Factors determining operative mortality of grade V blunt hepatic trauma

Survival following devastating penetrating gunshots polytrauma with grade 5 liver injuries requiring multiple massive transfusion protocols: A case report and review of the literature

Introduction

A devastating injury to the liver from a gunshot wound (GSW) challenges the most seasoned trauma surgeon. This challenge is intensified when patients develop severe shock with a high-grade injury. We present the case of a patient with a grade 5 liver injury after a GSW treated with operative and interventional radiology (IR) treatment simultaneously.

Case presentation

A 25-year-old male presented to our Trauma Center with hypotension, after an abdominal GSW. He was taken emergently to the operating room, which revealed a Grade 5 liver injury with massive hemorrhage. Operative intervention was initiated immediately and a non-anatomic left lobectomy with hepatorrhaphy was performed. IR was consulted intra-operatively and performed a left hepatic artery angioembolization. The patient received over 50 units of blood products during the combined procedures, with eventual bleeding control. On post-operative day 33, the patient became acutely hemodynamically unstable, and angiography revealed a splenic artery pseudoaneurysm, which was embolized but re-bled and resulted in splenectomy. The patient eventually recovered and follows up at 1-year revealed a patient doing well.

Discussion

High-grade liver injuries carry significant mortality. Mortality worsens when severe shock is present. Operative intervention is the standard approach for patients who remain in shock. To help improve outcomes patients may benefit from a combined approach with the interventional radiology team.

Conclusion

The acute management of severe liver injuries when presenting with ongoing shock is beneficial to include both trauma surgeons with interventional radiologists. Further studies are needed to determine the best approach for this devastating injury.

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Severe hepatic injuries may require both operative management & angioembolization.

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Class 4 hemorrhagic shock often requires a massive transfusion protocol.

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Algorithms for operative/angiographic treatment of liver/spleen injuries are needed.

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Delayed hemorrhage after angioembolization for splenic pseudoaneurysm can occur.

Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications

Traumatic abdominal injuries are life-threatening emergencies frequently seen in the Emergency Department (ED). The most common is liver trauma, which accounts for approximately 5% of all ED admissions for trauma. The management of blunt liver trauma has evolved significantly over the past few decades and, according to the injury’s severity, it may require massive resuscitation, radiological procedures, endoscopy, or surgery. Patients admitted to the ED with blunt abdominal trauma require a multidisciplinary evaluation, including emergency physicians, surgeons, radiologists, and anesthetists, who must promptly identify the extent of the injury to prevent serious complications. In case of a patient’s death, the execution of a forensic examination carried out with a multidisciplinary approach (radiological, macroscopic, and histological) is essential to understand the cause of death and to correlate the extent of the injuries to the possibility of survival to be able to manage any medico-legal disputes. This manuscript aims to collect the most up-to-date evidence regarding the management of hepatic trauma in the emergency room and to explore radiological findings and medico-legal implications.

A novel inflatable device for perihepatic packing and hepatic hemorrhage control: A proof-of-concept study

INTRODUCTION

Uncontrolled bleeding is the primary cause of death in complex liver trauma and perihepatic packing is regularly utilized for hemorrhage control. The purpose of this study was to investigate the effectiveness of a novel inflatable device (the airbag) for perihepatic packing using a validated liver injury damage control model in swine.

MATERIAL AND METHODS

The image of the human liver was digitally isolated within an abdominal computerized tomography scan to produce a silicone model of the liver to mold the airbag. Two medical grade polyurethane sheets were thermal bonded to the configuration of the liver avoiding compression of the hepatic pedicle, hepatic veins, and the suprahepatic vena cava after inflation. Yorkshire pigs (n = 22) underwent controlled hemorrhagic shock (35% of the total blood volume), hypothermia, and fluid resuscitation to reproduce the indications for damage control surgery (coagulopathy, hypothermia, and acidosis) prior to a liver injury. A 3 × 10 cm rectangular segment of the left middle lobe of the liver was removed to create the injury. Subsequently, the animals were randomized into 4 groups for liver damage control (240 min), Sponge Pack (n = 6), Pressurized Airbag (n = 6), Vacuum Airbag (n = 6), and Uncontrolled (n = 4). Animals were monitored throughout the experiment and blood samples obtained.

