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Zargaran D, Zargaran A, Khan M. Systematic Review of the Management of Retro-Hepatic Inferior Vena Cava Injuries. Open Access Emerg Med 2020; 12:163-171. [PMID: 32617024 PMCID: PMC7326178 DOI: 10.2147/oaem.s247380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/19/2020] [Indexed: 11/23/2022] Open
Abstract
Background Retro-hepatic inferior vena cava (RHIVC) injuries resulting from blunt or penetrating abdominal trauma are rare but devastating events that remain a considerable challenge to even the most experienced doctors, which continue to carry a considerable mortality. Aim To establish a better understanding of the management of RHIVC injuries and to identify any adjuncts or operative methods that were associated with an increased survival. Methods A systematic review of the MEDLINE database was conducted using Medical Search Headings and exploded keywords and phrases. Studies were screened and subjected to inclusion/exclusion criteria. Data were extracted in a methodical manner collecting population demographics, morbidity, mortality and operative intervention, where provided. Operative strategies were compared and discussed. Results An initial search identified 483 articles. Following duplicate removal and abstract screening, 85 full-text articles were assessed with 25 meeting the desired criteria and were, therefore, included in the systematic review. Key operative strategies and complications were identified and discussed. Conclusion The wide variety of operative interventions in the management of RHIVC liver injuries described attest to the increased efforts to improve outcomes. The overall improvement in mortality can be noted since the earlier descriptions reported mortality approaching 100% compared to the 52% reported in this review. An algorithm has been proposed based on these findings and our experiences for the management of RHIVC injuries.
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Affiliation(s)
- David Zargaran
- Department of Medicine, Imperial College London, London, UK
| | | | - Mansoor Khan
- Brighton and Sussex University Hospitals, Brighton, UK
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O'Neill SB, Hamid S, Nicolaou S, Qamar SR. Changes in Approach to Solid Organ Injury: What the Radiologist Needs to Know. Can Assoc Radiol J 2020; 71:352-361. [PMID: 32166970 DOI: 10.1177/0846537120908069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This review aims to examine the challenges facing radiologists interpreting trauma computed tomography (CT) images in this era of a changing approach to management of solid organ trauma. After reviewing the pearls and pitfalls of CT imaging protocols for detection of traumatic solid organ injuries, we describe the key changes in the 2018 American Association for the Surgery of Trauma Organ Injury Scales for liver, spleen, and kidney and their implications for management strategies. We then focus on the important imaging findings in observed in patients who undergo nonoperative management and patients who are imaged post damage control surgery.
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Affiliation(s)
- Siobhán B O'Neill
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Saira Hamid
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Savvas Nicolaou
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Sadia R Qamar
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Ahmad ZY, Baghdanian AH, Baghdanian AA. Multidetector Computed Tomography Imaging of Damage Control Surgery Patients. Radiol Clin North Am 2019; 57:671-687. [PMID: 31076025 DOI: 10.1016/j.rcl.2019.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Damage control surgery is a staged surgical procedure in a patient who has suffered penetrating or blunt abdominal traumatic injury with severe metabolic derangements. Multidetector computed tomography scanning is a vital tool for patient management in the damage control patient, providing many uses, including assessing the extent of traumatic injury, evaluating areas that were not surgically explored, evaluating for injuries that were missed during the initial surgery, and assessing the stability of surgical repair. Understanding the postsurgical multidetector computed tomography appearance of these patients can aid the radiologist in protocol optimization and provide immediate accurate diagnoses.
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Affiliation(s)
- Zohaib Y Ahmad
- Department of Radiology, Boston University Medical Center, 820 Harrison Avenue, FGH Building, 4th Floor, Boston, MA 02115, USA
| | - Arthur H Baghdanian
- Department of Radiology, University of San Francisco, 505 Parnassus Avenue, Room M392, Box 0628, San Francisco, CA 94143, USA
| | - Armonde A Baghdanian
- Department of Radiology, University of San Francisco, 505 Parnassus Avenue, Room M392, Box 0628, San Francisco, CA 94143, USA.
