Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps

Hepatic vascular injury: clinical profile, endovascular management and outcomes

BACKGROUND

Endovascular management using angiographic embolization (AE) has been widely used with success as non operative management (NOM) in blunt hepatic trauma. We, in a tertiary care hospital in North of India, assess our use of endovascular management in patients of blunt and post operative trauma with active hepatic vascular bleeding and unstable hemodynamics in controlling bleeding.

METHODS

A retrospective review of inpatients from January 2006 to July 2012 requiring transarterial embolization/stenting for active hepatic vascular bleeding was done. All patients had evidence of ongoing hemorrhage as proved by clinical, laboratory and radiological findings in emergency settings. Angiographic intervention in an interventional suite with ongoing resuscitation was performed following which patients were monitored for morbidity and mortality benefits on intermediate follow up.

RESULTS

10 adults and 3 children underwent AE with polyvinyl alcohol particle (PVA)/soft metal coil whereas 1 adult underwent revascularization with a covered stent for arterial bleeding. The mean age of case series was 36.18 ± 20.90 years with a mean liver injury computed tomography (CT) grade of 3.8 ± 0.83 in blunt trauma patients. The mean length of hospital stay was 9.62 ± 7.83 days and the mean follow up period of the group was 25.25 ± 21.02 months. All patients showed significant clinical improvement with prompt endovascular management resulting in no procedure related mortality.

CONCLUSION

Prompt endovascular management is the modality of choice in comparison to NOM without AE in both pediatric and adult patients with hemodynamically compromised inaccessible intra hepatic vascular trauma.

Influences on the amount of intraperitoneal haemorrhage after blunt liver injury: a retrospective autopsy study

OBJECTIVE

The amount of intraperitoneal blood loss due to traumatic liver injury is rarely addressed in correlation with concomitant injuries or pre-existing liver disease.

METHODS

We carried out a retrospective review of autopsy reports from 1995 until 2007 at the Institute of Forensic Medicine (Bern, Switzerland), and evaluated 126 cases of blunt liver trauma for the amount of blood in the abdominal cavity, severity of liver injury, pre-existing liver disease and concomitant injuries.

RESULTS

Grades IV and V liver injuries (American Association for the Surgery of Trauma classification) showed greater blood loss than grades I and II liver injuries. Grade III liver injuries showed no significant difference in the amount of intraperitoneal blood compared with grades IV and V liver injuries and 53 cases of liver injuries (42%) did not bleed at all. The amount of blood found in the abdominal cavity ranged from 0 to 4500 ml. Pre-existing liver steatosis showed no significant difference in injury pattern or bleeding from the liver. Three cases with liver haemangiomas and one with a liver cyst showed no lesion to their focal alteration. Because of the small number of cases, no statistical analysis was made concerning concomitant injuries such as head, thoracic or limb trauma.

CONCLUSION

Higher grades of liver injury severity are associated with higher blood loss into the abdominal cavity. In addition, a patient with pre-existing liver steatosis seems not to be at any greater risk of having a larger rupture or having stronger bleeding from the liver after a blunt impact compared with a patient with a normal liver.

Blunt polytrauma: evaluation with 64-section whole-body CT angiography

Blunt polytrauma remains a leading cause of death and disability worldwide. With the major advances in computed tomography (CT) technology over the past decade, whole-body CT is increasingly recognized as the emerging standard for providing rapid and accurate diagnoses within the narrow therapeutic window afforded to trauma victims with multiple severe injuries. With a single continuous acquisition, whole-body CT angiography is able to demonstrate all potentially injured organs, as well as vascular and bone structures, from the circle of Willis to the symphysis pubis. As its use becomes more widespread, the large volume of information inherent to whole-body CT poses new challenges to radiologists in providing efficient and timely interpretation. An awareness of trauma scoring systems and injury mechanisms is essential to maintain an appropriate level of suspicion in the search for multiple injuries, and the use of multiplanar reformation and three-dimensional postprocessing techniques is important to maximize efficiency in the search. Knowledge of the key injuries that require urgent surgical or percutaneous intervention, including major vascular injuries and active hemorrhage, diaphragmatic rupture, unstable spinal fractures, pancreatic injuries with ductal involvement, and injuries to the mesentery and hollow viscera, is also necessary.

Predictive factors of morbidity and mortality in grade IV and V liver trauma undergoing perihepatic packing: single institution 14 years experience at European trauma centre

PURPOSE

Major liver trauma in polytraumatic patients accounts for significant morbidity and mortality. We aimed to assess prognostic factors for morbidity and mortality in patients with severe liver trauma undergoing perihepatic packing.

METHODS

Prospectively collected records of 293 consecutive polytrauma patients with liver injury admitted at a level I trauma centre between 1996 and 2008 were reviewed. 39 patients with grade IV-V AAST liver injury and treated with peri-hepatic packing were identified and included for analysis. Univariate and multivariate analyses were performed to assess prognostic factors for morbidity and mortality.

RESULTS

Mean age of patients was 41 years. 34 patients were haemodynamically unstable at initial presentation. Ten of 39 patients were treated with angiographic embolization in addition to perihepatic packing. The overall mortality rate was 51.3%. Liver-related death occurred in 23.1%. Overall and liver-related morbidity rates were 90% and 28%, respectively. Glasgow Coma Scale (GCS), respiratory rate, packed red blood cells (PRBC) transfusion, pH and Base Excess (BE), Revised Trauma Score (RTS) and Trauma Injury Severity Score (TRISS), need for angiographic embolization as well as early OR and ICU admission were associated with significant decrease of early mortality.

CONCLUSIONS

Revised Trauma Score, haemodynamic instability, blood pH and BE are important prognostic factors influencing morbidity and mortality in polytrauma patients with grade IV/V liver injury. Furthermore, fast and effective surgical damage control procedure with perihepatic packing, followed by early ICU admission is associated with lower complication rate and shorter ICU stays in this patient population.

