Journal of Surgery (2011) 201, e5–e14
- 55. Empacado Franco Baldoni, M.D.a, Salomone Di Saverio. Refinement in the technique of perihepatic packing: a safe and effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma American Journal of Surgery (2011) 201, e5–e14
- 56. Empacado Franco Baldoni, M.D.a, Salomone Di Saverio. Refinement in the technique of perihepatic packing: a safe and effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma American Journal of Surgery (2011) 201, e5–e14
- 57. Empacado Franco Baldoni, M.D.a, Salomone Di Saverio. Refinement in the technique of perihepatic packing: a safe and effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma American Journal of Surgery (2011) 201, e5–e14
- 58. Maniobra de Pringle CVC importante La variante de la Arteria Hepatica Derecha
- 60. Hepatotomía
- 62. Aguja de Chang Yu-Chung Chan, Naofumi Nagasueg, Simplified Hepatic Resections With the Use of a Chang’s NeedleAnn Surg 2006;243: 169–172)
- 63. Aguja de Chang Yu-Chung Chan, Naofumi Nagasueg, Simplified Hepatic Resections With the Use of a Chang’s NeedleAnn Surg 2006;243: 169–172)
- 64. Aguja de Chang Yu-Chung Chan, Naofumi Nagasueg, Simplified Hepatic Resections With the Use of a Chang’s NeedleAnn Surg 2006;243: 169–172)
- 65. Aguja de Chang Yu-Chung Chan, Naofumi Nagasueg, Simplified Hepatic Resections With the Use of a Chang’s NeedleAnn Surg 2006;243: 169–172)
- 66. Aguja de Chang
- 67. Venas Hepáticas
- 68. Acceso a la Vena Cava
- 69. Venas Suprahepaticas Rafia Primaria Reseccion lobar con taponamiento vs empaque Venas Retrohepáticas taponamiento intravascular
- 70. Taponamiento
- 71. Taponamiento M.M. Beitner et al. / Injury, Int. J. Care Injured 43 (2012) 119–122
- 72. Taponamiento M.M. Beitner et al. / Injury, Int. J. Care Injured 43 (2012) 119–122
- 73. Taponamiento
- 74. Taponamiento M.M. Beitner et al. / Injury, Int. J. Care Injured 43 (2012) 119–122
- 75. Taponamiento con Epiplon y Drenaje
- 77. Journal of American College of Surgeons
- 78. Bypass Venoso
- 79. Bypass Venoso
- 80. Bypass Venoso
- 81. Decisiones Críticas Operar cuando esta indicado Pacientes inestables, si el sangrado se detiene, empacar y terminar la cirugía Si se va realizar una reseccion, tomar la decisión temprano En las resecciones: la experticia clinica/técnica, y rápidez son esenciales
- 82. Reintervenciones Lactato menor 2.5mmo/L Deficit de Base menor 4.0 mmol/L INR menor de 1.25 Temperatura mayor de 35 48 horas Salomone Di Saverio, Fausto CAtena Predictive factors of morbidity and mortality in grade IV and V liver trauma undergoing perihepatic packing: Single institution 14 years experience at European trauma centre Injurey Int. Care Injured Jana 2012
- 83. Laparoscopía Drenaje de Colecciones Drenaje de Ascitis Drenaje de Bilis C. Pilgrim, Usatoff Val Role of Laparoscopy in Blunt Trauma ANZ J. Surg. 2006; 76: 403–406
- 84. Trasplante
- 85. Trasplante Plackett, T; Bamparas G. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011
- 86. Algoritmos
- 87. Algoritmo
- 88. Pronostico
- 89. Pronostico W.L. Sikhondze, T.E. MadibaPredictors of outcome in patients requiring surgery for liver traumaInjury, Int. J. Care Injured (2007) 38, 65—70
- 90. Pronostico W.L. Sikhondze, T.E. MadibaPredictors of outcome in patients requiring surgery for liver traumaInjury, Int. J. Care Injured (2007) 38, 65—70
- 91. Bibliografía 1. Greta L. Piper, MDa, Andrew B. Peitzman Management of Hepatic TraumaSurg Clin N Am 90 (2010) 775–785 2. W.L. Sikhondze, T.E. MadibaPredictors of outcome in patients requiring surgery for liver traumaInjury, Int. J. Care Injured (2007) 38, 65—70 3. Plackett, T; Bamparas G. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 6, December 2011 4. C. Pilgrim, Usatoff Val Role of Laparoscopy in Blunt Trauma ANZ J. Surg. 2006; 76: 403–406 5. Salomone Di Saverio, Fausto CAtena Predictive factors of morbidity and mortality in grade IV and V liver trauma undergoing perihepatic packing: Single institution 14 years experience at European trauma centre Injurey Int. Care Injured Jana 2012 6. Yu-Chung Chan, Naofumi Nagasueg, Simplified Hepatic Resections With the Use of a Chang’s NeedleAnn Surg 2006;243: 169–172)
- 92. Bibliografía 7. Franco Baldoni, M.D.a, Salomone Di Saverio. Refinement in the technique of perihepatic packing: a safe and effective surgical hemostasis and multidisciplinary approach can improve the outcome in severe liver trauma American Journal of Surgery (2011) 201, e5–e14 8. Yi-Chieh Huang, M.D.a, Shih-Chi Wu, M.D.b Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury.j.amjsurg.2011.01.031 9. M.M. Beitner et al. / Injury, Int. J. Care Injured 43 (2012) 119–122 10.Trauma Sociedad Panamaricana de Trauma Segunda Edicion
Notas del editor
- 1,2,3 70 a 90% no sangran en la lpe 4 y 5 10 a 30% siguen sangrando mayoria sangrado venoso mortalidad 56% por hemoarrgai
- dos veces mayor al ALT y AST
- A total of 130 patients were enrolled. Injury severity scores, amount of blood transfusion before hemostatic procedure, and grade of liver injury were significantly higher in NOM failure than in NOM success patients. There was no statistical difference in the NOM success rate between patients with contrast leakage into the peritoneum and those with contrast confined in the hepatic parenchyma.
