Western Trauma Association/Critical Decisions in Trauma: Operative Management of Adult Blunt Hepatic Trauma

Management of complex pediatric and adolescent liver trauma: adult vs pediatric level 1 trauma centers

PURPOSE

Management of high-grade pediatric and adolescent liver trauma can be complex. Studies suggest that variation exists at adult (ATC) vs pediatric trauma centers (PTC); however, there is limited granular comparative data. We sought to describe and compare the management and outcomes of complex pediatric and adolescent liver trauma between a level 1 ATC and two PTCs in a large metropolitan city.

METHODS

A retrospective review of pediatric and adolescent (age < 21 years) patients with American Association for the Surgery of Trauma (AAST) Grade 4 and 5 liver injuries managed at an ATC and PTCs between 2016 and 2022 was performed. Demographic, clinical, and outcome data were obtained at the ATC and PTCs. Primary outcomes included rates of operative management and use of interventional radiology (IR). Secondary outcomes included packed red blood cell (pRBC) utilization, intensive care unit (ICU) length of stay (LOS), and hospital LOS.

RESULTS

One hundred forty-four patients were identified, seventy-five at the ATC and sixty-nine at the PTC. The cohort was predominantly black (65.5%) males (63.5%). Six injuries (8.7%) at the PTC and forty-five (60%) injuries at the ATC were penetrating trauma. Comparing only blunt trauma, ATC patients had higher Injury Severity Score (median 37 vs 26) and ages (20 years vs 9 years). ATC patients were more likely to undergo operative management (26.7% vs 11.0%, p = 0.016) and utilized IR more (51.9% vs 4.8%, p < 0.001) compared to the PTC. The patients managed at the ATC required higher rates of pRBC transfusions though not statistically significant (p = 0.06). There were no differences in mortality, ICU, or hospital LOS.

CONCLUSION

Our retrospective review of high-grade pediatric and adolescent liver trauma demonstrated higher rates of IR and operating room use at the ATC compared to the PTC in the setting of higher Injury Severity Score and age. While the PTC successfully managed > 95% of Grade 4/5 liver injuries non-operatively, prospective data are needed to determine the optimal algorithm for management in the older adolescent population.

LEVEL OF EVIDENCE

Level IV.

Evaluation of management of CT scan proved solid organ injury in blunt injury abdomen-a prospective study

BACKGROUND

Trauma especially road traffic injury is one of the major health-related issues throughout the world, especially in developing countries like India (Mattox 2022). Solid organ injury is the most common cause of morbidity and mortality in patients with blunt abdominal trauma. The non-operative management (NOM) is being consistently followed for hemodynamically stable patients with respect to solid organ injuries. This study aims to provide an evidence base for management modalities of solid organ injuries in blunt abdominal trauma.

AIM

The aim of this study is to evaluate the effectiveness of various treatment modalities for solid organ injury in blunt abdominal trauma.

OBJECTIVES

Evaluating the characteristics of blunt abdominal injury with respect to age and gender; distribution, mode of injury, most common organ injured, and severity of injury; effect of delay in getting treatment on the management outcome for patients with solid organ injury; evaluating the various modalities of treatment of CT-proven solid organ injury; incidence of complications in different modes of treatment.

METHODS

All patients aged more than 18 years and suffering from CT-proven solid organ injury secondary to blunt abdominal trauma between February 2021 and September 2022 were included in this prospective observational study. Sixty-five patients were enrolled in the study after meeting the inclusion criteria. Details such as age, gender, mechanism of injury, the time between injury to first hospital contact, presenting complaints, organ and grade of injury, Revised Trauma Score (RTS), Trauma Score and Injury Severity Score (TRISS), management, and outcomes were collected using self-designed pro forma and analyzed. Different modalities of treatment were evaluated and patients undergoing operative and non-operative management were compared. Patients in whom non-operative management failed were compared with patients with successful non-operative management.

