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Aryan N, Grigorian A, Tay-Lasso E, Cripps M, Carmichael H, McIntyre R, Urban S, Velopulos C, Cothren Burlew C, Ballow S, Dirks RC, LaRiccia A, Farrell MS, Stein DM, Truitt MS, Grossman Verner HM, Mentzer CJ, Mack TJ, Ball CG, Mukherjee K, Mladenov G, Haase DJ, Abdou H, Schroeppel TJ, Rodriquez J, Bala M, Keric N, Crigger M, Dhillon NK, Ley EJ, Egodage T, Williamson J, Cardenas TC, Eugene V, Patel K, Costello K, Bonne S, Elgammal FS, Dorlac W, Pederson C, Werner NL, Haan JM, Lightwine K, Semon G, Spoor K, Harmon LA, Samuels JM, Spalding MC, Nahmias J. High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study. Am J Surg 2024; 234:105-111. [PMID: 38553335 DOI: 10.1016/j.amjsurg.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND High-grade liver injuries with extravasation (HGLI + Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI + Extrav. Therefore, we evaluated the management of HGLI + Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS HGLI + Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p = 0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p > 0.05). CONCLUSION Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI + Extrav patients.
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Affiliation(s)
- Negaar Aryan
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, USA.
| | - Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, USA.
| | - Erika Tay-Lasso
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, USA.
| | | | | | | | | | | | | | - Shana Ballow
- University of California, San Francisco-Fresno, USA.
| | | | | | | | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, USA.
| | | | | | | | - T J Mack
- Spartanburg Regional Medical Center, USA.
| | | | | | - Georgi Mladenov
- Division of Acute Care Surgery, Loma Linda University Health, USA.
| | - Daniel J Haase
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Department of Emergency Medicine and Surgery, USA.
| | - Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Department of Emergency Medicine and Surgery, USA.
| | | | | | | | | | | | | | | | | | | | | | - Vadine Eugene
- Dell Medical School, University of Texas at Austin, USA.
| | | | | | - Stephanie Bonne
- Rutgers, Division of Trauma and Surgical Critical Care, Department of Surgery, New Jersey Medical School, USA.
| | - Fatima S Elgammal
- Rutgers, Division of Trauma and Surgical Critical Care, Department of Surgery, New Jersey Medical School, USA.
| | | | | | - Nicole L Werner
- University of Wisconsin-Madison School of Medicine and Public Health, USA.
| | - James M Haan
- Ascension Via Christi Saint Francis, Department of Trauma Services, USA.
| | - Kelly Lightwine
- Ascension Via Christi Saint Francis, Department of Trauma Services, USA.
| | - Gregory Semon
- Wright State University / Miami Valley Hospital, USA.
| | | | | | - Jason M Samuels
- Vanderbilt University Medical Center, Section of Surgical Sciences, USA.
| | - M C Spalding
- Division of Trauma and Acute Care Surgery, Mount Carmel East, Columbus, OH, USA.
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, USA.
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2
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Zhu L, Liu Z, Bao Z, Zhang Y. Comprehensive management of severe hepatic trauma: Case study on liver transplantation and rhabdomyolysis treatment. Asian J Surg 2024:S1015-9584(24)01065-0. [PMID: 38890046 DOI: 10.1016/j.asjsur.2024.05.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/28/2024] [Accepted: 05/23/2024] [Indexed: 06/20/2024] Open
Affiliation(s)
- Liuyang Zhu
- First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Zirong Liu
- Tianjin Medical University Nankai Hospital, Tianjin, China
| | - Zheheng Bao
- Department of Orthopedic Surgery, Tianjin First Central Hospital, Tianjin, China
| | - Yamin Zhang
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, Tianjin, China.
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3
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Field X, Crichton JCI, Kong V, Ko J, Laing GL, Bruce J, Clarke DL. AAST grade of liver injury is not the single most important consideration in decision making for liver trauma. Injury 2024:111526. [PMID: 38644076 DOI: 10.1016/j.injury.2024.111526] [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: 07/16/2023] [Revised: 02/28/2024] [Accepted: 04/02/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND The liver is one of the most injured organs in both blunt and penetrating trauma. The aim of this study was to identify whether the AAST liver injury grade is predictive of need for intervention, risk of complications and mortality in our patient population, and whether this differs between blunt and penetrating-trauma mechanisms. METHODS Retrospective review of all liver injuries from a single high-volume metropolitan trauma centre in South Africa from December 2012 to January 2022. Inclusion criteria were all adults who had sustained traumatic liver injury. Patients were excluded if they were under 15 years of age or had died prior to operation or assessment. Statistical analysis was undertaken using both univariate and multivariate models. RESULTS 709 patients were included, of which 351 sustained penetrating and 358 blunt trauma. Only 24.3 % of blunt compared to 76.4 % of penetrating trauma patients underwent laparotomy (p< 0.001). In blunt trauma, increasing AAST grade correlated directly with rates of laparotomy with an odds ratio of 1.7 (p < 0.001). In penetrating trauma, there was no statistical significance between increasing AAST grade and the rate of laparotomy. The rate of bile leak was 4.5 % (32/709) and of rebleed was 0.7 % (5/709). Five patients underwent ERCP and endoscopic sphincterotomy for bile leak, and three required angio-embolization for rebleeding. Increasing AAST grades were significantly associated with the odds of bile leak in both blunt and penetrating trauma. There was a statistically significant increase in the odds of a rebleed with increasing AAST grade in penetrating trauma. Five patients rebled, of which three died. Seven patients developed hepatic necrosis. Seventy-six patients died (10 %). There were 34/358 (9 %) deaths in the blunt cohort and 42 /351 (11 %) deaths in the penetrating trauma cohort. CONCLUSION AAST grade in isolation is not a good predictor of the need for operation in hepatic trauma. Increasing AAST grade was not found to correlate with increased risk of mortality for both blunt and penetrating hepatic trauma. In both blunt and penetrating trauma, increasing AAST grade is significantly associated with increased bile leak. The need for ERCP and endoscopic sphincterotomy to manage bile leak in our setting is low. Similarly, the rate of rebleeding and of angioembolization was low.
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Affiliation(s)
- Xavier Field
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand
| | - James C I Crichton
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Victor Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Department of Surgery, University of KwaZulu Natal, Durban, South Africa.
| | - Jonathan Ko
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Grant L Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - John Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Damian L Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Department of Surgery, University of KwaZulu Natal, Durban, South Africa
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Ren J, Chen H, Dong Y, Sun Q, Liu T, Dong F, Qiao Y. Multidisciplinary management of a pregnant woman with hepatic rupture complicated with HELLP syndrome. Am J Transl Res 2024; 16:933-939. [PMID: 38586103 PMCID: PMC10994784 DOI: 10.62347/rasl4490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/12/2024] [Indexed: 04/09/2024]
Abstract
A 32-year-old woman with preeclampsia who presented with persistent severe hypertension and epigastric pain underwent an emergency cesarean section for fetal distress and was diagnosed with hepatic rupture and HELLP (hemolysis, elevated liver enzymes, and a low platelet) syndrome. After the operation, the patient was transferred to the intensive care unit for supportive treatment and management of complications. Diagnosis and treatment decisions were made through multidisciplinary management. The patient received plasma exchange and continuous renal replacement therapy. One week after the operation, the patient developed deep vein thrombosis and received anticoagulant therapy, which triggered rebleeding. Conservative treatment was taken, including halving the dosage of anticoagulant medication and performing a blood transfusion, and the patient's condition gradually stabilized. The patient was discharged 44 days after the operation. Early diagnosis, effective treatment, and multidisciplinary management can help patients with this critical presentation achieve good clinical outcomes.
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Affiliation(s)
- Jing Ren
- Department of Obstetrics, Affiliated Hospital of Jining Medicine UniversityJining 272000, Shandong, China
| | - Hui Chen
- Department of Obstetrics, Affiliated Hospital of Jining Medicine UniversityJining 272000, Shandong, China
| | - Yan Dong
- Department of Obstetrics, Affiliated Hospital of Jining Medicine UniversityJining 272000, Shandong, China
| | - Qiang Sun
- Department of Critical Care Medicine, Affiliated Hospital of Jining Medicine UniversityJining 272000, Shandong, China
| | - Tao Liu
- Department of Hepatobiliary Surgery, Affiliated Hospital of Jining Medicine UniversityJining 272000, Shandong, China
| | - Fang Dong
- Department of Critical Care Medicine, Affiliated Hospital of Jining Medicine UniversityJining 272000, Shandong, China
| | - Yuangang Qiao
- Department of Vascular and Oncologic Interventional Medicine, Affiliated Hospital of Jining Medicine UniversityJining 272000, Shandong, China
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Smith AA, Cone JT, McNickle AG, Mitchao DP, Kostka R, Martinez B, Schroeppel T, Cavalea A, Shahan CP, Axtman B, Braverman MA. MultiCenter Study of Intra-Abdominal Abscess Formation After Major Operative Hepatic Trauma. J Surg Res 2024; 295:746-752. [PMID: 38147760 DOI: 10.1016/j.jss.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/10/2023] [Accepted: 11/09/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION One of the significant complications of operative liver trauma is intra-abdominal abscesses (IAA). The objective of this study was to determine risk factors associated with postoperative IAA in surgical patients with major operative liver trauma. METHODS A retrospective multi-institutional study was performed at 13 Level 1 and Level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Univariate and multivariate analyses were performed. RESULTS Three hundred seventy-two patients were included with 21.2% (n = 79/372) developing an IAA. No difference was found for age, gender, injury severity score, liver injury grade, and liver resections in patients between the groups (P > 0.05). Penetrating mechanism of injury (odds ratio (OR) 3.42, 95% confidence interval (CI) 1.54-7.57, P = 0.02), intraoperative massive transfusion protocol (OR 2.43, 95% CI 1.23-4.79, P = 0.01), biloma/bile leak (OR 2.14, 95% CI 1.01-4.53, P = 0.04), hospital length of stay (OR 1.04, 95% CI 1.02-1.06, P < 0.001), and additional intra-abdominal injuries (OR 2.27, 95% CI 1.09-4.72, P = 0.03) were independent risk factors for IAA. Intra-abdominal drains, damage control laparotomy, total units of packed red blood cells, number of days with an open abdomen, total abdominal surgeries, and blood loss during surgery were not found to be associated with a higher risk of IAA. CONCLUSIONS Patients with penetrating trauma, massive transfusion protocol activation, longer hospital length of stay, and injuries to other intra-abdominal organs were at higher risk for the development of an IAA following operative liver trauma. Results from this study could help to refine existing guidelines for managing complex operative traumatic liver injuries.
