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Introduction: Portal vein (PV) and superior mesenteric vein (SMV) injuries are lethal. We hypothesised outcomes have improved with modern trauma care., Methods: We reviewed patients presenting to our Level 1 trauma centre over ten-years with PV/SMV injuries, analysing physiology, operative management, associated injuries, and outcomes., Results: Twenty-four patients had 7 PV and 15 SMV injuries, 2 had both; all had operative exploration. Sixty-seven percent had penetrating trauma. While many had normal vitals, profound acidosis was common. All patients had ≥2 additional abdominal injuries, liver most common (50%). Additional abdominal vascular injuries were more common in non-survivors than survivors: IVC 46% vs 22%, common hepatic artery 20% vs 0%, SMA 26% vs 11%. The mean injury severity score (ISS) was 32.4, and the mean new injury severity score (NISS) was 44.5. Mortality was 63%. Eleven patients died from exsanguination, two from SMV thrombosis, and two from sequelae of other injuries. All survivors had venorrhaphy, as did 8 non-survivors. Non-survivors were also shunted; had ligation; or bypass, shunting, and ligation. Three exsanguinated prior to repair. Two survivors had SMV related complications. One with proximal SMV injury developed severe venous congestion and multiple enterocutaneous fistulae. Another developed an arterioportal fistula, managed with embolisation and percutaneous portal vein stenting., Conclusion: Despite advances (REBOA, damage control surgery and resuscitation, liberal use of ED thoracotomy), PV and SMV injuries remain lethal. Injuries to other structures are ubiquitous. Early exsanguination is the major cause of death. All survivors had successful venorrhaphy; those who required more complex repairs died. Compromised mesenteric venous flow causes morbidity and mortality., (Copyright © 2019. Published by Elsevier Ltd.)

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma. Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2% (70/72). The success rates of NOM in the patients with grade I-III, IV and V liver trauma were 100%, 94.4% and 83.3%. The complication rates were 10.0% and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived. NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.

A 73 year old lady developed abdominal pain, anaemia and obstructive jaundice 18 days after a road traffic accident. The jaundice was due to compression of the biliary confluence by a haematoma which was caused by a laceration of the left portal vein. The portal vein was repaired (lateral venorrhaphy) and post-operative recovery was uncomplicated. Porta hepatis injuries are difficult to diagnose and delayed presentation is not uncommon. Significant morbidity and mortality may ensue if aggressive management is not adopted.

A 42-year old man with a penetrating laceration of the right liver lobe with complete transection of the right hepatic artery, right portal vein and left hepatic duct presented with minimal clinical signs and haemorrhage. Selective coeliac angiography and computer tomography (CT) revealed the vascular injuries. Forty-three hours after hospital admission the patient underwent right hepatectomy and bilioenteric anastomosis of the transected left bile duct to a Roux-en-Y segment of upper jejunum without stenting. Abscess formation and thrombosis of the inferior caval vein complicated recovery, but the patient was discharged from the hospital six weeks after this major hepatic injury, which usually presents with an exsanguinating massive haemorrhage.

It is generally accepted that the transjugular intrahepatic portosystemic shunt (TIPS) procedure has lower morbidity and mortality rates than those of surgical shunting. Nevertheless, complications occur. The authors have reviewed their experience and that of other institutions in compiling an extensive list of complications. Complications are categorized according to those related to transhepatic needle puncture, transvenous access to the portal vein, portal venous cannulation, the stent, the puncture site, portosystemic shunting, and contrast material. Excluding hepatic encephalopathy and delayed stenosis or occlusion of the shunt, an overall complication rate of less than 10% can be expected for TIPS. The prevalence of aggravated or new cases of encephalopathy is 5%-35%, and over the long term, up to 75% of shunts may undergo stenosis or occlusion. The direct procedural mortality rate is less than 2%, and the 30-day mortality rate ranges from 4% to 45%, depending on several factors. The role to which TIPS is relegated will be influenced by the long-term success rate in the prevention of recurrent variceal hemorrhage.