Nonoperative management for patients with grade IV blunt hepatic trauma

Introduction

The treatment of complex liver injuries remains a challenge. Nonoperative treatment for such injuries is increasingly being adopted as the initial management strategy. We reviewed our experience, at a University teaching hospital, in the nonoperative management of grade IV liver injuries with the intent to evaluate failure rates; need for angioembolization and blood transfusions; and in-hospital mortality and complications.

Methods

This is a retrospective analysis conducted at a single large trauma centre in Brazil. All consecutive, hemodynamically stable, blunt trauma patients with grade IV hepatic injury, between 1996 and 2011, were analyzed. Demographics and baseline characteristics were recorded. Failure of nonoperative management was defined by the need for surgical intervention. Need for angioembolization and transfusions, in-hospital death, and complications were also assessed

Results

Eighteen patients with grade IV hepatic injury treated nonoperatively during the study period were included. The nonoperative treatment failed in only one patient (5.5%) who had refractory abdominal pain. However, no missed injuries and/or worsening of bleeding were observed during the operation. None of the patients died nor need angioembolization. No complications directly related to the liver were observed. Unrelated complications to the liver occurred in three patients (16.7%); one patient developed a tracheal stenosis (secondary to tracheal intubation); one had pleural effusion; and one developed an abscess in the pleural cavity. The hospital length of stay was on average 11.56 days.

Conclusions

In our experience, nonoperative management of grade IV liver injury for stable blunt trauma patients is associated with high success rates without significant complications.

Non-operative management of hepatic trauma and the interventional radiology: an update review

The growing trend to manage hepatic injuries nonoperatively has been increasing demand for advanced endovascular interventions. This brings up the necessity for general and trauma surgeons to update their knowledge in such matter. Effective treatment mandates a multispecialty team effort that is usually led by the trauma surgeon and includes vascular surgery, orthopedics, and, increasingly, interventional radiology. The focus on hemorrhage control and the angiographer's unique access to vascular structures gives interventional radiology (IR) an important and increasingly recognized role in the treatment of patients with hemodynamic instability. Our aim is to review the basic concepts of IR primarily in hepatic trauma and secondarily in some other special situations. A liver vascular anatomy review is also needed for better understanding the roles of IR. As a final point we propose a guideline for the operative/nonoperative management of traumatic hepatic injuries. The benefit of multidisciplinary approach (TAE) appears to be a powerful weapon in the medical arsenal against the high mortality of injured trauma liver patients.

Technological advancements in the care of the trauma patient

INTRODUTION

Medical technology has benefited many types of patients, but trauma care has arguably benefited more from technologic development than almost any other field.

METHODS

A literature review to identify key technological advances in the care of trauma patients was performed.

RESULTS

The advances in trauma care are in great measure due to the integration of many different systems. Medical technology impacts care in the field at the site of the trauma, in the transport to trauma facilities, and care at the trauma center itself. Once at the hospital, technology has impacted care in the trauma bay, intensive care units, the operating room, and in postoperative and long-term care settings. The integration of advancements, however, needs to be examined in a careful systematic fashion to insure that patients will actually derive benefit.

Severe hepatic trauma: nonoperative management, definitive repair, or damage control surgery?

BACKGROUND

Management of severe liver injuries has evolved to include the options for nonoperative management and damage control surgery. The present study analyzes the criteria for choosing between nonoperative management and early surgery, and definitive repair versus damage control strategy during early surgery.

METHODS

In a retrospective analysis of 144 patients with severe (AAST grade III-V) liver injuries (94% blunt trauma), early laparotomy was performed in 50 patients. Initial management was nonoperative in 94 blunt trauma patients with 8 failures. Uni- and multivariate analyses were used to calculate predictor odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Factors associated with early laparotomy in blunt trauma included shock on admission, associated grade IV-V splenic injury, grade IV-V head injury, and grade V liver injury. Only shock was an independent predictor (OR, 26.1; 95% CI, 8.9-77.1; P < 0.001). The presence of a grade IV-V splenic injury predicted damage control strategy (OR infinite; P = 0.021). Failed nonoperative management was associated with grade IV-V splenic injury (OR, 14.00; 95% CI, 1.67-117.55), and shock (OR, 6.82; 95% CI, 1.49-31.29). The hospital mortality rate was 15%; 8 of 21 deaths were liver-related. Shock (OR, 9.3; 95% CI, 2.4-35.8; P = 0.001) and severe head injury (OR, 9.25; 95% CI, 3.0-28.9; P = 0.000) were independent predictors for mortality.

CONCLUSIONS

In patients with severe liver injury, associated severe splenic injury favors early laparotomy and damage control strategy. Patients who arrive in shock or have an associated severe splenic injury should not be managed nonoperatively. In addition to severe head injury, uncontrollable bleeding from the liver injury is still a major cause of early death.

Penetrating liver injury managed with a combination of balloon tamponade and venous stenting. A case report and literature review

AAST-OIS grade V complex hepatic injuries are often fatal as a result of exsanguination. We report a patient presenting in extremis with a penetrating injury to the right kidney, liver, middle hepatic vein, diaphragm, and lung. A combination of intrahepatic balloon tamponade and hepatic venous stenting was used to control exsanguinating haemorrhage, the first time this combination has been reported. Rapid assessment and treatment and a team approach, together with the innovative application of haemostatic techniques, allowed a multidisciplinary team to salvage this patient.

Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury

BACKGROUND

Nonoperative management (NOM) has become the standard treatment of blunt hepatic injury (BHI) for stable patients. Contrast extravasation (CE) on computed tomography (CT) scan had been reported as a sign that is associated with NOM failure. The goal of this study was to further investigate the risk factors of NOM failure in patients with CE on CT scan.

METHODS

From January 2005 to September 2009, patients with CE noted on a CT scan as a result of BHI were studied retrospectively. Physiological parameters, severity of injury, amount of transfusion, type of contrast extravasation, as well as treatment outcome were compared between patients with NOM failure and NOM success.