RESULTS

The mean age of patients involved were 36.8 years with a male:female ratio of 7.125:1 and the most common age group affected being between 21 and 30 years. The most common mode of injury was noted to be road traffic accidents (72.3%). The most common presenting complaints were abdominal pain (64.6%) followed by chest pain (29.2%) and vomiting (13.8%). There was no significant relationship between latent period and type of intervention or failure of non-operative management. FAST positivity rate was noted to be 92.3%. Chronic alcoholism and bronchial asthma were significant predictors for patients undergoing upfront surgery (p = 0.003 and 0.006 respectively). The presence of pelvic and spine injury was statistically significant for predicting mortality in polytrauma patients (p = 0.003). Concurrent adrenal injury was found in 24.6% of patients but was not related to failure of non-operative management or mortality. RTS significantly predicts the multitude of organ involvement (p = 0.015). The liver was the most common organ injured (60%) followed by the spleen (52.3%) and the kidney (20%). The liver and the spleen (9.2%) were noted to be the most common organ combination involved. No specific organ or organ injury combination was noted to predict failure of non-operative management or mortality. But the multitude of organ involvement was statistically significant for predicting patients undergoing upfront surgery (p = 0.011). Out of 65 patients enrolled in the study, 7 patients (10.8%) underwent immediate surgery, and 58 patients (89.2%) underwent non-operative management. Among the 68 chosen for non-operative management, 6 patients (9.2%) failed non-operative management and 52 patients (80%) had success of non-operative management. A significant drop in hemoglobin (83.3%) on day 1 (66.6%) was seen to be the commonest reason for failure of non-operative management. The spleen was noted to be the most commonly involved organ intra-operatively (61.5%) followed by the liver (30.8%). Concordance between pre-operative and intra-operative grading of organ injuries was highest for liver and kidney injuries (100%) and lowest for pancreatic injuries (0%). Requirement of blood transfusion and liver injuries were significant factors for failure of non-operative management (p = 0.012 and 0.045 respectively). The presence of pancreatic leak was significant between the non-operated patients and patients operated upfront (p = 0.003). Mortality was noted to be 10.8% (7 patients) in our study.

CONCLUSION

Solid organ injury in blunt abdominal trauma is an important cause of morbidity and mortality. RTS was noted to be a good predictor for solid organ injury in blunt abdominal trauma. Pancreatic injuries are notorious for being under-staged on CT findings; hence, the need arises for multimodality imaging for suspected pancreatic injuries. Non-operative management is a successful modality of treatment for majority of patients suffering from multiple solid organ injuries in blunt abdominal trauma provided serial close monitoring of patient's clinical signs and hemoglobin is instituted along with the presence of an emergency surgery team.

Evaluating Mortality Outcomes, Transfusion Characteristics, and Risk Factors Associated With Cirrhotic Trauma Patients Undergoing Emergency Laparotomy Versus Non-Operative Management: A National Analysis

BACKGROUND

Patients with liver cirrhosis (LC) demonstrate significantly elevated mortality rates following a traumatic event. This study aims to examine and compare the clinical outcomes in adult trauma patients with pre-existing LC undergoing laparotomy or non-operative management (NOM). Additionally, the study aims to investigate various patient outcomes, including mortality rate based on transfusion needs and timing.

METHODS

This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) 2017-21 to compare laparotomy vs NOM in adults (≥18 years) with pre-existing LC who presented to trauma facilities with isolated blunt solid organ abdominal injuries (Injury Severity Score ≥16, Abbreviated Injury Scale solid organ abdomen ≥3).

RESULTS

Among 929 patients, 38.2% underwent laparotomy, while 61.7% received NOM. The in-hospital mortality rate was lower for patients who received NOM (52.3% vs 20.0%, P < .01). The risk of in-hospital mortality was significantly associated with laparotomy (OR 5.22, 95% CI: 2.06-13.18, P < .01) and sepsis (OR 99.50, 95% CI: 6.99-1415.28, P < .01). On average an increase in blood units in 4 hours was observed among those who experienced an in-hospital mortality (OR 5.65, 95% CI: 3.05-8.24, P < .01) and those who underwent laparotomy (OR 3.85, 95% CI: 1.36-6.34, P < .01).

CONCLUSION

Trauma patients with moderate to severe isolated organ injury and Liver cirrhosis had significantly higher mortality rates, acute renal failure, whole blood units received, as well as longer ICU-LOS when undergoing laparotomy compared to non-operative management.

