Liver trauma: WSES 2020 guidelines

Hepatic Portal Venous Perfusion Imaging Using Vessel-Labeling Super-Resolution Ultrasound

OBJECTIVE

Blood flow imaging and perfusion assessment of the hepatic portal vein are critical for the diagnosis of several liver diseases, including cirrhosis, primary and metastatic liver tumors. However, perfusion imaging of the portal vein is challenging due to the unique dual blood supply system of the liver.

METHODS

We developed a novel method for specific perfusion imaging of the portal vein and downstream vessels, which was validated on healthy mice (n = 4). The right lobe of the liver in healthy mice was sequentially imaged using ultrafast plane-wave Doppler imaging and vascular labeling. In each experiment, mice were first injected with phase-change nanodroplets (PCNDs), followed immediately by ultrafast Doppler imaging to determine the imaging section and locate portal vein branches. Through an interactive process, portal vein branches were selected by mouse click for data acquisition of vessel-labeling ultrasound (VLUS) based on PCNDs. Subsequent arrival time calculations and super-resolution ultrasound (SRUS) imaging were performed offline. To demonstrate the specificity of the proposed method for vascular imaging, one mouse was injected with Sonovue microbubbles for plane-wave ultrasound data acquisition and microbubble-based VLUS data acquisition. All imaging experiments were conducted on the Verasonics (Kirkland, WA, USA) Vantage 256 ultrasound system using an L22-8v linear array transducer with a center frequency of 15.625 MHz. The multi-angle coherent compounding plane-wave acquisition frame rate was 500 Hz.

RESULTS

Imaging results from healthy mice (n = 4) demonstrated that VLUS was able to label different branches of the hepatic portal vein and specifically image downstream vessels. Analysis of the in vivo results at different spatial scales showed that the brightness of the downstream perfusion area was significantly enhanced after labeling started, while there was no significant difference in image brightness before the labeling started and after it ended. By analyzing the acoustic field distribution at the focal point, the full width at half maximum in the x1 and z1 directions were 98.56 μm and 526.68 μm, respectively. Along the propagation path of the focused beam (outside the labeling area), no significant activation of the PCNDs was observed (p < 0.0001). Combined with SRUS technology, the resolution of the VLUS portal vein imaging results was further enhanced. The time-intensity curves of the downstream regions of interest indicated that VLUS provided a step input signal to the downstream vessels. Based on the arrival time of the step point in the time-intensity curves, the arrival time distribution map of the downstream vessels relative to the labeling point could be calculated.

CONCLUSION

We propose a novel method for hepatic portal vein perfusion imaging based on VLUS. In vivo experiments, simulation results and statistical analysis demonstrate that this method is able to accurately label portal vein vessels with millimeter-level precision, enabling specific high-resolution imaging and precise, non-invasive measurement of the downstream perfusion area. By combining VLUS with SRUS technology, the resolution of the portal vein imaging results can be further enhanced.

Potentially low-value operative care in abdominal trauma: A retrospective National Trauma Data Bank study

BACKGROUND

We currently lack national data on adherence to American College of Surgeons recommendations on nonoperative management for hemodynamically stable adults with solid-organ injuries. We aimed to estimate the incidence and interhospital variation in potentially low-value operative management for adults with blunt solid abdominal organ injuries.

METHODS

We included adults with blunt solid-organ injury eligible for nonoperative management (grades I-IV spleen and liver and grade I-III kidney, hemodynamically stable on arrival, and no blood products used in the emergency department) who were admitted to trauma centers in the United States that submitted data to the National Trauma Data Bank between 2016 and 2019. Low-value operative management was defined as laparotomy within 6 hours of admission. Interhospital variation was measured using risk-adjusted intraclass correlation coefficients (<5% low, 5-20% moderate, and >20% high).

RESULTS

In total, 62,601 adults in 324 American College of Surgeons-verified level I-III trauma centers and 297 state-designated centers were included. Adjusted incidences of potentially low-value operative management were 2.7% overall (6.8%, 2.1%, 0.8%, for spleen, liver, and kidney injuries) and 2.6%, 2.5%, and 3.0% for American College of Surgeons-verified level I, level II, and state-designated centers. Interhospital variation was moderate to high with a global intraclass correlation coefficient of 21% and intraclass correlation coefficients of 18%, 25%, and 21% for American College of Surgeons-verified level I, level II, and state-designated trauma centers, respectively.

CONCLUSION

Results suggest that low-value operative management is uncommon in US trauma centers, but variation between same-level trauma centers is moderate to high. Future research should strive to identify determinants, and assess impact on patient outcomes.

Development of a contrast-enhanced ultrasound-guided high-intensity focused ultrasound system for coagulation of liver parenchyma

BACKGROUND

The liver is the most common organ injured in blunt abdominal trauma and makes up roughly 5% of all trauma admissions. Current treatments are invasive and resource intensive, which may delay care. We aim to develop and validate a contrast-enhanced ultrasound (CEUS)-guided noninvasive tool to treat liver lacerations at the bedside.

METHODS

Two 1.8-MHz high-intensity focused ultrasound (HIFU) elements were coupled to a C1-6 diagnostic ultrasound probe and a Logiq E10 scanner (GE HealthCare, Waukesha, WI) using a custom enclosure for coregistered imaging and ablation. A phantom was created from polyacrylamide gel combined with thermochromic ink whose color changes above biological ablative temperatures (60°C). The HIFU wave was focused approximately 0.5 cm below the surface using a 50% duty cycle generating 11.9 MPa for 20, 30, 40, 50, and 60 seconds. Experiments were repeated on ex vivo chicken livers in a water bath. Finally, the livers of four live swine underwent up to six CEUS-guided treatments using parameters optimized from in vitro work.

RESULTS

Treatment of the phantom between 20 and 60 seconds produced ablation sizes from 0.016 to 0.4 cm 3 . The relationship between time and size was exponential ( R2 = 0.992). Ablation areas were also well visualized on with ultrasound imaging. The ex vivo liver ablation size at 20 seconds was 0.37 cm 3 , at 30 seconds was 0.66 cm 3 , and at 100 seconds was 5.0 cm 3 . For the in vivo swine experiments, the average ablation area measured 2.0 × 0.75 cm with a maximum of 3.5 × 1.5 cm. Contrast-enhanced ultrasound was used with the contrast agent Definity (Lantheus Medical Imaging, North Billerica, MA) for identification of lacerations and immediate postoperative evaluation of therapy.

CONCLUSION

These experiments demonstrate the feasibility of CEUS-guided transdermal HIFU ablation and the time-dependent size of ablation. This work warrants future investigations into using ultrasound to detect active bleeding and HIFU to coagulate grades III and IV liver laceration.

National Analysis of Clinical Outcomes Associated With Cirrhotic Blunt Trauma Patients Undergoing Emergency Laparotomy Versus Non-operative Management: A Propensity Case-Matched Analysis

IntroductionThis study aims to evaluate clinical outcomes among severely injured trauma patients presenting with isolated blunt abdominal solid organ injuries with a pre-diagnosis of liver cirrhosis (LC) undergoing emergency laparotomy vs nonoperative management (NOM).MethodsThis retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) dataset from 2017 to 2021. Adults (≥18 years) with a pre-existing diagnosis of LC who presented with severe blunt (ISS ≥ 16) isolated solid organ abdominal injuries and underwent laparotomy or NOM were included. Outcomes of interest included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and in-hospital complications such as acute renal failure and deep vein thrombosis.Results929 patients were included in this analysis, with 355 undergoing laparotomy and 574 managed nonoperatively. Laparotomy patients suffered greater in-hospital mortality (n = 186, 52.3% vs n = 115, 20.0%; P < .01), required significantly more blood within 4 hours (8.9 units vs 4.3 units, P < .01), and had a significantly longer ICU-LOS (10.2 days vs 6.7 days, P < .01). In the 1:1 propensity score matched analysis of 556 matched patients, in-hospital mortality was greater for laparotomy patients (52.3% vs 20.0%, P < .01).ConclusionLaparotomy was associated with significantly higher in-hospital mortality in propensity-matched trauma patients, longer ICU-LOS, and more blood products given at 4 hours compared to NOM. These findings illustrate that NOM may be a safe approach in managing severely injured trauma patients with isolated blunt abdominal solid organ injuries and a pre-diagnosis of LC.

