Evolution in the treatment of complex blunt liver injuries

Management of pediatric blunt abdominal trauma with split liver or spleen injuries: a retrospective study

BACKGROUND

Blunt abdominal trauma is a prevailing cause of pediatric morbidity and mortality. It constitutes the most frequent type of pediatric injuries. Contrast-enhanced sonography (CEUS) and contrast-enhanced computed tomography (CECT) are considered pivotal diagnostic modalities in hemodynamically stable patients.

AIM

To report the experience in management of pediatric split liver and spleen injuries using CEUS and CECT.

PATIENTS AND METHODS

This study included 246 children who sustained blunt abdominal trauma, and admitted and treated at three tertiary hospitals in the period of 5 years. Primary resuscitation was offered to all children based on the advanced trauma and life support (ATLS) protocol. A special algorithm for decision-making was followed. It incorporated the FAST, baseline ultrasound (US), CEUS, and CECT. Patients were treated according to the imaging findings and hemodynamic stability.

RESULTS

All 246 children who sustained a blunt abdominal were studied. Patients' age was 10.5 ± 2.1. Road traffic accidents were the most common cause of trauma; 155 patients (63%). CECT showed the extent of injury in 153 patients' spleen (62%) and 78 patients' liver (32%), while the remaining 15 (6%) patients had both injuries. CEUS detected 142 (57.7%) spleen injury, and 67 (27.2%) liver injury.

CONCLUSIONS

CEUS may be a useful diagnostic tool among hemodynamically stable children who sustained low-to-moderate energy isolated blunt abdominal trauma. It may be also helpful for further evaluation of uncertain CECT findings and follow-up of conservatively managed traumatic injuries.

Successful utilization of angioembolization and delayed laparoscopy in the management of grade 5 hepatic laceration: Case report and literature review

INTRODUCTION

The liver is the most commonly injured solid organ in blunt abdominal trauma. Although the incidence of hepatic lacerations continues to rise, non-operative management with angioembolization is currently the standard of care. While active arterial hemorrhage is commonly embolized in grade 3 or 4 injuries, patients with grade 5 injuries frequently require operative intervention.

PRESENTATION OF CASE

A 30-year-old man presented to our level I trauma center following a motor scooter accident. CT abdominal imaging revealed a grade 5 right lobar hepatic laceration. He underwent successful angioembolization without further hemorrhage. The patient later developed abdominal discomfort that worsened to peritonitis and he was taken for laparoscopic drainage of massive hemoperitoneum with bile peritonitis. Postoperatively, the patient's abdominal pain abated and he tolerated oral dietary advancement.

DISCUSSION

Surgical management of blunt hepatic trauma continues to evolve in tandem with minimally invasive interventional techniques. Patients with high-grade lacerations are at higher risk for developing biliary peritonitis, hemobilia, persistent hemoperitoneum, and venous hemorrhage after angioembolization. Accordingly, the primary role of surgery has shifted in select patients from laparotomy to delayed laparoscopy to address the aforementioned complications.

CONCLUSION

While laparotomy remains crucial for hemodynamically unstable patients, angioembolization is the primary treatment option for stable patients with hemorrhage from liver trauma. The combination of angioembolization and delayed laparoscopy may be considered in stable patients with even the highest liver injury grades.

Blunt liver trauma: a descriptive analysis from a level I trauma center

Background

We aimed to review liver injury experience in a level 1 trauma center; namely clinical presentation, grading, management approach and clinical outcomes.

Methods

It is a retrospective analysis to include all blunt liver injury patients who were admitted at the Level 1 trauma center over a 3-year period. Data were compared and analyzed based on the liver injury grades and management approaches.

