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

Liver Trauma: Until When We Have to Delay Surgery? A Review

Liver involvement after abdominal blunt trauma must be expected, and in up to 30% of cases, spleen, kidney, and pancreas injuries may coexist. Whenever hemodynamics conditions do not contraindicate the overcoming of the ancient dogma according to which exploratory laparotomy should be performed after every major abdominal trauma, a CT scan has to clarify the liver lesions so as to determine the optimal management strategy. Except for complete vascular avulsion, no liver trauma grade precludes nonoperative management. Every attempt to treat the injured liver by avoiding a strong surgical approach may be considered. Each time, a nonoperative management (NOM) consisting of a basic “wait and see” attitude combined with systemic support and blood replacement are inadequate. Embolization should be considered to stop the bleeding. Percutaneous drainage of collections, endoscopic retrograde cholangiopancreatography (ERCP) with papilla sphincterotomy or stent placement and percutaneous transhepatic biliary drainage (PTBD) may avoid, or at least delay, surgical reconstruction or resection until systemic and hepatic inflammatory remodeling are resolved. The pathophysiological principle sustaining these leanings is based on the opportunity to limit the further release of cell debris fragments acting as damage-associated molecular patterns (DAMPs) and the following stress response associated with the consequent immune suppression after trauma. The main goal will be a faster recovery combined with limited cell death of the liver through the ischemic events that may directly follow the trauma, exacerbated by hemostatic procedures and surgery, in order to reduce the gross distortion of a regenerated liver.

Follow-Up Imaging in Patients with Blunt Splenic or Hepatic Injury Managed Nonoperatively

Nonoperative management of blunt splenic and hepatic injuries has become the standard of care for hemodynamically stable patients. However, nonoperative management may lead to delayed complications and appropriate follow-up is therefore crucial. The aim of this systematic literature review was to assess the role of different imaging modalities in the follow-up assessment of patients with blunt splenic or hepatic injuries using the PubMed database. Eighteen studies were found to be relevant to the topic. A total of 2725 patients were enrolled in the included studies. Both retrospective and prospective studies, but no randomized controlled trials were found. In these studies, CT, ultrasound, and contrast-enhanced ultrasound were discussed. CT was the most commonly used imaging modality. Taking into account all studies included, only one patient underwent intervention due to a complication diagnosed by follow-up CTscan in the absence of clinical signs and symptoms. This equates to a total of 920 CT scans performed to diagnose one clinically nonevident complication that required intervention. Based on the reviewed literature, routine imaging follow-up CT scans may not be indicated in asymptomatic patients with lower grade blunt splenic or hepatic injuries. Contrast-enhanced ultrasound is a promising alternative imaging modality for the follow-up of these patients.

[Hepatic trauma. Interventional and conservative therapy]

The non-operative management of hemodynamically stable patients with liver trauma has become the standard of care. Non-operative treatment has a success rate of >80%. In the majority of cases of hemodynamic instability or high grade liver injuries, however, a surgical approach is necessary. As for conservative treatment of liver trauma the surveillance of patients in the ICU is of utmost importance. Repeat CT scans are only necessary in patients with high grade injuries or in case of complications. Interventional procedures, such as the endoscopic retrograde cholangiopancreatography in cases of biliary complications or angiography for vascular complications, are increasingly being used in order to avoid surgery. The success rates of non-operative strategies have been improving continuously over the last decades.

Role of laparoscopy in blunt liver trauma

Although much has been written about the role of laparoscopy in the acute setting for victims of blunt and penetrating trauma, little has been published on delayed laparoscopy relating specifically to complications of conservative management of liver trauma. There has been a shift towards managing liver trauma conservatively, with haemodynamic instability being the key indication for emergency laparotomy, rather than computed tomography findings. However, as a side-effect of more liver injuries being treated non-operatively, bile leak from a disrupted biliary tree presenting later in admission has appeared as a new problem to manage. We describe in this article three cases that have been managed by laparoscopy and drainage alone, outlining the advantages of this technique and defining a new role for delayed laparoscopy in blunt liver trauma.

Routine Follow-Up Imaging Is Unnecessary in the Management of Blunt Hepatic Injury

BACKGROUND

Nonoperative management of hemodynamically stable patients with blunt hepatic injuries has become the standard of care over the past decade. However, controversy regarding the role of in-hospital follow-up computed tomographic (CT) scans as a part of this nonoperative management scheme is ongoing. Although many institutions, including our own, have advocated routine in-hospital follow-up scans, others have suggested a more selective policy. Over time, we have perceived a low yield from follow-up studies. The hypothesis for this study is that routine follow-up imaging of asymptomatic patients is unnecessary.

METHODS

All patients selected for nonoperative management of blunt hepatic injury were evaluated for utility of follow-up CT scans over a 4-year period.

