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Akl MN, El-Qawaqzeh K, Anand T, Hosseinpour H, Colosimo C, Nelson A, Alizai Q, Ditillo M, Magnotti LJ, Joseph B. Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis. J Surg Res 2024; 294:128-136. [PMID: 37871495 DOI: 10.1016/j.jss.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy. METHODS We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed. RESULTS Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value <0.001), complications (49% versus 37%; P value = 0.01), failure to rescue (66% versus 36%, P value<0.001), and pRBC (units, median, 11 [7-18] versus 7 [4-11], P value <0.001) transfusion requirements. There were no significant differences in hospital and intensive care unit (ICU) lengths of stay (P value ≥0.05). On multivariate analysis, increasing age (adjusted odds ratio [aOR] 1.02, P value <0.001), Glasgow Coma Scale score ≤8 at presentation (aOR 3.3, P value <0.001), and total splenectomy (aOR 5.7, P value <0.001) were associated with higher odds of mortality. Platelet transfusion was associated with lower odds of mortality (aOR 0.84, P value = 0.044). CONCLUSIONS On a national scale, mortality following trauma laparotomy is twice as high for cirrhotic patients compared to noncirrhotic patients with higher rates of major complications and failure to rescue. Our finding of a protective effect of platelet transfusion may be explained by the platelet dysfunction associated with cirrhosis. Liver cirrhosis among trauma patients warrants heightened surveillance.
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Affiliation(s)
- Malak Nazem Akl
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Khaled El-Qawaqzeh
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Qaidar Alizai
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
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Elkbuli A, Breeding T, Martinez B, Patel H, Chin B, Wright DD, Patterson R, Roberts J, Rhodes H. Evaluating Mortality Outcomes, Transfusion Characteristics, and Risk Factors Associated With Cirrhotic Trauma Patients Undergoing Emergency Laparotomy Versus Non-Operative Management: A National Analysis. Am Surg 2024:31348241230087. [PMID: 38272456 DOI: 10.1177/00031348241230087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
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.
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Affiliation(s)
- Adel Elkbuli
- Division of Trauma and Surgical Critical Care, Department of Surgery, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Tessa Breeding
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Brian Martinez
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Heli Patel
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Brian Chin
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - D-Dre Wright
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | - Ryan Patterson
- Department of Surgery, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Jennifer Roberts
- Department of Trauma, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Heather Rhodes
- Center for Clinical Epidemiology and Public Health, Marshfield Clinic Research Institute, Marshfield, WI, USA
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L'Huillier R, Cayot B, Turc J, Milot L. Portal vein embolization following arterial portography for the management of an active portal bleeding after blunt liver trauma in a cirrhotic patient. CVIR Endovasc 2024; 7:5. [PMID: 38175362 PMCID: PMC10766936 DOI: 10.1186/s42155-023-00423-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The management of blunt liver trauma in cirrhotic patients is challenging, because while bleeding is most often of arterial origin, the increased pressure in the portal system associated with cirrhosis can increase the risk of portal bleeding, which is sometimes difficult to confirm on contrast-enhanced abdominal computed tomography. CASE PRESENTATION We managed a 54-year-old cirrhotic patient who presented with blunt liver trauma. Computed Tomography showed active intraperitoneal bleeding presumed to be of hepatic origin. Given the patient's hemodynamic stability, the decision was made to manage the patient non-surgically. The patient underwent hepatic arteriography to rule out an arterial origin to the bleeding. A superior mesenteric arterial portography confirmed the portal venous origin of the bleeding. To stop the bleeding, a distal portal vein embolization using coils and glue was performed by approaching a large paraumbilical vein. CONCLUSIONS Our case study shows the value of arterial portography in the management of these patients, when they are clinically stable enough to benefit from non-surgical management; This allows arterial bleeding to be excluded on hepatic arteriography, portal bleeding to be confirmed on portography following arteriography in the superior mesenteric artery, and guidance of portal vein embolization.
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Affiliation(s)
- Romain L'Huillier
- Department of Diagnostic and Interventional Radiology, Hôpital Edouard Herriot, Hospices Civils de Lyon, University of Lyon, Pavillon B, 5 Place D'Arsonval, Lyon, 69003, France.
- LabTAU - INSERM U1032, Lyon, 69003, France.
