Complications of Nonoperative Management of High-Grade Blunt Hepatic Injuries

Clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing non-operative management

BACKGROUND

Complications arising during non-operative management (NOM) of blunt hepatic and/or splenic trauma, particularly in cases of severe injury, are associated with significant morbidity and mortality. Abdominal computed tomography (CT) is the gold standard for the initial detection of complications during NOM. Although many institutions advocate routine in-hospital follow-up scans to improve success rates, others recommend a more selective approach. The use of follow-up CT remains a subject of ongoing debate, with no validated guidelines available regarding the timing, effectiveness, or intervals of follow-up imaging.

OBJECTIVE

We aimed to identify the clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing NOM.

MATERIALS AND METHODS

This retrospective cohort study included patients with blunt hepatic and/or splenic trauma treated at Songklanagarind Hospital, a level 1 trauma center, from 2013 to 2022. We assessed all patients indicated for non-operative management and examined their clinical parameters and complications.

RESULTS

Of 542 patients with blunt hepatic and/or splenic injuries, 315 (58%) were managed non-operatively. High-grade hepatic injuries were significantly associated with complications, as determined through a multivariate logistic regression analysis after adjusting for factors such as contrast blush findings, age, sex, and injury severity score (ISS) (adjusted OR = 7.69, 95% CI 1.59-37.13; p = 0.011). Among the patients with complications (n = 27), 17 (63%) successfully underwent non-operative management. Notably, eight patients presented with clinical symptoms prior to the diagnosis of complications, while only two patients had no clinical symptoms before the diagnosis. Tachycardia, abdominal pain, decreased hematocrit levels, and fever were significant indicators of complications (p < 0.05).

CONCLUSION

Routine CT to detect complications may not be necessary in patients with asymptomatic low-grade blunt hepatic injuries. By contrast, in those with isolated blunt hepatic injuries that are managed non-operatively, high-grade injuries, the presence of a contrast blush on initial imaging, and the patient's age may warrant consideration for routine follow-up CT scans. Clinical symptoms and laboratory observations during NOM, such as tachycardia, abdominal pain, decreased hematocrit levels, and fever, are significantly associated with complications. These symptoms necessitate further management, regardless of the initial injury severity, in patients with blunt hepatic and/or splenic injuries undergoing NOM.

Evaluation of management of CT scan proved solid organ injury in blunt injury abdomen-a prospective study

BACKGROUND

Trauma especially road traffic injury is one of the major health-related issues throughout the world, especially in developing countries like India (Mattox 2022). Solid organ injury is the most common cause of morbidity and mortality in patients with blunt abdominal trauma. The non-operative management (NOM) is being consistently followed for hemodynamically stable patients with respect to solid organ injuries. This study aims to provide an evidence base for management modalities of solid organ injuries in blunt abdominal trauma.

AIM

The aim of this study is to evaluate the effectiveness of various treatment modalities for solid organ injury in blunt abdominal trauma.

OBJECTIVES

Evaluating the characteristics of blunt abdominal injury with respect to age and gender; distribution, mode of injury, most common organ injured, and severity of injury; effect of delay in getting treatment on the management outcome for patients with solid organ injury; evaluating the various modalities of treatment of CT-proven solid organ injury; incidence of complications in different modes of treatment.

METHODS

All patients aged more than 18 years and suffering from CT-proven solid organ injury secondary to blunt abdominal trauma between February 2021 and September 2022 were included in this prospective observational study. Sixty-five patients were enrolled in the study after meeting the inclusion criteria. Details such as age, gender, mechanism of injury, the time between injury to first hospital contact, presenting complaints, organ and grade of injury, Revised Trauma Score (RTS), Trauma Score and Injury Severity Score (TRISS), management, and outcomes were collected using self-designed pro forma and analyzed. Different modalities of treatment were evaluated and patients undergoing operative and non-operative management were compared. Patients in whom non-operative management failed were compared with patients with successful non-operative management.

RESULTS

The mean age of patients involved were 36.8 years with a male:female ratio of 7.125:1 and the most common age group affected being between 21 and 30 years. The most common mode of injury was noted to be road traffic accidents (72.3%). The most common presenting complaints were abdominal pain (64.6%) followed by chest pain (29.2%) and vomiting (13.8%). There was no significant relationship between latent period and type of intervention or failure of non-operative management. FAST positivity rate was noted to be 92.3%. Chronic alcoholism and bronchial asthma were significant predictors for patients undergoing upfront surgery (p = 0.003 and 0.006 respectively). The presence of pelvic and spine injury was statistically significant for predicting mortality in polytrauma patients (p = 0.003). Concurrent adrenal injury was found in 24.6% of patients but was not related to failure of non-operative management or mortality. RTS significantly predicts the multitude of organ involvement (p = 0.015). The liver was the most common organ injured (60%) followed by the spleen (52.3%) and the kidney (20%). The liver and the spleen (9.2%) were noted to be the most common organ combination involved. No specific organ or organ injury combination was noted to predict failure of non-operative management or mortality. But the multitude of organ involvement was statistically significant for predicting patients undergoing upfront surgery (p = 0.011). Out of 65 patients enrolled in the study, 7 patients (10.8%) underwent immediate surgery, and 58 patients (89.2%) underwent non-operative management. Among the 68 chosen for non-operative management, 6 patients (9.2%) failed non-operative management and 52 patients (80%) had success of non-operative management. A significant drop in hemoglobin (83.3%) on day 1 (66.6%) was seen to be the commonest reason for failure of non-operative management. The spleen was noted to be the most commonly involved organ intra-operatively (61.5%) followed by the liver (30.8%). Concordance between pre-operative and intra-operative grading of organ injuries was highest for liver and kidney injuries (100%) and lowest for pancreatic injuries (0%). Requirement of blood transfusion and liver injuries were significant factors for failure of non-operative management (p = 0.012 and 0.045 respectively). The presence of pancreatic leak was significant between the non-operated patients and patients operated upfront (p = 0.003). Mortality was noted to be 10.8% (7 patients) in our study.

CONCLUSION

Solid organ injury in blunt abdominal trauma is an important cause of morbidity and mortality. RTS was noted to be a good predictor for solid organ injury in blunt abdominal trauma. Pancreatic injuries are notorious for being under-staged on CT findings; hence, the need arises for multimodality imaging for suspected pancreatic injuries. Non-operative management is a successful modality of treatment for majority of patients suffering from multiple solid organ injuries in blunt abdominal trauma provided serial close monitoring of patient's clinical signs and hemoglobin is instituted along with the presence of an emergency surgery team.

Repeat imaging increases detection of delayed pseudoaneurysms in patients with high-grade solid organ injury following abdominal trauma

BACKGROUND

Nonoperative management of abdominal trauma can be complicated by the development of delayed pseudoaneurysms. Early intervention reduces the risk of rupture and decreases mortality. The objective of this study is to determine the utility of repeat computed tomography (CT) imaging in detecting delayed pseudoaneurysms in patients with abdominal solid organ injury.

METHODS

A retrospective cohort study reviewing Montreal General Hospital registry between 2013 and 2019. Patients with The American Association for the Surgery of Trauma (AAST) grade 3 or higher solid organ injury following abdominal trauma were identified. A chart review was completed, and demographics, mechanism of injury, Injury Severity Score (ISS) score, AAST injury grade, CT imaging reports, and interventions were collected. Descriptive analysis and logistic regression model were completed.

