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Bonny P, Bogaert C, Abreu de Carvalho LF, Gryspeerdt F, Eker H, Hermie L, Berrevoet F. Evolution in liver trauma management: a single centre experience. Acta Chir Belg 2024:1-12. [PMID: 38607666 DOI: 10.1080/00015458.2024.2342132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/08/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVES Liver trauma is common and can be treated non-operatively, through radiological embolisation, or surgically. Non-operative management (NOM) is preferred when possible, but specific criteria remain unclear. This retrospective study at a level I trauma centre assessed the evolution and outcomes of liver injury management over more than 20 years. METHODS Data from January 1996 to June 2020 were analysed for liver trauma cases. Variables were evaluated, including the type of injury, diagnostic modalities, liver injury grade, transfer from other hospitals, treatment type, and length of hospital stay. Outcomes were assessed using soft (hospitalisation time and intensive care unit stay) and hard (mortality) endpoints. RESULTS In total 406 patients were analysed, of which 375 (92.4%) had a blunt and 31 (7.6%) a penetrating liver trauma. Approximately one-third (31.2%) were hemodynamically unstable, although 78.8% had low-grade liver lesions. The initial treatment was non-operative in 72.9% of the patients (68.5% conservative, 4.4% interventional radiology). Blunt trauma was treated by surgery in 23.2% of the patients, while 74.2% in case of penetrating trauma. Overall mortality was 11.1% including death caused by associated lesions. The 24-h mortality was 5.7%. Indication for surgical treatment was determined by hemodynamic instability, high grade liver lesion, penetrating trauma, and associated lesions. CONCLUSIONS Although the role of surgery in liver trauma management has strongly diminished over recent decades, hemodynamically unstable patients, high-grade lesions, penetrating trauma, and severe associated lesions are the main indications for surgery. In other situations, NOM by full conservative therapy or radiological embolisation seems effective.
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Affiliation(s)
- Paulien Bonny
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Constantijn Bogaert
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | | | - Filip Gryspeerdt
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Hasan Eker
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Laurens Hermie
- Division of Interventional Radiology, Department of Radiology, Ghent University Hospital, Ghent, Belgium
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
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Smith AA, Cone JT, McNickle AG, Mitchao DP, Kostka R, Martinez B, Schroeppel T, Cavalea A, Shahan CP, Axtman B, Braverman MA. MultiCenter Study of Intra-Abdominal Abscess Formation After Major Operative Hepatic Trauma. J Surg Res 2024; 295:746-752. [PMID: 38147760 DOI: 10.1016/j.jss.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/10/2023] [Accepted: 11/09/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION One of the significant complications of operative liver trauma is intra-abdominal abscesses (IAA). The objective of this study was to determine risk factors associated with postoperative IAA in surgical patients with major operative liver trauma. METHODS A retrospective multi-institutional study was performed at 13 Level 1 and Level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Univariate and multivariate analyses were performed. RESULTS Three hundred seventy-two patients were included with 21.2% (n = 79/372) developing an IAA. No difference was found for age, gender, injury severity score, liver injury grade, and liver resections in patients between the groups (P > 0.05). Penetrating mechanism of injury (odds ratio (OR) 3.42, 95% confidence interval (CI) 1.54-7.57, P = 0.02), intraoperative massive transfusion protocol (OR 2.43, 95% CI 1.23-4.79, P = 0.01), biloma/bile leak (OR 2.14, 95% CI 1.01-4.53, P = 0.04), hospital length of stay (OR 1.04, 95% CI 1.02-1.06, P < 0.001), and additional intra-abdominal injuries (OR 2.27, 95% CI 1.09-4.72, P = 0.03) were independent risk factors for IAA. Intra-abdominal drains, damage control laparotomy, total units of packed red blood cells, number of days with an open abdomen, total abdominal surgeries, and blood loss during surgery were not found to be associated with a higher risk of IAA. CONCLUSIONS Patients with penetrating trauma, massive transfusion protocol activation, longer hospital length of stay, and injuries to other intra-abdominal organs were at higher risk for the development of an IAA following operative liver trauma. Results from this study could help to refine existing guidelines for managing complex operative traumatic liver injuries.
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Affiliation(s)
- Alison A Smith
- Surgery Department, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana.
| | - Jennifer T Cone
- Surgery Department, University of Chicago School of Medicine, Chicago, Illinois
| | - Allison G McNickle
- Surgery Department, University of Nevada- Las Vegas School of Medicine, Las Vegas, Nevada
| | - Delbrynth P Mitchao
- Surgery Department, LAC+USC Medical Center, University of Southern California, Los Angeles, California
| | - Ryan Kostka
- Surgery Department, Baylor Scott and White Health, Dallas, Texas
| | - Benjamin Martinez
- Trauma Surgery Division, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana
| | - Thomas Schroeppel
- Surgery Department, University of Colorado Health, Colorado Springs, Colorado
| | - Alexander Cavalea
- Surgery Department, University of Tennessee Knoxville Medical Center, Knoxville, Tennessee
| | | | - Benjamin Axtman
- Trauma Division, Sanford Health Bismarck, Bismarck, North Dakota
| | - Maxwell A Braverman
- Surgery Department, St. Luke University Healthcare Network, Bethlehem, Pennsylvania
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Cheng CT, Lin HH, Hsu CP, Chen HW, Huang JF, Hsieh CH, Fu CY, Chung IF, Liao CH. Deep Learning for Automated Detection and Localization of Traumatic Abdominal Solid Organ Injuries on CT Scans. JOURNAL OF IMAGING INFORMATICS IN MEDICINE 2024:10.1007/s10278-024-01038-5. [PMID: 38366294 DOI: 10.1007/s10278-024-01038-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/18/2024]
Abstract
Computed tomography (CT) is the most commonly used diagnostic modality for blunt abdominal trauma (BAT), significantly influencing management approaches. Deep learning models (DLMs) have shown great promise in enhancing various aspects of clinical practice. There is limited literature available on the use of DLMs specifically for trauma image evaluation. In this study, we developed a DLM aimed at detecting solid organ injuries to assist medical professionals in rapidly identifying life-threatening injuries. The study enrolled patients from a single trauma center who received abdominal CT scans between 2008 and 2017. Patients with spleen, liver, or kidney injury were categorized as the solid organ injury group, while others were considered negative cases. Only images acquired from the trauma center were enrolled. A subset of images acquired in the last year was designated as the test set, and the remaining images were utilized to train and validate the detection models. The performance of each model was assessed using metrics such as the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, positive predictive value, and negative predictive value based on the best Youden index operating point. The study developed the models using 1302 (87%) scans for training and tested them on 194 (13%) scans. The spleen injury model demonstrated an accuracy of 0.938 and a specificity of 0.952. The accuracy and specificity of the liver injury model were reported as 0.820 and 0.847, respectively. The kidney injury model showed an accuracy of 0.959 and a specificity of 0.989. We developed a DLM that can automate the detection of solid organ injuries by abdominal CT scans with acceptable diagnostic accuracy. It cannot replace the role of clinicians, but we can expect it to be a potential tool to accelerate the process of therapeutic decisions for trauma care.
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Affiliation(s)
- Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Hou-Hsien Lin
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Po Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Huan-Wu Chen
- Department of Medical Imaging & Intervention, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Huang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - I-Fang Chung
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan.
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Beltzer C, Imach S, Wafaisade A, Lefering R, Kölbel B. Use of angioembolization, treatment modalities and mortality in association with blunt liver trauma in Germany - a data analysis of the TraumaRegister DGU®. Langenbecks Arch Surg 2023; 409:6. [PMID: 38093037 PMCID: PMC10719148 DOI: 10.1007/s00423-023-03196-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Angioembolization (ANGIO) is highly valued in national and international guideline recommendations as a treatment adjunct with blunt liver trauma (BLT). The literature on BLT shows that treatment, regardless of the severity of liver injury, can be accomplished with a high success rate using nonoperative management (NOM). An indication for surgical therapy (SURG) is only seen in hemodynamically instable patients. For Germany, it is unclear how frequently NOM ± ANGIO is actually used, and what mortality is associated with BLT. METHODS A retrospective systematic data analysis of patients with BLT from the TraumaRegister DGU® was performed. All patients with liver injury AIS ≥ 2 between 2015 and 2020 were included. The focus was to evaluate the use ANGIO as well as treatment selection (NOM vs. SURG) and mortality in relation to liver injury severity. Furthermore, independent risk factors influencing mortality were identified, using multivariate logistic regression. RESULTS A total of 2353 patients with BLT were included in the analysis. ANGIO was used in 18 cases (0.8%). NOM was performed in 70.9% of all cases, but mainly in less severe liver trauma (AIS ≤ 2, abbreviated injury scale). Liver injuries AIS ≥ 3 were predominantly treated surgically (64.6%). Overall mortality associated with BLT was 16%. Severity of liver injury ≥ AIS 3, age > 60 years, hemodynamic instability (INSTBL), and mass transfusion (≥ 10 packed red blood cells/pRBC) were identified as independent risk factors contributing to mortality in BLT. CONCLUSION ANGIO is rarely used in BLT, contrary to national and international guideline recommendations. In Germany, liver injuries AIS ≥ 3 are still predominantly treated surgically. BLT is associated with considerable mortality, depending on the presence of specific contributing risk factors.