- The French Comprehensive Liver Center, Hospices Civils de Lyon, University of Lyon, Lyon, 69004, France.
| | - Bénédicte Cayot
- Department of Diagnostic and Interventional Radiology, Hôpital Edouard Herriot, Hospices Civils de Lyon, University of Lyon, Pavillon B, 5 Place D'Arsonval, Lyon, 69003, France
| | - Jean Turc
- Department of Anesthesiology and Intensive Care Unit, Hôpital Edouard Herriot, Hospices Civils de Lyon, University of Lyon, Lyon, 69003, France
| | - Laurent Milot
- Department of Diagnostic and Interventional Radiology, Hôpital Edouard Herriot, Hospices Civils de Lyon, University of Lyon, Pavillon B, 5 Place D'Arsonval, Lyon, 69003, France
- LabTAU - INSERM U1032, Lyon, 69003, France
- The French Comprehensive Liver Center, Hospices Civils de Lyon, University of Lyon, Lyon, 69004, France
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4
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Kotowski K, Kucharski D, Machura B, Adamski S, Gutierrez Becker B, Krason A, Zarudzki L, Tessier J, Nalepa J. Detecting liver cirrhosis in computed tomography scans using clinically-inspired and radiomic features. Comput Biol Med 2023; 152:106378. [PMID: 36512877 DOI: 10.1016/j.compbiomed.2022.106378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 11/30/2022]
Abstract
Hepatic cirrhosis is an increasing cause of mortality in developed countries-it is the pathological sequela of chronic liver diseases, and the final liver fibrosis stage. Since cirrhosis evolves from the asymptomatic phase, it is of paramount importance to detect it as quickly as possible, because entering the symptomatic phase commonly leads to hospitalization and can be fatal. Understanding the state of the liver based on the abdominal computed tomography (CT) scans is tedious, user-dependent and lacks reproducibility. We tackle these issues and propose an end-to-end and reproducible approach for detecting cirrhosis from CT. It benefits from the introduced clinically-inspired features that reflect the patient's characteristics which are often investigated by experienced radiologists during the screening process. Such features are coupled with the radiomic ones extracted from the liver, and from the suggested region of interest which captures the liver's boundary. The rigorous experiments, performed over two heterogeneous clinical datasets (two cohorts of 241 and 32 patients) revealed that extracting radiomic features from the liver's rectified contour is pivotal to enhance the classification abilities of the supervised learners. Also, capturing clinically-inspired image features significantly improved the performance of such models, and the proposed features were consistently selected as the important ones. Finally, we showed that selecting the most discriminative features leads to the Pareto-optimal models with enhanced feature-level interpretability, as the number of features was dramatically reduced (280×) from thousands to tens.
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Affiliation(s)
| | | | | | | | - Benjamín Gutierrez Becker
- Roche Pharma Research and Early Development, Informatics, Roche Innovation Center Basel, Basel, Switzerland
| | - Agata Krason
- Roche Pharmaceutical Research and Early Development, Early Clinical Development Oncology, Roche Innovation Center Basel, Basel, Switzerland
| | - Lukasz Zarudzki
- Department of Radiology and Diagnostic Imaging, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Jean Tessier
- Roche Pharmaceutical Research and Early Development, Early Clinical Development Oncology, Roche Innovation Center Basel, Basel, Switzerland
| | - Jakub Nalepa
- Graylight Imaging, Gliwice, Poland; Department of Algorithmics and Software, Silesian University of Technology, Gliwice, Poland.
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Kumari D, Kwak DH, Fergus J. Role of Interventional Radiology in the Management of Venous Trauma. Semin Intervent Radiol 2022; 39:508-514. [PMID: 36561937 PMCID: PMC9767770 DOI: 10.1055/s-0042-1757941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Traumatic injury to the large, central venous vasculature, although rare, is associated with high morbidity and mortality rates. Conventional open surgical treatment by repair or ligation can be technically challenging in anatomically difficult areas to expose. Furthermore, open surgical approach can release tension on the venous injury and result in uncontrollable bleeding. Endovascular techniques such as stenting and embolization can be used effectively for the treatment of traumatic venous injury. This article will discuss the morbidity and mortality associated with traumatic venous injuries, venous anatomy, endovascular treatment options, and management of traumatic venous injury.
