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Orozco G, Gupta M, Ancheta A, Shah MB, Warriner Z, Marti F, Mei X, Desai S, Bernard A, Gedaly R. Liver transplantation for severe hepatic trauma: A multicenter analysis from the UNOS data set. J Trauma Acute Care Surg 2024; 96:763-768. [PMID: 37994467 DOI: 10.1097/ta.0000000000004220] [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: 11/24/2023]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is rarely indicated after hepatic trauma but it can be the only therapeutic option in some patients. There are scarce data analyzing the surgical outcomes of OLT after trauma. METHODS We used the UNOS data set to identify patients who underwent OLT for trauma from 1987 to 2022 and compared them to a cohort of patients transplanted for other indications. Cox proportional hazard and multivariable logistic regression analyses were performed to assess predictors of graft and patient survival. RESULTS Seventy-two patients underwent OLT for trauma during the study period. Patients with trauma were more frequently on mechanical ventilation at the time of transplantation (26.4% vs. 7.6%, p < 0.001) and had a greater incidence of pretransplant portal vein thrombosis (12.5% vs. 4%, p = 0.002). Our 4:1 matched analysis showed that trauma patients had significantly shorter wait times, higher incidence of pretransplant portal vein thrombosis and prolonged length of stay. Trauma was associated with decreased overall graft survival (hazards ratio, 1.42; 95% confidence interval, 1.01-1.98), and increased length of stay ( p = 0.048). There were no significant differences in long-term patient survival. CONCLUSION Unique physiological and vascular challenges after severe hepatic trauma might be associated with decreased graft survival in patients requiring liver transplantation. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Gabriel Orozco
- From the Division of Transplantation, Department of Surgery (G.O., M.G., A.A., M.B.S., F.M., X.M., S.D., R.G.), and Division of Acute Care Surgery, Trauma & Surgical Critical Care, Department of Surgery (Z.W., A.B.), University of Kentucky, Lexington, Kentucky
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2
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Keric N, Shatz DV, Schellenberg M, de Moya M, Moore LJ, Brown CVR, Hartwell JL, Inaba K, Ley EJ, Peck KA, Fox CJ, Rosen NG, Weinberg JA, Coimbra R, Kozar R, Martin MJ. Adult blunt hepatic injury: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2024; 96:123-128. [PMID: 37747241 DOI: 10.1097/ta.0000000000004141] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Affiliation(s)
- Natasha Keric
- From the Division of Trauma, Surgical Critical Care and Acute Care Surgery, Department of Surgery (N.K.), Banner University Medical Center, Phoenix, Arizona; University of California (D.V.S.), Davis, Sacramento, California; Division of Acute Care Surgery, Department of Surgery, University of Southern California (M.S., K.I., M.J.M.), Los Angeles, California; Division of Acute Care Surgery, Department of Surgery, Medical College of Wisconsin (M.d.M.), Milwaukee, Wisconsin; Division of Acute Care Surgery, Department of Surgery, University of Texas-Houston Medical Center (L.J.M.), Houston, Texas; Division of Acute Care Surgery, Department of Surgery, Dell Medical School (C.V.R.B.), University of Texas at Austin, Austin, Texas; Division of Acute Care Surgery, Department of Surgery, University of Kansas Medical Center (J.L.H.), Kansas City, Kansas; Division of Acute Care Surgery, Department of Surgery, Cedars-Sinai Medical Center (E.J.L.), Los Angeles, California; Scripps Mercy Hospital (K.A.P.), San Diego, California; Division of Vascular Surgery, Department of Surgery, R Adams Cowley Shock Trauma Center (C.J.F., R.K.), Baltimore, Maryland; Division of Pediatric General and Thoracic Surgery, Children's Hospital (N.G.R.), Cincinnati, Ohio; Division of Acute Care Surgery, Department of Surgery, St. Joseph's Medical Center (J.A.W.), Phoenix, Arizona; and Riverside University Health System Medical Center (R.C.), Riverside, California
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Wongweerakit O, Akaraborworn O, Sangthong B, Thongkhao K. Acute portal vein thrombosis in an isolated, blunt, minor liver injury near the porta hepatis. Chin J Traumatol 2023:S1008-1275(23)00092-5. [PMID: 37838579 DOI: 10.1016/j.cjtee.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 08/25/2023] [Accepted: 09/15/2023] [Indexed: 10/16/2023] Open
Abstract
Portal vein thrombosis (PVT) secondary to blunt abdominal trauma associated with liver injury is extremely rare in healthy individuals as well as in minor liver injury, and it carries a high rate of morbidity and mortality. Moreover, acute asymptomatic PVT is difficult to diagnose. We present a young trauma patient with isolated minor liver injury associated with acute PVT. A 27-year-old man presented to the emergency department after a motor vehicle collision. His primary survey findings were unremarkable. His secondary survey showed a large contusion (7 cm × 7 cm) at the epigastrium with marked tenderness and localized guarding. The CT angiography of the whole abdomen revealed liver injury grade 3 in hepatic segments 2/3 and 4b (according to the American Association for the Surgery of Trauma classification) extending near the porta hepatis with patent hepatic and portal veins and without other solid organ injury. The follow-up CT of the whole abdomen on post-injury day 7 showed a 1.8-cm thrombus in the left portal vein with patent right portal and hepatic veins, and a decreased size of the hepatic lacerations. A liver function test was repeated on post-injury day 4, and it revealed improved transaminitis. The patient received intravenous anticoagulant therapy with low-molecular-weight heparin according to weight-based dosing for treatment. The CT of the whole abdomen performed 2 weeks after anticoagulant therapy showed small residual thrombosis in the left portal vein. The patient received intravenous anticoagulant therapy for a total 3 months. On the follow-up visits at 1 month, 2 months, 6 months, and 1 year after the injury, the patients did not have any detectable abnormal symptoms. PVT post-blunt minor liver injury is an extremely rare complication. If the thrombosis is left untreated, serious morbidity and mortality can ensue. However, its diagnosis in asymptomatic patients is still challenging. Periodic imaging is necessary for highly suspected PVT, especially in liver injury with lacerations close to the porta hepatis, even in cases of a minor injury.
