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Smith AA, Cone JT, McNickle AG, Mitchao DP, Kostka R, Martinez B, Schroeppel T, Cavalea A, Shahan CP, Axtman B, Braverman MA. MultiCenter Study of Intra-Abdominal Abscess Formation After Major Operative Hepatic Trauma. J Surg Res 2024; 295:746-752. [PMID: 38147760 DOI: 10.1016/j.jss.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/10/2023] [Accepted: 11/09/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION One of the significant complications of operative liver trauma is intra-abdominal abscesses (IAA). The objective of this study was to determine risk factors associated with postoperative IAA in surgical patients with major operative liver trauma. METHODS A retrospective multi-institutional study was performed at 13 Level 1 and Level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Univariate and multivariate analyses were performed. RESULTS Three hundred seventy-two patients were included with 21.2% (n = 79/372) developing an IAA. No difference was found for age, gender, injury severity score, liver injury grade, and liver resections in patients between the groups (P > 0.05). Penetrating mechanism of injury (odds ratio (OR) 3.42, 95% confidence interval (CI) 1.54-7.57, P = 0.02), intraoperative massive transfusion protocol (OR 2.43, 95% CI 1.23-4.79, P = 0.01), biloma/bile leak (OR 2.14, 95% CI 1.01-4.53, P = 0.04), hospital length of stay (OR 1.04, 95% CI 1.02-1.06, P < 0.001), and additional intra-abdominal injuries (OR 2.27, 95% CI 1.09-4.72, P = 0.03) were independent risk factors for IAA. Intra-abdominal drains, damage control laparotomy, total units of packed red blood cells, number of days with an open abdomen, total abdominal surgeries, and blood loss during surgery were not found to be associated with a higher risk of IAA. CONCLUSIONS Patients with penetrating trauma, massive transfusion protocol activation, longer hospital length of stay, and injuries to other intra-abdominal organs were at higher risk for the development of an IAA following operative liver trauma. Results from this study could help to refine existing guidelines for managing complex operative traumatic liver injuries.
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Affiliation(s)
- Alison A Smith
- Surgery Department, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana.
| | - Jennifer T Cone
- Surgery Department, University of Chicago School of Medicine, Chicago, Illinois
| | - Allison G McNickle
- Surgery Department, University of Nevada- Las Vegas School of Medicine, Las Vegas, Nevada
| | - Delbrynth P Mitchao
- Surgery Department, LAC+USC Medical Center, University of Southern California, Los Angeles, California
| | - Ryan Kostka
- Surgery Department, Baylor Scott and White Health, Dallas, Texas
| | - Benjamin Martinez
- Trauma Surgery Division, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana
| | - Thomas Schroeppel
- Surgery Department, University of Colorado Health, Colorado Springs, Colorado
| | - Alexander Cavalea
- Surgery Department, University of Tennessee Knoxville Medical Center, Knoxville, Tennessee
| | | | - Benjamin Axtman
- Trauma Division, Sanford Health Bismarck, Bismarck, North Dakota
| | - Maxwell A Braverman
- Surgery Department, St. Luke University Healthcare Network, Bethlehem, Pennsylvania