Delayed versus early hepatic resection among patients with severe traumatic liver injuries undergoing damage control laparotomy

INTRODUCTION

We aimed to assess the effect of time to hepatic resection on the outcomes of patients with high-grade liver injuries who underwent damage control laparotomy (DCL).

METHODS

This is a 4-year (2017-2020) analysis of the ACS-TQIP. Adult trauma patients with severe liver injuries (AAST-OIS grade ​≥ ​III) who underwent DCL and hepatic resection were included. We excluded patients with early mortality (<24 ​h). Patients were stratified into those who received hepatic resection within the initial operation (Early) and take-back operation (Delayed).

RESULTS

Of 914 patients identified, 29% had a delayed hepatic resection. On multivariable regression analyses, although delayed resection was not associated with mortality (aOR:1.060,95%CI[0.57-1.97],p ​= ​0.854), it was associated with higher complications (aOR:1.842,95%CI[1.38-2.46],p ​< ​0.001), and longer hospital (β: +0.129, 95%CI[0.04-0.22],p ​= ​0.005) and ICU (β:+0.198,95%CI[0.14-0.25],p ​< ​0.001) LOS, compared to the early resection.

CONCLUSION

Delayed hepatic resection was associated with higher adjusted odds of major complications and longer hospital and ICU LOS, however, no difference in mortality, compared to early resection.

Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications

Traumatic abdominal injuries are life-threatening emergencies frequently seen in the Emergency Department (ED). The most common is liver trauma, which accounts for approximately 5% of all ED admissions for trauma. The management of blunt liver trauma has evolved significantly over the past few decades and, according to the injury’s severity, it may require massive resuscitation, radiological procedures, endoscopy, or surgery. Patients admitted to the ED with blunt abdominal trauma require a multidisciplinary evaluation, including emergency physicians, surgeons, radiologists, and anesthetists, who must promptly identify the extent of the injury to prevent serious complications. In case of a patient’s death, the execution of a forensic examination carried out with a multidisciplinary approach (radiological, macroscopic, and histological) is essential to understand the cause of death and to correlate the extent of the injuries to the possibility of survival to be able to manage any medico-legal disputes. This manuscript aims to collect the most up-to-date evidence regarding the management of hepatic trauma in the emergency room and to explore radiological findings and medico-legal implications.

Liver Trauma: Until When We Have to Delay Surgery? A Review

Liver involvement after abdominal blunt trauma must be expected, and in up to 30% of cases, spleen, kidney, and pancreas injuries may coexist. Whenever hemodynamics conditions do not contraindicate the overcoming of the ancient dogma according to which exploratory laparotomy should be performed after every major abdominal trauma, a CT scan has to clarify the liver lesions so as to determine the optimal management strategy. Except for complete vascular avulsion, no liver trauma grade precludes nonoperative management. Every attempt to treat the injured liver by avoiding a strong surgical approach may be considered. Each time, a nonoperative management (NOM) consisting of a basic “wait and see” attitude combined with systemic support and blood replacement are inadequate. Embolization should be considered to stop the bleeding. Percutaneous drainage of collections, endoscopic retrograde cholangiopancreatography (ERCP) with papilla sphincterotomy or stent placement and percutaneous transhepatic biliary drainage (PTBD) may avoid, or at least delay, surgical reconstruction or resection until systemic and hepatic inflammatory remodeling are resolved. The pathophysiological principle sustaining these leanings is based on the opportunity to limit the further release of cell debris fragments acting as damage-associated molecular patterns (DAMPs) and the following stress response associated with the consequent immune suppression after trauma. The main goal will be a faster recovery combined with limited cell death of the liver through the ischemic events that may directly follow the trauma, exacerbated by hemostatic procedures and surgery, in order to reduce the gross distortion of a regenerated liver.

A novel inflatable device for perihepatic packing and hepatic hemorrhage control: A proof-of-concept study

INTRODUCTION

Uncontrolled bleeding is the primary cause of death in complex liver trauma and perihepatic packing is regularly utilized for hemorrhage control. The purpose of this study was to investigate the effectiveness of a novel inflatable device (the airbag) for perihepatic packing using a validated liver injury damage control model in swine.

