80
A u s t r i a c a H e f t 2 1 9 9 9
From the Division of General Surgery, Department of Surgery, Karl-Franzens-University, Graz, Austria
Liver Trauma
H. J. Mischinger, H. Bacher, G. Werkgartner, H. Cerwenka, A. El-Shabrawi, G. Hdss, and S. Uraniis
Schliisselwdrter: Leber- Trauma.
Key-words: Liver- trauma.
Summary: Background: The choice of indications favoring an
operative or a conservative approach in liver trauma is difficult,
and can be a matter of life and death for the patient.
Methods: Evaluation of the abdomen in trauma cases is discuss-
ed with regard to assessment of the clinical picture and the val-
ue of individual imaging modalities and invasive diagnostic
procedures such as arteriography and peritoneal lavage. The
various surgical techniques are appraised with respect to the
kind and extent of liver trauma involved.
Results: IVlanagement of liver trauma has tended to become
more conservative when the course allows. On average, 30% to
50% of all liver-trauma patients can be treated conservatively.
Conservative observation does, however, require continuous
monitoring, regular re-evaluation with CT or sonography, he-
modynamic stability (no more than 2 units of packed erythro-
cytes) and absence of concomitant intraabdominal injuries.
Shock and peritonism require an immediate laparotomy.
Conclusions: Today, hematoperitoneum is no longer an indica-
tion for immediate laparotomy. With severe liver ruptures (grad-
es IV and V) requiring surgery, debridement rather than resec-
tion is favored as it reduces risk and spares parenchyma. With
shock and/or manifest coagulopathies, a perihepatic tampona-
de can serve as a bridging measure until the liver trauma can be
treated definitively.
(Acta Chir. Austriaca 1999;31:80-84
Lebertrauma
Zusammenfassung: Grundlagen: Die tndikationsstellung fiir
eine operative oder konservative Vorgangsweise beim Leber-
trauma ist schwierig und ftir den Patienten oft auch lebenswichtig.
Methodik: Bei der Abkl/irung des Abdomens im Rahmen eines
Traumas wird neben der Beurteilung des klinischen Bildes der
Stellenwert einzelner bildgebender Verfahren der Wertigkeit in-
vasiver diagnostischer Magnahmen wie etwa der Arteriographie
oder der Peritoneallavage gegeniibergestellt. Ebenso werden die
verschiedenen operativen Techniken in Abhiingigkeit von Art
und Ausma6 des Lebertraumas aufgezeigt.
Ergebnisse: Das Management beim Lebertrauma hat sich in Ab-
hfingigkeit yon entsprechenden Verlaufsparametern eher in Rich-
tung einer konservativen Vorgangsweise entwickelt. Durch-
schnittlich k6nnen heute zwischen 30% und 50% aller Patienten
mit einem Lebertrauma konservativ behandelt werden. Essentiell
ftir eine konservative Observierung sind, abgesehen yon der M6g-
lichkeit eines kontinuierlichen Monitorings und einer konse-
quenten Reevaluierung durch CT oder Sonographie, eine stabile
H~imodynamik (Substitution yon maximal 2 Erythrozytenkon-
zentraten) ohne Hinweis f~r eine intraabdominelle Begleitverlet-
zung. Hfimodynamische Instabilit~it und Peritonismus sollten
ohne VerzOgerung zur sofortigen Laparotomie fiihren.
Schlugfolgerungen: Ein Hfimatoperitoneum bedeutet heute kei-
neswegs mehr eine Indikation zur sofortigen Laparotomie. Bei
schweren Leberrupturen (IV und V), bei denen eine operative
Intervention angezeigt ist, wird das Debridement gegentiber der
Resektion bevorzugt, da es risikofirmer und parenchymsparend
Corresponding address: H. J. Mischinger, M.D., Division of
General Surgery, Department of Surgery, Karl-Franzens-University,
Auenbruggerplatz 29, A-8036 Graz.
Fax: ++43/316/385 - 4666
E-mail: werkgart @ kfunigraz.ac.at
A c t a Chir.
ist. In Fiillen mit instabiler Kreislaufsituation und manifester
Koagulopathie kann wfihrend der Stabilisierungsphase die peri-
hepatische Tamponade als ,,Bridging" bis zur definitiven Ver-
sorgung der Leberveletzung eingesetzt werden.
