Repair of suprahepatic caval lesions under extracorporeal circulation in major liver trauma.

A case of major hepatic injury with associated juxtahepatic trauma is reported. Repair of the injuries was effected with the aid of extracorporeal circulation. This aided exposure of the bleeding site while at the same time minimizing blood loss. Hypothermia is an added benefit of this approach, decreasing the risk of hepatic ischaemia.

[Cavo-suprahepatic lesions in severe hepatic injuries. Repair under extracorporeal circulation]. / Lésions cavo-sus-hépatiques des traumatismes hépatiques sévères. Réparation sous circulation extracorporelle.

Liver injuries always have a sombre prognosis. Triple or quadruple clamping has been suggested to control haemorrhages, but the risk of the heart running dry has warranted internal shunts which have only been successful in odd cases. The severity of these lesions justifies a temporary packing pending admission in specialized unit for subsequent treatment. A final treatment may be undertaken under extracorporeal circulation. In the case reported here, the superior right hepatic vein was sutured and the holes of the infrahepatic vena cava related to the tearing of middle and inferior right hepatic veins or the dorsal veins of segment I could be repaired. Rupture of the renal pelvis was also repaired.

[Surgical treatment of hepatoma on a cirrhotic liver]. / Le traitement chirurgical des hépatomes sur cirrhose.

From January 1, 1975 to July 1, 1984, 37 patients with a tentative diagnosis of hepatocarcinoma on cirrhosis were operated upon. There were 34 men and 3 women, aged from 32 to 82 years (mean: 60 years). The diagnosis of cirrhosis rested either on a history of liver failure associated with clinical and biochemical signs of hepatocellular dysfunction (4 cases), or on a positive liver biopsy (5 cases). In 20 cases the diagnosis was suspected on account of abnormal liver function tests, but in 8 patients it was revealed by macroscopic examination of the liver during surgery. Cirrhosis was attributed to chronic alcoholism in 25 cases, haemochromatosis in 11 cases and positive HBs antigen in 7 cases. The diagnosis of hepatocarcinoma, suggested by altered general condition or recent pain, rested on the finding of a tumoral image at scintigraphy (16 cases), ultrasonography (19 cases), computed tomography (7 cases), arteriography (17 cases) or laparoscopy (7 cases). In only 7/32 patients was the alpha-foetoprotein level higher than 500 ng/l. Surgery confirmed the diagnosis of hepatocarcinoma in every case but that of cirrhosis in only 14/37 cases; 10 patients had lesion of hepatic fibrosis and 1 had regenerative nodular hyperplasia. In 10 cases no accurate histological diagnosis could be made since the liver tissue sample had been taken too close to the tumour. The finding of normal liver tissue shows that one should not refrain from operating merely because the diagnosis of cirrhosis rests on clinical grounds. Since 1979, surgical treatment consists in an attempt to excise the tumour. Per-operative mortality is the same with excision surgery (21%) as with exploratory or palliative surgery (17%). Fourteen excisions were performed (i.e. aresectability rate of 38% for the series): 2 liver transplantations, 2 right hepatectomies, 2 left hepatectomies, 2 left lobectomies, 2 bisegmentectomies and 3 tumorectomies. The survival rate of 2 years was 27%, as opposed to 5% with exploratory or palliative surgery. Systematic monitoring of cirrhosis with ultrasonography should result in early diagnosis of hepatocarcinoma at a stage where limited hepatic excision is possible and the chances of surviving are highest.

[Repair of a suprahepaticocaval injury under extracorporeal circulation]. / Réparation d'un traumatisme sus-hépatico-cave sous circulation extracorporelle.

The case of a 29-year old man who presented with haemorrhage from hepatic veins and the retrohepatic vena cava is reported. On the belief that a conventional technique would be dangerous, total extracorporeal circulation was used as a supportive procedure. The method facilitated anatomic definition of the venous injuries. The repair could then be calmly and precisely carried out because of a practically bloodless operative field. The procedure was well tolerated and the postoperative course was uneventful; the patient was discharged 15 days later. Many surgical techniques have been described for the repair of traumatic injuries of the inferior vena cava and hepatic veins, but all with a high level of peroperative mortality. So, cardiopulmonary bypass and hypothermia seemed to be a useful procedure. However, some points need further consideration: heparin administration may promote bleeding from other lesions and, in the case of associated gastrointestinal injuries, the risk of major septic dissemination is great.