Surgical management of hepatic complications HELLP ד"ר ערן שדות יחידת ניתוחי כבד לבלב ודרכי מרה מרכז רפואי רבין, קמפוס בלינסון
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1 Surgical management of hepatic complications HELLP ד"ר ערן שדות יחידת ניתוחי כבד לבלב ודרכי מרה מרכז רפואי רבין, קמפוס בלינסון
2 Outline Introduction HELPP and surgical liver complications 5 slides Real-life test for surgery residents 2 slides Surgical management of liver complications Liver surgery in the 21 st century
3 HELLP: Hemolysis Elevated Liver enzymes Low Platelet count Incidence: 0.1%-1% of pregnancies 15% of women with severe preeclampsia/eclampsia. Pathogenesis: unclear Typically develops at the 3 rd trimester (in 30% presents postpartum)
4 PATIENT PRESENTATION:
5 HELLP diagnosis (Tennessee classification): Microangiopathic hemolytic anemia with characteristic schistocytes (helmet cells). Platelet count 100,000 cells/microl Total bilirubin 1.2 mg/dl (20.52 micromol/l) Serum AST >2 times upper limit.. Differential diagnosis: acute fatty liver of pregnancy (AFLP), gastroenteritis, hepatitis, appendicitis, gallbladder disease, immune thrombocytopenia (ITP), lupus flare, antiphospholipid syndrome, hemolytic-uremic syndrome (HUS), or thrombotic thrombocytopenic purpura (TTP), and nonalcoholic fatty liver disease Sibai BM et al. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol
6 Management of HELLP Initial steps: stabilize the mother assess the fetal condition decide whether prompt delivery is indicated Indications for delivery: Pregnancies 34 weeks of gestation or <23 weeks gestation Fetal demise Nonreassuring tests of fetal status (eg, biophysical profile, fetal heart rate testing) Severe maternal disease: multiorgan dysfunction, disseminated intravascular coagulation (DIC), liver infarction or hemorrhage, pulmonary edema, renal failure, or abruptio placenta
7 Types: Intraparenchymal hemorrhage Hepatic infarction Subcapsular hematoma or rupture Hepatic complications Signs and symptoms: severe RUQ pain, shoulder pain, neck pain, and/or hypotension
8 d Liver infarction subcapsular hematoma HELPP syndrome on CT scan Large subcapsular hematoma compressing the liver Large perfusion defects involving the R lobe and part of the L lobe
9 Liver infarction HELLP syndrome on CT scan Perfusion defects Subcapsular hematoma
10 a Small hematoma Subbcapsular hematoma on MR Hematoma with thrombus
11 a Liver hematoma with rupture Hematoma running from the dome along the right side, pushing the normal liver to the midline
12
13 Anterior Posterior
14 Anterior Posterior
15 Should we operate?
16 Similarities: Gunshot injury vs HELLP
17 Penetrating liver trauma
18 Penetrating liver trauma
19 Contained hematoma: volume replacement. If hematoma remains stable d/c home with outpatient follow-up. It may take months for the hematoma to resolve completely. Barton JR et al. Hepatic imaging in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). Am J Obstet Gynecol
20 Hepatic rupture: Percutaneous embolization: 1 st line if hemodynamically stable. Downside: available in referral centers, nonselective embo results in necrosis->sepsis Indications for surgical intervention: Hemodynamic instability Persistent bleeding Increasing pain Continued expansion of the hematoma. A team experienced in liver trauma surgery should be consulted. Operative management: Packing, drainage Hepatic artery ligation, and/or resection of affected areas of the liver. Grand'Maison S et al. Hepatic rupture in hemolysis, elevated liver enzymes, low platelets syndrome. Obstet Gynecol
21 Rare Management of hepatic infarction Presentation: ALT&AST 1000 to 2000IU/L, RUQ pain, fever. Diagnosis: MRI or CT. Management: Supportive care Percutaneous drainage Hepatic resection
22 Algorithm for the operative management of hepatic injuries Kozar RA, et al. Operative management of adult blunt hepatic trauma. J Trauma 71:1 5, 2011
23 Liver Injury Scale
24 Hemodynamic instability + free fluid surgery Even in the setting of high-grade injuries, nonoperative management can be attempted as long as the patient remains hemodynamically stable: no tachycardia, hypotension, metabolic acidosis, or physical examination evidence of shock No ongoing fluid recusitation
25 Complications of nonoperative management: Hepatic necrosis Bile leak with biloma formation, hemobilia, and development of liver abscess Management: CT percutaneous drainage ERCP + stent (decreases bile leak) Angioembolization (hemobilia)
26 Operative management: Midline incision vs MIS Falciform lig is mobilized perihepatic packing + compression resuscitate remove packing and re-evaluate need for further hemostasis: Further compression (low pressure system) Topical hemostatic agent Suture hepatorrhaphy Most liver injuries will require only superficial techniques for hemostasis to be obtained!
27 More severe bleeding: Pringle maneouver upto minutes (in the Trauma setting) Direct suture ligation of bleeding vessels Retrohepatic vena cava bleed: Packing An atriocaval (Shrock) shunt Diffuse liver bleeding due to coagulopathy (2/2 HELLP, severe shock) ICU
28 Extreme cases of severe bleeding: Hemorrhage, hypothermia, coagulopath) damage control approach (packing only) Anatomic liver resection indications: Total destruction of a segment/lobe Failure of prior measures Selective hepatic artery ligation (preferably intrahepatic ligation) Total vascular isolation with occlusion of: Infrahepatic IVC + suprahepatic IVC + Pringle M.
29 Introduced in the 1940s... Gelfoam Derived from purified pork skin gelatin.
30 Surgicel Acts as a physical matrix to which platelets can adhere which, in turn, aids in clot formation
31 EVICEL Fibrin Sealant (Human) Thicker matrix designed to stay where placed even during active bleeding
32 SURGICEL Fibrillar
33 Microfibrillar collagen(avitene) Collagen which is derived from bovine skin. binds tightly to blood surfaces (activates platelets)
34 HemCon Bandage PRO fabricated from chitosan (polysaccharide). Chitosan has a positive charge attracts RBC, which have a negative charge. The red blood cells create a seal over the wound as they are drawn into the bandage, forming a very tight, coherent seal.
35 Robotic liver surgery Combined navigation systems ( Waze )
36 Thank you!
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