RESULTS

Perihepatic packing with the pressurized airbag led to significantly higher mean arterial pressure during the liver damage control phase compared to sponge pack and vacuum airbag 52 mmHg (SD 2.3), 44.9 mmHg (SD 2.1), and 32 mmHg (SD 2.3), respectively (p < 0.0001), ejection fraction was also higher in that group. Hepatic hemorrhage was significantly lower in the pressurized airbag group compared to sponge pack, vacuum airbag, and uncontrolled groups; respectively 225 ml (SD 160), 611 ml (SD 123), 991 ml (SD 385), 1162 ml (SD 137) (p < 0001). Rebleeding after perihepatic packing removal was also significantly lower in the pressurized airbag group; respectively 32 ml (SD 47), 630 ml (SD 185), 513 ml (SD 303), (p = 0.0004). Intra-abdominal pressure remained similar to baseline, 1.9 mmHg (SD 1), (p = 0.297). Histopathology showed less necrosis at the border of the liver injury site with the pressurized airbag.

CONCLUSION

The pressurized airbag was significantly more effective at controlling hepatic hemorrhage and improving hemodynamics than the traditional sponge pack technique. Rebleeding after perihepatic packing removal was negligible with the pressurized airbag and it did not provoke hepatic injury.

Isolated liver trauma: A clinical perspective in a non-emergency center for liver surgery

The management of liver trauma is, currently, still heterogeneous ranging from conservative to major invasive liver resections. When appropriate, these cases should be referred to a regional care center. The objective of this study was to analyze the expertise of a non-emergency center for liver surgery from Romania after initial stabilization in county hospitals. This study is a monocentric, retrospective, observational study, including 12 patients with hepatic trauma after a car accident, admitted between 2015 and 2019. We analyzed various clinical and biochemical data as independent variables, and the main outcome was considered the intensive care unit (ICU) length of stay. Our results revealed that intubation status at admission, norepinephrine infusion during surgery, hyperfibrinogenemia and duration of mechanical ventilation in patients with isolated liver trauma were correlated with prolonged ICU length of stay. Further prospective, more comprehensive studies are needed in order to evaluate the exact prognostic factors in terms of short- and long-term mortality.

Damage Control in Penetrating Liver Trauma: Fear of the Unknown

The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.

Improved outcomes for hepatic trauma in England and Wales over a decade of trauma and hepatobiliary surgery centralisation

Background

Over the last decade trauma services have undergone a reconfiguration in England and Wales. The objective is to describe the epidemiology, management and outcomes for liver trauma over this period and examine factors predicting survival.

Methods

Patients sustaining hepatic trauma were identified using the Trauma Audit and Research Network database. Demographics, management and outcomes were assessed between January 2005 and December 2014 and analysed over five, 2-year study periods. Independent predictor variables for the outcome of liver trauma were analysed using multiple logistic regression.

Results

4368 Patients sustained hepatic trauma (with known outcome) between January 2005 and December 2014. Median age was 34 years (interquartile range 23–49). 81% were due to blunt and 19% to penetrating trauma. Road traffic collisions were the main mechanism of injury (58.2%). 241 patients (5.5%) underwent liver-specific surgery. The overall 30-day mortality rate was 16.4%. Improvements were seen in early consultant input, frequency and timing of computed tomography (CT) scanning, use of tranexamic acid and 30-day mortality over the five time periods. Being treated in a unit with an on-site HPB service increased the odds of survival (odds ratio 3.5, 95% confidence intervals 2.7–4.5).

Conclusions

Our study has shown that being treated in a unit with an on-site HPB service increased the odds of survival. Further evaluation of the benefits of trauma and HPB surgery centralisation is warranted.

Management of severe blunt hepatic injury in the era of computed tomography and transarterial embolization: A systematic review and critical appraisal of the literature

BACKGROUND

During the last decade, the management of blunt hepatic injury has considerably changed. Three options are available as follows: nonoperative management (NOM), transarterial embolization (TAE), and surgery. We aimed to evaluate in a systematic review the current practice and outcomes in the management of Grade III to V blunt hepatic injury.

