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Malhotra AK. Contribution by Dr Timothy C Fabian: liver trauma. Trauma Surg Acute Care Open 2023; 8:e001116. [PMID: 37082305 PMCID: PMC10111919 DOI: 10.1136/tsaco-2023-001116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
The liver is the most commonly injured organ within the abdomen. Dr Fabian and his associates have made remarkable contributions to our understanding and management of these injuries. The current review summarizes the contributions.
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Affiliation(s)
- Ajai K Malhotra
- Department of Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
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Ishida K, Katayama Y, Kitamura T, Hirose T, Ojima M, Nakao S, Tachino J, Umemura Y, Kiguchi T, Matsuyama T, Noda T, Kiyohara K, Shimazu T, Ohnishi M. Relationship between in‐hospital mortality and abdominal angiography among patients with blunt liver injuries: a propensity score‐matching from a nationwide trauma registry of Japan. Acute Med Surg 2022; 9:e725. [PMID: 35059219 PMCID: PMC8757632 DOI: 10.1002/ams2.725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 11/17/2021] [Accepted: 12/14/2021] [Indexed: 11/07/2022] Open
Abstract
Aim To assess relationships between abdominal angiography and outcomes in adults with blunt liver injuries. Methods A retrospective observational study carried out from January 2004 to December 2018. Adult blunt‐trauma patients with AAST grade Ⅲ–Ⅴ were analyzed with in‐hospital mortality as the primary outcome using propensity‐score‐(PS) matching to seek associations with abdominal angiography findings. Results A total of 1,821 patients were included, of which 854 had available abdominal angiography data (AA+) and 967 did not (AA−). From these, 562 patients were selected from each group by propensity score matching. In‐hospital mortality was found to be lower in the AA+ than in the AA− group (15.1% [87/562] versus 25.4% [143/562]; odds ratio 0.544, 95% confidence interval 0.398–0.739). Conclusion Abdominal angiography is shown to be of benefit for adult patients with blunt liver injury in terms of their lower in‐hospital mortality.
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Affiliation(s)
- Kenichiro Ishida
- Department of Acute Medicine and Critical Care Medical Center Osaka National Hospital, National Hospital Organization Osaka Japan
| | - Yusuke Katayama
- Department of Traumatology and Critical Care Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine Osaka University Graduate School of Medicine Suita Japan
| | - Tomoya Hirose
- Department of Traumatology and Critical Care Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Masahiro Ojima
- Department of Acute Medicine and Critical Care Medical Center Osaka National Hospital, National Hospital Organization Osaka Japan
| | - Shunichiro Nakao
- Department of Traumatology and Critical Care Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Jotaro Tachino
- Department of Traumatology and Critical Care Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka Japan
| | - Takeyuki Kiguchi
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine Kyoto Prefectural University of Medicine Kyoto Japan
| | - Tomohiro Noda
- Department of Traumatology and Critical Care Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Kosuke Kiyohara
- Department of Food Science, Faculty of Home Economics Otsuma Women's University Tokyo Japan
| | - Takeshi Shimazu
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka Japan
| | - Mitsuo Ohnishi
- Department of Acute Medicine and Critical Care Medical Center Osaka National Hospital, National Hospital Organization Osaka Japan
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Retrospective assessment of developing liver injuries in children brought to the emergency room due to the blunt abdominal trauma over the past 10 years; a single -center experience. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.896175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Hirooka R, Ito K, Takemura N, Mihara F, Kokudo N. Case report: direct suture repair of inferior vena cava to rescue a stab patient with hepatic and caval injury through left hepatectomy and total vascular exclusion. Surg Case Rep 2021; 7:55. [PMID: 33620557 PMCID: PMC7902743 DOI: 10.1186/s40792-021-01139-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The mortality of abdominal vena caval injuries is as high as 50-80%. Yet, there were few reports on how to repair injured inferior vena cava (IVC). This report presents a method of vena caval repair in a case of penetrating retrohepatic IVC injury, requiring hepatic resection and total vascular exclusion (TVE). CASE PRESENTATION The patient was a 20-year-old man with a stab wound in the epigastrium. An emergency laparotomy was performed in the emergency room, and a stab incision on the left liver was detected. As the Pringle's maneuver did not reduce bleeding, hepatic vein injury was suspected, and left hemihepatectomy was performed to confirm the bleeding point. After the hepatectomy, laceration was still evident deeper into the resection, and IVC injury was suspected. The bleeding was temporarily controlled by tentative hepatorrhaphy and gauze packing, and the initial damage control surgery was terminated. Definitive surgery was performed on the third postoperative day. The lacerated point was observed under TVE, and the laceration penetrated the retrohepatic IVC through its posterior wall. The slit of the posterior wall was sutured first, followed by suturing of the anterior wall of the IVC. Finally, the lacerated liver was closed with hepatorrhaphy. TVE was removed, and the massive bleeding was successfully controlled. CONCLUSION In severe liver injuries involving the retrohepatic IVC, hepatic resection and TVE may be useful for ensuring an optimized surgical field for repairing the injured IVC.
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Affiliation(s)
- Reina Hirooka
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
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Wu Q, Sun Q, Mei B. Hemobilia due to Hepatic artery pseudoaneurysm secondary to collateral circulation formation after liver trauma: a case report. BMC Surg 2021; 21:71. [PMID: 33530973 PMCID: PMC7856724 DOI: 10.1186/s12893-021-01078-6] [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] [Received: 11/27/2020] [Accepted: 01/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Hemobilia due to rupture of hepatic artery pseudoaneurysm and recurrent hemorrhage caused by hepatic artery collateral circulation are both rare complications after liver trauma. There have been a number of separate reports of both complications, but no cases have been reported in which the two events occurred in the same patient. Here we report a recurrent hemorrhage in the bile duct due to hepatic artery pseudoaneurysm secondary to collateral circulation formation after hepatic artery ligation in a patient with liver trauma. Case presentation A 52-year-old male patient was admitted to our hospital for liver trauma (Grade IV according to the American Association for the Surgery of Trauma (AAST) grading system) with active bleeding after a traffic accident. Hepatic artery ligation was performed for hemostasis. Three months after the surgery, the patient was readmitted for melena and subsequent hematemesis. Selective angiography examination revealed the formation of collateral circulation between the superior mesenteric artery and right hepatic artery. Moreover, a ruptured hepatic artery pseudoaneurysm was observed and transcatheter arterial embolization (TAE) was performed for hemostasis at the same time. After the treatment, the patient recovered very well and had an uneventful prognosis until the last follow-up. Conclusion For patients with hepatic trauma, the selection of the site of hepatic artery ligation and the diagnosis and treatment methods of postoperative biliary hemorrhage are crucial for the prognosis of the disease.
