tóm tắt tiếng anh đối chiếu lâm sàng với phân loại độ chấn thương gan bằng chụp cắt lớp vi tính và đánh giá kết quả phẫu thuật điều trị vỡ gan chấn thương

1 BACKGROUND Abdominal trauma in general and liver injury in special are considered intensive emergency which is increased nowadays The liver is one of the most commonly injured organs in abdominal trauma It is together with the urbanization, developed transportation and the development of civilization Most of liver trauma was indicated surgery many years ago Surgery of liver required advanced knowledge of anatomy, physiology of liver as well as good technique of recovery and surgeon However the complication in surgery and post opereation is in high rate Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population The precise indication for liver trauma would guide clinician classify the grade of liver injury At this present no previous study reviewed and compared grade of clinical liver trauma and CT images and the early result of surgery after liver trauma injury have been reviewed “The correlation between clinical and CT imaging features of liver trauma and evaluation of surgical management of liver trauma” Purposes: 1.Correlate clinical and CT grading features of liver trauma 2 Evaluate of surgical management of liver trauma Significance of study: - Study show the practical and sientific benefits by correlating clinical and CT imaging features - Methodology was done in sientific manner Sample were matching in 2 groups: group included clinical and CT imanging features, group 2 enrolled surgical management of liver trauma Data were confident Study has been done in major surgical center nationaly - Coded study was approval, data was first presented Layout of the thesis: The dissertation consists of 140 pages, 4 chapters, 46 tables, 14 charts, 45 figure, 159 references including 27 Vietnamese references, 130 English references , 2 French references 2 CHAPTER 1: OVERVIEW 1.1 Liver anatomy: 1.1.1 The structures to maintain hepatic fixed status: * The ligaments: + Right and left triangular ligaments which are easily torn of liver, parenchyma by indirect mechanism + Round ligament, falciform ligament is the most vulnerable – most likely to be torn + other ligaments: as liver-duodenum, liver-colon, abnormal adhesives between liver and abnormal diaphragm dome when injured by indirect mechanism, positions attached to the liver are also at risk of being torn, leads to bleeding * Porta hepatis and components of porta hepatis: Porta hepatis or Glisson pedicle includes 3 components: portal vein (PV), hepatic artery (HA), biliary tract + Right pedicle: including the posterior hepatic segment with 2 branches sub-segment (SS) VI, VII and anterior segment pedicle with SS V, VIII + Left pedicle: there are 3 branchs: SS IV, SS II and SS III * Hepatic veins + Median hepatic vein: receives blood from lobe IV, anterior segment and pour into IVC + Right hepatic vein: received blood from posterior segment and anterior segment + Left hepatic vein: receives blood from the left lobe and lobe IV + Spiegel Veins: receives blood directly from Spigel segment and consists of two groups: the small veins pouring directly into IVC and relatively large and pretty regular veins + The minor right hepatic vein (Makuuchi vein) guides blood directly from the right liver sections (V, VI, VII, VIII) poured straight into the side of IVC If there is severe injury, these positions could be torn violently, ensuing excessive bleeding 1.1.2 Application in hepatic resection surgery * According to British-American authors: In 1953, Healey and Schroy divided liver into 2 lobes – left and right 4 segments include: medial, lateral, posterior, anterior segments Caudate segment is also known as back segment Each segment is divided into 2 smaller parts: 3 superior and inferior Caudate segment has 3 sections: right, left and caudate * According to French authors: Couinaud in 1957 divided into 2 halves: right and left 4 parts include: right, right portal and left portal, left Caudate lobe makes the back segment 8 segments are numbered clockwise on the diaphragmatic surface * Vietnam school: In 1963, Tôn Thất Tùng the combined 2 views of British-American and French with experiences of Vietnam to suggest a particular uniform view of Vietnam As dividing 2 halves of liver, 8 subsegments is based on Couinaud theory and 4 segment following British-American authors In our study, we use Ton That Tung’s school In 2000, at Brisbane (Australia), the liver surgery conference come to an agreement on liver operation and hepatic resesction surgery 1.2 The methods of diagnostic imaging of liver injury 1.2.1 The visual probe methods * Abdominal radiograph: provide indirect signs of liver rupture * Ultrasound: detecting peritoneal fluid with a very high sensitivity, detecting which