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Rezende-Neto J, Doshi S, Gomez D, Camilotti B, Marcuzzi D, Beckett A. A novel inflatable device for perihepatic packing and hepatic hemorrhage control: A proof-of-concept study. Injury 2022; 53:103-111. [PMID: 34507832 DOI: 10.1016/j.injury.2021.08.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 08/04/2021] [Accepted: 08/24/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Uncontrolled bleeding is the primary cause of death in complex liver trauma and perihepatic packing is regularly utilized for hemorrhage control. The purpose of this study was to investigate the effectiveness of a novel inflatable device (the airbag) for perihepatic packing using a validated liver injury damage control model in swine. MATERIAL AND METHODS The image of the human liver was digitally isolated within an abdominal computerized tomography scan to produce a silicone model of the liver to mold the airbag. Two medical grade polyurethane sheets were thermal bonded to the configuration of the liver avoiding compression of the hepatic pedicle, hepatic veins, and the suprahepatic vena cava after inflation. Yorkshire pigs (n = 22) underwent controlled hemorrhagic shock (35% of the total blood volume), hypothermia, and fluid resuscitation to reproduce the indications for damage control surgery (coagulopathy, hypothermia, and acidosis) prior to a liver injury. A 3 × 10 cm rectangular segment of the left middle lobe of the liver was removed to create the injury. Subsequently, the animals were randomized into 4 groups for liver damage control (240 min), Sponge Pack (n = 6), Pressurized Airbag (n = 6), Vacuum Airbag (n = 6), and Uncontrolled (n = 4). Animals were monitored throughout the experiment and blood samples obtained. RESULTS Perihepatic packing with the pressurized airbag led to significantly higher mean arterial pressure during the liver damage control phase compared to sponge pack and vacuum airbag 52 mmHg (SD 2.3), 44.9 mmHg (SD 2.1), and 32 mmHg (SD 2.3), respectively (p < 0.0001), ejection fraction was also higher in that group. Hepatic hemorrhage was significantly lower in the pressurized airbag group compared to sponge pack, vacuum airbag, and uncontrolled groups; respectively 225 ml (SD 160), 611 ml (SD 123), 991 ml (SD 385), 1162 ml (SD 137) (p < 0001). Rebleeding after perihepatic packing removal was also significantly lower in the pressurized airbag group; respectively 32 ml (SD 47), 630 ml (SD 185), 513 ml (SD 303), (p = 0.0004). Intra-abdominal pressure remained similar to baseline, 1.9 mmHg (SD 1), (p = 0.297). Histopathology showed less necrosis at the border of the liver injury site with the pressurized airbag. CONCLUSION The pressurized airbag was significantly more effective at controlling hepatic hemorrhage and improving hemodynamics than the traditional sponge pack technique. Rebleeding after perihepatic packing removal was negligible with the pressurized airbag and it did not provoke hepatic injury.
