A 10-year experience of complex liver trauma

Liver Transplantation Following Life-threatening Abdominal Trauma: A Case Series of 5 Patients at a Single Institution

Managing traumatic liver injury (TLI) is always challenging and demands precise clinical judgment. Currently, treatment of TLI in most circumstances is non-operative; however, surgical therapy might be required for severe TLI, particularly those that result in extensive blood loss. In the current institutional study carried out from June 1995 to April 2017, we describe our experience with 5 patients who received an orthotopic liver transplant for severe TLI. One patient passed away postoperatively from cerebral edema; 1 patient died of renal failure 4 years after the liver transplantation, and 3 patients are still alive. Based on our experience, we conclude that in patients with TLI, especially those with uncontrollable bleeding or those who develop liver failure, liver transplantation should be taken into consideration.

Traumatic Liver Injury in Hong Kong: The Management Strategy and Outcome

Introduction

Management of liver injury is challenging and evolving. The aim of this article is to review the outcome of traumatic liver injury in Chinese people in Hong Kong.

Materials & methods

Records of 40 patients with hepatic injury who received treatment at the Prince of Wales Hospital between December 2000 and May 2005 were reviewed. Demographic data, severity of liver injury, Injury Severity Score (ISS), haemodynamic status and Glasgow Coma Scale (GCS) score on admission, investigations made, concomitant injuries, management scheme, and outcome of patients were analysed.

Results

There were 23 male and 17 female patients with a mean age of 31.3 (SD=15.4) years. Road traffic accident was the most common injury mechanism (65%). Half of the patients were treated by non-operative management (NOM). None of them required surgery during subsequent management. Patients in the operative management (OM) group had a significantly higher ISS (p=0.026), but there was no significant difference in the mortality rate between the OM and NOM groups. Patients with stable haemodynamic status and who were treated non-operatively had a significantly shorter hospital stay (p=0.006). High grade liver injury (OR=8.0, 95% CI=1.2 to 53.8, p=0.03) and ISS greater than 25 (OR=21.6, 95% CI=2.0 to 225.3, p=0.01) were independent risk factors for mortality on multivariate analysis.

Conclusions

Non-operative management of liver injury can be safely accomplished in haemodynamically stable patients, with the possible benefit of a shorter hospital stay.

Liver trauma

Management of blunt or penetrating injury to the liver remains a significant challenge to trauma surgeons. Liver injury remains common in both blunt and penetrating trauma of the abdomen. Unstable patients require immediate laparotomy. Selective patients can be managed without surgery and with careful monitoring. There has been a recent resurgence in the role of temporary packing in the management of liver trauma. Other commonly used techniques are resectional debribement and suture ligation of bleeding vessels. Complications include haemorrhage, bile leak and sepsis. Mortality is mainly due to damage to major hepatic blood vessels or other associated non-hepatic injuries. With improved understanding of the major causes of death from hepatic injury, improved resuscitation and intensive care, mortality has fallen below 10%.

Management of Liver Trauma in Minia University Hospital, Egypt

The aim of this study is to present the outcome of operative and non-operative management of patients with liver injury treated in a single institution depending on imaging. This study was conducted at the Causality Unit of Minia University Hospital, and included 60 patients with hepatic trauma from March 2012 to January 2013. In our study, males represent 80 % while females represent 20 % of the traumatized patients. The peak age for trauma found was 11-30 years. Blunt trauma is the most common cause of liver injury as it was the cause in 48 patients (80 %). Firearm injuries are the most common cause of penetrating trauma (60 %) followed by stab injuries (40 %). More than one half of our patients (34 out of 60) were treated with non-operative management (NOM) with a high success rate. The operative procedures done were suture hepatorrhaphy (20 cases), non-anatomical resection in one case, anatomical resection in one case, and damage control therapy using pads in two cases. In another two cases, nothing was done as subcapsular hematoma had resolved. Minia University Hospital is a big tertiary Hospital in Egypt at which blunt liver trauma is more common than penetrating liver trauma. Surgery is no longer the only option available. It has been reserved for extensive lesions with condition of hemodynamic instability or for the treatment of the complications. NOM is an effective treatment modality in most cases.

Comparison between operative versus non-operative management of traumatic liver injury

Backgrounds/Aims

The aim of this study was to compare operative versus non-operative management of patients with liver injury and to ascertain the differences of the clinical features.

Methods

From April 2000 to July 2012, 191 patients were admitted to Seoul St. Mary's Hospital and St. Vincent's Hospital for liver injuries. Of these, 148 patients were included in this study. All patients were diagnosed using computed tomography (CT). The liver injury was graded in accordance with the American Association for the Surgery of Trauma liver injury scoring scale. Patients were divided into two groups: those who underwent surgery and those treated with non-operative management (NOM). There was a comparison between these two groups concerning the clinical characteristics, grade of liver injury, hemodynamic stability, laboratory findings, and mortality.