METHOD

The MEDLINE database was searched using PubMed to identify English-language citations published after 2000 using the key words blunt, hepatic injury, severe, and grade III to V in different combinations. Liver injury was graded according to the American Association for the Surgery of Trauma classification on computed tomography (CT). Primary outcome analyzed was success rate in intention to treat. Critical appraisal of the literature was performed using the validated National Institute for Health and Care Excellence "Quality Assessment for Case Series" system.

RESULTS

Twelve articles were selected for critical appraisal (n = 4,946 patients). The median quality score of articles was 4 of 8 (range, 2-6). Overall, the median Injury Severity Score (ISS) at admission was 26 (range, 0.6-75). A median of 66% (range, 0-100%) of patients was managed with NOM, with a success rate of 94% (range, 86-100%). TAE was used in only 3% of cases (range, 0-72%) owing to contrast extravasation on CT with a success rate of 93% (range, 81-100%); however, 9% to 30% of patients required a laparotomy. Thirty-one percent (range, 17-100%) of patients were managed with surgery owing to hemodynamic instability in most cases, with 12% to 28% requiring secondary TAE to control recurrent hepatic bleeding. Mortality was 5% (range, 0-8%) after NOM and 51% (range, 30-68%) after surgery.

CONCLUSION

NOM of Grade III to V blunt hepatic injury is the first treatment option to manage hemodynamically stable patients. TAE and surgery are considered in a highly selective group of patients with contrast extravasation on CT or shock at admission, respectively. Additional standardization of the reports is necessary to allow accurate comparisons of the various management strategies.

LEVEL OF EVIDENCE

Systematic review, level IV.

Comparison between operative versus non-operative management of traumatic liver injury

Backgrounds/Aims

The aim of this study was to compare operative versus non-operative management of patients with liver injury and to ascertain the differences of the clinical features.

Methods

From April 2000 to July 2012, 191 patients were admitted to Seoul St. Mary's Hospital and St. Vincent's Hospital for liver injuries. Of these, 148 patients were included in this study. All patients were diagnosed using computed tomography (CT). The liver injury was graded in accordance with the American Association for the Surgery of Trauma liver injury scoring scale. Patients were divided into two groups: those who underwent surgery and those treated with non-operative management (NOM). There was a comparison between these two groups concerning the clinical characteristics, grade of liver injury, hemodynamic stability, laboratory findings, and mortality.

Results

According to the 148 patient records evaluated, 108 (72.9%) patients were treated with NOM, and 40 (27.1%) underwent surgery. Patients treated with NOM had significantly fewer severe injuries as rated using the Revised Traumatic Injury Scale, Injury Severity Score, and Glasgow Coma Scale. Grade of liver injury and number of patients with extravasation of contrast dye on CT and hemoperitoneum were higher in the operative group than in the NOM group. There were significant differences between the two groups for: heart rate, respiratory rate, systolic blood pressure, and mean hemoglobin levels at admission and after 4 hours. The operative group experienced a significantly higher mortality than the NOM group.

Conclusions

The results of our study suggest that hemodynamic stability and the following should be considered for deciding the treatment for liver injuries: grade of liver injury, amount of blood loss, and injury scales scores.

Scoring system for traumatic liver injury (SSTLI) in polytraumatic patients: a predictor of mortality

PURPOSE

The aim of this study was to examine prognostic factors in polytraumatic patients with liver injury and to develop a scoring system for traumatic liver injury (SSTLI) to predict mortality.

METHODS

The medical records of 175 patients treated for traumatic liver injury from July 2009 to April 2013 were reviewed. The primary outcome variable was hospital mortality. All risk factors were analyzed by multivariate logistic regression analysis. The SSTLI was created based on the predictive power of each factor.

RESULTS

Age, injury severity score (ISS), trauma and injury severity score, the shock index, and the volume of packed red blood cells transfused were strong predictors of mortality. We hypothesized that the SSTLI would use five clinical measures (total bilirubin, prothrombin time, serum creatinine, age, and ISS). Each measure was scored 0-1 (age and ISS) or 0-3 (total bilirubin, prothrombin time, and creatinine), with 3 indicating the most severe derangement. The receiver-operating characteristic curve of the SSTLI was significant at post-traumatic days 0, 1, 3, and 5 [area under the curve (AUC), 0.830; AUC, 0.912; AUC, 0.941; and AUC, 0.930, respectively]. A value of 5 points was the threshold for reliability dividing low-risk (<5) from high-risk (≥5) patients.