Introduction
Three decades ago, the mortality for severe liver trauma was
over 70%. Thanks to advances in technology and intensive care,
as well as in the surgeon's experience with these support mea-
sures, survival continues to improve.
There is also the fact that with a well organized emergency
service, patients with most severe liver trauma (grades V and
VI) who formerly would not have had any chance of survival at
the accident site now may reach the operating room.
Careful monitoring with imaging techniques such as CT or
sonography as indicated by the clinical picture will contribute to
treatment decisions. A hematoperitoneum is no longer an abso-
lute indication for an immediate exploratory laparotomy. In all,
there is a general trend toward conservative management with
careful monitoring of relevant parameters.
P r e f e r r e d sites a n d p a t t e r n s of i n j u r y
Liver trauma is usually the result of direct force. There are cer-
tain patterns and sites of injury that depend on the intensity and
form of the force applied (3).
a) Subhepatic, hilar or hilar-transhepatic injuries occur with cir-
cumscribed trauma below or directly to the right lower ribs. It
happens not infrequently that this is accompanied by bursting
of the right hepatic lobe and the subhepatic section of the vena
cava, due to the resistance of the diaphragm.
b) Injuries near the diaphragm are often due to frontal right tho-
racic compression trauma. Here, the caudal shift of the organ
can be combined with ruptures of hepatic veins and injury to
the subdiaphragmatic section of the vena cava.
c) Right thoracic injuries with organ compression between the
diaphragm and spine usually produce a transhepatic injury
pattern in the area of the right hepatic lobe.
d) Direct frontal force usually leads to multiple parenchymal
tears to the left and right of the falciforme ligament.
Diagnostic modalities
The aim of the initial examination of a polytraumatized patient
is to exclude the possibility of an acute abdomen due to trauma.
The most important element here is the clinical evaluation that
determines whether or not surgery is necessary. With an uncon-
scious patient, a primary differential diagnosis will be difficult
or impossible without additionaL diagnostic modalities.
C A T sca=
The introduction of the CAT scan in emergency medicine made
possible the description of the anatomy, form and severity of in-
jury, evaluation and quantification of hematoperitoneum, and
identification of concomitant injuries in the pelvic cavity and
retroperitoneum.
In the clinically stable patient with liver injury resulting from
blunt abdominal trauma, this imaging technique can be used to
monitor conservative treatment of a nonprogressive, central rup-
ture. Emergency surgery can often be avoided. This is especially
advantageous in the polytraumatized patient.
Diagnostic peritoneal lavage (DPL)
Positive lavage is no longer an absolute indication for
laparotomy if persisting bleeding can be ruled out on the basis of
the clinical picture, sonography and CAT scans (36). The disad-
Acta Chir. Austriaca Heft 2 1999
vantage of DPL is that it is oversensitive and unspecific. It does
not differentiate between organs that require immediate atten-
tion and less severe injuries that can be handled conservatively.
It is useful for staging liver injuries or for detecting additional
injuries to other organs.
In view of the low sensitivity of CAT scans for injuries to hol-
low organs (1 to 5%), the role of DPL must be redefined (12, 34,
35, 48). The examination should mainly aim to detect presence of
abdominal liquids when there is no indication of trauma to
parenchymal organs but injury to hollow visceral organs is sus-
pected. When clinical clarification is not possible, DPL can be used
to exclude abdominal injuries before nonabdominal surgery is per-
formed. The method itself will cause complications in 1% (45).
Sonography
This has the advantage of immediate availability for bedside di-
agnostics in the shock room and/or intensive-care unit. Sensitiv-
ity for hematoperitoneum is more than 95%. It does not, how-
ever, work so well with subcutaneous emphysema, severe flatu-
lence and obese patients.
Diagnostic laparoscopy (DL)
As the sensitivity for injuries to hollow visceral organs is only
18%, DL is not especially advantageous (24). A further disad-
vantage is that exploration to determine extent and depth of in-
jury to parenchymal organs is limited. There is the danger of gas
embolism when there are vascular injuries involving major ves-
sels, as well as the risk of tension pneumothorax.
Treatment options with traumatic liver i n j u r y
Liver rupture can basically be treated in one of two ways. There
is defensive, wait-and-see management, or operative manage-
ment. The choice should take into account the two factors that
can make liver trauma a matter of life and death:
a) ongoing bleeding,
b) the danger of a subsequent infection.