REBOA in patients with high-grade liver injury may be associated with worse outcomes

BACKGROUND

Although controversial, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used to manage liver injuries. This matched cohort study evaluated outcomes in severe liver injuries treated with REBOA or without REBOA.

METHODS

Trauma Quality Improvement Program database study. Patients with high-grade liver injuries (IV and V) treated with REBOA were propensity score matched (1:2) with similar patients managed without REBOA. Outcomes included mortality and complications.

RESULTS

252 patients treated with REBOA were matched with 503 patients managed without REBOA. Overall mortality was significantly higher in the REBOA group [57.9 ​% vs. 35.2 ​% (p ​< ​0.001)]. The REBOA group patients had higher blood product transfusion requirements.

CONCLUSION

REBOA use in patients with high-grade liver injuries may be associated with poorer outcomes.

Non-operative approaches to major blunt hepatic (Grade IV): a case report

BACKGROUND

Recent advancements in the management of pediatric liver trauma have highlighted the effectiveness of non-operative management as the preferred therapeutic approach. This report presents the case of an 8-year-old patient who sustained significant liver trauma from a substantial fall, successfully managed through non-operative management.

CASE PRESENTATION

An 8-year-old Iranian child presented with a Grade IV liver laceration and contusion, pneumothorax, and rib fractures after a 1.5 m fall. Initial stable vitals were confirmed. Diagnostic evaluations included serial focused assessment with sonography for trauma scans and computed tomography imaging of the thorax, abdomen, and pelvis. Treatment involved intensive care unit monitoring, intravenous fluid therapy, and a chest tube insertion. The patient's condition improved significantly after 6 days in the intensive care unit, demonstrating the efficacy of non-operative management. The patient was successfully discharged following conservative management. Written informed consent was obtained from the patient's legal guardian for publication of this case report and any accompanying images.

CONCLUSIONS

This case highlights the effectiveness of non-operative management in managing high-grade liver injuries. Over the past 2 decades, non-operative management has become increasingly prevalent, particularly in urban healthcare settings, due to its ability to manage hepatic trauma without surgical risks. Advanced imaging and multidisciplinary approaches are critical to its success.

Advances, challenges and future applications of liver organoids in experimental regenerative medicine

The liver is a vital organ responsible for numerous metabolic processes in the human body, including the metabolism of drugs and nutrients. After liver damage, the organ can rapidly return to its original size if the causative factor is promptly eliminated. However, when the harmful stimulus persists, the liver's regenerative capacity becomes compromised. Substantial theoretical feasibility has been demonstrated at the levels of gene expression, molecular interactions, and intercellular dynamics, complemented by numerous successful animal studies. However, a robust model and carrier that closely resemble human physiology are still lacking for translating these theories into practice. The potential for liver regeneration has been a central focus of ongoing research. Over the past decade, the advent of organoid technology has provided improved models and materials for advancing research efforts. Liver organoid technology represents a novel in vitro culture system. After several years of refinement, human liver organoids can now accurately replicate the liver's morphological structure, nutrient and drug metabolism, gene expression, and secretory functions, providing a robust model for liver disease research. Regenerative medicine aims to replicate human organ or tissue functions to repair or replace damaged tissues, restore their structure or function, or stimulate the regeneration of tissues or organs within the body. Liver organoids possess the same structure and function as liver tissue, offering the potential to serve as a viable replacement for the liver, aligning with the goals of regenerative medicine. This review examines the role of liver organoids in regenerative medicine.

High-grade liver injury: outcomes with a trauma surgery-liver surgery collaborative approach

Background

Operative mortality for high-grade liver injury (HGLI) remains 42% to 66%, with near-universal mortality after retrohepatic caval injury. The objective of this study was to evaluate mortality and complications of operative and nonoperative management (OM and NOM) of HGLI at our institution, characterized by a trauma surgery-liver surgery collaborative approach to trauma care.

Methods

This was an observational cohort study of adult patients (age ≥16) with HGLI (The American Association for Surgery of Trauma (AAST) grades IV and V) admitted to an urban level I trauma center from January 2010 to November 2021. Data were obtained from the electronic medical record and state trauma registry. Patients were categorized by management strategy: immediate OM or planned NOM. The primary outcome was 30-day mortality.

Results

Our institution treated 179 patients with HGLI (78% blunt, 22% penetrating); 122 grade IV (68%) and 57 grade V (32%) injuries. All abdominal gunshot wounds and 49% of blunt injuries underwent initial OM; 51% of blunt injuries were managed initially by NOM. Procedures at the initial operation included hepatorrhaphy±packing (66.4%), nonanatomic resection (5.6%), segmentectomy (9.3%), and hepatic lobectomy (7.5%). Thirty-day mortality in the OM group was substantially lower than prior reports (23.4%). Operative mortality attributable to the liver injury was 15.7%. 19.4% of patients failed NOM with one death (1.4%).

Conclusion

We report an operative mortality of 23.4% for HGLI in a trauma care system characterized by a collaborative approach by trauma surgeons and liver surgeons.

Level of evidence

III.

Limited Diagnostic Value of miRNAs in Early Trauma-Induced Liver Injury: Only miRNA-122 Emerges as a Late-Phase Marker

Background/Objectives: Liver injury is common after abdominal trauma. However, the established biomarkers of liver injury, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), lack accuracy. This study investigates whether specific liver-related microRNAs (miRNAs) are released into the circulation in trauma patients with liver injury and whether they can indicate liver damage in the early phase after major trauma. Methods: A retrospective analysis of prospectively collected data and blood samples from 26 trauma patients was conducted. The levels of miRNA-21-5p, -122-5p, -191-5p, -192-3p, and -212-3p were measured in patients with computed tomography-confirmed liver trauma (LT group, n = 12) and polytrauma patients without liver trauma (PT group, n = 14) upon emergency room (ER) admission, and 24 and 48 h after trauma. Additionally, liver-type fatty acid binding protein (L-FABP) was measured, as it has recently been discussed in the context of abdominal trauma. Results: Only miRNA-122-5p showed a significant increase in the LT group compared to the PT group, but only at the 48 h time point (p = 0.032). Conversely, L-FABP (p = 0.018) and ALT (p = 0.05) were significantly elevated in the LT group compared to the PT group at the time of ER admission. There was a moderate correlation between miRNA-122-5p and AISAbdomen (p = 0.056) and transfused red blood cell concentrates (p = 0.055). L-FABP correlated strongly with the ALT levels (p = 0.0009) and the length of stay in the ICU (p = 0.0086). Conclusions: In this study, the liver-specific miRNA-122-5p did not effectively indicate liver injury in the early acute post-traumatic phase. Future research with a large sample size should investigate whether other miRNAs can more accurately predict liver injury and the extent of hepatocellular injury, particularly in the acute post-traumatic phase.