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Affiliation(s)
- Onchuda Wongweerakit
- Division of Trauma and Critical Care, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
| | - Osaree Akaraborworn
- Division of Trauma and Critical Care, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Burapat Sangthong
- Division of Trauma and Critical Care, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Komet Thongkhao
- Division of Trauma and Critical Care, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Ventro GJ, Adams LM, Doucet JJ, Costantini TW, Weaver JL. Post-traumatic Liver Pseudoaneurysms: Rare but Serious Sequela. J Surg Res 2023; 285:85-89. [PMID: 36652772 DOI: 10.1016/j.jss.2022.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 11/18/2022] [Accepted: 12/14/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The liver is the most commonly injured organ after blunt abdominal trauma. Nonoperative management is the standard of care in stable individuals. Liver injuries, particularly high-grade injuries, can develop pseudoaneurysms (PSAs), which can rupture and cause life-threatening bleeding, even after hospital discharge. There is no consensus on whether patients should receive predischarge contrast computed tomography (CT) screening, or at what time interval after injury, nor which patients are at the highest risk for PSA. The purpose of this study was to identify the rates of PSA in our population and potential risk factors for their formation. METHODS The trauma registry at our Level 1 urban trauma center was queried for patients admitted with liver injuries between 2015 and 2021. Demographic information was collected from the registry. Individual charts were then reviewed for timing of CT scans, CT findings, interventions, and complications. Liver injury grade was assessed using radiology reports or operative findings. The frequency of PSAs was then analyzed using descriptive statistics using Microsoft Excel and SPSS for odds ratio. RESULTS A total of 172 patients were admitted with liver injuries during the study period. 130 patients received a CT scan diagnosing liver injury, 42 were diagnosed with liver injury intraoperatively. Of the 130 patients (59.9%) which received follow-up CT scans, six (6.5%) developed PSA, four of which being from penetrating injuries (odds ratio, 6.95). CONCLUSIONS This study demonstrated a low incidence of PSA consistent with the known literature. We found the majority of the PSA developed following penetrating injury. This may represent a significant indication for follow-up imaging regardless of grade. A larger study will be necessary to identify those most at risk for PSA formation and determine the best PSA screening algorithm.
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Affiliation(s)
- George J Ventro
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, California.
| | - Laura M Adams
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, California
| | - Jay J Doucet
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, California
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, California
| | - Jessica L Weaver
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, California
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Kanlerd A, Auksornchart K, Boonyasatid P. Non-operative management for abdominal solidorgan injuries: A literature review. Chin J Traumatol 2022; 25:249-256. [PMID: 34654595 PMCID: PMC9459001 DOI: 10.1016/j.cjtee.2021.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 07/18/2021] [Accepted: 07/26/2021] [Indexed: 02/04/2023] Open
Abstract
The philosophy of abdominal injury management is currently changing from mandatory exploration to selective non-operative management (NOM). The patient with hemodynamic stability and absence of peritonitis should be managed non-operatively. NOM has an overall success rate of 80%-90%. It also can reduce the rate of non-therapeutic abdominal exploration, preserve organ function, and has been defined as the safest choice in experienced centers. However, NOM carries a risk of missed injury such as hollow organ injury, diaphragm injury, and delayed hemorrhage. Adjunct therapies such as angiography with embolization, endoscopic retrograde cholangiopancreatography with stenting, and percutaneous drainage could increase the chances of successful NOM. This article aims to describe the evolution of NOM and define its place in specific abdominal solid organ injury for the practitioner who faces this problem.
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Affiliation(s)
- Amonpon Kanlerd
- Unit of Trauma and Surgical Critical Care, Division of General Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand.
| | - Karikarn Auksornchart
- Unit of Trauma and Surgical Critical Care, Division of General Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
| | - Piyapong Boonyasatid
- Unit of Trauma and Surgical Critical Care, Division of General Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand
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Predictive factors of non-operative management failure in 494 blunt liver injuries: a multicenter retrospective study. Updates Surg 2022; 74:1901-1913. [DOI: 10.1007/s13304-022-01367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/21/2022] [Indexed: 10/15/2022]
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Reina R, Anand T, Bhogadi SK, Nelson A, Hosseinpour H, Ditillo M, El-Qawaqzeh K, Castanon L, Stewart C, Joseph B. Nonoperative management of blunt abdominal solid organ injury: Are we paying enough attention to patients on preinjury anticoagulation? Am J Surg 2022; 224:1308-1313. [DOI: 10.1016/j.amjsurg.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/06/2022] [Accepted: 06/23/2022] [Indexed: 11/01/2022]
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García IC, Villalba JS, Iovino D, Franchi C, Iori V, Pettinato G, Inversini D, Amico F, Ietto G. Liver Trauma: Until When We Have to Delay Surgery? A Review. Life (Basel) 2022; 12:life12050694. [PMID: 35629360 PMCID: PMC9143295 DOI: 10.3390/life12050694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/06/2022] [Accepted: 04/29/2022] [Indexed: 01/09/2023] Open
Abstract
Liver involvement after abdominal blunt trauma must be expected, and in up to 30% of cases, spleen, kidney, and pancreas injuries may coexist. Whenever hemodynamics conditions do not contraindicate the overcoming of the ancient dogma according to which exploratory laparotomy should be performed after every major abdominal trauma, a CT scan has to clarify the liver lesions so as to determine the optimal management strategy. Except for complete vascular avulsion, no liver trauma grade precludes nonoperative management. Every attempt to treat the injured liver by avoiding a strong surgical approach may be considered. Each time, a nonoperative management (NOM) consisting of a basic “wait and see” attitude combined with systemic support and blood replacement are inadequate. Embolization should be considered to stop the bleeding. Percutaneous drainage of collections, endoscopic retrograde cholangiopancreatography (ERCP) with papilla sphincterotomy or stent placement and percutaneous transhepatic biliary drainage (PTBD) may avoid, or at least delay, surgical reconstruction or resection until systemic and hepatic inflammatory remodeling are resolved. The pathophysiological principle sustaining these leanings is based on the opportunity to limit the further release of cell debris fragments acting as damage-associated molecular patterns (DAMPs) and the following stress response associated with the consequent immune suppression after trauma. The main goal will be a faster recovery combined with limited cell death of the liver through the ischemic events that may directly follow the trauma, exacerbated by hemostatic procedures and surgery, in order to reduce the gross distortion of a regenerated liver.
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Affiliation(s)
- Inés Cañas García
- General and Digestive Surgery, Hospital Clínico San Cecilio of Granada, 18002 Granada, Spain;
| | - Julio Santoyo Villalba
- General and Digestive Surgery, Hospital Virgen de Las Nieves of Granada, 18002 Granada, Spain;
| | - Domenico Iovino
- General, Emergency and Transplant Surgery Department, ASST-Settelaghi and University of Insubria, 21100 Varese, Italy; (D.I.); (C.F.); (V.I.); (D.I.)
| | - Caterina Franchi
- General, Emergency and Transplant Surgery Department, ASST-Settelaghi and University of Insubria, 21100 Varese, Italy; (D.I.); (C.F.); (V.I.); (D.I.)
| | - Valentina Iori
- General, Emergency and Transplant Surgery Department, ASST-Settelaghi and University of Insubria, 21100 Varese, Italy; (D.I.); (C.F.); (V.I.); (D.I.)
| | - Giuseppe Pettinato
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA;
| | - Davide Inversini
- General, Emergency and Transplant Surgery Department, ASST-Settelaghi and University of Insubria, 21100 Varese, Italy; (D.I.); (C.F.); (V.I.); (D.I.)
| | - Francesco Amico
- Trauma Service, Department of Surgery, University of Newcastle, Newcastle 2308, Australia;
| | - Giuseppe Ietto
- General, Emergency and Transplant Surgery Department, ASST-Settelaghi and University of Insubria, 21100 Varese, Italy; (D.I.); (C.F.); (V.I.); (D.I.)