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YILDIRIM MB, ŞAHİNER İT, KENDİRCİ M, ÖZKAN B, ERKENT M, TOPCU R, BOSTANOĞLU S. Non-surgical follow-up success in blunt abdominal trauma. Can we protect patients with blunt abdominal trauma from surgery? JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.896899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Anticoagulation is Associated with Increased Mortality in Splenic Injuries. J Surg Res 2021; 266:1-5. [PMID: 33975026 DOI: 10.1016/j.jss.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/23/2021] [Accepted: 04/01/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Anticoagulation (AC) is associated with worse outcomes after trauma in some but not all studies. To further investigate the effect of AC on outcomes in patients with splenic injury, we analyzed the Trauma Quality Programs Participant Use File (PUF) METHODS: The 2017 PUF was used to identify adult (18+ y) with all mechanisms and grades of splenic injury. Demographics, comorbidities, hospital course and outcomes were compared between AC and non-AC patients. RESULTS A total of 18,749 patients were included, 622 were on AC. The AC patients were older but had comparable gender composition to non-AC patients. Injury Severity Score (18.2 versus 22.5) and rates of serious (AIS ≥ 3) injury were all lower in the AC group (P = 0.001). AC patients received fewer units of RBC (5.7 versus 8.0 units, P < 0.001) and FFP (3.9 versus 5.4 units, P < 0.001) in the first 24 h but underwent angiography at similar rates (23.6 versus 24.5%, P = 0.8). Among those who underwent angiography, patients were more likely to undergo embolization if they were on AC (89.7 versus 73.9%, P = 0.04). Rates of splenic surgery were comparable (19.3 versus 21.5%, P = 0.2) between AC versus non-AC patients. Median LOS was longer in AC patients (6.3 versus 5.6 d, P = 0.002). AC patients had a higher mortality (13.3 versus 7.0%, P = 0.001). In a multivariable binary logistic regression, AC was an independent risk factor for mortality with OR 1.4 (95% CI: 1.1-1.9) CONCLUSIONS: Anticoagulation is associated with increased mortality in patients with splenic injury.
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Bhattacharya B, Askari R, Davis KA, Dorfman J, Eid AI, Elsharkawy AE, Kasotakis G, Mackey S, Odom S, Okafor BU, Rosenblatt M, Ruditsky A, Velmahos G, Maung AA. The effect of anticoagulation on outcomes after liver and spleen injuries: A research consortium of New England centers for trauma (ReCONECT) study. Injury 2020; 51:1994-1998. [PMID: 32482426 DOI: 10.1016/j.injury.2020.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/26/2020] [Accepted: 05/01/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Liver and spleen injuries are the most commonly injured solid organs, the effects of anticoagulation on these injuries has not yet been well characterized. STUDY DESIGN Multicenter retrospective study. RESULT During the 4-year study period, 1254 patients, 64 (5%) on anticoagulation (AC), were admitted with liver and/or splenic injury. 58% of patients had a splenic injury, 53% had a liver injury and 11% had both. Patients on AC were older than non-AC patients (mean age 60.9 vs. 38.6 years, p < 0.001). The most common AC drug was warfarin (70%) with atrial fibrillation (47%) the most common indication for AC. There was no significant difference in AAST injury grade between AC and non-AC patients (median grade 2), but AC patients required a blood product transfusion more commonly (58 vs 40%, p = 0.007) particularly FFP (4 vs 19%, p < 0.01). Among those transfused, non-AC patients required slightly more PRBC (5.7 vs 3.8 units, p = 0.018) but similar amount of FFP (3.2 vs 3.1 units, p = 0.92). The two groups had no significant difference in the rates of initial non-operative management (50% (AC) vs 56% (non-AC), p = 0.3)) or failure of non-operative management (7 vs 4%, p = 0.16). AC patients were more likely to be managed initially with angiography (36 vs 20%, p = 0.001) while non-AC patients with surgery (24% vs 13%, p = 0.04). There was no significant difference in LOS and mortality. CONCLUSION The use of anticoagulation did not result in a difference in outcomes among patients with spleen and/or liver injuries.