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Baghdanian AA, Baghdanian AH, Khalid M, Armetta A, LeBedis CA, Anderson SW, Soto JA. Damage control surgery: use of diagnostic CT after life-saving laparotomy. Emerg Radiol 2016; 23:483-95. [PMID: 27166966 DOI: 10.1007/s10140-016-1400-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/15/2016] [Indexed: 11/30/2022]
Abstract
Damage control surgery (DCS) is a limited exploratory laparotomy that is performed in unstable trauma patients who, without immediate intervention, would acutely decompensate. Patients usually present with shock physiology and metabolic derangements including acidosis, hypothermia, and coagulopathy. Delayed medical correction of these metabolic derangements leads to an irreversible state of coagulopathic hemorrhagic shock and inevitable patient demise. Therefore, once a patient meets DCS criteria, a limited exploratory laparotomy is performed to stabilize life-threatening injury and expedite initiation of medical resuscitation in the intensive care unit (ICU). The surgeon plans to return to the operating room for definitive surgical treatment once the patient is hemodynamically stabilized and the metabolic derangements have been corrected. DCS patients are frequently sent to the ICU with an open abdomen and purposefully retained surgical equipment. The lack of response to resuscitation efforts, persistent hypotension, tachycardia, and/or the development of sepsis are common indications for this patient population to undergo CT imaging. The indications and findings of multi-detector CT (MDCT) in patients post-DCS have not been thoroughly evaluated in the radiology literature. A radiologist's knowledge of the DCS protocol and pre-imaging surgical interventions helps optimize the MDCT protocol. This enhances the radiologist's ability to evaluate for failure of surgical interventions performed prior to imaging and to search for injuries in areas that were not explored or that were missed during the initial surgical exploration.
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Affiliation(s)
- Armonde A Baghdanian
- Department of Radiology, Boston University Medical Center, 820 Harrison Avenue 3rd Floor, Boston, MA, 02118, USA.
| | - Arthur H Baghdanian
- Department of Radiology, Boston University Medical Center, 820 Harrison Avenue 3rd Floor, Boston, MA, 02118, USA
| | - Maria Khalid
- Department of Radiology, Boston University Medical Center, 820 Harrison Avenue 3rd Floor, Boston, MA, 02118, USA
| | - Anthony Armetta
- Department of Radiology, Boston University Medical Center, 820 Harrison Avenue 3rd Floor, Boston, MA, 02118, USA
| | - Christina A LeBedis
- Department of Radiology, Boston University Medical Center, 820 Harrison Avenue 3rd Floor, Boston, MA, 02118, USA
| | - Stephan W Anderson
- Department of Radiology, Boston University Medical Center, 820 Harrison Avenue 3rd Floor, Boston, MA, 02118, USA
| | - Jorge A Soto
- Department of Radiology, Boston University Medical Center, 820 Harrison Avenue 3rd Floor, Boston, MA, 02118, USA
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The swinging pendulum: a national perspective of nonoperative management in severe blunt liver injury. J Trauma Acute Care Surg 2013; 75:590-5. [PMID: 24064870 DOI: 10.1097/ta.0b013e3182a53a3e] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite a shift toward nonoperative management (NOM) of blunt liver trauma, severe injuries continue to require operative management. Our objective was to examine current trends of NOM for severe blunt liver injury from a national perspective. METHODS Patients with blunt liver injury with Abbreviated Injury Scale (AIS) score of 4 or greater and no other major solid organ injury or pelvic fracture were identified in the National Trauma Data Bank 2002 to 2008. Attempted NOM was defined as no surgery in 6 hours or less. Failed NOM was defined as surgery in greater than 6 hours. Cox regression evaluated the association of NOM outcome with 30-day mortality after controlling for injury severity and center. Logistic regression was used to define independent predictors of failed NOM. Annual attempted and failed NOM rates were compared during the study period. RESULTS A total of 3,627 patients were identified with a median Injury Severity Score (ISS) of 29 (interquartile range, 20-38) and 20% mortality. Early operative management occurred in 20%, while initial NOM occurred in 73% of the patients. Of these, 93% had successful NOM, and 7% had failed NOM. Failed NOM was an independent predictor of mortality (hazard ratio, 1.7; 95% confidence interval, 1.1-2.6; p = 0.01). Increasing age, male sex, increasing ISS, decreasing Glasgow Coma Scale (GCS) score, hypotension, and hepatic angioembolization were independent predictors of failed NOM. The rate of attempted and failed NOM increased during the study period (p < 0.01). CONCLUSION NOM for isolated severe blunt liver injury is increasing nationally with similar increment in failure. Failed NOM was associated with higher mortality. Several predictors of failed NOM were identified including age, sex, ISS, GCS, and hypotension. These factors may allow for better patient selection and improved outcomes. LEVEL OF EVIDENCE Therapeutic study, level IV; prognostic/epidemiologic study, level III.
