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Hsu TA, Kang SC, Tee YS, Bokhari F, Fu CY. The negative effect of preexisting cirrhosis on blunt liver trauma patients: a multifaceted approach from the trauma quality improvement program database. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02655-z. [PMID: 39251436 DOI: 10.1007/s00068-024-02655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 08/19/2024] [Indexed: 09/11/2024]
Abstract
PURPOSE To assess the impact of pre-existing cirrhosis on the outcomes of non-operatively managed blunt liver trauma within the Trauma Quality Improvement Program (TQIP) database. METHODS A study of non-operatively managed blunt liver injury patients from 2016 to 2019 was conducted. Propensity score matching analyzed mortality, complications, and hospital length of stay (LOS) for patients with and without cirrhosis. The effect of transcatheter arterial embolization (TAE) was determined using multivariate logistic regression. RESULTS Out of 63,946 patients, 767 (1.2%) had pre-existing cirrhosis. Following 1:1 matching, those with cirrhosis experienced more hemorrhage (TAE need: 5.7% vs. 2.7%; transfusion volume: 639.1 vs. 259.3 ml), complications (acute kidney injury: 5.1% vs. 2.8%; sepsis: 2.4% vs. 1.0%), and poorer outcomes (mortality: 19.5% vs. 10.2%; hospital LOS: 11.6 vs. 8.4 days; ICU LOS: 12.1 vs. 7.4 days; ventilator days: 7.6 vs. 1.6). Notably, TAE was associated with increased mortality in cirrhotic patients (odds ratio: 4.093) but did not significantly affect mortality in patients without cirrhosis. CONCLUSIONS Within TQIP, pre-existing cirrhosis is a significant negative determinant for outcomes in blunt liver trauma. Cirrhotic patients undergoing TAE for hemostasis face greater mortality risk than non-cirrhotic counterparts.
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Affiliation(s)
- Ting-An Hsu
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Shih-Ching Kang
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Yu-San Tee
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan
| | - Faran Bokhari
- Emergency Surgical Services, St. Francis Hospital, OSF Healthcare System, Peoria, IL, USA
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Kwei Shan Township, Taoyuan, Taiwan.
- Emergency Surgical Services, St. Francis Hospital, OSF Healthcare System, Peoria, IL, USA.
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Ashley JR, Burczak KW, Cotton BA, Clements TW. Management of blunt abdominal trauma. Br J Surg 2024; 111:znae168. [PMID: 39030780 DOI: 10.1093/bjs/znae168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 06/16/2024] [Indexed: 07/22/2024]
Affiliation(s)
- Janet R Ashley
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Red Duke Trauma Institute, and McGovern Medical School, Houston, Texas, USA
| | - Keith W Burczak
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Red Duke Trauma Institute, and McGovern Medical School, Houston, Texas, USA
| | - Bryan A Cotton
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Red Duke Trauma Institute, and McGovern Medical School, Houston, Texas, USA
| | - Thomas W Clements
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, Red Duke Trauma Institute, and McGovern Medical School, Houston, Texas, USA
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Tsurkan VA, Shabunin AV, Grekov DN, Bedin VV, Arablinskiy AV, Yakimov LA, Shikov DV, Ageeva AA. [Endovascular technologies in the treatment of patients with blunt abdominal trauma]. Khirurgiia (Mosk) 2024:108-117. [PMID: 39140952 DOI: 10.17116/hirurgia2024081108] [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] [Indexed: 08/15/2024]
Abstract
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.
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Affiliation(s)
- V A Tsurkan
- Botkin Moscow City Clinical Hospital, Moscow, Russia
| | - A V Shabunin
- Botkin Moscow City Clinical Hospital, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - D N Grekov
- Botkin Moscow City Clinical Hospital, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - V V Bedin
- Botkin Moscow City Clinical Hospital, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - A V Arablinskiy
- Botkin Moscow City Clinical Hospital, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - L A Yakimov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - D V Shikov
- Botkin Moscow City Clinical Hospital, Moscow, Russia
| | - A A Ageeva
- Botkin Moscow City Clinical Hospital, Moscow, Russia
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Chen JL, Cheng TT, Huang CC, Chang HH, Lam CF. Dual phenotypic characteristics of P-selectin in a mouse model of hemorrhagic shock and hepatectomy. Heliyon 2023; 9:e18627. [PMID: 37554775 PMCID: PMC10404689 DOI: 10.1016/j.heliyon.2023.e18627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/14/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Membrane-bound P-selectin induces endothelial adhesion of leucocytes and amplifies organ inflammations during major trauma, while soluble P-selectin (sP-sel) mediates survival rescue properties. This study characterized the differential effects of P-selectin in a "2-hit" model of hemorrhagic shock (HS) and partial hepatectomy (PH). MATERIALS AND METHODS HS was induced by withdrawing blood (0.3 mL) directly from the mouse femoral arteries. 70% or 50% of liver volumes were resected after inducing HS. Time of survival in P-selectin deficient (Selp -/-) mice treated with and without intraperitoneal injections of recombinant P-sel IgG-Fc fusion proteins (rP-sel-Fc, 1.5 mg/kg) were recorded for up to 72h after injury. In addition, liver regeneration at 72h after HS and 50% PH was assessed in wild-type and Selp -/- mice. RESULTS Compared to wild-types, Selp -/- mice had significantly higher mortality rates post HS and 70% PH, as none of these animals survived up to 48h postoperatively. The survival curve was restored in Selp -/- mice pre-treated with rP-sel-Fc. In the HS followed by 50% PH experimental arm, liver remnant growth ratios were significantly higher in Selp -/- mice (15.7 ± 3.1 vs 11.7 ± 4.9, P = 0.040). The elevated serum concentrations of alanine aminotransferase post-PH were significantly reduced in Selp -/- mice. Hepatocyte proliferation indices (CYP7a1 and PCNA) expression were enhanced and myeloperoxidase activity in the regenerated remnant liver was reduced in the Selp -/- mice. CONCLUSION In critical conditions induced by HS and PH, P-selectin mediates two distinct phenotypic characteristics. Soluble-form circulating P-selectin improves survival in the acute stage of HS and extensive loss of liver parenchyma; membrane-bound P-selectin induces regional pro-inflammatory reactions in the remnant liver after the acute stage of two insults, thereby inhibiting hepatic regeneration. The results of this pre-clinical study may provide molecular mechanistic insight and clinical therapeutic applications of P-selectin in the acute and regenerative phases of traumatic hepatic injury.