CONCLUSIONS

The SSTLI may be available to predict mortality in polytraumatic patients with liver injury, although external validation is needed before widespread implementation.

Non-operative management of isolated liver trauma

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma. Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2% (70/72). The success rates of NOM in the patients with grade I-III, IV and V liver trauma were 100%, 94.4% and 83.3%. The complication rates were 10.0% and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived. NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.

Liver transplantation after severe hepatic trauma: a sustainable practice. A single-center experience and review of the literature

Severe hepatic trauma is a rare indication for liver transplantation (LT). We report our single-center experience of LT for hepatic trauma. Four new cases are discussed in light of a literature review in order to depict the pathways leading from hepatic trauma to LT and to assess the outcomes of this practice. LT is generally indicated in case of uncontrollable hemorrhage, acute liver failure, or post-traumatic late sequelae. Hepatic vessels thrombosis, sepsis, major hepatic resections, and a late referral are factors associated with the progression toward irreversible liver failure. Considering all reported cases, early patient and graft survival reached 68% and 62%, respectively, but in the last decade both have improved to 84%. LT after severe hepatic trauma is a sustainable practice considering the current good outcomes and the ineluctable death of these patients without LT.

Surgical management and outcome of blunt major liver injuries: experience of damage control laparotomy with perihepatic packing in one trauma centre

INTRODUCTION

This retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries.

MATERIALS AND METHODS

From January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann-Whitney U test for continuous variables, either Pearson's chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p<0.05.

RESULTS

Of the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n=21), hepatorrhaphy (n=19), selective hepatic artery ligation (n=11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p=0.019), prolonged initial prothrombin time (PT) (p=0.004), active partial thromboplastin time (APTT) (p<0.0001) and decreased platelet count (p=0.005).

CONCLUSIONS

The mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries.

Penetrating liver injury managed with a combination of balloon tamponade and venous stenting. A case report and literature review

AAST-OIS grade V complex hepatic injuries are often fatal as a result of exsanguination. We report a patient presenting in extremis with a penetrating injury to the right kidney, liver, middle hepatic vein, diaphragm, and lung. A combination of intrahepatic balloon tamponade and hepatic venous stenting was used to control exsanguinating haemorrhage, the first time this combination has been reported. Rapid assessment and treatment and a team approach, together with the innovative application of haemostatic techniques, allowed a multidisciplinary team to salvage this patient.

Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury

BACKGROUND

Nonoperative management (NOM) has become the standard treatment of blunt hepatic injury (BHI) for stable patients. Contrast extravasation (CE) on computed tomography (CT) scan had been reported as a sign that is associated with NOM failure. The goal of this study was to further investigate the risk factors of NOM failure in patients with CE on CT scan.

METHODS

From January 2005 to September 2009, patients with CE noted on a CT scan as a result of BHI were studied retrospectively. Physiological parameters, severity of injury, amount of transfusion, type of contrast extravasation, as well as treatment outcome were compared between patients with NOM failure and NOM success.

RESULTS

A total of 130 patients were enrolled. Injury severity scores, amount of blood transfusion before hemostatic procedure, and grade of liver injury were significantly higher in NOM failure than in NOM success patients. There was no statistical difference in the NOM success rate between patients with contrast leakage into the peritoneum and those with contrast confined in the hepatic parenchyma.

