Delayed Hepatic Rupture

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Michael
The commendable heroic measures ultimately saved this man's life. Just a few
comments:

   - If the liver laceration was not bleeding at the time of laparotomy on
   day 2 (having embolised a  posterior sectoral RHA), why was 'hepatorraphy'
   performed? Amongst the 'trauma' community is there consensus on this?
   - What was the drop in Hb. at two weeks? Did he need a transfusion? Has
   the CT been reviewed again to check for missed findings, such as
   intra-hepatic haematoma?
   - At four weeks the patient arrests suddenly - presumably from a RHA
   bleed (?ruptured pseudo-aneurysm of right hepatic artery, with a small
   haemobilia prior to that). I can only postulate that he bled into his chest
   from an associated (?missed) diaphragmatic rupture? From the account it
   would seem that there was no source in the chest, and he did not bleed from
   an associated vena caval / right hepatic vein laceration?
   - A complete vascular isolation has tremendous haemodynamic consequences
   in a 'non-compromised' patient, would you recommend this manoeuvre in a
   similar situation again?
   - If the liver was placed in 'Seattle bag' and packed, then clamps were
   released - how was the bleeding from the liver controlled, which was now
   under a pack and swabs? Could you please tell us about the Seattle bag and
   its use in hepatic trauma?
   - It would seem the second angiography proved to be his 'definitive'
   treatment - embolising a presumed rupture of a RHA pseudo-aneurysm?
   - Embolisation of RHA does not mandate a right hepatic resection. I am
   unclear why a hepatic resection was deemed 'necessary'. In the great
   majority of patients who undergo RHA ligation (trauma or iatrogenic) do not
   progress to hepatic parenchymal necrosis because of dual blood supply.
   Personally, I think it was an overkill where you had already achieved
   haemstasis?

In summary, I can only postulate / hypothesise - this man underwent a
'sentinel' bleed from RHA (?pseudoaneurysm). This then progressed to a
pronounced bleed into the liver - right chest causing his arrest. His
condition was temporised with resuscitation, re-laparotomy etc. and treated
with angio-embolisation. I suspect his hepatic resection may not have been
required?

Saboor Khan
Coventry
UK

2009/1/11 michael parra <michaelwparra at yahoo.com>

> 30 yo male status post motor vehicle crash who arrived complaining of
> abdominal pain / hemodinamically stable. CT abdomen revealed a Grade IV
> liver laceration extending threw segments 7 & 8 with active extravasation of
> contrast, and moderate amount of hemoperitoneum. Taken immediately to angio
> where a distal right hepatic artery branch was successfully embolized. Next
> morning patient presents with an elevated WBC / worsening acidosis and
> increase abdominal tenderness for which patient is taken to the operating
> room for exploratory laparotomy to rule out any other missed injury. During
> laparotomy no other injuries found, abdominal washout is performed and
> hepatorraphy with several interrupted zero chromic liver mattress sutures.
> Two weeks post op patient presents with a sudden drop in his hemoglobin and
> a repeat CT abdomen is essentially negative.
> Four weeks post op patient presents with an abrupt episode of cardiac
> arrest following a melenotic stool. A rapid EGD is performed during CPR
> protocol to rule out a hepato-biliary or upper GI source. EGD was negative.
> FAST was negative. An acute abdominal compartment syndrome developed as a
> consequence of the aggressive IVF and blood product resuscitation during
> CPR. The abdomen was opened at the bedside in the TICU, and no
> hemoperitoneum was noted. CPR is continued and a significant and distinct
> cyanosis of the shoulders/neck /and head developed all of a sudden. A
> presumptive diagnosis of an acute superior vena cava syndrome is considered
> for which bilateral chest tubes are placed. Lt chest tube resulted no air or
> blood. Right chest tube decompressed a massive hemothorax of greater than 2
> liters. An immediate right antero-lateral thoracotomy was performed with
> packing of the right chest and the patient was transferred from the TICU to
> the OR with
>  ongoing CPR.
> In the OR both chest and abdominal incisions were united and the diaphragm
> was transected following the ligament of Teres down to the suprahepatic vena
> cava. Complete liver isolation was performed by placing vessel loops on the
> hepatoduodenal ligament (Pringle), the suprahepatic inferior vena cava and
> the suprarenal subhepatic vena cava.The liver is encased with a plastic bag
> ( "Seattle Bag") and then packed. All vascular controls were released and
> liver bleeding was controlled. Both the abdomen an the chest are left open
> and a poor mans VAC were placed on each cavity.Patient was taken back to the
> TICU for rewarming and correction of coagulapathy.Patient stabilizes
> overnight and is taken to the angio suite the next morning to coil any
> possible intrahepatic pseudo aneurysm, any persistent intrahepatic
> arterial bleeding and possibly prophylactic embolization of the right
> hepatic artery in preparation for planned surgical resection. Angiogram
>  revealed a blush of the right medial hepatic artery that was
> then successfully embolized. 48 hours later patient was taken back for
> packing removal and a subtotal right hepatectomy/cholecystectomy. Patient
> eventually undergoes thoracotomy and abdominal wall closure with alloderm.
> Patient recovers and is transferred to a rehab facility.
>
>
> Michael W. Parra, MD
> Trauma Research Director
> Broward General Medical Center
> Fort Lauderdale, Fl
>
>
>
>
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