RESULTS

We identified 195 patients with 214 solid organ injuries. The average age was 38.6 years; 28.2% were female, 90.3% had blunt trauma, and 9.7% had penetrating trauma. The average ISS score was 25.4 (SD 12.8) in patients without pseudoaneurysms and 19.5 (SD 8.6) in those who subsequently developed pseudoaneurysms. The initial management was nonoperative in 57.0% of the patients; 30.4% had initial angioembolization, and 12.6% went to the operating room. Of the cohort, 11.7% had pseudoaneurysms detected on repeat CT imaging within 72 h. Grade 3 represents the majority of the injuries at 68.0%. The majority of these patients underwent angioembolization.

CONCLUSIONS

In patients with high-grade solid organ injury following abdominal trauma, repeat CT imaging within 72 h enabled the detection of delayed development of pseudoaneurysms in 11.7% of injuries. The majority of the patients were asymptomatic.

[Endovascular technologies in the treatment of patients with blunt abdominal trauma]

Trauma is one of the leading causes of disability and mortality in working-age population. Abdominal injuries comprise 20-30% of traumas. Uncontrolled bleeding is the main cause of death in 30-40% of patients. Among abdominal organs, spleen is most often damaged due to fragile structure and subcostal localization. In the last two decades, therapeutic management has become preferable in patients with abdominal trauma and stable hemodynamic parameters. In addition to clinical examination, standard laboratory tests and ultrasound, as well as contrast-enhanced CT of the abdomen should be included in diagnostic algorithm to identify all traumatic injuries and assess severity of abdominal damage. Development of interventional radiological technologies improved preservation of damaged organs. Endovascular embolization can be performed selectively according to indications (leakage, false aneurysm, arteriovenous anastomosis) and considered for severe damage to the liver and spleen, hemoperitoneum or severe polytrauma. Embolization is essential in complex treatment of traumatic vascular injuries of parenchymal abdominal organs. We reviewed modern principles and methods of intra-arterial embolization for the treatment of patients with traumatic injuries of the liver and spleen.

Hepatic compartment syndrome treated with damage control surgery and transarterial embolization: A case report

Background

Hepatic compartment syndrome (HCS) is a complication of nonoperative management in patients with blunt hepatic injury. Although decompression of elevated intrahepatic pressure through surgical exploration or drainage and hemorrhage control are required to manage this condition, evidence for such a management for this complication is insufficient. Herein, we report a pediatric patient treated with a planned combination strategy of surgical decompression with perihepatic packing to reduce intrahepatic pressure and subcapsular hemorrhage control as well as angioembolization to control intraparenchymal hemorrhage.

Case presentation

A 12-year-old boy was referred to our emergency department 5 h after sustaining severe bruising in the upper abdomen in a traffic accident. Computed tomography (CT) showed an intraparenchymal hematoma in the right lobe of the liver; nonoperative management was selected based on stable hemodynamic status. Two days after the injury, he complained of severe abdominal pain and shock. CT showed an intraparenchymal and large subcapsular hematoma with right branch compression of the portal vein and extravasation of contrast material. Laboratory data showed progression of hepatocellular damage. We successfully managed this patient with a planned combination strategy of surgical decompression with perihepatic packing for reduction of intrahepatic pressure and subcapsular hemorrhage control, followed by angioembolization for control of intraparenchymal hemorrhage.

Conclusion

Our study suggests that for the management of HCS, a planned combination strategy of damage control surgery and angioembolization is a therapeutic option.

Experimental study of the effects of absorbable gelatin sponge and non‑absorbable polyvinyl alcohol particle material used in transcatheter arterial embolization on liver tissues

Hepatic trauma is a leading cause of death in major abdominal trauma, and transcatheter arterial embolization has been widely used to treat it. However, there is limited research on whether absorbable gelatin sponge (AGS) and non-absorbable polyvinyl alcohol particles (PVA) have different effects on liver tissue, making it an important area of exploration. The present study investigated this issue using animal experiments by performing transhepatic arterial embolization with AGS and PVA. The effects on normal liver tissue in rabbits were examined by detecting liver function and inflammatory indexes, conducting histopathological examination, and using western blotting to detect apoptotic proteins. There were significant differences between the AGS and PVA groups after embolization. The AGS group exhibited a trend of improvement at ~1 week after embolization, and all indicators were statistically different until day 21 compared with the PVA group. The AGS group exhibited improved repair of hepatocytes and the biliary system based on H&E staining, while the PVA group exhibited more severe necrosis of the hepatocytes and biliary system around the embolization site. The western blotting results indicated that the Bcl-2/Bax ratio decreased on day 1 and day 3, and then rebounded in the AGS group on days 7 and 21, demonstrating gradual repair of hepatocytes compared with the PVA group.

Gunshot wound versus blunt liver injuries: different liver-related complications and outcomes

PURPOSE

Severe hepatic injury due to gunshot (GSW) compared to blunt mechanism may have significantly different presentation, management, complications, and outcomes. The aim of this study was to identify the differences.

METHODS

Retrospective single-center analysis June 1, 2015-June 30, 2020, included all patients with Grade III-V liver injuries due to GSW or blunt mechanism. Clinical characteristics, severity of injury, liver-related complications (rebleeding, necrosis/abscess, bile leak/biloma, pseudoaneurysm, acute liver failure) and overall outcomes (mortality, hospital length of stay, intensive care unit length of stay, and ventilatory days) were compared.

RESULTS

Of 879 patients admitted with hepatic trauma, 347 sustained high-grade injury and were included: 81 (23.3%) due to GSW and 266 (76.7%) due to blunt force. A significantly larger proportion of patients with GSW were managed operatively (82.7 vs. 36.1%, p < 0.001). GSW was associated with significantly more liver-related complications (40.7% vs. 27.4%, p = 0.023), specifically liver necrosis/abscess (18.5% vs. 7.1%, p = 0.003) and bile leak/biloma (12.3% vs. 5.3%, p = 0.028). On subgroup analysis, in patients with grade III injury, the incidence of liver necrosis/abscess and bile leak/biloma remained significantly higher after GSW (13.9% vs. 3.1%, p = 0.008 and 11.1% vs. 2.5%, p = 0.018, respectively). In sub analysis of 88 patients with leading severe liver injuries, GSW had a significantly longer hospital length of stay, ICU length of stay, and ventilator days.

CONCLUSION

GSW mechanism to the liver is associated with a higher incidence of liver-related complications than blunt force injury.

The risk of hepatic pseudoaneurysm after liver trauma in relation to the severity of liver injury: a meta-analysis and meta-regression analysis

AIM

To determine the risk of hepatic pseudoaneurysm after liver trauma in relation to the severity of liver injury.

METHODS

We performed a systematic review and meta-analysis in compliance with PRISMA statement standards (Registration Number: CRD42022328834). A search of electronic information sources was conducted to identify all studies reporting the risk of hepatic pseudoaneurysm after liver trauma. The JBI assessment tool was used to assess the risk of bias of the included studies. Random-effects models were applied to calculate pooled outcome data.

