Hepatic trauma and its management

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Management of traumatic liver injuries without a valid trauma system

INTRODUCTION

Despite a global increase in conservative treatment of blunt liver injuries, the number of surgically treated traumas in one major trauma center in Iran has increased. The aim of this study was to unveil the reasons behind this increase in operative management by studying 228 consecutive patients at this regional center.

HYPOTHESIS

The increased number of liver injuries operated upon is due to the lack of a solid, well-defined trauma system.

METHODS

A retrospective review of all patients admitted for liver trauma at Bahonar Hospital, Kerman, Iran, from March 2001 until March 2006 was conducted. Patient data were collected, studied and statistically processed with regard to demographics, clinical and laboratory findings, surgical procedures, complications, and mortality.

RESULTS

All patients who were admitted between 30-360 minutes after injury were included. Twelve hemodynamically stable patients were treated conservatively in an ordinary surgical ward. The remaining 216 patients, 153 of whom had blunt injuries, were hemodynamically unstable. A total of 70 patients were in hemorrhagic shock at the time of arrival. Hemodynamically unstable patients with either the suspicion of associated injuries and/or who displayed clinical deterioration and could not be observed in an ordinary surgical ward were treated surgically. The majority of patients who were operated upon in this series had a grade-II liver injury. The total mortality rate in surgically treated patients was 18.1%. None of the patients treated conservatively died.

CONCLUSIONS

Despite the low grade of their liver injuries, the high number of surgically treated patients in this series was due to the absence of a valid trauma system. This result should encourage the authorities to review current trauma systems and trauma surgical guidelines.

[Surgical treatment of liver trauma: resection--when and how?]

Liver resection as an emergency procedure in patients with liver injury due to abdominal trauma has become a rare procedure. In most cases liver trauma can be managed conservatively. Currently surgery is only indicated in hemodynamically instable patients and in cases of progredient haematoma where the main aim is control of bleeding. Anatomical liver resection should be avoided and may only be performed in cases of total vascular avulsion. Debridement of devascularized tissue can also be carried out in terms of an atypical liver resection. This article elucidates the current indications for liver resection after traumatic liver injury.

[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.

Eleven years of liver trauma: the Scottish experience

The aim of this population based study was to assess the incidence, mechanisms, management, and outcome of patients who sustained hepatic trauma in Scotland (population 5 million) over the period 1992-2002. The Scottish Trauma Audit Group database was searched for details of any patient with liver trauma. Data on identified patients were analyzed for demographic information, mechanisms of injury, associated injuries, hemodynamic stability on presentation, management, and outcome. A total of 783 patients were identified as having sustained liver trauma. The male-to-female ratio was 3:1 with a median age of 31 years. Blunt trauma (especially road traffic accidents) accounted for 69% of injuries. Liver trauma was associated with injuries to the chest, head, and abdominal injuries other than liver injury; most commonly spleen and kidneys. In all, 166 patients died in the emergency department, and a further 164 died in hospital. The mortality rate was higher in patients with increasing age (p < 0.001), hemodynamic instability (p < 0.001), blunt trauma (p < 0.001), and increasing severity of liver injury (p < 0.001). The incidence of liver trauma in Scotland is low, but it accounts for significant mortality. Associated injuries were common. Outcome was worse in patients with advanced age, blunt trauma, multiple injuries and those requiring an immediate laparotomy.

A 10-year experience of complex liver trauma

BACKGROUND

Liver trauma is a relatively rare surgical emergency but mortality and morbidity rates remain significant. It is likely that surgeons outside specialist centres will have limited experience in its management; therefore best practice should be identified and a specialist approach developed.

METHODS

Data collected from 52 consecutive patients over a 10-year interval were examined to identify best practice in the management of these injuries.

RESULTS

The majority of injuries occurred as a result of road traffic accidents; 39 (75 per cent) of the 52 patients were stable at presentation to the referring hospital. In 36 patients (69 per cent) the liver injury was a component of multiple trauma. Ultrasonography, computed tomography or no radiological investigation was used in the referring hospital in 18 (35 per cent), 25 (48 per cent) and nine (17 per cent) patients respectively. Operative management was undertaken in the referring hospital in 26 patients (50 per cent). The overall mortality rate was 23 per cent (12 of 52 patients), and increased with increasing grade of severity. Eight of 26 patients managed surgically at the referring hospital died, compared with four of the 26 patients managed without operation (P not significant). The median time from arrival at the referring hospital to operation was 4 h for haemodynamically stable patients and 3 h for those who were haemodynamically unstable.

CONCLUSION

Most patients with liver trauma can be managed conservatively. Operative management carried out in non-specialized units is associated with high mortality and morbidity rates. Abdominal injuries should raise a high index of suspicion of liver injury, and the data suggest that computed tomography of the abdomen should precede laparotomy (even in some haemodynamically unstable patients) to facilitate discussion with a specialist unit at the earliest opportunity.

Management of liver trauma with implications for the rural surgeon

BACKGROUND

The majority of patients with liver trauma can be managed conservatively. However, the unstable patient requires emergency laparotomy to control bleeding. Controversy exists regarding the primary surgical management of these injuries. This is of particular relevance for the isolated rural general surgeon.

METHODS

The literature was reviewed by searching MEDLINE databases from 1966 to the present time. The majority of the evidence presented is level 3, with interpretations and recommendations based on the experience of the senior authors.

RESULTS

In the majority of patients, conservative management remains the mainstay of treatment. However, haemodynamic -instability requires urgent laparotomy. Perihepatic packing should be used to arrest bleeding. Primary anatomical resection is rarely indicated, especially in non-specialist centres.