Objective: To report our experience in the management of accidental injuries to the structures of the hepatoduodenal ligament., Design: Retrospective study of medical records., Setting: University department of surgery., Subjects: 8 patients admitted after accidents (road traffic accidents, n = 4; falls, n = 2; and gunshot and stab wounds, n = 1 each) who were found at laparotomy to have injuries of the structures of the hepatoduodenal ligament., Interventions: Laparotomy in all cases., Main Outcome Measures: Morbidity and mortality., Results: One patient died (13%) of multiple organ failure after a gunshot wound of the portal vein, liver, inferior vena cava, right renal artery, and right kidney. All patients had associated injuries. There were 3 complete transsections of the common bile duct, two of which were treated by Roux-en-Y cholecystojejunostomy and one by choledochojejunostomy over a T tube. Two lacerations of the common hepatic duct were treated by T tube choledochostomy. All injuries to blood vessels were sutured. Only one patient survived without any complications, and two developed cholangitis after cholecystojejunostomy that required further operation 5 and 16 months after the initial operation., Conclusions: Blunt injuries to the hepatoduodenal ligament are easily overlooked, leading to delayed morbidity. Complete transsections of the bile duct are best managed by choledochojejunostomy with a Roux-en-Y loop; T tube choledochostomy is usually sufficient when treating small partial lesions of lobar bile ducts; and most non-circumferential vascular lesions are best treated by suture.

Concomitant injury to the large vessels and other abdominal organs are related to the category of severe injuries with high postoperative mortality rates. The authors discuss 21 patients with the trauma, 9 of them with injury to the inferior vena cava. Early operation, adequate compensation for the blood loss, and co-operation with angiosurgeons will improve the number of favourable outcomes.

The authors report their experience with 14 patients with portal vein injuries (1976-1986) treated at a level I trauma center. Seven patients (50%) survived and included six of 10 patients (60%) who had venorrhaphy and one in whom the portal vein was ligated. Associated injuries were present in all the patients (mean Abdominal Trauma Index: 39.5) and accounted for the high mortality rate. Follow-up data after repair or ligation of the portal vein seldom are reported in the literature. The authors studied all three patients who survived portal venorrhaphy since 1982 by real-time ultrasonography. Patency of the repair could be established in two patients. In the third patient postvenorrhaphy thrombosis was diagnosed by ultrasonographic examination. Sequential ultrasonographic examinations demonstrated resolution of the thrombus on anticoagulant therapy. Ultrasonography provides a noninvasive and easily reproducible method of studying the portal vein after repair.

Severe devascularizing liver injuries continue to carry a high mortality. Rapid operative intervention to achieve hemostasis and debride devitalized tissue remains essential to salvaging these patients. For those with unsalvageable liver injuries liver transplantation can be employed. Careful support of the patient in the anhepatic state, reversal of coagulopathy, and use of venous bypass intraoperatively permit successful transplantation.

Abdominal vascular injuries remain rare in centers that primarily treat victims of blunt trauma, but when penetrating wounds of the abdomen are commonly treated, the incidence of abdominal vascular injuries is surprisingly high. With suitable management, many of these patients survive.

In the period 1970-1978, a mortality rate of 44% resulted in 45 patients who suffered major intra-abdominal venous injuries. An especially grave prognosis accompanied wounds to the inferior vena cava and the hepatic and portal venous systems. Management of damage to major veins presents several difficulties. Exposure is poor; veins tear easily when clamped or sutured; exsanguination can occur as rapidly as with arterial trauma; because of low intraluminal pressure, postoperative chances of thrombosis and occlusion are high; veins (unlike arteries) have no intrinsic vasomotor capabilities to halt bleeding. Finally, the misconception persists that venous wounds are less serious than comparable arterial injuries. Simple pressure by packs or hand often controls bleeding: otherwise clamps, balloons, hemostats, or ligation can be selectively chosen. Our experience suggests that atrial-caval shunting without prior identification and control of the bleeding site is doomed to failure.

The management of eleven patients with major venous and associated liver injuries has been summarized. Aggressive resuscitation includes early operative intervention. Repair of venous injury can be effected if hemorrhage is contained and stepwise exposure instituted. The critical steps in management include: 1) thoraco-abdominal exposure; 2) intermittent occlusion of the porta hepatis; 3) total liver mobilization; 4) judicious use of cava-hepatic bypass.