When life-saving measures lead to trauma: Subcapsular hepatic hematoma after CPR

Cardiopulmonary resuscitation (CPR) is a critical intervention for cardiac arrest but can result in significant internal injuries due to the force of chest compressions. Among these, subcapsular hepatic hematoma is a rare and serious complication. Here we present a 55-year-old male with a history of alcohol abuse presented with a severe ischemic stroke and subsequently required CPR due to pulseless ventricular tachycardia. Following resuscitation, the patient developed a subcapsular hepatic hematoma, likely caused by the trauma of chest compressions. The patient also had a complex clinical course involving hemorrhagic conversion of the stroke and the need for anticoagulation due to bilateral pulmonary emboli, which further complicated the management of the hepatic hematoma. The identification of the hematoma was achieved through contrast-enhanced CT imaging after the patient exhibited worsening abdominal discomfort and signs of internal bleeding. The management focused on balancing the need for anticoagulation with the risks of further bleeding from the hematoma. A multidisciplinary approach was essential, involving close monitoring, potential surgical intervention, and careful adjustment of anticoagulant therapy. This case emphasizes the importance of recognizing the potential for internal injuries following CPR, especially in patients requiring anticoagulation. Early detection through imaging and a coordinated, multidisciplinary approach are crucial in managing such complications and improving patient outcomes.

[Management of internal bleeding : Guidelines of the American Association for the Surgery of Trauma (AAST) and World Society of Emergency Surgery (WSES)]

BACKGROUND

Internal bleeding is a common and serious complication in trauma patients. The American Association for the Surgery of Trauma (AAST) and the World Society of Emergency Surgery (WSES) have developed comprehensive guidelines to standardize and optimize the care of these patients. In Germany, abdominal injuries are involved in around 20% of all polytraumas, often caused by falls or road traffic accidents. The liver and spleen are most frequently affected. Correct diagnosis and timely management are crucial for patient survival.

DIAGNOSIS AND CLASSIFICATION

Computed tomography (CT) is gold standard to assess organ injuries, while ultrasound (fokussiertes Assessment mit Sonographie für Trauma, FAST) provides a readily available, non-invasive diagnostic tool. Magnetic resonance imaging (MRI) is used for detailed soft tissue injuries. The AAST has developed a scoring system (Organ Injury Scale, OIS) to classify the severity of organ injuries. The WSES classifies the hemodynamic condition of the patient.

TREATMENT

Spleen: Treatment decisions are based on hemodynamic stability. Unstable patients often require emergency surgery, while stable patients can be treated conservatively. In the presence of active bleeding, embolization is a treatment option. Liver: Stable patients with a positive blush (leakage of contrast medium) are treated angiographically. Unstable patients should undergo surgery with perihepatic packing and Pringle maneuver. Kidney: Conservative treatment for stable patients. Embolization is used for active bleeding. Unstable patients require surgical treatment. Gastrointestinal tract: Duodenal hematomas can be treated conservatively. Pancreatic injuries require conservative or surgical intervention depending on the severity and stability of the patient.

CONCLUSION

These guidelines aim to improve the survival and outcome of trauma patients with internal bleeding.

[Surgical management of severe noncompressible torso and organ hemorrhages]

BACKGROUND

Noncompressible torso hemorrhages (NCTH) are now recognized as the leading cause of preventable death in the context of severe military and civilian injuries. Approximately 20% of all trauma patients still die from uncontrolled bleeding associated with rapidly evolving disorders of blood coagulation function.

OBJECTIVE

Summary of recent advances in the field of nonsurgical and surgical management, presentation of current treatment concepts and future research directions.

MATERIAL AND METHODS

Selective literature review and analysis.

RESULTS

The concepts for the early treatment of NCTH have considerably evolved over the last decade. The updated definition of NCTH includes a combination of high-grade anatomic body trunk injury, hemodynamic instability, urgent need for hemorrhage control, and aggressive hemostatic treatment. The treatment concepts consider the following 3 aspects: controlling the source of bleeding (close the tap), maintaining organ perfusion and restoring hemostasis (fill the tank) and increasing the body's resistance to ischemia (upgrade the armor). New tools, well-established damage control concepts and early and aggressive therapeutic intervention for hemostatic failure have significantly improved the outcomes.

CONCLUSION

Future research needs to refine and validate the current concepts for further clinical application.

Evolution in liver trauma management: a single centre experience

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.

Herniated Gallbladder Following a Bull Run: A Case Report

The liver is the most common organ injury associated with blunt trauma. Blunt hepatic trauma, due to the high kinetic impact on the liver, causes compression and parenchymal disruption, leading to tears in its vascular structures. By contrast, gallbladder injury is rare because it is located beneath and shielded by the liver. This report concerns a case where hepatic and abdominal wall tearing following blunt trauma led to gallbladder herniation.

Radiofrequency Ablation for Unstable Ruptured Hepatocellular Carcinoma: A Case Report and Literature Review

Spontaneous liver bleeding is a rare but life-threatening complication of hepatocellular carcinoma (HCC). The optimal management strategy for this condition remains a topic of ongoing debate. We present the case of a 74-year-old man with cirrhosis and hemorrhagic shock resulting from the spontaneous rupture of HCC. Following a contrast-enhanced CT scan, the patient underwent emergency laparotomy. Hemostasis was attempted using conventional techniques but was unsuccessful. Due to unstable conditions (low blood pressure and high heart rate), poor liver function reserve, and a multifocal tumor, we decided to perform ultrasound-guided radiofrequency ablation (RFA) to achieve hemostasis. The patient was admitted to the ICU for early postoperative monitoring. On the second postoperative day, the patient returned to the surgical department. In most cases, interventional treatment is necessary to achieve hemostasis, even in patients with Child-Pugh C liver function. While transarterial chemoembolization followed by staged hepatectomy is considered the treatment of choice based on current clinical evidence, RFA is a viable alternative. In this case report, we demonstrate that RFA is a safe and effective technique for achieving hemostasis. It should be considered as an option for selected patients with ruptured HCC who are hemodynamically unstable, when embolization or resection is unavailable or unfeasible due to the patient's condition, or in cases of end-stage liver disease.

Damage Control Interventional Radiology: The bridge between non-operative management and damage control surgery

Traumatic injuries continue to be on the rise globally and with it, the role interventional radiology (IR) has also expanded in managing this patient cohort. The role of damage control surgery (DCS) has been well established in the trauma management pathway, however it is only recently that Damage Control IR (DCIR) has become increasingly utilized in managing the extremis trauma and emergency patient.Visceral artery embolizations (both temporary and permanent), temporary balloon occlusions including Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in iliac arteries and aorta respectively are amongst the treatment options now available for the trauma (and non-traumatic bleeding) patient.We review the literature for the role of DCS and utilization of IR in trauma, outcomes and the paradigm shift towards minimally invasive techniques. The focus of this paper is to highlight the importance of multi-disciplinary working and having established pathways to ensure timely treatment of trauma patients as well as careful patient selection.We show that outcomes are best when both surgical and IR are involved in patient care from the outset and that DCIR should not be defined as Non-Operative Management (NOM) as it currently is categorized as.

Assessing associated factors for failure of nonoperative management in pediatric blunt liver and spleen injuries: a secondary analysis of the SHIPPs study

PURPOSE

The purpose of this study was to describe the characteristics of pediatric patients who underwent nonoperative management (NOM) for blunt splenic and hepatic injuries and to explore factors associated with NOM failure.

