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肝臟是 blunt trauma 第二常受損的器官, 穿刺傷中最常受損的器官
- Blunt trauma：脾臟 > 肝臟 > 腸子
- 穿刺傷：肝臟 > 腸子 > 胃 > 脾
AAST Liver injury grade 2018
Subcapsular hematoma (包膜下血腫) & Laceration (裂傷深度)
Grade I
- Hematoma : Subcapsular < 10% surface area
- Laceration : Capsular tear < 1 cm, parenchymal depth
Grade II
- Hematoma : Subcapsular 10-50% surface area, intraparenchymal < 10cm in diameter
- Laceration : Capsular tear 1-3 cm, depth < 10 cm in length
Grade III
- Hematoma : Subcapsular > 50% surface area, rupture Subcapsular or parenchymal hematoma
intraparenchymal hematoma > 10cm in diameter
- Laceration : > 3 cm parenchymal depth
** Any injury presence of liver vascular injury or active bleeding confined within liver parenchyma.
** 肝臟實質內有 Active bleeding 直接算 Grade III
** Multiple low grade 可加總到 Grade III
Grade IV
- Laceration : Parenchyma disruption involving 25 - 75% hepatic lobe
or 1 - 3 segements
** Any injury presence of liver vascular injury or active bleeding extending beyond liver parenchyma into the peritoneum.
Active bleeding 超出肝臟實質就到 Grade IV
Grade V
- Laceration : parenchyma disruption > 75% hepatic lobe or > 3 segements within single lobe
or 1 - 3 segements
- Vascular : juxtahepatic venous injury ( eg. retrohepatic IVC, Central major hepatic vein)
Grade VI
- Hepatic avulsion (供應肝臟主要的血管斷裂)
處置 : 目前主流傾向 Non-operative procedure
- 血流動力穩定者, 初步處置為非手術治療
- 血流動力不穩者, 進行手術或血管栓塞
- 有腹膜炎者, 進行手術
- 非手術適應症：血流動力學穩定, 能配合密切監控, 無其他開刀適應症
- 血流動力學穩定者, CT 發現有 contrast extravasation or vascular blush（代表進行性的出血）
或持續出血的證據, 考慮血管栓塞
- Embolotherapy for hepatic trauma :
* Failed OP or recurrent post OP hemorrhage
* Hemobilia
* HPF, HHF
* Non operative control of stable blunt trauma + extravasation confined within liver capsule or parenchyma
- 非手術治療的併發症：有再次出血, 延遲出血, 肝膿瘍, 黃疸, 膽道受損 ( 主要在grade 3以上出現 )
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