Results

Blunt liver injury accounted for 38% of the total blunt abdominal trauma cases with a mean age of 31 ± 13 years. Liver injury grade II (44.7%) was most common followed by grade I (28.8%), grade III (19.1%), grade IV (7.0%) and grade V (0.4%). Blood transfusion was more frequently required in patients with grade IV (p = 0.04). Out of 257 patients with blunt liver trauma, 198 were initially treated conservatively, that was successful in 192 (97%), whereas it failed in 6 (3%) patients due to delayed bleeding from hepatic hematoma, associated splenic rupture and small bowel injury which mandate surgical intervention. Fifty-nine patients (23%) underwent emergent surgery in terms of packing, resection debridement, left lobe hepatectomy and splenectomy. Hepatic complications included biloma, pseudoaneurysm and massive liver necrosis. Subanalysis of data using the World Society of Emergency Surgery (WSES) classification revealed 19 patients were categorized as a WSES grade IV who needed surgical intervention without having an initial computerized tomography scanning. The overall mortality was 7.8% which was comparable among the conservative and operative group.

Conclusions

In our center, low grade liver injury in young males prevails. NOM is successful even for high graded injuries. All conservatively treated patients with high-grade liver injuries should be closely monitored for signs of failure of the non-operative management. Introducing the new WSES classification makes clear how is important the hemodynamic status of the patients despite the lesion. However, further larger prospective and multicenter studies are needed to support our findings.

Surgical Management of Solid Organ Injuries

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Liver trauma: WSES position paper

The liver is the most injured organ in abdominal trauma. Road traffic crashes and antisocial, violent behavior account for the majority of liver injuries. The present position paper represents the position of the World Society of Emergency Surgery (WSES) about the management of liver injuries.

Non-operative management of blunt liver trauma in a level II trauma hospital in Saudi Arabia

Background:

To evaluate our experience with non-operative management of blunt liver trauma at a level II trauma hospital in the Kingdom of Saudi Arabia.

Materials and Methods:

We prospectively evaluated 56 patients treated for blunt liver trauma at our hospital over a 4-year period (April 2008 to April 2012). Patients who were hemodynamically stable [non-operative group I (NOP)] were treated conservatively in the intensive or intermediate care unit (ICU or IMCU). Patients who were hemodynamically unstable or needed laparotomy for other injuries were treated by urgent laparotomy [operative group II (OP)]. All NOP group patients had computed tomography (CT) of the abdomen with oral and intravenous contrast. Injuries grades were classified according to the American Association for the Surgery of Trauma (AAST). Follow-up CT of the abdomen was performed after 2 weeks in some cases.

Results:

A total of 56 patients were treated over a 4-year period. Twenty patients (35.7%) were treated by immediate surgery. NOP group of 36 patients (64.3%) were managed in the ICU by close monitoring. Surgically treated group had more patients with complex liver injury (90% versus 58.3%), required more units of blood (6.05 versus 1.5), but had a longer hospital stay (16.6 days versus 15.1 days). None of the patients from the non-operated group developed complications nor did they need operation. The only mortality (in two patients) was in the operated group.

Conclusion:

The NOP treatment is a safe and effective method in the management of hemodynamically stable patients with blunt liver trauma. The NOP treatment should be the treatment of choice in such patients whenever CT and ICU facilities are available.

Efficacy and safety of non-operative management of blunt liver trauma

BACKGROUND

The liver is the most frequently affected organ during blunt abdominal trauma. Blunt liver trauma management has changed in the last two decades with the introduction of the computed tomography (CT) scan and non-operative management of stable patients.

OBJECTIVE

To determine the incidence, efficacy, and failure rate of blunt liver trauma non-operative management as well as the risk factors associated with such treatment in a level 1 trauma center in Colombia.

METHODS

We conducted an observational descriptive study on patients with blunt liver trauma who were admitted to a level 1 trauma center in Colombia. The evaluated outcomes were indications of immediate surgical treatment and the success of non-operative management.

RESULTS

A total of 73 patients were studied. The most common mechanism of trauma continues to be motor vehicle crashes. In 14 patients (19.2%), immediate surgical intervention was necessary and we observed a Revised Trauma Score (RTS) above 7.8 and intra-abdominal injuries as risk factors. Three patients died (21.4%). Fifty-nine patients (80.8%) received non-operative management, which failed in seven patients (11.2%). Age, severity of liver injury, and intra-abdominal injuries were not risk factors in the failure of non-operative management. Mortality in the non-operative management group was 1.7%.

