PACKING IN SURGICAL TREATMENT OF SEVERE LIVER DAMAGE Shapkin Yu.G., Chalyk Yu.V., Stekolnikov N.Yu., Kuzyaev T.R.
Razumovsky Saratov State Medical University, Saratov, Russia
One of the main causes of deaths in working-age population is multiple or concomitant abdominal injury, with mortality of 50-74 % [1-4]. Among traumatic injuries to abdominal organs, the liver injury takes one of the main places owing to features of anatomic location and structure of parenchyma [5]. According to severity, diagnosis difficulties, treatment strategies, and high incidence of complications, traumatic injuries to the liver are of the most problematic among all injuries to abdominal organs [3, 6, 7].
Severe liver injuries are accompanied by massive blood loss, coagulopathy and hemorrhagic shock events. The mortality reaches 100 % [4], which is determined by severity of liver injury, as well as by presence of severe concurrent injuries [3]. In the end of 20th century, the damage control concept was developed by the scientists of Hannover High Medical School [8]. It means programmed and staged surgical strategies. According to this concept, the primary surgical intervention should be conducted in minimally invasive and life-threatening volume, including temporary hemostasis with liver packing, and with subsequent relaparotomy for final hemostasis [9]. This technique is used for patients with severe liver injury, with unstable hemodynamics, and in case of insufficient surgical experience, according to some authors [8, 10].
Objective – to conduct the analysis of the results of the clinical use of gauze packing in the framework of the damage control concept in patients with severe liver damages.
MATERIALS AND METHODS
The analysis included 248 patients with closed liver injuries operated in Koshelev City Clinical Hospital No.6 at the department of general surgery, Razumovsky Saratov State Medical University, in 1976-2018.
The study was conducted in compliance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013, and the Rules for Clinical Practice in the Russian Federation (the Order by Health Ministry of Russia, June, 19, 2003, No. 266).
The great number of patients (74 %) were at the most working age (20-50 years). There were 75 % (186 patients) of men and 25 % (62 patients) women. The table 1 shows the distribution of patients according to age and gender.
Table 1
Gender and age of patients with liver injury
|
|
Men |
Women |
|
< 20 |
23 |
12 |
|
21 – 50 |
143 |
40 |
|
older than 50 |
20 |
10 |
|
Total |
186 |
62 |
The indications for urgent laparotomy were clinical and laboratory signs of intraabdominal bleeding, data of laparocentesis (laparoscopy), ultrasonic examination and computer imaging of abdominal cavity.
Organ Injury Scale (OIS), developed by E. Moore in 1986, was used for estimation of severity of closed injuries to the liver. For severe injuries to the liver (degrees 4-5), they were of multiple or concomitant pattern. Injury Severity Score (ISS) was also used. There were only three patients with polytrauma and the liver injury of degree 5 in our study since this category of patients demonstrate high mortality at the presurgical stage.
The table 2 shows the distribution of patients with closed injuries to the liver according to E. Moore.
Table 2
Severity of injuries according to E. Moore
|
Injury degree |
I-II |
III |
IV-V |
|
Amount of patients |
151 |
29 |
68 |
|
Total |
248 |
||
The final digital materials were analyzed with MedCalc. v.12.1. χ2-test and Mann-Whitney test were used. The differences were statistically significant with p < 0.05.
RESULTS AND DISCUSSION
The results of distribution of treatment outcomes of patients with closed hepatic injuries of degrees 4-5 included three periods: I − 1976-1992; II − 1993-2008; III − 2009-2018. We think that comparison of these periods is possible since, despite of advances in anesthesiology and critical care medicine in the periods 2-3, the period 1 included massive hemotransfusion (autohemotransfusion, direct blood transfusion), which is the main method for shock correction according to some authors (Samokhvalov I.M., Afonchikov V.S., Badalov V.I., Borisov M.B., et al.). In all periods, hepatic injuries were dominating according to ISS (the table 3).
Table 3
Mean value of ISS in patients in various time intervals
|
Periods |
period I |
period II |
period III |
|
Total mean score |
38.75* |
38.9* |
38.95* |
|
Traumatic brain injury |
5.25 |
5.33 |
5.32 |
|
Spinal fractures |
0 |
0 |
0 |
|
Chest injury |
5.13 |
5.16 |
5.14 |
|
Abdominal injury |
25 |
25 |
25 |
|
Locomotor system injury |
2.06 |
2 |
2.07 |
|
Pelvic fractures |
1.31 |
1.41 |
1.42 |
The table 3 shows the absence of statistically significant differences in ISS for all periods.
The table 4 shows the characteristics of surgical interventions in the various periods.
Table 4
Distribution of patients according to the type of operations performed for severe liver injury in three periods of the clinic
|
Surgery type |
Periods of activity of clinic |
||
|
1976-1992 |
1993-2008 |
2009-2018 |
|
|
Packing |
1 (1)* |
3 (2) |
18 (10) |
|
Hemihepatectomy |
2 (1) |
- |
1 (0) |
|
Hemihepatectomy + packing |
4 (4) |
1 (0) |
1 (0) |
|
Resection – preparation |
5 (2) |
5 (4) |
- |
|
Resection-preparation + packing |
3 (3) |
- |
2 (1) |
|
Suturing/coagulation |
- |
8 (5) |
4 (2) |
|
Suturing/coagulation + packing |
1 (1) |
7 (2) |
2 (0) |
|
Total |
16 (12) |
24 (13) |
28 (13) |
|
Mortality |
75 %** |
54 %** |
46 %** |
Note: * – number of lethal outcomes is indicated in brackets; ** – p < 0.01.
In the first period (1976-1992), the clinical trends showed adherence to radical surgery for patients with severe hepatic injuries. It was determined by the trends of that time (Shapkin V.S., Grinenko Zh.A. Closed and opened hepatic injuries. M.: Medicine; 1997; 182 p.). 87.5 % of surgical interventions were presented by liver resection. The mortality was 75 %.
In the second period (1993-2008), the gradual refusal from primary atypical resection of the liver happened. During the second period, anatomic resection of the liver was conducted for 1 case, and atypical liver resections − for 5 patients. The total amount of radical operations decreased more than two times. Radical operations were replaced by less aggressive techniques in combination with packing, resulting in decreasing rate of lethal outcomes in patients with severe closed hepatic injuries to 54 %. The rate of use of primary gauze packing were 12.5 % for this period.
For the third period (2009-2018), active implementation of the damage control concept was realized. In 2009-2018, active use of primary gauze packing for surgery of severe hepatic injuries was noted (64 %, 18 patients). Resection interventions were conducted only for 14 %. Primary packing was accompanied by draining of the region around sponges with use of PVC drains. One should note that primary packing was also successfully used for 2 cases with degree 3 of hepatic injury, with extremely severe condition of patients. The time intervals of removal of sponges were individual. The total amount of complications of primary packing was 16.6 % (3 patients). Therefore, gradual implementation of the damage control for severe hepatic injuries decreased the mortality to 46 %, which is lower than in the previous periods (number of degrees of freedom − 12, χ2 – 36.286, critical values of χ2 with p < 0.01 – 26.217).
CONCLUSION
1. Active implementation of primary packing as a part of the damage control concept improved the outcomes of treatment of polytraumatized patients in surgery of liver injuries.
2. Liver resection refusal, and the use of gauze packing for primary hemostasis decrease the mortality in severe closed hepatic injuries.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.