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Affiliation(s)
- Jen-Lung Chen
- Division of General Surgery, Department of Surgery, E-Da Hospital, I-Shou University, Kaohsiung, 824, Taiwan
| | - Tzu-Ting Cheng
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, 824, Taiwan
| | - Chien-Chi Huang
- Department of Medical Research, E-Da Hospital, I-Shou University, Kaohsiung, 824, Taiwan
| | - Hsin-Hou Chang
- Department of Molecular Biology and Human Genetics, Tzu-Chi University, Hualien, 907, Taiwan
| | - Chen-Fuh Lam
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, 824, Taiwan
- Department of Anesthesiology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, 622, Taiwan
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Jeon S, Yu B, Lee GJ, Lee MA, Park Y, Cho J, Lee J, Choi ST, Choi KK. Liver Transplant After Severe Liver Trauma: The First Report in a Korean Adult. EXP CLIN TRANSPLANT 2023; 21:619-622. [PMID: 37584543 DOI: 10.6002/ect.2023.0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
Following a motor-vehicle accident, a 57-year-old man was diagnosed with a grade 4 liver injury (American Association for the Surgery of Trauma organ injury scale) with multiple contrast extravasations. He initially underwent nonoperative management, which included transcatheter arterial embolization. However, he experienced a hemorrhage after the first embo-lization procedure, and so the procedure was repeated. Thereafter, he was diagnosed with liver failure based on findings from computed tomography and liver function tests. On day 28 of hospitalization, the patient underwent deceased donor liver transplant. He experienced several complications, including acute renal failure, pneumonia, and bile leak. These were managed successfully, and the patient was discharged 4 months after the transplant. Although liver transplant procedure for hepatic trauma is technically challenging and risky, it should be considered a viable treatment option in some patients (such as patients with severe liver injury). This is the first reported case, to our knowledge, of a liver transplant performed successfully in a patient with severe hepatic trauma in Korea.
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Affiliation(s)
- Sebeom Jeon
- From the Department of Trauma Surgery, Gachon University, Gil Medical Center, Incheon, Korea
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Mitricof B, Kraft A, Anton F, Barcu A, Barzan D, Haiducu C, Brasoveanu V, Popescu I, Moldovan CA, Botea F. Severe liver trauma with complex portal and common bile duct avulsion: A case report and review of the literature. World J Clin Cases 2023; 11:3837-3846. [PMID: 37383130 PMCID: PMC10294146 DOI: 10.12998/wjcc.v11.i16.3837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/02/2023] [Accepted: 04/12/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Given its size and location, the liver is the third most injured organ by abdominal trauma. Thanks to recent advances, it is unanimously accepted that the non-operative management is the current mainstay of treatment for hemodynamically stable patients. However, those patients with hemodynamic instability that generally present with severe liver trauma associated with major vascular lesions will require surgical management. Moreover, an associated injury of the main bile ducts makes surgery compulsory even in the case of hemodynamic stability, thereby imposing therapeutic challenges in the tertiary referral hepato-bilio-pancreatic centers’ setting.
CASE SUMMARY We present the case of a 38-year-old male patient with The American Association for the Surgery of Trauma grade V liver injury and an associated right branch of portal vein and common bile duct avulsion, due to a crush polytrauma. The patient was referred to the nearest emergency hospital and because of the hemorrhagic shock, damage control surgery was performed by means of ligation of the right portal vein branch and right hepatic artery, and hemostatic packing. Afterwards, the patient was referred immediately to our tertiary hepato-bilio-pancreatic center. We performed depacking, a right hepatectomy and Roux-en-Y hepaticojejunostomy. On the 9th postoperative day, the patient developed a high output anastomotic bile leak that required a redo of the cholangiojejunostomy. The postoperative period was marked by a surgical incision site of incomplete evisceration that was managed non-operatively by negative wound pressure. The follow-up was optimal, with no complications at 55 mo.