CONCLUSION

Non-operative management is the treatment of choice for polytraumatized patients with blunt liver trauma who are hemodynamically stable. Non-operative management is an effective and safe treatment strategy. However, patients with an RTS score under 7.8 and other intra-abdominal non-liver injuries are at increased risk for an immediate surgical intervention.

Hepatic arterial embolization in the management of blunt hepatic trauma: indications and complications

BACKGROUND

The objective was to clarify the role of hepatic arterial embolization (AE) in the management of blunt hepatic trauma.

METHODS

Retrospective observational study of 183 patients with blunt hepatic trauma admitted to a trauma referral center over a 9-year period. The charts of 29 patients (16%) who underwent hepatic angiography were reviewed for demographics, injury specific data, management strategy, angiographic indication, efficacy and complications of embolization, and outcome.

RESULTS

AE was performed in 23 (79%) of the patients requiring angiography. Thirteen patients managed conservatively underwent emergency embolization after preliminary computed tomography scan. Six had postoperative embolization after damage control laparotomy and four had delayed embolization. Arterial bleeding was controlled in all the cases. Sixteen patients (70%) had one or more liver-related complications; temporary biliary leak (n=11), intra-abdominal hypertension (n=14), inflammatory peritonitis (n=3), hepatic necrosis (n=3), gallbladder infarction (n=2), and compressive subcapsular hematoma (n=1). Unrecognized hepatic necrosis could have contributed to the late posttraumatic death of one patient.

CONCLUSION

AE is a key element in modern management of high-grade liver injuries. Two principal indications exist in the acute postinjury phase: primary hemostatic control in hemodynamically stable or stabilized patients with radiologic computed tomography evidence of active arterial bleeding and adjunctive hemostatic control in patients with uncontrolled suspected arterial bleeding despite emergency laparotomy. Successful management of injuries of grade III upward often entails a combined angiographic and surgical approach. Awareness of the ischemic complications due to angioembolization is important.

Contrast-enhanced ultrasound imaging of active bleeding associated with hepatic and splenic trauma

PURPOSE

The aim of this study was to evaluate contrast-enhanced ultrasound (CEUS) imaging of active bleeding from hepatic and splenic trauma.

MATERIALS AND METHODS

Three hundred and ninety-two patients with liver or/and spleen trauma (179 liver and 217 spleen injuries), who underwent CEUS examinations following contrast-enhanced computed tomography (CT), were enrolled in this retrospective study over a period of >4 years. CEUS detected contrast medium extravasation or pooling in 16% (63/396) of liver or spleen lesions in 61 patients, which was confirmed by contrast-enhanced CT. Special attention was paid to observing the presence, location, and characteristics of the extravasated or pooled contrast medium.

RESULTS

The CEUS detection rate for active bleeding was not different from that of contrast-enhanced CT (p=0.333). Information from surgery, minimally invasive treatment and conservative treatment was used as reference standard, and the sensitivities of the two techniques were not different (p=0.122). Of 63 lesions in 61 patients, CEUS showed that 74.6% (47/63) (21 liver lesions and 26 spleen lesions) presented contrast medium extravasation or pooling, both in the organ and out the capsule, in 14.3% (9/63) and only outside the capsule in 11.1% (7/63). CEUS imaging of active bleeding from hepatic and splenic trauma presented various characteristics, and the sizes and shapes of the active bleeding due to contrast medium extravasation or pooling were variable.

CONCLUSIONS

CEUS can show the active bleeding associated with hepatic and splenic trauma with various imaging characteristics, thus making it possible to diagnose active bleeding using CEUS.

Hepatic trauma management and outcome; Our experience

BACKGROUND

Injuries to the liver have been reported in 35-45% of patients with significant blunt abdominal trauma. Since the introduction of ultrasonography and computerized tomography in the evaluation of these patients, there has been an increase in number of hepatic injuries diagnosed that previously would not have been apparent.

AIMS AND OBJECTIVES

The purpose of this study was to determine the epidemiology and pattern of isolated liver injury, significant factors related to management and outcome.

MATERIAL AND METHOD

A retrospective study of 50 cases of isolated Hepatic trauma admitted and managed over span of last three years (June 2006-June 2009) at MGM Medical College, Navi Mumbai.