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Affiliation(s)
- Divya Kumari
- Department of Radiology, University of Chicago Medicine, Chicago, Illinois
| | - Daniel H. Kwak
- Department of Radiology, University of Chicago Medicine, Chicago, Illinois
| | - Jonathan Fergus
- Department of Radiology, University of Chicago Medicine, Chicago, Illinois
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6
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Natkha VP, Southerland P, Almekdash MH, Keesair R, Dhanasekara CS, Dissanaike S. Predicting Outcomes in Trauma Patients With Cirrhosis Using Model for End-Stage Liver Disease Score: A Retrospective Study. Am Surg 2022:31348221093534. [PMID: 35521931 DOI: 10.1177/00031348221093534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Liver cirrhosis is associated with increased mortality in trauma victims. We stratified the impact of cirrhosis on trauma mortality by Model for End-stage Liver Disease (MELD) score. METHODS Trauma center database was accessed for patients with established diagnosis of cirrhosis presenting 2014 - 2018, matched to control patients without cirrhosis in a 2:1 ratio by age, sex, and TRISS. Primary outcome was mortality, secondary outcomes were length of stay, intensive care unit days, and ventilator dependent days. RESULTS Cirrhosis was present in 182 (1.5%) trauma patients. Mortality difference between 12 (7%) deaths in cirrhosis cohort versus 14 (4%) in control was not statistically significant (p = 0.38). No difference was found in secondary outcomes. Categorization of cirrhosis severity by MELD score range (MELD 6-7, 8-10, 11-14, 15-20, 21-30) showed a 1.9 fold increase in the odds of mortality for every increase in MELD score category (OR = 1.91, p = 0.03, 95% CI = 1.08 - 3.37). CONCLUSION Mortality effects of cirrhosis in trauma patients can be estimated using MELD score.
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Affiliation(s)
- Vitaliy P Natkha
- Department of Surgery, 12343Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Parker Southerland
- Department of Surgery, 12343Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Mhd Hasan Almekdash
- Department of Surgery, 12343Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Rohali Keesair
- Department of Surgery, 12343Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | | | - Sharmila Dissanaike
- Department of Surgery, 12343Texas Tech University Health Sciences Center, Lubbock, TX, USA
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7
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Jeong E, Jo Y, Park Y, Kim J, Jang H, Lee N. Very large haematoma following the nonoperative management of a blunt splenic injury in a patient with preexisting liver cirrhosis: a case report. JOURNAL OF TRAUMA AND INJURY 2022. [DOI: 10.20408/jti.2021.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The spleen is the most commonly injured organ after blunt abdominal trauma. Nonoperative management (NOM) is the standard treatment for blunt splenic injuries in haemodynamically stable patients without peritonitis. Complications of NOM include rebleeding, new pseudoaneurysm formation, splenic abscess, and symptomatic splenic infarction. These complications hinder the NOM of patients with blunt splenic injuries. We report a case in which a large haemorrhagic fluid collection that occurred after angio-embolisation was resolved by percutaneous drainage in a patient with liver cirrhosis who experienced a blunt spleen injury.
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8
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Renninger CH, Jaeblon T, Slobogean GP, O'Toole RV, O'Hara NN. Patients With Cirrhosis Who Have a Model for End-stage Liver Disease Sodium Score of 8 or Greater Are at Increased Risk of Poor Outcomes in Operatively Treated Tibia Fractures. Orthopedics 2022; 45:79-85. [PMID: 35021031 DOI: 10.3928/01477447-20220105-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to compare 30-day readmission rates for cirrhotic and non-cirrhotic patients after tibia fracture fixation by retrospectively identifying all surgically managed tibial plateau, tibial shaft, and pilon fractures from 2010 through 2018 in the National Surgical Quality Improvement Program database (N=14,028). The primary outcome measure was 30-day readmission rates. Secondary outcome measures included 30-day rates of reoperation, length of stay, pulmonary embolism, deep venous thrombosis, and wound complications, including deep or superficial infection. Cirrhotic patients (n=665) and non-cirrhotic patients (n=13,363) were identified using the aspartate aminotransferase to platelet ratio index test. Cirrhotic patients were more likely to have preoperative ascites, renal failure, bleeding disorders, and preoperative transfusions. No differences were reported between the two groups in readmission rate or any of the secondary outcome measures, except that cirrhotic patients' length of stay was longer by 0.5 day. Stratification of the cirrhotic cohort demonstrated that a Model for End-stage Liver Disease sodium (MELD-Na) score of 8 or greater was associated with a 4.1-fold increase in the rate of readmission (5.9% vs 1.5%; P<.01). No other differences were identified based on MELD-Na score stratification. Patients with advanced cirrhosis (MELD-Na score ≥8) have an increased risk of 30-day readmission after tibia fracture surgery. Cirrhosis associated with a lower MELD-Na score might not significantly increase the risk of 30-day complications in patients with tibia fractures. [Orthopedics. 2022;45(2):79-85.].