Conservative management
The increasing reliability of modern imaging techniques in the
hands of experienced operators has created a trend toward con-
servative management of liver trauma. It has also been shown
that in 50 to 80% of cases, bleeding has ceased at the time of
laparotomy (1, 25, 34, 35, 38, 39). Treatment should thus be re-
strictive or conservative rather than hyperactive. Sonograms and
CTs will permit quantitative evaluation of the hemoperitoneum
through estimation of the fluid-filled sections of the peritoneal
cavity (14, 27). Guidelines suggest a tolerable free blood volume
of about 500 ml. Other authors (13, 27, 37, 40, 41, 42, 43, 44)
stress that the choice between observation and surgical interven-
tion depends not on the volume of free blood but on the patient's
hemodynamic stability.
Conservative management is justified when the following cri-
teria are fulfilled (4, 11,18, 19, 2t3, 21, 22, 23, 27, 34, 35, 41, 42,
43, 44):
a) hemodynamic stability,
b) stable hematocrit,
c) peritonism absent,
d) no concomitant injuries requiring laparotomy,
e) not more than two units of blood required,
f) technical facilities for continuous intensive-care and/or radio-
logical monitoring are available.
The advantages are that there is less stress to the patient, fewer
abdominal complications and experience also indicates that
fewer units of blood will be required.
The situation should be monitored observing the clinical
course accompanied by sonography and CAT scans.
Surgical management
The basic rule is that the more unstable the patient is and the
more urgently hemostasis is required, the sooner a median
81
Table 1. Liver trauma grading scale after Moore.
Grade Injury description
I. Hematoma: Subcapsular, nonexpanding, < 10% surface area
Laceration: Capsular tear, nonbleeding, < 1 cm parenchy-
mal depth
lI. Hematoma: Subcapsular, nonexpanding, l0 to 50% surface
area
Intraparenchymal, nonexpanding, < 2 cm in
diameter
Laceration: Capsular tear, active bleeding, 1 to 3 cm paren-
chymal depth, < 10 cm in length
III. Hematoma: Subcapsular, > 50% surface area or expanding;
ruptured subcapsular hematoma with active
bleeding;
lIntraparenchymal hematoma > 2 cm or expan-
Iding
Laceration: > 3 cm parenchymal depth
IV. Hematoma: Ruptured intraparenchymal hematoma with ac-
tive bleeding
Laceration: Parenchymal disruption involving 25 to 50% of
hepatic lobe
V. Laceration: Parenchymal disruption involving > 50% of he-
patic lobe
Vascular: 'Juxtahepatic venous injuries; i.e., retrohepatic '
vena cava major hepatic veins
VL Vascular: Hepatic avulsion
laparotomy should be performed. There are two approaches for
exploration with liver injuries:
a) Median laparotomy: The main advantage of the median ap-
proach is that it is quickly performed, there is little loss of
blood, and as required a median sternotomy or a distal exten-
sion to explore the pelvis can be done quickly. The disadvan-
tage is the limited approach to the right dorsal segments of the
liver and the retrohepatic section of the vena cava.
b) Diagonal upper-abdominal laparotomy: The advantage of
this form of laparotomy is that it is easy to explore the retro-
hepatic space and the entire upper abdomen.
The definitive order of treatment of organ injuries can only be
established after a careful exploratory phase!
After the laparotomy has been performed, a four-quadrant
tamponade can be done quickly to achieve a good view and to al-
low immediate hemostasis and a careful exploration of the intra-
and retroperitoneal organ systems. Surgical measures will de-
pend on the nature and extent of liver injury (38, 39) (Table 1).
Some 70% of all liver injuries in the context of abdominal
trauma will fall into grades I and II of Moore's classification..
If at all, these injuries are usually attended to as concomitant or
secondary trauma in the context of a laparotomy that is per-
formed for other, more severe abdominal injuries. These cases
can be handled upon laparotomy with simple temporary com-
pression, a simple capsular suture, or application of fibrin adhe-
sive or hemostyptic fleece.
More severe injuries require mastery of the standard tech-
aiques of liver surgery. Satisfactory treatment requires that
grade IIH injuries be distinguished from the injury patterns
found in grades IV and V. If occlusion of the hepatoduodenal
ligament does not distinctly reduce bleeding from the injured
liver, an injury to the major vessels must be assumed and sought.