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Affiliation(s)
- Alison A Smith
- Surgery Department, Louisiana State University Health Sciences Center New Orleans, New Orleans, Louisiana.
| | - Jennifer T Cone
- Surgery Department, University of Chicago School of Medicine, Chicago, Illinois
| | - Allison G McNickle
- Surgery Department, University of Nevada- Las Vegas School of Medicine, Las Vegas, Nevada
| | - Delbrynth P Mitchao
- Surgery Department, LAC+USC Medical Center, University of Southern California, Los Angeles, California
| | - Ryan Kostka
- Surgery Department, Baylor Scott and White Health, Dallas, Texas
| | - Benjamin Martinez
- Trauma Surgery Division, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana
| | - Thomas Schroeppel
- Surgery Department, University of Colorado Health, Colorado Springs, Colorado
| | - Alexander Cavalea
- Surgery Department, University of Tennessee Knoxville Medical Center, Knoxville, Tennessee
| | | | - Benjamin Axtman
- Trauma Division, Sanford Health Bismarck, Bismarck, North Dakota
| | - Maxwell A Braverman
- Surgery Department, St. Luke University Healthcare Network, Bethlehem, Pennsylvania
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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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7
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Rozycki GF, Sakran JV, Manukyan MC, Feliciano DV, Radisic A, You B, Hu F, Wooster M, Noll K, Haut ER. Angioembolization May Improve Survival in Patients With Severe Hepatic Injuries. Am Surg 2023; 89:5492-5500. [PMID: 36786019 DOI: 10.1177/00031348231157416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
INTRODUCTION Although reports on angioembolization (AE) show favorable results for severe hepatic trauma, information is lacking on its benefit in the management and mechanisms of injury (MOI). This study examined patient outcomes with severe hepatic injuries to determine the association of in-hospital mortality with AE. The hypothesis is that AE is associated with increased survival in severe hepatic injuries. METHODS Demographics, age, sex, MOI, shock index (SI), ≥6 units packed red blood cells (PRBCs) per hospital length of stay (LOS), intensive care unit LOS, injury severity score (ISS), and AE were collected. The primary outcome was in-hospital mortality. Patients were stratified into groups according to MOI, AE, and operative vs non-operative management. Multivariable logistic regression determined the independent association of mortality with AE vs no AE and operative vs nonoperative management and modeled the odds of mortality controlling for MOI, AE vs no AE, age and ISS groups, SI >.9, and ≥6 units PRBCs/LOS. RESULTS From 2013 to 2018, 2462 patients (1744 blunt; 718 penetrating) were treated for severe hepatic injuries. AE was used in only 21% of patients. Mortality rates increased with higher ISS and age. AE was associated with mortality when compared to patients who did not undergo AE. The strongest associations with mortality were ISS ≥25, transfusion ≥ 6 units PRBCs/LOS, and age ≥65 years. CONCLUSIONS AE is underutilized in severe hepatic trauma. AE may be a valuable adjunct in the treatment of severe hepatic injuries especially in older patients and those needing exploratory laparotomy.
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Affiliation(s)
- Grace F Rozycki
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph V Sakran
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mariuxi C Manukyan
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David V Feliciano
- Shock Trauma Center/University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amanda Radisic
- Department of Surgery, School of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Bin You
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fang Hu
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meghan Wooster
- Southeast Iowa Regional Medical Center, Burlington, IA, USA
| | - Kathy Noll
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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8
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Fentoukh MK, Alqahtani AA, Salih AA, Koko AH. Unusual complication after shock wave lithotripsy (SWL) for a renal stone: A subcapsular hepatic hematoma. A case report and review of literature. Urol Case Rep 2023; 51:102604. [PMID: 38024509 PMCID: PMC10663668 DOI: 10.1016/j.eucr.2023.102604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Urolithiasis is a common urological condition that affects around 8 per 1000 people every year. Management depends on multiple factors varying between stone related and patient related factors. In some cases, shock wave lithotripsy (SWL), one of the most popular noninvasive and safe procedures, is required where conservative measures fail. However, it can lead to life-threatening complications. Here we present rare case of hepatic hematoma in a 57-year-old female patient following SWL for right kidney stone on the 2nd day post-SWL. The patient was managed successfully with conservative measures.
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Affiliation(s)
- Moath K. Fentoukh
- Department of Urology, Armed Forces Hospital, King Abdulaziz Air Base, Dhahran, Kingdom of Saudi Arabia
| | - Ali A. Alqahtani
- Department of Urology, Armed Forces Hospital, King Abdulaziz Air Base, Dhahran, Kingdom of Saudi Arabia
| | - Abdelwahab A. Salih
- Department of Urology, Armed Forces Hospital, King Abdulaziz Air Base, Dhahran, Kingdom of Saudi Arabia
| | - Abdelmoniem H. Koko
- Department of Urology, Armed Forces Hospital, King Abdulaziz Air Base, Dhahran, Kingdom of Saudi Arabia
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Deville PE, Marr AB, Cone JT, Hoefer LE, Mitchao DP, Inaba K, Kostka R, Mooney JL, McNickle AG, Smith AA. Multicenter Study of Perioperative Hepatic Angioembolization as an Adjunct for Management of Major Operative Hepatic Trauma. J Am Coll Surg 2023; 237:697-703. [PMID: 37366536 DOI: 10.1097/xcs.0000000000000791] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
BACKGROUND The management of major liver trauma continues to evolve in trauma centers across the US with increasing use of minimally invasive techniques. Data on the outcomes of these procedures remain minimal. The objective of this study was to evaluate patient complications after perioperative hepatic angioembolization as an adjunct to management of major operative liver trauma. STUDY DESIGN A retrospective multi-institutional study was performed at 13 level 1 and level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Patients were divided into 2 groups: angioembolization (AE) and no angioembolization (NO AE). Univariate and multivariate analyses were performed. RESULTS A total of 442 patients were included with AE performed in 20.4% (n = 90 of 442) of patients. The AE group was associated with higher rates of biloma formation (p = 0.0007), intra-abdominal abscess (p = 0.04), pneumonia (p = 0.006), deep vein thrombosis (p = 0.0004), acute renal failure (p = 0.004), and acute respiratory distress syndrome (p = 0.0003), and it had longer ICU and hospital length of stay (p < 0.0001). On multivariate analysis, the AE had a significantly higher amount intra-abdominal abscess formation (odds ratio 1.9, 95% CI 1.01 to 3.6, p = 0.05). CONCLUSIONS This is one of the first multicenter studies comparing AE in specifically operative high-grade liver injuries and found that patients with liver injury that undergo AE in addition to surgery have higher rates of both intra- and extra-abdominal complications. This provides important information that can guide clinical management.
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Affiliation(s)
- Paige E Deville
- From the Louisiana State University Health Sciences Center, New Orleans, LA (Deville, Marr, Smith)
| | - Alan B Marr
- From the Louisiana State University Health Sciences Center, New Orleans, LA (Deville, Marr, Smith)
| | - Jennifer T Cone
- University of Chicago School of Medicine, Chicago IL (Cone, Hoefer)
| | - Lea E Hoefer
- University of Chicago School of Medicine, Chicago IL (Cone, Hoefer)
| | - Delbrynth P Mitchao
- University of Southern California to LA General Medical Center, Keck School of Medicine of USC, Los Angeles, CA (Mitchao, Inaba)
| | - Kenji Inaba
- University of Southern California to LA General Medical Center, Keck School of Medicine of USC, Los Angeles, CA (Mitchao, Inaba)
| | - Ryan Kostka
- Baylor Scott and White Health, Dallas, TX (Koska, Mooney)
| | | | - Allison G McNickle
- University of Nevada, Las Vegas School of Medicine, Las Vegas, NV (McNickle)
| | - Alison A Smith
- From the Louisiana State University Health Sciences Center, New Orleans, LA (Deville, Marr, Smith)
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10
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Noorbakhsh S, Gomez L, Joung Y, Meyer C, Hanos DS, Freedberg M, Klingensmith N, Grant AA, Koganti D, Nguyen J, Smith RN, Sciarretta JD. Hepatic Arterioportal Fistula Following Liver Trauma: Case Series and Review of the Literature. Vasc Endovascular Surg 2023; 57:749-755. [PMID: 36940466 PMCID: PMC10724846 DOI: 10.1177/15385744231165155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
PURPOSE Hepatic arterioportal fistula (HAPF) is an uncommon complication of hepatic trauma, which can manifest with abdominal pain and the sequelae of portal hypertension months to years after injury. The purpose of this study is to present cases of HAPF from our busy urban trauma center and make recommendations for management. METHODS One hundred and twenty-seven patients with high-grade penetrating liver injuries (American Association for the Surgery of Trauma [AAST] - Grades IV-V) between January 2019 and October 2022 were retrospectively reviewed. Five patients were identified with an acute hepatic arterioportal fistula following abdominal trauma from our ACS-verified adult Level 1 trauma center. Institutional experience with overall surgical management is described and reviewed with the current literature. RESULTS Four of our patients presented in hemorrhagic shock requiring emergent operative intervention. The first patient had postoperative angiography and coil embolization of the HAPF. Patients 2 through 4 underwent damage control laparotomy with temporary abdominal closure followed by postoperative transarterial embolization with gelatin sponge particles (Gelfoam) or combined Gelfoam/n-butyl cyanoacrylate. The final patient went directly for angiography and Gelfoam embolization after identification of the HAPF. All 5 patients had resolution of HAPF on follow-up imaging with continued post management for traumatic injuries. CONCLUSION Hepatic arterioportal fistula can present as a complication of hepatic injury and manifest with significant hemodynamic aberrations. Although surgical intervention was required to achieve hemorrhage control in almost all cases, management of HAPF in the setting of high-grade liver injuries was achieved successfully with modern endovascular techniques. A multidisciplinary approach to such injuries is necessary to optimize care in the acute setting following traumatic injury.
