MINISTRY OF EDUCATION AND TRAINING MINISTRY OF NATIONAL DEFENCE
108 INSTITUTE OF CLINICAL MEDICAL SCIENCE RESEARCH
PHAM TIEN BIEN
DIAGNOSIS AND TREATMENT LIVER TRAUMA AT THE NORTHERN MOUNTAINOUS HOSPITALS
Speciality
: Gastroenterology surgery
Code
: 62720125
ABSTRACT OF PHD THESIS
Ha Noi – 2020
STUDY ARE COMPLETED AT
108 INSTITUTE OF CLINIC MEDICAL SCIENCE RESEARCH
Science instructor: Prof. Trinh Hong Son
Referee 1:
Referee 2:
Referee 3:
The thesis will be defended in front of the Institute's Thesis
Evaluation Council at:….. hour ….., day ….. month ….. year …..
Thesis can be found at:
1. National Library.
2. 108 institute of clinic medical science research’s Library.
LIST OF PUBLISHED RESEARCH ARTICLES
RELATED TO THE THESIS
1. Pham Tien Bien, Nguyen Hoang Dieu, Trinh Hong Son (2020),
“Diagnosis of liver trauma in northern mountain hospitals”,
VietNam medical Journal, 3 (2): 13-16.
2. Pham Tien Bien, Nguyen Hoang Dieu, Trinh Hong Son (2020),
“Treatment of liver trauma in northern mountain hospitals”,
VietNam medical Journal 3 (2): 29-32.
1
INTRODUCTION
Liver trauma (LT) is a solid organ trauma that is common in closed abdominal trauma (15-20%). According to statistics, 31% cases (TH) of multiple traumas had closed abdominal trauma, of which 16% were recorded with LT.
Today, with knowledge about anatomy, physiology, traumatic mechanisms, and the development of computerized tomography made a breakthrough in LT diagnosis and treatment.
the advancements in
In terms of treatment, previously surgery was indicated for LT popularly. Nowadays, with resuscitation anesthesia, surgical techniques, the trend of non-operative management for patients with grade I, II and III and stable hemodynamics is increasing and achieving good results. Many recent studies show that about 70-90% of LT is treated with non-operative management and successfullyrate is 85-94%.
The Northern mountainous provinces have underdeveloped economies, difficult life, inadequately developed health systems, inadequate human resources, limited and uneven qualifications, and lack of modern medical equipment, making it difficult to diagnose and treat surgical diseases, including LT.
Trinh Hong Son's study found that the diagnostic protocol and indications for treatment were inconsistent due to the lack of diagnostic equipment, the lack of diagnostic doctors, many surgeons who had no experience in assessing and difiniting lesions that lead to wrong indications, some hemostatic and resectiontechniques of liver rupture are not proficient, increasing the rate of complications. In order to improving the effectiveness of LT diagnosis and treatment in Northern mountainous hospitals, we carry out the project with two objectives: 1. To study about LT diagnosing at Northern mountainous hospitals. 2. To evaluate early results of LT treatment at Northern mountainous hospitals.
NEW CONTRIBUTIONS OF THE THESIS
The study was conducted on 124 patients (BN) diagnosed LT, treated at 11 Northern mountainous hospitals from November 2009 to the end of May 2013.
2
- Regarding diagnosis of LT: 60.5% patients had stable hemodynamics upon admission. 96.8% patients had abdominal ultrasound, 85% found liver lesions, 40.3% patients had computerized tomography. Patients who had computerized tomography had a higher rate of non-operative treatment than the group didn’t have CT (69.4% versus 11.3%). The accuracy of computerized tomography detecting abdominal fluid is 93.33%, detecting liver lesions is 100%
- Regarding treatment results: 50% patients were given non- operative treatment and 50% were given emergency surgery. 74.2% were treated with non-operative management and then 25.8% failed. The reason for changing to surgery in the non-operative management group was mainly due to increased abdominal distention, increased pain level, accounting for 43.75%. During surgery, a grade IV liver rupture was observed (47.43%). Liver suturing accounted for 92.3%. The rate of complications related to surgery is 24.4%. Four patients(3.23%) died during treatment coursewere in the surgical group.
- Evaluation of early results: + Non-operative management group: Good results accounted for 74.2%. + Surgery group: Goodresults(67.9%), averageresults(26.9%) and poorresults(5.2%).
These contributions expose reality and contribute to raising the status quo, thereby improving the efficiency of diagnosis and treatment LT at Northern mountainous hospitals.
STRUCTURE OF THE THESIS
The thesis consists of 133 pages: 2-page introduction, 36-page literature review, 23-page study subjects and research methods, 25-page research results, 43-page discussion, 2-page conclusions, 1-page recommendations. 3 articles, 39 tables, 05 charts, 11 pictures. 158 references.
3
Chapter 1 LITERATURE REVIEW
1.1. Liver surgery 1.1.1. Devices holding the liver’s place 1.1.2 Hepatic artery, ven and biliary tract 1.1.3 Liver division Currently, Ton That Tung's liver lobes division is most used and
convenient in liver surgery, especially liver resection. 1.2. Diagnosis of LT 1.2.1 Clinic
Systemic symptoms: Pay attention to the whole body condition, hemodynamics and signs of blood loss shock, multiple traumatic shock.