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Affiliation(s)
- Qiqi Wu
- Department of Hepatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Qianling Sun
- Department of Hepatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Bin Mei
- Department of Hepatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Brooks A, Reilly JJ, Hope C, Navarro A, Naess PA, Gaarder C. Evolution of non-operative management of liver trauma. Trauma Surg Acute Care Open 2020; 5:e000551. [PMID: 33178894 PMCID: PMC7640583 DOI: 10.1136/tsaco-2020-000551] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/19/2020] [Accepted: 08/31/2020] [Indexed: 11/03/2022] Open
Abstract
The management of complex liver injury has changed during the last 30 years. Operative management has evolved into a non-operative management (NOM) approach, with surgery reserved for those who present in extremis or become hemodynamically unstable despite resuscitation. This NOM approach has been associated with improved survival rates in severe liver injury and has been the mainstay of treatment for the last 20 years. Patients that fail NOM and require emergency surgery are associated with increased morbidity and mortality. Better patient selection may have an impact not only on the rate of failure of NOM, but the mortality rate associated with it. The aim of this article is to review the evidence that helped shape the evolution of liver injury management during the last 30 years.
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Affiliation(s)
- Adam Brooks
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - John-Joe Reilly
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Carla Hope
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Alex Navarro
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Stuckey ME, Abdul Ghani MO, Greeno A, Lovvorn HN, Danko ME. Non-accidental trauma causing inferior vena cava and liver injuries. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2020. [DOI: 10.1016/j.epsc.2020.101649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Adjunctive use of hepatic angioembolization following hemorrhage control laparotomy. J Trauma Acute Care Surg 2020; 88:636-643. [DOI: 10.1097/ta.0000000000002591] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Samuels JM, Urban S, Peltz E, Schroeppel T, Heise H, Dorlac WC, Britton LJ, Burlew CC, Robinson C, Swope ML, McIntyre RC. A modern, multicenter evaluation of hepatic angioembolization - Complications and readmissions persist. Am J Surg 2019; 219:117-122. [PMID: 31272677 DOI: 10.1016/j.amjsurg.2019.06.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/14/2019] [Accepted: 06/22/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Indications for angioembolization (AE) following liver injury are not clearly defined. This study evaluated the outcomes and complications of hepatic AE. We hypothesize hepatic angioembolization is a useful adjunct to non-operative management of liver injury but with significant morbidity. METHODS Subjects were identified utilizing trauma registries from centers in a regional trauma network from 2010 to 2017 with an Abbreviated Injury Scale (AIS) coded hepatic injury and an ICD9/10 for hepatic angiography (HA). RESULTS 1319 patients with liver injuries were identified, with 30 (2.3%) patients undergoing HA: median ISS was 26, and median liver AIS was 4. Twenty-three subjects required AE. 81% had extravasation on CT from a liver injury. 63% underwent HA as initial intervention. 43% of AE subjects had liver-related complications with 35% 30-day readmission but with zero 30-day mortality. CONCLUSIONS While there were zero reported deaths, a high rate of morbidity and readmission was found. This may be due to the angioembolization or the liver injury itself.
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Affiliation(s)
- Jason M Samuels
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, 12636 East 17th Ave, Room 5401, Aurora, CO, 80045, USA.
| | - Shane Urban
- Trauma Services, University of Colorado Hospital, Mail Stop-F756, 12401 E 17th Ave Aurora, CO, 80045, USA.
| | - Erik Peltz
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, 12636 East 17th Ave, Room 5401, Aurora, CO, 80045, USA.
| | - Thomas Schroeppel
- Department of Surgery, UC Health Memorial Hospital, 1400 E. Boulder Street, Suite 600, Colorado Springs, CO, 80909, USA.
| | - Holly Heise
- Department of Surgery, UC Health Memorial Hospital, 1400 E. Boulder Street, Suite 600, Colorado Springs, CO, 80909, USA.
| | - Warren C Dorlac
- Department of Surgery, UC Health Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Suite 2200 Loveland, CO, 80538, USA.
| | - Linda J Britton
- Department of Surgery, UC Health Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Suite 2200 Loveland, CO, 80538, USA.
| | - Clay Cothren Burlew
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, 12636 East 17th Ave, Room 5401, Aurora, CO, 80045, USA; Department of Surgery, Denver Health Medical Center, 700 Delaware St., Davis Pavilion, Pavilion D & E Denver, CO, 80204, USA.
| | - Caitlin Robinson
- Department of Surgery, Denver Health Medical Center, 700 Delaware St., Davis Pavilion, Pavilion D & E Denver, CO, 80204, USA.
| | - Megan L Swope
- Department of Surgery, Denver Health Medical Center, 700 Delaware St., Davis Pavilion, Pavilion D & E Denver, CO, 80204, USA.
| | - Robert C McIntyre
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, 12636 East 17th Ave, Room 5401, Aurora, CO, 80045, USA.
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Azzam AZ, Gazal AH, Kassem MI, Souror MA. The role of non-operative management (NOM) in blunt hepatic trauma. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Ayman Zaki Azzam
- General Surgery Department, Faculty of Medicine , Alexandria, Egypt
| | | | | | - Magdy A. Souror
- General Surgery Department, Faculty of Medicine , Alexandria, Egypt
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Chong CN, Cheung YS, Lee KF, Rainer TH, Lai BSP. Traumatic Liver Injury in Hong Kong: The Management Strategy and Outcome. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790901600403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction Management of liver injury is challenging and evolving. The aim of this article is to review the outcome of traumatic liver injury in Chinese people in Hong Kong. Materials & methods Records of 40 patients with hepatic injury who received treatment at the Prince of Wales Hospital between December 2000 and May 2005 were reviewed. Demographic data, severity of liver injury, Injury Severity Score (ISS), haemodynamic status and Glasgow Coma Scale (GCS) score on admission, investigations made, concomitant injuries, management scheme, and outcome of patients were analysed. Results There were 23 male and 17 female patients with a mean age of 31.3 (SD=15.4) years. Road traffic accident was the most common injury mechanism (65%). Half of the patients were treated by non-operative management (NOM). None of them required surgery during subsequent management. Patients in the operative management (OM) group had a significantly higher ISS (p=0.026), but there was no significant difference in the mortality rate between the OM and NOM groups. Patients with stable haemodynamic status and who were treated non-operatively had a significantly shorter hospital stay (p=0.006). High grade liver injury (OR=8.0, 95% CI=1.2 to 53.8, p=0.03) and ISS greater than 25 (OR=21.6, 95% CI=2.0 to 225.3, p=0.01) were independent risk factors for mortality on multivariate analysis. Conclusions Non-operative management of liver injury can be safely accomplished in haemodynamically stable patients, with the possible benefit of a shorter hospital stay.
