Immediate postoperative angiographic embolization after damage control surgery for liver injury: report of a case

Influence of postoperative hepatic angiography on mortality after laparotomy in Grade IV/V hepatic injuries

BACKGROUND

Mortality rate for severe liver injuries remains high. As an adjunct to surgery, postoperative hepatic angiography (PHA) may have a positive impact on outcomes. This study sought to compare outcomes following surgical management of severe liver injuries with and without PHA using propensity score matching analysis.

METHODS

Data from the National Trauma Data Bank from 2007 to 2014 were analyzed. The study population consisted of patients older than 18 years, sustaining severe liver injuries (i.e., American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade IV or V) who underwent surgery. Patients were divided into two groups. The PHA group consisted of those undergoing surgery followed by PHA. In the surgery-only group, no angiography was performed. To determine the impact of PHA on outcomes, propensity score matching analysis (1:3) was used.

RESULTS

A total of 3,871 patients met inclusion criteria. Of those, 205 (5.3%) patients underwent PHA. Prior to matching, patients in the PHA group had higher severity, but overall in-hospital mortality was found to be similar between the two groups. After 1:3 propensity-score matching, 196 patients in the PHA group were matched with 588 in the surgery-only group with well-balanced baseline characteristics. The in-hospital mortality was significantly lower in the PHA group compared with the surgery-only group (24.5% vs. 35.9%; odds ratio, 0.58; 95% confidence interval, 0.40-0.84). However, hospital length of stay was longer (16.0 [7.0-29.8] vs. 11 [1.0-25.0] days, p = 0.001), and the incidence of deep and organ/space surgical site infection (3.6% vs. 1.2%, 8.2% vs. 3.5%, respectively) was higher in the PHA group.

CONCLUSION

The use of PHA was associated with decreased mortality rates. A multimodality approach using both surgical intervention followed by PHA appears to identify patients that may benefit from arterial embolization, leading to decreased mortality of severe liver injuries.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Amyloidosis and spontaneous hepatic bleeding, transcatheter therapy for hepatic parenchymal bleeding with massive intraperitoneal hemorrhage: a case report and review of the literature

Hepatic hemorrhage can be devastating, especially in patients with underlying hepatic pathology. This is a case report of a 50-year-old man who presented to the emergency room with Stage 3 shock as evidenced by a systolic blood pressure of 90 mmHg, a heart rate of 125 beats per minute, respiration of 32, with delayed capillary refill and agitation. At this time, he was found to have a massive spontaneous intra-abdominal hemorrhage with an advanced stage of amyloidosis with multiple organ malfunctions. The initial diagnosis was based on an abdominal computed tomography scan and the patient was taken expeditiously to a hybrid angiography suite for a celiac angiogram. An intraoperative diagnosis of extravasation from amyloid related vasculopathy was made based on the angiographic appearance of hepatic circulation. Coil embolization of the feeding branch of the bleeder was achieved using the interlock coil system and a completion angiogram was done showing complete cessation of active bleeding. The postoperative phase was uneventful and the patient was discharged home on postoperative day three. His postoperative visit at five months later was unremarkable.

Treatment of major hepatic necrosis: lobectomy versus serial debridement

BACKGROUND

Major hepatic necrosis (MHN) is a common complication after angioembolization (AE) for severe liver injuries. We compared the outcomes of two treatment modalities.

METHODS

Patients with MHN were retrospectively reviewed from January 2002 to October 2007. Demographics, Injury Severity Scale score, length of stay, admission Glasgow Coma Scale Score, mortality, transfusion requirements, intra-abdominal complications, admission physiologic variables, and the number and type of abdominal procedures (operative or nonoperative) were collected. These patients were then divided into two groups-those treated with hepatic lobectomy (HL) and those treated with multiple procedures including serial operative debridements and/or percutaneous drainage (IR/OR).