Physical symptoms: - Abdominal exam: Abdominal distention, abdominal skin scraping, abdominal wall reaction, abdominal puncture. - Comprehensive examination, avoiding missed coordination
injuries 1.2.2. Subclinic 1.2.2.1. Blood tests Complete blood count, transaminase (GOT, GPT), Bilirubin. 1.2.2.2. Diagnostic imaging
- Ultrasound: is a simple, money and time savingtestthat can be done in a hospital bed. Most Northern mountainous hospitals have been equipped with color or black and white ultrasound machines, so this is a very important imaging test, consistent with the conditions of the hospitals, which helps to make a preliminary assessment as well as orientations for diagnosis, monitoring and treatment of LT. Ultrasound definite abdominal fluid in short time and it is very meaningful in emergency when patients have multiple traumas, unstable hemodynamics, can replace abdominal puncture. Ultrasound can detect direct signs in liver trauma such as: parenchymal contusion, rupture lines, hematoma in the parenchyma, subcortical hematoma or indirect signs: enlarged liver size, blood clots , fluid around the liver, abdominal fluid, helps orient damaged organs.
4
- CT scan: For patients havestable survival signs, abdominal or systemic CT scan is a useful technique to quickly detect all possible lesions in one scan and allow the doctor to evaluateabdominal fluid and gas; lesions of solid organs, gastrointestinal tract, excretion route, timely detection of associated lesions with high sensitivity and accuracy, prognosis and thereby making decisions about non-operative management or surgical treatment in multiple traumapatients.
Images of liver lesions caused by abdominal trauma on CT scan: Abdominal fluid, images of liver trauma (hematoma under the liver capsule, parenchymal tear or rupture, contusion and hematoma in the parenchyma)
Classification of liver rupture according to CLVT: There are many ways to classify liver damage in closed abdominal trauma. Nowadays, the grading system LT of American Association for the Surgery of Trauma (AAST) in 1994 is most applicable. This classification system is based only on anatomical damage of the liver. According to AAST- 1994, LT is classified into 6 degrees, based on the type of liver injury, lesion site, surface area of injury and other related lesions.
- Angiography - Biliary cholangiopathoscopy (ERCP) - Magnetic resonance imaging (MRI)
1.3. Treatment of LT 1.3.1. History 1.3.2. Surgical treatment
Indication: - Patients admitted to the hospital in the state of severe blood loss shock (need to move straight to the operating room) or unstable hemodynamics, not responding to resuscitation fluid, blood.
- Indication of surgery due to associated injuries such as hollow traumatic cases with in some multiple organ perforation or accompanying abdominal trauma. - Indication of non-operative treatment but through monitoring, bleeding or rupture of the liver was not controlled and/or peritonitis. Management of surgical lesions
5
- Temporarily hemostasis: Manually squeezing the liver, Pringle procedure, inserting hemostatic gauze, clamping the aorta or blocking the aorta below the diaphragm. - Complete hemostasis: electro-surgery or hemostatic suture,
selective hepatic artery ligaturing, liver resection. 1.3.3. Non-operative treatment
Most of the authors believe that non-operative treatment can only be used for patients with stable hemodynamics, patients who are hospitalized in a state of shock have a very high rate of emergency surgery. In addition, it is necessary to exclude coordinated lesions in the abdominal cavity requiring emergency surgery, especially perforation lesions, hollow organ rupture. Some other conditions that are needed to decide on monitoring and non-operativetreatment:
+ Having conditions for close and continuous monitoring of clinicic, subclinicic, image diagnosis (ultrasound, CT, emergency angiography). + Facility have capable of surgery at any time, a team of surgeons
have experience in liver surgery, including major liver resection 1.4. Current situation of LT diagnosis capability in northern mountainous hospitals 1.4.1. The basic features of geography, economy and population
The Northern mountainous provinces still face many socio- economic difficulties: they have a large area, quite complex topography, many high mountain ranges, large slopes, limited transportation,far distance from Hanoi capital and remote areas. The main area is the mountainous forests have few advantages in natural resources and trading, people are mainly ethnic minorities, the main economy is agriculture, and the income is still very low. This condition effect on diagnosis and treatment of LT and surgical diseases. 1.4.2. Human resources and LT diagnostic facilities
The lack of human resources as well as equipment systems limit the development of diagnostic techniques: CT scans, magnetic resonance imaging, endoscopic ultrasound, so that some diagnostic diseases are not adequate, especially multiple traumatic cases, closed abdominal trauma has many associated lesions.
6
1.4.3. Situation of LT diagnosis in Northern mountainous provinces Trinh Hong Son's study on 40 LT patients at 12 general hospitals in the northern mountainous provinces: 47.5% of patients are ethnic minorities (H.Mong minority 20%). The main cause of LT is traffic accidents (35%), CT was performed on 9/40 (22.5%) patients, abdominal lavage was performed on 5/40 (12.5%) patients. 1.5. Current situation of LT treatment in Northern mountainous hospitals
Due to the lack of gastrointestinal surgical specialists and image diagnostic equipments. The techniques of measuring liver volume or imaging intervention have not been transferred and applied in the Northern mountainous hospitals, lead to a high rate of LT surgery. Most hospitals have implemented basic techniques such as hemostatic swab inserting, hemostatic suturing, but liver resection in LT surgery is still difficult, not widely applied.