MATERIAL AND METHODS

The image of the human liver was digitally isolated within an abdominal computerized tomography scan to produce a silicone model of the liver to mold the airbag. Two medical grade polyurethane sheets were thermal bonded to the configuration of the liver avoiding compression of the hepatic pedicle, hepatic veins, and the suprahepatic vena cava after inflation. Yorkshire pigs (n = 22) underwent controlled hemorrhagic shock (35% of the total blood volume), hypothermia, and fluid resuscitation to reproduce the indications for damage control surgery (coagulopathy, hypothermia, and acidosis) prior to a liver injury. A 3 × 10 cm rectangular segment of the left middle lobe of the liver was removed to create the injury. Subsequently, the animals were randomized into 4 groups for liver damage control (240 min), Sponge Pack (n = 6), Pressurized Airbag (n = 6), Vacuum Airbag (n = 6), and Uncontrolled (n = 4). Animals were monitored throughout the experiment and blood samples obtained.

RESULTS

Perihepatic packing with the pressurized airbag led to significantly higher mean arterial pressure during the liver damage control phase compared to sponge pack and vacuum airbag 52 mmHg (SD 2.3), 44.9 mmHg (SD 2.1), and 32 mmHg (SD 2.3), respectively (p < 0.0001), ejection fraction was also higher in that group. Hepatic hemorrhage was significantly lower in the pressurized airbag group compared to sponge pack, vacuum airbag, and uncontrolled groups; respectively 225 ml (SD 160), 611 ml (SD 123), 991 ml (SD 385), 1162 ml (SD 137) (p < 0001). Rebleeding after perihepatic packing removal was also significantly lower in the pressurized airbag group; respectively 32 ml (SD 47), 630 ml (SD 185), 513 ml (SD 303), (p = 0.0004). Intra-abdominal pressure remained similar to baseline, 1.9 mmHg (SD 1), (p = 0.297). Histopathology showed less necrosis at the border of the liver injury site with the pressurized airbag.

CONCLUSION

The pressurized airbag was significantly more effective at controlling hepatic hemorrhage and improving hemodynamics than the traditional sponge pack technique. Rebleeding after perihepatic packing removal was negligible with the pressurized airbag and it did not provoke hepatic injury.

Hepatobiliary and pancreatic hemorrhage: Technical tools and tricks

Ongoing hemorrhage from hepatobiliary and pancreatic injuries continues to daunt even the most experienced surgeon. Despite the widespread centralization of elective hepatopancreatobiliary (HPB) surgery to high-volume centers, HPB trauma remains relatively common and requires a rapid and thoughtful approach [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]].

Damage control surgery for grade IV blunt hepatic injury with multiple organ damage in a child: a case report

BACKGROUND

Intra-abdominal hemorrhage caused by blunt hepatic injury is a major cause of morbidity and mortality in patients with abdominal trauma. Some of these patients require laparotomy, and rapid decision-making and life-saving surgery are essential. Damage control (DC) surgery is useful for treating children in critical situations. We performed this technique to treat an 8-year-old boy with grade IV blunt hepatic injury and multiple organ damage. This is the first report of the use of the ABTHERA Open Abdomen Negative Pressure Therapy System (KCI, now part of 3 M Company, San Antonio, TX, USA) for DC surgery to rescue a patient without neurological sequelae.

CASE PRESENTATION

An 8-year-old boy was brought to the emergency department of our hospital after being run over by a motor vehicle. He had grade IV blunt hepatic injury, thyroid injury, and bilateral hemopneumothorax. Although he was hemodynamically stable, the patient's altered level of consciousness, the presence of a sign of peritoneal irritation, and suspicion of intestinal injury led us to perform exploratory laparotomy. As part of a DC strategy, we performed gauze packing to control hemorrhage from the liver and covered the abdomen with an ABTHERA Open Abdomen Negative Pressure Therapy System to improve the patient's general condition. Eighteen days after admission, the patient was diagnosed with a biliary fistula, which improved with percutaneous and external drainage. He had no neurological sequelae and was discharged 102 days after injury.

CONCLUSION

The DC strategy was effective in children with severe blunt hepatic injury. We opted to perform DC surgery because children have less hemodynamic reserve than adults, and we believe that using this strategy before the appearance of trauma triad of death could save lives and improve outcomes. During conservative management, it is important to adopt a multistage, flexible approach to achieve a good outcome.