RESULTS

Thirty patients (41%) with MHN were identified from 71 patients who had AE. Sixteen patients with MHN underwent HL and 14 patients underwent multiple IR/OR procedures. The two groups were similar at baseline, except that the HL group had a higher Injury Severity Scale score. Outcomes between the two groups were similar. There was a significantly higher complication rate and increased number of procedures in the IR/OR group. There were no deaths in patients who had early HL (<5 days). There was one death in the later lobectomy group.

CONCLUSION

MHN is a common complication after AE. This complication can be safely managed with a series of operative debridements in conjunction with interventional procedures or with HL. Lobectomy is associated with a lower complication rate and a fewer number of procedures. Early lobectomy may be better than a delayed procedure.

Damage control surgery and open abdominal management: recent advances and our approach

The concept of damage control and improved understanding of the pathophysiology of abdominal compartment syndrome (ACS) have been proven to be great advances in the management of both traumatic and nontraumatic surgical conditions. The practice of damage control surgery includes 3 components: 1) abbreviated resuscitative surgery for rapid control of hemorrhage and abdominal contamination by gastrointestinal contents, followed by temporary abdominal wall closure for planned reoperation and prevention of ACS; 2) restoration of physiologic function, including rewarming and correction of coagulopathy and hemodynamic stabilization in the intensive care unit; and 3) re-exploration for the definitive management of injuries and abdominal wall closure. Although this new approach can decrease the mortality rate of patients with severe physiological derangement, the establishment of clearly defined indications is necessary. For patients who require damage control surgery, interventional radiology should be integrated into the strategy for achieving hemostasis. Angiographic evaluation and embolization should be considered immediately after initial operation, especially for patients with combined intraperitoneal and retroperitoneal hemorrhage, severe hepatic injury, or ongoing hemorrhage after damage control surgery. In many patients who require conventional open abdominal management following damage control surgery or decompressive laparotomy for ACS, the granulating abdominal contents are covered with only a skin graft, which is associated with a risk of enterocutaneous fistula. These patients will ultimately require complex abdominal wall reconstruction at a later stage. We have performed early fascial closure using an anterior rectus abdominis sheath turnover flap method. This technique may reduce the need for skin grafting and subsequent reconstruction and can be considered as an alternative method for the early management of patients with open abdomen.

Management of ongoing arterial haemorrhage after damage control laparotomy: optimal timing and efficacy of transarterial embolisation

INTRODUCTION

Patients undergoing damage control laparotomy need intensive and aggressive resuscitation, and may also require adjunctive transarterial embolisation (TAE) for ongoing arterial haemorrhage. We evaluated the effectiveness and timing of TAE in these patients as well as their final outcome.

MATERIALS AND METHODS

From January 1998 to December 2006, the case records of 16 patients with ongoing arterial haemorrhages (hepatic haemorrhage=7, extra-hepatic haemorrhage=9) who underwent TAE after damage control laparotomy were reviewed. Fourteen patients had blunt injuries and two had penetrating injuries.

RESULTS

There were 13 men and three women. Their ages ranged from 3 to 85 years (mean, 36 years). Of seven hepatic angiograms, contrast extravasation at the right hepatic artery and left hepatic artery was found in three patients each. Bilateral hepatic artery injuries were found in one patient. Of nine extra-hepatic angiograms, the internal iliac artery was the most commonly injured artery (n=6). After TAE, 14 of 16 ongoing arterial haemorrhages could be controlled and eight patients survived; however, two patients with uncontrolled haemorrhages eventually died (hepatic artery injury=1, lumbar artery injury=1). Of 16 patients overall, profound haemorrhagic shock (n=4) and multiple organ failure (n=4) resulted in eight deaths (hepatic injury=4, extra-hepatic injury=4), and accounted for a mortality rate of 50%. Of 16 patients, nine were taken directly from the operating room to the angiography suite and the mortality rate was 33.3%. The other seven patients were taken to the angiography suite from the intensive care unit and the mortality rate was 71.4%. Of three survivors who underwent hepatic TAE, the operative time ranged from 30 min to 72 min (mean, 48 min). However, of four nonsurvivors who underwent hepatic TAE, the operative time ranged from 58 min to 180 min (mean, 119 min).