Trinh Hong Son's study had 2.5% of patients were indicated to non-operative treatment, 39 patients (97.5%) were indicated to surgery. Indications for emergency surgery were shock (23.0%), abdominal distention increased (51.3%), peritonitis (7.7%); 7 patients (18%) had stable hemodynamics but the reason for surgery was only due to the detection of liver lesion. There were 7 LT patients (18%) of grade I and II alone and 22 LT patients (56.4%) of grade III ordered surgery. 19 patients (51.4%) had an intra-abdominal blood volume <500ml. Management of liver lesion in surgery: liver rupture suturing is the main procedure (84.4%), liver resection was performed on 4 patients (10.4%). Complications after surgery: bleeding 5.2%, 3 patients had infected surgical incisions (7.7%), 1 patient have abscess under the diaphragm (2.6%) and 1 patient have bile leakage (2.6%); The death rate is 7.7%.
7
Chapter 2 STUDY SUBJECTS AND RESEARCH METHODS
2.1. Study subjects
All patients were diagnosed LT and treated at 11 northern mountainous hospitals (Lai Chau, Dien Bien, Son La, Ha Giang, Cao Bang, Lao Cai, Tuyen Quang, Bac Kan, Lang Son, Bac Giang and Quang Ninh), from November 2009 to May 2013. 2.1.1. Selection criteria
- Patient was diagnosed liver rupture due to abdominal trauma and treated at 11 northern mountainous hospitals. Including patients were treated by surgical or non-operative treatment. - Full medical records, patients agree to participate in the study. 2.1.2. Exclusion criteria
- LT Patients due to abdominal stab wounds or death before hospitalization; Patients with a history of pre-existing hepatobiliary diseases such as liver tumors, cirrhosis, cysts, gallstones; Patients disagree to participate in the study, whose medical records are insufficient information. 2.2. Research Methods 2.2.1. Research design Observational describing retrospective combined prospective studies
Research period: from November 2009 to the end of May 2013. - Retrospective: From November 2009 to the end of November 2011, there were 81 patients - Research progress: From December 2011 to the end of May 2013,
there were 43 patients 2.2.2. Sample size and sample selection: Convenient sample selection 2.2.3. The protocol of diagnosis and treatment of liver trauma in research: according to the State-level Science and Technology project have code ĐTĐL.2009G/49.
8
2.2.3.1. Diagnostic protocol:
(1) Clinical diagnosis and identified diagnosis of LT (2) Determinated Diagnosis of LT level (3) Diagnosis of combined lesions (4) Diagnosis of treatment capacity. 2.2.3.2. Original resuscitation 2.2.3.3. Non-operative treatment
Indication + Merely LT grade I, II, III (a small number of liver trauma grade IV, V) according to CT, have stable hemodynamics. For patients who do not have CT scan, the indication of follow-up and non-operative treatment depends on the doctor's judgment, the hospital's monitoring and resuscitation conditions.
+ Hemodynamic stability returned after resuscitation: rapid response to initial resuscitation or temporary response to initial resuscitation but hemodynamics remains stable after compensation of fluid and the blood needs to be estimated but not more than 4 units of blood in the first 24 hours. + No detected organ damage in the abdominal cavity undergoing surgery (especially hollow organs).
+ Hematological indexes are stable or change within permitted limits. + Soft belly, no reaction. + Having adequate medical diagnostic facilities (ultrasound, CT scan) good monitor andresusciationconditions, a contingent of digestive surgeons and operating rooms at any times if non-operative treatment fails and require emergency surgery.
Non-operative treatment follow-up procedure - Patient is asked to rest in bed, closely monitored in the first 24 hours: + Hemodynamic status: pulse, blood pressure. + Abdominal condition,combined injuries. + Ultrasound and complete blood count tests may be repeated several times to monitor the progression of the lesion. - Compensation of fluid, blood, depending on the patient's condition and prophylactic antibiotics.
9
Monitoring and evaluating the results of non-operative treatment
- Success: patients do not suffer from surgery (the time from admission to discharging to the hospital), complications are treated with less invasive intervention.
- Failure: Patients are indicated non-operative treatment but then have to undergo surgery due to the following reasons: Continued bleeding, peritonitis due to hollow organ or combination organs lesions (pancreas, kidney , spleen). 2.2.3.4. Surgical treatment
Indication + Blood loss shock, no response or temporary response to initial resuscitation, after that hemodynamics is still unstable, even though after compensation of fluid and the blood needs.
+ Abdominal bloating, increased abdominal pain level and fluid. + There is a compromised lesion that needs intervention (hollow organs).
+ Hepatic liver damage spreads to the porta hepatis on CT scan. + Non-operative treatment failure: Hepatic rupture, continuous lesions requiring surgical bleeding, detection of hollow organ intervention
Surgical methods of LT treatment: Burning electrolyte, liver suturing, inserting hemostatic gauze, resection liver. If the surgery shows that the liver damage has stopped bleeding: Clean the abdomen, carefully examine other organs to avoid missing lesions, put backup drains. Dealing with combined injuries
2.2.4. Research indicators 2.2.4.1. General characteristics: Age, gender 2.2.4.2. Diagnosis of LT
Clinical manifestations: trauma causes, hemodynamic status at admission, perception, skin, mucosa, physical examination, abdominal puncture.
Subclinic: - Blood tests: Hematology, biochemistry (GOT, GPT).