RESULTS

A total of 2030 patients from six studies were included. Based on the American Association for the Surgery of Trauma classification system, 21% had grade I injury; 33% grade II injury; 28% grade III injury; 12% grade IV injury and 5% grade V injury. The pooled risk of hepatic pseudoaneurysm was 1.8% (95% CI 1.1-2.5%). The risk was 0.4% (0-1.2%) in patients with grade I injury, 0.7% (0-1.7%) in patients with grade II injury; 1.5% (0.4-2.7%) in patients with grade III injury; 4.6% (1.4-7.7%) in patients with grade IV injury and 10.6% (1.8-22.9%) in patients with grade V injury. The average time between liver injury and detection of hepatic pseudoaneurysm was 6 days (95% CI 1-10) CONCLUSIONS: The risk of hepatic pseudoaneurysm after liver trauma increases as the severity of liver injury increases. Hepatic pseudoaneurysms are rare after grade I or grade II injuries, and increasingly common after grades III, IV and V injuries. We recommend routine surveillance imaging in patients with grade III to V injuries.

Delayed laparoscopic peritoneal washout in non-operative management of blunt abdominal trauma: a scoping review

OBJECTIVES

Non-operative management (NOM) of blunt abdominal trauma has become increasingly common in hemodynamically stable patients. There are known complications of NOM from undrained intra-abdominal fluid accumulations including hemorrhage and peritonitis that require delayed operation. Thus, delayed operation can be considered as part of the overall management plan, instead of failure, of NOM. The aim of this scoping review is to establish key concepts regarding delayed laparoscopic peritoneal washout (DLPW) following NOM of blunt abdominal trauma patients.

METHODS

MEDLINE, EMBASE, CENTRAL, and gray literature were systematically searched. Studies were included if they investigated or reported on the use of delayed laparoscopy involving peritoneal washout following NOM of blunt abdominal trauma patients. Bibliographies of included studies were manually reviewed to identify additional articles for inclusion.

RESULTS

From 910 citations, 28 studies met inclusion criteria. This included seven case reports, eleven case series or observational cohort studies, six review articles, two management guidelines, one textbook chapter, and one randomized clinical trial. For those reported, medium grade liver injuries proved most common (95.2%). Indications for DLPW were primarily clinical features and changes in imaging findings, highlighting the importance of close observation. Authors reported clinical improvement after DLPW regarding symptomatology, vital signs, and biochemistry. A relatively high transfusion demand was reported with a mean of four units of packed red blood cells pre-operatively. Length of stay and post-operative complications were consistent with previously reported experiences with blunt abdominal injuries.

CONCLUSIONS

DLPW is beneficial in blunt abdominal trauma patients following NOM with improvement in symptoms, SIRS features, and a possible reduction in hospital length of stay. This study is limited by low-quality evidence and skewing of data toward isolated hepatic injuries. Future prospective cohort study comparing NOM with and without DLPW is required.

The American Association for the Surgery of Trauma (AAST) Liver Injury Grade Does Not Equally Predict Interventions in Blunt and Penetrating Trauma

INTRODUCTION

The AAST liver injury grade has a validated association with mortality and need for operation. AAST liver injury grade is the same regardless of the mechanism of trauma.

METHODS

A 5-year retrospective review of all liver injuries at an urban, level-one trauma center was performed.

RESULTS

Totally, 315 patients were included (29% blunt, 71% penetrating). In blunt trauma, AAST grade was associated with need for laparotomy (0%, 7%, 5%, 33%, 29%, Grade 1-5, p = 0.01), angiography (0%, 7%, 25%, 40%, 57%, p < 0.001), embolization (0%, 7%, 15%, 33%, 43%, p = 0.01), and percutaneous drainage procedures (13% use in Grade 4, otherwise 0%, p = 0.04), but not ERCP (0% for all grades). In penetrating trauma, AAST grade was associated with need for angiography (7%, 4%, 15%, 24%, 30%, p < 0.01) and percutaneous drainage (7%, 2%, 14%, 18%, 26%, p = 0.03) and had a marginal association with embolization (0%, 4%, 11%, 13%, 22%, p = 0.06). Laparotomy, ERCP, sphincterotomy, and stenting rates increased with AAST grade, but this was not statistically significant.

CONCLUSION

AAST grade is associated with the need for surgical hemostasis, angioembolization, and percutaneous drainage in both penetrating and blunt trauma. Operative, endoscopic, and percutaneous procedures are utilized more in penetrating trauma. Angioembolization was used more in blunt trauma. Mechanism should be considered when using AAST grade to guide management of liver injuries.

Outcomes of Highest Grade (IV and V) Liver Injuries in Blunt and Penetrating Trauma

BACKGROUND

High-grade hepatic trauma can be devastating, with complications being common if patients survive. Studies comparing outcome differences between blunt and penetrating mechanism are lacking. This study aimed to describe and evaluate the association of traumatic mechanism with complications in patients sustaining grades IV and V liver injuries.

METHODS

A retrospective review of all adults who suffered grades IV and V liver injury from 2015-2020 was performed at a level I trauma center in an urban area. Outcomes in patients with blunt and penetrating mechanisms were compared.

RESULTS

A total of 103 patients were included, of which 44 (43%) were penetrating and the remainder blunt. Patients with penetrating injuries were younger, more often male, and more likely to undergo initial operative management (82% vs 40%, P < .001). Regardless of mechanism, high grade liver injuries had similar rates of complications, including bile leak (17% vs 23%, P = .559) and intrabdominal abscess (7% vs 16%, P = .239), and similar need for endoscopic retrograde cholangiopancreatography (12% vs 19%, P = .379). Penetrating injuries required more re-interventions (42% vs 19%, P = .033), specifically more percutaneous drainage procedures (36% vs 12%, P = .016). Overall mortality was 29% and did not differ by mechanism.

DISCUSSION

Morbidity and mortality are high for grades IV and V liver injuries. Penetrating high-grade hepatic injuries are more likely to be managed operatively, but mortality and overall complications are similar to blunt mechanisms. This may allow for uniform algorithms to define management strategies regardless of mechanism.

Surveillance imaging following liver trauma has a low detection rate of liver complications

BACKGROUND

Surveillance imaging following liver trauma (LT) in asymptomatic patients is performed in many centers. Recent guidelines recommend follow-up imaging if there is a clinical indication.

AIM

To compare liver complications detected through surveillance versus selective imaging in patients following known LT.

METHODS

A retrospective review of a prospective trauma registry was undertaken including all patients that presented with LT at a single center. All radiology images and reports of patients with LT were reviewed. The indication for follow-up imaging was ascertained by reviewing the radiology request and the patients' clinical record.

RESULTS

During the 14-year study, 450 patients were admitted with LT. Liver complications occurred in 50 patients (11%). Follow-up imaging was performed in 169 patients (38%). Of the patients having follow-up imaging, 92 patients had this for clinical deterioration, 55 had surveillance imaging and 22 had follow-up imaging for a non-liver indication. The majority of patients undergoing surveillance imaging had an AAST grade III-V injury (68%). None of the 55 patients having surveillance imaging had a liver complication. In contrast, 36 out of 92 patients having follow-up imaging for clinical deterioration had a complication within their liver (39%). There was a significantly higher incidence of complication detection for clinical deterioration versus surveillance imaging (p = < 0.0001).

CONCLUSIONS

Although complications following high-grade LT are common, they invariably cause clinical deterioration. There is no evidence for surveillance imaging following LT. Follow-up imaging should be guided by the patient's clinical condition.