RESULTS

A total of 130 patients were enrolled. Injury severity scores, amount of blood transfusion before hemostatic procedure, and grade of liver injury were significantly higher in NOM failure than in NOM success patients. There was no statistical difference in the NOM success rate between patients with contrast leakage into the peritoneum and those with contrast confined in the hepatic parenchyma.

CONCLUSIONS

Higher injury severity score, more blood transfusion, and higher grade of liver injury are factors that correlate with NOM failure in patients with BHI. Contrast leakage into the peritoneum is not always a definite sign of NOM failure in BHI. Early and aggressive angioembolization is an effective adjunct of NOM in BHI patients, even with contrast leakage into peritoneum.

Hepatic arterial embolization in the management of blunt hepatic trauma: indications and complications

BACKGROUND

The objective was to clarify the role of hepatic arterial embolization (AE) in the management of blunt hepatic trauma.

METHODS

Retrospective observational study of 183 patients with blunt hepatic trauma admitted to a trauma referral center over a 9-year period. The charts of 29 patients (16%) who underwent hepatic angiography were reviewed for demographics, injury specific data, management strategy, angiographic indication, efficacy and complications of embolization, and outcome.

RESULTS

AE was performed in 23 (79%) of the patients requiring angiography. Thirteen patients managed conservatively underwent emergency embolization after preliminary computed tomography scan. Six had postoperative embolization after damage control laparotomy and four had delayed embolization. Arterial bleeding was controlled in all the cases. Sixteen patients (70%) had one or more liver-related complications; temporary biliary leak (n=11), intra-abdominal hypertension (n=14), inflammatory peritonitis (n=3), hepatic necrosis (n=3), gallbladder infarction (n=2), and compressive subcapsular hematoma (n=1). Unrecognized hepatic necrosis could have contributed to the late posttraumatic death of one patient.

CONCLUSION

AE is a key element in modern management of high-grade liver injuries. Two principal indications exist in the acute postinjury phase: primary hemostatic control in hemodynamically stable or stabilized patients with radiologic computed tomography evidence of active arterial bleeding and adjunctive hemostatic control in patients with uncontrolled suspected arterial bleeding despite emergency laparotomy. Successful management of injuries of grade III upward often entails a combined angiographic and surgical approach. Awareness of the ischemic complications due to angioembolization is important.

Dealing with liver trauma

Bleeding from a traumatic liver injury often ceases spontaneously, which is the basis for non-operative management, currently used in about 80% of patients with blunt hepatic trauma. The selection of patients for non-operative management is based on the assessment of haemodynamic stability and the presence of associated organ injuries requiring surgical repair. In patients requiring surgery, definitive repair is preferred in stable patients with normal tissue perfusion and temperature, and ranges from the use of local haemostats and sutures to non-anatomic hepatic resection and direct repair of juxtahepatic venous injuries. In the most seriously injured patients with major bleeding causing severe physiological derangement, a damage control strategy including perihepatic packing is the treatment method of choice. Adjunctive procedures including hepatic angiography and embolisation are often needed in high-grade liver injuries whether undergoing surgical or non-operative management. The multidisciplinary approach also includes procedures performed for biliary complications, such as percutaneous or endoscopic drainage of bile leaks.

Management of blunt hepatic trauma

Management of blunt liver trauma has progressed over the last 20 years with the adoption of conservative non-operative management (CM) as the gold standard in 80-90% of patients. Clinical and hemodynamic changes, and CT imaging guide the conservative attitude or pose an indication for urgent surgical intervention in unstable patients. The adoption of CM for blunt liver trauma has resulted in an increased incidence of late complications. These consist principally of persistent hemorrhage, fistulas and bile leaks, the abdominal compartment syndrome, and hepatic necrosis or abscess. These late complications can be managed secondarily by planned interventions via laparotomy or laparoscopy, interventional radiology and/or endoscopic techniques in a non-emergency setting as indicated by circumstances and with the benefit of multidisciplinary consultation. These secondary interventions should not be considered a failure of conservative treatment, but rather as an anticipated eventuality in the management of these patients.

Treatment of major hepatic necrosis: lobectomy versus serial debridement

BACKGROUND

Major hepatic necrosis (MHN) is a common complication after angioembolization (AE) for severe liver injuries. We compared the outcomes of two treatment modalities.

METHODS

Patients with MHN were retrospectively reviewed from January 2002 to October 2007. Demographics, Injury Severity Scale score, length of stay, admission Glasgow Coma Scale Score, mortality, transfusion requirements, intra-abdominal complications, admission physiologic variables, and the number and type of abdominal procedures (operative or nonoperative) were collected. These patients were then divided into two groups-those treated with hepatic lobectomy (HL) and those treated with multiple procedures including serial operative debridements and/or percutaneous drainage (IR/OR).

RESULTS

Thirty patients (41%) with MHN were identified from 71 patients who had AE. Sixteen patients with MHN underwent HL and 14 patients underwent multiple IR/OR procedures. The two groups were similar at baseline, except that the HL group had a higher Injury Severity Scale score. Outcomes between the two groups were similar. There was a significantly higher complication rate and increased number of procedures in the IR/OR group. There were no deaths in patients who had early HL (<5 days). There was one death in the later lobectomy group.

CONCLUSION

MHN is a common complication after AE. This complication can be safely managed with a series of operative debridements in conjunction with interventional procedures or with HL. Lobectomy is associated with a lower complication rate and a fewer number of procedures. Early lobectomy may be better than a delayed procedure.

Management of ongoing arterial haemorrhage after damage control laparotomy: optimal timing and efficacy of transarterial embolisation

INTRODUCTION

Patients undergoing damage control laparotomy need intensive and aggressive resuscitation, and may also require adjunctive transarterial embolisation (TAE) for ongoing arterial haemorrhage. We evaluated the effectiveness and timing of TAE in these patients as well as their final outcome.