10
- Abdominal ultrasound: Determine liver damage, abdominal fluid. - Abdominal CT scan: Determine liver damage, abdominal fluid. - Accuracy of ultrasound, CT compared to surgery. - Diagnosis of combined lesions. 2.2.4.2. Results of treatment - Treatment indications: First-aid surgery, non-operative treatment
(success/ failure to undergo surgery). - Reason for emergency surgery. Results of surgery: surgical incision, grading of liver rupture, degree of blood loss, methods to resolve lesions.
General results: Death, early complications, hospital stay time. - Evaluate results soon Non-operative treatment group (According to author Nguyen Ngoc Hung): + Good: Patients who received successfully non-operative treatment, there were no complications during monitoring and treatment. + Moderate: complications Patients have
duringnon- operativetreatment but have stable medical treatment or less invasive intervention, not undergo surgery. + Poor: Patients have failed non-operativetreatment then undergo surgery to management of liver and organs damage due to complications.
Surgical group (According to author Nguyen Hai Nam): + Good: Patients who have surgery and treatment of liver damage, postoperatively favorably without complications, discharged from hospital to good rehabilitate; Patients who received surgical treatment with mild complications were successfully treated by internal medicine without having to re-operate. + Moderate: Patients have complications who have surgery or stable procedure intervention. Restore normal function. + Poor: Deaths during or after the surgery,having serious
complications during or aftersurgery and/or poor clinical status. 2.2.5. Data collection and analyzing 2.2.6. Research ethics
11
Chapter 3 RESEARCH RESULTS 3.1. General features Average age: 25.74 ± 11.36 years (2 - 62). Male accounts for
78.2% 3.2. Diagnosis of LT 3.2.1. Clinical features 3.2.1.1. Reason - Causes of traumas due to traffic accidents account for the majority 61.3%. - 69.35% patients were admitted to the hospital before 6 hours. 3.2.1.2. Body signs
Hemodynamic condition
Table 3.4. Hemodynamic condition when hospitalized Percentage % 60,5 32,2 7,3 Stability Unstablity Unstablity, then Stability Number of patients 75 40 9
Comments: The hemodynamic condition of patients when hospitalized is mostly stable, accounting for 60.5%. There were 9 patients (7.3%) have unstable hemodynamics. 3.2.1.3. Clinical symptoms - The majority of patients (54.03%) were hospitalized in the condition of skin, mucosa pale - The majority of patients showed signs of bruising, abdominal skin rubbing (80.65%) and abdominal distention (83.87%).
- 98 patients (79.03%) did not have abdominal puncture. - 26 patients (20.97%) hadabdominal puncture and 18.55% had blood clotting, most of them were in emergency surgery group (17.74%). 3.2.2. Subclinic features 3.2.2.1. Complete blood count test: Most patients have normal test, accounting for 50%. 12 patients (9.78%) had severe anemia. 3.2.2.2. Liver enzyme test
The average liver enzymes of all patients with LT were high. Group IV liver trauma had average liver enzymes higher than other groups.
12
3.2.2.3. Abdominal ultrasound - 120 patients had abdominal ultrasound on admission, accounting for 96.8%.
- 94.2% patients were reported having abdominal fluid through ultrasound. The high volume abdominal fluid accounted for 39.2%. Ultrasound detected almost patients have traumatic liver damage, accounting for 57.5%. Ultrasound detected general liver damage with an accuracy of 76.0%. 3.2.2.4. Abdominal CT scan
CT Scan p
< 0,05 Non- Operative group (n = 62) 19(30,6%) 43(69,4%)
Table 3.14. Patient was given a CT scan on admission Emergency surgery group (n = 62) 55(88,7%) No Number of patients (%) Yes Number of patients (%) 7(11,3%) Comments: 50/124 patients (40.3%) had abdominal CT scan on admission. The patients who had CT scan had higher rate of non- operative treatment than the group not taken (69.4% compared to 11.3%) (p <0.05) - 80.0% of CT scan detected abdominal fluid. - 100% patients recorded liver damage through abdominal CT. The majority of them were hepatic parenchyma contusion (46.0%). The accuracy of CT scan when detecting abdominal fluid was 93.33%.In general CT scan detected liver damage with 100% accuracy. Table 3.18. Classification of liver rupture by CT scan according to AAST 1994 Non-operative group
Liver rupture by CT scan Total (n = 50) Success Emergency surgery group
Failed then Emergency surgery 2(4,0%) Grade II n (%) 16(32,0%) 1(2,0%) 19(36,0%)
n (%) 18(36,0%) 4(8,0%) 3(6,0%) 25(50,0%)
n (%) 1(2,0%) 2(4,0%) 3(6,0%) 6(12,0%)
n (%) 35 (70,0%) 8 (16,0%) 7 (14,0%) 50(100%) Grade III Grade IV Total
13
Comments: There were 25 cases (50.0%) with level III liver trauma, 19 with grade II liver trauma (36.0%). Most of patients have liver trauma grade II, III on CT scan are successfully non-operative treatment. 3.3. Results of treatment 3.3.1. Indications for initial treatment - 62 patients (50%) were assigned to non-operative treatment and
25.8%
Success
%
Failed then emergency surgery
74.2
62 patients (50%) were treated by emergency surgery immediately. - Indication initial emergency surgery due to patients have shock, hypotension accounted for 59.7%. 8 patients (12.9%) were operated due to coordinated organ damage. 3.3.2. Non-operative treatment results
Figure 3.5. Non-operative treatment results Comments: 46/62 patients (74.2%) were successfullynon-operative treatment. 25.8% of non-operative treatment failed then patients were had emergency surgery. Table 3.22. The reason for failure of non-operative treatment then patients were had emergency surgery
Số BN (n = 16) 5 7 3 Tỷ lệ % 31,25 43,75 18,75
1 6,25 The reason for failure of non-operative treatment Shock, hypotension Increased abdominal distention, pain Coordinated organ damage need surgery Abdominal puncture have non-coagulation blood
Comments: The reason for the emergency surgery in the failure of non-operative treatment group was mainly due to increased abdominal distension and pain (43.75%).