CONCLUSIONS

Higher injury severity score, more blood transfusion, and higher grade of liver injury are factors that correlate with NOM failure in patients with BHI. Contrast leakage into the peritoneum is not always a definite sign of NOM failure in BHI. Early and aggressive angioembolization is an effective adjunct of NOM in BHI patients, even with contrast leakage into peritoneum.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Fatores preditivos de morbidade e mortalidade no trauma hepático

OBJETIVO: Identificar os fatores preditivos de complicações e mortalidade em doentes operados com trauma hepático. MÉTODO: Estudo retrospectivo de 638 pacientes tratados no período de 1990 a 2003, identificando estatisticamente parâmetros epidemiológicos, fisiológicos e anatômicos associados com maior morbidade e mortalidade. RESULTADOS: Trauma penetrante foi o mecanismo mais freqüente. A instabilidade hemodinâmica esteve presente em 21,1% das vítimas e o Índice de Gravidade das Lesões anatômicas (ISS) médio foi de 20,7. A maioria das lesões hepáticas foi grau III. A morbidade foi de 50,4%, sendo as complicações relacionadas ao fígado mais freqüentes: sangramento persistente (9,8%), abscesso intraperitoneal (3,8%) e fístula biliar (3%). As complicações não hepáticas ocorreram em 273 pacientes (42,8%). A mortalidade foi de 22,1% (141 casos) decorrente principalmente de sangramento persistente e sepse. As vítimas fatais apresentaram-se com pior índice fisiológico na admissão, com lesões hepáticas mais complexas e índices anatômicos mais graves quando comparadas aos sobreviventes. CONCLUSÃO: Os fatores preditivos de ocorrência de complicações hepáticas foram: idade maior que 60 anos, instabilidade hemodinâmica ou alteração de parâmetros fisiológicos na admissão, presença de lesões hepáticas complexas (grau > III) e índices anatômicos de gravidade de lesão abdominal (ATI) ou em outros segmentos corpóreos (ISS) elevados (= 25). Todas estas variáveis, mais a presença de lesões associadas abdominais e não abdominais e o mecanismo de trauma fechado foram preditivas de ocorrência de complicações não-hepáticas. Todos os fatores estudados, exceto a presença de lesões associadas abdominais, foram preditivos para a evolução a óbito.

Emergency liver transplantation following severe liver trauma

Liver trauma is a major cause of mortality after major blunt and penetrating abdominal trauma. The need for life-saving emergency hepatectomy and liver transplantation is extremely rare. We report the management of 2 patients who required urgent liver transplantation for liver trauma. One patient developed hepatic failure following global ischemia after a gunshot injury. The second patient developed a severe postreperfusion injury following removal of a perihepatic pack after blunt abdominal trauma. We highlight the difficulties in the management of severe liver trauma with an emphasis on the clinical features, radiological investigations, and surgical treatment of these complex patients.

Hemostasis of active bleeding from the liver with percutaneous microwave coagulation therapy under contrast-enhanced ultrasonographic guidance: an experimental study

OBJECTIVE

The purpose of this study was to investigate the feasibility of percutaneous microwave coagulation therapy (PMCT) guided by contrast-enhanced ultrasonography (CEUS) for controlling active bleeding in rabbit livers.

METHODS

Twenty actively bleeding rabbit liver models, produced with an 18-gauge semiautomatic biopsy needle and confirmed with CEUS, were randomly divided into 2 groups: a PMCT group (n=10, with a microwave antenna placed into the bleeding site under ultra-sonographic guidance and worked at 60 W for 30 seconds on average) and a control group (n=10, with the active bleeding site not treated). After therapy procedures were performed, lactated Ringer's solution resuscitation was then performed in both groups to maintain the mean arterial pressure at 70 mm Hg for 1 hour. The intraperitoneal blood loss, total resuscitation volume, mean arterial pressure, and hematocrit value were recorded. Macroscopic and microscopic examinations were performed at the end of the study.

RESULTS

After PMCT, the former bleeding site appeared on CEUS as a round or an oval area devoid of contrast. The PMCT group had lower blood loss (30.4+/-7.2 versus 101.6 +/- 18.2 mL; P< .05) and a lower total resuscitation volume (56.5+/-10 versus 186+/-36.6 mL; P< .05) than the control group. The mean hematocrit value in the PMCT group was significantly higher than that in the control group (26%+/-4% versus 19%+/-4%; P< .05) at the end of the experiment.

CONCLUSIONS

Contrast-enhanced ultrasonographically guided PMCT significantly decreased blood loss in a rabbit model of active liver bleeding. It provides a simple and quick method to control blood loss in liver injuries with active bleeding.

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.

