Abstract
Retrohepatic venous injury presents as a rare but frequently lethal complication of trauma. The anatomic arrangement makes management of these injuries difficult at best. Operative exposure and isolation techniques ranging from cross-clamping the aorta, portal triad, suprarenal vena cava, and suprahepatic vena cava to the use of internal shunts are described in this report.
Our experience from 1968 to 1987 with internal shunting techniques includes 27 patients. We have successfully resuscitated 12 patients for an acute mortality of 55 %. We believe that this figure is high but compares favorably with published results. Late deaths from sepsis, disseminated intravascular coagulation, or multiple systems organ failure remain as significant causes of overall mortality.
Many techniques have been successfully employed over the years in achieving vascular isolation of the liver. The methods all have their own merits, but the key factor in each is the recognition that they need to be employed. Conservative selection of patients is undoubtedly justified, but aggressive approaches should not be delayed until they are the methods of last resort.
Résumé
Les lésions traumatiques veineuses rétrohépatiques sont une complication rare mais souvent mortelle. La position anatomique rend très difficile le traitement de ces lésions. Dans cet article, nous décrivons l'exposition chirurgicale et les techniques d'isolement et du clampage total de l'aorte, du pédicule hépatique, de la veine cave suprarénale et de la veine cave suprahépatique, ainsi que l'emploi de shunts internes.
Notre expérience des techniques de shunts internes compte 27 patients traités entre 1968 et 1987. Nous avons sauvé 12 patients alors que la mortalité globale était de 55%. Nous trouvons ce taux important mais pourtant avantageusement comparable aux résultats publiés. Les morts tardives par septicémie, coagulation intravasculaire disséminée, et défaillance pluriviscérale restent les causes essentielles de la mortalité globale.
Bien des tecniques ont été employées avec succès au cours du temps pour isoler le foie. Toutes les méthodes ont leurs avantages mais pour chacune la clef du succès est la capacité de reconnaître la nécessité de l'employer. L'attitude conservatrice pour des patients électifs se justifie sans aucun doute mais on ne doit pas attendre jusqu'à ce que les méthodes agressives deviennent celles de la dernière chance!
Resumen
La lesión traumática venosa retrohepática (vena cava retrohepática y venas suprahepáticas) es una complicación que aunque rara es frecuentemente letal. La disposición anatómica dificulta el manejo quirúrgico de estas lesiones. La exposición y la técnica operatorias van desde las técnicas de aislamiento vascular hasta la oclusión por pinzamiento de la aorta, la tríada portai, la vena cava suprarrenal, y la vena cava suprahepática, hasta el uso de “shunts” internos, tal como se describe en este informe.
Nuestra experiencia con el uso de “shunts” internos entre los años 1968 y 1987 corresponde a un total de 27 pacientes. Hemos logrado resucitar 12 pacientes, para una tasa de mortalidad aguda de 55%. Aunque esta cifra aparece alta, se compara favorablemente con los resultados publicados en la literatura. Muertes tardías por sepsis, coagulación diseminada intravascular, o falla orgánica multisistémica sigue siendo un factor significativo que afecta la tasa global de mortalidad.
Son muchas las técnicas que han sido empleadas a través de los años para lograr el aislamiento vascular del hígado. Cada método tiene sus propios méritos, pero el factor clave es realmente el reconocer oportunamente que se requiere el aislamiento vascular. Aunque la selección de los pacientes para manejo conservador es justificable, el aproche agresivo no debe ser demorado hasta el punto de llegar a convertirse en la última medida de desesperación.
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Ciresi, K.F., Lim, R.C. Hepatic vein and retrohepatic vena caval injury. World J. Surg. 14, 472–477 (1990). https://doi.org/10.1007/BF01658670
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DOI: https://doi.org/10.1007/BF01658670