14
Table 3.24. Association between CT scan and non-operative treatment outcome
Non-operative treatment outcome Total CT scan Success
Failed then Emergency surgery 8 (42,1%) 8 (19,6%) Số BN Tỷ lệ % Số BN Tỷ lệ % No (n = 19) Yes (n = 43) P 19 (100%) 43 (100%)
11 (57,9%) 35 (81,4%) < 0,01 Comment: The successfullyrate of non-operative treatment in the group of patients who had CT scan (81.4%) is higher than the group of patients who did not have CT scan (57.9%) (p <0.01). 3.3.3. Results in surgery
Because 62 patients were indicated initial emergency surgery and 16 patients were failed with non-operative treatment then undergo emergency surgery, so we counted 78 emergency surgery patients to evaluate the surgery results. - 66 patients (84.6%) used incision above and below the umbilicus. 2 patients (2.6%) had laparoscopic surgery. Table 3.26. Classification of liver rupture during surgery
Emergency surgery group Total (n = 78) Classification of liver rupture during surgery
Grade II n (%) 5 (6.41%) Failed then Emergency surgery 4 (5.13%) 9 (11.54%)
Grade III n (%) 21 (26.92%) 5 (6.41%) 26 (33.33%)
Grade IV n (%) 31 (39.74%) 6 (7.69%) 37 (47.43%)
Grade V n (%) 5 (6.41%) 1 (1.28%) 6 (7.69%)
Comment: During surgery process, there were 37 patients with grade IV liver trauma accounted for the majority (37.43%). There were 6 patients with grade V liver trauma, accounting for 7.69%. - Almost patients had 500-1000 ml blood loss during surgery,
accounting for 39.7%. 19 patients (24.4%) had blood loss> 2000 ml.
15
Table 3.28. Methods of handling liver damage
Tỷ lệ % Treatment liver damage
Liver damage hemostasis Electrocoagulation hemostasis Liver suturing Liver suturing with pads Liver resection Gauze insert Number of patients(n = 78) 6 3 72 1 8 16
7,7 3,8 92,3 1,3 10,3 20,5
Comments: The mainly management of lesions was liver sutiring,
accounting for 92.3%. 3.3.4. General results 3.3.4.1. Mortality There were 4 patients died during treatment (3.23%), they were all
in the surgical group 3.3.4.2. Complications In the successfullynon-operative treatment group, there was no patients have complication during monitoring and treatment.
The rate of complications related to LT surgery was 24.4%, of which the majority was surgical site infections with 9 patients (11.5%). 3.3.4.3. Time in hospital The hospitalization period of the successfullynon-operative group
(7.39 ± 2.71) was shorter than the emergency surgery group (12.44 ± 8.13) and the non-operative treatment group failed to undergo emergency surgery (16.0 ± 11,92). The difference was statistically significant with p <0.01. 3.3.4.4. early results Table 3.32. Evaluatingthe results of non-operative treatment
Percentage % Evaluating the results of non- operative treatment
Number of patient (n = 62) 46 0 16 74,2 0 25,8 Good Medium Poor
Comments:Almostnon-operative treatment group achieved good results, accounting for 74.2%. There were 16 patients (25.8%) who had poor results due to non-operative treatment failed to transfer surgery.
16
Table 3.33. Evaluating the results of surgical treatment
Percentage % Evaluating the results of surgical treatment
Number of patient (n = 78) 53 Good 67,9
21 4 Medium Poor 26,9 5,2
Comment: The surgical treatment group: 67.9% of patients achieved good results, 21 patients (26.9%) average and 4 patients (5.2%) had poor results.
Chapter 4 DISCUSSION 4.1. General features
The average age of patients was 25.74 ± 11.36 years old. Male patients accounted for 78.2%. Many other studies also showed that the age of LT patients ranged from 20 to 30 years, of which male patients were predominate. 4.2. Diagnosis of LT 4.2.1. Clinic 4.2.1.1. Cause of trauma
The study finds that the cause of LT is mainly due to traffic accidents (61.3%), followed by domestic accidents (25.8%) and the lowest is occupational accidents (12.9%). This rate is equivalent to the study of other authors. Almost patients (69.35%) were hospitalized to the hospital before 6 hours after accident. 30 patients (24.19%) were successfullynon-operative treatment and 50 patients (40.32%) had emergency surgery. 30 patients (24.19%) were hospitalized between 6 and 24 hours after accident. We found that, for patients were hospitalized to the hospital before 6 hours after accident, the rate of successfullynon-operative treatment is higher than patients in the latecomer group, on the other hand, patients who have early LT operation will reduce the rate of complications and death. 4.2.1.2. Whole body signs
Almost patients were hospitalized had stable hemodynamic condition, accounting for 60.5%, with 40 patients (32.2%) had unstable
17
hemodynamics and 9 patients (7.3%) had unstable hemodynamic on admission, but after being resuscitated, rehydration, hemodynamics returned to normal. 4.2.1.3. Clinical symptoms
Systemic symptoms: The study had 91.13% patients hospitalized in the conscious condition, in which 45 patients (36.29%) were successfully non-operative treatment. 7 patients (5.65%) were coma and 2 patients (1.61%) were indicated emergency surgery. We found that, for those patients who are hospitalized in a state of stimulation, drowsiness or coma are important signs of circulatory hypovolemic shock or multiple trauma shock, so it is necessary to quickly assess the condition, If there is an abdominal bleeding (ultrasound, CT scan, abdominal puncture), emergency surgery should be performed immediately.