Current advances in the surgical approach to abdominal trauma

The management of abdominal injury has changed dramatically during the past two decades. This review examines the historic perspectives and recent developments of diagnosis and treatment of liver injuries, splenic injuries, and pancreatic injuries. The incorporation of non-operative management for liver injuries has had a very positive effect on mortality. Likewise, splenic conservative therapy is routinely used. The early treatment of pancreatic injury has changed very little; however, the ability to recognize these difficult injuries has improved with higher quality CT scanning. The authors present their preferred treatment for these three common types of abdominal solid organ injury and present an illustrative case example.

The CT risk factors for the need of operative treatment in initially hemodynamically stable patients after blunt hepatic trauma

BACKGROUND

Most hemodynamically stable blunt hepatic trauma (BHT) patients are treated nonoperatively with a reported successful rate exceeding 80%. It is current clinical consensus that hemodynamic stability is the only determinant for a patient to be managed nonoperatively. However, conversion to operative treatment was found in around 10% of these patients.

METHODS

There were 214 computed tomography (CT) scans of hemodynamically stable patients with main or sole BHT studied. CT findings including injury severity grading, contrast extravasation, the amount of hemoperitoneum, the degree of maceration, the depth of laceration, the size of hematoma, and the involvement of great vessels were analyzed to determine risk factors leading to the need of operative treatment.

RESULTS

Intraperitoneal contrast extravasation, hemoperitoneum in six compartments, maceration >2 segments, high Mirvis' CT grade as well as American Association for the Surgery of Trauma injury scale, laceration > or =6 cm in depth, and porta hepatis involvement occurred significantly more frequently (p < or = 0.001, respectively) in patients who needed operative treatment. Logistic regression analysis identified "intraperitoneal contrast extravasation" (RR = 12.5, 95% CI: 7.8-20.0; p < 0.001) and "hemoperitoneum in six compartments" (RR = 22, 95% CI: 9.7-49.4; p < 0.001) to independently contribute to the need of operative treatment.

CONCLUSION

Intraperitoneal contrast extravasation and hemoperitoneum in six compartments on CT scan both indicate massive or active hemorrhage and should be regarded as high risk for the need of operation in hemodynamically stable patients after BHT. Patients with low risk profile can be successfully treated with nonoperative modalities.

[Surgical management, prognostic factors, and outcome in hepatic trauma]

Hepatic trauma is a rare surgical emergency with significant morbidity and mortality. Extensive experience in liver surgery is a prerequisite for the management of these injuries. The medical records of 68 consecutive patients with hepatic trauma were retrospectively reviewed for the severity of liver injury, management, morbidity, mortality, and risk factors. Of the patients, 14 were treated conservatively and 52 surgically (24 suture/fibrin glue, 16 perihepatic packing, 11 resections, 1 liver transplantation). Two patients died just before emergency surgery could be performed. Overall mortality was 21% (14/68), and 13, 14, 6, 27, and 50% for types I, II, III, IV, and V injuries, respectively. Only nine deaths (all type IV and V) were liver related, while four were caused by extrahepatic injuries and one by concomitant liver cirrhosis. With respect to treatment, conservative management, suture, and resection had a low mortality of 0, 4, and 9%, respectively. In contrast, mortality was 47% in patients in whom only packing was performed (in severe injuries). Stepwise multivariate regression analysis proved prothrombin values <40%, ISS scores >30, and transfusion requirements of more than 10 red packed cells to be significant risk factors for post-traumatic death. Type I-III hepatic injuries can safely be treated by conservative or simple surgical means. However, complex hepatic injuries (types IV and V) carry a significant mortality and may require hepatic surgery, including liver resection or even transplantation. Therefore, patients with severe hepatic injuries should be treated in a specialized institution.

Traumatismes graves fermés du foie : à la recherche de critères décisionnels pour le choix du traitement non-opératoire. À propos d'une série de 88 cas

AIM OF THE STUDY

To analyze the predictive value of computed tomography (CT) and initial physiologic and laboratory data findings in the immediate operative (OP) or non-operative (NOP) management of blunt liver injury (BL).