OBSERVATION

Out of 50 Patients of isolated liver injury, 36 (72%) were managed conservatively. 14(28%) Patients with refractory hypotension and hemoperitoneum were operated in emergency. The mortality of 3 (6%) cases was related to massive bleeding from liver parenchyma.

CONCLUSION

The line of management of isolated liver trauma is primarily guided by the haemodynamic status of the patient at the time of presentation in emergency department and findings on ultrasonography [FAST] and computerized tomography. There is significant association of line of management with volume of hemoperitoneum and number of blood transfusion.

Non-operative management of right side thoracoabdominal penetrating injuries--the value of testing chest tube effluent for bile

INTRODUCTION

While mandatory surgery for all thoracoabdominal penetrating injuries is advocated by some, the high rate of unnecessary operations challenges this approach. However, the consequences of intrathoracic bile remains poorly investigated. We sought to evaluate the outcome of patients who underwent non-operative management of right side thoracoabdominal (RST) penetrating trauma, and the levels of bilirubin obtained from those patients' chest tube effluent.

PATIENTS AND METHODS

We managed non-operatively all stable patients with a single RST penetrating injury. Chest tube effluent samples were obtained six times within (4-8 h; 12-16 h; 20-24 h; 28-32 h; 36-40 h; 48 h and 72 h) of admission for bilirubin measurement and blood for complete blood count, bilirubin, alanine (ALT) and aspartate aminotransferases (AST) assays. For comparison we studied patients with single left thoracic penetrating injury.

RESULTS

Forty-two patients with RST injuries were included. All had liver and lung injuries confirmed by CT scans. Only one patient failed non-operative management. Chest tube bilirubin peaked at 48 h post-trauma (mean 3.3+/-4.1 mg/dL) and was always higher than both serum bilirubin (p<0.05) and chest tube effluent from control group (27 patients with left side thoracic trauma). Serum ALT and AST were higher in RST injury patients (p<0.05). One RST injury patient died of line sepsis.

CONCLUSION

Non-operative management of RST penetrating trauma appears to be safe. Bile originating from the liver injury reaches the right thoracic cavity but does not reflect the severity of that injury. The highest concentration was found in the patient failing non-operative management. The presence of intrathoracic bile in selected patients who sustain RST penetrating trauma, with liver injury, does not preclude non-operative management. Our study suggests that monitoring chest tube effluent bilirubin may provide helpful information when managing a patient non-operatively.

Delayed celiotomy or laparoscopy as part of the nonoperative management of blunt hepatic trauma

BACKGROUND

Nonoperative management (NOM) is considered standard treatment for 80% of blunt hepatic trauma (BHT). NOM is associated with some events that may require delayed operation (DO), usually considered a criterion of failure of NOM.

METHODS

A retrospective case note review was performed on 257 consecutive patients with BHT, with a median age of 32.7 years, admitted from 1994 to 2005. We considered the 186 patients (72%) who had an initial indication of NOM, and focused on the 28 patients who were secondarily operated (DO), mainly on the 22 patients operated on for liver-related indications. Celioscopy was used in five cases.

RESULTS

The severity grade of these 22 patients was: zero grade I, seven grade II, ten grade III, four grade IV, one grade V. The timing of DO varied from day 0 to day 11. Ten patients were operated on for a peritoneal inflammatory syndrome. Death occurred in three patients at days 2, 10, and 125. One was attributed to underestimation of hepatic necrosis, another to a nondiagnosed peritoneal inflammatory syndrome; 27, 3% of the patients had liver-related complications.

CONCLUSIONS

Our data suggest that BHT treated by NOM must be frequently reevaluated and that DO is an actual part of the so-called nonoperative treatment. The use of laparoscopic washing has to be proposed as soon as day 3 or 5 in patients with large hemoperitoneum and any sign of inflammatory response (fever, leukocytosis, discomfort, tachycardia).

Contrast-enhanced sonographic guidance for local injection of a hemostatic agent for management of blunt hepatic hemorrhage: a canine study

OBJECTIVE

The purpose of this study was to determine whether injection of hemostatic agents directly into an injury site under the guidance of contrast-enhanced sonography can effectively control hemorrhage due to hepatic trauma.

