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

The negative effect of preexisting cirrhosis on blunt liver trauma patients: a multifaceted approach from the trauma quality improvement program database

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.

[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.

Dual phenotypic characteristics of P-selectin in a mouse model of hemorrhagic shock and hepatectomy

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.

Liver Transplant After Severe Liver Trauma: The First Report in a Korean Adult

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.

Severe liver trauma with complex portal and common bile duct avulsion: A case report and review of the literature

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 9^th 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.

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.

An observation-first strategy for liver injuries with "blush" on computed tomography is safe and effective

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.

Closed abdominal trauma in polytrauma. Part II: surgical tactics for the damages control

Closed abdominal trauma in polytrauma. Part II: surgical tactics for the damages control

Clinical outcomes of non-operative management and clinical observation in non-angioembolised hepatic trauma: A systematic review of the literature

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.

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.

Multicenter retrospective study of transcatheter arterial embolisation for life-threatening haemorrhage in patients with uncorrected bleeding diathesis

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.

Early re-laparotomy for patients with high-grade liver injury after damage-control surgery and perihepatic packing

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.

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.

Multidetector CT Findings of Solid Organ Injury Based on 2018 Updated American Association for the Surgery of Trauma Organ Injury Scaling System

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.

Managing post-traumatic gunshot thoraco-abdominal bleeding by intervention embolisation: A case report

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.

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

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.

Liver transplantation following hepatic artery avulsion in a trauma patient

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.

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.

Decreased mortality, laparotomy, and embolization rates for liver injuries during a 13-year period in a major Scandinavian trauma center

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.

Nonoperative management of blunt liver injury in hemodynamically stable versus unstable patients: a retrospective study

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.

Spleen and liver injuries: when to operate?

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.

Use of interventional radiology as initial hemorrhage control to improve outcomes for potentially lethal multiple blunt injuries

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.

Assessment of Progress in Early Trauma Care in Japan over the Past Decade: Achievements and Areas for Future Improvement

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.