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Affiliation(s)
| | - Reza Askari
- Brigham and Women's Hospital, Boston, MA, United States
| | | | - Jon Dorfman
- UMass Medical School, Worcester, MA, United States
| | - Ahmed I Eid
- Massachusetts General Hospital, Boston, MA, United States
| | | | | | | | - Stephen Odom
- Beth Israel Deaconess Medical Center, Boston, MA, United States
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Mitricof B, Brasoveanu V, Hrehoret D, Barcu A, Picu N, Flutur E, Tomescu D, Droc G, Lupescu I, Popescu I, Botea F. Surgical treatment for severe liver injuries: a single-center experience. MINERVA CHIR 2020; 75:92-103. [PMID: 32009332 DOI: 10.23736/s0026-4733.20.08193-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Bianca Mitricof
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
| | - Vladislav Brasoveanu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania.,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Doina Hrehoret
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Alexandru Barcu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Nausica Picu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Elena Flutur
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Dana Tomescu
- Center of Anesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Gabriela Droc
- Center of Anesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Ioana Lupescu
- Center of Diagnostic and Interventional Radiology, Fundeni Clinical Institute, Bucharest, Romania
| | - Irinel Popescu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania.,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Florin Botea
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania - .,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
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Fransvea P, Costa G, Massa G, Frezza B, Mercantini P, BaIducci G. Non-operative management of blunt splenic injury: is it really so extensively feasible? a critical appraisal of a single-center experience. Pan Afr Med J 2019; 32:52. [PMID: 31143357 PMCID: PMC6522183 DOI: 10.11604/pamj.2019.32.52.15022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 10/19/2018] [Indexed: 02/04/2023] Open
Abstract
Introduction The spleen is one of the most commonly injured organ following blunt abdominal trauma. Splenic injuries may occur in isolation or in association with other intra-and extra-abdominal injury. Nonoperative management of blunt injury to the spleen has become routine in children. In adult most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher grade injuries above all in multi-trauma patients. The aim of this study is the assessment of splenic trauma treatment, with particular attention to conservative treatment, its limits, its efficiency, and its safety in multi-trauma patient or in a severe trauma patient. Methods The present research focused on a retrospective review of patients with splenic injury. The research was performed by analyzing data of the trauma registry of St. Andrea University Hospital in Rome. The St. Andrea University Hospital trauma registry includes 1859. The variables taken into account were spleen injury and general injuries, age, sex, cause and dynamic of trauma, hemoglobin, hematocrit, white blood cells count, INR, number and time blood transfusion, hemodynamic stability, type of treatment provided, hospitalization period, morbidity and mortality. Assessment of splenic injuries was evaluated according to Abbreviated Injury Scale (AIS). Results The analysis among the general population of spleen trauma patients identified 68 patients with a splenic injury representing the 41.2% of all abdomen injury. The Average age was of 37.01 ± 17.18 years. The Average ISS value was of 22.88 ± 12.85; mediana of 24.50 (range 4-66). The average Spleen AIS value was of 3.13 ± 0.88; mediana 3.00 (range 2-5). The overall mortality ratio was of 19.1% (13 patients). The average ISS value in patients who died was of 41.92 ± 12.48, whereas in patients who survided was of 23.33 ± 10.15. The difference was considered to be statistically significant (p <0.001). The relashionship between the ISS and AIS values in patients who died was considered directly proportional but not statistically significant (Pearson test AIS/ISS = 0.132, p = n.s.). The initial management was a conservative treatment in 27 patients (39.7%) of them 4 patients (15%) failed, in the other 41 cases urgent splenectomies were performed. The average spleen AIS in all the patients who underwent splenectomy was 3.61 ± 0.63 whereas in the patients who were not treated surgically was 2.42 ± 0.69. The difference was deemed statistically significant (p <0.001). Conclusion Splenic injury, as reported in our statistic as well as in literature, is the most common injury in closed abdominal trauma. Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The preference of a conservative treatment must be based on the hemodynamic stability indices as well as on the spleen lesion severity and on the general trauma severity. The conservative treatment represent a feasible and safe therapeutic alternative even in case of severe lesions in politrauma patients, but the choice of the treatment form requires an assessment for each singular case.
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Affiliation(s)
- Pietro Fransvea
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Gianluca Costa
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Giulia Massa
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Barbara Frezza
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Paolo Mercantini
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Genoveffa BaIducci
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
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