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Affiliation(s)
- Christian Beltzer
- Department of General, Abdominal and Thoracic Surgery, German Armed Forces Hospital Ulm, Ulm, Germany.
| | - Sebastian Imach
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Arasch Wafaisade
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Benny Kölbel
- Department of General, Abdominal and Thoracic Surgery, German Armed Forces Hospital Ulm, Ulm, Germany
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Mann AJ, Rueda M, Azar F, Ramseyer M, Lottenberg L, Borrego R. Persistent pseudoaneurysm after non-operative management of a Grade 4 liver injury. Trauma Case Rep 2023; 48:100946. [PMID: 37822491 PMCID: PMC10562760 DOI: 10.1016/j.tcr.2023.100946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/13/2023] Open
Abstract
A hepatic pseudoaneurysm (HPA) after blunt or penetrating liver injury is an unusual but potentially lethal complication that can develop from an injured hepatic artery branch [1-5]. Endovascular intervention with coil embolization to treat HPA is a safe and effective method and has become the standard first-line treatment, with a success rate achieving 70-100 % [13,14,15]. Infrequently the pseudoaneurysm is fed by collateral vessels and endovascular intervention may be unsuccessful. Other minimally invasive treatment options that can be considered include image guided percutaneous thrombin injection, endovascular placement of covered stents and injection of liquid agents such as fibrin glue [10,11]. We present a case of a young female who developed a post-traumatic persistent hepatic pseudoaneurysm requiring a total of nine interventions, including six endovascular interventions with angiography, three endoscopic procedures for bleeding, one percutaneous injection, and two re-admissions to the hospital. Although she avoided initial operative management, her three-month hospital course can be considered a failure of conservative management of blunt hepatic trauma due to the accrued health care costs and resources. The literature on the management of persistent pseudoaneurysm is limited. The decision to treat a persistent HPA that are found incidentally and stable in size needs further investigation.
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Affiliation(s)
| | - Mario Rueda
- Florida Atlantic University, 777 Glades Rd, Boca Raton, FL 33431, United States of America
- St. Mary's Medical Center, 901 45th St, West Palm Beach, FL 33407, United States of America
| | - Faris Azar
- Florida Atlantic University, 777 Glades Rd, Boca Raton, FL 33431, United States of America
- St. Mary's Medical Center, 901 45th St, West Palm Beach, FL 33407, United States of America
| | - Matthew Ramseyer
- Florida Atlantic University, 777 Glades Rd, Boca Raton, FL 33431, United States of America
- St. Mary's Medical Center, 901 45th St, West Palm Beach, FL 33407, United States of America
| | - Lawrence Lottenberg
- Florida Atlantic University, 777 Glades Rd, Boca Raton, FL 33431, United States of America
- St. Mary's Medical Center, 901 45th St, West Palm Beach, FL 33407, United States of America
| | - Robert Borrego
- Florida Atlantic University, 777 Glades Rd, Boca Raton, FL 33431, United States of America
- St. Mary's Medical Center, 901 45th St, West Palm Beach, FL 33407, United States of America
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Sehgal M, Singh TR, Yadav D, Dhua A, Bajpai M. Traumatic Isolated Right Lobe Devascularization of the Liver: An Unusual Case. Cureus 2023; 15:e40621. [PMID: 37476146 PMCID: PMC10354828 DOI: 10.7759/cureus.40621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/22/2023] Open
Abstract
Isolated liver lobe devascularization is a very rare case, with conflicting literature regarding management. We describe a very unusual case of traumatic isolated right lobe devascularization of the liver with its attendant management challenges. An eight-year-old boy with a history of road traffic accidents presented with abdominal pain. Although the child was hemodynamically stable on presentation, extended focused assessment with sonography in trauma was positive. Contrast-enhanced computed tomography (CECT) scan of the torso revealed a nonenhancing right lobe of the liver involving segments 5-8 and the gross hemoperitoneum. Nonoperative management was tried. There were persistent high-grade fever spikes, for which prophylactic antibiotics were started, but the fever workup was negative. Abdominal drains were inserted to drain fluid and relieve distress. Output was noted to be bilious on day 21 of injury. Diagnostic laparoscopy on day 22 revealed hypertrophied left lobe of the liver with an absent (autolyzed) right lobe. The subsequent ward course was uneventful, and the child was discharged in stable condition. Thus, the indication of surgery in such cases is clinical deterioration, not radiological findings. Management should be in a dedicated trauma center with immediate operating room availability.
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Affiliation(s)
- Mehak Sehgal
- Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Teg R Singh
- Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Devendra Yadav
- Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Anjan Dhua
- Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Minu Bajpai
- Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
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Gunshot wound versus blunt liver injuries: different liver-related complications and outcomes. Eur J Trauma Emerg Surg 2023; 49:505-512. [PMID: 36115907 DOI: 10.1007/s00068-022-02096-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/23/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Severe hepatic injury due to gunshot (GSW) compared to blunt mechanism may have significantly different presentation, management, complications, and outcomes. The aim of this study was to identify the differences. METHODS Retrospective single-center analysis June 1, 2015-June 30, 2020, included all patients with Grade III-V liver injuries due to GSW or blunt mechanism. Clinical characteristics, severity of injury, liver-related complications (rebleeding, necrosis/abscess, bile leak/biloma, pseudoaneurysm, acute liver failure) and overall outcomes (mortality, hospital length of stay, intensive care unit length of stay, and ventilatory days) were compared. RESULTS Of 879 patients admitted with hepatic trauma, 347 sustained high-grade injury and were included: 81 (23.3%) due to GSW and 266 (76.7%) due to blunt force. A significantly larger proportion of patients with GSW were managed operatively (82.7 vs. 36.1%, p < 0.001). GSW was associated with significantly more liver-related complications (40.7% vs. 27.4%, p = 0.023), specifically liver necrosis/abscess (18.5% vs. 7.1%, p = 0.003) and bile leak/biloma (12.3% vs. 5.3%, p = 0.028). On subgroup analysis, in patients with grade III injury, the incidence of liver necrosis/abscess and bile leak/biloma remained significantly higher after GSW (13.9% vs. 3.1%, p = 0.008 and 11.1% vs. 2.5%, p = 0.018, respectively). In sub analysis of 88 patients with leading severe liver injuries, GSW had a significantly longer hospital length of stay, ICU length of stay, and ventilator days. CONCLUSION GSW mechanism to the liver is associated with a higher incidence of liver-related complications than blunt force injury.
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Gallaher J, Burton V, Schneider AB, Reid T, Raff L, Smith CB, Charles A. The Effect of Angioembolization Versus Open Exploration for Moderate to Severe Blunt Liver Injuries on Mortality. World J Surg 2023; 47:1271-1281. [PMID: 36705742 DOI: 10.1007/s00268-023-06926-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Blunt liver injury is common and is associated with a high morbidity and mortality. More severe injuries often require either angioembolization or open operative repair, depending on patient factors and facility capacity. We sought to describe patient outcomes based on intervention type. METHODS We analyzed the National Trauma Data Bank (2017-2019) using ICD-10 codes to identify adult patients with blunt liver injury and their interventions. AIS (Abbreviated Injury Scale) scores were used to group patients based on liver injury severity (AIS 2-6). Logistic regression modeling was used to estimate the adjusted odds ratio of death based on intervention type, excluding patients with severe injury. RESULTS Of 2,848,592 trauma patients, 50,250 patients had a blunt liver injury. Among patients with AIS 3/4/5 injury, 1,140 had angioembolization, 1,529 had an open repair, and 188 had both angioembolization and open repair. In comparison with no intervention and adjusted for age, sex, shock index, ISS, and transfusion total (first four hours), angioembolization was associated with a significant decrease in the odds of mortality for patients with an AIS 4 (OR 0.68, 95% CI 0.47, 0.99) and AIS 5 injury (OR 0.39, 95% CI 0.24, 0.64). In patients with an AIS 5 injury, open repair had an increased odds of mortality at OR 1.99 (95% CI 1.47, 2.69). CONCLUSION In an analysis of a national trauma database, patients with a moderate to severe injury (AIS 4 or 5), angioembolization was associated with a significant reduction in the adjusted odds of mortality compared to open repair and should be considered when clinically appropriate.
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Affiliation(s)
- Jared Gallaher
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA.
| | - Victoria Burton
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Andrew B Schneider
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Trista Reid
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Lauren Raff
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Charlotte B Smith
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Anthony Charles
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
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Malhotra AK. Contribution by Dr Timothy C Fabian: liver trauma. Trauma Surg Acute Care Open 2023; 8:e001116. [PMID: 37082305 PMCID: PMC10111919 DOI: 10.1136/tsaco-2023-001116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
The liver is the most commonly injured organ within the abdomen. Dr Fabian and his associates have made remarkable contributions to our understanding and management of these injuries. The current review summarizes the contributions.