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Yu J, Fulcher AS, Turner MA, Halvorsen RA. Multidetector Computed Tomography of Blunt Hepatic and Splenic Trauma: Pearls and Pitfalls. Semin Roentgenol 2012; 47:352-61. [DOI: 10.1053/j.ro.2012.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Abstract
BACKGROUND Hepatic angiography (HA) and hepatic angioembolization (HAE) are increasingly used to diagnose and treat intrahepatic arterial injuries. This study was performed to review indications, outcomes, and complications of HA/HAE in blunt trauma patients who underwent HAE as adjunct management of hepatic injury. METHODS A retrospective review of consecutive cases of HA/HAE at a Level I trauma center during an 8-year period. Data include demographics, physiologic condition, liver injury grade, HA/HAE indications, outcomes, morbidity, and mortality. RESULTS Seventy-nine patients underwent diagnostic HA; 31 (39%) had subsequent HAE. Fifty-eight hemodynamically stable patients had computerized axial tomographic (CT) scan followed by HA. HA was performed for contrast blush on CT in 30 (52%) of 58 patients, high-grade liver injury in 4 (7%), subsequent hemodynamic instability in 15 (27%), and angiography planned for other purpose in 9 (17%). HA confirmed arterial injury and led to HAE in 50% of patients with contrast blush on CT or high-grade liver injury. HA was negative when performed for hemodynamic instability or for other primary purposes. Twenty-one hemodynamically unstable patients underwent emergent laparotomy followed by postoperative HA with 11 (50%) requiring HAE. Overall mortality in HAE group was 16%, and liver-related morbidity was 29% usually presenting as gallbladder or liver necrosis. CONCLUSION HA/HAE should be used when CT scan suggests associated intrahepatic arterial or high-grade injury in the management of hepatic injuries and should also be considered after laparotomy and perihepatic packing to control inaccessible intrahepatic hemorrhage. Mortality related to HAE is uncommon, but morbidity occurs frequently.
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Affiliation(s)
- Andrew Holden
- Interventional Radiology Services, Auckland City Hospital, New Zealand.
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Dondelinger RF, Trotteur G, Ghaye B. Hemostatic Arterial Embolization in Trauma Victims at Admission. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
The spleen and liver are the 2 most commonly injured abdominal organs following trauma. Trends in management have changed over the years, and the majority of these injuries are now managed nonoperatively. Splenic injuries can be managed via simple observation or with angiography and embolization. Recent data suggest that there are few true contraindications in the setting of hemodynamic stability. Success rate of nonoperative management may be as high as 95%. Liver injuries can be approached similarly. In the setting of a hemodynamically stable patient, observation with or without angiography and embolization may similarly be used. As many as 80% of patients with liver injury can be successfully managed without laparotomy. This review will discuss current concepts in nonoperative management of liver and spleen, including diagnosis, patient selection, nonoperative management strategies, benefits, risks, and complications.