An Unusual Recurrent Bile Leak Following High Grade Liver Trauma

Non-operative management of blunt liver injury has been demonstrated as a safe and effective treatment for most grades of injury. As the severity of liver injury increases, so does the risk of complications. A 21-year-old male was brought to the trauma center following a high speed motorbike accident. He underwent a laparotomy and angioembolization for a Grade 4 liver injury. A biloma was diagnosed on Day 18 post injury, and he underwent Endoscopic Retrograde Cholangiopancreatography and biliary stenting which were unsuccessful. There were 2 re-admissions for infected perihepatic collections. In this case, an Endoscopic Retrograde Cholangiopancreatography was not a helpful procedure due to a disconnected liver segment, and morbidity occurred due to instrumentation of the biliary tree (the likely cause of infected biloma). Hepatic resection should be considered for patients who fail non-operative management. Further assessment of efficacy using a larger dataset for analysis is required.

The Role of the Interventional Radiologist in Bile Leak Diagnosis and Management

Bile leaks are rare but potentially devastating iatrogenic or posttraumatic complications. This is being diagnosed more frequently since the advent of laparoscopic cholecystectomy and propensity toward nonsurgical management in select trauma patients. Timely recognition and accurate characterization of a bile leak is crucial for favorable patient outcomes and involves a multimodal imaging approach. Management is driven by the type and extent of the biliary injury and requires multidisciplinary cooperation between interventional radiologists, endoscopists, and hepatobiliary/transplant surgeons. Interventional radiologists have a vital role in both the diagnosis and management of bile leaks. Percutaneous interventional procedures aid in the characterization of a bile leak and in its initial management via drainage of fluid collections. Most bile leaks resolve with decompression of the biliary system which is routinely done via endoscopic retrograde cholangiopancreaticography. Some bile leaks can be definitively treated percutaneously while others necessitate surgical repair. The primary principle of percutaneous management is flow diversion away from the site of a leak with the placement of transhepatic biliary drainage catheters. While this can be accomplished with relative ease in some cases, others call for more advanced techniques. Bile duct embolization or sclerosis may also be required in cases where a leaking bile duct is isolated from the main biliary tree.

Repeat Imaging in Blunt Hepatic Injuries Can Wait for Clinical Change

BACKGROUND

There is variability regarding the utilization and timing of repeat imaging in adult patients with blunt hepatic injury who are managed nonoperatively. This study examines the rate of delayed complications and interventions in patients with blunt hepatic injuries who undergo repeat imaging prompted either by clinical change (CC) or non-clinical change (NCC).

METHODS

A nine-year, retrospective, dual-institution study was performed of adult patients with blunt hepatic injuries. Patients were identified based on whether repeat imaging was performed and reason for reimaging: CC or NCC. The incidence of delayed complications and interventions was examined for each type of scan.

RESULTS

Of 365 patients, 122 (33.4%) underwent repeat imaging [CC, n = 72 (59%); NCC, n=50 (41%)]. Mean time to repeat imaging was shorter in the NCC group [CC = 7.6 ± 8 days; NCC = 4.7 ± 6.3 days, P = 0.034]. Delayed complications were found in 30 (25%) patients reimaged, [CC, n = 20; NCC, n = 10, P = 0.395]. Interventions were performed in 12 (40%) patients [CC, n = 10; NCC, n = 2, P = 0.120].

CONCLUSIONS

Repeat imaging due to NCC occurred earlier than imaging performed by CC. One quarter of patients reimaged demonstrated a delayed complication, with nearly half undergoing intervention. There was no difference in incidence of delayed complications or interventions between groups, suggesting repeat imaging can be prompted by clinical change in blunt hepatic injuries.

Imaging Features and Interventional Treatment for Liver Injuries and Their Complications

Liver injury is a common consequence of blunt abdominopelvic trauma. Contrast-enhanced CT allows for the rapid detection and evaluation of liver injury. The treatment strategy for blunt liver injury has shifted from surgical to nonoperative management, which has been widely complemented by interventional management to treat both liver injury and its complications. In this article, we review the major imaging features of liver injury and the role of interventional management for the treatment of liver injury.

Hepatic trauma

Management of trauma-related liver injury has undergone a paradigm shift over the past four decades. In hemodynamically stable patients, the standard of care in the majority of level-one trauma centers has shifted to nonoperative management with high success rates, especially with low-grade liver injuries (i.e., grade I and II liver injuries). Advances in critical care medicine, cross-sectional imaging, and transarterial embolization techniques have led to the improvement of patient outcomes and decreased mortality rates in patients with arterial injuries. Currently, no consensus guidelines on appropriate patient selection criteria have been published by the Society of Interventional Radiology (SIR) or the American Association for the surgery of Trauma (AAST). Based off the current literature, nonoperative management with hepatic angiography and transarterial embolization (TAE) should be the treatment of choice in hemodynamically stable patients with clinical suspicion of arterial injury. TAE has been shown to improve success rates of nonoperative management and is well tolerated by most patients with low complication rates. Hepatic necrosis is the most common and concerning reported complication but can be reduced with selective approach and choice of embolic agent. The majority of literature supporting the use of TAE for trauma-related liver injury consists of retrospective case series and additional larger scale studies are needed to determine the efficacy of TAE in this setting. However, it is clear from the current literature that hepatic TAE is an effective and safer option to operative management in treating arterial hemorrhage in the setting of traumatic hepatic injury.

Laparoscopic-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography With Placement of a Biliary Stent to Treat Traumatic Intrahepatic Bile Duct Disruption in a Patient With Roux-en-Y Gastric Bypass

Hepatic injuries are common following blunt trauma and while frequently managed expectantly, biliary injury as a result of the trauma requires a high index of suspicion, a focused workup, and likely interventional treatment. A 44-year-old female with a history of Roux-en-Y gastric bypass presented after a ground level fall and was initially discharged home but represented with worsening abdominal pain and elevated liver enzymes. She was found to have a segment 5/6 biliary injury requiring laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography with common bile duct stent placement. This case represents the difficulty of diagnosing biliary injuries following blunt trauma, and the need for advanced endoscopic interventions for treatment in patients with atypical anatomy.

Minimally invasive management of traumatic biliary fistula in the setting of gastric bypass

The current management of persistent biliary fistula includes biliary stenting and peritoneal drainage. Endoscopic retrograde cholangiopancreatography (ERCP) is preferred over percutaneous techniques and surgery. However, in patients with modified gastric anatomy, ERCP may not be feasible without added morbidity. We describe a 37-year-old woman with traumatic biliary fistula, large volume choleperitonitis and abdominal compartment syndrome following a motor vehicle collision who was treated with laparoscopic drainage, lavage and biliary drain placement via percutaneous transhepatic cholangiography.

Early hospital discharge following non-operative management of blunt liver and splenic trauma: A pilot randomized controlled trial

BACKGROUND

Despite the acceptance of non-operative management (NOM), there is no consensus on the optimal length of hospital stay in patients with blunt liver and splenic injury (BLSI). Recent studies on pediatric patients have demonstrated the safety of early discharge following NOM for BLSI. We aimed at evaluating the feasibility and safety of early discharge in adult patients with BLSI following NOM in a randomized controlled trial.