MATERIALS AND METHODS

From January 1998 to December 2006, the case records of 16 patients with ongoing arterial haemorrhages (hepatic haemorrhage=7, extra-hepatic haemorrhage=9) who underwent TAE after damage control laparotomy were reviewed. Fourteen patients had blunt injuries and two had penetrating injuries.

RESULTS

There were 13 men and three women. Their ages ranged from 3 to 85 years (mean, 36 years). Of seven hepatic angiograms, contrast extravasation at the right hepatic artery and left hepatic artery was found in three patients each. Bilateral hepatic artery injuries were found in one patient. Of nine extra-hepatic angiograms, the internal iliac artery was the most commonly injured artery (n=6). After TAE, 14 of 16 ongoing arterial haemorrhages could be controlled and eight patients survived; however, two patients with uncontrolled haemorrhages eventually died (hepatic artery injury=1, lumbar artery injury=1). Of 16 patients overall, profound haemorrhagic shock (n=4) and multiple organ failure (n=4) resulted in eight deaths (hepatic injury=4, extra-hepatic injury=4), and accounted for a mortality rate of 50%. Of 16 patients, nine were taken directly from the operating room to the angiography suite and the mortality rate was 33.3%. The other seven patients were taken to the angiography suite from the intensive care unit and the mortality rate was 71.4%. Of three survivors who underwent hepatic TAE, the operative time ranged from 30 min to 72 min (mean, 48 min). However, of four nonsurvivors who underwent hepatic TAE, the operative time ranged from 58 min to 180 min (mean, 119 min).

CONCLUSIONS

TAE is an effective tool in the management of ongoing arterial haemorrhage after damage control laparotomy and eight (50%) patients with ongoing arterial haemorrhages survived from this multidisciplinary treatment. To achieve a good outcome, the operative time of damage control laparotomy should be as short as possible and TAE should be performed without delay. Interventional radiology colleagues should be informed in advance during laparotomy and resuscitation continued in the angiography suite.

Major hepatic necrosis: a common complication after angioembolization for treatment of high-grade liver injuries

BACKGROUND

The management of high-grade liver injuries often involves a combination of operative and nonoperative strategies. Angioembolization (AE) is frequently used in the management of these injuries. Morbidity in patients with high-grade hepatic injuries remains high despite improvements in mortality with a multimodality approach. Major hepatic necrosis (MHN) is a morbid, but underappreciated complication of AE in this patient population. This study will examine the risk factors and outcomes of patients with high-grade liver injures managed with AE who developed the complication of MHN.

METHODS

Patients admitted to the R Adams Cowley Shock Trauma Center between January 2002 and December 2007 with high-grade blunt or penetrating liver injuries (grades III-VI) were identified from the trauma registry and the medical records were retrospectively reviewed. Demographic and injury specific data, complications, and admission physiologic variables were collected. Patients who had therapeutic AE, either preoperatively or postoperatively, and went on to develop liver-related complications including MHN were reviewed.

RESULTS

There were 538 patients with high-grade liver injuries admitted during a 5-year period. One hundred and sixteen patients (22%) underwent angiography, and 71 (13%) had a therapeutic AE. Sixteen patients (22.5%) had grade III injuries, 44 (62%) had grade IV injuries, and 11 (15.5%) had grade V injuries. Overall mortality in this group was 14% with eight patients (11.3%) dying as a result of their liver injury. Complication rates were 18.8%, 65.9%, and 100% in the patients with grades III, IV, and V injuries, respectively, for an overall complication rate of 60.6%. Thirty patients (42.2%) went on to develop MHN. Patients who developed MHN were compared with those who did not. Baseline characteristics, Injury Severity Score, and hemodynamic parameters at admission were no different between the two groups. Patients with MHN had higher grade injuries, required significantly more blood product transfusions, and had a significantly longer length of stay (all p < 0.001). Patients who developed MHN were more likely to have undergone operative intervention (96.7% vs. 41.5%, p < 0.001), with 87% having a damage control laparotomy. Other liver-related complications occurred more frequently in the patients that developed MHN (60.0% vs. 34.1%, p = 0.03). However, mortality was not different in the two groups.

CONCLUSION

High-grade liver injuries pose significant challenges to those who care for trauma patients. Many patients can be successfully managed nonoperatively, but there are still patients that require laparotomy. AE is the logical augmentation of damage control techniques for controlling hemorrhage. However, given the nature and severity of these injuries, these therapies are not without complications. MHN was found to be a common complication in our study. It tended to occur in high-grade injures, was associated with higher complication rates, longer hospital length of stay, and higher transfusion requirements. Management of MHN can be challenging. Factors that still need to be elucidated are the role of perihepatic packing and timing of second look operation.

Concomitant injuries are an important determinant of outcome of high-grade blunt hepatic trauma

BACKGROUND

Little is known about the clinical importance of concomitant injuries in polytraumatized patients with high-grade blunt liver injury. A retrospective single-centre study was performed to investigate the safety of non-operative management of liver injury and the impact of concomitant intra- and extra-abdominal injuries on clinical outcome.

METHODS

Some 183 patients with blunt liver injury were admitted to Berne University Hospital, Switzerland, between January 2000 and December 2006. Grade 3-5 injuries were considered to be high grade.

RESULTS

Immediate laparotomy was required by 35 patients (19.1 per cent), owing to extrahepatic intra-abdominal injury (splenic and vascular injuries, perforations) in 21 cases. The mortality rate was 16.9 per cent; 22 of the 31 deaths were due to concomitant lesions. Of 81 patients with high-grade liver injury, 63 (78 per cent) were managed without surgery; liver-related and extra-abdominal complication rates in these patients were 11 and 17 per cent respectively. Grades 4 and 5 liver injury were associated with hepatic-related and extra-abdominal complications.