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Affiliation(s)
- Ajai K Malhotra
- Department of Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
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10
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Clinical outcomes of non-operative management and clinical observation in non-angioembolised hepatic trauma: A systematic review of the literature. Chin J Traumatol 2022; 25:257-263. [PMID: 35487854 PMCID: PMC9458985 DOI: 10.1016/j.cjtee.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 01/30/2022] [Accepted: 02/26/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE. METHODS A systematic literature review searched "liver trauma", "hepatic trauma", "conservative management", "non operative management" on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs; studies reported NOM complications together with those post-intervention; case reports; studies including less than 5 cases; studies not written in English; and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test. RESULTS A total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%. CONCLUSION NOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.
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11
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Predictive factors of non-operative management failure in 494 blunt liver injuries: a multicenter retrospective study. Updates Surg 2022; 74:1901-1913. [DOI: 10.1007/s13304-022-01367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/21/2022] [Indexed: 10/15/2022]
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12
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Soma J, Ishii D, Miyagi H, Ishii S, Motoki K, Kawabata H, Ishitoya S, Hagiwara M, Kokita N, Hirasawa M. Damage control surgery for grade IV blunt hepatic injury with multiple organ damage in a child: a case report. Surg Case Rep 2021; 7:269. [PMID: 34928459 PMCID: PMC8688624 DOI: 10.1186/s40792-021-01348-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intra-abdominal hemorrhage caused by blunt hepatic injury is a major cause of morbidity and mortality in patients with abdominal trauma. Some of these patients require laparotomy, and rapid decision-making and life-saving surgery are essential. Damage control (DC) surgery is useful for treating children in critical situations. We performed this technique to treat an 8-year-old boy with grade IV blunt hepatic injury and multiple organ damage. This is the first report of the use of the ABTHERA Open Abdomen Negative Pressure Therapy System (KCI, now part of 3 M Company, San Antonio, TX, USA) for DC surgery to rescue a patient without neurological sequelae. CASE PRESENTATION An 8-year-old boy was brought to the emergency department of our hospital after being run over by a motor vehicle. He had grade IV blunt hepatic injury, thyroid injury, and bilateral hemopneumothorax. Although he was hemodynamically stable, the patient's altered level of consciousness, the presence of a sign of peritoneal irritation, and suspicion of intestinal injury led us to perform exploratory laparotomy. As part of a DC strategy, we performed gauze packing to control hemorrhage from the liver and covered the abdomen with an ABTHERA Open Abdomen Negative Pressure Therapy System to improve the patient's general condition. Eighteen days after admission, the patient was diagnosed with a biliary fistula, which improved with percutaneous and external drainage. He had no neurological sequelae and was discharged 102 days after injury. CONCLUSION The DC strategy was effective in children with severe blunt hepatic injury. We opted to perform DC surgery because children have less hemodynamic reserve than adults, and we believe that using this strategy before the appearance of trauma triad of death could save lives and improve outcomes. During conservative management, it is important to adopt a multistage, flexible approach to achieve a good outcome.
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Affiliation(s)
- Jun Soma
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Daisuke Ishii
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan.
| | - Hisayuki Miyagi
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Seiya Ishii
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Keita Motoki
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Hidemasa Kawabata
- Division of Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Shunta Ishitoya
- Department of Radiology, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Masahiro Hagiwara
- Division of Hepato-Biliary-Pancreatic Surgery and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Naohiro Kokita
- Department of Emergency Medicine, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
| | - Masatoshi Hirasawa
- Division of Pediatric Surgery, Department of Surgery, Asahikawa Medical University, 2-1-1, Midorigaokahigashi, Asahikawashi, Hokkaido, 078-8510, Japan
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13
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Re-visiting Drain Use in Operative Liver Trauma: A Retrospective Analysis. J Surg Res 2021; 270:76-84. [PMID: 34644621 DOI: 10.1016/j.jss.2021.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 07/18/2021] [Accepted: 08/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite the liver being one of the most frequently injured abdominal organs in trauma patients, clinical management strategies differ between trauma surgeons. Few studies have critically evaluated current practice patterns in the operative management of liver trauma. Historical studies recommended against the use of drains but there has not been a modern investigation of this issue. The objective of this study was to analyze outcomes associated with intra-operative drain use for liver trauma. METHODS A retrospective chart review of all adult trauma patients presenting to a Level I trauma center from 2012 to 2018 was performed. Patients who underwent operative management of liver trauma were divided into groups based on whether an intra-abdominal drain was utilized and differences in outcomes between the groups were analyzed. The primary endpoint evaluated was post-operative intra-abdominal abscesses. Univariate and multivariate analyses were performed. RESULTS 184 patients with operative management of liver trauma were included in the study. Closed suction drains were utilized in 26.1% of post-operative patients. Rate of intra-abdominal abscesses was significantly higher in the drain group (35.4% versus 8.8%, P < 0.001). Drains were more commonly used in patients receiving more units of PRBCs (median, 9 units [IQR 4-20] versus median 5.5 units, [IQR 2-14], P = 0.03). Drain use was found to be an independent risk factor for post-operative intra-abdominal abscess on multivariate analysis (OR 4.9, 95% CI 1.7-14, P = 0.003). CONCLUSIONS The results of this study support previous conclusions that drain placement for operative liver trauma is associated with increased risks of infectious complications. Drains were used in patients with more severe liver injury, intra-operative bile leaks, penetrating trauma, and increased blood transfusion requirements. Future studies should focus on the development of specific guidelines for the use of drains in liver trauma.
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14
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Fletcher KL, Perea LL, Morgan ME, Otaibi BW, Hazelton JP. Repeat Imaging in Blunt Hepatic Injuries Can Wait for Clinical Change. J Surg Res 2021; 268:119-124. [PMID: 34304007 DOI: 10.1016/j.jss.2021.06.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/11/2021] [Accepted: 06/08/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is variability regarding the utilization and timing of repeat imaging in adult patients with blunt hepatic injury who are managed nonoperatively. This study examines the rate of delayed complications and interventions in patients with blunt hepatic injuries who undergo repeat imaging prompted either by clinical change (CC) or non-clinical change (NCC). METHODS A nine-year, retrospective, dual-institution study was performed of adult patients with blunt hepatic injuries. Patients were identified based on whether repeat imaging was performed and reason for reimaging: CC or NCC. The incidence of delayed complications and interventions was examined for each type of scan. RESULTS Of 365 patients, 122 (33.4%) underwent repeat imaging [CC, n = 72 (59%); NCC, n=50 (41%)]. Mean time to repeat imaging was shorter in the NCC group [CC = 7.6 ± 8 days; NCC = 4.7 ± 6.3 days, P = 0.034]. Delayed complications were found in 30 (25%) patients reimaged, [CC, n = 20; NCC, n = 10, P = 0.395]. Interventions were performed in 12 (40%) patients [CC, n = 10; NCC, n = 2, P = 0.120]. CONCLUSIONS Repeat imaging due to NCC occurred earlier than imaging performed by CC. One quarter of patients reimaged demonstrated a delayed complication, with nearly half undergoing intervention. There was no difference in incidence of delayed complications or interventions between groups, suggesting repeat imaging can be prompted by clinical change in blunt hepatic injuries.
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Affiliation(s)
- Kelsey L Fletcher
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Lindsey L Perea
- Department of Surgery, Division of Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania.
| | - Madison E Morgan
- Department of Surgery, Division of Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania
| | - Banan W Otaibi
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Joshua P Hazelton
- Department of Surgery, Division of Trauma and Acute Care Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
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15
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Retrospective assessment of developing liver injuries in children brought to the emergency room due to the blunt abdominal trauma over the past 10 years; a single -center experience. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.896175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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16
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Nguyen I, Catanzano T. Hepatobiliary Injuries: A Pictoral Essay and Literature Review. Semin Ultrasound CT MR 2021; 42:332-346. [PMID: 34130847 DOI: 10.1053/j.sult.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Injuries to the liver and biliary tree carry significant morbidity and mortality if not diagnosed and managed rapidly. As clinical evaluation of suspected hepatobiliary injury is often limited in traumatic or post-surgical settings, imaging plays a critical role in the diagnosis of injury, assessment of treatment response and detection of delayed complications. In this paper, we review acute traumatic and iatrogenic hepatobiliary injuries and subsequent complications through different imaging modalities.
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Affiliation(s)
- Ivy Nguyen
- Department of Radiology, University of Massachusetts Medical School - Baystate, Springfield, MA.
| | - Tara Catanzano
- Department of Radiology, University of Massachusetts Medical School - Baystate, Springfield, MA
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17
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Abstract
Trauma is the leading cause of death in patients younger than 45 years. Over the last decade, there has been a progressive paradigm shift toward a nonoperative management of many blunt and penetrating injuries, placing interventional radiology in the forefront in this critical field. Transcatheter embolization is an established technique that plays a significant role in the modern treatment of traumatic injuries of the extremities, pelvis, and solid organs. The purpose of this article is to review the updated principles and techniques used in transcatheter embolization in trauma.