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9
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The effect of cirrhosis on trauma outcomes: A systematic review and meta-analysis. J Trauma Acute Care Surg 2020; 88:536-545. [PMID: 31389920 DOI: 10.1097/ta.0000000000002464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The negative effect of cirrhosis on mortality following traumatic injury has been quantified in multiple observational studies. However, to our knowledge, the information contained in these studies has never been synthesized. The aims of this study were: (1) to determine the magnitude of the effect of liver cirrhosis on mortality, morbidity, and hospital course among trauma patients and (2) to analyze sources of study heterogeneity that may lead to differing estimates in the observed mortality rate among patients with cirrhosis. METHODS A systematic search of EMBASE and PubMed was conducted. Data were extracted from eligible studies and analyzed using a random-effects model to compare trauma outcomes in cirrhotic and noncirrhotic patients (PROSPERO Registration CRD42018088464). Mortality was the primary outcome. Secondary outcomes included complication rate, length of hospital stay, length of intensive care unit stay, and mechanical ventilation days. RESULTS Title and abstract review of 15,958 articles led to the identification of 31 relevant articles. Ultimately, 18 observational studies were included in this meta-analysis. The pooled effect sizes for mortality (odds ratio [OR], 4.52; 95% confidence interval [CI], 3.13-6.54) and complication rate (OR, 1.92; 95% CI, 1.30-2.85) were higher in the cirrhotic group than the noncirrhotic group. Trauma patients with cirrhosis also incurred longer hospital stays (mean difference, 3.81 days; 95% CI, 1.22-6.41) and longer ICU stays (mean difference, 2.40 days; 95% CI, 0.65-4.15). There was no difference in days spent on mechanical ventilation. CONCLUSION Preexisting liver cirrhosis is associated with increased mortality rate, complication rate, and length of hospitalization among trauma patients, even after adjusting for confounding factors and potential sources of between-study heterogeneity. Trauma patients with cirrhosis would benefit from heightened surveillance and injury prevention interventions. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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10
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Grigorian A, Albertson S, Delaplain PT, Gabriel V, Maithel S, Dosch A, Schubl S, Joe V, Nahmias J. Cirrhosis increases complication rate and overall mortality in patients with traumatic lung injury. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408618774577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Spencer Albertson
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Patrick T Delaplain
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Viktor Gabriel
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Shelley Maithel
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Austin Dosch
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Sebastian Schubl
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Victor Joe
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Irvine, USA
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11
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Lu C, White SJ, Ye IB, Mikhail CM, Cheung ZB, Cho SK. The Effects of Liver Disease on Surgical Outcomes Following Adult Spinal Deformity Surgery. World Neurosurg 2019; 130:e498-e504. [PMID: 31254688 DOI: 10.1016/j.wneu.2019.06.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND As the prevalence of chronic liver disease continues to rise in the United States, understanding the effects of liver dysfunction on surgical outcomes has become increasingly important. The objective of this study was to assess the effects of chronic liver disease on 30-day complications following adult spinal deformity (ASD) surgery. METHODS We performed a retrospective cohort study of 2337 patients in the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program database who underwent corrective ASD surgery. Patients with liver disease were identified based on a Model for End-Stage Liver Disease-Na score ≥10. A univariate analysis was performed to compare 30-day postoperative complications between patients with and without liver disease. A multivariate regression analysis adjusting for differences in baseline patient characteristics was performed to identify complications that were associated with liver disease. RESULTS Patients with liver disease had a significantly greater incidence of postoperative pulmonary complications (6.3% vs. 2.9%; P < 0.001), blood transfusion (34.6% vs. 24.0%; P < 0.001), sepsis (2.2% vs. 0.9%; P = 0.011), prolonged hospitalization (19.0% vs. 8.0%; P < 0.001), as well as any 30-day complication (45.4% vs. 29.4%; P < 0.001). The multivariate regression analysis identified liver disease as a risk factor for prolonged hospitalization (odds ratio [OR] 2.16; 95% confidence interval [CI] 1.64-2.84; P < 0.001), pulmonary complications (OR 1.78; 95% CI 1.16-2.74; P = 0.009), blood transfusion (OR 1.67; 95% CI 1.36-2.05; P < 0.001), and any 30-day complication (OR 1.43; 95% CI 1.15-1.77; P = 0.001). CONCLUSIONS The multisystem pathophysiology of liver dysfunction predisposes patients to postoperative complications following ASD surgery. A multidisciplinary approach in surgical planning and preoperative optimization is needed to minimize liver disease-related complications and improve patient outcomes.