CONCLUSION

Concomitant injuries are a major determinant of outcome in patients with blunt hepatic injury and should be given high priority by trauma surgeons. An algorithm for the management of blunt liver injury is proposed.

Visceral trauma: principles of management and role of embolotherapy

Interventional radiology for the treatment of traumatic visceral hemorrhage has emerged as an important adjunct to modern trauma care. This article outlines the general surgical concepts of the acute care of trauma patients as a guideline for catheter-based therapy. Specific considerations are presented for embolizing visceral injuries in the liver, spleen, and kidney. Expected outcomes and follow-up are reviewed.

American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank

BACKGROUND

This study attempts to validate the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for spleen, liver, and kidney injuries using the National Trauma Data Bank (NTDB).

STUDY DESIGN

All NTDB entries with Abbreviated Injury Scale codes for spleen, liver, and kidney were classified by OIS grade. Injuries were stratified either as an isolated intraabdominal organ injury or in combination with other abdominal injuries. Isolated abdominal solid organ injuries were additionally stratified by presence of severe head injury and survival past 24 hours. The patients in each grading category were analyzed for mortality, operative rate, hospital length of stay, ICU length of stay, and charges incurred.

RESULTS

There were 54,148 NTDB entries (2.7%) with Abbreviated Injury Scale-coded injuries to the spleen, liver, or kidney. In 35,897, this was an isolated abdominal solid organ injury. For patients in which the solid organ in question was not the sole abdominal injury, a statistically significant increase (p < or = 0.05) in mortality, organ-specific operative rate, and hospital charges was associated with increasing OIS grade; the exception was grade VI hepatic injuries. Hospital and ICU lengths of stay did not show substantial increase with increasing OIS grade. When isolated organ injuries were examined, there were statistically significant increases (p < or = 0.05) in all outcomes variables corresponding with increasing OIS grade. Severe head injury appears to influence mortality, but none of the other outcomes variables. Patients with other intraabdominal injuries had comparable quantitative outcomes results with the isolated abdominal organ injury groups for all OIS grades.

CONCLUSIONS

This study validates and quantifies outcomes reflective of increasing injury severity associated with increasing OIS grades for specific solid organ injuries alone, and in combination with other abdominal injuries.

Emergency liver transplantation following severe liver trauma

Liver trauma is a major cause of mortality after major blunt and penetrating abdominal trauma. The need for life-saving emergency hepatectomy and liver transplantation is extremely rare. We report the management of 2 patients who required urgent liver transplantation for liver trauma. One patient developed hepatic failure following global ischemia after a gunshot injury. The second patient developed a severe postreperfusion injury following removal of a perihepatic pack after blunt abdominal trauma. We highlight the difficulties in the management of severe liver trauma with an emphasis on the clinical features, radiological investigations, and surgical treatment of these complex patients.

[Current treatment of hepatic trauma]

The therapeutic and diagnostic approach of liver trauma injuries (by extension, of abdominal trauma) has evolved remarkably in the last decades. The current non-surgical treatment in the vast majority of liver injuries is supported by the accumulated experience and optimal results in the current series. It is considered that the non-surgical treatment of liver injuries has a current rate of success of 83-100%, with an associated morbidity of 5-42%. The haemodynamic stability of the patient will determine the applicability of the non-surgical treatment. Arteriography with angioembolisation constitutes a key technical tool in the context of liver trauma. Patients with haemodynamic instability will need an urgent operation and can benefit from abdominal packing techniques, damage control and post-operative arteriography. The present review attempts to contribute to the current, global and practical management in the care of liver trauma.

Place of arterial embolization in severe blunt hepatic trauma: a multidisciplinary approach

This study evaluates the efficacy of arterial embolization (AE) for blunt hepatic traumas (BHT) as part of a combined management strategy based on the hemodynamic status of patients and CT findings. From 2000 to 2005, 84 patients were admitted to our hospital for BHT. Of these, 14 patients who had high-grade injuries (grade III [n = 2], grade IV [n = 9], grade V [n = 3]) underwent AE because of arterial bleeding and were included in the study. They were classified into three groups according to their hemodynamic status: (1) unresponsive shock, (2) shock improved with resuscitation, and (3) hemodynamic stability. Four patients (group 1) underwent, first, laparotomy with packing and, then, AE for persistent bleeding. Ten patients who were hemodynamically stable (group 1) or even unstable (group 2) underwent AE first, based on CT findings. AE was successful in all cases. The mortality rate was 7% (1/14). Only two angiography-related complications (gallbladder infarction) were reported. Liver-related complications (abdominal compartment syndrome and biliary complications) were frequent and often required secondary interventions. Our multidisciplinary approach for the management of BHT gives a main role to embolization, even for hemodynamically unstable patients. In this strategy AE is very efficient and has a low complication rate.

Multidisciplinary approach for the management of complex hepatic injuries AAST-OIS grades IV-V: a prospective study

BACKGROUND

Complex hepatic injuries grades IV-V are highly lethal. The objective of this study is to assess the multidisciplinary approach for their management and to evaluate if survival could be improved with this approach.

STUDY DESIGN

Prospective 54-month study of all patients sustaining hepatic injuries grades IV-V managed operatively at a Level I Trauma Center.

MAIN OUTCOME MEASURE

survival.

STATISTICAL ANALYSIS

univariate and stepwise logistic regression.

