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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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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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Cioffi SP, Cimbanassi S, Chiara O. Blunt abdominal trauma: watch and wait. Curr Opin Crit Care 2023; 29:674-681. [PMID: 37861213 DOI: 10.1097/mcc.0000000000001095] [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: 10/21/2023]
Abstract
PURPOSE OF REVIEW This review examines recent advancements in nonoperative management (NOM) of hemodynamically stable blunt abdominal trauma, focusing on expanding patient selection for observation-first strategies, particularly for high-grade solid organ injuries. RECENT FINDINGS Advances include a more deliberate nonoperative approach, allowing for broader patient inclusion in diagnostic and interventional angiography. Strict clinical monitoring and appropriate follow-up strategies are crucial to identify early signs of clinical progression and complications. Repeated contrast-enhanced CT (CECT) scan can be used for close observation of high-risk injuries, while the repetition of CECTs may be avoided for lower-risk cases, such as specific high-grade kidney injuries. The role of contrast-enhanced ultrasound (CEUS) in detecting sequelae of nonoperative approaches is still debated and has lot of potential, with ongoing trials exploring possible advantages. SUMMARY Multidisciplinary trauma teams play a crucial role in nonoperative management, particularly for high-grade injuries. A careful selection of patients is essential to minimize failure rates. Complications of nonoperative and angiographic approaches should be managed according to local expertise.
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Affiliation(s)
- Stefano Pb Cioffi
- Department of surgical science, Sapienza University of Rome, Rome
- General Surgery - Trauma Team, Niguarda Hospital, Milan
| | - Stefania Cimbanassi
- General Surgery - Trauma Team, Niguarda Hospital, Milan
- Department of surgical pathophysiology and transplant, University of Milan, Milan, Italy
| | - Osvaldo Chiara
- General Surgery - Trauma Team, Niguarda Hospital, Milan
- Department of surgical pathophysiology and transplant, University of Milan, Milan, Italy
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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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