METHODS

This was a secondary analysis of a multicenter cohort study of pediatric patients with blunt liver and spleen injuries in Japan. Participants included pediatric trauma patients aged 16 years or younger between 2008 and 2019 with NOM, which was defined as no surgery provided within 6 h of hospital arrival. NOM failure, defined as abdominal surgery performed after 6 h of hospital arrival, was the primary outcome. Descriptive statistics were provided and exploratory analysis to assess the associations with outcome using logistic regression.

RESULTS

During the study period, 1339 met our eligibility criteria. The median age was 9 years, with a majority being male. The median Injury Severity Score (ISS) was 10. About 14.0% required transfusion within 24 h, and 22.3% underwent interventional radiology procedures. NOM failure occurred in 1.0% of patients and the in-hospital mortality was 0.7%. Factors associated with NOM failure included age, positive focused assessment with sonography for trauma (FAST), contrast extravasation on computed tomography (CT), severe liver injury, concomitant pancreas injury, concomitant gastrointestinal injury, concomitant mesenteric injury, and ISS.

CONCLUSIONS

In our study, NOM failure were rare. Older age, positive FAST, contrast extravasation on CT, severe liver injury, concomitant pancreas injury, concomitant gastrointestinal injury, concomitant mesenteric injury, and higher ISS were suggested as possible risk factors for NOM failure.

Mussel-inspired sulfated hyaluronan cryogel patch with antioxidant, anti-inflammatory, and drug-loading properties for multifunctional wound adhesives

Wounds, characterized by the disruption of the continuity of body tissues resulting from external trauma, manifest in diverse types and locations. Although numerous wound dressings are available for various wound scenarios, it remains challenging to find an integrative wound dressing capable of addressing diverse wound situations. We focused on utilizing sulfated hyaluronan (sHA), known for its anti-inflammatory properties and capacity to load cationic drugs. By conjugating catechol groups to sHA (sHA-CA), we achieved several advantages in wound healing: 1) Fabrication of patches through crosslinking with catechol-modified high-molecular-weight hyaluronan (HA(HMW)-CA), 2) Adhesiveness that enabled stable localization, 3) Radical scavenging that could synergize with the immunomodulation of sHA. The sHA-CA patches demonstrated therapeutic efficacy in three distinct murine wound models: diabetic wound, hepatic hemorrhage, and post-surgical adhesion. Collectively, these findings underscore the potential of the sHA-CA patch as a promising candidate for the next-generation wound dressing.

Optimal Timing for Initiation of Thromboprophylaxis After Hepatic Angioembolization

OBJECTIVE

To evaluate the optimal timing of thromboprophylaxis (TPX) initiation after hepatic angioembolization in trauma patients.

BACKGROUND

TPX after hepatic trauma is complicated by the risk of bleeding, but the relative risk after hepatic angioembolization is unknown.

METHODS

Patients who underwent hepatic angioembolization within 24 hours were retrospectively identified from the 2017 to 2019 American College of Surgeons Trauma Quality Improvement Project data sets. Cases with <24-hour length of stay and other serious injuries were excluded. Venous thromboembolism (VTE) included deep venous thrombosis and PE. Bleeding complications included hepatic surgery, additional angioembolization, or blood transfusion after TPX initiation. Differences were tested with univariate and multivariate analyses.

RESULTS

Of 1550 patients, 1370 had initial angioembolization. Bleeding complications were higher in those with TPX initiation within 24 hours (20.0% vs 8.9%, P <0.001) and 48 hours (13.2% vs 8.4%, P =0.013). However, VTE was higher in those with TPX initiation after 48 hours (6.3% vs 3.3%, P =0.025). In the 180 patients with hepatic surgery before angioembolization, bleeding complications were higher in those with TPX initiation within 24 hours (72% vs 20%, P <0.001), 48 hours (50% vs 17%, P <0.001), and 72 hours (37% vs 14%, P =0.001). Moreover, deep venous thrombosis was higher in those with TPX initiation after 96 hours (14.3% vs 3.1%, P =0.023).

CONCLUSIONS

This is the first study to address the timing of TPX after hepatic angioembolization in a national sample of trauma patients. For these patients, initiation of TPX at 48 to 72 hours achieves the safest balance in minimizing bleeding while reducing the risk of VTE.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

A systematic review of the anti-inflammatory and anti-fibrotic potential of human umbilical cord mesenchymal stem cells-derived exosomes in experimental models of liver regeneration

Chronic liver injuries and their complications are leading causes of death, especially in developing countries (Sharma and Nagalli in Sex/Gender-Specific Medicine in the Gastrointestinal Diseases, StatPearls Publishing, 2023). The available and effective treatment plans are limited, implicating the need for innovative treatment approaches (Tsuchiya et al. in Inflamm Regener, 2019;Sharma and Nagalli in Sex/Gender-Specific Medicine in the Gastrointestinal Diseases, StatPearls Publishing, 2023;Younossi et al. in Clin Gastroenterol Hepatol 21:1978-1991, 2023;). This paper aims to summarize the effects and mechanisms of hUC-MSC-exo on liver injuries and its complications; it also suggests future directions for future research. The outcomes of interest are the morphology and histology of the liver, pathology score, liver function enzyme, glucose and lipid metabolism, and the effect hUC-MSC-exo had on gene regulation regarding liver diseases. A comprehensive review of nineteen studies was conducted to assess the effectiveness of the implementation of the hUC-MSC-Exo, instilling confidence in the validity of the findings. Regarding the morphology and histology of the liver and pathology score, hUC-MSC-exo treatment resulted in improved liver morphology post-treatment, as indicated by the reduction in pathology scores. However, these observed improvements in the liver surface are not directly attributed to the hUC-MSC-Exo itself but to the overall healing processes stimulated by the treatment. In physiological outcomes, hUC-MSC-exo also improves glucose and lipid metabolism, especially in diet-induced liver injury and its complications. In gene regulation, one interesting gene in this intervention is the fat mass and obesity-associated (FTO), in which hUC-MSC-exo combined with miRNAs can suppress FTO. HUC-MSC-Exo can improve by utilizing several possible pathways, targeting pinpoints in the pathogenesis of liver disease or glucose and lipid metabolism. This study presents hUC-MSC-exo better in all outcomes of interest compared to the control or sham group. Further specification of indications of the hUC-MSC-exo method may be beneficial and essential to be analyzed in future reviews to better understand the effectiveness of each hUC-MSC-exo dose, duration, and medium.

Post-traumatic pseudoaneurysm of the right hepatic artery: Two case reports - New Ukrainian reality

INTRODUCTION AND SIGNIFICANCE

The diagnostics and treatment management in conditions of massive sanitary losses with the use of staged treatment have their own specifics and require a multidisciplinary approach with the involvement of a wide range of specialists and the use of modern technologies. The number of sources covering the ultrasound diagnostics and clinical course of hepatic artery pseudoaneurysm as a complication of gunshot wounds is quite limited in world literature.

CASE PRESENTATION

We present the experience of the observation and management of the right hepatic artery pseudoaneurysm in case of the blast injury of liver in two patients: the example of successful resolution with spontaneous occlusion and the example with the occurrence of internal bleeding as a result of pseudoaneurysm rupture.

CLINICAL DISCUSSION

Clinical cases presented here belong to the category of severe injuries caused by high-energy weapons, which are characterized by a syndrome of mutual aggravation and need for simultaneous treatment of several damaged organs. The use of contrast methods in severely injured patients requires instrumental justification, and results of daily ultrasound monitoring with the use of color Doppler program can be the one.