- Correspondence: ; Tel.: +39-339-8758024
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Choi D, Kwon J, Jung K, Kang BH. Improvement of mortality in severe liver injury after trauma center implementation: a propensity score matched study. Eur J Trauma Emerg Surg 2022; 48:3349-3355. [PMID: 35165747 DOI: 10.1007/s00068-022-01909-y] [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: 12/21/2021] [Accepted: 01/29/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate changes in the management and outcome of severe liver injury after trauma center implementation. METHODS Trauma patients with severe liver injury (organ injury scale score ≥ 4) treated between January 2011 and December 2020 were retrospectively reviewed. A trauma center was built in 2016 at our institution, and patients were dichotomized into two groups: before trauma center (BTC) and after trauma center (ATC) group. Treatment methods and outcomes were compared between the groups with 1:1 propensity score matching. RESULTS We included 50 patients in the BTC group and 104 patients in the ATC group. Patients in the ATC group had frequent utilization of angiography (16% vs 47.1%, p < 0.001), faster transfusion [84 (37-152) min vs 17 (10-79) min, p < 0.001], and less fluid administration within 24 h [8.3 (5.7-13.7) L vs 5.7 (3.1-10.1) L, p = 0.002]. However, mortality rate was not significantly different between the groups (26.0% vs 20.2%, p = 0.416). 1:1 propensity score matching was performed using the variables of age, injury severity score, systolic blood pressure, Glasgow Coma Scale, and initial base excess level. After matching, the mortality rate (26.0% vs 10.0%, p = 0.037) and ventilator application (74.0% vs 54.0%, p = 0.037) significantly improved. CONCLUSION Severe liver injury management improved after trauma center implementation.
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Affiliation(s)
- Donghwan Choi
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Byung Hee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
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A Statewide Analysis of Pediatric Liver Injuries Treated at Adult Versus Pediatric Trauma Centers. J Surg Res 2022; 272:184-189. [PMID: 35032820 DOI: 10.1016/j.jss.2021.12.022] [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: 04/02/2021] [Revised: 10/25/2021] [Accepted: 12/15/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Hemodynamically normal pediatric trauma patients with solid organ injury receive nonoperative management. Prior research supports that pediatric patients have higher rates of nonoperative management at pediatric trauma centers (PTCs). We sought to evaluate differences in outcomes of pediatric trauma patients with liver injuries. We hypothesized that the type of trauma center (PTC versus adult trauma center [ATC]) would not be associated with any difference in mortality. METHODS The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2018 for all patients (<15 y) with liver injuries by International Classification of Disease 9 and 10 codes. Patients were categorized based on admission to the PTC or ATC. The primary endpoint was mortality with secondary endpoints being operative intervention and length of stay. Multivariate logistic regressions assessed the adjusted impact on mortality and surgical intervention. RESULTS Of the 1600 patients with liver trauma, 607 met inclusion criteria. A total of 78.4% were treated at PTCs. Patients underwent hepatobiliary surgery more frequently at ATCs (11.5% [n = 15] versus 2.74% [n = 13], P < 0.001). Adjusted analysis showed lower odds of surgical intervention for hepatobiliary injuries at PTCs (adjusted odds ratio: 0.17, P = 0.001). There was a decrease in mortality at PTCs versus ATCs (adjusted odds ratio: 0.38, P = 0.032). CONCLUSIONS Our statewide analysis showed that pediatric trauma patients with liver injuries treated at ATCs were associated with having higher odds of mortality and higher incidence of operative management for hepatobiliary injuries than those treated at PTCs. In addition, between centers, patients had similar functional status at discharge.
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11
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An engineered activated factor V for the prevention and treatment of acute traumatic coagulopathy and bleeding in mice. Blood Adv 2021; 6:959-969. [PMID: 34861695 PMCID: PMC8945312 DOI: 10.1182/bloodadvances.2021005257] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 11/15/2021] [Indexed: 11/25/2022] Open
Abstract
superFVa arrests severe bleeding and prevents the development of ATC after trauma. superFVa therapy restores functional hemostasis when initiated after onset of ATC caused by traumatic bleeding.
Acute traumatic coagulopathy (ATC) occurs in approximately 30% of patients with trauma and is associated with increased mortality. Excessive generation of activated protein C (APC) and hyperfibrinolysis are believed to be driving forces for ATC. Two mouse models were used to investigate whether an engineered activated FV variant (superFVa) that is resistant to inactivation by APC and contains a stabilizing A2-A3 domain disulfide bond can reduce traumatic bleeding and normalize hemostasis parameters in ATC. First, ATC was induced by the combination of trauma and shock. ATC was characterized by activated partial thromboplastin time (APTT) prolongation and reductions of factor V (FV), factor VIII (FVIII), and fibrinogen but not factor II and factor X. Administration of superFVa normalized the APTT, returned FV and FVIII clotting activity levels to their normal range, and reduced APC and thrombin-antithrombin (TAT) levels, indicating improved hemostasis. Next, a liver laceration model was used where ATC develops as a consequence of severe bleeding. superFVa prophylaxis before liver laceration reduced bleeding and prevented APTT prolongation, depletion of FV and FVIII, and excessive generation of APC. Thus, prophylactic administration of superFVa prevented the development of ATC. superFVa intervention started after the development of ATC stabilized bleeding, reversed prolonged APTT, returned FV and FVIII levels to their normal range, and reduced TAT levels that were increased by ATC. In summary, superFVa prevented ATC and traumatic bleeding when administered prophylactically, and superFVa stabilized bleeding and reversed abnormal hemostasis parameters when administered while ATC was in progress. Thus, superFVa may be an attractive strategy to intercept ATC and mitigate traumatic bleeding.
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Lewis M, Jakob DA, Benjamin ER, Wong M, Trust MD, Demetriades D. Nonoperative Management of Blunt Hepatic Trauma: Comparison of Level I and II Trauma Centers. Am Surg 2021:31348211038558. [PMID: 34399602 DOI: 10.1177/00031348211038558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Most blunt liver injuries are treated with nonoperative management (NOM), and angiointervention (AI) has become a common adjunct. This study evaluated the use of AI, blood product utilization, pharmacological venous thromboembolic prophylaxis (VTEp), and outcomes in severe blunt liver trauma managed nonoperatively at level I versus II trauma centers. METHODS American College of Surgeons Trauma Quality Improvement Program (TQIP) study (2013-2016), including adult patients with severe blunt liver injuries (AIS score>/= 3) treated with NOM, was conducted. Epidemiological and clinical characteristics, severity of liver injury (AIS), use of AI, blood product utilization, and VTEp were collected. Outcomes included survival, complications, failure of NOM, blood product utilization, and length of stay (LOS). RESULTS Study included 2825 patients: 2230(78.9%) in level I and 595(21.1%) in level II centers. There was no difference in demographics, clinical presentation, or injury severity between centers. Angiointervention was used in 6.4% in level I and 7.2% in level II centers (P=.452). Level II centers were less likely to use LMWH for VTEp (.003). There was no difference in mortality or failure of NOM. In level II centers, there was a significantly higher 24-hour blood product utilization (PRBC P = .015 and platelets P = .002), longer ventilator days (P = .012), and longer ICU (P< .001) and hospital LOS (P = .024). The incidence of ventilator-associated pneumonia was significantly higher in level II centers (P = .003). CONCLUSION Utilization of AI and NOM success rates is similar in level I and II centers. However, the early blood utilization, ventilator days, and VAP complications are significantly higher in level II centers.