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Affiliation(s)
| | | | | | - TH Rainer
- Prince of Wales Hospital, Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
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Johnsen NV, Betzold RD, Guillamondegui OD, Dennis BM, Stassen NA, Bhullar I, Ibrahim JA. Surgical Management of Solid Organ Injuries. Surg Clin North Am 2017; 97:1077-1105. [PMID: 28958359 DOI: 10.1016/j.suc.2017.06.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Niels V Johnsen
- Urological Surgery, Department of Urological Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232, USA
| | - Richard D Betzold
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Oscar D Guillamondegui
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA
| | - Bradley M Dennis
- Division of Trauma, Surgical Critical Care, Emergency General Surgery, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Avenue South, 404 Medical Arts Building, Nashville, TN 37212, USA.
| | - Nicole A Stassen
- Surgical Critical Care Fellowship and Surgical Sub-Internship, University of Rochester, Kessler Family Burn Trauma Intensive Care Unit, 601 Elmwood Avenue, Box Surg, Rochester, NY 14642, USA
| | - Indermeet Bhullar
- Orlando Health Physicians Surgical Group, Orlando Regional Medical Center, 86 West Underwood, Suite 201, Orlando, FL 32806, USA
| | - Joseph A Ibrahim
- Orlando Health Physicians Surgical Group, Orlando Regional Medical Center, 86 West Underwood, Suite 201, Orlando, FL 32806, USA
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Kaptanoglu L, Kurt N, Sikar HE. Current approach to liver traumas. Int J Surg 2017; 39:255-259. [PMID: 28193544 DOI: 10.1016/j.ijsu.2017.02.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/06/2017] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Liver injuries remain major obstacle for successful treatment, due to size and location of the liver. Requirement for surgery should be determined by clinical factors, most notably hemodynamical state. In this present study we tried to declare our approach to liver traumas. We also tried to emphasize the importance of conservative treatment, since surgeries for liver traumas carry high mortality rates. PRESENTATION OF CASE Patients admitted to the Department of Emergency Surgery at Kartal Research and Education Hospital, due to liver trauma were retrospectively analyzed between 2003 and 2013. Patient demographics, hepatic panel, APTT (activated partial thromboplastin time), PT (prothrombin time), INR (international normalized ratio), fibrinogen, biochemistry panel were recorded. Hemodynamic instability was the most prominent factor for surgery decision, in the lead of current Advanced Trauma Life Support (ATLS) protocols. Operation records and imaging modalities revealed liver injuries according to the Organ Injury Scale of the American Association for the Surgery of Trauma. 300 patients admitted to emergency department were included in our study (187 males and 113 females). Mean age was 47 years (range, 12-87). The overall mortality rate was 13% (40 out of 300). Major factor responsible for mortality rates and outcome was stability of cases on admission. 188 (% 63) patients were counted as stable, whereas 112 (% 37) cases were found unstable (blood pressure ≤ 90, after massive resuscitation). 192 patients were observed conservatively, whereas 108 cases received abdominal surgery. High levels of AST, ALT, LDH, INR, creatinine and low levels of fibrinogen and low platelet counts on admission were found to be associated with mortality and these cases also had Grade 4 and 5 injuries. Hemodynamic instability on admission and the type and grade of injury played major role in mortality rates). Packing was performed in 35 patients, with Grade 4 and 5 injuries. Mortality rate was %13 (40 out of 300). CONCLUSION A multidisciplinary approach to the management of hepatic injuries has evolved over the last few decades, but the basic principles of trauma continue to be observed. Diagnostic and therapeutic endeavors are chosen based mainly on the stability of the patient. Stable patients with reliable examinations and available resources can be managed nonoperatively. Unstable patients require surgery. Our current approach to liver traumas is non operative technique, if possible.
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Affiliation(s)
| | - Necmi Kurt
- Kartal Research and Education Hospital, Turkey
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15
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Abstract
Management of blunt or penetrating injury to the liver remains a significant challenge to trauma surgeons. Liver injury remains common in both blunt and penetrating trauma of the abdomen. Unstable patients require immediate laparotomy. Selective patients can be managed without surgery and with careful monitoring. There has been a recent resurgence in the role of temporary packing in the management of liver trauma. Other commonly used techniques are resectional debribement and suture ligation of bleeding vessels. Complications include haemorrhage, bile leak and sepsis. Mortality is mainly due to damage to major hepatic blood vessels or other associated non-hepatic injuries. With improved understanding of the major causes of death from hepatic injury, improved resuscitation and intensive care, mortality has fallen below 10%.
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Affiliation(s)
- I Ahmed
- Department of HPB Surgery, Queens Medical Centre, Nottingham University Hospitals, Nottingham, NG7 2UH, United Kingdom,
| | - IJ Beckingham
- Department of HPB Surgery, Queens Medical Centre, Nottingham University Hospitals, Nottingham, NG7 2UH, United Kingdom
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Abstract
Liver is one of the organs with the highest injury rate, and in recent decades, the guidelines for the treatment of liver trauma have changed considerably. Now, there is a growing consensus that the most important step is diagnosis and depending upon the degree of severity, non-operative therapy is the main treatment method for hepatic trauma if conditions permit. For serious hepatic trauma patients such as those with hemodynamic instability, they should be operated upon as soon as possible. Regardless of the surgical options, doctors should control damage to patients and try to prevent complications. New therapies such as hepatic artery embolization and liver transplantation have been more and more used for the treatment of serious hepatic damage in clinics.
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Williamson JML, Rees JRE, Streets CG, Strickland AD, Finch-Jones MD. Management of liver trauma. Br J Hosp Med (Lond) 2016; 74:432-8. [PMID: 23958980 DOI: 10.12968/hmed.2013.74.8.432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J M L Williamson
- General Surgical Speciality Training Registrar in the Department of Hepato-pancreato-biliary Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol
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Long-term follow-up after non-operative management of biloma due to blunt liver injury. World J Surg 2015; 39:179-83. [PMID: 25205342 DOI: 10.1007/s00268-014-2780-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Some case series have reported that hepatectomy was used to treat major bile leakage and biloma. However, it is unknown whether non-operative management (NOM) can be used to treat these complications. Our hospital uses NOM primarily for blunt liver injuries. This study describes the incidence and treatment of newly developed biloma in hemodynamically stable patients with blunt liver trauma and investigates NOM as a treatment option. METHODS A retrospective chart review was conducted from January 2006 to May 2012 at a tertiary care hospital in Japan. The primary outcome measures were the incidence of biloma and the number of patients who required operative management. Biloma was defined as a cystic lesion with low density near the site of liver injury on contrast-enhanced abdominal computed tomography. RESULTS Chart review identified 98 patients (63 males and 35 females). Thirty-five of 98 patients (35.7 % [95 % CI, 26.2-45.2]) developed biloma. Infected biloma in three, of whom one required percutaneous drainage. Hepatectomy was not performed. CONCLUSION Our data suggest that biloma after NOM of blunt liver injury is common (36 %), but infected biloma is rare. All patients with bilomas were treated using NOM. Most bilomas are self-limited, and NOM is feasible.