Added value of deep learning-based liver parenchymal CT volumetry for predicting major arterial injury after blunt hepatic trauma: a decision tree analysis

PURPOSE

In patients presenting with blunt hepatic injury (BHI), the utility of CT for triage to hepatic angiography remains uncertain since simple binary assessment of contrast extravasation (CE) as being present or absent has only modest accuracy for major arterial injury on digital subtraction angiography (DSA). American Association for the Surgery of Trauma (AAST) liver injury grading is coarse and subjective, with limited diagnostic utility in this setting. Volumetric measurements of hepatic injury burden could improve prediction. We hypothesized that in a cohort of patients that underwent catheter-directed hepatic angiography following admission trauma CT, a deep learning quantitative visualization method that calculates % liver parenchymal disruption (the LPD index, or LPDI) would add value to CE assessment for prediction of major hepatic arterial injury (MHAI).

METHODS

This retrospective study included adult patients with BHI between 1/1/2008 and 5/1/2017 from two institutions that underwent admission trauma CT prior to hepatic angiography (n = 73). Presence (n = 41) or absence (n = 32) of MHAI (pseudoaneurysm, AVF, or active contrast extravasation on DSA) served as the outcome. Voxelwise measurements of liver laceration were derived using an existing multiscale deep learning algorithm trained on manually labeled data using cross-validation with a 75-25% split in four unseen folds. Liver volume was derived using a pre-trained whole liver segmentation algorithm. LPDI was automatically calculated for each patient by determining the percentage of liver involved by laceration. Classification and regression tree (CART) analyses were performed using a combination of automated LPDI measurements and either manually segmented CE volumes, or CE as a binary sign. Performance metrics for the decision rules were compared for significant differences with binary CE alone (the current standard of care for predicting MHAI), and the AAST grade.

RESULTS

36% of patients (n = 26) had contrast extravasation on CT. Median [Q1-Q3] automated LPDI was 4.0% [1.0-12.1%]. 41/73 (56%) of patients had MHAI. A decision tree based on auto-LPDI and volumetric CE measurements (CEvol) had the highest accuracy (0.84, 95% CI 0.73-0.91) with significant improvement over binary CE assessment (0.68, 95% CI 0.57-0.79; p = 0.01). AAST grades at different cut-offs performed poorly for predicting MHAI, with accuracies ranging from 0.44-0.63. Decision tree analysis suggests an auto-LPDI cut-off of ≥ 12% for minimizing false negative CT exams when CE is absent or diminutive.

CONCLUSION

Current CT imaging paradigms are coarse, subjective, and limited for predicting which BHIs are most likely to benefit from AE. LPDI, automated using deep learning methods, may improve objective personalized triage of BHI patients to angiography at the point of care.

The Role of Angioembolization in Hepatic Trauma

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.

A Review of "Changes in the Management of Injuries to the Liver and Spleen" (2005)

Introduction: The article "Changes in the Management of Injuries to the Liver and Spleen" was originally presented as the Scudder Oration on Trauma at the American College of Surgeons' (ACS) 90th Annual Clinical Congress in New Orleans, Louisiana, in October 2004. Charles L. Scudder, MD, a founding member of the College, was the originator and first Chairman of the Committee on the Treatment of Fractures from 1922 to 1933. The first "Fracture Oration" of the ACS by Dr Scudder was entitled "Oration on Fractures," was presented at the Clinical Congress in October 1929, and was published in Surg Gynecol Obstet 1930; 50:193-195. Fracture Orations were presented from 1929 to 1941 and 1946 to 1951, while an Oration on Trauma was presented from 1952 to 1962. From 1963 to present, the Scudder Oration on Trauma has been presented at the annual Clinical Congress by an individual with significant contributions to the field.

Definitive Repair of Injuries to the Liver During Initial Trauma Laparotomy

INTRODUCTION

Numerous surgical approaches and hemostatic techniques are used and have been described when operating on the traumatized liver. Despite a substantial decline in operative liver trauma, there still remains a debate on the optimal surgical approach, and goals, during the initial trauma laparotomy. Hepatic resection during the first operation, including the damage control settings, is advocated and practiced in only a select few institutions and remains highly controversial. Here, we describe our success with hepatic resection, repair, and/or hepatic vascular repair, during the trauma laparotomy with our emphasis on the collaboration between the trauma and hepatobiliary surgical teams.