CONCLUSION

Pseudoaneurysm of hepatic arteries is a dangerous complication of severe liver wounds and injuries, which occurs in 3·2 % of patients according to our data. The method of ultrasound examination with the use of color Doppler mapping program allows to visualize pseudoaneurysms and monitor their progress. When identifying patients with pseudoaneurysm of hepatic arteries at the level II-III medical care (Role II-III), their further evacuation should be carried out to medical institutions equipped with endovascular correction technologies.

High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study

BACKGROUND

High-grade liver injuries with extravasation (HGLI ​+ ​Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI ​+ ​Extrav. Therefore, we evaluated the management of HGLI ​+ ​Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality.

METHODS

HGLI ​+ ​Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality.

RESULTS

From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p ​= ​0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p ​> ​0.05).

CONCLUSION

Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI ​+ ​Extrav patients.

Operative and non-operative treatment of injury to solid abdominal organs in adult patients: a single center experience

BACKGROUND

In major trauma, lesions of the parenchymatous organs are subject of a controversy as regards the choice between an operative management (OM) in the operating room and a non-operative management (NOM) associated or not with angiography/angioembolization (AG/AE).

METHODS

Retrospective study of all consecutive data of patients coded as "traumatic pathology" in the period between 2011 and 2021. Were enrolled 13740 entries of adult patients with abdominal injuries, including at least: either hepatic or splenic or renal injury of AAST-OIS I. The primary outcome was to establish the rate of efficacy, respectively of OM and NOM. The secondary outcome is to analyze General (CG) and Specific (CS) complications, mean ward and intensive care unit (ICU) hospital stays.

RESULTS

One hundred sixty-two patients were included with 89 splenic injuries, 70 hepatic and 50 renal lesions; 35 treated with OM and 127 with NOM±AG/AE. The CGs registered in OM patients are seven (20%); seven SCs (20%); four GCs+SCs (11.4%). The average hospital stay was 24.91 days; mean ICU hospital stay of 10.74; five deaths. The CGs registered are 22 (17%); 12 SCs (9.4%); three GCs+SCs (2.3%). Average hospital stays 18 days; mean ICU hospital stay of 3.15; 6 deaths. Failure of the NOM strategy was recorded in nine patients with a success rate of 92.91%.

CONCLUSIONS

In OM the presence of numerous high-grade lesions leads to a rapid stabilization. The NOM has reduced the hospital stay and UTI hospitalization in a feasible and safe way in selected CT.

Adrenal gland injury in trauma patients and its impact on clinical outcomes

BACKGROUND

Adrenal gland injury (AGI) associated with trauma is an uncommon and often overlooked condition. This study aimed to evaluate the frequency of AGI in individuals with severe trauma injuries and investigate the outcomes of patients with AGI.

METHODS

All patients admitted to a tertiary trauma referral center under the trauma protocol who had a computed tomography (CT) scan between January 2012 and January 2023 were analyzed retrospectively. Patients who were dead on arrival and patients with incomplete data were excluded. They were classified into two main groups, adult and pediatric, and further subcategorized by the presence or absence of radiologically evident AGI. Demographic data, mechanism of injury, injury severity scores (ISS), presence of concurrent abdominal injury, and 30-day mortality rates were compared. A separate analysis was performed for factors affecting mortality rates.

RESULTS

A total of 1,253 patients were included: 950 adults and 303 pediatric patients. In the adult group, AGI was detected in 45 (4.7%) patients and was more commonly associated with the following mechanisms of injury: motor vehicle accidents (26.7% vs. 14.3%) and pedestrian accidents (37.8% vs. 15.5%). Injury to the right side was more common (55.6%). Patients with AGI had higher rates of concurrent liver (17.8% vs. 3.9%), spleen (11.1% vs. 3.6%), and kidney injuries (15.6% vs. 1.3%). In the pediatric population, AGI was detected in 30 patients (14.8%), a significantly higher rate compared to the adult group. Similar to the adult group, AGI was more commonly associated with concurrent abdominal injuries and had a right-sided dominance (60%), but the rate of concurrent abdominal injuries was higher in the pediatric group (80% vs. 46%). The 30-day mortality was significantly higher in both adult and pediatric AGI groups compared to patients without AGI (adult: 15.6% vs. 2.9%, pediatric: 10% vs. 1.8%). In patients with AGI, major head and neck injuries and chest injuries were associated with mortality.

CONCLUSION

Adrenal gland injuries due to trauma are not uncommon. They are usually associated with blunt trauma and other concurrent abdominal organ injuries. The major contributors to mortality in patients with AGI were major head and neck injuries and chest injuries.

[Management of Injuries to the Parenchymal Abdominal Organs]

The most common organs affected by abdominal trauma are the spleen and the liver, often in combination. Pancreatic injuries are rare. In the case of blunt abdominal trauma, which is much more common, a clinical and laboratory examination as well as sonography should be performed. In the initial assessment, the circulatory situation must be screened. If there is haemodynamic instability and presentation of free fluid, an emergency laparotomy is indicated. If the situation is stable or stabilised and a pathological sonography is present, it is essential to perform triphasic contrast enhanced computed tomography, which is also mandatory in polytraumatised patients. If a renal injury is suspected, a late venous phase should be attached. In addition to the classification of the injury, attention should be paid to possible vascular injury or active bleeding. In this case, angiography with the possibility of intervention should be performed. Endoscopic treatment is possible for injuries of the pancreatic duct. If the imaging does not reveal any intervention target and a circulation is stable, a conservative approach is possible with continuous monitoring using clinical, laboratory and sonographic controls. Most injuries can be successfully treated by non-operative management (NOM).There are various surgical options for treating the injury, such as local and resecting procedures. There is also the option of "damage control surgery" with acute bleeding control and second look. Complex surgical procedures should be performed at centres. Postoperative complications arise out of elective surgery.In the less common case of penetrating abdominal trauma, the actual extent of the injury cannot be estimated from the visible wound. Here again, the circulatory situation determines the next steps. An emergency laparotomy should be carried out in case of instability. If the condition is stable, further diagnostics should be performed using contrast enhanced computed tomography. If penetration through the peritoneum cannot be clearly excluded, diagnostic laparoscopy should be performed.

Perineal laceration treated with negative pressure wound therapy following colostomy

A male in his early 30s was transported to the emergency room after being hit by a vehicle while inebriated and lying in the street. His general condition was stable; however, he had a perineal laceration that extended to the coccyx. Due to the proximity of the wound margin to the anus, we were concerned regarding the potential contamination and opted not to suture it. Therefore, we refrained from suturing the wound and kept the wound open after irrigation and debridement. Additionally, we performed a transverse colostomy. On day 4, we initiated negative pressure wound therapy for 40 days, during which sufficient wound granulation occurred. The patient was discharged, and the colostomy was closed approximately 4 months after the injury. Our case illustrates the effectiveness of negative pressure wound therapy in managing perineal lacerations.

Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper

Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.

Cirrhosis Increases the Rate of Failure of Nonoperative Management in Blunt Liver Injuries

Pre-existing cirrhosis is associated with increased mortality in blunt liver injury. Despite widespread use of nonoperative management (NOM) for blunt liver injury, there is a relative paucity of data regarding how pre-existing cirrhosis impacts the success of NOM. Herein, we perform a retrospective cohort study using ACS TQIP 2017-2020 data to assess the relationship between cirrhosis and failure of NOM for adult patients with blunt liver injury. 37,176 patients were included (342 cirrhosis and 36,834 without cirrhosis). After propensity-score matching, patients with pre-existing cirrhosis had higher rates of failure of NOM (32.2 vs 14.1%, p < 0.01) and in-hospital mortality (36.3 vs 10.8%, p < 0.01) than patients without cirrhosis. Hesitancy to operate on patients with pre-existing cirrhosis and trauma, as well as significant underlying coagulopathy, may explain these findings.