organ is damaged, plays important role in guiding and monitoring of lesion progression * Magnetic resonance imaging: MRCP can be used to assess biliary lesions * Scintigraphy: questioning bile leak into the abdominal cavity * Angiography: usually for treatment through endovascular intervention and can also be used in cases of biliary tract bleeding * Liver computerized tomography + Anatomy of liver in CT: based on hepatic veins and the left and right branches of the PV, virtual planes cut through the blood vessels helping distinguishing location of lobes and segments of the liver + Classification of the grade of liver injury on CT: In 1994, American Association for the Surgery of Trauma (AAST) divided liver lesions into 6 levels 1.2.2 The situation of computerized tomography studies in the diagnosis of liver injury * Around the world: Researches throughout the world from the 80s and 90s so far suggests that CTis enormously valuable in detecting hepatic trauma, allowing surgeons to be comfortable and confident in the treatment of conservation * In domestic regions: In 2007, local authors had high opinions of the 4 diagnostic ability of CT in hepatic trauma with the absolute level of sensitivity up to 100%, accuracy 94.8%, positive predictive value 94.8% 1.3 The method of treating liver injury 1.3.1 Inoperable conservation Treatment * Clinical: closely monitoring whole body condition, hemodynamic and abdomen status * Paraclinical: monitoring indicators of blood counts, biochemical and images-particularly CT * Treatment: intensive care, estate resting in hospital bed ward * During the follow-up, detecting complications so as to have management on intervention or surgical procedure: 1.3.2 Embolization treatment * Indication: From hepatic trauma grade III or beyond, there is vein damage,stable hemodynamic * Contra-indication: blood pressure decrease shock and there is vein damage in which surgery is inevitable *Intra-vesel intervention for treatment of hepatic artery damage: Using the material to cause embolism, according to damage 1.3.3 The methods of surgery treatment * Surgical indication: fatal shock and failed conservation treatment * Surgical rules: processing vessels, biliary tract, cut off dead hepatic parenchyma * Main techniques: + Simple liver sewing and cauterization: for insignificant hepatic trauma + Selective hepatic artery embolism: selective embolism of either right or left branch or hepatic artery + Mickulic’s method: for deep and wide lesions, not thorough hemostatic + Liver packing: severe shock patient can’t put up any longer with surgery + Simple hepatic draining tube: rarely applied + Hepatic venous repair - Repairing venous lesion without using shunt: includes the method of Ton That Bach, Heaney’s method and method of Dale coln - Repairing venous lesion using shunt: includes the Buckberg’s method, method of Albert E.Yellin and method of Pilcher - Repairing using out of body circulation: exactly assess lesions, 5 exactly and ensuring hemostatic, do not have risk of empty heart pulsation, embolism or hepatic anemia + Repairing bile duct lesion: hemostatic sewing is simple in small lesion in outer region of liver, liver cutting need to be considered in bile duct or segment injury, on-sonde sewing in common bile duct injury, bile duct-plasty, choledo-jejunum stomy Cholescystis-stomy or common bile duct drainage to reduce pressure in bile duct + Liver implant: in cases of complex and serious lesion + Liver resection: includes the method of Ton That Tung, Lortat Jacob and Bismuth Method of Ton That Tung has a lot of pros and is currently widely used * Treatment of post-operative complications: + Post-operative hemorrhage: depend on particular cases, blood transfer, scintigraphy or emergency operation + Bile duct hemorrhage: intervened embolization is considered a valuable treatment + Abscess inside and outside of liver: ultrasound guided puncture and drainage give good result + Biliary peritonitis: immediate emergency operation 1.3.4 Status of research on domestic and world * Status of research on the world + The first stage: not paying attention to the anatomical boundaries, focus only on hemostatic treatment + Modern Period of liver cutting: a deep understanding of liver anatomy to improve liver cutting techniques with the aim of reducing bleeding when cut liver parenchyma The advancement of CT helped to accurately assess the degree of liver damage, alter attitudes in patients treated hepatic trauma, treatment rate increased non-operative conservation * Status of Research domestic: Ton That Tung’s liver cutting method was first published in 1962 in Berlin Trinh Hong Son’s study of hepatic trauma in Vietnam-Germany Hospital for 6 years from 1990 to 1995, emphasized the hemodynamic status when patient come in hospital have prognostic significance and