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Affiliation(s)
- Charles Lu
- The New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, USA
| | - Samuel J White
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ivan B Ye
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher M Mikhail
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zoe B Cheung
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel K Cho
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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12
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Adamson DT, Bozeman MC, Benns MV, Burton A, Davis EG, Jones CM. Operative Considerations for the General Surgeon in Patients with Chronic Liver Disease. Am Surg 2019. [DOI: 10.1177/000313481908500236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Chronic liver disease remains a prevalent and challenging comorbidity in the American population at large. Scarring and fibrosis cause physical and physiological changes that may prove challenging in both medical and surgical management. However, because there has been relevant improvements in preoperative diagnostic, perioperative hepatologic, and intensive care management, as well as in surgical techniques, patients with cirrhosis can safely be operated on but patient selection remains vital. Patients with chronic liver disease may present to a general surgeon for evaluation of a number of elective or emergent surgical conditions. Here, we review current literature on the perioperative management and operative strategies of seemingly routine general surgery issues and provide a review of the pathophysiology associated with chronic liver disease.
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Affiliation(s)
- Dylan T. Adamson
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Matthew C. Bozeman
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Matthew V. Benns
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Alison Burton
- Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Eric G. Davis
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
| | - Christopher M. Jones
- Hiram C. Polk, Jr., M.D., Department of Surgery, University of Louisville, Louisville, Kentucky and
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13
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Hickman L, Tanner L, Christein J, Vickers S. Non-Hepatic Abdominal Surgery in Patients with Cirrhotic Liver Disease. J Gastrointest Surg 2019; 23:634-642. [PMID: 30465191 PMCID: PMC7102012 DOI: 10.1007/s11605-018-3991-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 09/20/2018] [Indexed: 01/31/2023]
Abstract
Cirrhotic liver disease is an important cause of peri-operative morbidity and mortality in general surgical patients. Early recognition and optimization of liver dysfunction is imperative before any elective surgery. Patients with MELD <12 or classified as Child A have a higher morbidity and mortality than matched controls without liver dysfunction, but are generally safe for elective procedures with appropriate patient education. Patients with MELD >20 or classified as Child C should undergo transplantation before any elective procedure given mortality exceeds 40%. Laparoscopic procedures are feasible and safe in cirrhotic patients.
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Affiliation(s)
- Laura Hickman
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - John Christein
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Selwyn Vickers
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
- Dean's Office, UAB School of Medicine, FOT 1203, 510 20th Street South, Birmingham, AL, 35233, USA.
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14
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Harrison MF. The Misunderstood Coagulopathy of Liver Disease: A Review for the Acute Setting. West J Emerg Med 2018; 19:863-871. [PMID: 30202500 PMCID: PMC6123093 DOI: 10.5811/westjem.2018.7.37893] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 07/08/2018] [Accepted: 07/14/2018] [Indexed: 12/13/2022] Open
Abstract
The international normalized ratio (INR) represents a clinical tool to assess the effectiveness of vitamin-K antagonist therapy. However, it is often used in the acute setting to assess the degree of coagulopathy in patients with hepatic cirrhosis or acute liver failure. This often influences therapeutic decisions about invasive procedures or the need for potentially harmful and unnecessary transfusions of blood product. This may not represent a best-practice or evidence-based approach to patient care. The author performed a review of the literature related to the utility of INR in cirrhotic patients using several scientific search engines. Despite the commonly accepted dogma that an elevated INR in a cirrhotic patient corresponds with an increased hemorrhagic risk during the performance of invasive procedures, the literature does not support this belief. Furthermore, the need for blood-product transfusion prior to an invasive intervention is not supported by the literature, as this practice increases the risk of complications associated with a patient's hospital course. Many publications ranging from case studies to meta-analyses refute this evidence and provide examples of thrombotic events despite elevated INR values. Alternative methods, such as thromboelastogram, represent alternate means of assessing in vivo risk of hemorrhage in patients with acute or chronic liver disease in real-time in the acute setting.