CASE SERIES

From 207 patients with liver injuries during the study period, 7 patients had definitive liver resection or repair during the initial trauma laparotomy. One had hepatic tissue repair, 1 had hepatic vein repair, and 5 had liver resections. All the operations involved a hepatobiliary surgeon together with the trauma team. There were no fatalities in the liver operation group, no sepsis, or need for emergent angiography because of hemorrhage. Four patients needed endoscopic retrograde cholangiopancreatography (ERCP) and stenting because of biliary leak. Three patients were discharged home and 4 to rehabilitation.

DISCUSSION

Hepatic resection, and/or definitive hepatic repair, may be safe and beneficial to the patients during the initial operation even in a damage control setting when the patients' overall condition allows. We emphasize the benefit of collaboration with experienced and trained liver surgery, especially in lower volume trauma centers. ERCP is commonly needed for postoperative biliary leak and should be readily utilized.

Blunt liver trauma: effectiveness and evolution of non-operative management (NOM) in 145 consecutive cases

In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors' approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10 years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10 years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10 years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.

Hepatic Pseudoaneurysm Incidence After Liver Trauma

BACKGROUND

Posttraumatic hepatic artery pseudoaneurysm is a potentially devastating complication after complex liver injury. Increasing computed tomography (CT) use may lead to more frequent identification of posttraumatic hepatic complications. This study was designed to determine the rate of hepatic pseudoaneurysm after traumatic liver injury.

METHODS

We conducted a retrospective review of patients at an urban level 1 trauma center over 5 y (2012-2016). Injury characteristics, patient management, and complications were extracted from trauma registry data and chart review.

RESULTS

Six hundred thirty-four hepatic injuries (11 no grade/no CT, 159 grade I, 154 grade II, 165 grade III, 93 grade IV, and 52 grade V) were identified from our trauma registry. No patient with a grade I or II injury had a subsequent bleeding complication. Eighteen patients had a documented hepatic pseudoaneurysm: grade III n = 3 (1.8%), grade IV n = 6 (6.5%), grade V n = 9 (17.3%). The median time to pseudoaneurysm identification was 6.5 d. Seven pseudoaneurysms were found on asymptomatic surveillance CT-angiography on average 5 d after injury. Eleven patients were symptomatic at the time of CT-angiography performed at a median of 9 d after admission. Of the 11 symptomatic patients, four were in hemorrhagic shock, and two died from hepatic-related complications.

CONCLUSIONS

The incidence of hepatic artery pseudoaneurysm increases with higher grade liver injury. Aggressive surveillance for hepatic pseudoaneurysm with interval CT-angiography 5-7 d postinjury may be warranted, especially for grade IV and V injuries.

Intrahepatic pseudoaneurysm following penetrating abdominal injury: Surgical and endovascular management of 2 complicated cases

INTRODUCTION

Post-traumatic pseudoaneurysm of the hepatic artery is a rare complication of abdominal injury. Prompt intervention is essential to avoid a life-threatening hemorrhage. We report two complicated cases of intrahepatic pseudoaneurysm (IHPA).

PRESENTATION OF CASES

Case 1: A victim of a bomb blast with thoracoabdominal injury presented in hypovolemic shock. Emergency laparotomy revealed actively bleeding liver lacerations, which had been successfully controlled with perihepatic packing. After 72 h, computed tomography (CT) of the abdomen showed a 3 cm × 1.8 cm IHPA of the left hepatic artery, which was treated with endovascular microcoils embolization. Postoperatively, the patient developed bile leakage and biliopleural fistula, which were managed conservatively. Case 2: A patient suffered a shotgun injury to the abdomen. In laparotomy, a grade III liver laceration was noted. The bleeding was controlled with perihepatic packing. The packs were removed 48 h later. Ten days postoperatively, the patient developed severe abdominal pain with shock, CT of the abdomen showed; 24 cm × 13 cm × 8 cm subcapsular liver hematoma. Superselective hepatic angiography showed a 1-cm IHPA of the right hepatic artery. The entry and exit points of the aneurysm were successfully embolized with two microcoils. No complications related to angioembolizaion were encountered.