RESULTS

Seventy-five patients sustained penetrating (47/63%) and blunt (28/37%) injuries. Seven (9%) patients underwent emergency department thoracotomy with a mortality of 100%. Out of the 75 patients, 52 (69%) sustained grade IV, and 23 (31%) grade V. The estimated blood loss was 3,539+/-3,040 ml. The overall survival was 69%, adjusted survival excluding patients requiring emergency department thoracotomy was 76%. Survival stratified to injury grade: grade IV 42/52-81%, grade V 10/23-43%. Mortality grade IV versus V injuries (p < 0.002; RR 2.94; 95% CI 1.52-5.70). Risk factors for mortality: packed red blood cells transfused in operating room (p=0.024), estimated blood loss (p < 0.001), dysryhthmia (p < 0.0001), acidosis (p = 0.051), hypothermia (p = 0.04). The benefit of angiography and angioembolization indicated: 12% mortality (2/17) among those that received it versus a 36% mortality (21/58) among those that did not (p = 0.074; RR 0.32; 95% CI 0.08-1.25). Stepwise logistic regression identified as significant independent predictors of outcome: estimated blood loss (p= 0.0017; RR 1.24; 95% CI 1.08-1.41) and number of packed red blood cells transfused in the operating room (p = 0.0358; RR 1.16; 95% CI 1.01-1.34).

CONCLUSIONS

The multidisciplinary approach to the management of these severe grades of injuries appears to improve survival in these highly lethal injuries. A prospective multi-institutional study is needed to validate this approach.

Is it more dangerous to perform inadequate packing?

Peri-hepatic packing procedure, which is the basic damage control technique for the treatment of hepatic hemorrhage, is one of the cornerstones of the surgical strategy for abdominal trauma. The purpose of this study was to evaluate the efficacy of the perihepatic packing procedure by comparing the outcomes of appropriately and inappropriately performed interventions. Trauma patients with liver injury were retrospectively evaluated. The patients who had undergone adequate packing were classified as Group A, and the patients who had undergone inappropriate packing, as Group B. Over a five-year period, nineteen patients underwent perihepatic packing. Thirteen of these patients were referred by other hospitals. Of 13 patients, 9 with inappropriate packing procedure due to insertion of intraabdominal drainage catheter (n=4) and underpacking (n=5) were evaluated in Group B, and the others (n=10) with adequate packing were assessed in Group A. Mean 3 units of blood were transfused in Group A and unpacking procedure was performed in the 24th hour. Only 3 (30%) patients required segment resection with homeostasis, and the mortality rate was 20% (2/10 patients). In Group B, 4 patients required repacking in the first 6 hrs. Mean 8 units of blood were transfused until unpacking procedure. The mortality rate was 44% (4/9 patients). The length of intensive care unit stay and requirement of blood transfusion were statistically significantly lower in Group A (p < 0.05). The mortality rate of this group was also lower. However, the difference between the groups for mortality rates was not statistically significant. This study emphasizes that efficacy of the procedure is one of the determinants that affects the results, and inadequate or inappropriate packing may easily result in poor outcome.

Complex Hepatic Injuries: an Audit from a Tertiary Center

BACKGROUND

Nonoperative management is being increasingly employed in the management of blunt hepatic injuries.

PATIENTS AND METHODS

We analyzed patients with complex hepatic injuries over a period of 10 years (1996-2006).

RESULTS

Two hundred and ten patients with blunt hepatic injury were admitted and 103 patients had complex liver injuries. The predominant mode of injury was road traffic accidents in 91.2%. The grade distribution of liver injuries was grade III (72.8%), grade IV (23.3%) and grade V (4.9%). Twenty-four patients (23.3%) underwent surgery for persistent hemodynamic instability, persistent fall in hemoglobin level, bile leaks and intra-abdominal collection with sepsis. Associated intra-abdominal injuries were present in 19.4%, and 58.4% had associated extra-abdominal injuries. The operative procedures included hepatectomy (1), suture hepatorraphy (12), T-tube drainage for bile duct injuries (5), perihepatic sponge and gel foam packing (9), liver abscess drainage (3), and resection and debridement of liver tissue in six patients. The mortality and morbidity in this series was 10.7 and 56.4%, respectively. Multiorgan failure was present in 5, single organ failure in 37, sepsis in 24, biliary complications in 16 and intra-abdominal collection in 17 patients. Endoscopic management for bile leaks was performed in five patients, image-guided pig-tail drainage for abscesses in 11 patients, while angioembolization was done in two patients for right hepatic artery bleed. The mortality was not significantly different in surgical and nonoperative groups but operated patients had significantly higher morbidity.

CONCLUSIONS

Complex liver injuries can be managed successfully with conservative treatment in majority, with low mortality and acceptable morbidity. Surgery is reserved for selected indications.

Packing for control of hemorrhage in major liver trauma

BACKGROUND

Packing for complex liver injuries has been associated with an increased risk of abdominal sepsis and bile leaks. The aim of the present study was to determine the optimum timing of pack removal and to assess whether the total duration of packing increases the incidence of these complications.

METHODS

The study was based on a retrospective review of all patients requiring liver packing over an 8-year period in a level 1 trauma center.

RESULTS

Ninety-three (17%) of 534 liver injuries identified at laparotomy required perihepatic packing. Penetrating and blunt trauma occurred in 72 (77%) and 21 (23%), respectively. The mean total duration of packing was 2.4 days (range: 0.5-6.0 days). There was no association between the total duration of packing and the development of liver-related complications (P = 0.284) or septic complications (P = 0.155). Early removal of packs at 24 h was associated with a higher rate of re-bleeding than removal of packs at 48 h (P = 0.006).

CONCLUSIONS

The total duration of liver packing does not result in an increase in septic complications or bile leaks. The first re-look laparotomy should only be performed after 48 h. An early re-look at 24 h is associated with re-bleeding and does not lead to early removal of liver packs.

Liver injuries--improved results with a formal protocol including angiography

OBJECTIVE

We hypothesised that a formal treatment protocol for liver injuries including angiography would increase the non-operative management (NOM) rate and would be efficient as an adjunct to damage control surgery.

METHODS

During the 4-year period from 1 August 2000, a total of 138 adult patients with liver injuries were admitted to the largest trauma centre in Norway and prospectively included in the institutional trauma registry. On 1 August 2002, a protocol mandating angiography in all NOM patients with OIS grades 3-5 liver injuries and after packing of the liver was implemented. All patients admitted during the subsequent 2-year period (group 2) were compared with the previous 2 years as historic controls (group 1).