CONCLUSION In conclusion, the current case clearly supports that a favorable outcome in severe liver trauma with associated vascular and biliary injuries is achieved thru proper therapeutic management, conducted in a tertiary referral hepato-bilio-pancreatic center, where a stepwise and complex surgical approach is mandatory.
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Affiliation(s)
- Bianca Mitricof
- Medicine Doctoral School, Titu Maiorescu University of Bucharest, Bucharest 040441, Romania
| | - Alin Kraft
- Department of General Surgery, Regina Maria Military Emergency Hospital, Brasov 500007, Romania
| | - Florentina Anton
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 050474, Romania
| | - Alexandru Barcu
- Medicine Doctoral School, Titu Maiorescu University of Bucharest, Bucharest 040441, Romania
| | - Darina Barzan
- Dan Setlacec Center for General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Carmen Haiducu
- Dan Setlacec Center for General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Vladislav Brasoveanu
- Dan Setlacec Center for General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
- Department of Medical-Surgical and Prophylactic Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
| | - Irinel Popescu
- Dan Setlacec Center for General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
- Department of Medical-Surgical and Prophylactic Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
| | - Cosmin Alec Moldovan
- Department of Medical-Surgical and Prophylactic Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of General Surgery, Witting Clinical Hospital, Bucharest 010243, Romania
| | - Florin Botea
- Dan Setlacec Center for General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
- Department of Medical-Surgical and Prophylactic Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
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Liu J, Wang S, Xue X, Hu T, Peng X, Huang J, Zhou S. Experimental study of the effects of absorbable gelatin sponge and non‑absorbable polyvinyl alcohol particle material used in transcatheter arterial embolization on liver tissues. Exp Ther Med 2023; 25:229. [PMID: 37114170 PMCID: PMC10126803 DOI: 10.3892/etm.2023.11928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/03/2023] [Indexed: 04/29/2023] Open
Abstract
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.
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Affiliation(s)
- Jianping Liu
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Shaoyi Wang
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Xiaojun Xue
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Tiansong Hu
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Xinjian Peng
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Junhao Huang
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Song Zhou
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
- Correspondence to: Professor Song Zhou, Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, 269 Zhanghua Middle Road, Zhangzhou, Fujian 363000, P.R. China
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An observation-first strategy for liver injuries with "blush" on computed tomography is safe and effective. J Trauma Acute Care Surg 2023; 94:281-287. [PMID: 36149844 DOI: 10.1097/ta.0000000000003786] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE Therapeutic/Care Management; Level II.
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Panasenko SI, Guriev SO, Lysun DM, Kushnir VA, Saliutin RV. Closed abdominal trauma in polytrauma. Part II: surgical tactics for the damages control. KLINICHESKAIA KHIRURGIIA 2022. [DOI: 10.26779/2522-1396.2022.3-4.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Closed abdominal trauma in polytrauma. Part II: surgical tactics for the damages control
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10
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Clinical outcomes of non-operative management and clinical observation in non-angioembolised hepatic trauma: A systematic review of the literature. Chin J Traumatol 2022; 25:257-263. [PMID: 35487854 PMCID: PMC9458985 DOI: 10.1016/j.cjtee.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 01/30/2022] [Accepted: 02/26/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE. METHODS A systematic literature review searched "liver trauma", "hepatic trauma", "conservative management", "non operative management" on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs; studies reported NOM complications together with those post-intervention; case reports; studies including less than 5 cases; studies not written in English; and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test. RESULTS A total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%. CONCLUSION NOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.
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Roberts R, Sheth RA. Hepatic trauma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1195. [PMID: 34430636 PMCID: PMC8350720 DOI: 10.21037/atm-20-4580] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 01/25/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Rene Roberts
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Rahul A. Sheth
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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12
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The Role of Angioembolization in Liver Trauma: the 10-Year Retrospective Experience of a Level One Trauma Center. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02726-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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13
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Spiliopoulos S, Katsanos K, Paraskevopoulos I, Mariappan M, Festas G, Kitrou P, Papageorgiou C, Reppas L, Palialexis K, Karnabatidis D, Brountzos E. Multicenter retrospective study of transcatheter arterial embolisation for life-threatening haemorrhage in patients with uncorrected bleeding diathesis. CVIR Endovasc 2020; 3:95. [PMID: 33301058 PMCID: PMC7728894 DOI: 10.1186/s42155-020-00186-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/29/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND We retrospectively investigated outcomes of emergency TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding diathesis. MATERIALS AND METHODS This multicenter, retrospective, study, was designed to investigate the safety and efficacy of percutaneous TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding disorder at the time of embolization. All consecutive patients with uncorrected coagulation who underwent TAE for the treatment of haemorrhage, between January 1st and December 31th 2019 in three European centers were included. Inclusion criteria were thrombocytopenia (platelet count < 50,000/mL) and/or International Normalized Ratio (INR) ≥2.0, and/or activated partial thromboplastin time (aPTT) > 45 s, and/or a pre-existing underlying blood-clotting disorder such as factor VIII, Von Willebrand disease, hepatic cirrhosis with abnormal liver function tests. Primary outcome measures were technical success, rebleeding rate and clinical success. Secondary outcome measures included patients' 30-day survival rate, and procedure-related complications. RESULTS In total, 134 patients underwent TAE for bleeding control. A subgroup of 17 patients with 18 procedures [11 female, mean age 70.5 ± 15 years] which represent 12.7% of the total number of patients, presented with pathological coagulation parameters at the time of TAE (haemophilia n = 3, thrombocytopenia n = 1, cirrhosis n = 5, anticoagulants n = 7, secondary to bleeding n = 1) and were analyzed. Technical success was 100%, as in all procedures the bleeding site was detected and successfully embolised. Clinical success was 100%, as none of the patients died of bleeding during hospitalization, nor was surgically treated for bleeding relapse. Only one rebleeding case was noted (5.9%) that was successfully treated with a second TAE. No procedure-related complications were noted. According to Kaplan-Meier analysis the estimated 30-day survival rate was 84.2%. CONCLUSION TAE in selected patients with uncorrected bleeding diathesis should be considered as a suitable individualized management approach. Emergency TAE for life threatening haemorrhage in patients with coagulation cascade disorders should be used as an aid in realistic clinical decision making.