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Affiliation(s)
- Soroosh Noorbakhsh
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Lissette Gomez
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Yoo Joung
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Courtney Meyer
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Dustin S. Hanos
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Mari Freedberg
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Nathan Klingensmith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - April A. Grant
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Deepika Koganti
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Jonathan Nguyen
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Randi N. Smith
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Jason D. Sciarretta
- Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
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Murphy PB. Invited Commentary: Pseudoaneurysm after Penetrating High-Grade Solid Organ Injury: Should We Be Screening? J Am Coll Surg 2023; 237:438-440. [PMID: 37204152 DOI: 10.1097/xcs.0000000000000767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
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12
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Fujita M, Sato T, Takase K, Sato T, Furukawa H, Kushimoto S. Hepatic compartment syndrome treated with damage control surgery and transarterial embolization: A case report. Trauma Case Rep 2023; 46:100857. [PMID: 37292437 PMCID: PMC10245332 DOI: 10.1016/j.tcr.2023.100857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2023] [Indexed: 06/10/2023] Open
Abstract
Background Hepatic compartment syndrome (HCS) is a complication of nonoperative management in patients with blunt hepatic injury. Although decompression of elevated intrahepatic pressure through surgical exploration or drainage and hemorrhage control are required to manage this condition, evidence for such a management for this complication is insufficient. Herein, we report a pediatric patient treated with a planned combination strategy of surgical decompression with perihepatic packing to reduce intrahepatic pressure and subcapsular hemorrhage control as well as angioembolization to control intraparenchymal hemorrhage. Case presentation A 12-year-old boy was referred to our emergency department 5 h after sustaining severe bruising in the upper abdomen in a traffic accident. Computed tomography (CT) showed an intraparenchymal hematoma in the right lobe of the liver; nonoperative management was selected based on stable hemodynamic status. Two days after the injury, he complained of severe abdominal pain and shock. CT showed an intraparenchymal and large subcapsular hematoma with right branch compression of the portal vein and extravasation of contrast material. Laboratory data showed progression of hepatocellular damage. We successfully managed this patient with a planned combination strategy of surgical decompression with perihepatic packing for reduction of intrahepatic pressure and subcapsular hemorrhage control, followed by angioembolization for control of intraparenchymal hemorrhage. Conclusion Our study suggests that for the management of HCS, a planned combination strategy of damage control surgery and angioembolization is a therapeutic option.
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Affiliation(s)
- Motoo Fujita
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital Emergency Center, Sendai-shi 980-8574, Japan
| | - Takeaki Sato
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital Emergency Center, Sendai-shi 980-8574, Japan
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai-shi 980-8574, Japan
| | - Tomomi Sato
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai-shi 980-8574, Japan
| | - Hajime Furukawa
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital Emergency Center, Sendai-shi 980-8574, Japan
| | - Shigeki Kushimoto
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital Emergency Center, Sendai-shi 980-8574, Japan
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Jung HS, Jeon CH, Seo SH. [Clinical Role of Interventional Radiology in Abdominal Solid Organ Trauma]. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:824-834. [PMID: 37559810 PMCID: PMC10407070 DOI: 10.3348/jksr.2023.0046] [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: 04/25/2023] [Revised: 06/09/2023] [Accepted: 07/12/2023] [Indexed: 08/11/2023]
Abstract
Interventional management is commonly used for traumatic injuries to the abdominal solid organs. The American Association for the Surgery of Trauma (AAST) and the World Society of Emergency Surgery (WSES) recently published guidelines for the management and treatment of liver, spleen, and kidney injuries, emphasizing the importance of interventions. Here, we discuss the characteristics of each organ and the procedure method for each organ that interventional radiologists need to know when treating trauma patients.
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Jeon S, Yu B, Lee GJ, Lee MA, Park Y, Cho J, Lee J, Choi ST, Choi KK. Liver Transplant After Severe Liver Trauma: The First Report in a Korean Adult. EXP CLIN TRANSPLANT 2023; 21:619-622. [PMID: 37584543 DOI: 10.6002/ect.2023.0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
Following a motor-vehicle accident, a 57-year-old man was diagnosed with a grade 4 liver injury (American Association for the Surgery of Trauma organ injury scale) with multiple contrast extravasations. He initially underwent nonoperative management, which included transcatheter arterial embolization. However, he experienced a hemorrhage after the first embo-lization procedure, and so the procedure was repeated. Thereafter, he was diagnosed with liver failure based on findings from computed tomography and liver function tests. On day 28 of hospitalization, the patient underwent deceased donor liver transplant. He experienced several complications, including acute renal failure, pneumonia, and bile leak. These were managed successfully, and the patient was discharged 4 months after the transplant. Although liver transplant procedure for hepatic trauma is technically challenging and risky, it should be considered a viable treatment option in some patients (such as patients with severe liver injury). This is the first reported case, to our knowledge, of a liver transplant performed successfully in a patient with severe hepatic trauma in Korea.
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Affiliation(s)
- Sebeom Jeon
- From the Department of Trauma Surgery, Gachon University, Gil Medical Center, Incheon, Korea
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15
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Hörer TM, Ierardi AM, Carriero S, Lanza C, Carrafiello G, McGreevy DT. Emergent vessel embolization for major traumatic and non-traumatic hemorrhage: Indications, tools and outcomes. Semin Vasc Surg 2023; 36:283-299. [PMID: 37330241 DOI: 10.1053/j.semvascsurg.2023.04.011] [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: 02/10/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 06/19/2023]
Abstract
Endovascular embolization of bleeding vessels in trauma and non-trauma patients is frequently used and is an important tool for bleeding control. It is included in the EVTM (endovascular resuscitation and trauma management) concept and its use in patients with hemodynamic instability is increasing. When the correct embolization tool is chosen, a dedicated multidisciplinary team can rapidly and effectively achieve bleeding control. In this article, we will describe the current use and possibilities for embolization of major hemorrhage (traumatic and non-traumatic) and the published data supporting these techniques as part of the EVTM concept.
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Affiliation(s)
- Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Sciences, Örebro University Hospital and Örebro University, Södra Grev Rosengatan, 701 85 Örebro, Sweden; Department of Surgery, Faculty of Life Sciences, Örebro University Hospital and Örebro University, Örebro, Sweden; Carmel Lady Davis Hospital, Technion Medical Faculty, Haifa, Israel.
| | - Anna Maria Ierardi
- Radiology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Serena Carriero
- Post Graduate School of Radiology, University of Milan, Milan, Italy
| | - Carolina Lanza
- Post Graduate School of Radiology, University of Milan, Milan, Italy
| | - Gianpaolo Carrafiello
- Radiology Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - David T McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Sciences, Örebro University Hospital and Örebro University, Södra Grev Rosengatan, 701 85 Örebro, Sweden
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Liu J, Wang S, Xue X, Hu T, Peng X, Huang J, Zhou S. Experimental study of the effects of absorbable gelatin sponge and non‑absorbable polyvinyl alcohol particle material used in transcatheter arterial embolization on liver tissues. Exp Ther Med 2023; 25:229. [PMID: 37114170 PMCID: PMC10126803 DOI: 10.3892/etm.2023.11928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/03/2023] [Indexed: 04/29/2023] Open
Abstract
Hepatic trauma is a leading cause of death in major abdominal trauma, and transcatheter arterial embolization has been widely used to treat it. However, there is limited research on whether absorbable gelatin sponge (AGS) and non-absorbable polyvinyl alcohol particles (PVA) have different effects on liver tissue, making it an important area of exploration. The present study investigated this issue using animal experiments by performing transhepatic arterial embolization with AGS and PVA. The effects on normal liver tissue in rabbits were examined by detecting liver function and inflammatory indexes, conducting histopathological examination, and using western blotting to detect apoptotic proteins. There were significant differences between the AGS and PVA groups after embolization. The AGS group exhibited a trend of improvement at ~1 week after embolization, and all indicators were statistically different until day 21 compared with the PVA group. The AGS group exhibited improved repair of hepatocytes and the biliary system based on H&E staining, while the PVA group exhibited more severe necrosis of the hepatocytes and biliary system around the embolization site. The western blotting results indicated that the Bcl-2/Bax ratio decreased on day 1 and day 3, and then rebounded in the AGS group on days 7 and 21, demonstrating gradual repair of hepatocytes compared with the PVA group.
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Affiliation(s)
- Jianping Liu
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Shaoyi Wang
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Xiaojun Xue
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Tiansong Hu
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Xinjian Peng
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Junhao Huang
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
| | - Song Zhou
- Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, Zhangzhou, Fujian 363000, P.R. China
- Correspondence to: Professor Song Zhou, Department of General Surgery, Dongnan Hospital of Xiamen University, School of Medicine, Xiamen University, 269 Zhanghua Middle Road, Zhangzhou, Fujian 363000, P.R. China
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An observation-first strategy for liver injuries with "blush" on computed tomography is safe and effective. J Trauma Acute Care Surg 2023; 94:281-287. [PMID: 36149844 DOI: 10.1097/ta.0000000000003786] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE Therapeutic/Care Management; Level II.