MATERIALS AND METHODS

Fifteen mixed-breed dogs 2-3 years old and weighing 17-20 kg were anesthetized with intramuscular pentobarbital sodium (30 mg/kg). A special impacting device was used to induce hepatic trauma with a mean force of 5.3 +/- 0.3 kN. Twelve of the 15 dogs had hepatic injuries with a grade of 3-4 or 4. The 12 dogs were divided into treatment and control groups. In the treatment group, hemocoagulase atrox (1 Klobusitzky unit) and alpha-cyanoacrylate (1 mL) were administered by transcutaneous injection into the injury site and the bleeding site, respectively, under the guidance of contrast-enhanced sonography. The control group received injections of 0.9% normal saline solution.

RESULTS

After injection into the treatment group, no active bleeding was observed at the liver injury site. In the control group, evidence of active bleeding was present on contrast-enhanced sonograms. Laparotomy of the treatment group showed that hepatic injuries had been covered and adhered by clots and the glue membrane of the hemostatic agents and that free intraperitoneal blood volume was significantly less than in the control group (p < 0.001). Bleeding did not stop in the control group.

CONCLUSION

In dogs, transcutaneous local injection of hemostatic agents can effectively reduce blood loss due to severe liver trauma. Because it is simple, convenient, and effective, the technique may be an alternative for bedside and battlefield management of hepatic hemorrhage due to trauma.

[Current treatment of hepatic trauma]

The therapeutic and diagnostic approach of liver trauma injuries (by extension, of abdominal trauma) has evolved remarkably in the last decades. The current non-surgical treatment in the vast majority of liver injuries is supported by the accumulated experience and optimal results in the current series. It is considered that the non-surgical treatment of liver injuries has a current rate of success of 83-100%, with an associated morbidity of 5-42%. The haemodynamic stability of the patient will determine the applicability of the non-surgical treatment. Arteriography with angioembolisation constitutes a key technical tool in the context of liver trauma. Patients with haemodynamic instability will need an urgent operation and can benefit from abdominal packing techniques, damage control and post-operative arteriography. The present review attempts to contribute to the current, global and practical management in the care of liver trauma.

Multidisciplinary approach for the management of complex hepatic injuries AAST-OIS grades IV-V: a prospective study

BACKGROUND

Complex hepatic injuries grades IV-V are highly lethal. The objective of this study is to assess the multidisciplinary approach for their management and to evaluate if survival could be improved with this approach.

STUDY DESIGN

Prospective 54-month study of all patients sustaining hepatic injuries grades IV-V managed operatively at a Level I Trauma Center.

MAIN OUTCOME MEASURE

survival.

STATISTICAL ANALYSIS

univariate and stepwise logistic regression.

RESULTS

Seventy-five patients sustained penetrating (47/63%) and blunt (28/37%) injuries. Seven (9%) patients underwent emergency department thoracotomy with a mortality of 100%. Out of the 75 patients, 52 (69%) sustained grade IV, and 23 (31%) grade V. The estimated blood loss was 3,539+/-3,040 ml. The overall survival was 69%, adjusted survival excluding patients requiring emergency department thoracotomy was 76%. Survival stratified to injury grade: grade IV 42/52-81%, grade V 10/23-43%. Mortality grade IV versus V injuries (p < 0.002; RR 2.94; 95% CI 1.52-5.70). Risk factors for mortality: packed red blood cells transfused in operating room (p=0.024), estimated blood loss (p < 0.001), dysryhthmia (p < 0.0001), acidosis (p = 0.051), hypothermia (p = 0.04). The benefit of angiography and angioembolization indicated: 12% mortality (2/17) among those that received it versus a 36% mortality (21/58) among those that did not (p = 0.074; RR 0.32; 95% CI 0.08-1.25). Stepwise logistic regression identified as significant independent predictors of outcome: estimated blood loss (p= 0.0017; RR 1.24; 95% CI 1.08-1.41) and number of packed red blood cells transfused in the operating room (p = 0.0358; RR 1.16; 95% CI 1.01-1.34).

CONCLUSIONS

The multidisciplinary approach to the management of these severe grades of injuries appears to improve survival in these highly lethal injuries. A prospective multi-institutional study is needed to validate this approach.