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Affiliation(s)
- Jorge E Lopera
- Department of Radiology, UT Health San Antonio, San Antonio, Texas
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18
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Pohlan J, Miller H, Lerchbaumer MH, Krenzien F, Benzing C, Mogl MT, Diekhoff T. Multiple liver perforations: complication of an outpatient liposuction procedure. Radiol Case Rep 2021; 16:906-910. [PMID: 33603942 PMCID: PMC7873377 DOI: 10.1016/j.radcr.2021.01.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 11/26/2022] Open
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19
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Mansor S, Aldiasy A, Algialany A, Buzaja A. The Operative Management for Gunshot Liver Injuries: an Experience of Seventy-One Patients in 5 Years. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02727-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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20
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The Role of Angioembolization in Liver Trauma: the 10-Year Retrospective Experience of a Level One Trauma Center. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02726-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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21
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Oo J, Smith M, Ban EJ, Clements W, Tagkalidis P, Fitzgerald M, Pilgrim CHC. Management of bile leak following blunt liver injury: a proposed guideline. ANZ J Surg 2021; 91:1164-1169. [PMID: 33459492 DOI: 10.1111/ans.16552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/19/2020] [Accepted: 12/19/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bile leak following blunt liver trauma is uncommon. Management is difficult due to complex vasculo-biliary and liver parenchymal injury and lack of consensus on optimal care compared with bile leak following elective hepatectomy especially in regards to endoscopic retrograde pancreaticocholangiography (ERCP) timing and patient selection. METHODS This is a retrospective cohort study from a level 1-trauma centre of patients with bile leak following blunt liver injury between July 2010 and December 2019 identified from the trauma registry. Clinical data retrieved include patient demographics, injury severity score, liver injury grading and its associated complications and treatment. This was supplemented by surgical audit database and patients' electronic medical record. RESULTS There were 31 bile leaks amongst 639 patients with blunt liver trauma (4.9%). Bile leak was associated with higher liver injury grade (odds ratio (OR) 36, P = 0.001), hepatic embolization (OR 16, P = 0.003) and need for trauma laparotomy (OR 14, P = 0.024). ERCP was performed in 58.1% (n = 18). This was complicated in 27.7% (n = 5) by mild pancreatitis (n = 1) and intra-abdominal sepsis (n = 4) requiring surgical drainage of abscess (n = 2) and liver resection (n = 1). Bile leak settled conservatively (including percutaneous drainage) without ERCP in the remaining patients (41.9%). Overall mortality was not increased in those with bile leak (P = 0.998). CONCLUSION Bile leaks resolved conservatively in 41.9% of patients. Complications following ERCP were seen in 27.7%, frequently requiring intervention. Failure of conservative management was more likely in patients with hepatic embolization, in whom early ERCP remains appropriate. ERCP should otherwise be reserved for those who fail conservative management to minimize infective complications.
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Affiliation(s)
- June Oo
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Marty Smith
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Hepatopancreaticobiliary Surgery, Western Hospital, Melbourne, Victoria, Australia
| | - Ee Jun Ban
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Trauma, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Peter Tagkalidis
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Department of Trauma, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Charles H C Pilgrim
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Hepatopancreaticobiliary Surgery, Frankston Hospital, Melbourne, Victoria, Australia
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22
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Abstract
The liver is one of the most commonly injured solid organs in blunt abdominal trauma. Non-operative management is considered to be the gold standard for the care of most blunt liver injuries. Angioembolization has emerged as an important adjunct that is vital to the success of the non-operative management strategy for blunt hepatic injuries. This procedure, however, is fraught with some possible serious complications. The success, as well as rate of complications of this procedure, is determined by degree and type of injury, hepatic anatomy and physiology, and embolization strategy among other factors. In this review, we discuss these important considerations to help shed further light on the contribution and impact of angioembolization with regards to complex hepatic injuries.
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Affiliation(s)
- Ali Cadili
- Department of Surgery, University of Connecticut, CT, USA
| | - Jonathan Gates
- Department of Surgery, University of Connecticut, CT, USA
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23
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Brooks A, Reilly JJ, Hope C, Navarro A, Naess PA, Gaarder C. Evolution of non-operative management of liver trauma. Trauma Surg Acute Care Open 2020; 5:e000551. [PMID: 33178894 PMCID: PMC7640583 DOI: 10.1136/tsaco-2020-000551] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/19/2020] [Accepted: 08/31/2020] [Indexed: 11/03/2022] Open
Abstract
The management of complex liver injury has changed during the last 30 years. Operative management has evolved into a non-operative management (NOM) approach, with surgery reserved for those who present in extremis or become hemodynamically unstable despite resuscitation. This NOM approach has been associated with improved survival rates in severe liver injury and has been the mainstay of treatment for the last 20 years. Patients that fail NOM and require emergency surgery are associated with increased morbidity and mortality. Better patient selection may have an impact not only on the rate of failure of NOM, but the mortality rate associated with it. The aim of this article is to review the evidence that helped shape the evolution of liver injury management during the last 30 years.
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Affiliation(s)
- Adam Brooks
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - John-Joe Reilly
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Carla Hope
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Alex Navarro
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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24
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Management of liver trauma in urban university hospitals in India: an observational multicentre cohort study. World J Emerg Surg 2020; 15:58. [PMID: 33059728 PMCID: PMC7560107 DOI: 10.1186/s13017-020-00338-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low- and middle-income countries (LMICs) contribute to 90% of injuries occurring in the world. The liver is one of the commonest organs injured in abdominal trauma. This study aims to highlight the demographic and management profile of liver injury patients, presenting to four urban Indian university hospitals in India. METHODS This is a retrospective registry-based study. Data of patients with liver injury either isolated or concomitant with other injuries was used using the ICD-10 code S36.1 for liver injury. The severity of injury was graded based on the World Society of Emergency Surgery (WSES) grading for liver injuries. RESULTS A total of 368 liver injury patients were analysed. Eighty-nine percent were males, with road traffic injuries being the commonest mechanism. As per WSES liver injury grade, there were 127 (34.5%) grade I, 96 (26.1%) grade II, 70 (19.0%) grade III and 66 (17.9%) grade IV injuries. The overall mortality was 16.6%. Two hundred sixty-two patients (71.2%) were managed non-operatively (NOM), and 106 (38.8%) were operated. 90.1% of those managed non-operatively survived. CONCLUSION In this multicentre cohort of liver injury patients from urban university hospitals in India, the commonest profile of patient was a young male, with a blunt injury to the abdomen due to a road traffic accident. Success rate of non-operative management of liver injury is comparable to other countries.
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25
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AbuAleid LH, Elshaar K, Alhazmi AA, Sherbini MA, Albohiri K. Intrahepatic pseudoaneurysm following penetrating abdominal injury: Surgical and endovascular management of 2 complicated cases. Int J Surg Case Rep 2020; 71:250-256. [PMID: 32492639 PMCID: PMC7264984 DOI: 10.1016/j.ijscr.2020.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Post-traumatic pseudoaneurysm of the hepatic artery is a rare complication of abdominal injury. Prompt intervention is essential to avoid a life-threatening hemorrhage. We report two complicated cases of intrahepatic pseudoaneurysm (IHPA). PRESENTATION OF CASES Case 1: A victim of a bomb blast with thoracoabdominal injury presented in hypovolemic shock. Emergency laparotomy revealed actively bleeding liver lacerations, which had been successfully controlled with perihepatic packing. After 72 h, computed tomography (CT) of the abdomen showed a 3 cm × 1.8 cm IHPA of the left hepatic artery, which was treated with endovascular microcoils embolization. Postoperatively, the patient developed bile leakage and biliopleural fistula, which were managed conservatively. Case 2: A patient suffered a shotgun injury to the abdomen. In laparotomy, a grade III liver laceration was noted. The bleeding was controlled with perihepatic packing. The packs were removed 48 h later. Ten days postoperatively, the patient developed severe abdominal pain with shock, CT of the abdomen showed; 24 cm × 13 cm × 8 cm subcapsular liver hematoma. Superselective hepatic angiography showed a 1-cm IHPA of the right hepatic artery. The entry and exit points of the aneurysm were successfully embolized with two microcoils. No complications related to angioembolizaion were encountered. DISCUSSION IHPA following bomb blast and shotgun injury is rarely reported. Timely diagnosis is crucial. CONCLUSION We advise to keep in mind the possibility of IHPA, when dealing with high-grade liver injury. CT is recommended before removal of perihepatic packs, as it may pick up a life-threatening pseudoaneurysm.