Results

According to the 148 patient records evaluated, 108 (72.9%) patients were treated with NOM, and 40 (27.1%) underwent surgery. Patients treated with NOM had significantly fewer severe injuries as rated using the Revised Traumatic Injury Scale, Injury Severity Score, and Glasgow Coma Scale. Grade of liver injury and number of patients with extravasation of contrast dye on CT and hemoperitoneum were higher in the operative group than in the NOM group. There were significant differences between the two groups for: heart rate, respiratory rate, systolic blood pressure, and mean hemoglobin levels at admission and after 4 hours. The operative group experienced a significantly higher mortality than the NOM group.

Conclusions

The results of our study suggest that hemodynamic stability and the following should be considered for deciding the treatment for liver injuries: grade of liver injury, amount of blood loss, and injury scales scores.

Mechanisms of blunt liver trauma patterns: An analysis of 53 cases

Blunt liver trauma is the most dangerous and the second most frequent solid organ trauma that occurs in the abdominal cavity. Management of this life-threatening situation remains a significant challenge. The present study identified that the patterns of blunt liver trauma were closely correlated with the characteristics of the blunt force. Illustrations of findings from this study have been included in the hope that they may aid surgeons in improving the management of this emergency. In total, 53 cases of blunt liver trauma that underwent laparotomy in the First Affiliated Hospital of Wenzhou Medical College between 1999 and 2009 were retrospectively studied. The cause of the injury, the direction and site of the blunt force, surgical records and CT films were carefully studied to obtain information on the patterns and severity of the liver injury and the correlation with blunt forces. Trauma in the right lobe of the liver was mainly caused by acceleration, deceleration and compression of the liver, while in the left lobe of the liver, acceleration was the main cause of the trauma. Liver lacerations were always located close to the attachment sites of the ligaments which bore the majority of the shearing stress. The characteristics of the blunt force play a key role in the different patterns of blunt liver trauma. A thorough understanding of the mechanisms of blunt liver trauma may aid doctors in the management of patients with this condition.

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.

Non-operative management of liver trauma

The liver is one of the commonest intra-abdominal organs injured worldwide in blunt and penetrating trauma and its management has evolved significantly in the last 30 years. Mandatory laparotomy has been replaced by an acceptance that for most blunt hepatic trauma, a selective non-operative approach is safe and effective with a failure rate ie the need to proceed to delayed laparotomy of approximately 10%. There is a markedly lower rate of complications in those that are managed non-operatively. Adjuncts to this conservative regimen such as angioembolisation and delayed laparoscopy to treat biliary peritonitis increase the chances of avoiding laparotomy. This belief in non-operative management has also been transferred to some degree to penetrating liver trauma, where there is a gradual accumulation of evidence to support this non-operative approach in a carefully selected group of patients. This article examines the evidence supporting the selective non-operative management of both blunt and penetrating liver trauma and describes the outcomes and complications.

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.

Surgical Management of Complex Liver Trauma: A Single Liver Transplant Center Experience

Complex liver trauma often presents major diagnostic and management problems. Current operative management is mainly centered on packing, damage control, and early utilization of interventional radiology for angiography and embolization. In this retrospective observational study of patients admitted to the Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy, from 1999 to 2010, we included patients that underwent hepatic resection for complex liver injuries (grade I to Vaccording to the American Association for the Surgery of Trauma-Organ Injury Scale). Age, gender, mechanism of trauma, type of resection, surgical complications, length of hospital stay, and mortality were the variables analyzed. A total of 53 adult patients were admitted with liver injury and 29 underwent surgical treatment; the median age was 26.7 years. Mechanism was blunt in 52 patients. The overall morbidity was 30 per cent, morbidity related to liver resection was 15.3 per cent. Mortality was 2 per cent in the series of patients undergoing liver resection for complex hepatic injury, whereas in the nonoperative group, morbidity was 17 per cent and mortality 2 per cent. Liver resection should be considered a serious surgical option, as initial or delayed management, in patients with complex liver injury and can be accomplished with low mortality and liver-related morbidity when performed in specialized liver surgery/transplant centers.

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.

A reaudit of specialist-managed liver trauma after establishment of regional referral and management guidelines

BACKGROUND

An earlier liver trauma audit (52 patients) noted that 50% were surgically managed at referring hospitals with a high morbidity and mortality, after which a regional referral and management algorithm was implemented in 2001. This study aims to reaudit specialist-managed liver trauma outcomes.

METHODS

Prospective analysis of 99 patients (68 male) treated for liver injury (LI) between 2001 and 2008. Patient characteristics, management, and outcome results of these were compared with the results of previous audit. LI severity was determined by computed tomography, operative findings, and classified according to liver Organ Injury Scale.