Multislice computed tomography in blunt abdominal trauma

Blunt abdominal trauma is a frequent finding in patients with multiple trauma, and is associated with significant morbidity and mortality. Multislice computed tomography (MSCT), allowing for multiplanar reconstructions and three-dimensional images, has become the imaging modality of choice for these patients. MSCT is indicated in all haemodynamically stable patients with suspected blunt abdominal trauma. A `focussed CT' algorithm, as recommended by the Advanced Trauma Life Support (ATLS®) program, may be useful for patients with isolated abdominal trauma who are conscious and cooperative. For unconscious patients with or without multiple trauma `unfocussed' whole-body MSCT algorithms should be used, as these lead to earlier as well as more accurate diagnosis. MSCT allows for rapid diagnosis of abdominal and retroperitoneal injuries and for grading of solid organ injuries. Active haemorrhage may be detected with accuracy similar to angiography. Even bowel, diaphragmatic and bladder injuries, where CT used to miss a significant number of injuries, can be diagnosed with high accuracy by the new generation of MSCT scanners.

Prevention of Bile Peritonitis by Laparoscopic Evacuation and Lavage after Nonoperative Treatment of Liver Injuries

One of the major lessons learned in the World War II experience with liver injuries was that bile peritonitis was a major factor in morbidity and mortality; the nearly uniform drainage of liver injuries in the subsequent operative era prevented this problem. In the era of nonoperative management, patients who do not require operative treatment for hemodynamic instability may develop large bile and/or blood collections that are often ignored or inadequately drained by percutaneous methods. These inadequately treated bile collections may cause systemic inflammatory response syndrome and/or respiratory distress. We present an experience with laparoscopic evacuation of major bile/blood collections that may prevent the inflammatory sequelae of bile peritonitis. Patients usually underwent operation between 3 and 5 days postinjury (range, 2–18) if CT demonstrated large fluid collections throughout the abdomen/pelvis not amenable to percutaneous drainage. Most patients had signs of systemic inflammatory response syndrome, respiratory compromise, or elevated bilirubin. The bile and retained hematoma was evacuated from around the liver and closed-suction drainage was placed. Twenty-eight patients underwent laparoscopic evacuation/lavage of bile collections (about 4% of total blunt liver injuries). The majority (75%) had Grade IV or V injury. The amount of evacuated fluid ranged from 300 to 3800 mL. Other adjunctive procedures (endoscopic retrograde pancreaticocholangiography, angiography, and laparotomy) were occasionally required. There were no complications related to the procedure. Most patients had a dramatic decline in tachycardia, temperature, white blood cell count, serum bilirubin, and pain. Respiratory failure also resolved in most patients. Large bile and/or blood accumulations are present in a subset of patients with severe liver injuries treated nonoperatively. Delayed laparoscopic evacuation of these collections prevents bile peritonitis and decreases inflammatory response and avoiding early operation, which has been implicated in increased death from hemorrhage.

Advances and Changes in the Management of Liver Injuries

Because of advances in noninvasive imaging techniques and a better understanding of the natural history of hepatic injuries; currently, most patients with complex liver injuries are treated in a nonoperative manner. Additionally, the availability of less invasive procedures has expanded dramatically the treatment options for these patients, optimizing the outcomes of initial nonoperative management. Even though nonoperative management has become the standard of care in patients with complex liver injuries in most trauma centers in the United States, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Transcatheter arterial embolization for hemorrhage caused by injury of the hepatic artery

BACKGROUND

The aims of the study were to compare (i) the effects of transcatheter arterial embolization on initial hemostasis and the control of rebleeding in the treatment of hemorrhage due to hepatic artery injury; and (ii) the outcomes of embolization by different locations.

METHODS

Subjects were 32 patients with suspected hepatic artery injury who were transferred to Chi-Mei Foundation Medical Center for hepatic angiography and embolization. The causes of arterial injury included liver trauma (n = 15) and iatrogenic injury (n = 17). The sites of embolization were classified into four groups: group 1 (n = 8) was classified as 'combined outlet, target and inlet control' with embolization of the vascular lesion (target) and hepatic artery distal (outlet) and proximal (inlet) to the vascular lesion simultaneously; group 2 (n = 11) as 'combined target and inlet control'; group 3 (n = 8) as 'combined outlet and inlet control'; group 4 (n = 5) as 'inlet control' only.

