Nghiên cứu chẩn đoán và điều trị chấn thương gan tại một số bệnh viện tỉnh miền núi phía bắc tt tiếng anh

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.
In terms of treatment, previously surgery was indicated for LT
popularly. Nowadays, with the advancements in 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 nonoperative 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 AAST1994, 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
organ perforation or in some multiple traumatic cases with
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 socioeconomic 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
bleeding, detection of hollow organ lesions requiring surgical
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: Patients have complications duringnonoperativetreatment 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
Table 3.4. Hemodynamic condition when hospitalized
Number Percentage
Hemodynamic condition
of patients
%
Stability
75
60,5
Unstablity
40
32,2
Unstablity, then Stability
9
7,3
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
Table 3.14. Patient was given a CT scan on admission
NonEmergency
Operative
surgery
CT Scan
p
group (n =
group (n =
62)
62)
No
Number of patients (%)
19(30,6%)

55(88,7%)
<
0,05
Yes Number of patients (%)
43(69,4%)
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 nonoperative 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
Emergency
Liver rupture by
Total
Failed then
surgery
CT scan
(n = 50)
Success
Emergency
group
surgery
Grade II n (%) 16(32,0%)
2(4,0%)

1(2,0%)
19(36,0%)
Grade
n (%) 18(36,0%)
4(8,0%)
3(6,0%)
25(50,0%)
III
Grade
n (%)
1(2,0%)
2(4,0%)
3(6,0%)
6(12,0%)
IV
Total
n (%) 35 (70,0%)
8 (16,0%)
7 (14,0%) 50(100%)


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
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

Success

25.8%
74.2%

Failed then
emergency surgery

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
The reason for failure of non-operative
Số BN
Tỷ lệ
treatment
(n = 16)
%
Shock, hypotension
5
31,25
Increased abdominal distention, pain
7

43,75
Coordinated organ damage need surgery
3
18,75
Abdominal puncture have non-coagulation
1
6,25
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
Failed then
Success
Emergency
surgery
Số BN
11
8
No
19
Tỷ lệ %

(57,9%)
(42,1%)
(n = 19)
(100%)
Số BN
35
8
Yes
43
Tỷ lệ %
(81,4%)
(19,6%)
(n = 43)
(100%)
P
< 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
Classification of
Failed then
Emergency

Total
liver rupture during
Emergency
surgery group
(n = 78)
surgery
surgery
Grade II
n (%)
5 (6.41%)
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
Number of
Tỷ lệ %
Treatment liver damage
patients(n = 78)
Liver damage hemostasis
6
7,7
Electrocoagulation hemostasis
3
3,8
Liver suturing
72
92,3
Liver suturing with pads

1
1,3
Liver resection
8
10,3
Gauze insert
16
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
Number of
Evaluating the results of nonpatient
Percentage %

operative treatment
(n = 62)
Good
46
74,2
Medium
0
0
Poor
16
25,8
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
Number of
Evaluating the results of
patient
Percentage %
surgical treatment
(n = 78)
Good
53
67,9
Medium
21
26,9

Poor
4
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 nonoperative 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 noncoagulation 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 nonoperative treatment study was 7.4% (13/175 patients). In the
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 nonoperative 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 nonoperative 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.