RESULTS

As implementation of guidelines, referrals increased from 5.2 patients/yr to 14.1 patients/yr, while LI profile was unchanged. Fewer patients were managed surgically with lower surgical intervention at referring hospitals (26 of 52 [50%] vs. 29 of 77 [38%]; p = 0.2). There has been a decrease in liver resection rates (14 of 26 [54%] vs. 3 of 37 [8%]; p = 0.0001]), overall mortality rate (12 of 52 [23%] vs. 11 of 99 [11%]; p = 0.059), and postoperative deaths.

CONCLUSION

This reaudit confirms the role of nonoperative management of liver trauma. Early use of computed tomography scan with specialist discussion, selective use of perihepatic packing, and transfer to a specialist unit should be standard practice in the management of complex liver trauma.

Treatment of Liver Trauma: Operative or Conservative Management

Background

The liver is one of the most frequently damaged organs when abdominal trauma occurs. Currently, a conservative management constitutes the treatment of choice in patients with hemodynamic stability. The aim of this study is to evaluate the results of an operative and conservative management of 143 patients with liver injury treated in a single institution.

Methods

A retrospective study of the patients admitted with the diagnosis of liver trauma was performed from 1992-2008. The patients were classified according to the intention to treatment: Group I, operative management; Group II, conservative management. Variables analyzed included demographic data, injury classification, associated lesions, surgical treatment, transfusions, morbi-mortality, and hospital stay. We established two periods (1992-1999; 2000-2008) in order to compare diagnosis and management.

Results

A total of 143 patients were analyzed. Thirty-one percent correspond to severe injuries. Conservative treatment was followed in 60.8 % with surgery undertaken in 14.9 % of patients from this group due to failure of conservative treatment. Immediate surgery was carried out in 38.2 %. Total mortality was 14 %. Morbidity (35.7-38.5 %) in the group of immediate surgery and failure of conservative management is similar, but not in mortality (28.6-15.4 %). In the second group (2000-2008) there are more patients with conservative treatment, with a low percentage of failure of this treatment and morbi-mortality.

Conclusions

Conservative treatment is an adequate treatment in a great number of patients. Failure of conservative treatment did not show a higher incidence of complications or mortality but it should be performed in centers with experienced surgeons.

[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.

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.

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.

Fatores preditivos de morbidade e mortalidade no trauma hepático

OBJETIVO: Identificar os fatores preditivos de complicações e mortalidade em doentes operados com trauma hepático. MÉTODO: Estudo retrospectivo de 638 pacientes tratados no período de 1990 a 2003, identificando estatisticamente parâmetros epidemiológicos, fisiológicos e anatômicos associados com maior morbidade e mortalidade. RESULTADOS: Trauma penetrante foi o mecanismo mais freqüente. A instabilidade hemodinâmica esteve presente em 21,1% das vítimas e o Índice de Gravidade das Lesões anatômicas (ISS) médio foi de 20,7. A maioria das lesões hepáticas foi grau III. A morbidade foi de 50,4%, sendo as complicações relacionadas ao fígado mais freqüentes: sangramento persistente (9,8%), abscesso intraperitoneal (3,8%) e fístula biliar (3%). As complicações não hepáticas ocorreram em 273 pacientes (42,8%). A mortalidade foi de 22,1% (141 casos) decorrente principalmente de sangramento persistente e sepse. As vítimas fatais apresentaram-se com pior índice fisiológico na admissão, com lesões hepáticas mais complexas e índices anatômicos mais graves quando comparadas aos sobreviventes. CONCLUSÃO: Os fatores preditivos de ocorrência de complicações hepáticas foram: idade maior que 60 anos, instabilidade hemodinâmica ou alteração de parâmetros fisiológicos na admissão, presença de lesões hepáticas complexas (grau > III) e índices anatômicos de gravidade de lesão abdominal (ATI) ou em outros segmentos corpóreos (ISS) elevados (= 25). Todas estas variáveis, mais a presença de lesões associadas abdominais e não abdominais e o mecanismo de trauma fechado foram preditivas de ocorrência de complicações não-hepáticas. Todos os fatores estudados, exceto a presença de lesões associadas abdominais, foram preditivos para a evolução a óbito.

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.

Prehospital ultrasound imaging improves management of abdominal trauma

BACKGROUND

Blunt abdominal trauma with intra-abdominal bleeding is often underdiagnosed or even overlooked at trauma scenes. The purpose of this prospective, multicentre study was to compare the accuracy of physical examination and prehospital focused abdominal sonography for trauma (PFAST) to detect abdominal bleeding.

METHODS

Six rescue centres took part in the study from December 2002 to December 2003, including 230 patients with suspected abdominal injury. The accuracy of physical examination at the scene and PFAST were compared. Later examinations in the emergency department (ultrasonography and/or computed tomography) were used as the reference standard.