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Affiliation(s)
- Joao Rezende-Neto
- Department of Surgery, Trauma and Acute Care Surgery St. Michael's Hospital and Keenan Research Center for Biomedical Sciences, University of Toronto, 30 Bond Street, Room 3073B Donnelly Wing, Toronto, Ontario M5B 1W8, Canada; Department of Haematology and Oncology St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
| | - Sachin Doshi
- Department of Surgery, Division of General Surgery, University of Toronto, 1 King College Circle, Toronto, Ontario M5S 1A8, Canada; Department of Haematology and Oncology St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - David Gomez
- Department of Surgery, Trauma and Acute Care Surgery St. Michael's Hospital and Keenan Research Center for Biomedical Sciences, University of Toronto, 30 Bond Street, Room 3073B Donnelly Wing, Toronto, Ontario M5B 1W8, Canada; Department of Haematology and Oncology St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Bruna Camilotti
- Department of Surgery, Trauma and Acute Care Surgery St. Michael's Hospital and Keenan Research Center for Biomedical Sciences, University of Toronto, 30 Bond Street, Room 3073B Donnelly Wing, Toronto, Ontario M5B 1W8, Canada; Department of Haematology and Oncology St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Dan Marcuzzi
- Department of Haematology and Oncology St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Department of Radiology St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Andrew Beckett
- Department of Haematology and Oncology St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Department of Surgery, Trauma and Acute Care Surgery St. Michael's Hospital and Keenan Research Center for Biomedical Sciences, University of Toronto, 30 Bond Street, Room 3073B Donnelly Wing, Toronto, Ontario M5B 1W8, Canada
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Soma J, Ishii D, Miyagi H, Ishii S, Motoki K, Kawabata H, Ishitoya S, Hagiwara M, Kokita N, Hirasawa M. Damage control surgery for grade IV blunt hepatic injury with multiple organ damage in a child: a case report. Surg Case Rep 2021; 7:269. [PMID: 34928459 PMCID: PMC8688624 DOI: 10.1186/s40792-021-01348-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intra-abdominal hemorrhage caused by blunt hepatic injury is a major cause of morbidity and mortality in patients with abdominal trauma. Some of these patients require laparotomy, and rapid decision-making and life-saving surgery are essential. Damage control (DC) surgery is useful for treating children in critical situations. We performed this technique to treat an 8-year-old boy with grade IV blunt hepatic injury and multiple organ damage. This is the first report of the use of the ABTHERA Open Abdomen Negative Pressure Therapy System (KCI, now part of 3 M Company, San Antonio, TX, USA) for DC surgery to rescue a patient without neurological sequelae. CASE PRESENTATION An 8-year-old boy was brought to the emergency department of our hospital after being run over by a motor vehicle. He had grade IV blunt hepatic injury, thyroid injury, and bilateral hemopneumothorax. Although he was hemodynamically stable, the patient's altered level of consciousness, the presence of a sign of peritoneal irritation, and suspicion of intestinal injury led us to perform exploratory laparotomy. As part of a DC strategy, we performed gauze packing to control hemorrhage from the liver and covered the abdomen with an ABTHERA Open Abdomen Negative Pressure Therapy System to improve the patient's general condition. Eighteen days after admission, the patient was diagnosed with a biliary fistula, which improved with percutaneous and external drainage. He had no neurological sequelae and was discharged 102 days after injury. CONCLUSION The DC strategy was effective in children with severe blunt hepatic injury. We opted to perform DC surgery because children have less hemodynamic reserve than adults, and we believe that using this strategy before the appearance of trauma triad of death could save lives and improve outcomes. During conservative management, it is important to adopt a multistage, flexible approach to achieve a good outcome.
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Affiliation(s)
- Jun Soma
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Daisuke Ishii
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan.
| | - Hisayuki Miyagi
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Seiya Ishii
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Keita Motoki
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Hidemasa Kawabata
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Shunta Ishitoya
- Department of Radiology, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Masahiro Hagiwara
- Division of Hepato-Biliary-Pancreatic Surgery and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Naohiro Kokita
- Department of Emergency Medicine, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Masatoshi Hirasawa
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
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Kanani A, Sandve KO, Søreide K. Management of severe liver injuries: push, pack, pringle - and plug! Scand J Trauma Resusc Emerg Med 2021; 29:93. [PMID: 34256814 PMCID: PMC8278654 DOI: 10.1186/s13049-021-00907-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Arezo Kanani
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Knut Olav Sandve
- Department of Radiology, Interventional Radiology Unit, Stavanger University Hospital, Stavanger, Norway
- Stavanger Medical Image Laboratory, Stavanger University Hospital, Stavanger, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Ward J, Alarcon L, Peitzman AB. Management of blunt liver injury: what is new? Eur J Trauma Emerg Surg 2015; 41:229-37. [PMID: 26038039 DOI: 10.1007/s00068-015-0521-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/11/2015] [Indexed: 12/26/2022]
Abstract
Nonoperative management has become the surgical treatment of choice in the hemodynamically stable patient with blunt hepatic trauma. The increased use and success of nonoperative management have been facilitated by the development of increasingly higher resolution computed tomography imaging, improved management of physiology and resuscitation (damage control), and routine availability of interventional procedures such as angiography and embolization, image-guided percutaneous drainage, and endoscopy. On the other hand, recognition of the patient who should proceed to immediate laparotomy is of utmost importance. A systematic and logical approach to the control of hemorrhage is required in the operating room. Thorough knowledge of the anatomy and surgical techniques, such as perihepatic packing, effective Pringle maneuver, hepatic mobilization, infrahepatic and suprahepatic control of the IVC, and stapled hepatectomy, is essential.