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Affiliation(s)
- Stavros Spiliopoulos
- grid.5216.00000 0001 2155 08002nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
- grid.417581.e0000 0000 8678 4766Department of Clinical Radiology, Interventional Radiology Unit, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, AB25 2ZN UK
| | - Konstantinos Katsanos
- grid.412458.eDepartment of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Ioannis Paraskevopoulos
- grid.417581.e0000 0000 8678 4766Department of Clinical Radiology, Interventional Radiology Unit, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, AB25 2ZN UK
| | - Martin Mariappan
- grid.417581.e0000 0000 8678 4766Department of Clinical Radiology, Interventional Radiology Unit, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, AB25 2ZN UK
| | - Georgios Festas
- grid.5216.00000 0001 2155 08002nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Panagiotis Kitrou
- grid.412458.eDepartment of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Christos Papageorgiou
- grid.412458.eDepartment of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Lazaros Reppas
- grid.5216.00000 0001 2155 08002nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Konstantinos Palialexis
- grid.5216.00000 0001 2155 08002nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Dimitrios Karnabatidis
- grid.412458.eDepartment of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Elias Brountzos
- grid.5216.00000 0001 2155 08002nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
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Early re-laparotomy for patients with high-grade liver injury after damage-control surgery and perihepatic packing. Surg Today 2020; 51:891-896. [PMID: 33170365 PMCID: PMC7652704 DOI: 10.1007/s00595-020-02178-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/18/2020] [Indexed: 02/05/2023]
Abstract
Purpose The likelihood of re-bleeding after damage-control surgery (DCS) and perihepatic packing for high-grade liver injuries is a major concern. Thus, although early re-laparotomy tends to be recommended, we conducted this study to evaluate the feasibility of performing definite laparotomy within ≤ 48 h in this clinical population. Methods The subjects of this retrospective study were 65 patients (n = 24, ≤ 48-h group; n = 41, > 48-h group) who underwent DCS and perihepatic packing. The primary outcome was the rate of repacking for bleeding during re-laparotomy and the secondary outcomes were mortality and length of stay in the intensive care unit (ICU). Results The ≤ 48-h group had a higher rate of angioembolization and transfusion of red blood cells (RBCs), fresh frozen plasma, and platelets, but the rates of repacking and mortality were not significantly different between the groups. However, the incidence of pneumonia and ventilation support requirement were significantly lower in the ≤ 48-h group than in the > 48-h group. Conclusion The re-laparotomy performed within ≤ 48 h after DCS and perihepatic packing is feasible for patients with high grade liver injury, using angioembolization and aggressive transfusion, as required. Early re-laparotomy reduces the need for prolonged ventilator support and the incidence of ventilator-associated pneumonia.
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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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Yu HH, Won YD, Lee SL, Ku YM, Song SW. Multidetector CT Findings of Solid Organ Injury Based on 2018 Updated American Association for the Surgery of Trauma Organ Injury Scaling System. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:1348-1363. [PMID: 36237708 PMCID: PMC9431845 DOI: 10.3348/jksr.2020.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/17/2020] [Accepted: 03/31/2020] [Indexed: 11/16/2022]
Abstract
2018년에 새롭게 개정된 장기 손상척도는 이전 미국외상수술협회의 응급수술분류체계와 유사한 형식을 가지며, 고형장기 손상의 등급을 지정하는 기준을 영상(imaging), 수술(operative), 병리(pathologic) 세 가지 세트로 나누어 분류하였다. 2018년 개정에서 가장 중요한 변화는 거짓동맥류와 동정맥 누공을 포함한 혈관 손상의 다중검출CT (multidetector CT; 이하 MDCT) 소견을 정의하여 장기 손상척도에 통합한 것이다. 이전 장기 손상척도와 동일하게 세 가지 기준 중에 가장 높은 등급이 최종 등급이 된다. 또한 한 장기 내에 여러 개의 1등급 또는 2등급 소견이 있으면, 다발성 손상에 대해 3등급의 부여가 가능하다. 본 임상화보에서는 2018년 개정된 미국외상수술협회 장기 손상척도의 MDCT 소견을 소개하고자 한다.