METHODS

Eighty-eight BL, grade III (51), grade IV (28) and nine grade V (9), aged 26.2 years (16-75) were identified. Hemoperitoneum on CT, hemodynamic status, physiologic and laboratory data <24 hours or preoperative (transfusion, vascular filling) and follow-up >48 hours were analyzed.

RESULTS

Data of 71/88 (80%) NOP and 17/88 (20%) OP patients were reviewed. A secondary laparotomy or laparoscopy was necessary in 11/71 TNO. Six OP (35%) and 1 NOP patients died. Blood units transfused were 1.33 (0-10) vs 5.9 (0-22) and vascular filling 1.45 (0.5-5.5) vs 3.6L (2-12) (P<10(-6), P<4.10(-3) respectively). NOP patients had less severe hemoperitoneum (31 vs 94%, P<10(-5)) and hemodynamic instability (8.5 vs 94%, P<10(-4)). But, there was an overlap of values of blood units transfused, amount of vascular filling and initial haemoglobin levels between NOP and OP patients and among CT grades of liver injury. No cut-off values could be determined: 33% NOP received >4 blood units and >3 L vascular filling; 30% had severe hemoperitoneum. In OP group 23.5% patients had lower values and no severe hemoperitoneum.

CONCLUSION

In the management of BL, vascular filling and blood transfusion increased with the grade of CT liver injury and were globally more elevated in the operative group but did not individually correlate with hemodynamic stability and did not authorize, by themselves, to decide between operative versus non-operative management.

Impact of alcohol intoxication on hemodynamic, metabolic, and cytokine responses to hemorrhagic shock

BACKGROUND

Alcohol intoxication is associated with a high incidence of traumatic injury, particularly in the young healthy population. The impact of alcohol intoxication on the immediate pathophysiologic response to injury has not been closely examined. We hypothesized that acute alcohol intoxication would aggravate the immediate outcome from hemorrhagic shock by impairing homeostatic counterregulation to blood loss.

METHODS

Chronically catheterized male Sprague-Dawley rats were randomized to receive an intragastric infusion of ethyl alcohol (1.75 g/kg followed by 250-300 mg/kg/h) or isocaloric dextrose (3-mL bolus + 0.375 mL/h) for 15 hours. Before initiating fixed-pressure hemorrhage followed by fluid resuscitation, an additional intragastric bolus of ethyl alcohol (1.75 g/kg) was administered. Hemodynamic, metabolic, cytokine, and acid-base parameters were assessed during the hemorrhage period and at completion of resuscitation. Lungs were obtained for cytokine determinations.

RESULTS

Basal mean arterial pressure was significantly lower in alcohol-intoxicated (blood-alcohol concentration, 135 +/- 12 mg/dL) animals than in controls during baseline (20%) and after the initial fluid resuscitation period (30%). Hemorrhage decreased arterial HCO3 and Pco2, and increased Po2 without significant alteration in arterial blood pH. Alcohol intoxication blunted the decrease in Pco2 and increase in Po2 and decreased blood pH during baseline and throughout the course of the hemorrhage period. Hemorrhage produced marked and progressive elevations in plasma glucose and lactate levels in controls, and this was inhibited by alcohol intoxication. Hemorrhage elevated plasma tumor necrosis factor-alpha (TNF-alpha) (686 +/- 252 pg/mL) and interleukin (IL)-10 (178 +/- 25 pg/mL), and did not alter IL-6 and IL-1 levels. Alcohol blunted the hemorrhage-induced rise in plasma TNF-alpha (142 +/- 48 pg/mL) and enhanced the hemorrhage-induced increase in IL-10 (678 +/- 187 pg/mL). Hemorrhage produced a two- to threefold increase in lung content of TNF-alpha, IL-1alpha, and IL-6 without significantly altering lung IL-10. Alcohol exacerbated the hemorrhage-induced increase in lung TNF-alpha, and did not alter the IL-1alpha, IL-6, and IL-10 lung responses.

CONCLUSION

These results indicate marked alterations in the hemodynamic and metabolic responses to hemorrhagic shock by alcohol intoxication. Furthermore, our findings suggest that alcohol modulates the early proinflammatory responses to hemorrhagic shock. Taken together, these alterations in metabolic and inflammatory responses to hemorrhage are likely to impair immediate outcome and predispose to tissue injury.