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

Transcatheter arterial embolization in a hemodynamically unstable patient with grade IV blunt liver injury: is nonsurgical management an option?

The prevalence of liver injury in patients who have sustained blunt multiple trauma was reported to range from 1 to 8%. Because previous mortality rates were as high as 50-80% for severe hepatic injury, the choice of treatment was under intensive investigation. Whereas nonsurgical management was the standard treatment for the hemodynamically stable patient, there is no consensus on how to treat hemodynamically unstable patients. This report details the case of a patient who sustained blunt multiple trauma, resulting in a grade IV liver injury, graded according to the American Association for the Surgery of Trauma (AAST) Liver Injury Scale. With massive fluid and blood resuscitation, the patient was stable enough to be managed nonsurgically. With transcatheter arterial embolization (TAE), the left and right hepatic arteries were embolized with coils, which allowed for a good recovery. We hypothesize that TAE can be used in the hemodynamically unstable patient who responds to rapid fluid resuscitation and blood transfusion. We caution that there is insufficient evidence until now and would therefore not make any recommendations; however, we would question the need for surgery in unstable patients with this kind of injury in the future.

Complications of Nonoperative Management of High-Grade Blunt Hepatic Injuries

BACKGROUND

Nonoperative management of blunt hepatic injuries is highly successful. Complications associated with high-grade injuries, however, have not been well characterized. The purpose of the present study was therefore to define hepatic-related complications and associated treatment modalities in patients undergoing nonoperative management of high-grade blunt hepatic injuries.

METHODS

Three hundred thirty-seven patients from two regional Level I trauma centers with grade 3 to 5 blunt hepatic injuries during a 40-month period were reviewed. Complications and treatment of hepatic-related complications in patients not requiring laparotomy in the first 24 hours were identified.

RESULTS

Of 337 patients with a grade 3 to 5 injury, 230 (68%) were managed nonoperatively. There were 37 hepatic-related complications in 25 patients (11%); 63% (5 of 8) of patients with grade 5 injuries developed complications, 21% (19 of 92) of patients with grade 4 injuries, but only 1% (1 of 130) of patients with grade 3 injuries. Complications included bleeding in 13 patients managed by angioembolization (n = 12) and laparotomy (n = 1), liver abscesses in 2 patients managed with computed tomography-guided drainage (n = 2) and subsequent laparotomy (n = 1). In one patient with bleeding, hepatic necrosis followed surgical ligation of the right hepatic artery and required delayed hepatic lobectomy. Sixteen biliary complications were managed with endoscopic retrograde cholangiopancreatography and stenting (n = 7), drainage (n = 5), and laparoscopy (n = 4). Three patients had suspected abdominal sepsis and underwent a negative laparotomy, whereas an additional three patients underwent laparotomy for abdominal compartment syndrome.

CONCLUSION

Nonoperative management of high-grade liver injuries can be safely accomplished. Mortality is low; however, complications in grade 4 and 5 injuries should be anticipated and may require a combination of operative and nonoperative management strategies.

Use of a Refined Operative Strategy in Combination with the Multidisciplinary Approach to Manage Blunt Juxtahepatic Venous Injuries

BACKGROUND

Despite continuous advances in traumatology, juxtahepatic venous injuries are still the most difficult and deadly form of liver trauma. Most deaths result from exsanguination, and reported mortality ranges from 50% to 80%. This is an evaluation on our experience with the management of this high mortality injury following a refined operative strategy.

METHODS

This is a retrospective study of consecutive patients sustaining blunt juxtahepatic venous injuries. The management for these patients was mainly a refined operative strategy combined with a multidisciplinary approach. Preoperative conditions and the patient demographics were gathered. In addition, the number and type of interventional procedures, overall complications, and operative procedures were collected and analyzed.

RESULTS

From January, 1996 to March, 2004, 19 patients (M:F = 13:6) with juxtahepatic venous injuries were included and all were managed operatively. The operative procedures included hepatectomy by finger fracture technique for direct repair (8), perihepatic packing (1), packing and hepatic artery embolization (1), packing and hepatic artery ligation (1), hepatorrhaphy and packing (5), packing followed by hepatectomy (2) and atriocaval shunt for direct repair (1). The survival rate for the packing group was higher than that of the direct repair group (75% versus 45%), but was not statistically significant (p = 0.352). Injury to the retrohepatic vena cava influenced the patient's survival significantly (p = 0.041). The overall survival was 58% (11/19).

CONCLUSION

A well-defined operative strategy helps surgeons deal with the problem of blunt juxtahepatic venous injury, and its combination with multidisciplinary management will improve patient outcomes.

Use of Recombinant Activated Factor VII to Treat the Acquired Coagulopathy of Trauma

Recombinant activated factor VII (rFVIIa) is a drug commonly utilized in the treatment of patients with hemophilia and inhibitors. However, its use in previously normal patients with an acquired coagulopathy after trauma and surgery is increasing. Multiple trauma case reports and several case series are available, lending support for the efficacy of the drug in reversing the coagulopathy of trauma. Data from six large animal studies evaluating the efficacy in trauma models are available for evaluation. A single prospective randomized study in elective surgery has recently been published, documenting reduced blood loss and decreased transfusion after a single preoperative dose. This review describes those studies and reiterates the need for well designed prospective randomized human trauma studies.