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Affiliation(s)
- Hyo Hyeon Yu
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo Dong Won
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Su Lim Lee
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Mi Ku
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Wha Song
- Department of Radiology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Elshaer AR, Abdelsalam AA, Elgeyoushi FA, Allam AR. Managing post-traumatic gunshot thoraco-abdominal bleeding by intervention embolisation: A case report. J Taibah Univ Med Sci 2019; 14:193-198. [PMID: 31555071 PMCID: PMC6708075 DOI: 10.1016/j.jtumed.2019.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 11/14/2022] Open
Abstract
We report an interesting life-threating case of post-traumatic severe bleeding in the thoraco-abdominal region. The patient was initially treated by open surgery, which failed to control bleeding in the intrahepatic and sub-diaphragmatic regions of the liver with associated haematoma collection. As bleeding continued, on the 2nd post-operative day, the patient underwent super-selective embolisation of the bleeding vessels to cease serious bleeding. The pre-embolisation arterial feeders with active bleeding and post-embolisation images by computed tomography subtraction angiography showed complete cessation of haemorrhage. Torrential haemorrhage in the thoraco-abdominal regions can be successfully managed by trained interventional radiologists in highly specialised centres.
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Affiliation(s)
- Anas R Elshaer
- Department of Diagnostic and Interventional Radiology, King Fahad Hospital Madinah, KSA
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19
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Increased Severe Trauma Patient Volume is Associated With Survival Benefit and Reduced Total Health Care Costs: A Retrospective Observational Study Using a Japanese Nationwide Administrative Database. Ann Surg 2019; 268:1091-1096. [PMID: 28594743 DOI: 10.1097/sla.0000000000002324] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the associations of severe trauma patient volume with survival benefit and health care costs. BACKGROUND The effect of trauma patient volume on survival benefit is inconclusive, and reports on its effects on health care costs are scarce. METHODS We conducted a retrospective observational study, including trauma patients who were transferred to government-approved tertiary emergency hospitals, or hospitals with an intensive care unit that provided an equivalent quality of care, using a Japanese nationwide administrative database. We categorized hospitals according to their annual severe trauma patient volumes [1 to 50 (reference), 51 to 100, 101 to 150, 151 to 200, and ≥201]. We evaluated the associations of volume categories with in-hospital survival and total cost per admission using a mixed-effects model adjusting for patient severity and hospital characteristics. RESULTS A total of 116,329 patients from 559 hospitals were analyzed. Significantly increased in-hospital survival rates were observed in the second, third, fourth, and highest volume categories compared with the reference category [94.2% in the highest volume category vs 88.8% in the reference category, adjusted odds ratio (95% confidence interval, 95% CI) = 1.75 (1.49-2.07)]. Furthermore, significantly lower costs (in US dollars) were observed in the second and fourth categories [mean (standard deviation) for fourth vs reference = $17,800 ($17,378) vs $20,540 ($32,412), adjusted difference (95% CI) = -$2559 (-$3896 to -$1221)]. CONCLUSIONS Hospitals with high volumes of severe trauma patients were significantly associated with a survival benefit and lower total cost per admission.
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Fernández Cepedal L, Gastaca Mateo M, Prieto Calvo M, Valdivieso López A, Fernández Gómez Cruzado L, Perez González C, Perfecto Valero A, Colina Alonso A. Liver transplantation following hepatic artery avulsion in a trauma patient. J Surg Case Rep 2019; 2019:rjz063. [PMID: 30976384 PMCID: PMC6451184 DOI: 10.1093/jscr/rjz063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 03/11/2019] [Indexed: 01/12/2023] Open
Abstract
Background Hepatic artery avulsion following politrauma is an extremely rare condition with a very high mortality rate. Management is based on damage control surgery given the precarious situation of these patients. Ligating the artery is one option under such circumstances, despite potential consequences including ischemic cholangiopathy (IC). Ischemic cholangiopathy, which can be caused by an insufficient blood supply to the bile duct, generally results in stricture and recurrent cholangitis, and the need for a liver transplant in extreme cases. Case presentation We present the case of a 37-year-old male with multiple traumas after falling from the third floor of a building. He was hemodynamically unstable upon arrival at the emergencies department, with no improvement on administration of aggressive fluid therapy. A Echo-FAST exam evidenced fluid in all quadrants, so the patient was transferred to the operating room where a 4-litre hemoperitoneum secondary to total avulsion of the proper hepatic artery was observed. The patient required massive transfusion and vasoactive drugs, with instability throughout the intervention; therefore, we decided to ligate the proper hepatic artery. Hepatic dysfunction and diffuse IC with multiple episodes of recurrent cholangitis were observed during the postoperative period. Given the irreversible clinical picture, we opted for a liver transplant 70 days after the patient’s initial admission. The patient died on Day 34 post-transplant due to irreversible ischemic brain damage and a right occipital hemorrhage. Conclusions Hepatic artery avulsion due to trauma is very rare and its management very complex, and in certain situations the artery must be ligated. The main consequence of ligating the hepatic artery is IC, which is more frequently observed secondary to iatrogenic lesions or systemic diseases, while very few cases have been published in which IC is secondary to hepatic artery avulsion caused by hepatic trauma. Treatment depends on the extent of ischemia, and when the damage is diffuse, as in our case, it may involve a liver transplant.