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Affiliation(s)
- Michael F Harrison
- Henry Ford Hospital, Department of Emergency Medicine, Department of Internal Medicine, Department of Critical Care Medicine, Detroit, Michigan
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15
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Isbell C, Cohn SM, Inaba K, O'Keeffe T, De Moya M, Demissie S, Ghneim M, Davis ML. Cirrhosis, Operative Trauma, Transfusion, and Mortality: A Multicenter Retrospective Observational Study. Cureus 2018; 10:e3087. [PMID: 30324043 PMCID: PMC6171781 DOI: 10.7759/cureus.3087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: In trauma patients with cirrhosis who require laparotomy, little data exists to establish clinical predictors of the outcome. We sought to determine the prognosticators of mortality in this population. Methods: We performed a 10-year review at four, busy Level I trauma centers of patients with cirrhosis identified during trauma laparotomy. We compared vital signs, laboratory values, and transfusion requirements for those who survived versus those who died. A linear regression was then conducted to determine the variables associated with death in this population. Results: A total of 66 patients were included and 47% (31/66) died. The model for end-stage liver disease (MELD) score was low (7.8 in Lived, 10.2 in Died). Packed red blood cell (PRBC) transfusion at six hours was greater in those who died; those receiving > 6 units of PRBCs at 6 hours had an increased likelihood of death (odds ratio OR 5.8 (95% CI 1.9, 17.4)). All patients receiving ≥ 17 units of PRBCs died. We found an association between lower preoperative platelets (PLTs), higher preoperative international normalized ratio (INR) and partial thromboplastin time (PTT), lower preoperative pH (presence of profound acidemia), increased intraoperative crystalloid use, and increased intraoperative blood product administration to be associated with death (p < 0.05). Conclusions: Cirrhotic trauma patients requiring laparotomy should be considered to have a high chance of mortality if they receive six or more PRBCs, are acidotic (pH ≤ 7.25) at the time of hospital arrival, or have coagulopathy at the time of admission (INR > 1.2, PTT > 40).
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Affiliation(s)
| | - Stephen M Cohn
- Surgery, Staten Island University Hospital, Queens Village, USA
| | | | | | - Marc De Moya
- Surgery, Medical College of Wisconsin, Wisconsin, USA
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16
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Xu H, Jie L, Kejian S, Xiaojun H, Chengli L, Hongyi Z, Yalin K. Selective Angiographic Embolization of Blunt Hepatic Trauma Reduces Failure Rate of Nonoperative Therapy and Incidence of Post-Traumatic Complications. Med Sci Monit 2017; 23:5522-5533. [PMID: 29155699 PMCID: PMC5706383 DOI: 10.12659/msm.905115] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Conflict still remains as to the benefit of angioembolization (AE) for non-operative therapy (NOT) of blunt hepatic trauma (BHT). The aim of this study was to determine whether AE could result in lower failure rates in hemodynamically stable BHT patients with high failure risk factors for NOT, and to systematically evaluate the effectiveness of AE for NOT of BHT. Material/Methods Medical records of all BHT patients from January 1, 1998 to December 31, 2015 at a large trauma center were collected and analyzed. Failure of NOT (FNOT) occurred if hepatic surgery was performed after attempted NOT. Logistic regression analysis was used to identify factors associated with FNOT. Hepatobiliary complications related to hepatic trauma during follow-up were reviewed. Results No significant difference in FNOT for the no angiographic embolization (NO-AE) group versus angiographic embolization (AE) group was found in hepatic trauma of grades I, II, and V. However, decrease in FNOT was significant with AE performed for hepatic trauma of grades III to IV. Risk factors for FNOT included grade III to IV injuries and contrast blush on CT. Follow-up data of six months also showed that the incidence of hepatobiliary complications in the NO-AE group was higher than the AE group. Conclusions Hemodynamically stable BHT patients with grade III to IV injuries, contrast blush on initial CT, and/or decreasing hemoglobin levels can be candidates for selective AE during NOT course.
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Affiliation(s)
- Han Xu
- Department of Hepatobiliary Surgery, Zibo Central Hospital, Zibo, Shandong, China (mainland)
| | - Li Jie
- Department of Hepatobiliary Surgery, Zibo Central Hospital, Zibo, Shandong, China (mainland)
| | - Sun Kejian
- Department of Hepatobiliary Surgery, Zibo Central Hospital, Zibo, Shandong, China (mainland)
| | - He Xiaojun
- Department of Hepatobiliary Surgery, Chinese PLA Air Force General Hospital, Beijing, China (mainland)
| | - Liu Chengli
- Department of Hepatobiliary Surgery, Chinese PLA Air Force General Hospital, Beijing, China (mainland)
| | - Zhang Hongyi
- Department of Hepatobiliary Surgery, Chinese PLA Air Force General Hospital, Beijing, China (mainland)
| | - Kong Yalin
- Department of Hepatobiliary Surgery, Chinese PLA Air Force General Hospital, Beijing, China (mainland)
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17
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Abstract
More than 4 decades after the creation of the Brooke and Parkland formulas, burn practitioners still argue about which formula is the best. So it is no surprise that there is no consensus about how to resuscitate a thermally injured patient with a significant comorbidity such as heart failure or cirrhosis or how to resuscitate a patient after an electrical or inhalation injury or a patient whose resuscitation is complicated by renal failure. All of these scenarios share a common theme in that the standard rule book does not apply. All will require highly individualized resuscitations.