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Affiliation(s)
- Laila H AbuAleid
- Department of General Surgery, King Fahad Central Hospital, Jazan, Saudi Arabia.
| | - Khaled Elshaar
- Department of General Surgery, King Fahad Central Hospital, Jazan, Saudi Arabia
| | - Almoaiad A Alhazmi
- Department of Interventional Radiology, King Fahad Central Hospital, Jazan, Saudi Arabia
| | | | - Khalid Albohiri
- Department of Thoracic Surgery, King Fahad Central Hospital, Jazan, Saudi Arabia
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26
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Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, Biffl W, Peitzman A, Horer T, Abu-Zidan FM, Sartelli M, Fraga GP, Cicuttin E, Ansaloni L, Parra MW, Millán M, DeAngelis N, Inaba K, Velmahos G, Maier R, Khokha V, Sakakushev B, Augustin G, di Saverio S, Pikoulis E, Chirica M, Reva V, Leppaniemi A, Manchev V, Chiarugi M, Damaskos D, Weber D, Parry N, Demetrashvili Z, Civil I, Napolitano L, Corbella D, Catena F. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020; 15:24. [PMID: 32228707 PMCID: PMC7106618 DOI: 10.1186/s13017-020-00302-7] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy.
| | - Raul Coimbra
- Riverside University Health System, CECORC Research Center, Loma Linda University, Loma Linda, USA
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | - Felipe Vega
- Department of Surgery, Hospital Angeles Lomas, Huixquilucan, Mexico
| | | | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital La Jolla, San Diego, CA, USA
| | - Andrew Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, FL, USA
| | - Mauricio Millán
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Nicola DeAngelis
- Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | - Kenji Inaba
- General and Trauma Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - George Velmahos
- General and Emergency Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Salomone di Saverio
- General and Trauma Surgery Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mircea Chirica
- Chirurgie Digestive, CHUGA-CHU Grenoble Alpes, Grenoble, France
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | | | - Ian Civil
- Trauma Surgery, Auckland University Hospital, Auckland, New Zealand
| | - Lena Napolitano
- Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
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27
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Gilyard S, Shinn K, Nezami N, Findeiss LK, Dariushnia S, Grant AA, Hawkins CM, Peters GL, Majdalany BS, Newsome J, Bercu ZL, Kokabi N. Contemporary Management of Hepatic Trauma: What IRs Need to Know. Semin Intervent Radiol 2020; 37:35-43. [PMID: 32139969 DOI: 10.1055/s-0039-3401838] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Trauma remains one of the leading causes of death in the United States in patients younger than 45 years. Blunt trauma is most commonly a result of high-speed motor vehicular collisions or high-level fall. The liver and spleen are the most commonly injured organs, with the liver being the most commonly injured organ in adults and the spleen being the most affected in pediatric blunt trauma. Liver injuries incur a high level of morbidity and mortality mostly secondary to hemorrhage. Over the past 20 years, angiographic intervention has become a mainstay of treatment of hepatic trauma. As there is an increasing need for the interventional radiologists to embolize active hemorrhage in the setting of blunt and penetrating hepatic trauma, this article aims to review the current level of evidence and contemporary management of hepatic trauma from the perspective of interventional radiologists. Embolization techniques and associated outcome and complications are also reviewed.
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Affiliation(s)
- Shenise Gilyard
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Kaitlin Shinn
- Department of Medical Education, Emory University School of Medicine, Atlanta, Georgia
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Laura K Findeiss
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Sean Dariushnia
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - April A Grant
- Division of Trauma/Surgical Critical Care, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - C Matthew Hawkins
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Gail L Peters
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Bill S Majdalany
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Janice Newsome
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Zachary L Bercu
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nima Kokabi
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Mitricof B, Brasoveanu V, Hrehoret D, Barcu A, Picu N, Flutur E, Tomescu D, Droc G, Lupescu I, Popescu I, Botea F. Surgical treatment for severe liver injuries: a single-center experience. MINERVA CHIR 2020; 75:92-103. [PMID: 32009332 DOI: 10.23736/s0026-4733.20.08193-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The liver is one of the most frequently injured organs in abdominal trauma. The advancements in diagnosis and interventional therapy shifted the management of liver trauma towards a non-operative management (NOM). Nevertheless, in severe liver injuries (LI), surgical treatment often involving liver resection (LR) and rarely liver transplantation (LT) remains the main option. The present paper analyses a single center experience in a referral HPB center on a series of patients with high-grade liver trauma. METHODS Forty-five patients with severe LI, that benefitted from NOM (6 pts), LRs (38 pts), and LT (1 pt) performed in our center between June 2000 and June 2019, were included in a combined prospective and retrospective study. The median age of the patients was 29 years (median 33, range 10-76), and the male/female ratio of 33/12. Almost all cases had blunt trauma, except 2 with stab wound (4.4%). RESULTS LIs classified according to the American Association for the Surgery of Trauma (AAST) system were 13.3% (grade III), 44.2% (grade IV), and 42.2% (grade V); none were grade I, II or VI. The rate of major LR was 56.4% (22 LRs). The median operative time was 200 minutes (mean 236; range 150-420). The median blood loss was 750 ml (mean 940; range 500-6500). Overall and major complication rates were 100% (45 pts) and 33.3% (15 pts), respectively. Overall mortality rate was 15.6% (7 pts). CONCLUSIONS Severe liver trauma, often involving complex liver resections, should be managed in a referral HPB center, thus obtaining the best results in terms of morbidity and mortality.
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Affiliation(s)
- Bianca Mitricof
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
| | - Vladislav Brasoveanu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania.,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Doina Hrehoret
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Alexandru Barcu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Nausica Picu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Elena Flutur
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Dana Tomescu
- Center of Anesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Gabriela Droc
- Center of Anesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Ioana Lupescu
- Center of Diagnostic and Interventional Radiology, Fundeni Clinical Institute, Bucharest, Romania
| | - Irinel Popescu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania.,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Florin Botea
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania - .,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
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Society of Interventional Radiology Position Statement on Endovascular Intervention for Trauma. J Vasc Interv Radiol 2020; 31:363-369.e2. [PMID: 31948744 DOI: 10.1016/j.jvir.2019.11.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 11/22/2022] Open
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Zurita Saavedra M, Pérez Alonso A, Pérez Cabrera B, Haro García AM, Ruiz García VM, Mirón Pozo B, Petrone P. Management of Splenic Injuries Utilizing a Multidisciplinary Protocol in 110 Consecutive Patients at a Level II Hospital. Cir Esp 2019; 98:143-148. [PMID: 31739975 DOI: 10.1016/j.ciresp.2019.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/19/2019] [Accepted: 08/31/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Non-operative treatment (NOM) of splenic trauma is the management of choice in hemodynamically stable patients. The aim of the present study was to assess the failure rate of NOM after implementation of a multidisciplinary protocol for splenic injuries compared to literature results. METHODS A retrospective study was performed over a 16-year period. Patient data and management of splenic trauma was recorded according to our hospital protocol: demographic data, blood pressure, respiratory rate, Glasgow Coma Scale(GCS), Revised Trauma Score(RTS), Injury Severity Score(ISS), injury grade according to the American Association for the Surgery of Trauma(AAST), failure of NOM, morbidity and mortality. RESULTS One hundred ten patients were included: 90(81.8%) men, 20(18.2%) women; mean age 37 years; 106(96.5%) cases were blunt and four(3.5%) penetrating by knife. The diagnosis was established by US/CT. AAST classification: 14(13%) grade I; 24(22%) grade II; 34(31%) grade III; 37(34%) grade IV. Emergency laparotomy was performed in 54 patients: 37 due to grade IV injuries, 17 due to hemodynamic instability. NOM was utilized in 56 patients, spleen-preserving surgery in 16, and splenectomy in 38. Ten patients had postoperative complications: seven in the splenectomy group, two in the spleen-preserving surgery group, and one in the NOM group. One patient died. Average hospital stay: 22.8 days- NOM 17.6 days, conservative surgery 29 days, splenectomy 22.4 days. CONCLUSIONS Although we continue with a high hospital stay, the literature reports support our results. The implementation of the protocol by consensus contributed to the change towards NOM.
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Affiliation(s)
| | - Alejandro Pérez Alonso
- Unidad de Cirugía HBP, Servicio de Cirugía General y Aparato Digestivo, Complejo Hospitalario de Jaén, Jaén, España; Departamento de Cirugía y sus Especialidades, Facultad de Medicina, Universidad de Granada, Granada, España
| | | | | | - Víctor Manuel Ruiz García
- Unidad de Cirugía HBP, Servicio de Cirugía General y Aparato Digestivo, Complejo Hospitalario de Jaén, Jaén, España; Departamento de Cirugía y sus Especialidades, Facultad de Medicina, Universidad de Granada, Granada, España
| | - Benito Mirón Pozo
- Servicio de Cirugía General, Hospital Universitario San Cecilio, Granada, España
| | - Patrizio Petrone
- Department of Surgery, NYU Winthrop Hospital, NYU Long Island School of Medicine, Mineola (Nueva York), Estados Unidos.