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Affiliation(s)
- Lara Fernández Cepedal
- Department of General and Digestive Surgery, Cruces University Hospital, Plaza Cruces s/n, 48903, Barakaldo, Vizcaya, Spain
| | - Mikel Gastaca Mateo
- Department of General and Digestive Surgery, Cruces University Hospital, Plaza Cruces s/n, 48903, Barakaldo, Vizcaya, Spain
| | - Mikel Prieto Calvo
- Department of General and Digestive Surgery, Cruces University Hospital, Plaza Cruces s/n, 48903, Barakaldo, Vizcaya, Spain
| | - Andrés Valdivieso López
- Department of General and Digestive Surgery, Cruces University Hospital, Plaza Cruces s/n, 48903, Barakaldo, Vizcaya, Spain
| | - Laura Fernández Gómez Cruzado
- Department of General and Digestive Surgery, Cruces University Hospital, Plaza Cruces s/n, 48903, Barakaldo, Vizcaya, Spain
| | - Christian Perez González
- Department of General and Digestive Surgery, Cruces University Hospital, Plaza Cruces s/n, 48903, Barakaldo, Vizcaya, Spain
| | - Arkaitz Perfecto Valero
- Department of General and Digestive Surgery, Cruces University Hospital, Plaza Cruces s/n, 48903, Barakaldo, Vizcaya, Spain
| | - Alberto Colina Alonso
- Department of General and Digestive Surgery, Cruces University Hospital, Plaza Cruces s/n, 48903, Barakaldo, Vizcaya, Spain
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Virdis F, Reccia I, Di Saverio S, Tugnoli G, Kwan SH, Kumar J, Atzeni J, Podda M. Clinical outcomes of primary arterial embolization in severe hepatic trauma: A systematic review. Diagn Interv Imaging 2018; 100:65-75. [PMID: 30555019 DOI: 10.1016/j.diii.2018.10.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- F Virdis
- General Surgery Department, Hillingdon Hospital NHS Foundation Trust, Uxbridge, UB8 3NN, London, United Kingdom.
| | - I Reccia
- Haepato-Biliary-Pancreatic Unit, Hammersmith Hospital, Imperial College, Du Cane Road W120HS, London, United Kingdom
| | - S Di Saverio
- Department of Surgery, Addenbrooke's Hospital, Hills Rd, CB2 0QQ, Cambridge, United Kingdom
| | - G Tugnoli
- Trauma and Emergency Surgery Unit, Maggiore Hospital, Largo Nigrisoli, 2, 40133 Bologna BO, Italy
| | - S H Kwan
- Royal Perth Hospital, 97, Wellington St, Perth WA 6000, Australia
| | - J Kumar
- Department of Surgery & Cancer, Imperial College, Du Cane Road, W120HS London, United Kingdom
| | - J Atzeni
- General and Emergency Surgery Unit, Ns Signora di Bonaria Hospital, 09037 San Gavino, Italy
| | - M Podda
- General, Emergency and Robotic Surgery Unit, San Francesco Hospital, 08100 Nuoro NU, Italy
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Gaski IA, Skattum J, Brooks A, Koyama T, Eken T, Naess PA, Gaarder C. Decreased mortality, laparotomy, and embolization rates for liver injuries during a 13-year period in a major Scandinavian trauma center. Trauma Surg Acute Care Open 2018; 3:e000205. [PMID: 30539153 PMCID: PMC6242012 DOI: 10.1136/tsaco-2018-000205] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/26/2018] [Accepted: 10/03/2018] [Indexed: 12/05/2022] Open
Abstract
Background Although non-operative management (NOM) has become the treatment of choice in hemodynamically normal patients with liver injuries, the optimal management of Organ Injury Scale (OIS) grades 4 and 5 injuries is still controversial. Oslo University Hospital Ulleval (OUHU) has since 2008 performed angiography only with signs of bleeding. Simultaneously, damage control resuscitation was implemented. Would these changes result in a decreased laparotomy rate and need for angioembolization (AE), as well as decreased mortality? Methods We performed a retrospective study on all adult patients with liver injuries admitted at OUHU between 2002 and 2014. The total study population and patients with OIS grades 4 and 5 liver injuries underwent comparison between the periods before (P1) and after (P2) August 1, 2008. Results 583 patients were included (P1: 237, P2: 346), with a median Injury Severity Score (ISS) of 29. The total population and the subgroup of OIS 4 and 5 injuries were comparable in age, gender, mechanism of injury, injury severity and physiology. Overall laparotomy rates decreased from P1 to P2 (35%–24%; p<0.01), as did the AE rate (11%–5%; p<0.01). The 30-day crude mortality decreased from 14% to 7% (p<0.05). A logistic regression model predicted an OR of 0.45 (95% CI 0.21 to 0.98) for dying when admitted in P2. In OIS grades 4 and 5 injuries (n=149, median ISS 34), similar reduction in AE rate was seen (30%–12%; p<0.05). The NOM rate for OIS grades 4 and 5 injuries was 70%, with 98% success rate. For the 30% requiring surgery, the mortality remained high (P1 52%; P2 40%), despite more balanced transfusion strategy. Discussion Changes in resuscitation and treatment protocols were associated with decreased laparotomy, and AE rates as well as overall mortality. NOM is safe in 70% of patients with OIS grades 4 and 5 injuries, in contrast to the critically ill 30% requiring surgery who still have poor outcome. Level of evidence IV.