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Affiliation(s)
- Meghan Lewis
- Division of Trauma and Surgical Critical Care, 5116Lac+Usc Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Dominik A Jakob
- Division of Trauma and Surgical Critical Care, 5116Lac+Usc Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Elizabeth R Benjamin
- Division of Trauma and Surgical Critical Care, 5116Lac+Usc Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Monica Wong
- Division of Trauma and Surgical Critical Care, 5116Lac+Usc Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Marc D Trust
- Division of Trauma and Surgical Critical Care, 5116Lac+Usc Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, 5116Lac+Usc Medical Center, University of Southern California, Los Angeles, CA, USA
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Recent Trends in Management of Liver Trauma. Indian J Surg 2021. [DOI: 10.1007/s12262-019-02056-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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14
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Yu SH, Park SH, Kim JW, Kim JH, Hwang JH, Park S, Lee KH. Imaging Features and Interventional Treatment for Liver Injuries and Their Complications. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:851-861. [PMID: 36238055 PMCID: PMC9514414 DOI: 10.3348/jksr.2020.0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 06/16/2023]
Abstract
Liver injury is a common consequence of blunt abdominopelvic trauma. Contrast-enhanced CT allows for the rapid detection and evaluation of liver injury. The treatment strategy for blunt liver injury has shifted from surgical to nonoperative management, which has been widely complemented by interventional management to treat both liver injury and its complications. In this article, we review the major imaging features of liver injury and the role of interventional management for the treatment of liver injury.
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YILDIRIM MB, ŞAHİNER İT, KENDİRCİ M, ÖZKAN B, ERKENT M, TOPCU R, BOSTANOĞLU S. Non-surgical follow-up success in blunt abdominal trauma. Can we protect patients with blunt abdominal trauma from surgery? JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.896899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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16
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Hong JY, Suh SW, Lee ES, Shin J. Initial Risk Stratification of Liver Injuries Based on Elevated Transaminases in a Medical Resource-Constrained Area. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02720-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Kumar V, Mishra B, Joshi MK, Purushothaman V, Agarwal H, Anwer M, Sagar S, Kumar S, Gupta A, Bagaria D, Choudhary N, Kumar A, Priyadarshini P, Soni KD, Aggarwal R. Early hospital discharge following non-operative management of blunt liver and splenic trauma: A pilot randomized controlled trial. Injury 2021; 52:260-265. [PMID: 33041017 DOI: 10.1016/j.injury.2020.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/22/2020] [Accepted: 10/02/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite the acceptance of non-operative management (NOM), there is no consensus on the optimal length of hospital stay in patients with blunt liver and splenic injury (BLSI). Recent studies on pediatric patients have demonstrated the safety of early discharge following NOM for BLSI. We aimed at evaluating the feasibility and safety of early discharge in adult patients with BLSI following NOM in a randomized controlled trial. MATERIALS AND METHODS After initial assessment and management, patients aged 18-60 years with BLSI planned for NOM were randomized into 2 groups: Group A (test group; discharge day 3), and Group B (control group; discharge day 5). Standard NOM protocol was followed. These patients were discharged on the proposed day if they met the pre-defined discharge criteria. All patients were followed at days 7, 15, and 30 of discharge. RESULTS Sixty patients were recruited, 30 randomized to each arm. Most patients were males and aged less than 30 years. Road traffic injury was the most common mode of injury. Both groups were comparable in demography and injury-related parameters. 27 patients (90%) from group A and 28 patients (93%) from group B were discharged on the proposed day. Three patients had unplanned hospital visits for reasons unrelated to BLSI. All patients were asymptomatic and had a normal examination during their scheduled follow-up visits. CONCLUSION Adult patients undergoing NOM for BLSI can be safely discharged after 48 h of in-hospital observation, provided other injuries precluding discharge do not exist.
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Affiliation(s)
- Vignesh Kumar
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India; Department of Trauma Surgery, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
| | - Biplab Mishra
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Mohit Kumar Joshi
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India.
| | - Vijayan Purushothaman
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Harshit Agarwal
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Majid Anwer
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Sushma Sagar
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Subodh Kumar
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Amit Gupta
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Dinesh Bagaria
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Narendra Choudhary
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Abhinav Kumar
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Pratyusha Priyadarshini
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Kapil Dev Soni
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Richa Aggarwal
- Division of Trauma Surgery & Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
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Traumatic Intraparenchymal Pseudoaneurysm on Initial Imaging Predicts Injury Progression in Patients with Nonoperative Major Blunt Liver Injury. Int Surg 2021. [DOI: 10.9738/intsurg-d-16-00200.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Most patients who present with hemodynamic stability and no evidence of peritonitis after blunt liver injury are successfully managed nonoperatively. Little information is available regarding the utility of reimaging major blunt liver injuries for patients who are managed nonoperatively. A retrospective review of patients admitted to a level I trauma center with major blunt liver injuries (AAST grades 3–5) was conducted. Inclusion criteria were those admitted from July 2012 to June 2014 with blunt liver trauma who survived the first 24 hours and underwent repeat imaging. Data included demographics, procedures performed, and computerized tomography (CT) scan findings. Findings on the second CT scan were categorized as Unchanged, Worse, Improved, or Negative. A total of 128 patients had blunt major liver injuries; 66 patients underwent repeat imaging. The mean time to repeat CT was 1.95 days. On repeat CT, 47 were Unchanged, 3 Worse, 14 Improved, and 2 Negative. Three patients underwent angiography. One required embolization of a pseudoaneurysm. In 63 patients (95%), the second CT did not change the management plan. The presence of a pseudoaneurysm was significantly related to a worsening of the second CT (P = 0.0475). Patients with admission hematocrit (Hct) below 32% were more likely to have a worsened second CT (P = 0.0370). A pseudoaneurysm on admission CT and Hct <32% predict major liver injury progression suggesting that routine reimaging is warranted in this group.