With extensive parenchymal injuries, temporary exclusion of
the portal and arterial blood supply to the liver will facilitate ex-
ploration and purposeful treatment. Temporary ischemia is
achieved with the Pringle maneuver. Normothermic ischemia
will be tolerated for up to 60 min without serious postischemic
impairment of liver function.
Dangers that the Pringle maneuver can involve:
1) Concomitant injuries in the area supplied by the portal circu-
lation (spleen, mesenterial root, portal vein) can lead to much
82
Sono CAI'
~ Clll
L'nstabl
Hcmat~x;lil Ihlls
Peritoneal siglLs
|~.Cp~Zll ('.~1"
I .irma" Ill tU~,
l~.csolution
or
no chan~c
Succcsslial
+
I Obscrvalion
Fig. 1. Flow chart for treatment of liver trauma.
more severe bleeding. If the spleen is also ruptured, a primary
splenectomy may be necessary before the Pringle maneuver is
performed.
2) The additive effect of extended shock may decrease the tole-
rance period for normothermic ischemia during liver surgery.
Grade IV to VI parenchymal injuries are usually accompa-
nied by dangerous hemorrhage that persists in spite of the
Pringle maneuver. In these cases, the most important emergency
measure is the total vascular isolation of the liver.
This means the temporary occlusion of blood circulation to
and from the liver. Basically, the Pringle maneuver is supple-
mented by supra- and infrahepatic occlusion of the vena cava.
The simplest and fastest approach to the vena cava is as fol-
lows:
Preparation over the lesser omentum, luxation of the caudate
lobe with incision of the serosa along the vena cava followed by
snaring of the vena cava with a torniquet that may be
infrahepatic, caudal to the caudate process, or suprahepatic, ab-
dominal or thoracic.
If a hypovolemic patient cannot tolerate the vascular isolation,
circulatory arrest may occur (hypovolemia, bradycardia,
asystolia). This may be prevented with a forced increase in vol-
ume, clamping of the aorta and the release of the cava clamp af-
ter the source of bleeding has been localized (if possible partial
restoration of perfusion to the noninjured lobe).
Selective treatment
Swaths of purse-string sutures in a surgical field with poor
visibility always carry the risk of that something will be overlooked
and there will be afierbleeding (especiaily with hemorrhagic con-
gestion in the context of hepatic-vein occlusion) or occlusion of an
essential arteriopo~al vascular pedicle or gall duct which in turn
can lead to ischemia or atrophy of one or more liver segments.
Acta Chir. Austriaca - Heft 2 1999
Vascular injuries: When the portal vein is injured recon-
struction is mandatory and ligature should only be performed
out of vital necessity. However, when hepatic veins are injured,
the falciform, coronary and triangular ligaments must be severed
i L nstablc
to mobilize the liver. Snaring and occlusion of the
subdiaphragmal and subhepatic segments of the vena cava along
with the Pringle maneuver wilt permit repair of a tear or rupture
of hepatic veins at the point where they enter the vena cava but
Stugcr3
ligature is generally preferable to an attempt at reconstruction.
Injured bile ducts should only be reconstructed when the pa-
tient's condition permits. An exterior drain will serve as a bridg-
ing measure until definitive treatment is possible.
Selective ligature of a hepatic artery: This means selective
ligature of the hepatic artery that corresponds to the hepatic lobe
in which parenchymal bleeding is occurring. Arterial ligature
can be effective with arterial bleeding but does not contribute to
adequate hemostasis with bleeding from hepatic veins or
branches of the portal vein (16, 32). Bleeding can be controlled in
70 to 80% of cases. As most cases involve venous or portal bleed-
ing, this method will suffice for hemostasis in only about 10%.
Hepatotomy
For a better view and approach, it may be necessary to open up
the rupture further (hepatotomy). This is a transparenchymal ex-
tension of a short but deep parenchymal defect that is bleeding
heavily. The aim is to create an adequate approach and situation
for repair of an injured vessel. The finger-fracture technique as
described by Lin (29) is used. Injured portal triads are treated
with clips, ligatures or purse-string ligature; larger vessels or
gall ducts are sutured. Fibrin adhesive or fleece can be used for
lit: ........ tia ~----- diffuse parenchymal bleeding.