RESULTS

The complete protocol and follow-up was obtained in 202 patients. The sensitivity, specificity and accuracy of PFAST were 93 per cent, 99 per cent and 99 per cent, respectively, compared with 93 per cent, 52 per cent and 57 per cent for physical examination at the scene. Scanning with PFAST occurred a mean(s.d.) 35(13) min earlier than ultrasound in the emergency department. Abdominal bleeding was detected in 14 per cent of patients. Using PFAST led to a change in either prehospital therapy or management in 30 per cent of patients, and a change to admitting hospital in 22 per cent.

CONCLUSION

In this study, PFAST was a useful and reliable diagnostic tool when used as part of surgical triage at the trauma scene.

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.

[Surgical management, prognostic factors, and outcome in hepatic trauma]

Hepatic trauma is a rare surgical emergency with significant morbidity and mortality. Extensive experience in liver surgery is a prerequisite for the management of these injuries. The medical records of 68 consecutive patients with hepatic trauma were retrospectively reviewed for the severity of liver injury, management, morbidity, mortality, and risk factors. Of the patients, 14 were treated conservatively and 52 surgically (24 suture/fibrin glue, 16 perihepatic packing, 11 resections, 1 liver transplantation). Two patients died just before emergency surgery could be performed. Overall mortality was 21% (14/68), and 13, 14, 6, 27, and 50% for types I, II, III, IV, and V injuries, respectively. Only nine deaths (all type IV and V) were liver related, while four were caused by extrahepatic injuries and one by concomitant liver cirrhosis. With respect to treatment, conservative management, suture, and resection had a low mortality of 0, 4, and 9%, respectively. In contrast, mortality was 47% in patients in whom only packing was performed (in severe injuries). Stepwise multivariate regression analysis proved prothrombin values <40%, ISS scores >30, and transfusion requirements of more than 10 red packed cells to be significant risk factors for post-traumatic death. Type I-III hepatic injuries can safely be treated by conservative or simple surgical means. However, complex hepatic injuries (types IV and V) carry a significant mortality and may require hepatic surgery, including liver resection or even transplantation. Therefore, patients with severe hepatic injuries should be treated in a specialized institution.

The management of coagulopathy and blood loss in liver surgery

Liver surgery has long been associated with massive perioperative blood loss and high rates of postsurgery morbidity and mortality. Recent advances in our knowledge of hepatic segmental anatomy have led to the evolution of liver resection, and a growing awareness of the coagulopathy present in cirrhotic patients has produced a greater understanding of the factors influencing surgical hemostasis. This review will examine the risk factors for perioperative hemorrhage in liver disease patients, and will describe current pharmacological, surgical, and radiological methods available for controlling bleeding and achieving effective hemostasis during liver resection and orthotopic liver transplantation (OLT). The potential role of recombinant factor VIIa (rFVIIa) in providing safe hemostasis during such procedures will also be explored. Today, due to careful monitoring and correction of coagulopathy, improved surgical techniques, and judicious patient selection, liver surgery is no longer a high-risk specialty with an unfavorable risk profile, but a safe and widely practiced procedure.

Management of blunt liver trauma in a tertiary referral centre

BACKGROUND

In recent years, several reports from North America have highlighted the success of conservative treatment in patients with blunt liver trauma. The aim of this study was to identify trends in the management of blunt liver trauma in a UK tertiary referral centre dealing with both adults and children over a 10-year period.

METHODS

A retrospective case note review was performed on 71 consecutive patients (58 male patients) of median age 25 years admitted to the hepatobiliary unit over the 10-year period from 1992 to 2001 with blunt liver trauma. Data relating to referring source, severity of liver injury, initial and subsequent management and outcome were collected using a standard pro forma.

RESULTS

Sixty-two of the 71 patients were referred from other surgical units. Of these, 14 had undergone laparotomy at the referring hospital, with ten having perihepatic packing; the other 48 were managed conservatively. Of the 62 patients transferred to the authors' unit, 12 required surgical intervention for the liver injury. The mean number of patients with blunt liver trauma increased between the first second 5-year periods, from 3.2 to 11.0 patients per year. There was a significant reduction in the proportion of patients requiring surgery for the liver injury in both the authors' unit (from seven of 16 patients in 1992-1996 to seven of 55 in 1997-2001; P = 0.017, chi(2) test) and referring hospitals (from six of 12 to eight of 50; P = 0.014, chi(2) test). The reduction in the mortality rate, from two (12.5 per cent) of 16 in the first period to four (7.3 per cent) of 55 in the second, was not significant (P = 0.880, chi(2) test).

CONCLUSION

This study demonstrated a marked increase in the number of patients with blunt liver trauma referred to a regional hepatobiliary centre in recent years. It has confirmed that the majority of such patients can be treated successfully without surgery.