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Affiliation(s)
- Deborah M Stein
- Division of Critical Care/Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Anderson IB, Kortbeek JB, Al-Saghier M, Kneteman NM, Bigam DL. Liver Transplantation in Severe Hepatic Trauma after Hepatic Artery Embolization. ACTA ACUST UNITED AC 2005; 58:848-51. [PMID: 15824668 DOI: 10.1097/01.ta.0000101491.62777.8e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ian B Anderson
- Department of Surgery and Critical Care, University of Calgary, Alberta, Canada.
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Mohr AM, Lavery RF, Barone A, Bahramipour P, Magnotti LJ, Osband AJ, Sifri Z, Livingston DH. Angiographic Embolization for Liver Injuries: Low Mortality, High Morbidity. ACTA ACUST UNITED AC 2003; 55:1077-81; discussion 1081-2. [PMID: 14676654 DOI: 10.1097/01.ta.0000100219.02085.ab] [Citation(s) in RCA: 190] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Angiographic embolization (AE) is a safe and effective method for controlling hemorrhage in both blunt and penetrating liver injuries. Improved survival after hepatic injuries has been documented using a multimodality approach; however, patients still have significant long-term morbidity. This study examines further the role of AE in both blunt and penetrating liver injuries and the outcomes of its use. METHODS The medical records of 37 consecutive patients admitted from 1995 to 2002 to a Level I trauma center who underwent hepatic angiography with the intent to embolize were reviewed. Demographic and clinical information including Injury Severity Score, length of stay, mortality, intra-abdominal complications, admission physiologic variables, and the number and type of abdominal operations performed were collected. RESULTS Thirty-seven patients underwent hepatic angiography and 26 patients had hepatic embolization performed. Eleven patients underwent early-AE, immediately after computed tomographic scanning, and 15 underwent late-AE, after liver-related operations or later in their hospital course. There was a 27% mortality rate overall. There were 11 liver-related complications in the 26 embolizations. Excluding the early deaths, the associated morbidity was 58%, which included hepatic necrosis, hepatic abscesses, and bile leaks. CONCLUSION There is increasing adjunctive use of AE in patients managed both operatively and nonoperatively. Intra-abdominal complications are common in these salvaged patients with severe liver injuries. Those patients that underwent early-AE received significantly fewer blood transfusions and more commonly had sterile hepatic collections. Only 26% of patients required liver-related surgery after AE. Therefore, the integration of AE as an adjunctive modality for patients with high-grade liver injuries is a safe and effective therapeutic option.
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Affiliation(s)
- Alicia M Mohr
- Department of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medcial School, Newark, 07103, USA.
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Demetriades D, Velmahos G. Technology-driven triage of abdominal trauma: the emerging era of nonoperative management. Annu Rev Med 2003; 54:1-15. [PMID: 12471178 DOI: 10.1146/annurev.med.54.101601.152512] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Selective nonoperative management of blunt or penetrating abdominal trauma is safe, has eliminated the complications associated with nontherapeutic laparotomies, and is cost-effective. Appropriately selected investigations, such as focused abdominal sonography for trauma, diagnostic peritoneal lavage, spiral computed tomography (CT) scan, diagnostic laparoscopy, or thoracoscopy and angiography, play a critical role in the triage of patients. Future technological advances, such as improvement of the ultrasonic hardware and software that provide automated interpretation and the availability of portable CT scan machines in the emergency room, may improve the speed and accuracy of the initial evaluation. Improvement of the optical system of minilaparoscopes may allow reliable bedside laparoscopy for suspected diaphragmatic injuries.
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Affiliation(s)
- D Demetriades
- Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA.
