Franklin Glen A, Richardson J David, Brown Aaron L, Christmas A Britton, Miller Frank B, Harbrecht Brian G, Carrillo Eddy H
Department of Surgery, University of Louisville, Louisville, Kentucky 40292, USA.
Am Surg. 2007 Jun;73(6):611-6; discussion 616-7.
One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2-18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic inflammatory response syndrome, respiratory compromise, or elevated bilirubin. The bile and retained hematoma was evacuated from around the liver and closed-suction drainage was placed. Twenty-eight patients underwent laparoscopic evacuation/lavage of bile collections (about 4% of total blunt liver injuries). The majority (75%) had Grade IV or V injury. The amount of evacuated fluid ranged from 300 to 3800 mL. Other adjunctive procedures (endoscopic retrograde pancreaticocholangiography, angiography, and laparotomy) were occasionally required. There were no complications related to the procedure. Most patients had a dramatic decline in tachycardia, temperature, white blood cell count, serum bilirubin, and pain. Respiratory failure also resolved in most patients. Large bile and/or blood accumulations are present in a subset of patients with severe liver injuries treated nonoperatively. Delayed laparoscopic evacuation of these collections prevents bile peritonitis and decreases inflammatory response and avoiding early operation, which has been implicated in increased death from hemorrhage.
二战期间肝脏损伤治疗中得到的一个主要经验教训是，胆汁性腹膜炎是导致发病和死亡的主要因素；在随后的手术时代，对肝脏损伤几乎一律进行引流，从而避免了这个问题。在非手术治疗时代，因血流动力学不稳定而无需手术治疗的患者可能会出现大量胆汁和/或血液积聚，而这些情况往往被忽视，或者经皮引流方法引流不充分。这些治疗不充分的胆汁积聚可能会导致全身炎症反应综合征和/或呼吸窘迫。我们介绍了腹腔镜清除大量胆汁/血液积聚的经验，这可能预防胆汁性腹膜炎的炎症后遗症。如果CT显示整个腹部/盆腔有大量不适合经皮引流的液体聚集，患者通常在受伤后3至5天（范围为2至18天）接受手术。大多数患者有全身炎症反应综合征、呼吸功能不全或胆红素升高的体征。从肝脏周围清除胆汁和残留血肿，并放置闭式吸引引流。28例患者接受了腹腔镜清除/冲洗胆汁积聚（约占钝性肝损伤总数的4%）。大多数（75%）为IV级或V级损伤。清除的液体量在300至3800毫升之间。偶尔需要其他辅助程序（内镜逆行胰胆管造影、血管造影和剖腹手术）。没有与该手术相关的并发症。大多数患者的心动过速、体温、白细胞计数、血清胆红素和疼痛都有显著下降。大多数患者的呼吸衰竭也得到缓解。在非手术治疗的严重肝损伤患者中，有一部分存在大量胆汁和/或血液积聚。对这些积聚进行延迟腹腔镜清除可预防胆汁性腹膜炎，减少炎症反应，并避免早期手术，而早期手术被认为会增加出血导致的死亡。