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Affiliation(s)
- Iver Anders Gaski
- Department of Traumatology, Oslo University Hospital Ulleval and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jorunn Skattum
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Adam Brooks
- Department of Hepatobiliary, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tomohide Koyama
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Torsten Eken
- Department of Anesthesiology, Oslo University Hospital Ulleval and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital Ulleval and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
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Inukai K, Uehara S, Furuta Y, Miura M. Nonoperative management of blunt liver injury in hemodynamically stable versus unstable patients: a retrospective study. Emerg Radiol 2018; 25:647-652. [PMID: 30022309 DOI: 10.1007/s10140-018-1627-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/11/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE The success rate of nonoperative management (NOM) of traumatic liver injury is approximately 90%. Although NOM has become the standard treatment when patients' vital signs are stable, open surgical hemostasis is often selected when these signs are unstable. At our hospital, we extensively use NOM along with transcatheter arterial embolization (TAE) to treat patients with severe abdominal trauma, as per our original protocol. We also apply NOM for severe liver injury with unstable hemodynamics. This retrospective study aimed to investigate the efficacy of NOM for blunt liver injury in hemodynamically stable and unstable patients. METHODS We retrospectively examined 23 patients with severe liver injuries who underwent NOM after visiting our emergency outpatient department between 2007 and 2017. Patients were assigned to either the stable group with stable hemodynamics or the unstable group with unstable hemodynamics. RESULTS The stable group comprised 13 patients, and the unstable group comprised 10 patients. All patients underwent TAE. While all patients in the stable group were discharged alive, one patient in the unstable group died during the hospital stay. The response rate to NOM was 90%, and no patient switched from NOM to open surgery. A higher rate of complications with a significantly longer average stay in the intensive care unit was observed in the unstable group. CONCLUSIONS Even in the unstable group, NOM with TAE performed under careful general management facilitated avoidance of open surgery and provided high survival rates.
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Affiliation(s)
- Koichi Inukai
- Department of Surgery, Kariya Toyota General Hospital, 5-15 Sumiyoshi-cho, Kariya, Aichi, 448-8505, Japan.
| | - Shuhei Uehara
- Department of Surgery, Kariya Toyota General Hospital, 5-15 Sumiyoshi-cho, Kariya, Aichi, 448-8505, Japan
| | - Yoshiteru Furuta
- Department of Radiology, Kariya Toyota General Hospital, 5-15, Sumiyoshi-cho, Kariya, Aichi, 448-8505, Japan
| | - Masanao Miura
- Department of Emergency and Intensive Care, Kariya Toyota General Hospital, 5-15 Sumiyoshi-cho, Kariya, Aichi, 448-8505, Japan
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Abstract
PURPOSE OF REVIEW Although nonoperative management (NOM) is the safest option in most patients with liver and splenic injuries or splenic injuries, some cases still need operative intervention. The aim of this review is to address the most recent literature and the evidence it provides for indications and timing of operative treatment for liver and spleen injuries. RECENT FINDINGS There seems to be a decrease in publication rate on these topics over the last years, parallel to the acceptance of NOM as the 'gold standard', with little added to the existing body of evidence over the last 12-24 months. Most published studies are retrospective descriptions or comparisons with historical controls, some observational studies, but no randomized control trials (RCTs).There is a striking lack of high-level evidence for the optimal treatment of solid organ injuries. The role of angiographic embolization as an adjunct to the treatment of liver and spleen injuries is still a matter of discussion. SUMMARY Unstable patients with suspected ongoing bleeding from liver and spleen injuries or spleen injuries with inadequate effect of resuscitation should undergo immediate explorative laparotomy.More RCTs are needed to further determine the role of angiographic embolization and who can be safely be treated nonoperatively and who needs surgical intervention.
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Otsuka H, Sato T, Sakurai K, Aoki H, Yamagiwa T, Iizuka S, Inokuchi S. Use of interventional radiology as initial hemorrhage control to improve outcomes for potentially lethal multiple blunt injuries. Injury 2018; 49:226-229. [PMID: 29221814 DOI: 10.1016/j.injury.2017.11.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recently, trauma management has been markedly improved with interventional radiology (IVR) and damage-control strategies. However, the indications for its use in hemodynamically unstable patients with severe trauma remains unclear. In some cases, IVR may be more effective than surgery for damage-control hemostasis; however, performing IVR in life-threatening trauma settings is challenging. To address this, we practiced and evaluated a trauma-management system with emergency physicians who trained for both severe trauma management, and techniques of surgery and IVR. MATERIALS AND METHODS Among the 1822 patients with severe trauma admitted between October 2014 and December 2016, 201 underwent emergency surgery or IVR. Among these, 16 patients whose systolic blood pressure was ≤90 mmHg, without improvement following primary resuscitation, and whose first intervention was IVR, were analyzed. We retrospectively evaluated the admission characteristics, IVR-related characteristics, and prognoses, and compared several parameters before and after IVR. RESULTS This study included 10 men and 6 women (median age: 46 years). IVR was performed for 10 pelvic fractures; five liver-, one splenic-, and one renal injury; and one transection each of the external carotid-, vertebral-, axillosubclavian-, intercostal-, and lumbar arteries. The mean times from the patient arrival, and diagnosis to the start of IVR were 56.3 ± 26.6 and 15.1 ± 3.8 min, respectively. The mean time spent in the angiography suite was 50 min. The systolic blood pressure, pulse rate, base excess/deficit, serum-lactate levels, and D-dimer values were significantly improved after IVR. Although two patients needed additional treatment for morbidities following IVR intervention, all achieved complete recovery. The mortality rate was 25.0%, and no preventable deaths were noted. Eight patients showed unexpected survival. CONCLUSIONS In some cases, IVR may be the best first measure for resuscitative hemostasis in potentially lethal multiple injuries, given efficient diagnoses/actions and the ability to deal with complications.