I Hepatostomy
in contrast to the procedure with blunt injuries, some authors ad-
vise hepatostomy with penetrating injuries like gunshot or stab
wounds (4 l, 42). A percutaneous Robinson drain is inserted into
the wound canal to effect internal compression and, at the same
time, drainage of blood and gall. It can be safely removed after
14 days. The most common error in the treatment of penetrating
injuries is the superficial closure of the wound without checking
for the actual source of bleeding. This can result in uncontrolled
intrahepatic hematoma or bilioma, formation of an abscess or
fistula; and liver function failure due to these complications.
Anatomic and nonanatomic resection
Resection plays a rather subordinate role in the treatment of liver
trauma; it will be required in only 10% of liver-trauma patients.
Due to the high mortality rates of 40 to I00%, more defensive
forms of treatment should always be preferred to any form of re-
section. Most series give an average mortality of 50% (2, 5, 6,
10, 40-44, 50). The mortality of posttraumatic resections is
30-40% higher than elective operations but it must be borne in
mind that there is the additive risk of concomitant injuries in
trauma cases. The high mortality is due to severe liver trauma
(grades tV to VI), coagulopathies, shock, unconsciousness and
concomitant injuries to the head and thorax (30, 38, 39, 46).
!ndications that eoutd nonetheless favor a liver resection are:
a) injuries with total destruction of the parenchyma,
b) when the form of the rupture is such that the resection can be
completed with just a few moves,
c) when injuries preclude perihepatic packing.
Debridement
Surgically, this is an atypical, nonanatomical resection of
non-vital liver tissue. The line of demarcation follows the area of
liver parenchyma that is not perfused with blood or is necrotic. In
addition to debridement, i.e. resection of ruptured ischemic parts
of the liver, there is the completion of traumatic partial ruptures
(atypical resection or debridement resection). Debridement resec-
tions must not be confused with conventional liver resection.
Acta Chir. Austriaca Heft 2 . 1999 83

The non-anatomical resection (debridement) made it possible

to achieve a mortality rate of 0 to 40%.

Compression tamponade of the liver ("packing")

The tamponade is intended to keep the trauma patient from
bleeding to death until shock treatment or substitution therapy
has reestablished hemostasis. The method mainly features com-
pression of the ruptured edge and compression of the liver
against the subphrenium without hindering venous flow from the
liver.
It is the method of choice:
a) with temporary clotting disorders,
b) as a bridging measure when the patient must be transported to
a trauma center,
c) with an unstable patient with complex liver injury when ade-
quate surgical treatment is not initially possible.
It should be emphasized that adequate compression is only
possible when the liver is sufficiently mobilized. Hepatic venous Fig. 2. lntraoperative picture of a central liver rupture ~hte to butting
flow should not be hindered by excessive compression of the with a bull's horn.
subphrenic part of the vena cava. It should be borne in mind that
the danger of infection increases with duration of compression and
definitive care should be administered within the first 24 to 48 h.
The disadvantages of the procedure are that it does not consti-
tute definitive care, re-operation is necessary, and the foreign
material inserted can be a source of infection.

Intralumina] cava shunt

An inner cava shunt is usually inserted to treat a subhepatic in-
jury of the vena cava. A large-lumen catheter is pushed distally
from the right atrium and fixed in place with a subphrenic and
subhepatic tourniquet. It permits venous blood flow from the
lower part of the body to the heart during the period of vascular
isolation of the liver. Installation of the shunt requires some time
bur the total ischemic period is shortened. The numerous modifi-
cations of this method and the scant data on its use indicate that it
is rarely helpful.

Liver transplantation
Fig. 3. Postoperative CT from patient as in figure I showing rerouting
Transplantation is the only alternative with irreparable liver
of bile flow from the left half of the liver via b iliodigestive anastomosis.
trauma. It can be considered under the circumstances of
posttraumatic progressive hepatic failure after initially success-
ful hemostasis or when the liver trauma does not permit
hemostasis involving a portocaval shunt as a bridging measure.
In this cases an organ must be available within 48 h.
The prognosis depends mainly on potential or manifest infec-
tion at the time of transplantation.

Discussion
Most liver traumas fall into the categories I to III, meaning that
conservative management is usually possible. Hemodynamic in-
stability does not necessarily indicate bleeding from the liver; it
can just as well come from concomitant injuries. Simultaneous
injuries such as fractures can have a major impact on the total
evaluation of a borderline circulatory situation. This, however
requires careful and exact staging of the injury.