summarize the accompanying lesions, method of treatment and postoperative complication rate Most recently, Nguyen Ngoc Hung’s study showed that treatment of liver preservation injury is applied to the 84.4%, 89% achieved good results 6 Chapter 2: SUBJECTS AND METHODS 2.1 Research Subjects * For Objective 1: To compare the clinical presentation and liver injury grade in CT of simple liver trauma * For objective 2: Results of surgical treatment of simple liver trauma 2.2 Methodology of research: descriptive study with prospective analysis During the period from January 2009 to the end of December 2011 Research’s Steps: + Diagnosis and management of simple hepatic trauma comply with a uniform regimen of treatment indications, assessment of liver injury on CT and in operation + The level of hepatic trauma was assessed by CT + Decide between non-operative conservation management or emergency surgery The content of research: * Compare hepatic trauma grade in CT with the general characteristics of the study groups: including the causes, mechanism of injury, age, gender, occupational status prior to hospitalization and time from the accident until hospital * Reconciliation of hepatic trauma grade with clinical presentation + Systemic symptoms: breathing and hemodynamic changes, signs of severe blood loss, shock condition, coma, decreased consciousness + Functional symptoms: right hypochondrium abdominal pain, stomach aches or no symptoms + Physical symptoms: - Crash in lower region of right chest and hypochondrium - Abdominal bloating: abdominal distension, bloating, moderate, mild or no stumbling block - Response to localized or diffuse abdominal wall - Abdominal wall tetanus, peritoneum touch * Compare hepatic trauma grade with laboratory studies: + The blood tests include: red blood cells, white blood cells, hemoglobin, hematocrit were grouped into 3 levels of blood loss + The tests include the coagulation rate Prothromobine, Fibrinogene, platelet counts to assess clotting function + Quantification of liver enzymes: SGOT, SGPT ; blood bilirubin, albumin and blood protein, urea quantification, blood creatinine * Compare hepatic trauma grade with diagnostic imaging: + Abdominal ultrasound: Find free fluid in the abdomen, locate and nature of liver damage + Abdominal CT: locate, nature liver damage, grade according to 7 Association USA (American Association for the Surgery of Trauma AAST, 1994) Table 2.1: Classification of traumatic hepatic of AAST 1994 Grade Type of Injury Description of injury * I Hematoma Subcapsular, 75% of hepatic lobe or >3 Couinaud’s segments within a single lobe Vascular Juxtahepatic venous injuries; ie, retrohepatic vena cava/central major hepatic veins VI Vascular Hepatic avulsion + Machine: single - receiver array CT in diagnostic imaging departments of Vietnam-Germany Hospital Slice thickness can vary 1mm - 10mm + Technique: patient supine, hands raised to the top Slices were taken from the top of the diaphragmatic dome to the ischium joint with 10mm thickness, if small lesions is suspicious conduct shooting 3 - 5mm thin layer on the damaged area Slices were taken before and after contrast agent injection + Read the result: Location of lesions (Ton That Tung) Hepatic trauma signs: rupture; parenchymal contusion; parenchymal hematoma ; subcapsular hematoma ; parenchymal anemia; Escape of contrast agent Classification of hepatic trauma in CT according to AAST grading of 1994 8 * Evaluation of abdominal fluid: On ultrasound and CT, based on the number of abdominal cavities with fluid * Diagnosis of hepatic trauma: Based on the results of CT * Evaluate the severity of hepatic trauma: the classification of AAST 1994 * Assess the level of blood loss: based on the level of blood loss to estimate the amount of fluid, blood must be compensated * Indications: + Non-operative operation: hemodynamic stability, no damage to other abdominal organs require operation + Emergency abdominal surgery: blood loss shock, non-operative conservative treatment failed * Surgical Treatment + The patient in the supine position under general anesthesia endotracheal + Open surgery or laparoscopy + Abdominal incision: midline, hypochondrium, line of Mercedes or Kehr + To assess the extent of liver damage: liver damage location based on the anatomy of the liver of Ton That Tung, distribution of liver damage in the operation according to Moore + The treatment of liver damage - Electro-burning: Using monopolar or bipolar electrocoagulation knife - Sewing hemostatic: slow absorbable suture, perform a U stitches taken out depth break lines - Liver cutting according to damage region: Just take away the region which is loss of nourishing and not really interested in the circuitry of this region - Cut the liver according anatomy (Ton That Tung method) including left liver, right liver, left