RESULTS

There were 530 stable patients with hepatic injury on admission CT scans in which follow-up scans were obtained within a week of admission. All injuries were classified according to the revised American Association for the Surgery of Trauma Organ Injury Scale: 102 (19.2%) grade I, 181 (34.1%) grade II, 158 (29.8%) grade III, 74 (13.9%) grade IV, and 15 (2.8%) grade V. Follow-up scans showed that most injuries were either unchanged (51%) or improved (34.7%). Only three patients underwent intervention based on their follow-up scans: two patients had arteriography (one with therapeutic embolization) and one had percutaneous drainage. Each of those patients had clinical signs or symptoms that were indicative of ongoing hepatic abnormality.

CONCLUSION

These data demonstrate that, regardless of injury grade, routine in-hospital follow-up scans are not indicated as part of the nonoperative management of blunt liver injuries. Follow-up scans are indicated for patients who develop signs or symptoms suggestive of hepatic abnormality.

Ultrasonography for Interval Assessment in the Nonoperative Management of Hepatic Trauma

Abdominal ultrasonography (US) is gaining widespread acceptance as a valuable diagnostic tool in the initial evaluation of trauma victims. We investigated the utility of US as a follow-up radiologic study in nonoperative hepatic trauma. Patients with liver injury designated for non-operative management were prospectively studied over a 2-year period at our primary adult resource center for trauma. Computed tomography (CT) and radiologist-performed US were obtained at admission and at 1 week. The ability of US to detect lesions, fluid, and complications was evaluated by comparing with the corresponding CT. Twenty-five hepatic trauma patients in the study were successfully managed nonoperatively and had both initial and follow-up US and CT scans: 1 (4%) grade I, 5 (20%) grade II, 7 (28%) grade III, 7 (28%) grade IV, and 5 (20%) grade V. Four complications developed [biloma (3) and biliary fistula (1)] in 3 patients with grade IV injury and 1 with a grade II injury. Interval US appropriately detected a complication or confirmed the absence of complication in all (13/13, 100%) patients with low-grade (I–III) injury and only missed a small biloma in one patient with a grade IV injury. Interval US and CT agreement was 92 per cent for change in hemoperitoneum or parenchymal lesion. Ultrasonography is a convenient imaging modality in the evaluation of hepatic trauma. US is sufficient to detect or exclude complications in low-grade injuries. In high-grade injuries, US may be an adjunct to CT for definitive interval assessment.

Penetrating stab wounds to the abdomen: use of serial US and contrast-enhanced CT in stable patients

PURPOSE

To evaluate the usefulness of computed tomography (CT) and ultrasonography (US) for the initial assessment of penetrating abdominal stab wounds in patients who presented to the emergency department without indication for immediate laparotomy.

MATERIALS AND METHODS

During 36 months, 32 patients with a penetrating stab wound to the abdomen were examined with serial US (at admission and 12 hours later) and helical CT, with contrast material administered orally, intravenously, and rectally. Presence of hemoperitoneum and integrity of solid and hollow viscera were evaluated with both methods. Sonograms were interpreted by the radiologist who performed the examination, and CT images were independently evaluated by two radiologists. Findings of both techniques were compared with clinical outcome and/or surgical findings.

RESULTS

One (3.1%) of 32 patients required surgery: Surgical findings were massive hemoperitoneum and an extensive hepatic laceration. Both US and CT depicted these abnormalities. Thirty-one (96.9%) patients were treated conservatively, without surgery, and remained asymptomatic during 28 days of clinical follow-up after discharge from the hospital. US and/or CT showed intraperitoneal abnormalities in 21 of these patients. In 11 patients, both methods showed no evidence of visceral injury or hemoperitoneum, and none of these patients required surgery.

CONCLUSION

Serial US and CT help guide treatment for stable patients with penetrating stab injuries to the abdomen.

Evolution in the treatment of complex blunt liver injuries

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

Nonoperative Management of Blunt Liver Trauma: The Value of Follow-Up Abdominal Computed Tomography Scans

Our hypothesis was that follow-up abdominal CT scans are not routinely necessary in patients with blunt liver injury treated nonoperatively. We conducted an 8-year retrospective review of hospital chart and outpatient clinic records. We reviewed all admission and follow-up CT scans. There were 42 adults and 12 children. There were 1 (2%) grade I, 15 (28%) grade II, 28 (52%) grade III, 8 (15%) grade IV, and 2 (4%) grade V liver injuries. Two patients died during the first 24 hours, both from associated injuries. Nonoperative management was successful in 51 (98%) of the remaining 52 patients. No follow-up abdominal CT scans were performed on 21 (40%) patients; none developed hepatic complications. An initial follow-up CT scan was obtained in 31 (60%) patients. Information from these scans directly affected management in 3 (9%) patients; in each case, the scans were prompted by a change in clinical status. One significant biloma with bile leak was managed by nasobiliary stenting and percutaneous drainage. One hepatic artery-to-portal vein fistula was obliterated by transarterial embolization. A single missed diaphragm rupture necessitated laparotomy. Additional late follow-up CT scans were obtained in 13 patients; no clinically useful information was evident on any of these examinations. We conclude that follow-up abdominal CT scans are not routinely necessary in patients with liver injuries treated nonoperatively. Selective criteria based on the severity of liver injury, presence of associated intraabdominal pathology, and clinical parameters should dictate the need for follow-up imaging studies.