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Rocca A, Andolfi E, Zamboli AGI, Surfaro G, Tafuri D, Costa G, Frezza B, Scricciolo M, Amato M, Bianco P, Brongo S, Ceccarelli G, Giuliani A, Amato B. Management of Complications of First Instance of Hepatic Trauma in a Liver Surgery Unit: Portal Vein Ligation as a Conservative Therapeutic Strategy. Open Med (Wars) 2019; 14:376-383. [PMID: 31157303 PMCID: PMC6534101 DOI: 10.1515/med-2019-0038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 03/15/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND According to the National Trauma Data Bank, the liver, after the spleen, is the first most injured organ in closed abdominal trauma. METHODS From June 2010 to December 2015 we observed in our department of Hepato-biliary Surgery and Liver Transplant Unit of the A.O.R.N. A. Cardarelli of Naples 40 patients affected by hepatic trauma. In our retrospective study, we review our experience and propose portal vein ligation (PVL) as a first - line strategy for damage control surgery (DCS) in liver trauma. RESULTS 26/40 patients (65%) which received gauze-packing represented our study group. In 10 cases out of 26 patients (38,4%) the abdominal packing was enough to control the damage. In 7 cases (18,4%) we performed a liver resection. In 7 cases, after de-packing, we adopted PVL to achieve DCS. Trans Arterial Embolization was chosen in 6 patients. 2 of them were discharged 14 days later without performing any other procedure.In 3 cases we had to perform a right epatectomy in second instance. Two hepatectomies were due to hemoperitoneum, and the other for coleperitoneum. Two patients were treated in first instance by only doing hemostasis on the bleeding site. We observed 6 patients in first instance. Five of them underwent surgery with hepatic resection and surgical hemostasis of the bleeding site. The other one underwent to conservative management. In summary we performed 15 hepatic resections, 8 of them were right hepatectomies, 1 left hepatectomy, 2 trisegmentectomies V-VI-VII. So in second instance we operated on 10 patients out of 34 (30%). CONCLUSIONS The improved knowledge of clinical physio-pathology and the improvement of diagnostic and instrumental techniques had a great impact on the prognosis of liver trauma. We think that a rigid diagnostic protocol should be applied as this allows timely pathological finding, and consists of three successive but perfectly integrated steps: 1) patient reception, in close collaboration with the resuscitator; 2) accurate but quick diagnostic framing 3) therapeutic decisional making. Selective portal vein ligation is a well-tolerated and safe manoeuvre, which could be effective, even if not definitive, in treating these subjects. That is why we believe that it can be a choice to keep in mind especially in post-depacking bleeding.
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Affiliation(s)
- Aldo Rocca
- Department of Translational Medical Sciences, University of Naples “Federico II”, Naples, Italy
- Via Sergio Pansini, 80131 Naples, Italy General Surgery Unit, Clinica Padre Pio, Mondragone (CE), Italy Department of Abdominal Oncology, Fondazione Giovanni Pascale, IRCCS, Naples, Italy
- Centre of Hepatobiliarypancreatic surgery, Pineta Grande Hospital, Castelvolturno (CE), Italy
| | - Enrico Andolfi
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | | | | | - Domenico Tafuri
- Department of Sport Sciences and Wellness, University of Naples “Parthenope”, Naples, Italy
| | - Gianluca Costa
- Surgical and Medical Department of Traslational Medicine, Sapienza University of Rome, Sant’Andrea Hospital, Via di Grottarossa 1035-39, 00189Rome, Italy
| | - Barbara Frezza
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | - Marta Scricciolo
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | - Maurizio Amato
- Department of Clinical Medicine and Surgery, University Federico II of Naples. Naples, Italy
| | - Paolo Bianco
- Centre of Hepatobiliarypancreatic surgery, Pineta Grande Hospital, Castelvolturno (CE), Italy
| | - Sergio Brongo
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", San Giovanni di Dio e Ruggi D'Aragona University Hospital, University of Salerno, Salerno, Italy
| | - Graziano Ceccarelli
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | - Antonio Giuliani
- Department of Transplantation, Unit of Hepatobiliary Surgery and Liver Transplant Center, ‘A. Cardarelli’ Hospital, Naples, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University Federico II of Naples. Naples, Italy
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Sorour MA, Kassem MI, Ghazal AH, Azzam A, El-Khashab ESI, Shehata GM. Conservative approach in the management of isolated penetrating liver trauma. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Magdy A. Sorour
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | - Mohamed I. Kassem
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | - Abdel Hamid Ghazal
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | - Aymen Azzam
- General Surgery Department, Faculty of Medicine , University of Alexandria , Egypt
| | | | - Gihan M. Shehata
- Medical Informatics and Medical Statistics Department, Medical Research Institute , Alexandria University , Egypt
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Sakaray YR, Gupta V, Yadav TD, Kalra N, Singh V. Biliovascuar complications: a price to pay for non-operative management of major liver trauma. MINERVA CHIR 2019; 74:385-391. [PMID: 31062944 DOI: 10.23736/s0026-4733.19.07925-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND With non-operative management of major liver trauma, there has been an increased incidence of biliovascular complications which are reported variably. METHODS Fifty-six patients with age of 29.79±11.40 years and M:F 8.3:1, with grade III or more liver trauma were evaluated after stabilization for the development of liver related complications. Patients with active contrast extravasation at admission were managed with immediate angioembolization. Patients with prolonged hospital stay underwent repeat CT prior to discharge. Radiological, endoscopic and surgical interventions were carried out as appropriate. RESULTS Ninety-eight percent had blunt abdominal injury. Mean injury severity score was 25.68±10.389. Four (7%) required damage control laparotomy. CECT showed grade III injuries in 52%, grade IV in 30.4%, and grade V in 18%. 11% had laceration extending to porta. Seventeen patients had 21 liver-related complications: 4 biliary, 12 vascular and 1 combined biliary and vascular. Liver related complications were- 3.5% in grade III, 52% in grade IV and 70% in grade V. One patient with active arterio-portal fistula required urgent angioembolization while other arterial pseudoaneurysms were detected 7.23±5.14 days after trauma. Angioembolization was successful in 83% patients. On univariate and multivariate analysis, PRBC requirement and injury grade were the predictors of bilivascular complications. Laceration extending to porta was a predictor for biliary complications and not vascular. Repeat CT picked up 13 complications in 10 patients. CONCLUSIONS Biliovascular complications are managed by multidisciplinary approach. Lacerations extending to porta and grade IV/V injuries have a higher chance of developing biliovascular complications and should be observed closely.
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Affiliation(s)
- Yashwant R Sakaray
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India -
| | - Thakur D Yadav
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naveen Kalra
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Afifi I, Abayazeed S, El-Menyar A, Abdelrahman H, Peralta R, Al-Thani H. Blunt liver trauma: a descriptive analysis from a level I trauma center. BMC Surg 2018; 18:42. [PMID: 29914487 PMCID: PMC6006727 DOI: 10.1186/s12893-018-0369-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 05/24/2018] [Indexed: 11/18/2022] Open
Abstract
Background We aimed to review liver injury experience in a level 1 trauma center; namely clinical presentation, grading, management approach and clinical outcomes. Methods It is a retrospective analysis to include all blunt liver injury patients who were admitted at the Level 1 trauma center over a 3-year period. Data were compared and analyzed based on the liver injury grades and management approaches. Results Blunt liver injury accounted for 38% of the total blunt abdominal trauma cases with a mean age of 31 ± 13 years. Liver injury grade II (44.7%) was most common followed by grade I (28.8%), grade III (19.1%), grade IV (7.0%) and grade V (0.4%). Blood transfusion was more frequently required in patients with grade IV (p = 0.04). Out of 257 patients with blunt liver trauma, 198 were initially treated conservatively, that was successful in 192 (97%), whereas it failed in 6 (3%) patients due to delayed bleeding from hepatic hematoma, associated splenic rupture and small bowel injury which mandate surgical intervention. Fifty-nine patients (23%) underwent emergent surgery in terms of packing, resection debridement, left lobe hepatectomy and splenectomy. Hepatic complications included biloma, pseudoaneurysm and massive liver necrosis. Subanalysis of data using the World Society of Emergency Surgery (WSES) classification revealed 19 patients were categorized as a WSES grade IV who needed surgical intervention without having an initial computerized tomography scanning. The overall mortality was 7.8% which was comparable among the conservative and operative group. Conclusions In our center, low grade liver injury in young males prevails. NOM is successful even for high graded injuries. All conservatively treated patients with high-grade liver injuries should be closely monitored for signs of failure of the non-operative management. Introducing the new WSES classification makes clear how is important the hemodynamic status of the patients despite the lesion. However, further larger prospective and multicenter studies are needed to support our findings.
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Affiliation(s)
- Ibrahim Afifi
- Department of surgery, Trauma Surgery section, Hamad General Hospital (HGH), Doha, Qatar
| | | | - Ayman El-Menyar
- Clinical Research, Trauma & Vascular Surgery, HGH, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, PO Box 3050, Doha, Qatar.
| | - Husham Abdelrahman
- Department of surgery, Trauma Surgery section, Hamad General Hospital (HGH), Doha, Qatar
| | - Ruben Peralta
- Department of surgery, Trauma Surgery section, Hamad General Hospital (HGH), Doha, Qatar
| | - Hassan Al-Thani
- Department of surgery, Trauma Surgery section, Hamad General Hospital (HGH), Doha, Qatar
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A case report as a novel technique in the management of liver injury combined with common hepatic duct avulsion in pediatrics. ANNALS OF PEDIATRIC SURGERY 2018. [DOI: 10.1097/01.xps.0000531237.69931.d3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Tarchouli M, Elabsi M, Njoumi N, Essarghini M, Echarrab M, Chkoff MR. Liver trauma: What current management? Hepatobiliary Pancreat Dis Int 2018; 17:39-44. [PMID: 29428102 DOI: 10.1016/j.hbpd.2018.01.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 11/02/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years. METHODS The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed. RESULTS The study involved 83 patients, with a mean age of 33 years and a marked male predominance (85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries (81.9%) were of low severity (grades I, II, III), while 15 (18.1%) were of high severity (grade IV or greater). Fifty-six patients (67.5%) had multiple injuries. Surgical treatment was performed in 26 (31.3%) patients. Non-operative management was undertaken in 57 cases (68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group. CONCLUSIONS Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.