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Kushimoto S, Arai M, Aiboshi J, Harada N, Tosaka N, Koido Y, Yoshida R, Yamamoto Y, Kumazaki T. The role of interventional radiology in patients requiring damage control laparotomy. THE JOURNAL OF TRAUMA 2003; 54:171-6. [PMID: 12544914 DOI: 10.1097/00005373-200301000-00022] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Interventional angiography has been used as a less invasive alternative to surgery to control hemorrhage resulting from trauma. This retrospective study analyzed the role of interventional radiology in patients requiring damage control laparotomy. METHODS Twenty patients underwent damage control laparotomy between January 1994 and May 2001. Eight of the 20 patients also underwent angiographic evaluation and treatment before or after the damage control laparotomy. RESULTS Three patients underwent angiography before damage control laparotomy, because a large, pelvic retroperitoneal hematoma was seen on computed tomographic scan, and the amount of intraperitoneal blood seemed insufficient to account for the magnitude of the patient's hemodynamic instability. Five patients underwent angiography after damage control laparotomy. The indication was a nonexpanding retroperitoneal hematoma in three patients, a nonexpanding hepatic hilar hematoma in one patient, and a hepatic injury associated with cirrhosis in one patient. Lumbar artery injuries were identified and treated by embolization in three patients. Four of the eight patients who underwent both damage control laparotomy and angiography survived. CONCLUSION Angiography before damage control laparotomy may be indicated to control retroperitoneal pelvic hemorrhage in hemodynamically unstable patients who have insufficient intraperitoneal blood loss to account for their hemodynamic instability. Angiography after damage control laparotomy should be considered when a nonexpanding, inaccessible hematoma is found at operation in a patient with a coagulopathy.
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Affiliation(s)
- Shigeki Kushimoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan. kushimoto/
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Carrillo EH, Wohltmann C, Richardson JD, Polk HC. Evolution in the treatment of complex blunt liver injuries. Curr Probl Surg 2001; 38:1-60. [PMID: 11202160 DOI: 10.1067/msg.2001.110096] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Over the last decade, major changes in the treatment of patients with blunt liver injuries have occurred, specifically with the nonoperative treatment of more complex injuries. These major changes can be summarized as follows: 1. Patients with blunt liver injuries are screened expeditiously by surgeon-performed ultrasonography. Depending on the initial findings and response to resuscitation, further decisions are made regarding the further evaluation. 2. Computed tomographic scanning is the mainstay of diagnosis for hepatic injuries after blunt trauma; the initial CT findings will help the trauma surgeon to determine the nonoperative treatment. 3. Liver injuries of grades I through III can be observed safely in a monitored unit and not necessarily in an ICU setting. Patients with injuries of grades IV and V are best initially observed in an ICU. 4. More than two thirds of patients with injuries of grades IV and V can be treated nonoperatively. However, 50% of these patients will require some type of interventional treatment, but not necessarily a laparotomy. 5. Initial findings on the CT scan can help to identify those patients who will need some type of interventional treatment and to identify associated injuries. 6. Elderly patients or patients with associated medical comorbidities can also be treated nonoperatively if strict guidelines are followed. 7. Complications in patients with complex blunt liver injuries are not uncommon. However, most of the complications can be safely treated by less invasive procedures.
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Affiliation(s)
- E H Carrillo
- University of Louisville, Trauma Services, University of Louisville Hospital, Louisville, Kentucky, USA
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Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF. Damage control: collective review. THE JOURNAL OF TRAUMA 2000; 49:969-78. [PMID: 11086798 DOI: 10.1097/00005373-200011000-00033] [Citation(s) in RCA: 271] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M B Shapiro
- Division of Trauma, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Poletti PA, Mirvis SE, Shanmuganathan K, Killeen KL, Coldwell D. CT criteria for management of blunt liver trauma: correlation with angiographic and surgical findings. Radiology 2000; 216:418-27. [PMID: 10924563 DOI: 10.1148/radiology.216.2.r00au44418] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the contrast material-enhanced computed tomographic (CT) criteria for selection of hemodynamically stable patients with blunt hepatic injury for angiographic evaluation. MATERIALS AND METHODS Seventy-two patients with blunt liver injury underwent CT and hepatic angiography. Hepatic injuries were graded with CT-based classification. Scans were assessed for evidence of contrast extravasation and laceration or contusion extending into the hepatic vein(s), inferior vena cava, porta hepatis, or gallbladder fossa. Medical, angiographic, and surgical records were reviewed to determine angiographic findings, surgical indications and findings, and outcomes. RESULTS Compared with hepatic angiography, CT was 65% (11 of 17 patients) sensitive and 85% (41 of 48 patients) specific for detection of arterial vascular injury. When CT severity grades 2 and 3 were analyzed, the sensitivity and specificity of CT were 100% (three of three patients) and 94% (34 of 36 patients), respectively (P <.001). Injury involving at least one major hepatic vein was found in 15 (88%) of 17 patients who required liver-related surgery and in 23 (42%) of 55 of the other patients (P <.01). CONCLUSION CT-based criteria, including hepatic injury grade, signs of arterial vascular injury, and presence or absence of major hepatic venous involvement assists in selecting patients for hepatic angiography and those at increased risk of ongoing or delayed hepatic bleeding or other posttraumatic complications.