CONCLUSION

In the remote rural setting, severe liver trauma remains a daunting condition for the general surgeon to manage. Primary surgical treatment should be perihepatic packing, stabilization and urgent transfer; there is no place for primary anatomical resection outside specialist units.

Evolution in the treatment of complex blunt liver injuries

Over the last decade, major changes in the treatment of patients with blunt liver injuries have occurred, specifically with the nonoperative treatment of more complex injuries. These major changes can be summarized as follows: 1. Patients with blunt liver injuries are screened expeditiously by surgeon-performed ultrasonography. Depending on the initial findings and response to resuscitation, further decisions are made regarding the further evaluation. 2. Computed tomographic scanning is the mainstay of diagnosis for hepatic injuries after blunt trauma; the initial CT findings will help the trauma surgeon to determine the nonoperative treatment. 3. Liver injuries of grades I through III can be observed safely in a monitored unit and not necessarily in an ICU setting. Patients with injuries of grades IV and V are best initially observed in an ICU. 4. More than two thirds of patients with injuries of grades IV and V can be treated nonoperatively. However, 50% of these patients will require some type of interventional treatment, but not necessarily a laparotomy. 5. Initial findings on the CT scan can help to identify those patients who will need some type of interventional treatment and to identify associated injuries. 6. Elderly patients or patients with associated medical comorbidities can also be treated nonoperatively if strict guidelines are followed. 7. Complications in patients with complex blunt liver injuries are not uncommon. However, most of the complications can be safely treated by less invasive procedures.

Management of liver trauma

BACKGROUND AND METHODS

Management of blunt or penetrating injuries to the liver remains a significant challenge. This review discusses the mechanisms of liver injury, grading system for severity, available diagnostic modalities and current management options. It is based on a Medline literature search and the authors' clinical experience.

RESULTS

Unstable patients require immediate laparotomy, but selected patients who are haemo- dynamically stable may be managed without operation. The preferred operative techniques include resectional debridement, hepatotomy with direct suture ligation and perihepatic packing; anatomical resection, hepatic artery ligation and various bypass techniques have a limited, more defined role for selected injuries. Major complications include haemorrhage, sepsis and bile leak.

CONCLUSION

Enhanced resuscitation, anaesthesia and intensive care have contributed to a significant reduction in mortality rates from liver trauma. Optimum results are obtained with a specialist team that includes an experienced liver surgeon, anaesthetist, endoscopist and interventional hepatobiliary radiologist with expertise in managing postoperative complications.

Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries

BACKGROUND

Recognizing the significant mortality and complications inherent in the operative management of blunt hepatic injuries, hepatic arterial embolization was evaluated as a bridge between operative and nonoperative interventions in patients defined as hemodynamically stable only with continuous resuscitation.

METHODS

Seven of 11 patients with grade IV or V hepatic injuries identified by computed tomography underwent hepatic arterial embolization. A prospective evaluation of hepatic embolization based on subsequent hemodynamic parameters was assessed by matched-pair analysis. A summary of this study population's demographic data and outcomes is presented, including age, Glasgow Coma Scale score, Injury Severity Score, Revised Trauma Score, computed tomography grade, intensive care unit and hospital length of stay, transfusion requirements, complications, and mortality.

RESULTS

No statistical difference was demonstrated between pre-embolization and postembolization hemodynamics and volume requirements. After embolization, however, continuous resuscitation was successfully reduced to maintenance fluids. Hepatic embolization was the definitive therapy for all seven patients who underwent embolization.

CONCLUSION

Results of this preliminary investigation suggest that hepatic arterial embolization is a viable alternative bridging the therapeutic options of operative and nonoperative intervention for a subpopulation of patients with hepatic injury.

Clinical analysis of the utility of repeat computed tomographic scan before discharge in blunt hepatic injury

OBJECTIVES

Nonoperative management of hemodynamically stable blunt hepatic injury has emerged as an acceptable and safe treatment. Surveillance of this population's injuries is costly. As a prelude to establishing practice guidelines, the utility of repeat computed tomographic (CT) scans was investigated.

METHODS

A retrospective study was conducted on 243 hepatic injuries. The CT scans of 95 patients managed nonoperatively who did not have ongoing transfusion requirements were reviewed and graded according to the American Association for the Surgery of Trauma (AAST) hepatic injury scale. Patients were grouped according to injury grade, assigned to two subgroups (patients with one CT scan versus more than one CT scan) and compared with respect to several physiologic and clinical variables.

RESULTS

Statistical analysis revealed no significant difference between subgroups with the same grade of injury. No significant difference was demonstrated between subgroups' length of stay.

CONCLUSIONS

No patients failed nonoperative treatment or succumbed to their injuries. Findings on repeat CT scan have not altered the decision to discharge the clinically stable patient having suffered a grade III or lower liver injury.

Review of liver trauma management in Tasmania: an analysis of risk factors for mortality and morbidity

A review of liver trauma treated by the major trauma care facilities of Tasmania in the 5 year period between 1989 and 1993 is presented. The aim of this retrospective review was to provide an audit of the management of liver trauma in the island of Tasmania and to analyse the risk factors contributing to mortality and major morbidity. Thirty-seven patients were treated with a median Injury Severity Score (ISS) of 14 (range 9-34). The overall mortality rate of this series was 5.8%. Age, mechanism of injury (blunt or penetrating), delay prior to hospital presentation and modality of treatment (operative or non-operative) were not significant risk factors for mortality and morbidity; however, transfusion requirement of over 10 units of blood (P < 0.005), ISS score of over 20 (P < 0.0005), haemodynamic instability at presentation (P < 0.05) and a Hepatic Injury Score (HIS) grade of 3 or more (P < 0.05) were statistically significant risk factors.