[Liver trauma due to penetrating lesions: miscellanea, personal case series, clinical and CT findings]. / Traumi epatici da lesioni penetranti. Miscellanea, casistica personale, aspetti clinici e con Tomografia Computerizzata.

ABSTRACT

PURPOSE: Penetrating liver wounds are related to many causes and rank second after blunt abdominal and liver trauma. We will report the clinical and radiological findings of our personal series of patients with penetrating trauma, especially by firearms and stab and cut wounds. We will also try to define the diagnostic workup of these traumas, which is especially based on CT signs of liver damage and associated changes and which is of basic importance for following treatment, both surgical or conservative. MATERIAL AND METHODS: In the last seven years we retrospectively reviewed 31 cases of penetrating liver trauma. The patients were 19 men and 12 women, ranging in age 18 to 73 (mean 42), with penetrating liver injuries from firearms (16 patients) and stab (9 cases) wounds; 6 patients had injuries from different causes. Abdominal CT was carried out in emergency with the CT Angiography (CTA) technique in all patients. In the patients with suspected chest and abdomen involvement CT was performed from the mid-chest for accurate assessment of diaphragm and lung bases and to exclude associated pleuropulmonary damage. RESULTS: Penetrating liver wounds were caused by firearms in 70% of cases, by stabbing in 12% and, in the extant 18%, by other causes such as home accidents, road and work traumas, and liver biopsy. In our series, the liver was most frequently involved, especially by firearms wounds; in our 16 cases the most frequent injuries were hemorrhagic tears. We found bullets in the liver in 6 cases. In one case of home accident the patient wounded himself while slicing bread with a long knife, which cut into the anterior abdominal wall and tore the anterior liver capsule, as seen at CTA. DISCUSSION AND CONCLUSIONS: Penetrating wounds to liver and abdomen are less frequent than those to the chest. In the past decade the use of CT has changed the diagnostic and therapeutic approach to such injuries completely, decreasing the resort to explorative laparotomy and hepatorrhaphy. Indeed, CT provides a clear picture of the extent and severity of damage, which permits to choose a conservative treatment in case of intraparenchymal hematomas and lacerocontusive foci without hemoperitoneum, which can be followed-up with physical and CT examinations. Moreover, Helical CT could provide the early diagnosis of active bleeding in the peritoneum and of focal bleeding in the liver, thus permitting prompt hepatorrhaphy or targeted hepatectomy. A diaphragm injury suspected at CT should always prompt the surgeon to intervention, especially when hemothorax, lung base pneumothorax, large liver hematoma or tear of the liver dome are associated. Finally, subdiaphragmatic free gas indicates gut perforation associated with liver damage, in which case surgery is necessary too.