Physical symptoms: abdominal distention is commonly (83.87%) and rubbed the abdominal wall in right lower quadrant (80.65%). In addition, the study had 7 patients (5.65%) with abdominal wall spasticity. This is a very important sign to help diagnose hollow organ damage, requiring emergency surgery, although liver damage can be conserved. 4.2.2. Subclinic 4.2.2.1. Complete blood count
All of our patients were tested for complete blood counts on admission, whereby the majority of patients had normal tests, accounting for 50%. 21 patients (16.94%) had moderate anemia and 9.78% patients had severe anemia. The results is similar to Nguyen Ngoc Hung. 4.2.2.2. Liver enzyme test
Our study also found that the level of elevated liver enzymes is directly proportional to the degree of liver damage. According to Table 3.11, comparing with the degree of liver trauma showed the average increase in liver enzymes (AST and ALT) in patients with liver trauma in grade II were 362.7 ± 282.9 and 268.2 ± 180.3; in patients had LT level III, the average increase in liver enzymes were 425.9 ± 312.0 and 382.6 ± 245.0; in patients had LT level IV increase in liver enzymes was 654.0 ± 499.4 and 401.8 ± 225.4. However, in LT level V patients had an increase in liver enzymes of 486.9 ± 350.8 and 352.8 ± 215.1 lower than the IV level, possibly because our patient was hospitalized at
18
different times after accident and sample size of group grade V trauma is small and not enough for a comprehensive assessment. 4.2.2.3. Abdominal ultrasound
The study included 120 patients (96.8%) who had abdominal ultrasound on admission. Because the Northern mountainous hospitals have many difficulties in economic conditions as well as modern equipment in LT diagnosis and treatment. Therefore, ultrasound is a very important imaging test, applied regularly, in accordance with the conditions of the hospitals, allowing a quick preliminary assessment, as well as the orientation of LT diagnosis, monitoring and treatment. In addition, 4 patients (3.2%) did not perform ultrasound due to patients being hospitalized in the state of multiple trauma shock, closed abdominal trauma, distended abdomen, high pain level, puncture the abdomen have non-coagulation blood .
94.2% patients recorded abdominal fluid through ultrasound. In which the high volume of fluid accounted for 39.2%, 7 patients (5.8%) did not have abdominal fluid. We recorded ultrasound detecting liver damage at 96/120 patients (80%), most of which were hepatic parenchyma (57.5%), liver rupture line (16.67%), hematoma under the liver capsule only 5.83%. Our liver damage detection rate is lower than liver damage detection rate of Nguyen Ngoc Hung 95.5% and Nguyen Quang Duy by 83.62%. 4.2.2.4. Abdominal CT scan
According to the results of Table 3.14, the study had 50 patients (40.3%) had abdominal CT on admission. The patients who had abdominal CT scan had a higher rate of non-operative treatment than the group not taken (69.4% compared to 11.3%), while in the emergency surgery group, there were 88.7% patients did not have CT. From this, we can see the very important role of CT scan in the comprehensive assessment of the level of liver and other organ damage in the closed abdominal trauma, so that we can choose the appropriate treatment method for each patient's condition.
80.0% patients were reported having abdominal fluid through CT scan. In which, the low volume accounted for 42.0%. Almost patients did not have abdominal fluid, the patients had low or medium volume of fluid were successfully non-operative treatment.
100% (50) patients were recorded liver damage through abdominal CT scan. In which 46.0% is hepatic parenchyma. In addition, signs of
19
hepatic rupture were found in CT images in 18 patients (36.0%), of which 9 patients were successfully non-operative treatment, 5 patients had emergency surgery and 4 patients had failure non-operative treatment then underwent emergency surgery. The accuracy of CT when detecting rupture liver lines is 69.23%.
The accuracy of CT compared to surgery when detecting abdominal fluid is 93.33%. In general, CT detected liver damage with an accuracy of 100.0%. However, the accuracy of CT in detecting liver contusion and rupture lines were 40.0% and 69.23%, respectively. This ratio is lower than most of authors, this is explained by the majority of CT cameras in general hospitals in the Northern mountainous region are the old generation, besides, The lack of human resources as well as the experience of doctors who read CT films also lead to many erroneous results.