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19
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Angioembolization in intra-abdominal solid organ injury: Does delay in angioembolization affect outcomes? J Trauma Acute Care Surg 2020; 89:723-729. [PMID: 33017133 DOI: 10.1097/ta.0000000000002851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Angioembolization (AE) is an integral component in multidisciplinary algorithms for achieving hemostasis in patients with trauma. The American College of Surgeons Committee on Trauma recommends that interventional radiologists be available within 30 minutes to perform emergent AE. However, the impact of the timing of AE on patient outcomes is still not well known. We hypothesized that a delay in AE would be associated with increased mortality and higher blood transfusion requirements in patients with blunt intra-abdominal solid organ injury. METHODS A 4-year (2013-2016) retrospective review of the ACS Trauma Quality Improvement Program database was performed. We included adult patients (age, ≥18 years) with blunt intra-abdominal solid organ injury who underwent AE within 4 hours of hospital admission. Patients who underwent operative intervention before AE were excluded. The primary outcome was 24-hour mortality. The secondary outcome was blood product transfusions. Patients were grouped into four 1-hour intervals according to their time from admission to AE. Multivariate regression analysis was performed to accommodate patient differences. RESULTS We analyzed 1,009,922 trauma patients, of which 924 (1 hour, 76; 1-2 hours, 224; 2-3 hours, 350; 3-4 hours, 274) were deemed eligible. The mean ± SD age was 44 ± 19 years, and 66% were male. The mean ± SD time to AE was 144 ± 54 minutes, and 92% of patients underwent AE more than 1 hour after admission. Overall 24-hour mortality was 5.2%. On univariate analysis, patients receiving earlier AE had decreased 24-hour mortality (p = 0.016), but no decrease in blood products transfused. On regression analysis, every hour delay in AE was significantly associated with increased 24-hour mortality (p < 0.05). CONCLUSION Delayed AE for hemorrhagic control in blunt trauma patients with an intra-abdominal solid organ injury is associated with increased 24-hour mortality. Trauma centers should ensure timeliness of interventional radiologist availability to prevent a delay in vital AE, and it should be a focus of quality improvement projects. LEVEL OF EVIDENCE Prognostic, level III.
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20
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Schembari E, Sofia M, Latteri S, Pesce A, Palumbo V, Mannino M, Russello D, La Greca G. Blunt liver trauma: effectiveness and evolution of non-operative management (NOM) in 145 consecutive cases. Updates Surg 2020; 72:1065-1071. [PMID: 32851597 DOI: 10.1007/s13304-020-00861-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors' approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10 years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10 years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10 years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.
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Affiliation(s)
- Elena Schembari
- General Surgery, Barts Health NHS Trust, Whipps Cross Hospital, London, UK.
| | - Maria Sofia
- General Surgery, Cannizzaro Hospital, Catania, Italy
| | - Saverio Latteri
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Antonio Pesce
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Valentina Palumbo
- General Surgery, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Maurizio Mannino
- General Surgery, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Domenico Russello
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gaetano La Greca
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
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21
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Hepatic autotransplant for hepatic vein avulsion after blunt abdominal trauma. J Trauma Acute Care Surg 2020; 89:e55-e58. [PMID: 32345904 DOI: 10.1097/ta.0000000000002750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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22
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Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, Biffl W, Peitzman A, Horer T, Abu-Zidan FM, Sartelli M, Fraga GP, Cicuttin E, Ansaloni L, Parra MW, Millán M, DeAngelis N, Inaba K, Velmahos G, Maier R, Khokha V, Sakakushev B, Augustin G, di Saverio S, Pikoulis E, Chirica M, Reva V, Leppaniemi A, Manchev V, Chiarugi M, Damaskos D, Weber D, Parry N, Demetrashvili Z, Civil I, Napolitano L, Corbella D, Catena F. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020; 15:24. [PMID: 32228707 PMCID: PMC7106618 DOI: 10.1186/s13017-020-00302-7] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy.
| | - Raul Coimbra
- Riverside University Health System, CECORC Research Center, Loma Linda University, Loma Linda, USA
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | - Felipe Vega
- Department of Surgery, Hospital Angeles Lomas, Huixquilucan, Mexico
| | | | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital La Jolla, San Diego, CA, USA
| | - Andrew Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, FL, USA
| | - Mauricio Millán
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Nicola DeAngelis
- Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | - Kenji Inaba
- General and Trauma Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - George Velmahos
- General and Emergency Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Salomone di Saverio
- General and Trauma Surgery Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mircea Chirica
- Chirurgie Digestive, CHUGA-CHU Grenoble Alpes, Grenoble, France
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | | | - Ian Civil
- Trauma Surgery, Auckland University Hospital, Auckland, New Zealand
| | - Lena Napolitano
- Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
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23
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Gilyard S, Shinn K, Nezami N, Findeiss LK, Dariushnia S, Grant AA, Hawkins CM, Peters GL, Majdalany BS, Newsome J, Bercu ZL, Kokabi N. Contemporary Management of Hepatic Trauma: What IRs Need to Know. Semin Intervent Radiol 2020; 37:35-43. [PMID: 32139969 DOI: 10.1055/s-0039-3401838] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Trauma remains one of the leading causes of death in the United States in patients younger than 45 years. Blunt trauma is most commonly a result of high-speed motor vehicular collisions or high-level fall. The liver and spleen are the most commonly injured organs, with the liver being the most commonly injured organ in adults and the spleen being the most affected in pediatric blunt trauma. Liver injuries incur a high level of morbidity and mortality mostly secondary to hemorrhage. Over the past 20 years, angiographic intervention has become a mainstay of treatment of hepatic trauma. As there is an increasing need for the interventional radiologists to embolize active hemorrhage in the setting of blunt and penetrating hepatic trauma, this article aims to review the current level of evidence and contemporary management of hepatic trauma from the perspective of interventional radiologists. Embolization techniques and associated outcome and complications are also reviewed.
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Affiliation(s)
- Shenise Gilyard
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Kaitlin Shinn
- Department of Medical Education, Emory University School of Medicine, Atlanta, Georgia
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Radiology and Radiological Science, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Laura K Findeiss
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Sean Dariushnia
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - April A Grant
- Division of Trauma/Surgical Critical Care, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - C Matthew Hawkins
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Gail L Peters
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Bill S Majdalany
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Janice Newsome
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Zachary L Bercu
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nima Kokabi
- Division of Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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24
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Kashani P, Saberinia A. Management of multiple traumas in emergency medicine department: A review. J Family Med Prim Care 2019; 8:3789-3797. [PMID: 31879615 PMCID: PMC6924209 DOI: 10.4103/jfmpc.jfmpc_774_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/16/2019] [Accepted: 10/09/2019] [Indexed: 11/04/2022] Open
Abstract
One of the main causes of adults' disability during their working age is multiple trauma. The process of medical care of patients who are injured seriously is still a challenging job. The primary treatment of these patients in the emergency medicine departments is the most required choice after the wilderness first aid and also would be very required before definitive care in the hospital. The main aim of emergency medicine departments is quick recognition and treatment of injuries which pose severe threat to patients' life in appropriate order of priority. The procedure of primary evaluation in emergency medicine department with the help of medical routine examination and ultrasonography is based on the concept of focused assessment with sonography in trauma (FAST) for identifying spontaneous intraperitoneal hemorrhage. Emergency patients who suffer from massive hematothorax, serious lung and heart traumas, and penetrating traumas to the chest would undergo thoracotomy and patients who have few symptoms of perforated hollow viscous will undergo emergency laparotomy. Based on the trauma severity, emergency treatment could be the way to fast recovery of the structure of injured organ and its function. The subsequent goal, in the acute phase, will concentrate on preventing and stopping bleeding and secondary injuries like painful compartment syndrome or intra-abdominal infections (IAIs). However, the main aim of emergency medicine department in taking care of severely injured patients is the management of airway, protecting circulation and breathing, identification of neurologic problems, and whole body clinical examination with the help of healthcare providers.