Nonoperative management of solid organ injuries. Past, present, and future

All patients with injuries to the solid organs of the abdomen and who are hemodynamically stable should be considered candidates for nonoperative management after their injuries have been staged by abdominal CT scanning, but because the CT stage of the injury does not always predict which patients require laparotomy, these patients must remain under the care of experienced trauma surgeons who can not only recognize the presence of an associated hollow viscus injury in need of repair but also will be readily available to operate if the nonoperative approach fails. Until continued bleeding can be safely ruled out, a period of close monitoring in an ICU-like setting seems warranted. Although delayed bleeding from the liver seems extremely rare, delayed rupture of the spleen and continued hemorrhage into the retroperitoneum from an injured kidney are not unusual, so patients with splenic and renal injuries should be considered candidates for repeat imaging procedures before discharge. Others likely to benefit from a second look at their injuries include patients with subcapsular hematomas, patients with recognized extravasation on the initial scan, and athletes anxious to return to contact sports. Experience from major trauma centers suggests that the incidence of missed intestinal injuries is low in adults and children managed nonoperatively, but surgeons must be diligent in monitoring for increasing abdominal pain, abdominal distention, vomiting, and signs of inflammation, which may be delayed manifestations of intestinal disruption. Patients with vascular injuries (grade V injuries to the spleen, liver, or kidney) may be candidates for radiologic procedures, such as angioembolization or stenting, but some of these patients are best served by immediate laparotomy. Selected patients with penetrating injuries may also be candidates for the nonoperative approach, but further research in this area is needed before this approach can be widely embraced. As we approach the year 2000, the nonoperative approach to hepatic, splenic, and renal injuries will continue to have a major role in the treatment of trauma patients. Currently, the morbidity and mortality rates of nonoperative management are acceptably low, but surgeons still must monitor their results carefully as they apply these methods more liberally among injured patients.

[Current treatment of closed injuries of the liver: benefits and pitfalls]

STUDY AIM

The management of blunt hepatic trauma has been modified by the development of conservative methods. Risks and pitfalls of this new approach must be determined.

PATIENTS AND METHODS

From January 1985 to September, 1998, 130 patients with blunt hepatic trauma were treated by the same team. Among them, 38 patients were referred from another centre (21 already having undergone operations). Eighty patients (61%) had an initial non operative management and 50 patients (39%) underwent emergency laparotomy. Perihepatic packing was performed in 24 patients, hepatic sutures in 22, limited hepatic resection in six, and major hepatectomy in two patients only.

RESULTS

There were three deaths in the non operative management group (mortality rate: 3.5%) and 11 patients required a secondary laparotomy: four for haemorrhage, one for enteric injury, two for acute pancreatitis, one for bile leakage, one for subphrenic abscess, one for acute cholecystitis. There were 14 deaths in the emergency laparotomy group (mortality rate: 28%), including four intraoperative deaths due to haemorrhage and two due to abdominal compartment syndrome.

CONCLUSIONS

In the nonoperative management group a close clinical survey of the patient is necessary and a secondary laparotomy often indicated. In the operative management group, early packing requires reintervention if the patient is unstable. Alternative means of temporary closure may allow coverage without tension in order to avoid the abdominal compartment syndrome.

Non-operative management of blunt hepatic trauma

BACKGROUND

Non-operative management is currently considered the treatment of choice in over 50 per cent of adult patients with blunt liver injury. This report reviews the criteria for non-operative management and its potential downside.

METHODS

English language publications were reviewed.

RESULTS

Most reports from major trauma centres in the USA support the non-operative treatment of patients with blunt liver injury if well established criteria are met. Using such criteria, non-operative treatment is successful in 50-80 per cent of cases. Adjunctive radiological techniques may be helpful in managing some complications of non-operative treatment.

CONCLUSION

Non-operative management is safe in haemodynamically stable patients with blunt liver injury. Computed tomography (CT) of the abdomen is extremely useful to document the extent of the damage and the presence of associated injuries, but it is not possible, based on CT alone, to predict failure; careful physiological monitoring in selected patients is indicated to avoid catastrophic complications.