Bioactive compound schaftoside from Clinacanthus nutans attenuates acute liver injury by inhibiting ferroptosis through activation the Nrf2/GPX4 pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Clinacanthus nutans (Burm. f.) Lindau, a traditional herb renowned for its anti-tumor, antioxidant, and anti-inflammatory properties, has garnered considerable attention. Although its hepatoprotective effects have been described, there is still limited knowledge of its treatment of acute liver injury (ALI), and its mechanisms remain unclear.

AIM OF THE STUDY

To assess the efficacy of Clinacanthus nutans in ALI and to identify the most effective fractions and their underlying mechanism of action.

METHODS

Bioinformatics was employed to explore the underlying anti-hepatic injury mechanisms and active compounds of Clinacanthus nutans. The binding ability of schaftoside, a potential active ingredient in Clinacanthus nutans, to the core target nuclear factor E2-related factor 2 (Nrf2) was further determined by molecular docking. The role of schaftoside in improving histological abnormalities in the liver was observed by H&E and Masson's staining in an ALI model induced by CCl4. Serum and liver biochemical parameters were measured using AST, ALT and hydroxyproline kits. An Fe2+ kit, transmission electron microscopy, western blotting, RT-qPCR, and DCFH-DA were used to measure whether schaftoside reduces ferroptosis-induced ALI. Subsequently, specific siRNA knockdown of Nrf2 in AML12 cells was performed to further elucidate the mechanism by which schaftoside attenuates ferroptosis-induced ALI.

RESULTS

Bioinformatics analysis and molecular docking showed that schaftoside is the principal compound from Clinacanthus nutans. Schaftoside was shown to diminish oxidative stress levels, attenuate liver fibrosis, and forestall ferroptosis. Deeper investigations revealed that schaftoside amplified Nrf2 expression and triggered the Nrf2/GPX4 pathway, thereby reversing mitochondrial aberrations triggered by lipid peroxidation, GPX4 depletion, and ferroptosis.

CONCLUSION

The lead compound schaftoside counters ferroptosis through the Nrf2/GPX4 axis, providing insights into a novel molecular mechanism for treating ALI, thereby presenting an innovative therapeutic strategy for ferroptosis-induced ALI.

The role of big data management, data registries, and machine learning algorithms for optimizing safe definitive surgery in trauma: a review

Digital data processing has revolutionized medical documentation and enabled the aggregation of patient data across hospitals. Initiatives such as those from the AO Foundation about fracture treatment (AO Sammelstudie, 1986), the Major Trauma Outcome Study (MTOS) about survival, and the Trauma Audit and Research Network (TARN) pioneered multi-hospital data collection. Large trauma registries, like the German Trauma Registry (TR-DGU) helped improve evidence levels but were still constrained by predefined data sets and limited physiological parameters. The improvement in the understanding of pathophysiological reactions substantiated that decision making about fracture care led to development of patient's tailored dynamic approaches like the Safe Definitive Surgery algorithm. In the future, artificial intelligence (AI) may provide further steps by potentially transforming fracture recognition and/or outcome prediction. The evolution towards flexible decision making and AI-driven innovations may be of further help. The current manuscript summarizes the development of big data from local databases and subsequent trauma registries to AI-based algorithms, such as Parkland Trauma Mortality Index and the IBM Watson Pathway Explorer.

Deep Learning for Automated Detection and Localization of Traumatic Abdominal Solid Organ Injuries on CT Scans

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.

Multidisciplinary management of high-grade pediatric liver injuries

OBJECTIVE

To present our experience of multidisciplinary management of high-grade pediatric liver injuries.

INTRODUCTION

Pediatric high-grade liver injuries pose significant challenge to management due to associated morbidity and mortality. Emergency surgical intervention to control hemorrhage and biliary leak in these patients is usually suboptimal. Conservative management in selected high-grade liver injuries is now becoming standard of care. Management of hemobilia due to pseudoaneurysm formation and traumatic bile leaks requires multidisciplinary management.

METHODS

A retrospective review was undertaken for patients presenting with blunt liver injuries at two tertiary care centers in Karachi, Pakistan, from March 2021 to December 2022. Twenty-eight patients were identified, and four patients fulfilled the criteria for grade 4 and above blunt liver injury during this period.

RESULTS

One case with grade 4 liver injury developed hemobilia on 7th day of injury. He required two settings of angioembolization but had recurrent leak from pseudoaneurysm. He ultimately needed right hepatic artery ligation. Second patient presented with massive biliary peritonitis 2 days following injury. He was managed initially with tube laparostomy followed by ERCP and stent placement. The third patient developed large hemoperitoneum managed conservatively. One case with grade 5 injury expired during emergency surgery.

CONCLUSION

Conservative management of advanced liver injuries can result in significant morbidity and mortality due to high risk of complications. Trauma surgeons need to have multidisciplinary team for management of these patients to gain optimal outcome.

Clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing non-operative management

BACKGROUND

Complications arising during non-operative management (NOM) of blunt hepatic and/or splenic trauma, particularly in cases of severe injury, are associated with significant morbidity and mortality. Abdominal computed tomography (CT) is the gold standard for the initial detection of complications during NOM. Although many institutions advocate routine in-hospital follow-up scans to improve success rates, others recommend a more selective approach. The use of follow-up CT remains a subject of ongoing debate, with no validated guidelines available regarding the timing, effectiveness, or intervals of follow-up imaging.

OBJECTIVE

We aimed to identify the clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing NOM.

MATERIALS AND METHODS

This retrospective cohort study included patients with blunt hepatic and/or splenic trauma treated at Songklanagarind Hospital, a level 1 trauma center, from 2013 to 2022. We assessed all patients indicated for non-operative management and examined their clinical parameters and complications.

RESULTS

Of 542 patients with blunt hepatic and/or splenic injuries, 315 (58%) were managed non-operatively. High-grade hepatic injuries were significantly associated with complications, as determined through a multivariate logistic regression analysis after adjusting for factors such as contrast blush findings, age, sex, and injury severity score (ISS) (adjusted OR = 7.69, 95% CI 1.59-37.13; p = 0.011). Among the patients with complications (n = 27), 17 (63%) successfully underwent non-operative management. Notably, eight patients presented with clinical symptoms prior to the diagnosis of complications, while only two patients had no clinical symptoms before the diagnosis. Tachycardia, abdominal pain, decreased hematocrit levels, and fever were significant indicators of complications (p < 0.05).

CONCLUSION

Routine CT to detect complications may not be necessary in patients with asymptomatic low-grade blunt hepatic injuries. By contrast, in those with isolated blunt hepatic injuries that are managed non-operatively, high-grade injuries, the presence of a contrast blush on initial imaging, and the patient's age may warrant consideration for routine follow-up CT scans. Clinical symptoms and laboratory observations during NOM, such as tachycardia, abdominal pain, decreased hematocrit levels, and fever, are significantly associated with complications. These symptoms necessitate further management, regardless of the initial injury severity, in patients with blunt hepatic and/or splenic injuries undergoing NOM.