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Affiliation(s)
- David T Harrington
- Rhode Island Burn Center, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 444, Providence, RI 02903, USA.
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18
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Cook MR, Fair KA, Burg J, Cattin L, Gee A, Arbabi S, Schreiber M. Cirrhosis increases mortality and splenectomy rates following splenic injury. Am J Surg 2015; 209:841-7; discussion 847. [PMID: 25769879 DOI: 10.1016/j.amjsurg.2015.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/31/2014] [Accepted: 01/05/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cirrhosis may be a risk factor for mortality following blunt splenic injury (BSI) and it predicts the need for an operative intervention. METHODS We performed a case-control study at 3 level 1 trauma centers. Comparisons were made with chi-square test, Wilcoxon rank-sum test, and binary logistic regression, and stratified by propensity for splenectomy. Data are presented as odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS Mortality was 27% (21/77) and cirrhosis was a strong risk factor for death (OR 8.8, 95% CI 3.7 to 21.1). Compared with controls, cirrhosis was an independent risk factor for splenectomy (OR 5.4, 95% CI 2.5 to 11.5), and only splenic injury grade was associated with splenectomy (OR 2.2, 95% CI 1.3 to 3.6). Only admission model for end-stage liver disease was independently associated with mortality after an operation (OR 1.7, 95% CI 1.1 to 2.8). After propensity score matching, we found no association between splenectomy and mortality in cirrhotic patients. CONCLUSION Cirrhosis dramatically increases mortality and the odds of an operative intervention in BSI patients with pre-existing cirrhosis, and BSI requires vigilant attention and early intervention should be considered.
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Affiliation(s)
- Mackenzie R Cook
- Division of Trauma, Critical Care and Acute Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Kelly A Fair
- Division of Trauma, Critical Care and Acute Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Jennifer Burg
- Division of Trauma, Critical Care and Acute Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Lindsay Cattin
- Division of Trauma, Burns and Critical Care, Harborview Medical Center, Seattle, WA, USA
| | - Arvin Gee
- Pacific Surgical, Legacy Emanuel Medical Center, Portland, OR, USA
| | - Saman Arbabi
- Division of Trauma, Burns and Critical Care, Harborview Medical Center, Seattle, WA, USA
| | - Martin Schreiber
- Division of Trauma, Critical Care and Acute Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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Peck-Radosavljevic M, Angeli P, Cordoba J, Farges O, Valla D. Managing complications in cirrhotic patients. United European Gastroenterol J 2015; 3:80-94. [PMID: 25653862 DOI: 10.1177/2050640614560452] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/21/2014] [Indexed: 12/13/2022] Open
Abstract
Liver cirrhosis is a serious and potentially life-threatening condition. This life-threatening condition usually arises from complications of cirrhosis. While variceal bleeding is the most acute and probably best studied, several other complications of liver cirrhosis are more insidious in their onset but nevertheless more important for the long-term management and outcome of these patients. This review summarizes the topics discussed during the UEG-EASL Hepatology postgraduate course of the United European Gastroenterology Week 2013 and discusses emergency surgical conditions in cirrhotic patients, the management of hepatic encephalopathy, ascites and hepatorenal syndrome, coagulation disorders, and liver cancer.