MATERIALS AND METHODS

After initial assessment and management, patients aged 18-60 years with BLSI planned for NOM were randomized into 2 groups: Group A (test group; discharge day 3), and Group B (control group; discharge day 5). Standard NOM protocol was followed. These patients were discharged on the proposed day if they met the pre-defined discharge criteria. All patients were followed at days 7, 15, and 30 of discharge.

RESULTS

Sixty patients were recruited, 30 randomized to each arm. Most patients were males and aged less than 30 years. Road traffic injury was the most common mode of injury. Both groups were comparable in demography and injury-related parameters. 27 patients (90%) from group A and 28 patients (93%) from group B were discharged on the proposed day. Three patients had unplanned hospital visits for reasons unrelated to BLSI. All patients were asymptomatic and had a normal examination during their scheduled follow-up visits.

CONCLUSION

Adult patients undergoing NOM for BLSI can be safely discharged after 48 h of in-hospital observation, provided other injuries precluding discharge do not exist.

Value of repeat CT for nonoperative management of patients with blunt liver and spleen injury: a systematic review

PURPOSE

To evaluate the effectiveness of routine repeat computed tomography (CT) for nonoperative management (NOM) of adults with blunt liver and/or spleen injury.

METHODS

We conducted a systematic review of randomized and non-randomized controlled trials (RCTs), quasi-experimental and observational studies of repeat CT in adult patients with blunt abdominal injury. We searched Medline, Embase, Web of Science, and Cochrane Central from their inception to October 2020 using Cochrane guidelines. Primary outcomes were change in clinical management (e.g., emergency surgery, embolization, blood transfusion, clinical surveillance), mortality, and complications. Secondary outcomes were hospital readmission and length of stay.

RESULTS

Search results yielded 1611 studies of which 28 studies including 2646 patients met our inclusion criteria. The majority reported on liver (n = 9) or spleen injury (n = 16) or both (n = 3). No RCTs were identified. Meta-analyses were not possible because no study performed direct comparisons of study outcomes across intervention groups. Only seven of the twenty-eight studies reported whether repeat CT was routine or prompted by clinical indication. In these 7 studies, among the 254 repeat CT performed, 188 (74%) were routine and 8 (4%) of these led to a change in clinical management. Of the 66 (26%) repeated CT prompted by clinical indication, 31 (47%) led to a change in management. We found no data allowing comparison of any other outcomes across intervention groups.

CONCLUSION

Routine repeat CT without clinical indication is not useful in the management of patients with liver and/or spleen injury. However, effect estimates were imprecise and included studies were of low methodological quality. Given the risks of unnecessary radiation and costs associated with repeat CT, future research should aim to estimate the frequency of such practices and assess practice variation.

LEVEL OF EVIDENCE

Systematic reviews and meta-analyses, Level II.

Hepatic Pseudoaneurysm Incidence After Liver Trauma

BACKGROUND

Posttraumatic hepatic artery pseudoaneurysm is a potentially devastating complication after complex liver injury. Increasing computed tomography (CT) use may lead to more frequent identification of posttraumatic hepatic complications. This study was designed to determine the rate of hepatic pseudoaneurysm after traumatic liver injury.

METHODS

We conducted a retrospective review of patients at an urban level 1 trauma center over 5 y (2012-2016). Injury characteristics, patient management, and complications were extracted from trauma registry data and chart review.

RESULTS

Six hundred thirty-four hepatic injuries (11 no grade/no CT, 159 grade I, 154 grade II, 165 grade III, 93 grade IV, and 52 grade V) were identified from our trauma registry. No patient with a grade I or II injury had a subsequent bleeding complication. Eighteen patients had a documented hepatic pseudoaneurysm: grade III n = 3 (1.8%), grade IV n = 6 (6.5%), grade V n = 9 (17.3%). The median time to pseudoaneurysm identification was 6.5 d. Seven pseudoaneurysms were found on asymptomatic surveillance CT-angiography on average 5 d after injury. Eleven patients were symptomatic at the time of CT-angiography performed at a median of 9 d after admission. Of the 11 symptomatic patients, four were in hemorrhagic shock, and two died from hepatic-related complications.

CONCLUSIONS

The incidence of hepatic artery pseudoaneurysm increases with higher grade liver injury. Aggressive surveillance for hepatic pseudoaneurysm with interval CT-angiography 5-7 d postinjury may be warranted, especially for grade IV and V injuries.

Systematic Review of the Management of Retro-Hepatic Inferior Vena Cava Injuries

Background

Retro-hepatic inferior vena cava (RHIVC) injuries resulting from blunt or penetrating abdominal trauma are rare but devastating events that remain a considerable challenge to even the most experienced doctors, which continue to carry a considerable mortality.

Aim

To establish a better understanding of the management of RHIVC injuries and to identify any adjuncts or operative methods that were associated with an increased survival.

Methods

A systematic review of the MEDLINE database was conducted using Medical Search Headings and exploded keywords and phrases. Studies were screened and subjected to inclusion/exclusion criteria. Data were extracted in a methodical manner collecting population demographics, morbidity, mortality and operative intervention, where provided. Operative strategies were compared and discussed.

Results

An initial search identified 483 articles. Following duplicate removal and abstract screening, 85 full-text articles were assessed with 25 meeting the desired criteria and were, therefore, included in the systematic review. Key operative strategies and complications were identified and discussed.

Conclusion

The wide variety of operative interventions in the management of RHIVC liver injuries described attest to the increased efforts to improve outcomes. The overall improvement in mortality can be noted since the earlier descriptions reported mortality approaching 100% compared to the 52% reported in this review. An algorithm has been proposed based on these findings and our experiences for the management of RHIVC injuries.

Grade of injury, not initial management, is associated with unplanned interventions in liver injury

INTRODUCTION

Risk factors for complications after liver injury do not distinguish between patients undergoing selective non-operative management (sNOM) vs operative management (OM) as the initial treatment strategy. Our objective was to identify risk factors for complications requiring an unplanned intervention following sNOM or OM. We hypothesized that patient undergoing sNOM will have fewer unplanned interventions.

METHODS

Adults presenting to a level I trauma center with grade III or higher liver injury over a period of 6 years were reviewed. Patient and injury factors, initial management strategy, subsequent complications and interventions were obtained. Bivariate analysis was performed between patients undergoing sNOM vs OM to determine factors associated with unplanned interventions, defined as intervention >48 h after injury. Logistic regression was performed to identify independent risk factors for unplanned interventions.

RESULTS

191 patients were identified: 105 (55%) grade III, 64 (34%) grade IV, and 22 (12%) grade V injury; 136 (71%) underwent sNOM and 55 (29%) underwent OM. 21 (15%) patients required an unplanned intervention: 26 percutaneous drainage, 10 ERCP, and 3 angiography; 12 had multiple procedures. Male gender, younger age, higher ISS, higher grade of injury, firearm mechanism, and initial OM (all p < 0.05) were associated with unplanned interventions. Firearm mechanism and injury grade IV and V, but not initial OM, were independent risk factors for an unplanned intervention.

CONCLUSIONS

Grade of liver injury, not the initial mode of treatment, was significantly associated with requiring an unplanned intervention for liver-related complications. Surveillance at 7-10 days, or prior to discharge, in the high-risk group may be able to capture those requiring unplanned intervention and readmission.