RESULTS

Successful initial hemostasis was achieved in 30 of the 32 patients (93.8%), with two failures, both of which were caused by liver injury and occurred in subjects in group 4. Rebleeding was seen in three patients who had successful initial hemostasis: two of them in group 4 (66.7%) and one in group 1 (12.5%). All rebleedings were successfully managed by repeat embolization. Abscess formation was found in two group 1 patients, and both were successfully managed by percutaneous drainage.

CONCLUSIONS

Transcatheter arterial embolization is an effective method for hemostasis in hepatic artery hemorrhage for both patients with liver trauma and patients with iatrogenic injuries to the hepatic artery. Based on this experience, embolization of the vascular lesion and/or the arterial lumen distal to the vascular lesion combined with inlet control is recommended for preventing recurrent hemorrhage, but studies with larger sample sizes will be required to validate this conclusion.

Radio-Frequency Tissue Ablation in Liver Trauma: An Experimental Study

The liver is the most frequently injured intra-abdominal organ. Radio-frequency tissue ablation (RFA) with cooled tip electrodes is here experimentally used for the treatment of liver trauma. A grade III and a grade III to IV trauma each were produced in the livers of 10 domestic pigs. RFA was applied around the sites of injury until hemostasis was achieved. The animals were sacrificed at 0, 3, 7, 14, and 21 days and examined. The livers were subjected to histologic and radiologic examination. Two similar traumas were created in the livers of two more animals and were left surgically untreated as a control group. The two untreated animals died immediately postoperatively, proving the severity of the injuries. Hemostasis was achieved in all treated animals. Mortality and morbidity were zero. No blood, pus, bile, or other fluid was found in the abdomen at sacrifice. A three-zone pattern of lesion was recognized around the electrode placement at histology. RFA is an efficient and safe hemostatic method for grade HI and grade III to IV hepatic trauma. Further studies are required for its use in humans.

Minimally invasive surgery in trauma: technology looking for an application

BACKGROUND

Minimally invasive surgery has achieved pre-eminence for certain operations in general surgery over the last two decades, as the reduction in surgical insult has produced faster recovery with enhanced patient satisfaction and favourable health economics. Minimally invasive techniques have been less enthusiastically adopted by the trauma surgical community, despite some evidence of efficacy for nearly 40 years.

METHODS

The literature on minimally invasive techniques in trauma was reviewed.

RESULTS AND CONCLUSIONS

To date, minimally invasive surgery has played only a small role in trauma surgery. As clearer indications emerge and technology improves, surgeons should be encouraged to incorporate laparoscopy and video-assisted thoracoscopy (VATS) into their protocols and gain familiarity and expertise with their use.

Blunt injury to solid abdominal organs

Injuries to the solid abdominal viscera (spleen, liver, kidney, pancreas) are common in children sustaining trauma by blunt mechanisms. Success with nonoperative management of these injuries has led to recent extensions of this approach to the management of higher-grade more complicated injuries typically treated operatively. This review will discuss the current status of evaluation, management and outcome of children sustaining blunt injury to solid abdominal organs.

A 10-year experience of complex liver trauma

BACKGROUND

Liver trauma is a relatively rare surgical emergency but mortality and morbidity rates remain significant. It is likely that surgeons outside specialist centres will have limited experience in its management; therefore best practice should be identified and a specialist approach developed.

METHODS

Data collected from 52 consecutive patients over a 10-year interval were examined to identify best practice in the management of these injuries.