Traumatic ureteral injuries: a single institution experience validating the American Association for the Surgery of Trauma-Organ Injury Scale grading scale

PURPOSE

Ureteral injuries are uncommon and challenging. In this study we report our institutional experience with ureteral injuries. We evaluated the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for ureteral injuries as a predictor of outcomes for complexity of repair, morbidity, mortality and associated injuries.

MATERIALS AND METHODS

We performed a retrospective, 120-month study (January 1992 to December 2002) at an urban, level I trauma center.

RESULTS

In the 57 patients mean hospital Admission blood pressure +/- SD was 115 +/- 25 mm Hg, mean Revised Trauma Score was 7.38 +/- 0.84 and mean Injury Severity Score was 15 +/- 1.15. The mechanism of injury was penetrating in 55 cases (96.5%), including gunshot wound in 52 (54.5%) and stab wound in 2 (5.5%), and in blunt 2 of motor vehicle accidents (3.5%). The anatomical location was the left side in 33 cases (58%), right side in 23 (40%) and bilateral in 1 (2%). The distribution of injuries was proximal in 15 cases (26%), mid in 21 (37%) and distal in 21 (37%). Associated injuries were present in 56 patients (98%). An intraoperative diagnosis was made in 44 cases (77%). Of the patients 50 (88%) required complex repairs or an adjunct procedure, including a double pigtail stent in 33 (58%), ureteroureterostomy in 20 (35%), ureteroneocystostomy with a psoas hitch in 10 (18%), external diversion in 9 (16%), suprapubic cystostomy in 8 (14%), nephrostomy in 2 (3.5%), nephrectomy in 2 (3.5%) and ligation in 2 (3.5%). Injury grade was I to V in 5 (8%), 8 (13%), 13 (22.8%), 18 (31.6%) and 13 (22.8%) cases, respectively. Overall 51 patients (89%) survived. No deaths were related to ureteral injury. Renal salvage was achieved in 49 of the 51 surviving patients (96%).

CONCLUSIONS

Ureteral injuries are uncommon. The complexity of repair and number of associated injuries increase with AAST-OIS injury grade. Mortality increases with AAST-OIS injury grade but it is not related to the ureteral injury. Excellent results can be achieved with complex techniques of primary repair, leading to renal salvage.

Multi-detector row CT imaging of blunt abdominal trauma

CT is the imaging modality of choice to evaluate hemodynamically stable patients suffering blunt abdominal trauma. During the past five years, single-slice helical CT has been replaced by multidetector row CT (MDCT). This development has revolutionized cross-sectional imaging for blunt trauma patients. Volumetric imaging with helical CT has been a major factor supporting the nonoperative management of solid organ injury. Trauma centers in the United States are replacing single-slice helical CT scanners with state-of-the-art MDCT in suites proximate to the patient receiving area and with facilities for monitoring and maintaining physiologic support. The ability to obtain high-resolution images with MDCT during optimal contrast enhancement at unparalleled speed helps detect the presence and define the extent of injuries, and crucially, to diagnose hemorrhage and vascular injuries. This article describes our current imaging protocol with MDCT-16 (i.e., 16 detector MDCT), the spectrum of diagnostic findings seen in blunt abdominal injury, and the role of MDCT in the characterization of hemorrhage and planning injury management.

Reevaluating the Management and Outcomes of Severe Blunt Liver Injury

BACKGROUND

The purpose of this study was to identify risk factors that predict the need for operative management (OM) of severe blunt liver injury. We also sought to determine the impact of interventional angiography (Ang) in the treatment and outcomes of these patients.

METHODS

Patients with blunt liver injuries of grade IV or higher were retrospectively reviewed for their demographics, hemodynamics, blood product requirements, laboratory and radiologic data, hospital course, and outcomes.

RESULTS

Forty-four patients underwent OM. They had a significantly higher Injury Severity Score (ISS) and lower Glasgow Coma Scale score (p = 0.004), a lower systolic blood pressure (p = 0.002) and a higher heart rate (p = 0.02), and higher fluid and transfusion requirements (p < 0.001) than those treated without OM. Their mortality rate was 66%; 59% of deaths were from uncontrolled bleeding. Initial platelet count and fluid requirements at 4 hours were independent predictors of the need for OM. Ang was performed in 48 patients. Patients who were treated without Ang required more fluids (p = 0.03) and more packed red blood cells (p = 0.02) at 4 hours. Patients requiring both OM and Ang had a higher complication rate (p = 0.02) and longer intensive care unit and hospital length of stay (p < 0.001) than those who had OM alone, but mortality was the same (p = 0.1). Patients treated nonoperatively had longer intensive care unit (p = 0.006) and hospital stays (p < 0.05) if they required Ang, but mortality was the same. The only survival advantage to the use of Ang was when Ang alone was compared with OM alone.

CONCLUSION

Select high-grade injuries can be successfully managed nonoperatively. Initial platelet count and crystalloid fluid use at 4 hours predict the need for OM. Patients requiring OM are less stable and have substantial mortality but often do not die as a result of uncontrolled bleeding. Ang has a role in stable patients who do not require OM initially but does not improve outcome in patients who require OM.