Evaluating Mortality Outcomes, Transfusion Characteristics, and Risk Factors Associated With Cirrhotic Trauma Patients Undergoing Emergency Laparotomy Versus Non-Operative Management: A National Analysis

BACKGROUND

Patients with liver cirrhosis (LC) demonstrate significantly elevated mortality rates following a traumatic event. This study aims to examine and compare the clinical outcomes in adult trauma patients with pre-existing LC undergoing laparotomy or non-operative management (NOM). Additionally, the study aims to investigate various patient outcomes, including mortality rate based on transfusion needs and timing.

METHODS

This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) 2017-21 to compare laparotomy vs NOM in adults (≥18 years) with pre-existing LC who presented to trauma facilities with isolated blunt solid organ abdominal injuries (Injury Severity Score ≥16, Abbreviated Injury Scale solid organ abdomen ≥3).

RESULTS

Among 929 patients, 38.2% underwent laparotomy, while 61.7% received NOM. The in-hospital mortality rate was lower for patients who received NOM (52.3% vs 20.0%, P < .01). The risk of in-hospital mortality was significantly associated with laparotomy (OR 5.22, 95% CI: 2.06-13.18, P < .01) and sepsis (OR 99.50, 95% CI: 6.99-1415.28, P < .01). On average an increase in blood units in 4 hours was observed among those who experienced an in-hospital mortality (OR 5.65, 95% CI: 3.05-8.24, P < .01) and those who underwent laparotomy (OR 3.85, 95% CI: 1.36-6.34, P < .01).

CONCLUSION

Trauma patients with moderate to severe isolated organ injury and Liver cirrhosis had significantly higher mortality rates, acute renal failure, whole blood units received, as well as longer ICU-LOS when undergoing laparotomy compared to non-operative management.

Management of Pediatric Solid Organ Injuries

Solid organ injury (SOI) is common in children who experience abdominal trauma, and the management of such injuries has evolved significantly over the past several decades. In 2000, the American Pediatric Surgical Association (APSA) published the first societal guidelines for the management of blunt spleen and/or liver injury (BLSI), advocating for optimized resource utilization while maintaining patient safety. Nonoperative management (NOM) has become the mainstay of treatment for SOI, and since the publication of the APSA guidelines, numerous groups have evaluated how invasive procedures, hospitalization, and activity restrictions may be safely minimized in children with SOI. Here, we review the current evidence-based management guidelines in place for the treatment of injuries to the spleen, liver, kidney, and pancreas in children, including initial evaluation, inpatient management, and long-term care, as well as gaps that exist in the current literature that may be targeted for further optimization of protocols for pediatric SOI.

Future Perspectives on Radiomics in Acute Liver Injury and Liver Trauma

Background: Acute liver injury occurs most frequently due to trauma, but it can also occur because of sepsis or drug-induced injury. This review aims to analyze artificial intelligence (AI)'s ability to detect and quantify liver injured areas in adults and pediatric patients. Methods: A literature analysis was performed on the PubMed Dataset. We selected original articles published from 2018 to 2023 and cohorts with ≥10 adults or pediatric patients. Results: Six studies counting 564 patients were collected, including 170 (30%) children and 394 adults. Four (66%) articles reported AI application after liver trauma, one (17%) after sepsis, and one (17%) due to chemotherapy. In five (83%) studies, Computed Tomography was performed, while in one (17%), FAST-UltraSound was performed. The studies reported a high diagnostic performance; in particular, three studies reported a specificity rate > 80%. Conclusions: Radiomics models seem reliable and applicable to clinical practice in patients affected by acute liver injury. Further studies are required to achieve larger validation cohorts.

Epidemiological profile of patients undergoing non-operative management of solid organ injury and associated factors with mortality

INTRODUCTION

Trauma primarily affects the economically active population, causing social and economic impact. The non-operative management of solid organ injuries aims to preserve organ function, reducing the morbidity and mortality associated with surgical interventions. The aim of study was to demonstrate the epidemiological profile of patients undergoing non-operative management in a trauma hospital and to evaluate factors associated with mortality in these patients.

METHODS

This is a historical cohort of patients undergoing non-operative management for solid organ injuries at a Brazilian trauma reference hospital between 2018 and 2022. Included were patients with blunt and penetrating trauma, analyzing epidemiological characteristics, blood transfusion, and association with the need for surgical intervention.

RESULTS

A total of 365 patients were included in the study. Three hundred and forty-three patients were discharged (93.97%), and the success rate of non-operative treatment was 84.6%. There was an association between mortality and the following associated injuries: hemothorax, sternal fracture, aortic dissection, and traumatic brain injury. There was an association between the need for transfusion and surgical intervention. Thirty-eight patients required some form of surgical intervention.

CONCLUSION

The profile of patients undergoing non-operative treatment consists of young men who are victims of blunt trauma. Non-operative treatment is safe and has a high success rate.

Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.

Liver transplantation for severe hepatic trauma: A multicenter analysis from the UNOS data set

BACKGROUND

Orthotopic liver transplantation (OLT) is rarely indicated after hepatic trauma but it can be the only therapeutic option in some patients. There are scarce data analyzing the surgical outcomes of OLT after trauma.

METHODS

We used the UNOS data set to identify patients who underwent OLT for trauma from 1987 to 2022 and compared them to a cohort of patients transplanted for other indications. Cox proportional hazard and multivariable logistic regression analyses were performed to assess predictors of graft and patient survival.

RESULTS

Seventy-two patients underwent OLT for trauma during the study period. Patients with trauma were more frequently on mechanical ventilation at the time of transplantation (26.4% vs. 7.6%, p < 0.001) and had a greater incidence of pretransplant portal vein thrombosis (12.5% vs. 4%, p = 0.002). Our 4:1 matched analysis showed that trauma patients had significantly shorter wait times, higher incidence of pretransplant portal vein thrombosis and prolonged length of stay. Trauma was associated with decreased overall graft survival (hazards ratio, 1.42; 95% confidence interval, 1.01-1.98), and increased length of stay ( p = 0.048). There were no significant differences in long-term patient survival.

CONCLUSION

Unique physiological and vascular challenges after severe hepatic trauma might be associated with decreased graft survival in patients requiring liver transplantation.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Survival benefits of interventional radiology and surgical teams collaboration during primary trauma surveys: a single-centre retrospective cohort study

BACKGROUND

A team approach is essential for effective trauma management. Close collaboration between interventional radiologists and surgeons during the initial management of trauma patients is important for prompt and accurate trauma care. This study aimed to determine whether trauma patients benefit from close collaboration between interventional radiology (IR) and surgical teams during the primary trauma survey.

METHODS

A retrospective observational study was conducted between 2014 and 2021 at a single institution. Patients were assigned to an embolization group (EG), a surgery group (SG), or a combination group (CG) according to their treatment. The primary and secondary outcomes were survival at hospital discharge compared with the probability of survival (Ps) and the time course of treatment.

RESULTS

The analysis included 197 patients, consisting of 135 men and 62 women, with a median age of 56 [IQR, 38-72] years and an injury severity score of 20 [10-29]. The EG, SG, and CG included 114, 48, and 35 patients, respectively. Differences in organ injury patterns were observed between the three groups. In-hospital survival rates in all three groups were higher than the Ps. In particular, the survival rate in the CG was 15.5% higher than the Ps (95% CI: 7.5-23.6%; p < 0.001). In the CG, the median time for starting the initial procedure was 53 [37-79] min and the procedure times for IR and surgery were 48 [29-72] min and 63 [35-94] min, respectively. Those times were significantly shorter among three groups.

CONCLUSION

Close collaboration between IR and surgical teams, including the primary survey, improves the survival of severe trauma patients who require both IR procedures and surgeries by improving appropriate treatment selection and reducing the time process.