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Latifi R, Khalaf H. Selective vascular isolation of the liver as part of initial damage control for grade 5 liver injuries: Shouldn't we use it more frequently? Int J Surg Case Rep 2014; 6C:292-5. [PMID: 25569195 PMCID: PMC4334949 DOI: 10.1016/j.ijscr.2014.12.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 12/11/2014] [Accepted: 12/13/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Severe liver trauma (grade 4 and 5) carries mortality greater than 40%. It represents a major surgical challenge in patients with hemodynamic instability who require an immediate exploratory laparotomy. Perihepatic packing and damage control can sometimes work, but for severe liver injuries, adjunct maneuvers might be needed (such as early embolization or hepatic artery ligation). During a patient's first operation for severe liver trauma, anatomic resection is rarely tolerated. MATERIALS AND METHODS We managed a 31 year-old male with a blunt grade 5 right-lobe liver injury in severe hypovolemic shock. RESULTS As part of the initial damage control operation, concurrently with intermittent Pringle maneuver, he underwent intra- and perihepatic packing; selective isolation and ligation of the right portal vein, right hepatic artery, and right hepatic vein; and repair of the retrohepatic inferior vena cava. Then, 36h later, the patient underwent a right hepatectomy. CONCLUSION For patients with severe liver injuries, selective vascular isolation and ligation may be considered as part of damage control (in addition to intermittent Pringle maneuver) and might enable anatomic resection at a later stage.
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Affiliation(s)
- Rifat Latifi
- Department of Surgery, University of Arizona, Tucson, AZ, USA; Trauma Section, Hamad Medical Corporation, Doha, Qatar.
| | - Hatem Khalaf
- Hamad Medical Corporation, Transplant Section, Doha, Qatar
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Wilson SG, White AD, Young AL, Davies MH, Pollard SG. The management of the surgical complications of HELLP syndrome. Ann R Coll Surg Engl 2014; 96:512-6. [PMID: 25245729 DOI: 10.1308/003588414x13946184901362] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Complications from HELLP (Haemolysis, Elevated Liver enzymes and Low Platelet) syndrome may present as an emergency to any surgeon. We review the ten-year experience of a tertiary hepatobiliary centre managing HELLP patients. Three selected cases are described to highlight our management strategy and a systematic review of the recent literature is presented. METHODS All patients with HELLP syndrome were identified from a prospectively maintained database and their details collated. Subsequently, a detailed search of PubMed was carried out to identify all case series of HELLP syndrome in the literature in the English language since 1999. RESULTS On review of 1,002 cases, 10 patients were identified with surgical complications of HELLP syndrome. Seven of these patients had a significant liver injury. Only three of these required surgical intervention for liver injury although four other patients required surgical intervention for other complications. There was no maternal mortality in this series. Review of the literature identified 49 cases in 31 publications. The management approaches of these patients were compared with ours. CONCLUSIONS We have presented a large series of patients with surgical complications resulting from HELLP syndrome managed without maternal mortality. This review has confirmed that haemodynamically stable patients with HELLP syndrome associated hepatic rupture can be conservatively treated successfully. However, in unstable patients, perihepatic packing and transfer to a specialist liver unit is recommended.
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Abstract
BACKGROUND Bile leaks occur in 4% to 23% of patients after major liver injuries. The role of conservative management versus internal biliary drainage has not been clearly defined. The safety and efficacy of nonoperative management of bile leaks were studied. METHODS Four hundred twelve patients with liver injuries were assessed in a prospective study between 2008 and 2013. All patients with clinically significant injuries to the intrahepatic biliary tract were evaluated. Bile leaks were classified as minor or major (>400 mL/d or persistent drainage >14 days). Minor leaks were managed conservatively, and major leaks underwent endoscopic retrograde cholangiogram and endoscopic biliary stenting. RESULTS Fifty-one patients (12%) developed a bile leak after liver trauma. Eleven patients (22%) with an extrahepatic duct injury underwent open surgery. Forty patients (78%) had an intrahepatic bile leak. Twenty-six patients (65%) with minor bile leaks were treated conservatively, and 14 patients (35%) with major leaks underwent endoscopic retrograde cholangiogram and internal drainage. All bile leaks resolved. There was no significant difference in the two groups with respect to septic complications (p = 0.125), intensive care unit stay (p = 0.534), hospital stay (p = 0.164), or mortality (p = 1.000). CONCLUSION Sixty-five percent of the intrahepatic bile leaks following trauma are minor and easily managed conservatively. Endoscopic retrograde cholangiogram and internal drainage should be reserved for major leaks. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Interhospital transfer of liver trauma in New Mexico: a state of austere resources. J Surg Res 2014; 191:25-32. [DOI: 10.1016/j.jss.2014.05.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 04/13/2014] [Accepted: 05/16/2014] [Indexed: 11/18/2022]
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Lamb C, MacGoey P, Navarro A, Brooks A. Damage control surgery in the era of damage control resuscitation. Br J Anaesth 2014; 113:242-9. [DOI: 10.1093/bja/aeu233] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Edelmuth RCL, Buscariolli YDS, Ribeiro MAF. [Damage control surgery: an update]. Rev Col Bras Cir 2014; 40:142-51. [PMID: 23752642 DOI: 10.1590/s0100-69912013000200011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 08/15/2012] [Indexed: 11/22/2022] Open
Abstract
The damage control surgery is a widely accepted concept today among abdominal trauma specialists when it comes to the severely traumatized. In these patients, the death is due, in most cases, to the installation of the lethal triad (hypothermia, coagulopathy and acidosis) and not the inability to repair the serious initial damage. In this review, the authors address the lethal triad in its three phases and emphasize the measures taken to prevent them, as well as discussing the indication and employment of damage control surgery in its various stages. Restoring the physiological status of the patient in the ICU, so that he/she can be submitted to final operation and closure of the abdominal cavity, another challenge in severe trauma patients, is also discussed.