DISCUSSION

IHPA following bomb blast and shotgun injury is rarely reported. Timely diagnosis is crucial.

CONCLUSION

We advise to keep in mind the possibility of IHPA, when dealing with high-grade liver injury. CT is recommended before removal of perihepatic packs, as it may pick up a life-threatening pseudoaneurysm.

Liver trauma: WSES 2020 guidelines

Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.

Kidney and uro-trauma: WSES-AAST guidelines

Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

Management of Complications of First Instance of Hepatic Trauma in a Liver Surgery Unit: Portal Vein Ligation as a Conservative Therapeutic Strategy

BACKGROUND

According to the National Trauma Data Bank, the liver, after the spleen, is the first most injured organ in closed abdominal trauma.

METHODS

From June 2010 to December 2015 we observed in our department of Hepato-biliary Surgery and Liver Transplant Unit of the A.O.R.N. A. Cardarelli of Naples 40 patients affected by hepatic trauma. In our retrospective study, we review our experience and propose portal vein ligation (PVL) as a first - line strategy for damage control surgery (DCS) in liver trauma.

RESULTS

26/40 patients (65%) which received gauze-packing represented our study group. In 10 cases out of 26 patients (38,4%) the abdominal packing was enough to control the damage. In 7 cases (18,4%) we performed a liver resection. In 7 cases, after de-packing, we adopted PVL to achieve DCS. Trans Arterial Embolization was chosen in 6 patients. 2 of them were discharged 14 days later without performing any other procedure.In 3 cases we had to perform a right epatectomy in second instance. Two hepatectomies were due to hemoperitoneum, and the other for coleperitoneum. Two patients were treated in first instance by only doing hemostasis on the bleeding site. We observed 6 patients in first instance. Five of them underwent surgery with hepatic resection and surgical hemostasis of the bleeding site. The other one underwent to conservative management. In summary we performed 15 hepatic resections, 8 of them were right hepatectomies, 1 left hepatectomy, 2 trisegmentectomies V-VI-VII. So in second instance we operated on 10 patients out of 34 (30%).

CONCLUSIONS

The improved knowledge of clinical physio-pathology and the improvement of diagnostic and instrumental techniques had a great impact on the prognosis of liver trauma. We think that a rigid diagnostic protocol should be applied as this allows timely pathological finding, and consists of three successive but perfectly integrated steps: 1) patient reception, in close collaboration with the resuscitator; 2) accurate but quick diagnostic framing 3) therapeutic decisional making. Selective portal vein ligation is a well-tolerated and safe manoeuvre, which could be effective, even if not definitive, in treating these subjects. That is why we believe that it can be a choice to keep in mind especially in post-depacking bleeding.

Influence of postoperative hepatic angiography on mortality after laparotomy in Grade IV/V hepatic injuries

BACKGROUND

Mortality rate for severe liver injuries remains high. As an adjunct to surgery, postoperative hepatic angiography (PHA) may have a positive impact on outcomes. This study sought to compare outcomes following surgical management of severe liver injuries with and without PHA using propensity score matching analysis.

METHODS

Data from the National Trauma Data Bank from 2007 to 2014 were analyzed. The study population consisted of patients older than 18 years, sustaining severe liver injuries (i.e., American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade IV or V) who underwent surgery. Patients were divided into two groups. The PHA group consisted of those undergoing surgery followed by PHA. In the surgery-only group, no angiography was performed. To determine the impact of PHA on outcomes, propensity score matching analysis (1:3) was used.

RESULTS

A total of 3,871 patients met inclusion criteria. Of those, 205 (5.3%) patients underwent PHA. Prior to matching, patients in the PHA group had higher severity, but overall in-hospital mortality was found to be similar between the two groups. After 1:3 propensity-score matching, 196 patients in the PHA group were matched with 588 in the surgery-only group with well-balanced baseline characteristics. The in-hospital mortality was significantly lower in the PHA group compared with the surgery-only group (24.5% vs. 35.9%; odds ratio, 0.58; 95% confidence interval, 0.40-0.84). However, hospital length of stay was longer (16.0 [7.0-29.8] vs. 11 [1.0-25.0] days, p = 0.001), and the incidence of deep and organ/space surgical site infection (3.6% vs. 1.2%, 8.2% vs. 3.5%, respectively) was higher in the PHA group.