Acute liver abscess after non-operative management of blunt liver injury: A rare case managed with laparoscopic drainage

•

Non-operative management (NOM) has today become the first treatment of choice when possible in patients with blunt liver injury.

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Liver abscess as a complication after NOM of blunt liver injury is a rare entity, with an incidence rate of 1.5%.

•

The most common bacteria responsible for liver abscess include Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pyogenes, gram-positive cocci, Clostridium, and mixed organisms.

•

Laparoscopic drainage can be performed safely and effectively for the liver abscess.

Introduction

Liver abscess may develop as a rare complication of the non-operative management (NOM) of blunt liver injury.

Presentation

A 36-year-old male was injured in a motorcycle accident on November 28, 2017. First aid was performed at the local hospital, then he was transferred to our trauma center for further management. The abdominal computed tomography (CT) revealed a segment 7/8 liver laceration, and the liver injury was of grade III according to the American Association for the Surgery of Trauma-Organ Injury Scale for liver injury. Intermittent high fever was observed for the first 3 days after NOM, and repeat abdominal CT showed an abscess with rupture at the previously injured liver parenchyma. He underwent laparoscopic drainage of the liver abscess, and culture revealed the presence of Salmonella enterica, serogroup D. After laparoscopic drainage, the patient recovered well, with a 21-day hospital stay.

Discussion

Liver abscess as a complication after NOM of blunt liver injury is a rare entity, with an incidence rate of 1.5%. It is usually seen in major liver injuries (grade III and above) and the abscesses take a median of 6 days (range, 1–12 days) to form and be diagnosed. The management of liver abscess may be by surgical drainage (laparotomy or laparoscopy) or percutaneous drainage.

Conclusion

This report reminds us the liver abscess complication after NOM of blunt liver injury, although it is a rare entity. Results of this patient support drainage of the liver abscess can be safely and effectively performed by laparoscopy.

Surgical treatment for severe liver injuries: a single-center experience

BACKGROUND

The liver is one of the most frequently injured organs in abdominal trauma. The advancements in diagnosis and interventional therapy shifted the management of liver trauma towards a non-operative management (NOM). Nevertheless, in severe liver injuries (LI), surgical treatment often involving liver resection (LR) and rarely liver transplantation (LT) remains the main option. The present paper analyses a single center experience in a referral HPB center on a series of patients with high-grade liver trauma.

METHODS

Forty-five patients with severe LI, that benefitted from NOM (6 pts), LRs (38 pts), and LT (1 pt) performed in our center between June 2000 and June 2019, were included in a combined prospective and retrospective study. The median age of the patients was 29 years (median 33, range 10-76), and the male/female ratio of 33/12. Almost all cases had blunt trauma, except 2 with stab wound (4.4%).

RESULTS

LIs classified according to the American Association for the Surgery of Trauma (AAST) system were 13.3% (grade III), 44.2% (grade IV), and 42.2% (grade V); none were grade I, II or VI. The rate of major LR was 56.4% (22 LRs). The median operative time was 200 minutes (mean 236; range 150-420). The median blood loss was 750 ml (mean 940; range 500-6500). Overall and major complication rates were 100% (45 pts) and 33.3% (15 pts), respectively. Overall mortality rate was 15.6% (7 pts).

CONCLUSIONS

Severe liver trauma, often involving complex liver resections, should be managed in a referral HPB center, thus obtaining the best results in terms of morbidity and mortality.

Biliovascuar complications: a price to pay for non-operative management of major liver trauma

BACKGROUND

With non-operative management of major liver trauma, there has been an increased incidence of biliovascular complications which are reported variably.

METHODS

Fifty-six patients with age of 29.79±11.40 years and M:F 8.3:1, with grade III or more liver trauma were evaluated after stabilization for the development of liver related complications. Patients with active contrast extravasation at admission were managed with immediate angioembolization. Patients with prolonged hospital stay underwent repeat CT prior to discharge. Radiological, endoscopic and surgical interventions were carried out as appropriate.

RESULTS

Ninety-eight percent had blunt abdominal injury. Mean injury severity score was 25.68±10.389. Four (7%) required damage control laparotomy. CECT showed grade III injuries in 52%, grade IV in 30.4%, and grade V in 18%. 11% had laceration extending to porta. Seventeen patients had 21 liver-related complications: 4 biliary, 12 vascular and 1 combined biliary and vascular. Liver related complications were- 3.5% in grade III, 52% in grade IV and 70% in grade V. One patient with active arterio-portal fistula required urgent angioembolization while other arterial pseudoaneurysms were detected 7.23±5.14 days after trauma. Angioembolization was successful in 83% patients. On univariate and multivariate analysis, PRBC requirement and injury grade were the predictors of bilivascular complications. Laceration extending to porta was a predictor for biliary complications and not vascular. Repeat CT picked up 13 complications in 10 patients.

CONCLUSIONS

Biliovascular complications are managed by multidisciplinary approach. Lacerations extending to porta and grade IV/V injuries have a higher chance of developing biliovascular complications and should be observed closely.

Nonoperative management of solid abdominal organ injuries: From past to present

BACKGROUND AND AIMS

Today, a significant proportion of solid abdominal organ injuries, whether caused by penetrating or blunt trauma, are managed nonoperatively. However, the controversy over operative versus nonoperative management started more than a hundred years ago. The aim of this review is to highlight some of the key past observations and summarize the current knowledge and guidelines in the management of solid abdominal organ injuries.

MATERIALS AND METHODS

A non-systematic search through historical articles and references on the management practices of abdominal injuries was conducted utilizing early printed volumes of major surgical and medical journals from the late 19th century onwards.

RESULTS

Until the late 19th century, the standard treatment of penetrating abdominal injuries was nonoperative. The first article advocating formal laparotomy for abdominal gunshot wounds was published in 1881 by Sims. After World War I, the policy of mandatory laparotomy became standard practice for penetrating abdominal trauma. During the latter half of the 20th century, the concept of selective nonoperative management, initially for anterior abdominal stab wounds and later also gunshot wounds, was adopted by major trauma centers in South Africa, the United States, and little later in Europe. In blunt solid abdominal organ injuries, the evolution from surgery to nonoperative management in hemodynamically stable patients aided by the development of modern imaging techniques was rapid from 1980s onwards.

CONCLUSION

With the help of modern imaging techniques and adjunctive radiological and endoscopic interventions, a major shift from mandatory to selective surgical approach to solid abdominal organ injuries has occurred during the last 30-50 years.

Clinical outcomes of primary arterial embolization in severe hepatic trauma: A systematic review

PURPOSE

This purpose of this systematic review was to determine the safety and efficacy of arterial embolization as the primary treatment for grade III-V liver trauma, excluding the postoperative use of arterial embolization.

MATERIAL AND METHODS

A total of 24 studies published between January 2000 and June 2018 qualified for inclusion in this study. Four of them were prospective studies and 20 were retrospective. A total of 3855 patients (mean age, 33.5 years; range: 22-52.5 years) were treated non-operatively and 659 patients (659/3855; 17.09%) with hepatic hemorrhage underwent primary arterial embolization from 2000 to 2017. Indication for arterial embolization was a contrast blush visible on computed tomography in hemodynamically stable patient in all studies.

RESULTS

The arterial embolization success rate ranged from 80% to 97%. The most commonly reported complication was bile leak, with an incidence of 5.7%. Nineteen bilomas (2.8%) were reported in five studies with a range between 4% and 45%. Hepatic ischemia was reported in eight studies, with a mean incidence of 8.6%.