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Hsu CP, Wang SY, Hsu YP, Chen HW, Lin BC, Kang SC, Yuan KC, Liu EH, Kuo IM, Liao CH, Ouyang CH, Yang SJ. Risk factors for liver abscess formation in patients with blunt hepatic injury after non-operative management. Eur J Trauma Emerg Surg 2013; 40:547-52. [PMID: 26814510 DOI: 10.1007/s00068-013-0346-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 10/14/2013] [Indexed: 11/24/2022]
Abstract
PURPOSE To identify risk factors for liver abscess formation in patients with blunt hepatic injury who underwent non-operative management (NOM). METHODS From January 2004 to October 2008, retrospective data were collected from a single level I trauma center. Clinical data, hospital course, and outcome were all extracted from patient medical records for further analysis. RESULTS A total of 358 patients were enrolled for analysis. There were 13 patients with liver abscess after blunt hepatic injury. Patients with abscess had a significant increase in glutamic oxaloacetic transaminase (GOT, p = 0.006) and glutamic pyruvic transaminase (GPT, p < 0.0001), and a decrease in arterial blood pH (p = 0.023) compared to patients without abscess in the univariate analyses. In addition, high-grade hepatic injury and transarterial embolization (TAE, p < 0.001) were also risk factors for liver abscess formation. Five factors (GOT, GPT, pH level in the arterial blood sample, TAE, and high-grade hepatic injury) were included in the multivariate analysis. TAE, high-grade hepatic injury, and GPT level were statistically significant. The odds ratios of TAE and high-grade hepatic injury were 15.41 and 16.08, respectively. A receiver operating characteristic (ROC) analysis was used for GPT, and it suggested cutoff values of 372.5 U/L. A prediction model based on the ROC analysis had 100 % sensitivity and 86.7 % specificity to predict liver abscess formation in patients with two of the three independent risk factors. CONCLUSIONS TAE, high-grade hepatic injury, and a high GPT level are independent risk factors for liver abscess formation.
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Affiliation(s)
- C-P Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - S-Y Wang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Y-P Hsu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan.
| | - H-W Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - B-C Lin
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - S-C Kang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - K-C Yuan
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - E-H Liu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - I-M Kuo
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - C-H Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - C-H Ouyang
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - S-J Yang
- 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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Ordoñez C, Pino L, Badiel M, Sanchez A, Loaiza J, Ramirez O, Rosso F, García A, Granados M, Ospina G, Peitzman A, Puyana JC, Parra MW. The 1-2-3 approach to abdominal packing. World J Surg 2013; 36:2761-6. [PMID: 22955950 DOI: 10.1007/s00268-012-1745-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Abdominal packing (AP) in damage-control laparotomy (DCL) is a lifesaving technique that controls coagulopathic hemorrhage in severely injured trauma patients. However, the impact of the duration of AP on the incidence of re-bleeding and on intra-abdominal infections in penetrating abdominal trauma is not clear. The objective of the present study was to evaluate the complications related to the duration of AP and to determine the optimal time for AP removal. METHODS Prospectively collected/retrospectively analyzed data at an urban level I trauma center from January 2003 to December 2010 were used as the basis for this study. Inclusion criteria were adults (≥18 years old) with penetrating abdominal trauma, who had survived both the initial DCL procedure and their first re-laparotomy. All initial DCL patients included in the study underwent abdominal packing for coagulopathic hemorrhage control. The outcome measures of this study were re-bleeding after packing removal, intra-abdominal infection, and 30-day cumulative mortality. We considered time after packing as an independent variable. This was defined as the total amount of time (in days) that the packs were left in the patient's abdomen. Patients were grouped according to the duration in days of their AP in <1, 1-2, 2-3, and >3 days. RESULTS Of 503 patients with penetrating abdominal trauma, 121 underwent DCL and AP. The mean age was 30.1± 11.5 years, and the male to female ratio was 9:1. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) score was 17.6±7.2. The mean Injury Severity Score (ISS) score was 24.9±9.1. The right upper quadrant was packed in 39 (32.2%) patients, retroperitoneum in 70 (57.8%), pelvis in 13 (10.7%), and left upper quadrant in 9 (7.4%). Fifty-one patients (42.1%) had associated colon injuries and 58 (47.9%) had small bowel injuries. Twenty-six patients (21.5%) had AP<1 day, 42 patients (34.7%) had AP between 1 and 2 days, 35 patients (28.9%) had AP between 2 and 3 days, and 18 patients (14.8%) had AP>3 days. The re-bleeding rate in patients packed for 1-2 days compared to those packed for <1 day was a third lower, 14.3%, (95% confidence interval [95% CI]: 8.06, 20.5) versus 38.5% (95% CI: 25.4, 51.5). Conversely, an increasing trend toward intra-abdominal infection occurred as time after packing increased. The infection rate tripled from 16.7% (95% CI: 6.6, 26.7) to 44.4% (95% CI: 31.03, 57.7) when comparing 1-2 days versus >3 days. Overall mortality was 16.5%. Of these deaths, 8.26% were attributable to re-bleeding, and 13.2% to intra-abdominal infection. Deaths secondary to re-bleeding seemed to decrease with time of AP, whereas intra-abdominal infection deaths increased with time of AP (Chi square for trend p value=0.04). CONCLUSIONS The present study suggests that AP used in the setting of DCL for coagulopathic hemorrhage control should not be removed prior to the first postoperative day because of the increased risk of re-bleeding. The ideal length of AP is 2-3 days, and AP left in longer than 3 days is associated with a significantly increased risk of infectious complications.
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Affiliation(s)
- Carlos Ordoñez
- Departamento de Cirugía, Fundación Valle del Lili, Avenida Simón Bolivar, Carrera 98 Número 18-49, Cali, Colombia.
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Chatoupis K, Papadopoulou G, Kaskarelis I. New technology in the management of liver trauma. Ann Gastroenterol 2013; 26:41-44. [PMID: 24714662 PMCID: PMC3959513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2012] [Accepted: 07/26/2012] [Indexed: 10/26/2022] Open
Abstract
The liver is the second most frequently injured solid organ in patients with blunt abdominal trauma. Hence the diagnosis and clinical assessment of hepatic trauma is of great importance because of the relationship of the liver to high morbidity and mortality. Multi detector-row computed tomography is the main diagnostic modality for the examination of hepatic parenchyma and other associated organ injuries, such as acute or delayed complications. Based on clinical and radiological findings, the majority of patients are managed conservatively, with the most important criterion of surgical therapy being hemodynamic instability. Radiologists must demonstrate a high knowledge of imaging recommendations and standardization of reporting to enable the selection of the appropriate treatment algorithm. Transcatheter embolization therapy is a method of great potential for the management of patients with traumatic hepatic injuries.