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Affiliation(s)
- Parvin Kashani
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Loghman Hakim Hospital, Tehran, Iran
| | - Amin Saberinia
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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25
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Fodor M, Primavesi F, Morell-Hofert D, Kranebitter V, Palaver A, Braunwarth E, Haselbacher M, Nitsche U, Schmid S, Blauth M, Gassner E, Öfner D, Stättner S. Non-operative management of blunt hepatic and splenic injury: a time-trend and outcome analysis over a period of 17 years. World J Emerg Surg 2019; 14:29. [PMID: 31236129 PMCID: PMC6580509 DOI: 10.1186/s13017-019-0249-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/04/2019] [Indexed: 11/28/2022] Open
Abstract
Background A widespread shift to non-operative management (NOM) for blunt hepatic and splenic injuries has been observed in most centers worldwide. Furthermore, many countries introduced safety measures to systematically reduce severe traffic and leisure sports injuries. This study aims to evaluate the effect of these nationwide implementations on individual patient characteristics and outcomes through a time-trend analysis over 17 years in an Austrian high-volume trauma center. Methods A retrospective review of all emergency trauma patients admitted to the Medical University of Innsbruck from 2000 to 2016. Injury severity, clinical data on admission, operative and non-operative treatment parameters, complications, and in-hospital mortality were evaluated. Results In total, 731 patients were treated with blunt hepatic and/or splenic injuries. Among these, 368 had a liver injury, 280 splenic injury, and 83 combined hepatic/splenic injury. Initial NOM was performed in 82.6% of all patients (93.5% in hepatic and 71.8% in splenic injuries) with a success rate of 96.7%. The secondary failure rate of NOM was 3.3% and remained consistent over 17 years (p = 0.515). In terms of injury severity, we observed a reduction over time, resulting in an overall mortality rate of 4.8% and 3.5% in the NOM group (decreasing from 7.5 to 1.9% and from 5.6 to 1.3%, respectively). These outcomes confirmed an improved utilization of the NOM approach. Conclusion Our cohort represents one of the largest Central European single-center experiences available in the literature. NOM is the standard of care for blunt hepatic and splenic injuries and successful in > 96% of all patients. This rate was quite constant over 17 years (p = 0.515). Overall, national and regional safety measures resulted in a significantly decreased severity of observed injury patterns and deaths due to blunt hepatic or splenic trauma. Although surgery is nowadays only applied in about one third of splenic injury patients in our center, these numbers might further decrease by intensified application of interventional radiology and modern coagulation management. Electronic supplementary material The online version of this article (10.1186/s13017-019-0249-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Margot Fodor
- 1Department of Visceral, Transplantation and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Florian Primavesi
- 1Department of Visceral, Transplantation and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | | | - Veronika Kranebitter
- 1Department of Visceral, Transplantation and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Anna Palaver
- 1Department of Visceral, Transplantation and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Eva Braunwarth
- 1Department of Visceral, Transplantation and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Matthias Haselbacher
- 3Department of Trauma Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Ulrich Nitsche
- 4Department of Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Stefan Schmid
- 5Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Blauth
- 3Department of Trauma Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Eva Gassner
- 2Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- 1Department of Visceral, Transplantation and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Stefan Stättner
- 1Department of Visceral, Transplantation and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
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26
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Leppäniemi A. Nonoperative management of solid abdominal organ injuries: From past to present. Scand J Surg 2019; 108:95-100. [PMID: 30832550 DOI: 10.1177/1457496919833220] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Today, a significant proportion of solid abdominal organ injuries, whether caused by penetrating or blunt trauma, are managed nonoperatively. However, the controversy over operative versus nonoperative management started more than a hundred years ago. The aim of this review is to highlight some of the key past observations and summarize the current knowledge and guidelines in the management of solid abdominal organ injuries. MATERIALS AND METHODS A non-systematic search through historical articles and references on the management practices of abdominal injuries was conducted utilizing early printed volumes of major surgical and medical journals from the late 19th century onwards. RESULTS Until the late 19th century, the standard treatment of penetrating abdominal injuries was nonoperative. The first article advocating formal laparotomy for abdominal gunshot wounds was published in 1881 by Sims. After World War I, the policy of mandatory laparotomy became standard practice for penetrating abdominal trauma. During the latter half of the 20th century, the concept of selective nonoperative management, initially for anterior abdominal stab wounds and later also gunshot wounds, was adopted by major trauma centers in South Africa, the United States, and little later in Europe. In blunt solid abdominal organ injuries, the evolution from surgery to nonoperative management in hemodynamically stable patients aided by the development of modern imaging techniques was rapid from 1980s onwards. CONCLUSION With the help of modern imaging techniques and adjunctive radiological and endoscopic interventions, a major shift from mandatory to selective surgical approach to solid abdominal organ injuries has occurred during the last 30-50 years.