The CAT scan is used to assess the extent of hepatic injury but
~s no tonger essen~ia~ for selection of patients for nonopera'~ive
management. Studies comparing CT and intraoperative findings
showed that extent of injuries tended to be underestimated. A
correlation with operative findings is found only in < 16% and in
41% the CAT scan underestimated the extent of injury (9, 27).
With an acute abdomen without CAT scan and regardless of
clinical stability, a laparotomy will usually be performed imme-
diately if peritoneal lavage indicates hematoperitoneum. Fig. 4. Drawing of biliodigestive anastomosis as described in Figure 2.
Sonography and CT have replaced DPL as diagnostic modalities
and DPL is generally done only when injuries to hollow visceral
organs are suspected. hemodynamic stability and the absence of peritoneal signs. Un-
The indication for surgery is given not primarily by the radio- necessary laparotomies are, of course, to be avoide~ but the prin-
logical findings but depends mainly on the clinical course. The ciple is still valid that an unnecessary laparotomy is less danger-
conservative course is based primarily on the patient's ous than the risk of a delayed operation.
 84
Further investigations by angiography are recommended in
patients who are hemodynamically stable but who have shown
no evidence of intraperitoneal blood resorption, or when follow
up scans indicate deterioration (17, 27). Routine angiography is
also recommended when there are potential vascular complica-
tions in grade IV liver injuries treated conservatively (49). In ar-
terial-portal-venous fistulas, false aneurysms or when serial
hematocrits drop and the patient remains hemodynamically sta-
ble, selective hepatic angiography and embolization should be
attempted.
Unstable patients usually have grade IV to V trauma and re-
quire surgery. Conservative treatment is shown to be possible in
20 to 30% of grade IV to V cases if they are hemodynamically
stable (40).
Surgery should be strongly considered when patients become
hemodynamically unstable, require more than two transfusions
in the presence of a hematoperitoneum indicating an ongoing
intraabdominal hemorrhage, and other potential sources of
bleeding by concomitant injuries are excluded. Surgical treat-
ment of liver trauma that could be managed conservatively
should also be considered when concomitant injuries require ex-
tensive surgery. Relaparotomies increase the risk of complica-
tions in polytraumatized patients; thus, the aim should be for de-
finitive care during the primary operation after careful abdomi-
nal exploration.
Liver resections in trauma cases have a high mortality rate and
are only performed in extraordinary cases. Metastudies give
mortality rates of 52 to 58%, whereby this form of treatment is
only used in 0.8 to 7% of liver-trauma cases (8, 40-44).
Trauma involving major hepatic vessels carries an especially
poor prognosis (47, 51, 52). Further disadvantages for emer-
gency resection of the liver are bilobular injuries in which bleed-
ing cannot be controlled, ruptured subcapsular hematomas and
concomitant injuries, especially to the head and thorax (31).
High mortality is also associated with coagulopathies due to
profound hypothermia, acidosis, loss of thrombocytes and clot-
ting factors or transfusion-induced coagulopathy (7, 38, 39).
When a coagulopathy precludes conventional hemostasis,
perihepatic packing is a suitable bridging procedure until defini-
tive surgical care is possible or when patients require transporta-
tion to specialized trauma centers. A compression tamponade
will minimize or control the loss of thrombocytes and clotting
factors, permit substitution of electrolytes, clotting factors and
volume, and compensate for acidosis. (5, 6, 21,22, 23). The opti-
mal time for removal is determined by reversal of acidosis, hy-
pothermia and coagulopathy. In order to reduce the increased
risk of abscess formation, packing should be removed within 24
to 48 h. The risk for postoperative perihepatic sepsis ranges
within 10% to 27%; when packing remains in place for more
than 3 days the risk may rise to 80% 115, 28).
When resection is required, resectional debridement is the rule
(21, 22, 23, 26, 33). While anatomical resection utilizes anatomi-
cal planes, in resectional debridement the plane of injury is used
as the line of resection. Not all authors follow the trend away
from liver resection in favor of conservative measures. Japanese
and Australian centers emphasize the advantages of resection
(lobectomy) and report more efficient hemostasis. Isolated re-
ports of anatomic resections in 63% of surgical]y managed cases
and a mortality of 13% are ~:he exception 12t, 22, 23, 26).
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