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Affiliation(s)
- J Ward
- Department of Surgery, University of Pittsburgh, F-1281, UPMC-Presbyterian, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
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Hashim PW, Hashim SW. Liver laceration from a diaphragmatic suture in minithoracotomy mitral valve repair. J Card Surg 2014; 29:476-7. [PMID: 24750236 DOI: 10.1111/jocs.12346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Mitral valve operations are increasingly performed through minimally invasive approaches such as the right anterior minithoracotomy. To facilitate exposure with this technique, a diaphragmatic suture may be implemented. We describe a liver laceration caused by the diaphragmatic suture in minithoracotomy mitral repair and its successful nonoperative management with arterial embolization.
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Affiliation(s)
- Peter W Hashim
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
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Jansen J. Selective Non-Operative Management of Abdominal Injury in the Military Setting. J ROY ARMY MED CORPS 2011; 157:237-42. [DOI: 10.1136/jramc-157-03-10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Western Trauma Association/Critical Decisions in Trauma: Operative Management of Adult Blunt Hepatic Trauma. ACTA ACUST UNITED AC 2011; 71:1-5. [DOI: 10.1097/ta.0b013e318220b192] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Western Trauma Association critical decisions in trauma: nonoperative management of adult blunt hepatic trauma. ACTA ACUST UNITED AC 2010; 67:1144-8; discussion 1148-9. [PMID: 20009658 DOI: 10.1097/ta.0b013e3181ba361f] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Stalhschmidt CMM, Formighieri B, Marcon DM, Takejima AL, Soares LGS. Trauma hepático: epidemiologia de cinco anos em um serviço de emergência. Rev Col Bras Cir 2008. [DOI: 10.1590/s0100-69912008000400004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: analisar características epidemiológicas relacionadas ao trauma hepático e fazer breve revisão das modalidades diagnósticas e de tratamento. MÉTODO: estudo retrospectivo de fevereiro/2002 a maio/2007 através de prontuários de 154 pacientes admitidos com trauma hepático no Hospital Universitário Cajuru (HUC). RESULTADOS: Foram encontrados 90,26% das vítimas de trauma hepático do sexo masculino e a média de idade de 26,28 anos. Quanto ao mecanismo de trauma, 72,73% foram por trauma penetrante, sendo que destes, 55,84% foram por arma de fogo e 16,88% por arma branca; e 27,27% por trauma contuso, no qual 73,81% envolveram colisões por veículos automotores e 26,49% outros. Na admissão o período de 0h - 12h foi o de maior prevalência, a média da pressão arterial foi de 117,6/72,3 mmHg, da freqüência cardíaca de 99,03 bpm e do Glasgow de 13,6. O tempo decorrido entre a admissão e a realização da primeira cirurgia foi de menos de 2 horas em 60,43%. Verificou-se maior incidência da lesão Grau II, seguida da Grau III e IV (totalizando 88,3%). As lesões cirúrgicas associadas foram encontradas em mais de 75% dos casos. O ISS médio foi de 15,09, 19,85, 27,83, 35,47 e 40,93 e a sobrevida de 100%, 88,88%, 81,25%, 48,48% e 22,23% nas lesões grau I, II, III, IV e V, respectivamente. CONCLUSÃO: os dados epidemiológicos encontrados neste estudo refletem a violência na sociedade moderna, que se traduz com aumento da complexidade das lesões encontradas e constitui desafio para decisão da melhor conduta terapêutica.
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