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Affiliation(s)
- Konstantinos Chatoupis
- Department of Radiology, Asklepieion Voulas General Hospital, Athens, Greece,
Correspondence to: Konstantinos Chatoupis, Radiology Department, Asklepieion Voulas General Hospital, Vas. Pavlou 1, 16673 Athens, Greece, Tel.: +30 210 8959 522, Fax: +30 210 8923 122, e-mail:
| | | | - Ioannis Kaskarelis
- Department of Radiology, Asklepieion Voulas General Hospital, Athens, Greece
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Ebrahimi S, Tahmasebi S, Rouhezamin MR, Mousavi SM, Abbasi HR, Bolandparvaz S, Paydar S. Modified Perihepatic Packing; A Creative and Beneficial Method for Management of High Grade Liver Injury. Bull Emerg Trauma 2013; 1:22-27. [PMID: 27162817 PMCID: PMC4771238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 09/21/2012] [Accepted: 10/03/2012] [Indexed: 06/05/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy of modified perihepatic packing (MPHP) in reducing the rate of re-bleeding rate after packing removal. METHODS This was an experimental study being performed in Shiraz animal laboratory. High grade liver parenchymal injury was induced in 30 transgenic Australian rabbits which were then divided into two groups. Group A (control) included 14 and group B (experimental) comprised 16 rabbits. The animals in group A underwent standard perihepatic packing (SPHP) and those in group B were subjected to MPHP. Re-bleeding was assessed and compared between the two groups, after removal of perihepatic packings. RESULTS There was no significant difference between two study groups regarding baseline and perioperative characteristics. Rabbits in group A had significantly lower rate of postoperative re-bleeding compared to those in group A (57.1% vs. 12.5%; p=0.019). The mean bleeding volume was also significantly lower in group B compared to group A (76.88 ± 22.12 vs. 98.93 ± 33.8 mL; p<001). Although the survival rate was higher in group A compared to group B (93.8% vs. 78.6%) but the difference was not statistically significant (p=0.315). CONCLUSION MPHP is a simple and safe procedure for surgical management of high grade liver parenchymal injury concomitant with severe loss of glisson's capsule. This procedure significantly decreases re-bleeding after packing removal in comparison with SPHP.
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Affiliation(s)
- Sajjad Ebrahimi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Sedigheh Tahmasebi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Mohammad Reza Rouhezamin
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Seyed Mohsen Mousavi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Hamid Reza Abbasi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Shahram Bolandparvaz
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Shahram Paydar
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.
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Influences on the amount of intraperitoneal haemorrhage after blunt liver injury: a retrospective autopsy study. Eur J Gastroenterol Hepatol 2012; 24:1333-40. [PMID: 22872075 DOI: 10.1097/meg.0b013e3283579445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The amount of intraperitoneal blood loss due to traumatic liver injury is rarely addressed in correlation with concomitant injuries or pre-existing liver disease. METHODS We carried out a retrospective review of autopsy reports from 1995 until 2007 at the Institute of Forensic Medicine (Bern, Switzerland), and evaluated 126 cases of blunt liver trauma for the amount of blood in the abdominal cavity, severity of liver injury, pre-existing liver disease and concomitant injuries. RESULTS Grades IV and V liver injuries (American Association for the Surgery of Trauma classification) showed greater blood loss than grades I and II liver injuries. Grade III liver injuries showed no significant difference in the amount of intraperitoneal blood compared with grades IV and V liver injuries and 53 cases of liver injuries (42%) did not bleed at all. The amount of blood found in the abdominal cavity ranged from 0 to 4500 ml. Pre-existing liver steatosis showed no significant difference in injury pattern or bleeding from the liver. Three cases with liver haemangiomas and one with a liver cyst showed no lesion to their focal alteration. Because of the small number of cases, no statistical analysis was made concerning concomitant injuries such as head, thoracic or limb trauma. CONCLUSION Higher grades of liver injury severity are associated with higher blood loss into the abdominal cavity. In addition, a patient with pre-existing liver steatosis seems not to be at any greater risk of having a larger rupture or having stronger bleeding from the liver after a blunt impact compared with a patient with a normal liver.
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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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Predictive factors of morbidity and mortality in grade IV and V liver trauma undergoing perihepatic packing: single institution 14 years experience at European trauma centre. Injury 2012; 43:1347-54. [PMID: 22281197 DOI: 10.1016/j.injury.2012.01.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 12/22/2011] [Accepted: 01/04/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE Major liver trauma in polytraumatic patients accounts for significant morbidity and mortality. We aimed to assess prognostic factors for morbidity and mortality in patients with severe liver trauma undergoing perihepatic packing. METHODS Prospectively collected records of 293 consecutive polytrauma patients with liver injury admitted at a level I trauma centre between 1996 and 2008 were reviewed. 39 patients with grade IV-V AAST liver injury and treated with peri-hepatic packing were identified and included for analysis. Univariate and multivariate analyses were performed to assess prognostic factors for morbidity and mortality. RESULTS Mean age of patients was 41 years. 34 patients were haemodynamically unstable at initial presentation. Ten of 39 patients were treated with angiographic embolization in addition to perihepatic packing. The overall mortality rate was 51.3%. Liver-related death occurred in 23.1%. Overall and liver-related morbidity rates were 90% and 28%, respectively. Glasgow Coma Scale (GCS), respiratory rate, packed red blood cells (PRBC) transfusion, pH and Base Excess (BE), Revised Trauma Score (RTS) and Trauma Injury Severity Score (TRISS), need for angiographic embolization as well as early OR and ICU admission were associated with significant decrease of early mortality. CONCLUSIONS Revised Trauma Score, haemodynamic instability, blood pH and BE are important prognostic factors influencing morbidity and mortality in polytrauma patients with grade IV/V liver injury. Furthermore, fast and effective surgical damage control procedure with perihepatic packing, followed by early ICU admission is associated with lower complication rate and shorter ICU stays in this patient population.
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Advanced operative techniques in the management of complex liver injury. J Trauma Acute Care Surg 2012; 73:765-70. [DOI: 10.1097/ta.0b013e318265cef5] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Parray FQ, Wani ML, Malik AA, Thakur N, Wani RA, Naqash SH, Chowdri NA, Wani KA, Bijli AH, Irshad I, Nayeem-Ul-Hassan. Evaluating a conservative approach to managing liver injuries in Kashmir, India. J Emerg Trauma Shock 2012; 4:483-7. [PMID: 22090742 PMCID: PMC3214505 DOI: 10.4103/0974-2700.86635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 03/14/2011] [Indexed: 11/04/2022] Open
Abstract
AIM There has been a steep rise in incidence of liver injury in the past few years because of increase in incidence of road traffic accidents. The aim of this study was to evaluate the role of non-operative management of liver injury due to blunt abdominal trauma. MATERIALS AND METHODS All patients with liver injury from blunt trauma abdomen were studied between January 2000 and January 2010. A total of 152 patients with liver injury were put on conservative management. Hundred and three (67.77%) patients were males and 49 (32.23%) were females with an age range of 15-60 years (32.8 years). Most of the injuries were because of road traffic accidents (81.57%). Liver injuries were graded according to Moore's classification using computed tomography. Patients with Grade V and VI were excluded from the study. Patients who were unstable hemodynamically on admission were also excluded from the study. RESULTS There was no mortality in our series. Eight patients needed exploration because they developed hemodynamic instability. Four of the patient developed post-operative liver abscess which was treated conservatively. CONCLUSION Non-operative management of liver injury due to blunt trauma abdomen is a safe, effective and treatment modality of choice in hemodynamically stable Moore's grade I to Grade IV injury.