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Affiliation(s)
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, University of Padova, Italy
| | - Juan Cordoba
- Liver Unit, Hospital Valld'Hebron, Barcelona, Spain
| | - Oliver Farges
- Department of HPB surgery HôpitalBeaujon, AP-HP, Université Paris-Diderot, Clichy-la-Garenne, France
| | - Dominique Valla
- Service d'Hépatologie, HôpitalBeaujon, AP-HP, Université Paris-Diderot, Clichy-la-Garenne, France
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20
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Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis. J Trauma Acute Care Surg 2014; 76:1354-61. [PMID: 24854300 DOI: 10.1097/ta.0000000000000244] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The response of liver cirrhosis (LC) patients to abdominal trauma, including blunt splenic injury (BSI) is unfavorable. To better understand the response to BSI in LC patients, the present study reviewed a much larger group of such patients, derived from the National Trauma Data Bank. METHODS The National Trauma Data Bank was queried for 2002 to 2010, and all adult BSI patients without severe brain trauma were identified. LC and non-LC patients were compared using nonoperative management (NOM) failure and mortality as primary outcomes. Predictors of these outcomes in LC patients were identified. RESULTS Of the 77,753 identified BSI patients, 289 (0.37%) had LC. Overall, 90% of the patients underwent initial NOM (86% in LC and 90% in non-LC patients, p = 0.091) with a global 90% success rate. Compared with non-LC patients, LC patients had a lower NOM success rate (83% vs. 90%, p = 0.004) despite increased use of splenic artery angioembolization (13% vs. 8%, p = 0.001). LC patients also had more complications per patient, an increased hospital and intensive care unit lengths of stay, and a higher mortality (22% vs. 6%, p < 0.0001), which was independent of the treatment paradigm. In the LC group, mortality in those who underwent immediate surgery was 35% versus 46% in failed NOM (p = 0.418) and 14% (p = 0.019) in successful NOM patients. LC patients who did not require surgery were more likely to survive than those who had surgery alone (adjusted odds ratio [AOR], 0.30). Preexisting coagulopathy (AOR, 3.28) and Grade 4 to 5 BSI (AOR, 11.6) predicted NOM failure in LC patients, whereas male sex (AOR, 4.34), hypotension (AOR, 3.15), preexisting coagulopathy (AOR, 3.06), and Glasgow Coma Scale (GCS) score of less than 13 (AOR, 6.33) predicted mortality. CONCLUSION LC patients have a higher rate of complications, mortality, and NOM failure compared with non-LC patients. Because LC patients with failed NOM have a mortality rate similar to those undergoing immediate surgery, judgment must be exerted in selecting initial management options. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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21
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Wang SY, Liao CH, Fu CY, Kang SC, Ouyang CH, Kuo IM, Lin JR, Hsu YP, Yeh CN, Chen SW. An outcome prediction model for exsanguinating patients with blunt abdominal trauma after damage control laparotomy: a retrospective study. BMC Surg 2014; 14:24. [PMID: 24775970 PMCID: PMC4009036 DOI: 10.1186/1471-2482-14-24] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 04/22/2014] [Indexed: 11/24/2022] Open
Abstract
Background We present a series of patients with blunt abdominal trauma who underwent damage control laparotomy (DCL) and introduce a nomogram that we created to predict survival among these patients. Methods This was a retrospective study. From January 2002 to June 2012, 91 patients underwent DCL for hemorrhagic shock. We excluded patients with the following characteristics: a penetrating abdominal injury, age younger than 18 or older than 65 years, a severe or life-threatening brain injury (Abbreviated Injury Scale [AIS] ≥ 4), emergency department (ED) arrival more than 6 hours after injury, pregnancy, end-stage renal disease, or cirrhosis. In addition, we excluded patients who underwent DCL after ICU admission or later in the course of hospitalization. Results The overall mortality rate was 61.5%: 35 patients survived and 56 died. We identified independent survival predictors, which included a preoperative Glasgow Coma Scale (GCS) score < 8 and a base excess (BE) value < -13.9 mEq/L. We created a nomogram for outcome prediction that included four variables: preoperative GCS, initial BE, preoperative diastolic pressure, and preoperative cardiopulmonary cerebral resuscitation (CPCR). Conclusions DCL is a life-saving procedure performed in critical patients, and devastating clinical outcomes can be expected under such dire circumstances as blunt abdominal trauma with exsanguination. The nomogram presented here may provide ED physicians and trauma surgeons with a tool for early stratification and risk evaluation in critical, exsanguinating patients.
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Affiliation(s)
| | | | | | - Shih-Ching Kang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan.
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Sundarakumar DK, Smith CM, Lopera JE, Kogut M, Suri R. Endovascular interventions for traumatic portal venous hemorrhage complicated by portal hypertension. World J Radiol 2013; 5:381-385. [PMID: 24179633 PMCID: PMC3812449 DOI: 10.4329/wjr.v5.i10.381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 09/02/2013] [Accepted: 10/16/2013] [Indexed: 02/06/2023] Open
Abstract
Life-threatening hemorrhage rarely occurs from the portal vein following blunt hepatic trauma. Traditionally, severe portal bleeding in this setting has been controlled by surgical techniques such as packing, ligation, and venorrhaphy. The presence of portal hypertension could potentially increase the amount of hemorrhage in the setting of blunt portal vein trauma making it more difficult to control. This case series describes the use of indirect carbon dioxide portography to identify portal hemorrhage. Furthermore, these cases illustrate attempted endovascular treatment utilizing a transjugular intrahepatic portosystemic shunt in one scenario and transmesocaval shunt coiling of a jejunal varix in the other.
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