Is it possible to predict mortality in patients with high-grade blunt liver injury? A single trauma center study

BACKGROUND

Blunt abdominal trauma constitutes a significant portion of trauma cases and is often associated with liver injury. Given that high-grade liver injuries remain life-threatening, identifying patients who will likely require more vigilant attention and care is crucial. This study aims to determine the parameters that increase mortality in patients with high-grade liver trauma.

METHODS

This study enrolled 38 patients with Grade III or higher liver injuries, treated by the general surgery department between 2008 and 2023. Eleven patients who died were categorized into Group 1, and 27 survivors were placed in Group 2. We evaluated their respective mechanisms of injury, imaging results, Glasgow Coma Scale scores, Base Excess, Lactate levels, pH, and Injury Severity Score findings. Receiver Operating Characteristics (ROC) analysis was performed for parameters with significant differences, and certain cutoff values were determined.

RESULTS

The grade of liver injury and additional abdominal organ injuries were significantly higher in Group 1 (p<0.05). The difference in extra-abdominal injury sites was statistically insignificant between the groups (p>0.05). Erythrocyte suspension requirements were significantly higher in Group 1 (p<0.05). Average lactate and base deficit values were also significantly higher in Group 1 (p<0.05), while leukocyte counts were significantly lower in Group 1 (p<0.05).

CONCLUSION

Base deficit, hemoglobin (Hb), lactate levels, injury severity, liver injury grade, accompanying abdominal injuries at admission, and erythrocyte suspension demands were found to be associated with increased mortality rates. Certain cutoff values for the aforementioned parameters could be established. However, further data are required to confirm these findings.

Therapeutic Dilemma: Acute Myocardial Infarction in a Patient with Traumatic Hepatic and Mesenteric Injuries: A Case Report

ST-elevation myocardial infarction (STEMI) in a trauma patient with solid abdominal organ or vascular injuries can present complex diagnostic and therapeutic challenges. Evidence for managing such demanding cases is scarce, and isolated case reports remain the source of information in treating these patients. We present a patient with traumatic mesenteric and hepatic injuries who developed acute STEMI in the immediate postoperative period.

Damage Control Interventional Radiology in Liver Trauma: A Comprehensive Review

The liver is the second most common solid organ injured in blunt and penetrating abdominal trauma. Non-operative management (NOM) has become the standard of care for liver injuries in stable patients, where transarterial embolization (TAE) represents the main treatment, increasing success rates and avoiding invasive surgical procedures. In hemodynamically (HD) unstable patients, operative management (OM) is the standard of care. To date, there are no consensus guidelines about the endovascular treatment of patients with HD instability or in ones that responded to initial infusion therapy. A review of the literature was performed for published papers addressing the outcome of using TAE as the primary treatment for HD unstable/transient responder trauma liver patients with hemorrhagic vascular lesions, both as a single treatment and in combination with surgical treatment, focusing additionally on the different definitions used in the literature of unstable and transient responder patients. Our review demonstrated a good outcome in HD unstable/transient responder liver trauma patients treated with TAE but there still remains much debate about the definition of unstable and transient responder patients.

Angioembolization performed by trauma surgeons for trauma patients: is it feasible in Korea? A retrospective study

Purpose

Recent advancements in interventional radiology have made angioembolization an invaluable modality in trauma care. Angioembolization is typically performed by interventional radiologists. In this study, we aimed to investigate the safety and efficacy of emergency angioembolization performed by trauma surgeons.

Methods

We identified trauma patients who underwent emergency angiography due to significant trauma-related hemorrhage between January 2020 and June 2023 at Jeju Regional Trauma Center. Until May 2022, two dedicated interventional radiologists performed emergency angiography at our center. However, since June 2022, a trauma surgeon with a background and experience in vascular surgery has performed emergency angiography for trauma-related bleeding. The indications for trauma surgeon-performed angiography included significant hemorrhage from liver injury, pelvic injury, splenic injury, or kidney injury. We assessed the angiography results according to the operator of the initial angiographic procedure. The term "failure of the first angioembolization" was defined as rebleeding from any cause, encompassing patients who underwent either re-embolization due to rebleeding or surgery due to rebleeding.

Results

No significant differences were found between the interventional radiologists and the trauma surgeon in terms of re-embolization due to rebleeding, surgery due to rebleeding, or the overall failure rate of the first angioembolization. Mortality and morbidity rates were also similar between the two groups. In a multivariable logistic regression analysis evaluating failure after the first angioembolization, pelvic embolization emerged as the sole significant risk factor (adjusted odds ratio, 3.29; 95% confidence interval, 1.05-10.33; P=0.041). Trauma surgeon-performed angioembolization was not deemed a significant risk factor in the multivariable logistic regression model.

Conclusions

Trauma surgeons, when equipped with the necessary endovascular skills and experience, can safely perform angioembolization. To further improve quality control, an enhanced training curriculum for trauma surgeons is warranted.

MultiCenter Study of Intra-Abdominal Abscess Formation After Major Operative Hepatic Trauma

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.

Liver cirrhosis requiring transplantation in the context of hepaticojejunostomy stricture after a traumatic bile duct injury

Biliary injury secondary to trauma is frequently associated with long-term complications. Liver transplantation is rarely indicated but might be the best therapeutic option in severe or intractable cases. We report the case of a 19-year-old male referred for liver transplantation due to biliary injury after abdominal trauma. A Roux-en-Y hepaticojejunostomy was initially performed without immediate complications. Anastomotic stricture developed requiring several trials of biliary dilatation and stenting through a percutaneous approach. The presence of liver cirrhosis and the intractability of this complication culminated in the decision of liver transplantation. The authors present clinical course, complications and interventional procedures that were used in a judicious step-up approach.

[Total saponins of Panax japonicus alleviates CCl4-induced acute liver injury in rats by regulating the PI3K/AktNF-κB signaling pathway]

OBJECTIVE

To investigate the protective effect of total saponins of Panax japonicus (TSPJ) against CCl4-induced acute liver injury (ALI) in rats and explore the underlying pharmacological mechanisms.

METHODS

Male SD rat models of CCl4-induced ALI were given intraperitoneal injections of distilled water, 100 mg/kg biphenyl bisabololol, or 50, 100, and 200 mg/kg TSPJ during modeling (n=8). Liver functions (AST, ALT, TBil and ALP) of the rats were assessed and liver pathologies were observed with HE staining. Immunohistochemistry was used to detect the expressions of PI3K/Akt/NF-κB signaling pathway molecules in liver tissue; ELISA was used to determine the levels of T-SOD, GSH-Px, and MDA. Western blotting was performed to detect the expression levels of PI3K-Akt and SIRT6-NF-κB pathways in the liver tissue.

RESULTS

Network pharmacological analysis indicated that the key pathways including PI3K/Akt mediated the therapeutic effect of TSPJ on ALI. In the rat models of ALI, treatments with biphenyl bisabololol and TSPJ significantly ameliorated CCl4-induced increase of serum levels AST, ALT, ALP, TBil and MDA and decrease of T-SOD and GSH-Px levels (all P < 0.01). The rat models of ALI showed significantly increased expression of p-NF-κB (P < 0.01), decreased expressions of PI3K, p-Akt and SIRT6 proteins, and elevated expression levels of p-NF-κB, TNF-α and IL-6 proteins in the liver, which were all significantly improved in the treatment groups (P < 0.05 or 0.01).

CONCLUSION

TSPJ can effectively alleviate CCl4-induced ALI in rats by suppressing inflammatory responses and oxidative stress in the liver via regulating the PI3K/Akt and SIRT6/NF-κB pathways.