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Gallaher J, Burton V, Schneider AB, Reid T, Raff L, Smith CB, Charles A. The Effect of Angioembolization Versus Open Exploration for Moderate to Severe Blunt Liver Injuries on Mortality. World J Surg 2023; 47:1271-1281. [PMID: 36705742 DOI: 10.1007/s00268-023-06926-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Blunt liver injury is common and is associated with a high morbidity and mortality. More severe injuries often require either angioembolization or open operative repair, depending on patient factors and facility capacity. We sought to describe patient outcomes based on intervention type. METHODS We analyzed the National Trauma Data Bank (2017-2019) using ICD-10 codes to identify adult patients with blunt liver injury and their interventions. AIS (Abbreviated Injury Scale) scores were used to group patients based on liver injury severity (AIS 2-6). Logistic regression modeling was used to estimate the adjusted odds ratio of death based on intervention type, excluding patients with severe injury. RESULTS Of 2,848,592 trauma patients, 50,250 patients had a blunt liver injury. Among patients with AIS 3/4/5 injury, 1,140 had angioembolization, 1,529 had an open repair, and 188 had both angioembolization and open repair. In comparison with no intervention and adjusted for age, sex, shock index, ISS, and transfusion total (first four hours), angioembolization was associated with a significant decrease in the odds of mortality for patients with an AIS 4 (OR 0.68, 95% CI 0.47, 0.99) and AIS 5 injury (OR 0.39, 95% CI 0.24, 0.64). In patients with an AIS 5 injury, open repair had an increased odds of mortality at OR 1.99 (95% CI 1.47, 2.69). CONCLUSION In an analysis of a national trauma database, patients with a moderate to severe injury (AIS 4 or 5), angioembolization was associated with a significant reduction in the adjusted odds of mortality compared to open repair and should be considered when clinically appropriate.
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Affiliation(s)
- Jared Gallaher
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA.
| | - Victoria Burton
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Andrew B Schneider
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Trista Reid
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Lauren Raff
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Charlotte B Smith
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Anthony Charles
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
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Segalini E, Morello A, Leati G, Di Saverio S, Aseni P. Primary angioembolization in liver trauma: major hepatic necrosis as a severe complication of a minimally invasive treatment-a narrative review. Updates Surg 2022; 74:1511-1519. [PMID: 36059024 PMCID: PMC9481502 DOI: 10.1007/s13304-022-01372-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/27/2022] [Indexed: 11/25/2022]
Abstract
The liver is the second most commonly solid organ injured in blunt abdominal trauma. Liver injuries are classified according to the American Association for the Surgery of Trauma Injury Scale. The choice of Non-Operative Management is based on generalized clinical patients’ conditions combined with the evidence on CT scan imaging. To date, there are no consensus guidelines on appropriate patient selection criteria for those who would benefit from angiography and angioembolization. Major hepatic necrosis is a clinical condition of extended liver damage and is the most common complication after angioembolization. Large amounts of necrotic liver require therapy, but it is unclear if the better technique is debridements supplemented by percutaneous drainage procedures or definitive resection. A systematic review of the literature was performed with a computerized search in a database such as Medline for published papers on the use of angioembolization in trauma patients with hepatic injuries and on the most common complication, the major hepatic necrosis. The systematic review was conducted according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A total of 3643 patients were included in the study, suffering liver trauma and 1703 (47%) were treated with Non-Operative Management; angioembolization was performed 10% of cases with a variable rate between 2 and 20%. Patients developed different complications. Hepatic necrosis accounted for 16% ranging from 0 to 42%. 74% of patients underwent operative management with a mortality rate of 11%. High-grade liver injuries pose significant challenges to surgeons who care for trauma patients. Many patients can be successfully managed nonoperatively. In hemodynamically stable patients with arterial blush, without other lesions requiring immediate surgery, selective and super-selective AE of the hepatic artery branches is an effective technique. However, these therapies are not without complications and major hepatic necrosis is the most common complication in high-grade injures. Level III, Systematic review
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Affiliation(s)
- Edoardo Segalini
- Department of General and Emergency Surgery, ASST Ospedale Maggiore, Crema, CR, Italy
| | - Alessia Morello
- Department of General and Emergency Surgery, ASST Ospedale Maggiore, Crema, CR, Italy
| | - Giovanni Leati
- Department of Interventional Radiology, ASST Ospedale Maggiore, Crema, CR, Italy
| | - Salomone Di Saverio
- Department of General Surgery, Ospedale Civile "Madonna del Soccorso", San Benedetto del Tronto, AP, Italy.
| | - Paolo Aseni
- Department of Emergency, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Clinical outcomes of non-operative management and clinical observation in non-angioembolised hepatic trauma: A systematic review of the literature. Chin J Traumatol 2022; 25:257-263. [PMID: 35487854 PMCID: PMC9458985 DOI: 10.1016/j.cjtee.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 01/30/2022] [Accepted: 02/26/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Liver is the most frequently injured organ in abdominal trauma. Today non-operative management (NOM) is considered as the standard of care in hemodynamically stable patients, with or without the adjunct of angioembolisation (AE). This systematic review assesses the incidence of complications in patients who sustained liver injuries and were treated with simple clinical observation. Given the differences in indications of treatment and severity of liver trauma and acknowledging the limitations of this study, an analysis of the results has been done in reference to the complications in patients who were treated with AE. METHODS A systematic literature review searched "liver trauma", "hepatic trauma", "conservative management", "non operative management" on MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials databases, EMBASE, and Google Scholar, to identify studies published on the conservative management of traumatic liver injuries between January 1990 and June 2020. Patients with traumatic liver injuries (blunt and penetrating) treated by NOM, described at least one outcome of interests and provided morbidity outcomes from NOM were included in this study. Studies reported the outcome of NOM without separating liver from other solid organs; studies reported NOM complications together with those post-intervention; case reports; studies including less than 5 cases; studies not written in English; and studies including patients who had NOM with AE as primary management were excluded. Efficacy of NOM and overall morbidity and mortality were assessed, the specific causes of morbidity were investigated, and the American Association for the Surgery of Trauma classification was used in all the studies analysed. Statistical significance has been calculated using the Chi-square test. RESULTS A total of 19 studies qualified for inclusion criteria were in this review. The NOM success rate ranged from 85% to 99%. The most commonly reported complications were hepatic collection (3.1%), followed by bile leak (1.5%), with variability between the studies. Other complications included hepatic haematoma, bleeding, fistula, pseudoaneurysm, compartment syndrome, peritonitis, and gallbladder ischemia, all with an incidence below 1%. CONCLUSION NOM with simple clinical observation showed an overall low incidence of complications, but higher for bile leak and collections. In patients with grade III and above injuries, the incidence of bile leak, collections and compartment syndrome did not show a statistically significant difference with the AE group. However, the latter result is limited by the small number of studies available and it requires further investigations.
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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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Trends in Reduction of Mortality in Liver Trauma. Crit Care Nurs Clin North Am 2022; 34:351-359. [DOI: 10.1016/j.cnc.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Cadavid-Navas M, Valdés-Giraldo D, Mejía-Toro DA, Correa-Cote JC, Morales-Uribe CH, Delgado-López CA. Resultados del manejo no operatorio en trauma hepático de los pacientes que se presentaron al servicio de urgencias del Hospital San Vicente Fundación, Medellín. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.1116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. El hígado continúa siendo uno de los órganos más afectados en los pacientes con trauma. Su evaluación y manejo han cambiado sustancialmente con los avances tecnológicos en cuanto a diagnóstico y las técnicas de manejo menos invasivas. El objetivo de este estudio fue realizar un análisis de los resultados del manejo no operatorio del trauma hepático en cuanto a incidencia, eficacia, morbimortalidad, necesidad de intervención quirúrgica, tasa y factores relacionados con el fallo del manejo no operatorio.
Métodos. Se realizó un estudio descriptivo observacional retrospectivo, analizando pacientes con trauma hepático confirmado con tomografía o cirugía, durante un periodo de 72 meses, en el Hospital Universitario San Vicente Fundación, un centro de IV nivel de atención, en Medellín, Colombia.
Resultados. Se incluyeron 341 pacientes con trauma hepático, 224 por trauma penetrante y 117 por trauma cerrado. En trauma penetrante, 208 pacientes fueron llevados a cirugía inmediatamente, el resto fueron manejados de manera no operatoria, con una falla en el manejo en 20 pacientes. En trauma cerrado, 22 fueron llevados a cirugía inmediata y 95 sometidos a manejo no operatorio, con una falla en 9 pacientes. La mortalidad global fue de 9,7 % y la mortalidad relacionada al trauma hepático fue de 4,4 %. El grado del trauma, el índice de severidad del trauma y las lesiones abdominales no hepáticas no se consideraron factores de riesgo para la falla del manejo no operatorio.
Conclusiones. El manejo no operatorio continúa siendo una alternativa segura y efectiva para pacientes con trauma hepático, sobretodo en trauma cerrado. En trauma penetrante se debe realizar una adecuada selección de los pacientes.
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Gavrilyuk VP, Lipatov VA, Mishina ES, Severinov DA. Analyzing Liver Tissue Responses To Local Hemostatic Agents. RUSSIAN OPEN MEDICAL JOURNAL 2022. [DOI: 10.15275/rusomj.2022.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objective – Our study aimed at evaluating changes in liver tissues after simulated injury and use of novel hemostatic agents (containing tranexamic acid) in the course of in vivo experiment. Material and Methods – The following hemostatic agents were studies: TachoComb collagen plate (Group 1); samples of novel local hemostatic agents based on sodium carboxymethyl cellulose (CMC), Na-CMC (Group 2); Na-CMC + tranexamic acid (Group 3). We performed the study on 30 rabbits with simulated liver laceration via laparoscopy, and were stopping bleeding by means of the above-mentioned methods. Then, on liver tissue micrographs, we were measuring capsule thickness (μm), sizes of hepatocytes and their nuclei (px), number of binuclear hepatocytes. We were also calculating nuclear-cytoplasmic ratio (NCR) of hepatocytes, as well as identifying qualitative and quantitative capsule composition in tested samples. Results – In the collagen plate group, the capsule width was 3.2-fold and 3.6-fold of this parameter in samples from Groups 2 and 3. Indirectly, this finding implied more severe inflammatory and regenerative processes aimed at limiting injury area, and was confirmed by statistically significant differences in the cellular composition of the capsule surrounding tested samples (fibroblastic cells predominated in Groups 2 and 3, and there were fewer of them in Group 1). The highest cell index (CI) value was detected in Group 3. Conclusion – A significant boundary zone separating tested materials from the liver parenchyma was also observed due to connective tissue growth as part of inflammatory response.