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Affiliation(s)
- Mohamed Tarchouli
- Department of Digestive Surgery, Mohammed V Military Hospital, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fes, Morocco.
| | - Mohamed Elabsi
- Department of Visceral Surgical Emergency, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Noureddine Njoumi
- Department of Digestive Surgery, Mohammed V Military Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Mohamed Essarghini
- Department of Digestive Surgery, Mohammed V Military Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Mahjoub Echarrab
- Department of Visceral Surgical Emergency, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Mohamed Rachid Chkoff
- Department of Visceral Surgical Emergency, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
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Chong CN, Cheung YS, Lee KF, Rainer TH, Lai BSP. Traumatic Liver Injury in Hong Kong: The Management Strategy and Outcome. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790901600403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | - TH Rainer
- Prince of Wales Hospital, Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
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Early mobilization of patients with non-operative liver and spleen injuries is safe and cost effective. Eur J Trauma Emerg Surg 2017; 44:883-887. [DOI: 10.1007/s00068-017-0864-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 10/16/2017] [Indexed: 10/18/2022]
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Kalil M, Amaral IMA. Epidemiological evaluation of hepatic trauma victims undergoing surgery. Rev Col Bras Cir 2017; 43:22-7. [PMID: 27096853 DOI: 10.1590/0100-69912016001006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 11/30/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to evaluate the epidemiological variables and diagnostic and therapeutic modalities related to hepatic trauma patients undergoing laparotomy in a public referral hospital in the metropolitan region of Vitória-ES. METHODS we conducted a retrospective study, reviewing charts of trauma patients with liver injuries, whether isolated or in association with other organs, who underwent exploratory laparotomy, from January 2011 to December 2013. RESULTS We studied 392 patients, 107 of these with liver injury. The male: female ratio was 6.6 : 1 and the mean age was 30.12 years. Penetrating liver trauma occurred in 78.5% of patients, mostly with firearms. Associated injuries occurred in 86% of cases and intra-abdominal injuries were more common in penetrating trauma (p <0.01). The most commonly used operative technique was hepatorrhaphy and damage control surgery was applied in 6.5% of patients. The average amounts of blood products used were 6.07 units of packed red blood cells and 3.01 units of fresh frozen plasma. The incidence of postoperative complications was 29.9%, the most frequent being infectious, including pneumonia, peritonitis and intra-abdominal abscess. The survival rate of patients suffering from blunt trauma was 60%, and penetrating trauma, 87.5% (p <0.05). CONCLUSION despite technological advances in diagnosis and treatment, mortality rates in liver trauma remain high, especially in patients suffering from blunt trauma in relation to penetrating one.
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Affiliation(s)
- Mitre Kalil
- Departamento de Clínica Cirúrgica, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória, Brasil
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Johnsen NV, Betzold RD, Guillamondegui OD, Dennis BM, Stassen NA, Bhullar I, Ibrahim JA. Surgical Management of Solid Organ Injuries. Surg Clin North Am 2017; 97:1077-1105. [PMID: 28958359 DOI: 10.1016/j.suc.2017.06.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.
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Affiliation(s)
- Niels V Johnsen
- Urological Surgery, Department of Urological Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232, USA
| | - Richard D Betzold
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Oscar D Guillamondegui
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Bradley M Dennis
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA.
| | - Nicole A Stassen
- Surgical Critical Care Fellowship and Surgical Sub-Internship, University of Rochester, Kessler Family Burn Trauma Intensive Care Unit, 601 Elmwood Avenue, Box Surg, Rochester, NY 14642, USA
| | - Indermeet Bhullar
- Orlando Health Physicians Surgical Group, Orlando Regional Medical Center, 86 West Underwood, Suite 201, Orlando, FL 32806, USA
| | - Joseph A Ibrahim
- Orlando Health Physicians Surgical Group, Orlando Regional Medical Center, 86 West Underwood, Suite 201, Orlando, FL 32806, USA
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El-Menyar A, Abdelrahman H, Al-Hassani A, Peralta R, AbdelAziz H, Latifi R, Al-Thani H. Single Versus Multiple Solid Organ Injuries Following Blunt Abdominal Trauma. World J Surg 2017; 41:2689-2696. [DOI: 10.1007/s00268-017-4087-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Buci S, Torba M, Gjata A, Kajo I, Bushi G, Kagjini K. The rate of success of the conservative management of liver trauma in a developing country. World J Emerg Surg 2017; 12:24. [PMID: 28596799 PMCID: PMC5463417 DOI: 10.1186/s13017-017-0135-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The conservative treatment of liver trauma has made important progress over the last 10 years at the Trauma University Hospital in Tirana, Albania. The percentage of success was 58.7%. The aims of this study were to analyze the conservative treatment of liver trauma and to compare the results with those in the literature. METHODS This study was conducted prospectively from January 2009 to December 2012. We analyzed 173 patients admitted to our hospital with liver trauma. Liver injuries were evaluated according to the American Association for the Surgery of Trauma and the World Society of Emergency Surgery classification, while the anatomic gravity of the associated injuries was defined using the Injury Severity Score system. The potential mortality was estimated with the Revised Trauma Score. RESULTS Out of the 173 patients with liver trauma, 83.2% were male. The main cause of liver trauma was motor vehicle crashes (50.9%). Blunt trauma was the cause of liver injury in 129 cases (74.6%), and penetrating trauma occurred in 44 cases (25.4%). Initially, the decision was to manage 88 cases (50.9%) via the conservative approach. Of these, 73 cases (42.2%) were successfully treated with conservative treatment, while in 15 cases (17.2%), this approach failed. The success rate of conservative treatment by grade of injuries was as follows: grade I (38.4%), grade II (30.1%), grade III (28.8%), and grade IV (2.7%). The likelihood of the success of conservative treatment had a significant correlation with the grade of the liver injury (p < 0.00001), associated intra-abdominal injuries (p = 0.00051), and complications (z = 2.3169, p = 0.02051). The overall mortality rate of liver trauma was 13.2%. CONCLUSIONS The likelihood of success in using conservative treatment had a significant correlation with the grade of liver injury and associated intra-abdominal injuries. The limited hospital resources and low level of consensus on conservative treatment had a negative impact on the level of success.
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Affiliation(s)
- S Buci
- Service of General Surgery, Trauma University Hospital, Tirana, Albania
| | - M Torba
- Service of General Surgery, Trauma University Hospital, Tirana, Albania
| | - A Gjata
- Department of Surgery, UHC "Mother Teresa", Tirana, Albania
| | - I Kajo
- Department of Internal Medicine, Trauma University Hospital, Tirana, Albania
| | - Gj Bushi
- Service of General Surgery, Trauma University Hospital, Tirana, Albania
| | - K Kagjini
- Service of General Surgery, Trauma University Hospital, Tirana, Albania
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Graves JA, Hanna TN, Herr KD. Pearls and pitfalls of hepatobiliary and splenic trauma: what every trauma radiologist needs to know. Emerg Radiol 2017; 24:557-568. [DOI: 10.1007/s10140-017-1515-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/05/2017] [Indexed: 12/26/2022]
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Lee KF, Chong CCN, Yeung JHH, Cheung NK, Siu EYY, Cheung YS, Wong J, Lai PBS. Factors affecting outcomes in traumatic liver injury: A retrospective study. SURGICAL PRACTICE 2017; 21:63-69. [DOI: 10.1111/1744-1633.12237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Kit-Fai Lee
- Department of Surgery; Prince of Wales Hospital; Hong Kong
| | | | | | - Nai-Kwong Cheung
- Department of Trauma and Emergency Centre; Prince of Wales Hospital; Hong Kong
| | - Eva Yin-Yu Siu
- Department of Surgery; Prince of Wales Hospital; Hong Kong
| | - Yue-Sun Cheung
- Department of Surgery; Prince of Wales Hospital; Hong Kong
| | - John Wong
- Department of Surgery; Prince of Wales Hospital; Hong Kong
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Fu CJ, Wong YC, Tsang YM, Wang LJ, Chen HW, Ku YK, Wu CH, Chen HW, Kang SC. Computed tomography arterial portography for assessment of portal vein injury after blunt hepatic trauma. Diagn Interv Radiol 2016; 21:361-7. [PMID: 26268303 DOI: 10.5152/dir.2015.14445] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Intrahepatic portal vein injuries secondary to blunt abdominal trauma are difficult to diagnose and can result in insidious bleeding. We aimed to compare computed tomography arterial portography (CTAP), reperfusion CTAP (rCTAP), and conventional computed tomography (CT) for diagnosing portal vein injuries after blunt hepatic trauma. METHODS Patients with blunt hepatic trauma, who were eligible for nonoperative management, underwent CTAP, rCTAP, and CT. The number and size of perfusion defects observed using the three methods were compared. RESULTS A total of 13 patients (seven males/six females) with a mean age of 34.5±14.1 years were included in the study. A total of 36 hepatic segments had perfusion defects on rCTAP and CT, while there were 47 hepatic segments with perfusion defects on CTAP. The size of perfusion defects on CT (239 cm3; interquartile range [IQR]: 129.5, 309.5) and rCTAP (238 cm3; IQR: 129.5, 310.5) were significantly smaller compared with CTAP (291 cm3; IQR: 136, 371) (both, P = 0.002). CONCLUSION Perfusion defects measured by CTAP were significantly greater than those determined by either rCTAP or CT in cases of blunt hepatic trauma. This finding suggests that CTAP is superior to rCTAP and CT in evaluating portal vein injuries after blunt liver trauma.