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Affiliation(s)
- Fazl Qadir Parray
- Department of General Surgery, Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar
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Allard MA, Dondero F, Sommacale D, Dokmak S, Belghiti J, Farges O. Liver packing during elective surgery: an option that can be considered. World J Surg 2012; 35:2493-8. [PMID: 21597886 DOI: 10.1007/s00268-011-1156-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Packing is a life-saving procedure in patients undergoing emergency surgery for blunt hepatic trauma, especially when massive blood transfusions, acidosis, or hypothermia have resulted in coagulation disorders. The purpose of this study was to apply this concept to the setting of elective liver surgery. METHODS Elective packing was performed in 7 patients who had sustained prolonged bleeding mainly related to partial outflow obstruction during the course of liver resection (n = 3) or transplantation (n = 4). At the time of packing, conventional methods of hemostasis had failed and surgery had lasted for 490 (range, 380-695) minutes, blood loss was 5,700 (range, 2,100-13,700) ml, and all patients had coagulation disorders (prothrombin time PT <30%, platelets <45 g/l), hypothermia (body temperature 35.4 °C), acidosis (median blood pH 7.24; serum lactate 6.5 mmol/l) and required catecholamine support. RESULTS Unpacking was performed after a median of 37 (range, 26-60) hours. At that time, all patients were normothermic, with platelet counts >45 g/l, PT >30%, and restored acid-base balance. Active bleeding had stopped, and secondary fascia closure was feasible. With a minimum follow-up of 6 months, all patients are alive without sequel. CONCLUSIONS Packing is a safe and efficient means to control venous bleeding when conventional methods of hemostasis have failed, knowing that commonly the reason for failure of conventional method of hemostasis is partial outflow obstruction.
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Affiliation(s)
- Marc Antoine Allard
- Department of Hepato-Biliary Surgery, Hôpital Beaujon, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris 7, 100 bld du Général Leclerc, 92118, Clichy, France
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Prometheus bound: evolution in the management of hepatic trauma--from myth to reality. J Trauma Acute Care Surg 2012; 72:321-9. [PMID: 22327973 DOI: 10.1097/ta.0b013e31824b15a7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Morales C, Barrera L, Moreno M, Villegas M, Correa J, Sucerquia L, Sanchez W. Efficacy and safety of non-operative management of blunt liver trauma. Eur J Trauma Emerg Surg 2011; 37:591-6. [PMID: 26815470 DOI: 10.1007/s00068-010-0070-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 12/20/2010] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- C Morales
- Surgery Department, University of Antioquia, Hospital Universitario San Vicente de Paúl, Carrera 51D No. 62-29, 1226-229, Medellín, Antioquia, Colombia.
| | - L Barrera
- Surgery Department, University of Antioquia, Hospital Universitario San Vicente de Paúl, Carrera 51D No. 62-29, 1226-229, Medellín, Antioquia, Colombia
| | - M Moreno
- Surgery Department, University of Antioquia, Hospital Universitario San Vicente de Paúl, Carrera 51D No. 62-29, 1226-229, Medellín, Antioquia, Colombia
| | - M Villegas
- Surgery Department, University of Antioquia, Hospital Universitario San Vicente de Paúl, Carrera 51D No. 62-29, 1226-229, Medellín, Antioquia, Colombia
| | - J Correa
- Surgery Department, University of Antioquia, Hospital Universitario San Vicente de Paúl, Carrera 51D No. 62-29, 1226-229, Medellín, Antioquia, Colombia
| | - L Sucerquia
- Surgery Department, University of Antioquia, Hospital Universitario San Vicente de Paúl, Carrera 51D No. 62-29, 1226-229, Medellín, Antioquia, Colombia
| | - W Sanchez
- Surgery Department, University of Antioquia, Hospital Universitario San Vicente de Paúl, Carrera 51D No. 62-29, 1226-229, Medellín, Antioquia, Colombia
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Western Trauma Association/Critical Decisions in Trauma: Operative Management of Adult Blunt Hepatic Trauma. ACTA ACUST UNITED AC 2011; 71:1-5. [DOI: 10.1097/ta.0b013e318220b192] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Eftekhari A, Albuali AA, Keer D, Galea-Soler S, Nicolaou S. Low-dose MDCT findings of blunt hepatobiliary trauma. Emerg Radiol 2011; 18:235-47. [PMID: 21286773 DOI: 10.1007/s10140-011-0938-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 01/13/2011] [Indexed: 10/18/2022]
Abstract
This pictorial essay shows low-dose multi-detector computed tomography (MDCT) findings of blunt hepatobiliary trauma, and describes the indications and protocol for MDCT. Given the universal usage of MDCT in assessing the liver in blunt abdominal trauma, reduction of patient dose is essential. The new l0se MDCT protocol presented here can achieve up to 50% dose reduction while maintaining diagnostic image quality and thus facilitate dose sensitive patient management. Our institution's blunt hepatobiliary MDCT imaging algorithm can help determine which patients require operative therapy. Injury to the liver is graded on various schemes, one being the Organ Injury Scale devised by the American Association for the Surgery of Trauma classification based on the extension of the lesion and bleeding.
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Affiliation(s)
- Arash Eftekhari
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
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Lehmann T, Heger M, Münch S, Kirschfink M, Klar E. In vivo microscopy reveals that complement inhibition by C1-esterase inhibitor reduces ischemia/reperfusion injury in the liver. Transpl Int 2011. [DOI: 10.1111/j.1432-2277.2000.tb02101.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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40
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Ahmed N, Vernick JJ. Management of liver trauma in adults. J Emerg Trauma Shock 2011; 4:114-9. [PMID: 21633579 PMCID: PMC3097559 DOI: 10.4103/0974-2700.76846] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 07/22/2010] [Indexed: 12/21/2022] Open
Abstract
The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of the liver and use of atriocaval shunt are rarely indicated.
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Affiliation(s)
- Nasim Ahmed
- Department of Surgery & Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center 1945 State Rt. 33, Neptune, US
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[Damage control surgery in abdominal trauma]. ACTA ACUST UNITED AC 2010; 57:15-24. [PMID: 20681194 DOI: 10.2298/aci1001015k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The damage control laparotomy is an advancement in the management of massively injured trauma patients. Massive liver injuries, pelvic trauma and some retroperitoneal injuries are some of the indications for this approach. The damage control laparotomy is the phased approach to severe abdominal injury that might best be described with the acronym STIR (Staged Trauma Injury Repair). The initial procedure requires rapid abdominal exploration with hemorrhage and contamination control, using suture repair combined with abdominal packing. Temporary abdominal wall closure without tension is recommended. After abrevated initial surgical procedure, the patient is transferred to the intensive care unit where continued resuscitation is performed. Careful replacement of blood and blood products along with correction of hypothermia, acidosis and optimalization of oxygen transport represents a critical phase in this management approach. Once the coagulation profile has normalized, planned re-intervention, with repeat abdominal exploration to remove the packs and perform definitive surgical repair and reconstruction takes place. When applied judiciously, the damage control laparotomy with the staged abdominal repair and reconstruction for severe trauma is associated with an improved outcome in the selected group of patients.