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Leung-Tack M, Ong EGP, McGuirk S. Interventional radiology and open surgery: An effective partnership for solid organ trauma. J Pediatr Surg 2022; 57:266-270. [PMID: 34838307 DOI: 10.1016/j.jpedsurg.2021.10.037] [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: 10/21/2021] [Accepted: 10/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Management algorithms of paediatric blunt abdominal solid organ injury (BASOI) are evolving to include interventional radiology, but there are few studies documenting the application and clinical outcomes of cases in children. METHODS A retrospective case note review of all paediatric BASOI at a single Paediatric Major Trauma Centre was completed. CT scans and injuries have been retrospectively graded according to AAST guidelines. RESULTS In the period February 2012 - October 2019, there were 106 children (median age 10.6 years (range 10 days - 16 years)) with BASOI. Of these, 71% (n = 75) suffered liver injuries, 29% (n = 31) spleen, and 27% (n = 29) renal. 95 children (89.6%) were treated with non-operative management, of which 15% (n = 14) went on to require secondary operative management (surgery, n = 1 & interventional radiology, n = 14). There were no deaths or loss of organ in the group which required secondary operative management, regardless of the grade of injury. CONCLUSION The majority of BASOI can be successfully treated conservatively, but IR is a useful additional tool in management for all grades of injury and is complementary to open surgery. LEVEL OF EVIDENCE Level IV Case Series.
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Affiliation(s)
- Mirana Leung-Tack
- University of Birmingham School of Medicine, Birmingham, United Kingdom
| | - Evelyn Geok Peng Ong
- The Liver Unit, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, United Kingdom.
| | - Simon McGuirk
- Interventional Radiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
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Le TD, Nguyen MD, Than VS. Transhepatic glue injection for hepatic pseudoaneurysm and arteriohepatic venous fistula after the failure of transarterial embolization. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii210022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Thanh Dung Le
- Department of Radiology, Viet Duc University Hospital, Hanoi, Vietnam
| | - Minh Duc Nguyen
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh, Vietnam
- Department of Radiology, Children’s Hospital 2, Ho Chi Minh, Vietnam
| | - Van Sy Than
- Department of Radiology, Viet Duc University Hospital, Hanoi, Vietnam
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Huang JF, Hsu CP, Fu CY, Huang YTA, Cheng CT, Wu YT, Hsieh FJ, Liao CA, Kuo LW, Chang SH, Hsieh CH. Preinjury warfarin does not cause failure of nonoperative management in patients with blunt hepatic, splenic or renal injuries. Injury 2022; 53:92-97. [PMID: 34756739 DOI: 10.1016/j.injury.2021.10.014] [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: 06/21/2021] [Revised: 09/22/2021] [Accepted: 10/15/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND For patients sustaining major trauma, preinjury warfarin use may make adequate haemostasis difficult. This study aimed to determine whether preinjury warfarin would result in more haemostatic interventions (transarterial embolization [TAE] or surgeries) and a higher failure rate of nonoperative management for blunt hepatic, splenic or renal injuries. METHODS This was a retrospective cohort study from the Taiwan National Health Insurance Research Database (NHIRD) from 2003 to 2015. Patients with hepatic, splenic or renal injuries were identified. The primary outcome measurement was the need for invasive procedures to stop bleeding. One-to-two propensity score matching (PSM) was used to minimize selection bias. RESULTS A total of 37,837 patients were enrolled in the study, and 156 (0.41%) had preinjury warfarin use. With proper 1:2 PSM, patients who received warfarin preinjury were found to require more haemostatic interventions (39.9% vs. 29.1%, p=0.016). The differences between the two study groups were that patients with preinjury warfarin required more TAE than the controls (16.3% vs 8.2%, p = 0.009). No significant increases were found in the need for surgeries (exploratory laparotomy (5.2% vs 3.6%, p = 0.380), hepatorrhaphy (9.2% vs 7.2%, p = 0.447), splenectomy (13.1% vs 13.7%, p = 0.846) or nephrectomy (2.0% vs 0.7%, p = 0.229)). Seven out of 25 patients (28.0%) in the warfarin group required further operations after TAE, which was not significantly different from that in the nonwarfarin group (four out of 25 patients, 16.0%, p = 0.306) CONCLUSION: Preinjury warfarin increases the need for TAE but not surgeries. With proper haemostasis with TAE and resuscitation, nonoperative management can still be applied to patients with preinjury warfarin sustaining blunt hepatic, splenic or renal injuries. Patients with preinjury warfarin had a higher risk for surgery after TAE.
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Affiliation(s)
- Jen-Fu Huang
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chih-Po Hsu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chih-Yuan Fu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan; Medical School, Chang Gung University, Taiwan.
| | - Yu-Tung Anton Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chi-Tung Cheng
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Tung Wu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Feng-Jen Hsieh
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chien-An Liao
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ling-Wei Kuo
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Shang-Hung Chang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan; Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan; Medical School, Chang Gung University, Taiwan; Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Chi-Hsun Hsieh
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
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Re-visiting Drain Use in Operative Liver Trauma: A Retrospective Analysis. J Surg Res 2021; 270:76-84. [PMID: 34644621 DOI: 10.1016/j.jss.2021.08.039] [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] [Received: 10/18/2020] [Revised: 07/18/2021] [Accepted: 08/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite the liver being one of the most frequently injured abdominal organs in trauma patients, clinical management strategies differ between trauma surgeons. Few studies have critically evaluated current practice patterns in the operative management of liver trauma. Historical studies recommended against the use of drains but there has not been a modern investigation of this issue. The objective of this study was to analyze outcomes associated with intra-operative drain use for liver trauma. METHODS A retrospective chart review of all adult trauma patients presenting to a Level I trauma center from 2012 to 2018 was performed. Patients who underwent operative management of liver trauma were divided into groups based on whether an intra-abdominal drain was utilized and differences in outcomes between the groups were analyzed. The primary endpoint evaluated was post-operative intra-abdominal abscesses. Univariate and multivariate analyses were performed. RESULTS 184 patients with operative management of liver trauma were included in the study. Closed suction drains were utilized in 26.1% of post-operative patients. Rate of intra-abdominal abscesses was significantly higher in the drain group (35.4% versus 8.8%, P < 0.001). Drains were more commonly used in patients receiving more units of PRBCs (median, 9 units [IQR 4-20] versus median 5.5 units, [IQR 2-14], P = 0.03). Drain use was found to be an independent risk factor for post-operative intra-abdominal abscess on multivariate analysis (OR 4.9, 95% CI 1.7-14, P = 0.003). CONCLUSIONS The results of this study support previous conclusions that drain placement for operative liver trauma is associated with increased risks of infectious complications. Drains were used in patients with more severe liver injury, intra-operative bile leaks, penetrating trauma, and increased blood transfusion requirements. Future studies should focus on the development of specific guidelines for the use of drains in liver trauma.
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Huang JF, Cheng CT, Fu CY, Huang YTA, Hsu CP, OuYang CH, Liao CH, Hsieh CH, Chang SH. Aspirin does not increase the need for haemostatic interventions in blunt liver and spleen injuries. Injury 2021; 52:2594-2600. [PMID: 34049700 DOI: 10.1016/j.injury.2021.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 04/21/2021] [Accepted: 05/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The prohemorrhagic effect of aspirin may cause concern about worse prognoses when treating blunt hepatic or splenic injuries. This study investigated whether preinjury aspirin yields an increasing need for haemostatic interventions. METHODS Admission and outpatient records were extracted from the Taiwan National Health Insurance Research Database (NHIRD) from 2003 to 2015. Patients with splenic or hepatic injuries were identified, and those with preinjury nonaspirin APAC or with penetrating injuries were excluded. The primary outcome measurement was the necessity of invasive procedures to stop bleeding, including transarterial embolization (TAE) and surgeries. One-to-two propensity score matching (PSM) was used to minimize selection bias. Multilogistic regression (MLR) analysis was used to identify factors associated with haemostatic interventions. RESULTS A total of 20,470 patients had blunt hepatic injuries, and 15,235 had blunt splenic injuries, of whom 691 (3.4%) and 667 (4.4%) used preinjury aspirin, respectively. In the blunt hepatic injury cohort, there was no significant difference in the need for haemostatic procedures (TAE (6.1% vs 6.1%, p = 1.000), exploratory laparotomy (3.3% vs 4.3%, p = 0.312), hepatectomy (3.0% vs 2.7%, p = 0.686) or hepatorrhaphy (14.3% vs 15.0%, p = 0.683)). Regarding the blunt splenic injury cohort, there was no significant difference in the need for haemostatic procedures (TAE (11.5% vs 10.6%, p = 0.553), splenectomy (43.5% vs 41.4%, p = 0.230) or splenorrhaphy (3.0% vs 3.3%, p = 0.117)). An MLR analysis showed that preinjury aspirin did not increase the need for haemostatic interventions in either cohort. CONCLUSIONS Preinjury aspirin use is not associated with increased haemostatic procedures in blunt hepatic or splenic injuries.
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Affiliation(s)
- Jen-Fu Huang
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chi-Tung Cheng
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chih-Yuan Fu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan; Medical School, Chang Gung University, Taiwan.
| | - Yu-Tung Anton Huang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chih-Po Hsu
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chun-Hsiang OuYang
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chien-Hung Liao
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chi-Hsun Hsieh
- Division of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Shang-Hung Chang
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan; Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan; Medical School, Chang Gung University, Taiwan; Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
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Roberts R, Sheth RA. Hepatic trauma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1195. [PMID: 34430636 PMCID: PMC8350720 DOI: 10.21037/atm-20-4580] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 01/25/2021] [Indexed: 12/13/2022]
Abstract
Management of trauma-related liver injury has undergone a paradigm shift over the past four decades. In hemodynamically stable patients, the standard of care in the majority of level-one trauma centers has shifted to nonoperative management with high success rates, especially with low-grade liver injuries (i.e., grade I and II liver injuries). Advances in critical care medicine, cross-sectional imaging, and transarterial embolization techniques have led to the improvement of patient outcomes and decreased mortality rates in patients with arterial injuries. Currently, no consensus guidelines on appropriate patient selection criteria have been published by the Society of Interventional Radiology (SIR) or the American Association for the surgery of Trauma (AAST). Based off the current literature, nonoperative management with hepatic angiography and transarterial embolization (TAE) should be the treatment of choice in hemodynamically stable patients with clinical suspicion of arterial injury. TAE has been shown to improve success rates of nonoperative management and is well tolerated by most patients with low complication rates. Hepatic necrosis is the most common and concerning reported complication but can be reduced with selective approach and choice of embolic agent. The majority of literature supporting the use of TAE for trauma-related liver injury consists of retrospective case series and additional larger scale studies are needed to determine the efficacy of TAE in this setting. However, it is clear from the current literature that hepatic TAE is an effective and safer option to operative management in treating arterial hemorrhage in the setting of traumatic hepatic injury.