CONCLUSION

Primary arterial embolization has a high success rate in patients with hepatic trauma. Complications, including biloma and hepatic ischemia, have acceptable rates in the context of a minimally-invasive procedure that allows stabilization of life-threatening, complex liver injuries.

Preliminary Report of Percutaneous Cholecystostomy as Diagnosis and Treatment of Biliary Tract Trauma

BACKGROUND

Biliary leak following severe blunt liver injuries is a complex problem becoming more frequent with improvements in non-operative management. Standard treatment requires main bile duct drainage usually performed by endoscopic sphincterotomy and stent placement. We report our experience with cholecystostomy as a first minimally invasive diagnostic and therapeutic approach.

METHODS

We performed a retrospective analysis of consecutive patients with post-traumatic biliary leak between 2006 and 2015. In the first period (2006-2010), biliary fistula was managed using perihepatic drainage and endoscopic, percutaneous or surgical main bile duct drainage. After 2010, cholecystostomy as an initial minimally invasive approach was performed.

RESULTS

Of 341 patients with blunt liver injury, 18 had a post-traumatic biliary leak. Ten patients received standard treatment and eight patients underwent cholecystostomy. The cholecystostomy (62.5%) and the standard treatment (80%) groups presented similar success rates as the first biliary drainage procedure (p = 0.41). Cholecystostomy presented no severe complications and resulted, when successful, in a bile flow rate inversion between the perihepatic drains and the gallbladder drain within a median [IQR] 4 days [1-7]. The median time for bile leak resolution was 26 days in the cholecystostomy group and 39 days in the standard treatment group (p = 0.09). No significant difference was found considering median duration of hospital stay (54 and 74 days, respectively, p = 0.37) or resuscitation stay (17.5 and 19.5 days, p = 0.59).

CONCLUSION

Cholecystostomy in non-operative management of biliary fistula after blunt liver injury could be an effective, simple and safe first-line procedure in the diagnostic and therapeutic approach of post-traumatic biliary tract injuries.

Detection and characterization of traumatic bile leaks using Gd-EOB-DTPA enhanced magnetic resonance cholangiography

Expanding bile leaks after blunt liver trauma require more aggressive treatment than contained bile leaks. In this retrospective study approved by institution review board, we analyzed if non-invasive contrast-enhanced magnetic resonance cholangiography (CEMRC) using hepatocyte-specific contrast agent (gadoxetic acid disodium) could detect and characterize traumatic bile leaks. Between March 2012 and December 2014, written informed consents from 22 included patients (17 men, 5 women) with a median age of 24.5 years (IQR 21.8, 36.0 years) were obtained. Biliary tree visualization and bile leak detection on CEMRC acquired at 10, 20, 30, 90 minutes time points were independently graded by three radiologists on a 5-point Likert scale. Intraclass Correlation (ICC) was computed as estimates of interrater reliability. Accuracy was measured by area under receiver operating characteristic curves (AUROC). Biliary tree visualization was the best on CEMRC at 90 minutes (score 4.30) with excellent inter-rater reliability (ICC = 0.930). Of 22 CEMRC, 15 had bile leak (8 expanding, 7 contained). The largest AUROC of bile leak detection by three radiologists were 0.824, 0.914, 0.929 respectively on CEMRC at 90 minutes with ICC of 0.816. In conclusion, bile leaks of blunt liver trauma can be accurately detected and characterized on CEMRC.

Liver trauma: What current management?

BACKGROUND

The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years.

METHODS

The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed.

RESULTS

The study involved 83 patients, with a mean age of 33 years and a marked male predominance (85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries (81.9%) were of low severity (grades I, II, III), while 15 (18.1%) were of high severity (grade IV or greater). Fifty-six patients (67.5%) had multiple injuries. Surgical treatment was performed in 26 (31.3%) patients. Non-operative management was undertaken in 57 cases (68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group.

CONCLUSIONS

Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.

Traumatic Liver Injury in Hong Kong: The Management Strategy and Outcome

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.

Management of Traumatic Liver and Bile Duct Laceration

Posttraumatic major bile leak in children is uncommon, with few cases reported in the literature. These injuries are seen in high-grade liver trauma and are difficult to diagnose and manage. We describe a 7-year-old boy with grade IV hepatic trauma and bile leak following blunt abdominal trauma. The leak was successfully managed by percutaneous drainage and endoscopic retrograde cholangiopancreatography (ERCP) stenting of the injured hepatic duct. How to cite this article: Tiwari C, Shah H, Waghmare M, Khedkar K, Dwivedi P. Management of Traumatic Liver and Bile Duct Laceration. Euroasian J Hepato-Gastroenterol 2017;7(2):188-190.

Outcomes and complications of angioembolization for hepatic trauma: A systematic review of the literature

BACKGROUND

The liver is one of the most frequently injured abdominal organs. Hepatic hemorrhage is a complex and challenging complication following hepatic trauma. Significant shifts in the treatment of hepatic hemorrhage, including the increasing use of angioembolization, are believed to have improved patient outcomes. We aimed to describe the efficacy of angioembolization in the setting of acute hepatic arterial hemorrhage as well as the complications associated with this treatment modality.

METHODS

A systematic review of published literature (MEDLINE, SCOPUS, and Cochrane Library) describing hepatic angioembolization in the setting of trauma was performed. Articles that fulfilled the predetermined inclusion and exclusion criteria were included. We analyzed the efficacy rate of angioembolization in the setting of traumatic hepatic hemorrhage as well as the complications associated with hepatic angioembolization.

RESULTS

Four hundred fifty-nine articles were identified in the literature search. Of these, 10 retrospective studies and 1 prospective study met inclusion and exclusion criteria. Efficacy rate of angioembolization was 93%. The most frequently reported complications following hepatic angioembolization included hepatic necrosis (15%), abscess formation (7.5%), and bile leaks.

CONCLUSION

Although the outcomes of hepatic angioembolization were generally favorable with a high success rate, the treatment modality is not without associated morbidity. The most frequently associated major complication was hepatic necrosis. Rates of complications were affected by study heterogeneity and should be better defined in future studies.

LEVEL OF EVIDENCE

Systematic review, level III.

The role of interventional radiology in abdominopelvic trauma

The management of trauma patients has evolved in recent decades owing to increasing availability of advanced imaging modalities such as CT. Nowadays, CT has replaced the diagnostic function of angiography. The latter is considered when a therapeutic option is hypothesized. Arterial embolization is a life-saving procedure in abdominopelvic haemorrhagic patients, reducing relevant mortality rates and ensuring haemodynamic stabilization of the patient. Percutaneous transarterial embolization has been shown to be effective for controlling ongoing bleeding for patients with high-grade abdominopelvic injuries, thereby reducing the failure rate of non-operative management, preserving maximal organ function. Surgery is not always the optimal solution for stabilization of a patient with polytrauma. Mini-invasivity and repeatability may be considered as relevant advantages. We review technical considerations, efficacy and complication rates of hepatic, splenic, renal and pelvic embolization to extrapolate current evidence about transarterial embolization in traumatic patients.