Classification of liver rupture through CT scan according to AAST 1994: There were 25 patients (50.0%) had grade III liver trauma and 19 patients had grade II liver trauma (36.0%). Almost patient had grade II and III liver trauma on CT were successfully non-operative treatment, in addition, 5/6 patients had grade IV liver trauma had surgical intervention. 4.3. Results of treatment 4.3.1. Indications for initial treatment
The study had 62 patients (50.0%) indicated for emergency surgery, of which the main cause was shock, hypotension accounted for 59.7%, 8 patients (12.9%) were operated due to coordinated organ damage and 1 patients was performed surgery due to abdominal puncture have non-coagulation blood.
We have the same opinion as Trinh Hong Son, due to the lack of human resources as well as equipment for resuscitation and monitoring, many surgeons have no experience in monitoring LT non-operative treatment, along with fear of missing lesions due to many limitations of imaging diagnosis, leading to higher surgery rates than most other studies in Vietnam as well as in the world. 4.3.2. Results of non-operative treatment
In terms of treatment, previously surgery was usually indicated for LT. Today, advances in resuscitation anatomy, surgical techniques and the use of intravascular interventions have reduced the mortality rate of LT. The trend of non-operative treatment for patients have grade I, II
20
and III LT with stable hemodynamics is increasing and achieving good results. Many recent studies show that about 70-90% of LT is treated by non-operative method with successfully rate of 85-94%.
In our study, 62 patients (50%) were indicated to non-operative treatment, of which 46 patients were successfully non-operative treatment (74.2%) and 16 patients had failure non-operative treatment then underwent surgery (25.8%). Compared to other studies, our non- operative treatment rate is still low. This may be due to the basic characteristics, imaging diagnostic and resuscitation equipment in the Northern mountainous hospitals are still limited, unable to perform complex procedures such as transcatheter arterial embolization. The protocol of monitoring non-operative treatment at the Northern mountainous hospitals is mainly the initial resuscitation, rehydration, guide patients lying down in bed and closely monitoring the clinical and subclinical developments of patients .
Failed non-operative treatment then transfer to surgery Non-operative treatment is considered to be a failure when surgery is needed to examine the abdomen due to hemodynamic instability, decreased hemoglobin levels, clinical signs of peritonitis, and other organ injuries. In the study, 16/62 patients (25.8%) of non-operative treatment group failed to undergo surgery. The cause of surgery was mainly due to increased abdominal distension, pain level, accounting for 43.75%. There was 1 patient had abdominal puncture found non- coagulation blood (6.25%). Especially, we had 3 patients (18.75%) were found the combined other organ lesions in the monitoring process (2 cases jejunum rupture and 1 pancreatic rupture) required emergency surgery. In these 3 patients, 2 patients had stable hemodynamics then were performed CT scan, then 1 patient was detected pancreatic rupture, 1 patient was detected free gas in the abdomen due to hollow organ rupture, so on the following day we indicated surgery for this patient; The remaining patient only had ultrasound. On the third day of monitoring process we indicated surgery for this patient due to peritonitis, during surgery process abdomen had non-coagulation blood and gastrointestinal fluid due to rupture of the jejunum, beside liver damage had stopped bleeding.
Through this, we also recognize the very important role of Ct scan in diagnosing and monitoring non-operative treatment. The study results showed that the rate of successfully non-operative treatment in patients
21
had CT scan group (81.4%) is higher than the group of patients who did not have CT scan (57.9%). The failure rate of non-operative treatment due to closed abdominal trauma according to studies from 11-15%. Ajai k.Malhotra used non-operative treatment for 560 LT patients, failure rate 7.5%
Our failure rate of non-operative treatment is higher than almost other studies because ur doctors have no experience in LTs monitoring and resuscitation, many patients are afraid of missing lesions so when this patients have changing hemodynamics or abdominal puncture had non-coagulating blood, the doctor orders surgery. 4.3.3. Results in surgery 4.3.2.1. Incision
According to the results of Table 3.25, in most of the cases we used the upper and lower navel incision, accounting for 84.6%, 1 patient had to be combined thoracotomy (1.3%) and 2 patients were diagnosed with laparoscopy. 4.3.2.2. Classification of liver trauma during surgery
In surgery, the grade IV trauma was the majority with 37 patients (47.43%), grade III accounted for 33.33%, grade II 11.54% and 7.69% grade V trauma. Trinh Hong Son's study met LT grade I, II: 41%, III: 37%, IV: 0%,
V: 22%. …… 4.3.2.3. The volume of blood in the abdominal cavity
In the study, almost patients who were indicated to surgery, had blood loss during surgery from 500-1000 ml, accounting for 39.7%. 19 patients (24.4%) had blood loss > 2000 ml. 4.3.2.4. Methods of handling liver damage
According to Table 3.28, injury management is predominantly liver suturing, accounting for 92.3%. Other combinated methods include hemostatic swabs (20.5%), electrocautery (3.8%), padded sutures (1.3%), liver resection (10.3%). In addition, 6 cases (7.7%) had abdominal surgery in which the liver injury of grade I and II had stopped bleeding. General results 4.3.3.1. Mortality
The study had 4 patients died (3.23%), were in the emergency surgery group. All of these patients are quite young, hospitalized in shock, closed abdominal trauma with many solid organs trauma (liver,
22
spleen, kidney), ultrasound found high volume of blood fluid in the abdomen (blood volume 2500 - 4000 ml). According to our opinion, the cause of death may be due to doctors didtn’t have enough experience when receiving patients initially, facilities lacking in-bed ultrasound machines, lack of surgeons, many cases have to invite the surgeon came from a long distance, leading to the patients were delayed surgery (after 2 hours admitted to hospital). 4.3.3.2. Complications
The overall complication rate in Antonio Brillantino's LT non- operative the treatment study was 7.4% (13/175 patients). In successfully non-operative treatment group, we did not have any cases with complications. This result is probably due to the fact that most of our non-operative treatment clinics are admitted to the hospital with mild LT grade I - II (contusion, hematoma under the liver) and do not have many coordinated lesions.