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Affiliation(s)
- Rene Roberts
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Rahul A Sheth
- Department of Interventional Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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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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Tamura S, Maruhashi T, Kashimi F, Kurihara Y, Masuda T, Hanajima T, Kataoka Y, Asari Y. Transcatheter arterial embolization for severe blunt liver injury in hemodynamically unstable patients: a 15-year retrospective study. Scand J Trauma Resusc Emerg Med 2021; 29:66. [PMID: 34256826 PMCID: PMC8278697 DOI: 10.1186/s13049-021-00881-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/21/2021] [Indexed: 11/18/2022] Open
Abstract
Background Transcatheter arterial embolization (TAE) is the first-line nonsurgical treatment for severe blunt liver injury in patients, whereas operative management (OM) is recommended for hemodynamically unstable patients. This study investigated the comparative efficacy of TAE in hemodynamically unstable patients who responded to initial infusion therapy. Methods This retrospective study enrolled patients with severe blunt liver injuries, which were of grades III–V according to the American Association for the Surgery of Trauma Organ Injury Scale (OIS). Patients who responded to initial infusion therapy underwent computed tomography to determine the treatment plan. A shock index > 1, despite undergoing initial infusion therapy, was defined as hemodynamic instability. We compared the clinical outcomes and mortality rates between patients who received OM and those who underwent TAE. Results Sixty-two patients were included (eight and 54 who underwent OM and TAE, respectively; mean injury severity score, 26.6). The overall in-hospital mortality rate was 6% (13% OM vs. 6% TAE, p = 0.50), and the hemodynamic instability was 35% (88% OM vs. 28% TAE, p < 0.01). Hemodynamically unstable patients who underwent TAE had 7% in-hospital mortality and 7% clinical failure. Logistic regression analysis showed that the treatment choice was not a predictor of outcome, whereas hemodynamic instability was an independent predictor of intensive care unit stay ≥7 days (odds ratio [OR], 3.80; p = 0.05) and massive blood transfusion (OR, 7.25; p = 0.01); OIS grades IV–V were predictors of complications (OR, 6.61; p < 0.01). Conclusions TAE in hemodynamically unstable patients who responded to initial infusion therapy to some extent has acceptable in-hospital mortality and clinical failure rates. Hemodynamic instability and OIS, but not treatment choice, affected the clinical outcomes.
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Affiliation(s)
- Satoshi Tamura
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Takaaki Maruhashi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Fumie Kashimi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yutaro Kurihara
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Tomonari Masuda
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Tasuku Hanajima
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yuichi Kataoka
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yasushi Asari
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
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Al-Thani H, Abdelrahman H, Barah A, Asim M, El-Menyar A. Utility of Angioembolization in Patients with Abdominal and Pelvic Traumatic Bleeding: Descriptive Observational Analysis from a Level 1 Trauma Center. Ther Clin Risk Manag 2021; 17:333-343. [PMID: 33907407 PMCID: PMC8064722 DOI: 10.2147/tcrm.s303518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/29/2021] [Indexed: 12/03/2022] Open
Abstract
Background Massive bleeding is a major preventable cause of early death in trauma. It often requires surgical and/or endovascular intervention. We aimed to describe the utilization of angioembolization in patients with abdominal and pelvic traumatic bleeding at a level 1 trauma center. Methods We conducted a retrospective analysis for all trauma patients who underwent angioembolization post-traumatic bleeding between January 2012 and April 2018. Patients’ data and details of injuries, angiography procedures and outcomes were extracted from the Qatar national trauma registry. Results A total of 175 trauma patients underwent angioembolization during the study period (103 for solid organ injury, 51 for pelvic injury and 21 for other injuries). The majority were young males. The main cause of injury was blunt trauma in 95.4% of the patients. The most common indication of angioembolization was evident active bleeding on the initial CT scan (contrast pool or blushes). Blood transfusion was needed in two-third of patients. The hepatic injury cases had higher ISS, higher shock index and more blood transfusion. Absorbable particles (Gelfoam) were the most commonly used embolic material. The overall technical and clinical success rate was 93.7% and 95%, respectively, with low rebleeding and complication rates. The hospital and ICU length of stay were 13 and 6 days, respectively. The median injury to intervention time was 320 min while hospital arrival to intervention time was 274 min. The median follow-up time was 215 days. The overall cohort mortality was 15%. Conclusion Angioembolization is an effective intervention to stop bleeding and support nonoperative management for both solid organ injuries and pelvic trauma. It has a high success rate with a careful selection and proper implementation.
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Affiliation(s)
- Hassan Al-Thani
- Department of Surgery, Trauma&Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Ali Barah
- Department of Radiology, Hamad General Hospital, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar.,Department of Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
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Pillai AS, Srinivas S, Kumar G, Pillai AK. Where Does Interventional Radiology Fit in with Trauma Management Algorithm? Semin Intervent Radiol 2021; 38:3-8. [PMID: 33883796 DOI: 10.1055/s-0041-1725114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Trauma is a major cause of death in the United States, particularly in the younger population. Many traumatic deaths, as well as major morbidity, occur secondary to uncontrolled hemorrhage and eventual exsanguination. Interventional radiology plays a major role in treating these patients, and interventional techniques have evolved to the point where they are an integral part of treatment in these critically ill patients. This article reviews the role of interventional radiology in the treatment algorithms for traumatic injury sponsored by major societies and associations.
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Affiliation(s)
- A S Pillai
- University of Texas, Medical Branch Galveston, Galveston, Texas
| | - S Srinivas
- University of Texas, Medical Branch Galveston, Galveston, Texas
| | - G Kumar
- Southwestern Medical Center, University of Texas, Dallas, Texas
| | - A K Pillai
- Southwestern Medical Center, University of Texas, Dallas, Texas
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Abstract
Trauma is the leading cause of death in patients younger than 45 years. Over the last decade, there has been a progressive paradigm shift toward a nonoperative management of many blunt and penetrating injuries, placing interventional radiology in the forefront in this critical field. Transcatheter embolization is an established technique that plays a significant role in the modern treatment of traumatic injuries of the extremities, pelvis, and solid organs. The purpose of this article is to review the updated principles and techniques used in transcatheter embolization in trauma.
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Affiliation(s)
- Jorge E Lopera
- Department of Radiology, UT Health San Antonio, San Antonio, Texas
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Kumar S, Gupta A, Sagar S, Bagaria D, Kumar A, Choudhary N, Kumar V, Ghoshal S, Alam J, Agarwal H, Gammangatti S, Kumar A, Soni KD, Agarwal R, Gunjaganvi M, Joshi M, Saurabh G, Banerjee N, Kumar A, Rattan A, Bakhshi GD, Jain S, Shah S, Sharma P, Kalangutkar A, Chatterjee S, Sharma N, Noronha W, Mohan LN, Singh V, Gupta R, Misra S, Jain A, Dharap S, Mohan R, Priyadarshini P, Tandon M, Mishra B, Jain V, Singhal M, Meena YK, Sharma B, Garg PK, Dhagat P, Kumar S, Kumar S, Misra MC. Management of Blunt Solid Organ Injuries: the Indian Society for Trauma and Acute Care (ISTAC) Consensus Guidelines. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02820-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Thurman P. Hemostatic Strategies in Trauma. AACN Adv Crit Care 2021; 32:51-63. [PMID: 33725103 DOI: 10.4037/aacnacc2021473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Bleeding is a leading cause of early death from trauma. Consequently, effective hemostasis can improve the odds of survival after severe traumatic injury. Understanding the pathophysiology of trauma-induced coagulopathy can provide insights into effective strategies to assess and halt hemorrhage. Both physical assessment and appropriate laboratory studies are important in the diagnosis and evaluation of coagulopathy to identify the most effective mechanical and pharmacological strategies to achieve hemostasis. This article uses a case study approach to explore evidence-based techniques to evaluate hemorrhage and strategies to promote hemostasis.
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Affiliation(s)
- Paul Thurman
- Paul Thurman is Nurse-Scientist, Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Paca Pratt, 3-S-134, 110 S Paca St, Baltimore, MD 21201
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Luckhurst CM, Mendoza AE. The Current Role of Interventional Radiology in the Management of Acute Trauma Patient. Semin Intervent Radiol 2021; 38:34-39. [PMID: 33883799 PMCID: PMC8049765 DOI: 10.1055/s-0041-1725113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Trauma is one of the most common causes of death, particularly in younger individuals. The development of specialized trauma centers, trauma-specific intensive care units, and trauma-focused medical subspecialties has led to the formation of comprehensive multidisciplinary teams and an ever-growing body of research and innovation. The field of interventional radiology provides a unique set of minimally invasive, endovascular techniques that has largely changed the way that many trauma patients are managed. This article discusses the role of interventional radiology in the care of this complex patient population, and in particular how the specialty fits into the overall team management of these patients.
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Affiliation(s)
- Casey M. Luckhurst
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - April E. Mendoza
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
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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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Abstract
The liver is one of the most commonly injured solid organs in blunt abdominal trauma. Non-operative management is considered to be the gold standard for the care of most blunt liver injuries. Angioembolization has emerged as an important adjunct that is vital to the success of the non-operative management strategy for blunt hepatic injuries. This procedure, however, is fraught with some possible serious complications. The success, as well as rate of complications of this procedure, is determined by degree and type of injury, hepatic anatomy and physiology, and embolization strategy among other factors. In this review, we discuss these important considerations to help shed further light on the contribution and impact of angioembolization with regards to complex hepatic injuries.