CONCLUSIONS

TAE is an effective tool in the management of ongoing arterial haemorrhage after damage control laparotomy and eight (50%) patients with ongoing arterial haemorrhages survived from this multidisciplinary treatment. To achieve a good outcome, the operative time of damage control laparotomy should be as short as possible and TAE should be performed without delay. Interventional radiology colleagues should be informed in advance during laparotomy and resuscitation continued in the angiography suite.

Major hepatic necrosis: a common complication after angioembolization for treatment of high-grade liver injuries

BACKGROUND

The management of high-grade liver injuries often involves a combination of operative and nonoperative strategies. Angioembolization (AE) is frequently used in the management of these injuries. Morbidity in patients with high-grade hepatic injuries remains high despite improvements in mortality with a multimodality approach. Major hepatic necrosis (MHN) is a morbid, but underappreciated complication of AE in this patient population. This study will examine the risk factors and outcomes of patients with high-grade liver injures managed with AE who developed the complication of MHN.

METHODS

Patients admitted to the R Adams Cowley Shock Trauma Center between January 2002 and December 2007 with high-grade blunt or penetrating liver injuries (grades III-VI) were identified from the trauma registry and the medical records were retrospectively reviewed. Demographic and injury specific data, complications, and admission physiologic variables were collected. Patients who had therapeutic AE, either preoperatively or postoperatively, and went on to develop liver-related complications including MHN were reviewed.

RESULTS

There were 538 patients with high-grade liver injuries admitted during a 5-year period. One hundred and sixteen patients (22%) underwent angiography, and 71 (13%) had a therapeutic AE. Sixteen patients (22.5%) had grade III injuries, 44 (62%) had grade IV injuries, and 11 (15.5%) had grade V injuries. Overall mortality in this group was 14% with eight patients (11.3%) dying as a result of their liver injury. Complication rates were 18.8%, 65.9%, and 100% in the patients with grades III, IV, and V injuries, respectively, for an overall complication rate of 60.6%. Thirty patients (42.2%) went on to develop MHN. Patients who developed MHN were compared with those who did not. Baseline characteristics, Injury Severity Score, and hemodynamic parameters at admission were no different between the two groups. Patients with MHN had higher grade injuries, required significantly more blood product transfusions, and had a significantly longer length of stay (all p < 0.001). Patients who developed MHN were more likely to have undergone operative intervention (96.7% vs. 41.5%, p < 0.001), with 87% having a damage control laparotomy. Other liver-related complications occurred more frequently in the patients that developed MHN (60.0% vs. 34.1%, p = 0.03). However, mortality was not different in the two groups.

CONCLUSION

High-grade liver injuries pose significant challenges to those who care for trauma patients. Many patients can be successfully managed nonoperatively, but there are still patients that require laparotomy. AE is the logical augmentation of damage control techniques for controlling hemorrhage. However, given the nature and severity of these injuries, these therapies are not without complications. MHN was found to be a common complication in our study. It tended to occur in high-grade injures, was associated with higher complication rates, longer hospital length of stay, and higher transfusion requirements. Management of MHN can be challenging. Factors that still need to be elucidated are the role of perihepatic packing and timing of second look operation.

Pediatric injuries: prevention to resolution

Despite improved education and prevention initiatives, trauma remains the leading cause of death in children. A variety of preventative measures have been developed to decrease the morbidity and mortality, and the financial burden on the health care system. This article discusses injury prevention strategies, issues in prehospital care, and key points of initial resuscitation. In addition, the major injury patterns are described with attention paid to the diagnosis and management of patients with multiple traumatic injuries.