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Affiliation(s)
- P A Poletti
- Departments of Diagnostic Radiology, University of Maryland Medical Center and Shock Trauma Center, 22 S Greene St, Baltimore, MD 21201, USA
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Ciraulo DL, Luk S, Palter M, Cowell V, Welch J, Cortes V, Orlando R, Banever T, Jacobs L. Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries. THE JOURNAL OF TRAUMA 1998; 45:353-8; discussion 358-9. [PMID: 9715195 DOI: 10.1097/00005373-199808000-00025] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Recognizing the significant mortality and complications inherent in the operative management of blunt hepatic injuries, hepatic arterial embolization was evaluated as a bridge between operative and nonoperative interventions in patients defined as hemodynamically stable only with continuous resuscitation. METHODS Seven of 11 patients with grade IV or V hepatic injuries identified by computed tomography underwent hepatic arterial embolization. A prospective evaluation of hepatic embolization based on subsequent hemodynamic parameters was assessed by matched-pair analysis. A summary of this study population's demographic data and outcomes is presented, including age, Glasgow Coma Scale score, Injury Severity Score, Revised Trauma Score, computed tomography grade, intensive care unit and hospital length of stay, transfusion requirements, complications, and mortality. RESULTS No statistical difference was demonstrated between pre-embolization and postembolization hemodynamics and volume requirements. After embolization, however, continuous resuscitation was successfully reduced to maintenance fluids. Hepatic embolization was the definitive therapy for all seven patients who underwent embolization. CONCLUSION Results of this preliminary investigation suggest that hepatic arterial embolization is a viable alternative bridging the therapeutic options of operative and nonoperative intervention for a subpopulation of patients with hepatic injury.
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Affiliation(s)
- D L Ciraulo
- Department of Trauma/EMS, Hartford Hospital, Connecticut, USA
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Ciraulo DL, Nikkanen HE, Palter M, Markowitz S, Gabram S, Cowell V, Luk S, Jacobs L. Clinical analysis of the utility of repeat computed tomographic scan before discharge in blunt hepatic injury. THE JOURNAL OF TRAUMA 1996; 41:821-4. [PMID: 8913210 DOI: 10.1097/00005373-199611000-00009] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Nonoperative management of hemodynamically stable blunt hepatic injury has emerged as an acceptable and safe treatment. Surveillance of this population's injuries is costly. As a prelude to establishing practice guidelines, the utility of repeat computed tomographic (CT) scans was investigated. METHODS A retrospective study was conducted on 243 hepatic injuries. The CT scans of 95 patients managed nonoperatively who did not have ongoing transfusion requirements were reviewed and graded according to the American Association for the Surgery of Trauma (AAST) hepatic injury scale. Patients were grouped according to injury grade, assigned to two subgroups (patients with one CT scan versus more than one CT scan) and compared with respect to several physiologic and clinical variables. RESULTS Statistical analysis revealed no significant difference between subgroups with the same grade of injury. No significant difference was demonstrated between subgroups' length of stay. CONCLUSIONS No patients failed nonoperative treatment or succumbed to their injuries. Findings on repeat CT scan have not altered the decision to discharge the clinically stable patient having suffered a grade III or lower liver injury.
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Affiliation(s)
- D L Ciraulo
- Department of Trauma/EMS, Hartford Hospital, Connecticut 06102-5037, USA
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