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Affiliation(s)
- Ali Cadili
- Department of Surgery, University of Connecticut, CT, USA
| | - Jonathan Gates
- Department of Surgery, University of Connecticut, CT, USA
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Wong YC, Wang LJ, Wu CH, Chen HW, Yuan KC, Hsu YP, Lin BC, Kang SC. Differences of liver CT perfusion of blunt trauma treated with therapeutic embolization and observation management. Sci Rep 2020; 10:19612. [PMID: 33184342 PMCID: PMC7661500 DOI: 10.1038/s41598-020-76618-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 10/23/2020] [Indexed: 11/09/2022] Open
Abstract
Massive hepatic necrosis after therapeutic embolization has been reported. We employed a 320-detector CT scanner to compare liver perfusion differences between blunt liver trauma patients treated with embolization and observation. This prospective study with informed consent was approved by institution review board. From January 2013 to December 2016, we enrolled 16 major liver trauma patients (6 women, 10 men; mean age 34.9 ± 12.8 years) who fulfilled inclusion criteria. Liver CT perfusion parameters were calculated by a two-input maximum slope model. Of 16 patients, 9 received embolization and 7 received observation. Among 9 patients of embolization group, their arterial perfusion (78.1 ± 69.3 versus 163.1 ± 134.3 mL/min/100 mL, p = 0.011) and portal venous perfusion (74.4 ± 53.0 versus 160.9 ± 140.8 mL/min/100 mL, p = 0.008) were significantly lower at traumatic parenchyma than at non-traumatic parenchyma. Among 7 patients of observation group, only portal venous perfusion was significantly lower at traumatic parenchyma than non-traumatic parenchyma (132.1 ± 127.1 vs. 231.1 ± 174.4 mL/min/100 mL, p = 0.018). The perfusion index between groups did not differ. None had massive hepatic necrosis. They were not different in age, injury severity score and injury grades. Therefore, reduction of both arterial and portal venous perfusion can occur when therapeutic embolization was performed in preexisting major liver trauma, but hepatic perfusion index may not be compromised.
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Affiliation(s)
- Yon-Cheong Wong
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsin Street, Gueishan, Taoyuan, 333, Taiwan.
| | - Li-Jen Wang
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsin Street, Gueishan, Taoyuan, 333, Taiwan
| | - Cheng-Hsien Wu
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsin Street, Gueishan, Taoyuan, 333, Taiwan
| | - Huan-Wu Chen
- Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5 Fu-Hsin Street, Gueishan, Taoyuan, 333, Taiwan
| | - Kuo-Ching Yuan
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Pao Hsu
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Being-Chuan Lin
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ching Kang
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Gakumazawa M, Toida C, Muguruma T, Yogo N, Shinohara M, Takeuchi I. Transcatheter arterial embolisation is efficient and safe for paediatric blunt torso trauma: a case-control study. BMC Emerg Med 2020; 20:86. [PMID: 33129269 PMCID: PMC7603746 DOI: 10.1186/s12873-020-00381-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/22/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND It remains unclear whether transcatheter arterial embolisation (TAE) is as safe and effective for paediatric patients with blunt torso trauma as it is for adults in Japan, owing to few trauma cases and sporadic case reports. The study aimed to compare the efficacy and safety of TAE performed in paediatric (age ≤ 15 years) and adult patients with blunt torso trauma. METHODS This was a single-centre, retrospective chart review study that included blunt torso trauma patients who underwent TAE in the trauma centre from 2012 to 2017. The comparative study was carried out between a 'paediatric patient group' and an 'adult patient group'. The outcome measures for TAE were the success of haemorrhage control and complications and standardised mortality ratio (SMR). RESULTS A total of 504 patients with blunt torso trauma were transported to the trauma centre, out of which 23% (N = 114) with blunt torso trauma underwent TAE, including 15 paediatric and 99 adult patients. There was no significant difference between the use of TAE in paediatric and adult patients with blunt torso trauma (29% vs 22%, P = .221). The paediatric patients' median age was 11 years (interquartile ranges 7-14). The predicted mortality rate and SMR for paediatric patients were lower than those for adult patients (18.3% vs 25.9%, P = .026, and 0.37 vs 0.54). The rate of effective haemorrhage control without repeated TAE or additional surgical intervention was 93% in paediatric patients, which was similar to that in adult patients (88%). There were no complications in paediatric patients at our centre. There were no significant differences in the proportion of paediatric patients who underwent surgery before TAE or urgent blood transfusion (33% vs 26%, P = .566, or 67% vs 85%, P = .084). CONCLUSIONS It is possible to provide an equal level of care related to TAE for paediatric and adult patients as it relates to TAE for blunt torso trauma with haemorrhage in the trauma centre. Alternative haemorrhage control procedures should be established as soon as possible whenever the patients reach a haemodynamically unstable state.
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Affiliation(s)
- Masayasu Gakumazawa
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Chiaki Toida
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan.
| | - Takashi Muguruma
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Naoki Yogo
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Mafumi Shinohara
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, 4-57 Urafunecho, Minami-ku, Yokohama, 232-0024, Japan
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Lada NE, Gupta A, Anderson SW, Dinh DC, Campbell JM, Maggi A, Gandhi J, Qureshi MM, Wing H, Schulze R, LeBedis CA. Liver trauma: hepatic vascular injury on computed tomography as a predictor of patient outcome. Eur Radiol 2020; 31:3375-3382. [PMID: 33125557 DOI: 10.1007/s00330-020-07373-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/12/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate hepatic vascular injury (HVI) on CT in blunt and penetrating trauma and assess its relationship to patient management and outcome. METHOD AND MATERIALS This retrospective study was IRB approved and HIPAA compliant. Informed consent was waived. Included were patients ≥ 16 years old who sustained blunt or penetrating trauma with liver laceration seen on a CT performed at our institution within 24 h of presentation over the course of 10 years and 6 months (August 2007-February 2018). During this interval, 171 patients met inclusion criteria (123 males, 48 females; mean age 34; age range 17-80 years old). Presence of HVI was evaluated and liver injury was graded in a blinded fashion by two radiologists using the 1994 and 2018 American Association for the Surgery of Trauma (AAST) liver injury scales. Hospital length of stay and treatment (angioembolization or operative) were recorded from the electronic medical record. Multivariate linear regressions were used to determine our variables' impact on the length of stay, and logistic regressions were used for categorical outcomes. RESULTS Of the included liver trauma patients, 25% had HVI. Patients with HVI had a 3.2-day longer length of hospital stay on average and had a 40.3-fold greater odds of getting angioembolization compared to those without. Patients with high-grade liver injury (AAST grades IV-V, 2018 criteria) had a 3.2-fold greater odds of failing non-operative management and a 14.3-fold greater odds of angioembolization compared to those without. CONCLUSION HVI in liver trauma is common and is predictive of patient outcome and management. KEY POINTS • Hepatic vascular injury occurs commonly (25%) with liver trauma. • Hepatic vascular injury is associated with increased length of hospital stay and angioembolization. • High-grade liver injury is associated with failure of non-operative management and with angioembolization.
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Affiliation(s)
- Nicholas Ellerman Lada
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, Boston, MA, 02118, USA.
| | - Avneesh Gupta
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, Boston, MA, 02118, USA
| | - Stephan W Anderson
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, Boston, MA, 02118, USA
| | - Diana C Dinh
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, Boston, MA, 02118, USA
| | - John M Campbell
- Boston University, School of Medicine, 72 East Concord St., Boston, MA, 02118, USA
| | - Alec Maggi
- Boston University, School of Medicine, 72 East Concord St., Boston, MA, 02118, USA
| | - Jasmine Gandhi
- Boston University, School of Medicine, 72 East Concord St., Boston, MA, 02118, USA
| | - Muhammad Mustafa Qureshi
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, Boston, MA, 02118, USA
| | - Heidi Wing
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
| | - Robert Schulze
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
| | - Christina A LeBedis
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, 820 Harrison Ave, Boston, MA, 02118, USA
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Armas-Phan M, Keihani S, Agochukwu-Mmonu N, Cohen AJ, Rogers DM, Wang SS, Gross JA, Joyce RP, Hagedorn JC, Voelzke B, Moses RA, Sensenig RL, Selph JP, Gupta S, Baradaran N, Erickson BA, Schwartz I, Elliott SP, Mukherjee K, Smith BP, Santucci RA, Burks FN, Dodgion CM, Carrick MM, Askari R, Majercik S, Nirula R, Myers JB, Breyer BN. Clinical and Radiographic Factors Associated With Failed Renal Angioembolization: Results From the Multi-institutional Genitourinary Trauma Study (Mi-GUTS). Urology 2020; 148:287-291. [PMID: 33129870 DOI: 10.1016/j.urology.2020.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma. MATERIAL AND METHODS Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy. RESULTS A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan. CONCLUSION Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization.
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Affiliation(s)
- Manuel Armas-Phan
- School of Medicine, University of California-San Francisco, San Francisco, CA; Department of Urology, Emory University, Atlanta, GA
| | - Sorena Keihani
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT
| | | | - Andrew J Cohen
- Department of Urology, University of California-San Francisco, San Francisco, CA; Department of Urology, James Buchanan Brady Urological Institute, Baltimore, MD
| | | | - Sherry S Wang
- Department of Radiology, University of Utah, Salt Lake City, UT
| | - Joel A Gross
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, WA
| | - Ryan P Joyce
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, WA
| | - Judith C Hagedorn
- Department of Urology, Harborview Medical Center, University of Washington, Seattle, WA
| | | | - Rachel A Moses
- Department of Surgery, Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Rachel L Sensenig
- Department of Surgery, Division of Trauma, Cooper University Hospital, Camden, NJ
| | - J Patrick Selph
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL
| | - Shubham Gupta
- Department of Urology, Case Western Reserve University, Cleveland, OH
| | - Nima Baradaran
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Ian Schwartz
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Brian P Smith
- Division of Trauma and Surgical Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Frank N Burks
- Department of Urology, Oakland University William Beaumont School of Medicine, Auburn Hills, MI
| | | | | | - Reza Askari
- Department of Surgery, Division of Trauma, Brigham and Women's Hospital, Boston, MA
| | - Sarah Majercik
- Division of Trauma and Surgical Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT
| | - Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Benjamin N Breyer
- Department of Urology, University of California-San Francisco, San Francisco, CA; Department of Biostatistics and Epidemiology, University of California-San Francisco, San Francisco, CA.