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Affiliation(s)
- A Leppäniemi
- Abdominal Center, Meilahti Hospital, University of Helsinki, Helsinki, Finland
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27
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Nonoperative management of abdominal solid-organ injuries following blunt trauma in adults: Results from an International Consensus Conference. J Trauma Acute Care Surg 2019; 84:517-531. [PMID: 29261593 DOI: 10.1097/ta.0000000000001774] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fransvea P, Costa G, Massa G, Frezza B, Mercantini P, BaIducci G. Non-operative management of blunt splenic injury: is it really so extensively feasible? a critical appraisal of a single-center experience. Pan Afr Med J 2019; 32:52. [PMID: 31143357 PMCID: PMC6522183 DOI: 10.11604/pamj.2019.32.52.15022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 10/19/2018] [Indexed: 02/04/2023] Open
Abstract
Introduction The spleen is one of the most commonly injured organ following blunt abdominal trauma. Splenic injuries may occur in isolation or in association with other intra-and extra-abdominal injury. Nonoperative management of blunt injury to the spleen has become routine in children. In adult most minor splenic injuries are readily treated nonoperatively but controversy exists regarding the role of nonoperative management for higher grade injuries above all in multi-trauma patients. The aim of this study is the assessment of splenic trauma treatment, with particular attention to conservative treatment, its limits, its efficiency, and its safety in multi-trauma patient or in a severe trauma patient. Methods The present research focused on a retrospective review of patients with splenic injury. The research was performed by analyzing data of the trauma registry of St. Andrea University Hospital in Rome. The St. Andrea University Hospital trauma registry includes 1859. The variables taken into account were spleen injury and general injuries, age, sex, cause and dynamic of trauma, hemoglobin, hematocrit, white blood cells count, INR, number and time blood transfusion, hemodynamic stability, type of treatment provided, hospitalization period, morbidity and mortality. Assessment of splenic injuries was evaluated according to Abbreviated Injury Scale (AIS). Results The analysis among the general population of spleen trauma patients identified 68 patients with a splenic injury representing the 41.2% of all abdomen injury. The Average age was of 37.01 ± 17.18 years. The Average ISS value was of 22.88 ± 12.85; mediana of 24.50 (range 4-66). The average Spleen AIS value was of 3.13 ± 0.88; mediana 3.00 (range 2-5). The overall mortality ratio was of 19.1% (13 patients). The average ISS value in patients who died was of 41.92 ± 12.48, whereas in patients who survided was of 23.33 ± 10.15. The difference was considered to be statistically significant (p <0.001). The relashionship between the ISS and AIS values in patients who died was considered directly proportional but not statistically significant (Pearson test AIS/ISS = 0.132, p = n.s.). The initial management was a conservative treatment in 27 patients (39.7%) of them 4 patients (15%) failed, in the other 41 cases urgent splenectomies were performed. The average spleen AIS in all the patients who underwent splenectomy was 3.61 ± 0.63 whereas in the patients who were not treated surgically was 2.42 ± 0.69. The difference was deemed statistically significant (p <0.001). Conclusion Splenic injury, as reported in our statistic as well as in literature, is the most common injury in closed abdominal trauma. Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The preference of a conservative treatment must be based on the hemodynamic stability indices as well as on the spleen lesion severity and on the general trauma severity. The conservative treatment represent a feasible and safe therapeutic alternative even in case of severe lesions in politrauma patients, but the choice of the treatment form requires an assessment for each singular case.
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Affiliation(s)
- Pietro Fransvea
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Gianluca Costa
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Giulia Massa
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Barbara Frezza
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Paolo Mercantini
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
| | - Genoveffa BaIducci
- Faculty of Medicine and Psychology, University of Rome "La Sapienza" St Andrea Hospital, Italy
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Ilhan M, Sönmez RE, Kut A, Toprak S, Gök AFK, Günay MK, Ertekin C. Are radiological modalities really necessary for the long-term follow-up of patients having blunt solid organ injuries? A single center study. World J Emerg Med 2019; 10:177-181. [PMID: 31171949 PMCID: PMC6545375 DOI: 10.5847/wjem.j.1920-8642.2019.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/10/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Mehmet Ilhan
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Recep Erçin Sönmez
- Department of General Surgery, İstanbul Medeniyet University, İstanbul, Turkey
| | - Abdullah Kut
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Safa Toprak
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Ali Fuat Kaan Gök
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Mustafa Kayıhan Günay
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Cemalettin Ertekin
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
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Frink M, Lechler P, Debus F, Ruchholtz S. Multiple Trauma and Emergency Room Management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:497-503. [PMID: 28818179 DOI: 10.3238/arztebl.2017.0497] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 10/16/2016] [Accepted: 04/24/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The care of severely injured patients remains a challenge. Their initial treatment in the emergency room is the essential link between first aid in the field and definitive in-hospital treatment. METHODS We present important elements of the initial in-hospital care of severely injured patients on the basis of pertinent publications retrieved by a selective search in PubMed and the current German S3 guideline on the care of severely and multiply traumatized patients, which was last updated in 2016. RESULTS The goal of initial emergency room care is the rapid recognition and prompt treatment of acutely life-threatening injuries in the order of their priority. The initial assessment includes physical examination and ultrasonography according to the FAST concept (Focused Assessment with Sonography in Trauma) for the recognition of intraperitoneal hemorrhage. Patients with penetrating chest injuries, massive hematothorax, and/or severe injuries of the heart and lungs undergo emergency thoracotomy; those with signs of hollow viscus perforation undergo emergency laparotomy. If the patient is hemo - dynamically stable, the most important diagnostic procedure that must be performed is computerized tomography with contrast medium. Therapeutic decision-making takes the patient's physiological parameters into account, along with the overall severity of trauma and the complexity of the individual injuries. Depending on the severity of trauma, the immediate goal can be either the prompt restoration of organ structure and function or so-called damage control surgery. The latter focuses, in the acute phase, on hemostasis and on the avoidance of secondary damage such as intra-abdominal contamination or compartment syndrome. It also involves the temporary treatment of fractures with external fixation and the planning of definitive care once the patient's organ functions have been securely stabilized. CONCLUSION The care of the severely injured patient should be performed in structured fashion according to the A-B-C-D-E scheme, which involves the securing of the airway, breathing, and circulation, the recognition of neurologic deficits, and whole-body examination by the interdisciplinary team.
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Affiliation(s)
- Michael Frink
- Center for Orthopedics and Trauma Surgery, Gießen and Marburg University Hospital, Marburg Campus, Marburg
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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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Tarchouli M, Elabsi M, Njoumi N, Essarghini M, Echarrab M, Chkoff MR. Liver trauma: What current management? Hepatobiliary Pancreat Dis Int 2018; 17:39-44. [PMID: 29428102 DOI: 10.1016/j.hbpd.2018.01.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 11/02/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years. METHODS The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed. RESULTS The study involved 83 patients, with a mean age of 33 years and a marked male predominance (85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries (81.9%) were of low severity (grades I, II, III), while 15 (18.1%) were of high severity (grade IV or greater). Fifty-six patients (67.5%) had multiple injuries. Surgical treatment was performed in 26 (31.3%) patients. Non-operative management was undertaken in 57 cases (68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group. CONCLUSIONS Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.