Nonoperative management of blunt hepatic trauma: A systematic review

BACKGROUND

Nonoperative management (NOM) has become the standard treatment in hemodynamically stable patients with blunt hepatic injuries. While the reported overall success rates of NOM are excellent, there is a lack of consensus regarding the risk factors predicting the failure of NOM. The aim of this systematic review was to identify the incidence and prognostic factors for failure of NOM in adult patients with blunt hepatic trauma.

METHODS

Prospective studies reporting prognostic factors for the failure of nonoperative treatment of blunt liver injuries were identified by searching MEDLINE and the Cochrane Central Register of Controlled Trials.

RESULTS

We screened 798 titles and abstracts, of which 8 single-center prospective observational studies, reporting 410 patients, were included in the qualitative and quantitative synthesis. No randomized controlled trials were found. The pooled failure rate of NOM was 9.5% (0-24%). Twenty-six prognostic factors predicting the failure of NOM were reported, of which six reached statistical significance in one or more studies: blood pressure (p < 0.05), fluid resuscitation (p = 0.02), blood transfusion (p = 0.003), peritoneal signs (p < 0.0001), Injury Severity Score (ISS) (p = 0.03), and associated intra-abdominal injuries (p < 0.01).

CONCLUSION

There is evidence that patients presenting with clinical signs of shock, a high ISS, associated intra-abdominal injuries, and peritoneal signs are at an increased risk of failure of NOM for the treatment of blunt hepatic injuries.

LEVEL OF EVIDENCE

Systematic review, level III.

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.

Non-operative management versus operative management in high-grade blunt hepatic injury

BACKGROUND

Surgery used to be the treatment of choice in cases of blunt hepatic injury, but this approach gradually changed over the last two decades as increasing non-operative management (NOM) of splenic injury led to its use for hepatic injury. The improvement in critical care monitoring and computed tomographic scanning, as well as the more frequent use of interventional radiology techniques, has helped to bring about this change to non-operative management. Liver trauma ranges from a small capsular tear, without parenchymal laceration, to massive parenchymal injury with major hepatic vein/retrohepatic vena cava lesions. In 1994, the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (AAST) revised the Hepatic Injury Scale to have a range from grade I to VI. Minor injuries (grade I or II) are the most frequent liver injuries (80% to 90% of all cases); severe injuries are grade III-V lesions; grade VI lesions are frequently incompatible with survival. In the medical literature, the majority of patients who have undergone NOM have low-grade liver injuries. The safety of NOM in high-grade liver lesions, AAST grade IV and V, remains a subject of debate as a high incidence of liver and collateral extra-abdominal complications are still described.

OBJECTIVES

To assess the effects of non-operative management compared to operative management in high-grade (grade III-V) blunt hepatic injury.

SEARCH METHODS

The search for studies was run on 14 April 2014. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), PubMed, ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), clinical trials registries, conference proceedings, and we screened reference lists.

SELECTION CRITERIA

All randomised trials that compare non-operative management versus operative management in high-grade blunt hepatic injury.

DATA COLLECTION AND ANALYSIS

Two authors independently applied the selection criteria to relevant study reports. We used standard methodological procedures as defined by the Cochrane Collaboration.

MAIN RESULTS

We were unable to find any randomised controlled trials of non-operative management versus operative management in high-grade blunt hepatic injury.

AUTHORS' CONCLUSIONS

In order to further explore the preliminary findings provided by animal models and observational clinical studies that suggests there may be a beneficial effect of non-operative management versus operative management in high-grade blunt hepatic injury, large, high quality randomised trials are needed.

Delayed bile leak in a patient with grade IV blunt liver trauma: A case report and review of the literature

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A case with delayed bile leak in a young male patient who presented with grade IV blunt liver injury following a motor vehicle collision.

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In addition to a high grade injury; centrally located liver injury is a significant risk factor for major bile duct injury.

•

For such patients, early MRCP and ERCP may be warranted to rule out a significant bile leak.

•

Patients with high grade liver injury are at risk of serious complications.

•

There is a need for prompt diagnosis and treatment of delayed bile leak in blunt liver injuries.

Introduction

Delayed bile leak following blunt liver trauma is not common.

Presentation of case

We presented a case report and literature review of delayed bile leak in a young male patient who presented with grade IV blunt liver injury following a motor vehicle collision; he was a restrained driver who hit a fixed object. Physical examination was unremarkable except for revelaed tachycardia, right upper quadrant abdominal tenderness, and open left knee fracture. A diagnosis of grade IV multiple liver lacerations with large hemo-peritoneum was made and urgent exploratory laparotomy was performed. The patient developed a biloma collection post- operatively. He underwent endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct stenting. His recovery was uneventful, and he was discharged home after 1 month.

Discussion

This is a rare case with no intra or extra hepatic biliary radicle injury seen on magnetic resonance cholangiopancreatography (MRCP) and no evidence of leak by ERCP. A review of the literature to highlight the incidence of delayed bile leak revealed only few reported cases.

Conclusion

Our findings demonstrate the need for prompt diagnosis and treatment of delayed bile leak in blunt liver injuries. When these principles are followed, a successful outcome is possible.

Management of blunt liver trauma in 134 severely injured patients

BACKGROUND

In haemodynamic stable patients without an acute abdomen, nonoperative management (NOM) of blunt liver injuries (BLI) has become the standard of care with a reported success rate of between 80 and 100%. Concern has been expressed about the potential overuse of NOM and the fact that failed NOM is associated with higher mortality rate. The aim of this study was to evaluate factors that might indicate the need for surgical intervention, and to assess the efficacy of NOM.

METHODS

A single centre prospective study between 2008 and 2013 in a level-1 Trauma Centre. One hundred thirty four patients with BLI were diagnosed on CT-scan or at laparotomy. The median ISS was 25 (range 16-34).

RESULTS

Thirty five (26%) patients underwent an early exploratory laparotomy. The indication for surgery was haemodynamic instability in 11 (31%) patients, an acute abdomen in 16 (46%), and 8 (23%) patients had CT findings of intraabdominal injuries, other than the hepatic injury, that required surgical repair. NOM was initiated in 99 (74%) patients, 36 patients had associated intraabdominal solid organ injuries. Seven patients developed liver related complications. Five (5%) patients required a delayed laparotomy (liver related (3), splenic injury (2)). NOM failure was not related to the presence of shock on admission (p=1000), to the grade of liver injury (p=0.790) or associated intraabdominal injuries (p=0.866).

CONCLUSION

Physiologic behaviour or CT findings dictated the need for operative intervention. NOM of BLI has a high success rate (95%). Nonoperative management of BLI should be considered in patients who respond to resuscitation, irrespective of the grade of liver trauma. Associated intraabdominal solid organ injuries do not exclude NOM.

[Diagnosis and treatment of abdominal trauma]

Abdominal trauma represents the leading cause of haemorrhagic shock in the severely injured patient and is associated with high mortality and morbidity rates. The trauma surgeon has a central role in the multidisciplinary team addressing the specific diagnostic and therapeutic needs of patients with abdominal trauma. The management of blunt and penetrating abdominal trauma has undergone substantial changes in recent decades. Major innovations have been established in the field of diagnostic imaging and of nonoperative interventions such as angioembolization and endoscopic procedures. Another key development is the introduction of the damage control concept for the care of patients with abdominal trauma. The present manuscript comprises a review of the current management of abdominal trauma with an emphasis on diagnostic and therapeutic innovations.