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Samuels JM, Carmichael H, Kovar A, Urban S, Vega S, Velopulos C, McIntyre RC. Exercise Caution Using Hepatic Angioembolization in the Stable Trauma Patient: In reply to Clements and Colleagues. J Am Coll Surg 2020; 231:778. [PMID: 32972833 DOI: 10.1016/j.jamcollsurg.2020.08.739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/21/2020] [Indexed: 11/15/2022]
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Boonsinsukh T, Maroongroge P. Effectiveness of transcatheter arterial embolization for patients with shock from abdominopelvic trauma: A retrospective cohort study. Ann Med Surg (Lond) 2020; 55:97-100. [PMID: 32477504 PMCID: PMC7248579 DOI: 10.1016/j.amsu.2020.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/23/2020] [Accepted: 04/28/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Transcatheter arterial embolization (TAE) is a useful endovascular technique for controlling hemorrhage in blunt abdominopelvic trauma without shock. However, several studies have reported that TAE is safe and effective for controlling hemorrhage in hypovolemic shock. OBJECTIVE To evaluate the effectiveness of TAE for patients with shock from abdominopelvic trauma. METHOD The medical records of patients with abdominopelvic trauma at Her Royal Highness Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University from January 2014 to January 2019 were retrospectively reviewed. We enrolled patients with shock caused by injury to solid organs or pelvic fractures who underwent TAE. RESULT Of the 320 patients, 14 patients with shock underwent TAE. A total of 78.6% were male. The mean age was 37.5 years. The average injury severity score was 31.3. The most common mechanism of injury was traffic accidents (85.7%). Embolization was performed for 8 liver injuries, 5 pelvic fractures and 1 splenic injury. The treatment time for TAE was approximately 47.9 ± 33.2 min. The mean length of hospital stay was 21.3 ± 15.9 days. Two patients died (14.3%). There were no embolization-related complications. A significant improvement in systolic blood pressure (p = 0.028) and a decrease in heart rate (p = 0.001), lactate concentration (p = 0.011), and crystalloid fluid (p = 0.001) and blood transfusion requirements (p = 0.002) were observed after TAE. CONCLUSIONS TAE is a safe and effective method for treating shock patients with a rapid or transient response to resuscitation. For patients who are nonresponsive to resuscitation, TAE is an additional useful option for arterial hemorrhage control in abdominopelvic trauma.
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Affiliation(s)
- Thana Boonsinsukh
- Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, 26120, Thailand
| | - Panitpong Maroongroge
- Department of Radiology, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, 26120, Thailand
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Edalatpour A, Young BT, Brown LR, Tseng ES, Ladhani HA, Patel NJ, Claridge JA, Ho VP. Grade of injury, not initial management, is associated with unplanned interventions in liver injury. Injury 2020; 51:1301-1305. [PMID: 32305163 PMCID: PMC7331849 DOI: 10.1016/j.injury.2020.03.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/12/2020] [Accepted: 03/27/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Risk factors for complications after liver injury do not distinguish between patients undergoing selective non-operative management (sNOM) vs operative management (OM) as the initial treatment strategy. Our objective was to identify risk factors for complications requiring an unplanned intervention following sNOM or OM. We hypothesized that patient undergoing sNOM will have fewer unplanned interventions. METHODS Adults presenting to a level I trauma center with grade III or higher liver injury over a period of 6 years were reviewed. Patient and injury factors, initial management strategy, subsequent complications and interventions were obtained. Bivariate analysis was performed between patients undergoing sNOM vs OM to determine factors associated with unplanned interventions, defined as intervention >48 h after injury. Logistic regression was performed to identify independent risk factors for unplanned interventions. RESULTS 191 patients were identified: 105 (55%) grade III, 64 (34%) grade IV, and 22 (12%) grade V injury; 136 (71%) underwent sNOM and 55 (29%) underwent OM. 21 (15%) patients required an unplanned intervention: 26 percutaneous drainage, 10 ERCP, and 3 angiography; 12 had multiple procedures. Male gender, younger age, higher ISS, higher grade of injury, firearm mechanism, and initial OM (all p < 0.05) were associated with unplanned interventions. Firearm mechanism and injury grade IV and V, but not initial OM, were independent risk factors for an unplanned intervention. CONCLUSIONS Grade of liver injury, not the initial mode of treatment, was significantly associated with requiring an unplanned intervention for liver-related complications. Surveillance at 7-10 days, or prior to discharge, in the high-risk group may be able to capture those requiring unplanned intervention and readmission.
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Affiliation(s)
- Armin Edalatpour
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Brian T Young
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Laura R Brown
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Esther S Tseng
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Husayn A Ladhani
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nimitt J Patel
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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Samuels JM, Carmichael H, Kovar A, Urban S, Vega S, Velopulos C, McIntyre RC. Reevaluation of Hepatic Angioembolization for Trauma in Stable Patients: Weighing the Risk. J Am Coll Surg 2020; 231:123-131.e3. [PMID: 32422347 DOI: 10.1016/j.jamcollsurg.2020.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Angioembolization (AE) is recommended for extravasation from liver injury on CT. Data supporting AE are limited to retrospective series that have found low mortality but high morbidity. These studies did not focus on stable patients. We hypothesized that AE is associated with increased complications without improving mortality in stable patients. STUDY DESIGN We queried the 2016 Trauma Quality Improvement Project database for patients with grade III or higher liver injury (Organ Injury Score ≥ 3), blunt mechanism, with stable vitals (systolic blood pressure ≥ 90 mmHg and heart rate of 50 to 110 beats/min). Exclusion criteria were nonhepatic intra-abdominal or pelvic injury (Organ Injury Score ≥ 3), laparotomy less than 6 hours, and AE implementation more than 24 hours. Patients were matched 1:2 (AE to non-AE) on age, sex, Injury Severity Score, liver Organ Injury Score, arrival systolic blood pressure and heart rate, and transfusion in the first 4 hours using propensity score logistic modeling. Primary outcomes were in-hospital mortality, length of stay, transfusion, hepatic resection, interventional radiology drainage, and endoscopic procedure. RESULTS There were 1,939 patients who met criteria, with 116 (6%) undergoing hepatic AE. Median time to embolization was 3.3 hours. After successfully matching on all variables, groups did not differ with respect to mortality (5.4% vs 3.2%; p = 0.5, AE vs non-AE, respectively) or transfusion at 4 to 24 hours (4.4% vs 7.5%; p = 0.4). A larger percentage of the AE group underwent interventional radiology drainage (13.3% vs 2.2%; p < 0.001), with more ICU days (4 vs 3 days; p = 0.005) and longer length of stay (10 vs 6 days; p < 0.001). CONCLUSIONS Hepatic AE was associated with increased morbidity without improving mortality, suggesting the benefits of AE do not outweigh the risks in stable liver injury. Observing these patients is likely a more prudent approach.
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Affiliation(s)
- Jason M Samuels
- Department of Surgery, University of Colorado Anschutz, Aurora, CO.
| | | | - Alexandra Kovar
- Department of Surgery, University of Colorado Anschutz, Aurora, CO
| | - Shane Urban
- Trauma Services, University of Colorado Hospital, Aurora, CO
| | - Stephanie Vega
- Trauma Services, University of Colorado Hospital, Aurora, CO
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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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Mitricof B, Brasoveanu V, Hrehoret D, Barcu A, Picu N, Flutur E, Tomescu D, Droc G, Lupescu I, Popescu I, Botea F. Surgical treatment for severe liver injuries: a single-center experience. MINERVA CHIR 2020; 75:92-103. [PMID: 32009332 DOI: 10.23736/s0026-4733.20.08193-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The liver is one of the most frequently injured organs in abdominal trauma. The advancements in diagnosis and interventional therapy shifted the management of liver trauma towards a non-operative management (NOM). Nevertheless, in severe liver injuries (LI), surgical treatment often involving liver resection (LR) and rarely liver transplantation (LT) remains the main option. The present paper analyses a single center experience in a referral HPB center on a series of patients with high-grade liver trauma. METHODS Forty-five patients with severe LI, that benefitted from NOM (6 pts), LRs (38 pts), and LT (1 pt) performed in our center between June 2000 and June 2019, were included in a combined prospective and retrospective study. The median age of the patients was 29 years (median 33, range 10-76), and the male/female ratio of 33/12. Almost all cases had blunt trauma, except 2 with stab wound (4.4%). RESULTS LIs classified according to the American Association for the Surgery of Trauma (AAST) system were 13.3% (grade III), 44.2% (grade IV), and 42.2% (grade V); none were grade I, II or VI. The rate of major LR was 56.4% (22 LRs). The median operative time was 200 minutes (mean 236; range 150-420). The median blood loss was 750 ml (mean 940; range 500-6500). Overall and major complication rates were 100% (45 pts) and 33.3% (15 pts), respectively. Overall mortality rate was 15.6% (7 pts). CONCLUSIONS Severe liver trauma, often involving complex liver resections, should be managed in a referral HPB center, thus obtaining the best results in terms of morbidity and mortality.
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Affiliation(s)
- Bianca Mitricof
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
| | - Vladislav Brasoveanu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania.,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Doina Hrehoret
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Alexandru Barcu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Nausica Picu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Elena Flutur
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Dana Tomescu
- Center of Anesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Gabriela Droc
- Center of Anesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Ioana Lupescu
- Center of Diagnostic and Interventional Radiology, Fundeni Clinical Institute, Bucharest, Romania
| | - Irinel Popescu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania.,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Florin Botea
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania - .,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
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