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Injury. 2019 Oct 7. pii: S0020-1383(19)30596-0. doi: 10.1016/j.injury.2019.10.015. [Epub ahead of print]

Outcomes and complications for portal vein or superior mesenteric vein injury: No improvement in the era of damage control resuscitation.

Author information

1
R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
2
Department of Surgery, University of California San Francisco School of Medicine, San Francisco, CA, USA. Electronic address: deborah.stein@ucsf.edu.
3
R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA. Electronic address: tscalea@som.umaryland.edu.

Abstract

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.

KEYWORDS:

Abdominal vascular injury; Portal vein; Superior mesenteric vein; Surgical technique

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