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Affiliation(s)
- Hiroyuki Otsuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Toshiki Sato
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Keiji Sakurai
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Hiromichi Aoki
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Takeshi Yamagiwa
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Shinichi Iizuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
| | - Sadaki Inokuchi
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara-City, Kanagawa 259-1193, Japan.
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Perumean JC, Martinez M, Neal R, Lee J, Olajire-Aro T, Imran JB, Williams BH, Phelan HA. Low-grade blunt hepatic injury and benefits of intensive care unit monitoring. Am J Surg 2017; 214:1188-1192. [DOI: 10.1016/j.amjsurg.2017.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 08/24/2017] [Accepted: 09/05/2017] [Indexed: 11/24/2022]
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Lee KF, Chong CCN, Yeung JHH, Cheung NK, Siu EYY, Cheung YS, Wong J, Lai PBS. Factors affecting outcomes in traumatic liver injury: A retrospective study. SURGICAL PRACTICE 2017; 21:63-69. [DOI: 10.1111/1744-1633.12237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Kit-Fai Lee
- Department of Surgery; Prince of Wales Hospital; Hong Kong
| | | | | | - Nai-Kwong Cheung
- Department of Trauma and Emergency Centre; Prince of Wales Hospital; Hong Kong
| | - Eva Yin-Yu Siu
- Department of Surgery; Prince of Wales Hospital; Hong Kong
| | - Yue-Sun Cheung
- Department of Surgery; Prince of Wales Hospital; Hong Kong
| | - John Wong
- Department of Surgery; Prince of Wales Hospital; Hong Kong
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Endo A, Shiraishi A, Matsui H, Hondo K, Otomo Y. Assessment of Progress in Early Trauma Care in Japan over the Past Decade: Achievements and Areas for Future Improvement. J Am Coll Surg 2016; 224:191-198.e5. [PMID: 27825915 DOI: 10.1016/j.jamcollsurg.2016.10.051] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 10/18/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Strategies to optimize early trauma care have been introduced in Japan; however, detailed evaluation of the progress achieved has not been reported. STUDY DESIGN In this retrospective observational study, patients registered in the Japanese nationwide trauma registry were stratified according to probability of survival (Ps) > 0.5 or ≤ 0.5, respectively. Mortality rates during the first 2 days and in-hospital mortality rates were compared between early (2004 to 2009) and late cohorts (2010 to 2014) in each group, using mixed effects logistic regression analysis. Improvement in mortality rates during the first 2 days among subgroups were also assessed. RESULTS We analyzed 80,949 patients with Ps > 0.5 (early, 25,917; late, 55,032) and 8,898 patients with Ps ≤ 0.5 (early, 3,511; late, 5,387). Mortality rates during the first 2 days in both groups were significantly reduced (adjusted odds ratio [AOR; 95% CI] 0.61 [0.53 to 0.69] in the Ps > 0.5 group and 0.67 [0.60 to 0.76] in the Ps ≤ 0.5 group). In-hospital mortality rates in both groups were also significantly reduced (AOR [95% CI] 0.70 [0.64 to 0.76] and 0.73 [0.64 to 0.82], respectively). Significant improvements were observed in patients with a Revised Trauma Score ≥ 7 on arrival or an Abbreviated Injury Scale (AIS) of the abdomen ≥ 3. Limited improvements were observed in patients with head AIS ≥ 3 and in patients who underwent thoracotomy. CONCLUSIONS Although early trauma care has generally improved, specific progress was variable. Focused panel review of patients with severe head injury or undergoing thoracotomy may be an efficient strategy for further improvement.
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Affiliation(s)
- Akira Endo
- Trauma and Acute Critical Care Medical Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Atsushi Shiraishi
- Trauma and Acute Critical Care Medical Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan; Emergency and Trauma Center, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Kenichi Hondo
- Trauma and Acute Critical Care Medical Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Medical Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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Bailón-Cuadrado M, Barrera-Rebollo A, Sarmentero-Prieto JC, Rodríguez-López M, Blanco-Álvarez JI. Hemoperitoneo y síndrome compartimental abdominal por catéter venoso femoral intraperitoneal. Cir Esp 2016; 94:487-8. [DOI: 10.1016/j.ciresp.2016.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 03/02/2016] [Accepted: 03/07/2016] [Indexed: 02/03/2023]
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Initial Evaluation and Triage of the Injured Patient: Mechanisms of Injury and Triggers for Operating Room Versus Emergency Department Stabilization. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0148-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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