RESULTS

Fifty-five patients were included in group 1 and 59 in group 2. The groups were statistically comparable, both with a mean ISS of 31. Patients selected for NOM increased from 28 (51%) to 45 (76%) (p<0.05), without increasing failure rate, liver-related complications, mortality or transfusion rate. Angiography was performed in 26 patients in group 2 (44%). Only nine patients underwent embolisation (35%), and five of these were in the NOM group. Angiography was negative in the eight NOM stable patients with OIS grade 3 injury.

CONCLUSION

The implementation of a formal NOM protocol decreased total laparotomy rate and seemed to improve patient outcome without jeopardising patient safety. Surprisingly few of the patients undergoing angiography required embolisation. Angiography is not indicated in stable OIS grade 3 liver injuries, and the protocol in our institution has been adjusted accordingly. AE seems to be a valuable adjunct to DCS with packing of liver injuries.

Diagnosis and management of blunt abdominal solid organ injury

PURPOSE OF REVIEW

Nonoperative management of solid organ injuries has become the standard of care for over 25 years. Benefits of this practice include reduced operative complications, reduced transfusions, lower infectious morbidity, and shorter length of stay. Patients eligible for this management practice include those who are hemodynamically stable and who do not have associated injuries that require celiotomy. Operative interventions need to occur expeditiously in hemodynamically unstable patients with hepatic and splenic injuries.

RECENT FINDINGS

Recent literature has focused on the continued success with nonoperative management of blunt solid organ injuries. The role of angioembolization for both splenic and hepatic injuries continues to be explored. Other authors are also questioning the appropriateness of clinical decisions for selection of hemodynamically unstable patients for nonoperative management. Operative management of blunt pancreatic trauma remains the rule.

SUMMARY

Nonoperative management of solid organ injuries continues to have high success rates in the appropriate patient population. Minimally invasive adjuncts have a definite role in management of this patient population. Pancreatic trauma remains an operative injury. Surgeons must, however, temper the enthusiasm for nonoperative management of patients with solid organ injury, and exclude from this management scheme patients who would best be treated with surgery.

Prevention of Bile Peritonitis by Laparoscopic Evacuation and Lavage after Nonoperative Treatment of Liver Injuries

One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2–18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic inflammatory response syndrome, respiratory compromise, or elevated bilirubin. The bile and retained hematoma was evacuated from around the liver and closed-suction drainage was placed. Twenty-eight patients underwent laparoscopic evacuation/lavage of bile collections (about 4% of total blunt liver injuries). The majority (75%) had Grade IV or V injury. The amount of evacuated fluid ranged from 300 to 3800 mL. Other adjunctive procedures (endoscopic retrograde pancreaticocholangiography, angiography, and laparotomy) were occasionally required. There were no complications related to the procedure. Most patients had a dramatic decline in tachycardia, temperature, white blood cell count, serum bilirubin, and pain. Respiratory failure also resolved in most patients. Large bile and/or blood accumulations are present in a subset of patients with severe liver injuries treated nonoperatively. Delayed laparoscopic evacuation of these collections prevents bile peritonitis and decreases inflammatory response and avoiding early operation, which has been implicated in increased death from hemorrhage.

Trauma care at rural level III trauma centers in a state trauma system

BACKGROUND

Although much has been written about the benefits of trauma center care, most experiences are urban with large numbers of patients. Little is known about the smaller, rural trauma centers and how they function both independently and as part of a larger trauma system. The state of Missouri has designated three levels of trauma care. The cornerstone of rural trauma care is the state-designated Level III trauma center. These centers are required to have the presence of a trauma team and trauma surgeon but do not require orthopedic or neurosurgical coverage. The purpose of this retrospective study was to determine how Level III trauma centers compared with Level I and Level II centers in the Missouri trauma system and, secondly, how trauma surgeon experience at these centers might shape future educational efforts to optimize rural trauma care.

METHODS

During a 2-year period in 2002 and 2003, the state trauma registry was queried on all trauma admissions for centers in the trauma system. Demographics and patient care outcomes were assessed by level of designation. Trauma admissions to the Level III centers were examined for acuity, severity, and type of injury. The experiences with chest, abdominal, and neurologic trauma were examined in detail.

RESULTS

A total of 24,392 patients from 26 trauma centers were examined, including all eight Level III centers. Acuity and severity of injuries were higher at Level I and II centers. A total of 2,910 patients were seen at the 8 Level III centers. Overall deaths were significantly lower at Level III centers (Level I, 4% versus Level II, 4% versus Level III, 2%, p < 0.001). Numbers of patients dying within 24 hours were no different among levels of trauma care (Level I, 37% versus Level II, 30% versus Level III, 32%). Among Level III centers 45 (1.5%) patients were admitted in shock, and 48 (2%) had a Glasgow Coma Scale score <9. Twenty-six patients had a surgical head injury (7 epidural, 19 subdural hematomas). Twenty-eight patients (1%) needed a chest or abdominal operation. There were 15 spleen and 12 liver injuries with an Abbreviated Injury Score of 4 or 5.

CONCLUSIONS

Level III trauma centers performed as expected in a state trauma system. Acuity and severity were less as was corresponding mortality. There were a paucity of life-threatening head, chest, and abdominal injuries, which provide a challenge to the rural trauma surgeon to maintain necessary skills in management of these critical injuries.

Immediate postoperative angiographic embolization after damage control surgery for liver injury: report of a case

A multimodality strategy, including damage control and angioembolization techniques, has been reported to reduce the mortality associated with surgery for complex blunt hepatic injuries. However, the indications for angiographic evaluation and embolization in patients who require surgery for hepatic injury remain unclear. We report a case of blunt hepatic injury requiring emergency laparotomy, which we treated by damage control surgery because of an inaccessible major venous injury and the fact that coagulopathy was stopping hemostasis. The decision to perform immediate postoperative angiography was based on the hemorrhagic response to Pringle's maneuver and its release after perihepatic packing during surgery. Hepatic angiography revealed extravasation from a branch of the middle hepatic artery, which was embolized successfully. Although the definitive indications for immediate postoperative angioembolization for hepatic injury have not been established, the hemorrhagic response to Pringle's maneuver and its release after perihepatic packing during damage control surgery is an indication for immediate postoperative angioembolization.