The rate of complications related to LT surgery in our study was 24.4%, of which the majority was surgical site infections in 9 patients (11.5%). There were 5 patients (6.5%) have non-LT complications including 1 pneumonia (1.3%), 1 pleural effusion (1.3%), 1 respiratory failure (1.3%) , 1 acute renal failure (1.3%) and 1 necrotizing perineal wound (1.3%). 4.3.3.3. Time in hospital
The study found that the duration of hospitalization for the non- operative group (7.39 ± 2.71) was shorter than for the emergency surgery group (12.44 ± 8.13) and the non-operative treatment group failed to undergo surgery (16 ,0 ± 11,92). The difference was statistically significant with p <0.01. 4.3.3.4. Evaluating early results
According to Table 3.32, the non-operative treatment group achieved good results, accounting for 74.2%. There were 16 patients (25.8%) who had poor results due to failure of non-operative treatment and then had to undergo surgery. The authors all agree that non- operative treatment for LT is a safe and effective treatment for both mild and severe trauma, achieving a high success rate with an acceptable rate of complications.
In surgical treatment group, the study had 67.9% patients achieved good results, 26.9% medium and 5.2% poor (4 patients died). Our results are similar to Nguyen Van Son.
23
CONCLUSION 1. Diagnosis of LT in the Northern Mountainous Hospitals
The average age is 25.74 ± 11.36. Men account for 78.2%. The cause of traffic accidents accounted for 61.3%. 69.35% patients were admitted to the hospital before 6 hours after the accident.
60.5% patients had stable hemodynamics when hospitalized. 91.13% patients were hospitalized in the conscious state. Common physical symptoms are bruising, abdominal wall rubbing (80.65%) and abdominal distention (83.87%).
120 patients (96.8%) had abdominal ultrasound, 85% found liver damage. The accuracy of ultrasound when detecting abdominal fluid is 98.67%.
There were 50/124 patients (40.3%) had computed tomography on admission. Patients with computerized tomography had a higher rate of non-operative treatment than the group did not have the CT scan (69.4% versus 11.3%). The difference was statistically significant with p <0.05.
The accuracy of computerized tomography to detect abdominal fluid was 93.33%, general liver injury was 100.0%, liver contusion and broken lines were 40.0% and 69.23% respectively. 2. Treatment results at the Northern Mountainous Hospitals
Indications for primary treatment: 62 patients (50%) were given non-operative treatment and 62 patients (50%) had emergency surgery immediately.
Indications for emergency surgery were mainly due to patients with shock, hypotension accounted for 59.7%. 8 patients (12.9%) were performed operations due to coordinated organ damage requiring intervention.
Non-operative treatment results 46/62 patients (74.2%) were successfully non-operative treatment. 25.8% of non-operative treatment failed to undergo surgery.
The reason for undergoing surgery in the non-operative treatment group was mainly due to increased abdominal distension, pain level, accounting for 43.75%. There was 1 patient had pectoral puncture found non-coagulation blood (6.25%).
The majority of patients with stable hemodynamics were successfully non-operative treatment, accounting for 83.7%. Among
24
patients with unstable hemodynamics, the rate of non-operative treatment failure was 100% (p <0.05). The rate of successfully non- operative treatment in the group of patients who had CT scan (81.4%) is higher than the group of patients who did not have CT scan (57.9%).
Results in surgery 84.6% patients had above and below the navel incisions. During surgery, a grade IV liver trauma was observed 47.43%. Suturing liver accounted for 92.3%. Other combinations include hemostatic swabs (20.5%).
Early results The rate of complications related to LT surgery was 24.4%, of which the majority were surgical site infections in 9 patients (11.5%). 4 patients who died during treatment (3.23%) were all in the surgical group. The hospitalization period of the successfully non-operative group was 7.39 ± 2.71 days, the emergency surgery group 12.44 ± 8.13 days.
Evaluating early results Almost patients in non-operative treatment group achieved good results, accounting for 74.2%. There were 16 patients (25.8%) who had poor results due to failure of non-operative treatment that had to undergo surgery. Surgery group: Good 67.9%, average 26.9% and poor 5.2%
RECOMMENDATION
Diagnosis and treatment of liver trauma is a complex issue, requiring the coordination of many specialties such as imaging diagnosis doctors, emergency resuscitation doctors and doctors have experience in gastrointestinal surgery in general and hepatobiliary surgery in particular. In order to improve the quality of treatment of liver trauma at the general provincial hospitals with similar facilities, equipment and human resources like the mountainous provinces and the northern border, it is necessary to: - Continue to apply the protocol of diagnosis and treatment of liver trauma under the State-level project code: DTĐ.2.2009G / 49.
- Enhance training and practicing of human resources such as: diagnostic imaging doctors, gastroenterologists and hepatobiliary surgeons. Enhancing imaging diagnostic equipment such as multi-array CT scan machine, replacing old and broken equipment.