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Affiliation(s)
- Mohamed Tarchouli
- Department of Digestive Surgery, Mohammed V Military Hospital, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fes, Morocco.
| | - Mohamed Elabsi
- Department of Visceral Surgical Emergency, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Noureddine Njoumi
- Department of Digestive Surgery, Mohammed V Military Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Mohamed Essarghini
- Department of Digestive Surgery, Mohammed V Military Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Mahjoub Echarrab
- Department of Visceral Surgical Emergency, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Mohamed Rachid Chkoff
- Department of Visceral Surgical Emergency, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
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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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Khatsilouskaya T, Haltmeier T, Cathomas M, Eberle B, Candinas D, Schnüriger B. Thromboembolic Prophylaxis with Heparin in Patients with Blunt Solid Organ Injuries Undergoing Non-operative Treatment. World J Surg 2017; 41:1193-1200. [PMID: 27942848 DOI: 10.1007/s00268-016-3820-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with blunt solid organ injuries (SOI) are at risk for venous thromboembolism (VTE), and VTE prophylaxis is crucial. However, little is known about the safety of early prophylactic administration of heparin in these patients. METHODS This is a retrospective study including adult trauma patients with SOI (liver, spleen, kidney) undergoing non-operative management (NOM) from 01/01/2009 to 31/12/2014. Three groups were distinguished: prophylactic heparin (low molecular weight heparin or low-dose unfractionated heparin) ≤72 h after admission ('early heparin group'), >72 h after admission ('late heparin group'), and no heparin ('no heparin group'). Patient and injury characteristics, transfusion requirements, and outcomes (failed NOM, VTE, and mortality) were compared between the three groups. RESULTS Overall, 179 patients were included; 44.7% in the 'early heparin group,' 34.6% in the 'late heparin group,' and 20.8% in the 'no heparin group.' In the 'late heparin group,' the ISS was significantly higher than in the 'early' and 'no heparin groups' (median 29.0 vs. 17.0 vs. 19.0; p < 0.001). The overall NOM failure rate was 3.9%. Failed NOM was significantly more frequent in the 'no heparin group' compared to the 'early' and 'late heparin groups' (10.8 vs. 3.2 vs. 1.3%; p = 0.043). In the 'early heparin group' 27.5% patients suffered from a high-grade SOI; none of these patients failed NOM. Mortality did not differ significantly. Although not statistically significant, VTE were more frequent in the 'no heparin group' compared to the 'early' and 'late heparin groups' (10.8 vs. 4.8 vs. 1.3%; p = 0.066). CONCLUSION In patients with SOI, heparin was administered early in a high percentage of patients and was not associated with an increased NOM failure rate or higher in-hospital mortality.
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Affiliation(s)
- Tatsiana Khatsilouskaya
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Haltmeier
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marionna Cathomas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Barbara Eberle
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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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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Kaptanoglu L, Kurt N, Sikar HE. Current approach to liver traumas. Int J Surg 2017; 39:255-259. [PMID: 28193544 DOI: 10.1016/j.ijsu.2017.02.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/06/2017] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Liver injuries remain major obstacle for successful treatment, due to size and location of the liver. Requirement for surgery should be determined by clinical factors, most notably hemodynamical state. In this present study we tried to declare our approach to liver traumas. We also tried to emphasize the importance of conservative treatment, since surgeries for liver traumas carry high mortality rates. PRESENTATION OF CASE Patients admitted to the Department of Emergency Surgery at Kartal Research and Education Hospital, due to liver trauma were retrospectively analyzed between 2003 and 2013. Patient demographics, hepatic panel, APTT (activated partial thromboplastin time), PT (prothrombin time), INR (international normalized ratio), fibrinogen, biochemistry panel were recorded. Hemodynamic instability was the most prominent factor for surgery decision, in the lead of current Advanced Trauma Life Support (ATLS) protocols. Operation records and imaging modalities revealed liver injuries according to the Organ Injury Scale of the American Association for the Surgery of Trauma. 300 patients admitted to emergency department were included in our study (187 males and 113 females). Mean age was 47 years (range, 12-87). The overall mortality rate was 13% (40 out of 300). Major factor responsible for mortality rates and outcome was stability of cases on admission. 188 (% 63) patients were counted as stable, whereas 112 (% 37) cases were found unstable (blood pressure ≤ 90, after massive resuscitation). 192 patients were observed conservatively, whereas 108 cases received abdominal surgery. High levels of AST, ALT, LDH, INR, creatinine and low levels of fibrinogen and low platelet counts on admission were found to be associated with mortality and these cases also had Grade 4 and 5 injuries. Hemodynamic instability on admission and the type and grade of injury played major role in mortality rates). Packing was performed in 35 patients, with Grade 4 and 5 injuries. Mortality rate was %13 (40 out of 300). CONCLUSION A multidisciplinary approach to the management of hepatic injuries has evolved over the last few decades, but the basic principles of trauma continue to be observed. Diagnostic and therapeutic endeavors are chosen based mainly on the stability of the patient. Stable patients with reliable examinations and available resources can be managed nonoperatively. Unstable patients require surgery. Our current approach to liver traumas is non operative technique, if possible.
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Affiliation(s)
| | - Necmi Kurt
- Kartal Research and Education Hospital, Turkey
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Coccolini F, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Ceresoli M, Montori G, Sartelli M, Weber D, Fraga G, Naidoo N, Moore FA, Zanini N, Ansaloni L. WSES classification and guidelines for liver trauma. World J Emerg Surg 2016; 11:50. [PMID: 27766112 PMCID: PMC5057434 DOI: 10.1186/s13017-016-0105-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/13/2016] [Indexed: 11/10/2022] Open
Abstract
The severity of liver injuries has been universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale. In determining the optimal treatment strategy, however, the haemodynamic status and associated injuries should be considered. Thus the management of liver trauma is ultimately based on the anatomy of the injury and the physiology of the patient. This paper presents the World Society of Emergency Surgery (WSES) classification of liver trauma and the management Guidelines.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore Hospital, Parma, Italy
| | | | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Walter Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Marco Ceresoli
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Gustavo Fraga
- Faculdade de Ciências Médicas (FCM)-Unicamp, Campinas, SP Brazil
| | - Noel Naidoo
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | | | - Nicola Zanini
- General Surgery Department, Infermi Hospital, Rimini, Italy
| | - Luca Ansaloni
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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Callahan DS, Ashman Z, Kim DY, Plurad DS. Anticipated Transfusion Requirements and Mortality in Patients with Orthopedic and Solid Organ Injuries. Am Surg 2016. [DOI: 10.1177/000313481608201016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Long bone fractures are cited as an etiology for significant blood loss; however, there is scant supporting literature. We examined the relationship between long bone fractures, blood transfusions, and solid organ injuries. We hypothesize that transfusions are rare with long bone fractures in the absence of a liver or splenic injury. We performed a retrospective analysis of patients admitted with femur, tibia, and humerus fractures. Outcomes included transfusion requirements and mortality. A total of 1837 patients were included. There were 182 patients with at least one solid organ injury. A greater portion of patients with femur fractures and a lower proportion of patients with tibia fractures required transfusion. Adjusting for solid organ injuries, there was no difference in transfusions for any patient with these fractures compared with the group, or when grouped by organ injury severity. A solid organ injury significantly increases the risk of death among patients with long bone fractures. Blood loss requiring transfusion in patients with orthopedic and solid organ injuries should not be attributed to the presence of fractures alone. The need for transfusions in these patients should lower the threshold for reimaging or intervention for the solid organ injury. Further study is warranted to quantify blood loss by fracture type with or without solid organ.
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Affiliation(s)
- Devon S. Callahan
- From the Division of Trauma/Emergency Surgery/Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Zane Ashman
- From the Division of Trauma/Emergency Surgery/Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Dennis Y. Kim
- From the Division of Trauma/Emergency Surgery/Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - David S. Plurad
- From the Division of Trauma/Emergency Surgery/Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
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