lobe, right lobe, segments cutting - Packing: - Handle the hepatic artery lesions: Sewing HA or selective ligation - The handling of surgical lesions hepatic veins, portal vein, IVC: Fix direct venous injury using shunt and circulation outside the body - The surgical drainage of the bile ducts, the processing techniques of biliary lesions: drainage of common bile duct, cholecystis stomy, hepatic duct on-sonde sewing, choledo-jejunum stomy, or liver cutting * Subscribe to detect postoperative complications: postoperative hemorrhage, biliary duct hemorrhage, biliary peritonitis, bilioma, liver abscess, abscess under the diaphragm, bile leakage after surgery, complications in the lungs and pleura, liver failure, multi-organ failure * Treatment of complications: indication of surgery or procedure is depended on developments, complications 9 * Number of days in hospital * Results of surgical treatment soon after + Good: No complication present or minor complications present but have been treated without intervention + Average: patients with complications were stably handling + Bad: Death, serious complications 2.2.5 Gathering and processing data All selected patients have complete individual profile with all necessary parameters mentioned Data processing program according to medical statistics software SPSS 15.0 2.2.6 Research Ethics The patient's personal information in the records completely confidential and used only for research The research program is through a review board of the Military Medical Academy, Department of Defense decision Research was accepted by Viet-Duc Hospital and the Military Medical Academy CHAPTER 3: RESEARCH RESULTS 3.1 General Characteristics From January 2009 to the end of December 2011, there are 176 patients on hepatic trauma in Viet-Duc hospital in which 166 patients were designated to assess liver CT capture and classify of hepatic trauma on computerized tomography scans 142 patients received conservative treatment no-surgery accounting for 78.1% 24 patients (accounting for 15%) of the patients after taken CT to detect liver damage were emergency surgery 10 patients (6.9% percentage) was hospitalized in condition hemorrhagic shock, that is indicated emergency surgery to assess liver injury without CT 3.2 Group of patients diagnosed liver injury simply by taking CT Table 3.5: Comparing the grade of hepatic trauma to cause injury Kind of trauma Traffic Labor Accidents Accidents Accidents activities Grade n % n % n % I 1 0,7 1 5,9 0 0,0 II 20 15,4 3 17,6 7 36,8 III 60 46,2 5 29,4 8 42,1 IV 38 29,2 6 35,3 3 15,8 V 11 8,5 2 11,8 1 5,3 Total 130 78,3 17 10,2 19 11,5 10 P p = 0,011 Table 3.8: Comparing the grade of hepatic trauma and pulse at admission pulse ≤ 90 90 – 120 ≥ 120 grade N % n % n % I 2 2,0 0 0,0 0 0,0 II 20 20,4 10 16,9 0 0,0 III 48 49,0 24 40,7 1 11,2 IV 23 23,5 20 33,9 4 44,4 V 5 5,1 5 0,5 4 44,4 total 98 59,0 59 35,6 9 5,4 P p = 0,001 Table 3.9: Comparing the grade of hepatic trauma with the grade of initial anemia grade II grade III grade IV anemia grade I grade n % n % n % n % I 2 1,5 0 0,0 0 0,0 0 0,0 II 27 20,1 3 12,5 0 0,0 0 0,0 III 63 47,0 9 37,5 1 14,4 0 0,0 IV 34 25,4 9 37,5 3 42,8 1 100,0 V 8 6,0 3 12,5 3 42,8 0 0,0 Tổng 134 80,7 24 14,5 7 4,2 1 0,6 P p = 0,005 Table 3.10: Relation between the initial grade of anemia and methods of treatment Delaying Method conservation emergency total treatment surgery Anemia n % n % I 123 91,8 11 8,2 134 II 17 70,8 7 29,2 24 III 2 28,6 5 71,4 7 12 II III IV V 18 43 21 3 20,7 49,4 24,1 3,5 8 21 9 4 19,0 50,0 21,4 9,6 2 7 15 2 7,7 26,9 57,7 7,7 2 2 2 5 18,2 18,2 18,2 45,4 Table 3:15: Comparing the grade of hepatic trauma with blood biochemical tests (SGOT) First time Second time Third time SGOT X X X n n n Grade ± SD ± SD ± SD I 2 193,5±92,6 2 87,0±42,4 1 29,0 II 30 346,0±385,8 24 136,1±110,1 11 80,1±61,0 III 73 600,1±783,1 55 429,8±1184,5 31 259,0±665,2 IV 47 1257,0±1476,6 42 614,1±811,8 25 200,2±275,7 V 14 907,1±550,1 13 966,2±835,2 11 242,6±343,4 Total 166 762,2±1023,4 136 481,2±936,8 79 210,6±343,4 P p < 0,001 p < 0,001 p < 0,05 Table 3:16: Comparing the grade of hepatic trauma with blood biochemical tests (SGPT) First time Second time Third time SGPT X X X grade n N n ± SD ± SD ± SD I 2 96,0±14,6 2 67,0±12,7 1 40,0 II 30 264,0±288,0 24 183,5±201,7 11 132,7±71,5 III 73 456,4±434,0 55 361,8±361,4 31 259,1±272,7 IV 47 799,9±623,4 42 526,7±413,4 25 310,0±292,0 V 14 614,7±393,6 13 818,5±551,8 11 315,9±349,2 Total 166 530,9±507,0 136 420,6±412,4 79 263,0±274,4 P < 0,001 < 0,001 < 0,05 Table 3:20: Comparing the grade of hepatic trauma with abdominal fluid on CT Abdominal None less medium A lot Total fluid n % n % n % n % n % grade 13 I II III IV V Total P 2 10 12 2 0 26 7,7 38,5 46,1 7,7 0,0 15,7 0 9 20 5 2 36 0,0 25,0 55,6 13,9 5,5 27,7 0 0,0 6 17,6 14 41,2 11 32,4 3 8,8 34 20,5 p