- Hemobilia presents as gastrointestinal bleeding with or without abdominal pain and jaundice caused by bile ducts occluded by blood clots. It has been reported immediately after the initial trauma or up to 4 months later,
- 92% de fallo de manejo conservador si esta ausente 2% de fallo
- 96 min de duracion The associa- tion of DCS strategy with early packing followed by angioembo- lization in patients with grade IV–V injury, resulted in a significant decrease of overall and liver specific mortality rate compared to immediate definitive surgery with resection, sutures or other complex haemostatic attempts (0% vs 36.7% for overall and 0% vs 23% for liver specific mortality) with shorter operative time (92 min vs 127 min) 12 porciento de mortalidad en lesiones grado IV y V vs 36%
- 69 pacientes ... 11 pacientes manejo conservador solo lesiones 1 y 2
- 6 u de GRE , 4 PFC y una aferesis de plaquetas mejoran la mortalidad
- Tiene que ser usando las marcas antomicas y sobre la el diafragma
- All 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P .02); the liver-related mortality was 8.3% versus 34.8% (P not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P not significant). The overall (81.8% vs 100%, P not significant) and liver-related morbidity rate (18.2% vs 41.7%, P not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P not significant) decreased.
- All 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P .02); the liver-related mortality was 8.3% versus 34.8% (P not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P not significant). The overall (81.8% vs 100%, P not significant) and liver-related morbidity rate (18.2% vs 41.7%, P not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P not significant) decreased.
- All 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P .02); the liver-related mortality was 8.3% versus 34.8% (P not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P not significant). The overall (81.8% vs 100%, P not significant) and liver-related morbidity rate (18.2% vs 41.7%, P not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P not significant) decreased.
- All 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P .02); the liver-related mortality was 8.3% versus 34.8% (P not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique (P not significant). The overall (81.8% vs 100%, P not significant) and liver-related morbidity rate (18.2% vs 41.7%, P not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P not significant) decreased.
- controla sangrado de vena porta y arteria hepatica si el sangrado persiste oscuro y profuso de cara anterior puede ser una suprahepatica3 30 min por 15 de descanso
- Reseccion Anatomiaca 50% de mortalidad
- Blood loss during parenchyma transection was reduced in 11 right lobectomies (652 mL), 1 3-segmentectomy (300 mL), 14 bisegmentectomies (252 mL), 7 segmentectomies (104 mL), 12 subsegmentectomies (19 mL), 5 wedge resections (7 mL), 18 left lateral segmentectomies (110 mL), and 1 hepatorrhaphy (minimal). There was no procedure-related mortality. A mild bile leakage occurred in 1 case (1.5%) but healed spontaneously.
- Vascular isolation may be achieved with atriocaval shunting to bypass the bleeding caval segment, as first described by Schrock et al. in 1968 or femorocaval shunting, as introduced by Pilcher et al. in 1977. However, the non-shunt approach to these injuries resulted in better survival in several studies, including that by Buechter.14 Other methods of vascular isolation include intrahe- patic vascular clamps,15 sequential16 or concurrent17 vascular clamping of the suprarenal cava, suprahepatic cava and portal triad, with or without aortic cross-clamping,13 and interventional endovascular isolation.18 However, total vascular isolation results in prohibitively high mortality and is not recommended.1
- apuñalado
- la ventaja es que no hay que abrir el trayecto que puede provocar mas coagulopatia suturas el extremo distal y proximal es dificil
- The new protocol (Fig. 1) mandated angiography in all adult patients with liver injury OIS grades 3—5 and in any patient with clinical suspicion of ongoing bleeding, defined as falling haemoglobin and tachy- cardia, or any transfusion requirement where the liver could not be ruled out as a significant bleeding source.
- 105 pacientes prospectivo