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Badger SA, Barclay R, Campbell P, Mole DJ, Diamond T. Management of liver trauma. World J Surg 2010; 33:2522-37. [PMID: 19760312 DOI: 10.1007/s00268-009-0215-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems. METHODS A literature review was undertaken to determine the current consensus on investigation and management strategies. RESULTS The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing. CONCLUSIONS Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.
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Affiliation(s)
- S A Badger
- Hepatobiliary Surgical Unit, Mater Hospital, Crumlin Road, Belfast, BT14 6AB Northern Ireland, UK.
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Abstract
BACKGROUND Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems. METHODS A literature review was undertaken to determine the current consensus on investigation and management strategies. RESULTS The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing. CONCLUSIONS Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.
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Affiliation(s)
- S A Badger
- Hepatobiliary Surgical Unit, Mater Hospital, Crumlin Road, Belfast, BT14 6AB Northern Ireland, UK.
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Karim T, Topno M, Reza A, Patil K, Gautam R, Talreja M, Tiwari A. Hepatic trauma management and outcome; Our experience. Indian J Surg 2010; 72:189-93. [PMID: 23133245 DOI: 10.1007/s12262-010-0054-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 12/14/2009] [Indexed: 10/19/2022] Open
Abstract
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.
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Affiliation(s)
- Tanweer Karim
- Department of General Surgery, MGM Medical College, Navi Mumbai, India
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Reconstruction of a total avulsion of the hepatic veins and the suprahepatic inferior vena cava secondary to blunt thoracoabdominal trauma. Langenbecks Arch Surg 2010; 396:261-5. [DOI: 10.1007/s00423-010-0652-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 05/18/2010] [Indexed: 11/27/2022]
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Abstract
With the shift toward nonoperative management, most hepatic injuries are managed nonoperatively. On the other hand, up to two-thirds of high-grade hepatic injuries require laparotomy; these cases are technically difficult and challenging. Damage-control approaches, understanding of liver anatomy, and advances in technology have dramatically changed the approach to hepatic trauma, with improved outcomes. Anatomic or nonanatomic liver resection is required in 2% to 5% of liver injuries. Mortality with liver injury following resection is 9% with current advances.
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Affiliation(s)
- Greta L Piper
- Department of Surgery, University of Pittsburgh, F-1265, UPMC-Presbyterian, Pittsburgh, PA 15213, USA
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Bruns H, von Frankenberg M, Radeleff B, Schultze D, Büchler MW, Schemmer P. [Surgical treatment of liver trauma: resection--when and how?]. Chirurg 2010; 80:915-22. [PMID: 19711022 DOI: 10.1007/s00104-009-1729-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Liver resection as an emergency procedure in patients with liver injury due to abdominal trauma has become a rare procedure. In most cases liver trauma can be managed conservatively. Currently surgery is only indicated in hemodynamically instable patients and in cases of progredient haematoma where the main aim is control of bleeding. Anatomical liver resection should be avoided and may only be performed in cases of total vascular avulsion. Debridement of devascularized tissue can also be carried out in terms of an atypical liver resection. This article elucidates the current indications for liver resection after traumatic liver injury.
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Affiliation(s)
- H Bruns
- Klinik für Allgemein-, Viszeral und Transplantationschirurgie, Ruprecht-Karls-Universität, Im Neuenheimer Feld 110, 69120 Heidelberg
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Lin BC, Wong YC, Lim KE, Fang JF, Hsu YP, Kang SC. Management of ongoing arterial haemorrhage after damage control laparotomy: optimal timing and efficacy of transarterial embolisation. Injury 2010; 41:44-9. [PMID: 19539285 DOI: 10.1016/j.injury.2009.01.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Revised: 11/22/2008] [Accepted: 01/06/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients undergoing damage control laparotomy need intensive and aggressive resuscitation, and may also require adjunctive transarterial embolisation (TAE) for ongoing arterial haemorrhage. We evaluated the effectiveness and timing of TAE in these patients as well as their final outcome. MATERIALS AND METHODS From January 1998 to December 2006, the case records of 16 patients with ongoing arterial haemorrhages (hepatic haemorrhage=7, extra-hepatic haemorrhage=9) who underwent TAE after damage control laparotomy were reviewed. Fourteen patients had blunt injuries and two had penetrating injuries. RESULTS There were 13 men and three women. Their ages ranged from 3 to 85 years (mean, 36 years). Of seven hepatic angiograms, contrast extravasation at the right hepatic artery and left hepatic artery was found in three patients each. Bilateral hepatic artery injuries were found in one patient. Of nine extra-hepatic angiograms, the internal iliac artery was the most commonly injured artery (n=6). After TAE, 14 of 16 ongoing arterial haemorrhages could be controlled and eight patients survived; however, two patients with uncontrolled haemorrhages eventually died (hepatic artery injury=1, lumbar artery injury=1). Of 16 patients overall, profound haemorrhagic shock (n=4) and multiple organ failure (n=4) resulted in eight deaths (hepatic injury=4, extra-hepatic injury=4), and accounted for a mortality rate of 50%. Of 16 patients, nine were taken directly from the operating room to the angiography suite and the mortality rate was 33.3%. The other seven patients were taken to the angiography suite from the intensive care unit and the mortality rate was 71.4%. Of three survivors who underwent hepatic TAE, the operative time ranged from 30 min to 72 min (mean, 48 min). However, of four nonsurvivors who underwent hepatic TAE, the operative time ranged from 58 min to 180 min (mean, 119 min). CONCLUSIONS TAE is an effective tool in the management of ongoing arterial haemorrhage after damage control laparotomy and eight (50%) patients with ongoing arterial haemorrhages survived from this multidisciplinary treatment. To achieve a good outcome, the operative time of damage control laparotomy should be as short as possible and TAE should be performed without delay. Interventional radiology colleagues should be informed in advance during laparotomy and resuscitation continued in the angiography suite.
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Affiliation(s)
- Being-Chuan Lin
- Division of Trauma & Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei-Shan, Tao-Yuan Hsien 333, Taiwan.
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Balanced management of hepatic trauma is associated with low liver-related mortality. Langenbecks Arch Surg 2009; 395:381-6. [PMID: 19908061 DOI: 10.1007/s00423-009-0566-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 10/16/2009] [Indexed: 10/20/2022]
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