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Affiliation(s)
- Chen Ju Fu
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, TaoYuan, Taiwan.
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Sulava E, Bergin S, Long B, Koyfman A. Elevated Liver Enzymes: Emergency Department-Focused Management. J Emerg Med 2016; 52:654-667. [PMID: 27889359 DOI: 10.1016/j.jemermed.2016.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/18/2016] [Accepted: 10/14/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Liver function test (LFT) abnormalities are a common problem faced by emergency physicians. This has become more common with the introduction of laboratory panels and automated routine laboratory testing. Fortunately, not all patients with irregularities in liver enzymes possess underlying pathology. This emergency medicine focused review provides a discussion of the various biochemical tests, their underlying biological basis, and an algorithmic approach to the interpretation of abnormalities. OBJECTIVE Our aim was to provide emergency physicians with an overview of the evaluation and management of patients with elevated LFTs. DISCUSSION The liver is a complex organ with multiple roles. The key biochemical markers of hepatic function can be organized into the groupings of hepatocellular, cholestatic, or functioning liver, based on underlying enzymatic roles. Pathologic alterations to these markers can be algorithmically assessed by separating disease processes of these groupings, followed by assessment of the magnitude of enzymatic elevation. This review conducts an in-depth evaluation of the differential diagnosis and emergency department-centered clinical response of elevated LFTs based on subcategories of mild, moderate, and severe transaminase elevation. CONCLUSIONS By understanding the biochemical basis of each LFT, it is possible to correlate laboratory findings to a patient's clinical presentation. An algorithmic approach can be taken to help narrow the spectrum of a differential diagnosis. This may assist providers in ensuring appropriate management and evaluation of the patient with elevated LFTs.
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Affiliation(s)
- Eric Sulava
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Samuel Bergin
- Department of Emergency Medicine, University Medical Center of Southern Nevada, Las Vegas, Nevada
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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Tan GXV, Miranda R, Sutherland T. Causes of hepatic capsular retraction: a pictorial essay. Insights Imaging 2016; 7:831-840. [PMID: 27686493 PMCID: PMC5110478 DOI: 10.1007/s13244-016-0520-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/20/2016] [Accepted: 08/29/2016] [Indexed: 12/11/2022] Open
Abstract
Abstract Hepatic capsular retraction refers to the loss of the normal convex hepatic contour, with the formation of an area of flattening or concavity. This can result from myriad causes, including intrinsic hepatic conditions such as cirrhosis, biliary obstruction, benign tumours, malignancy and infections, as well as extrahepatic causes such as trauma. This article aims to provide familiarity with this wide spectrum of conditions, including mimics of hepatic capsular retraction, by highlighting the anatomic, pathologic and imaging features that help distinguish these entities from one another. Teaching Points • Hepatic capsular retraction can occur due to various intrinsic or extrinsic hepatic causes. • Hepatic capsular retraction is observed in both benign and malignant conditions. • Recognising associated imaging features can help elicit causes of hepatic capsular retraction.
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Affiliation(s)
- Gary Xia Vern Tan
- Department of Medical Imaging, St Vincent's Hospital Melbourne, 41, Victoria Parade, Fitzroy, Victoria, 3065, Australia.
| | | | - Tom Sutherland
- Department of Medical Imaging, St Vincent's Hospital Melbourne, 41, Victoria Parade, Fitzroy, Victoria, 3065, Australia
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Retrospective Evaluation of Magnitude, Severity and Outcome of Traumatic Hepatobiliary Injury at a Level-I Trauma Center in India. Indian J Surg 2016; 78:281-7. [PMID: 27574345 DOI: 10.1007/s12262-015-1356-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/15/2015] [Indexed: 11/27/2022] Open
Abstract
Liver injury is the major cause of morbidity and mortality in polytrauma patients. This study was conducted to know the burden of hepatobiliary injury and its outcome in our setup. It is a retrospective study of all patients with traumatic hepatobiliary injuries from January 2008 through April 2012 at JPNATC, New Delhi. All patients were resuscitated as per ATLS guidelines. Management of patients was based on hemodynamic status and associated injuries. Liver injury occurred in 7.52 % of all trauma admissions and 20.34 % of total abdominal trauma patients. Most common mechanism of injury was blunt trauma due to road traffic injury among all age groups (n = 234, 67.83 %). Seventy-five percent of the patients with liver injury were hemodynamically stable at presentation (n = 262, 75 %). Isolated liver injury was seen in 27 % of the patients. Grade II (n = 138, 40 %) liver injury was the most common. Of the patients, 68.70 % were managed nonoperatively. Among operatively managed patients (n = 100, 29 %), 38 % patient underwent immediate laparotomy due to hemodynamic instability. The failure of nonoperative management was in eight (2.32 %) patients with success rate of 96.73 %, i.e., 237 patients out of 245 were successfully managed nonoperatively. Packing was done in 27 % of the patients of high-grade liver injury and was associated with high morbidity and mortality (51 %). The morbidity and mortality of liver trauma were 28.99 % and 12.17 %, respectively. Liver injury is common in abdominal trauma patients. Most of the patients with liver injury are hemodynamically stable and should be managed nonoperatively with careful monitoring.
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Abstract
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%.
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Affiliation(s)
- I Ahmed
- Department of HPB Surgery, Queens Medical Centre, Nottingham University Hospitals, Nottingham, NG7 2UH, United Kingdom,
| | - IJ Beckingham
- Department of HPB Surgery, Queens Medical Centre, Nottingham University Hospitals, Nottingham, NG7 2UH, United Kingdom
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Matsushima K, Inaba K, Cho J, Mohammed H, Herr K, Leichtle S, Zada G, Demetriades D. Therapeutic anticoagulation in patients with traumatic brain injury. J Surg Res 2016; 205:186-91. [PMID: 27621017 DOI: 10.1016/j.jss.2016.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/02/2016] [Accepted: 06/14/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Therapeutic anticoagulation (TAC) is often required in trauma patients for various indications. However, it remains unknown whether TAC can be safely initiated in the postinjury period for patients with traumatic brain injury (TBI). The purpose of this study was to evaluate the safety of TAC in TBI patients. MATERIALS AND METHODS We conducted a 7-y retrospective study. All TBI patients who received TAC within 60 d postinjury were included. In addition to patient and injury characteristics, detailed information regarding TAC was collected. The primary outcome was the incidence of neurologic deterioration or progression of hemorrhagic TBI on repeat head computed tomography (CT) after initiation of TAC. Univariate and multivariate analyses were used to identify factors associated with progression of hemorrhagic TBI after TAC. RESULTS A total of 3355 TBI patients were identified. Of those, 72 patients (2.1%) received TAC. Median age, 59; 76.4% male; median Injury Severity Score, 19; median admission Glasgow Coma Scale, 14; and median Rotterdam score on the initial head CT, 3. Although atrial fibrillation was the most common preinjury indication for TAC, venous thromboembolism was the most common postinjury indication. The median postinjury time of initiation of TAC was 9 d. Intravenous heparin infusion was the most commonly used agent for TAC (70.8%). None of our study patients developed any signs of neurologic deterioration due to TAC. Progression of hemorrhagic TBI on repeat head CT was observed in six patients. In a multiple logistic regression model, aged ≥65 y was significantly associated with progression of hemorrhagic TBI after TAC (odds ratio, 15.2; 95% confidence interval, 1.1-212.7; P = 0.04). CONCLUSIONS This study shows preliminary data regarding TAC initiated in patients with TBI. Further prospective study is warranted to determine the risks and benefits of TAC in this specific group of patients.
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Affiliation(s)
- Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California.
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Jayun Cho
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Hussan Mohammed
- Department of Radiology, University of Southern California, Los Angeles, California
| | - Keith Herr
- Department of Radiology, University of Southern California, Los Angeles, California
| | - Stefan Leichtle
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Demetrios Demetriades
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
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