Nonoperative management of spleen and liver injuries

The spleen and liver are the 2 most commonly injured abdominal organs following trauma. Trends in management have changed over the years, and the majority of these injuries are now managed nonoperatively. Splenic injuries can be managed via simple observation or with angiography and embolization. Recent data suggest that there are few true contraindications in the setting of hemodynamic stability. Success rate of nonoperative management may be as high as 95%. Liver injuries can be approached similarly. In the setting of a hemodynamically stable patient, observation with or without angiography and embolization may similarly be used. As many as 80% of patients with liver injury can be successfully managed without laparotomy. This review will discuss current concepts in nonoperative management of liver and spleen, including diagnosis, patient selection, nonoperative management strategies, benefits, risks, and complications.

Current advances in the surgical approach to abdominal trauma

The management of abdominal injury has changed dramatically during the past two decades. This review examines the historic perspectives and recent developments of diagnosis and treatment of liver injuries, splenic injuries, and pancreatic injuries. The incorporation of non-operative management for liver injuries has had a very positive effect on mortality. Likewise, splenic conservative therapy is routinely used. The early treatment of pancreatic injury has changed very little; however, the ability to recognize these difficult injuries has improved with higher quality CT scanning. The authors present their preferred treatment for these three common types of abdominal solid organ injury and present an illustrative case example.

[Surgical management of abdominal injury]

PURPOSE

Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury.

METHODS

Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine.

RESULTS

Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this.

DISCUSSION

Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.

Major hepatic trauma: warm ischemic tolerance of the liver after hemorrhagic shock

BACKGROUND

The management of severe hepatic trauma frequently involves exposing the liver to varying periods of warm ischemia. The ischemic tolerance of the liver, in the setting of hemorrhagic shock (HS) and trauma, is presently unknown. We tested the hypothesis that warm ischemic tolerance of the porcine liver will be decreased following resuscitation from HS.

MATERIALS AND METHODS

Twenty-three Yorkshire pigs were divided into three groups: 1) hepatic ischemia alone (HI, n = 9); 2) hemorrhagic shock alone (HS, n = 3); and 3) hemorrhagic shock plus hepatic ischemia combined (HSHI, n = 11). Following reperfusion, a liver biopsy was obtained and serial blood chemistries were sampled.

RESULTS

Post-operative day 7 mortality was increased in the HSHI group (7/11) compared to the HI (0/9) group, P = 0.038. Notably, deaths did not result from acute liver failure, but rather from intra-operative hemodynamic collapse shortly following hepatic reperfusion. In addition, the HSHI group experienced significantly elevated lactic acid, serum creatinine and liver enzyme levels. Analysis of the liver biopsy samples is consistent with a more severe liver injury in the HSHI group.

CONCLUSIONS

The warm ischemic tolerance of the liver following resuscitation from HS is significantly decreased in this porcine model compared to HS or HI alone. Mortality was associated with acute intra-operative hemodynamic collapse occurring shortly after hepatic reperfusion.

Staged management and outcome of combined pelvic and liver trauma. An international experience of the deadly duo

Pelvic fracture associated with liver trauma is not an uncommon injury combination in multiple trauma and is associated with high morbidity and mortality. The aim of this study was to examine the characteristics of this specific patient group, to describe the diagnostic and treatment protocols and finally to analyse risk factors associated with mortality. Data were collected over a 6-year period, ending in 2001. The pelvic injury was graded according to the Tile classification system and the hepatic injury was scored using the organ injury scale (OIS). Treatment protocol, associated injuries, complications, length of ICU/Hospital stay and mortality were recorded and analysed. A total of 140 patients (40% female) with a mean age of 35.1+/-15.9 years and a median ISS of 41 were included in this study. The overall mortality rate was 40.7%. Binomial logistic regression analysis revealed age, initial blood pressure, transfusion requirement as well as the severity of head, chest, spleen and liver injury as independent parameters predicting reduced survival rates. This deadly duo of injuries presents a challenge to the trauma surgeon. Rapid assessment and treatment is required to prevent death by haemorrhage. The presence of concomitant injuries renders the patient very sensitive to ongoing or additional physiological disturbance. The principles of 'damage control surgery' must be applied to avoid complications such as acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS).

CT in blunt liver trauma

Nonsurgical treatment has become the standard of care in hemodynamically stable patients with blunt liver trauma. The use of helical computed tomography (CT) in the diagnosis and management of blunt liver trauma is mainly responsible for the notable shift during the past decade from routine surgical to nonsurgical management of blunt liver injuries. CT is the diagnostic modality of choice for the evaluation of blunt liver trauma in hemodynamically stable patients and can accurately help identify hepatic parenchymal injuries, help quantify the degree of hemoperitoneum, and reveal associated injuries in other abdominal organs, retroperitoneal structures, and the gastrointestinal tract. The CT features of blunt liver trauma include lacerations, subcapsular or parenchymal hematomas, active hemorrhage, juxtahepatic venous injuries, periportal low attenuation, and a flat inferior vena cava. It is important that radiologists be familiar with the liver injury grading system based on these CT features that was established by the American Association for the Surgery of Trauma. CT is also useful in the assessment of delayed complications in blunt liver trauma, including delayed hemorrhage, hepatic or perihepatic abscess, posttraumatic pseudoaneurysm and hemobilia, and biliary complications such as biloma and bile peritonitis. Follow-up CT is needed in patients with high-grade liver injuries to identify potential complications that require early intervention.