RESULTS

The majority of injuries occurred as a result of road traffic accidents; 39 (75 per cent) of the 52 patients were stable at presentation to the referring hospital. In 36 patients (69 per cent) the liver injury was a component of multiple trauma. Ultrasonography, computed tomography or no radiological investigation was used in the referring hospital in 18 (35 per cent), 25 (48 per cent) and nine (17 per cent) patients respectively. Operative management was undertaken in the referring hospital in 26 patients (50 per cent). The overall mortality rate was 23 per cent (12 of 52 patients), and increased with increasing grade of severity. Eight of 26 patients managed surgically at the referring hospital died, compared with four of the 26 patients managed without operation (P not significant). The median time from arrival at the referring hospital to operation was 4 h for haemodynamically stable patients and 3 h for those who were haemodynamically unstable.

CONCLUSION

Most patients with liver trauma can be managed conservatively. Operative management carried out in non-specialized units is associated with high mortality and morbidity rates. Abdominal injuries should raise a high index of suspicion of liver injury, and the data suggest that computed tomography of the abdomen should precede laparotomy (even in some haemodynamically unstable patients) to facilitate discussion with a specialist unit at the earliest opportunity.

Examination of the role of abdominal computed tomography in the evaluation of victims of trauma with increased aspartate aminotransferase in the era of focused abdominal sonography for trauma

BACKGROUND

Current evaluation of patients with negative findings on a focused abdominal sonography for trauma scan and an isolated increase of admission hepatic enzymes includes abdominal computed tomography (CT). Many of these patients do not have clinically important hepatic injuries. The purpose of this study was to establish the admission aspartate aminotransferase (AST) level below which patients do not need an abdominal CT for injury evaluation and treatment.

METHODS

Patients who were hemodynamically stable, had a focused abdominal sonography for trauma scan with negative findings, and an AST level greater than 200 IU/L were identified over a 1-year period. Medical records were reviewed for demographics, injuries sustained, mechanism, evaluation, interventions, and complications.

RESULTS

A total of 67 patients, mostly with blunt trauma, were identified; 42 (63%) had an AST level < 360 IU/L, and 25 (37%) had an AST level > 360 IU/L. Patients with an AST level > 360 IU/L had a 88% chance of having any hepatic injury and a 44% chance of having an injury of grade III or greater (P =.0001). Patients with an AST level of < 360 IU/L only had a 14% chance of having a liver injury and no chance of having an injury of grade III or greater (P =.036).

CONCLUSIONS

Clinically important hepatic injuries are not missed if an abdominal CT is only performed for patients with a focused abdominal sonography for trauma scan with negative findings and an AST level of > 360 IU/L. Eliminating unnecessary CT allows for more cost-effective use of resources.

Free hemoglobin enhances tumor necrosis factor-alpha production in isolated human monocytes

BACKGROUND

A systemic inflammatory response (SIR) is seen in approximately 75% of patients with complex blunt liver injuries treated nonoperatively. Many feel this response is caused by blood, bile, and necrotic tissue accumulation in the peritoneal cavity. Our current treatment for these patients is a delayed laparoscopic washout of the peritoneal cavity, resulting in a dramatic resolution of the SIR. Spectrophotometric analysis of the intraperitoneal fluid has confirmed the presence of high concentrations of free hemoglobin (Hb). We hypothesize that free Hb enhances the local peritoneal response by increasing tumor necrosis factor-alpha (TNF-alpha) production by monocytes, contributing to the local inflammatory response and SIR.

METHODS

Monocytes from five healthy volunteers were isolated and cultured in RPMI-1640 for 24 hours. Treatment groups included saline controls, lipopolysaccharide ([LPS], 10 ng/mL, from Escherichia coli), human Hb (25 microg/mL), and Hb + LPS. Supernatants were analyzed by enzyme-linked immunosorbent assay. Student's t test with Mann-Whitney posttest was used for statistical analysis with p < or = 0.05 considered significant.

RESULTS

Free Hb significantly increased TNF-alpha production 915 +/- 223 pg/mL versus saline (p = 0.02). LPS and Hb + LPS further increased TNF-alpha production (2294 pg/mL and 2501 pg/mL, respectively, p < 0.001) compared with saline controls.

CONCLUSION

These data confirm that free Hb is a proinflammatory mediator resulting in the production of significant amounts of TNF-alpha. These in vitro findings support our clinical data in which timely removal of intraperitoneal free hemoglobin helps prevent its deleterious local and systemic inflammatory effects in patients with complex liver injuries managed nonoperatively.