CONCLUSION

The use of PHA was associated with decreased mortality rates. A multimodality approach using both surgical intervention followed by PHA appears to identify patients that may benefit from arterial embolization, leading to decreased mortality of severe liver injuries.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Stereological Comparison of Imbibed Fibrinogen Gauze versus Simple Gauze in External Packing of Grade IV Liver Injury in Rats

Objective

To evaluate the effect of imbibed fibrinogen gauze on survival, bleeding and healing in liver trauma.

Methods

This animal experimental study was conducted on 20 adult male Sprague-Dawley rats; with a mean weight of 300±50 gram; divided into two groups. Grade IV injury was induced to the subjects' liver. Then, the bleeding site was packed with simple gauze in the control group, and imbibed fibrinogen gauze in the experimental group. All animals were re-evaluated for liver hemostasis 48 hours after the initial injury. Bleeding in the intra peritoneal cavity was measured using Tuberculosis Syringe in the first and second operations. Subjects were followed-up for 14 days. Eventually, the rats were sacrificed and their livers were sent to a lab for stereological assessment. Statistical comparisons were performed via Mann-Whitney U-test using SPSS. P-Values less than 0.05 were considered to be statistically significant.

Results

Half of the rats in the control group died, while all the rats in the imbibed fibrinogen gauze group survived after two weeks (p= 0.032). Bleeding in the imbibed fibrinogen gauze was significantly less than control group, 48 hours' post-surgery (p<0.001). According to the stereological results, granulation tissue in the imbibed fibrinogen gauze group were more than the control group (P= 0.032). Also, fibrosis in the imbibed fibrinogen gauze group were more than the control group (P= 0.014).

Conclusion

Our study indicated that imbibed fibrinogen gauze can potentially control liver bleeding and improve survival through increasing granulation tissue and fibrosis in injured liver.

Reduction of resource utilization in children with blunt solid organ injury

BACKGROUND/PURPOSE

Nonoperative management of blunt solid organ injuries continues to progress and improve cost-effective utilization of resources while maximizing patient safety. The purpose of this study is to compare resource utilization and patient outcomes after changing admission criteria from a grade-based protocol to one based on hemodynamic stability.

METHODS

A retrospective review of isolated liver and spleen injuries was done using prospectively collected trauma registry data from 2013 to 2017. The 2 years preceding the change were compared to the 2 years after protocol change. All analyses were performed using SAS 9.4.

RESULTS

There were 121 patients in the preprotocol cohort and 125 patients in the postprotocol cohort. Baseline demographics were similar along with injury mechanisms and severity. The ICU admission rate decreased from 40% to 22% (p = 0.002). There were no adverse events on the floor and no patient needed to be transferred to the ICU.

CONCLUSIONS

A protocol for ICU admission based on physiologic derangement versus solely on radiologic grade significantly reduced admission rates to the ICU in children with solid organ injury. The protocol was safe and effectively reduced resource utilization.

LEVEL OF EVIDENCE

Level II, prospective comparison study.

Blunt liver trauma: a descriptive analysis from a level I trauma center

Background

We aimed to review liver injury experience in a level 1 trauma center; namely clinical presentation, grading, management approach and clinical outcomes.

Methods

It is a retrospective analysis to include all blunt liver injury patients who were admitted at the Level 1 trauma center over a 3-year period. Data were compared and analyzed based on the liver injury grades and management approaches.

Results

Blunt liver injury accounted for 38% of the total blunt abdominal trauma cases with a mean age of 31 ± 13 years. Liver injury grade II (44.7%) was most common followed by grade I (28.8%), grade III (19.1%), grade IV (7.0%) and grade V (0.4%). Blood transfusion was more frequently required in patients with grade IV (p = 0.04). Out of 257 patients with blunt liver trauma, 198 were initially treated conservatively, that was successful in 192 (97%), whereas it failed in 6 (3%) patients due to delayed bleeding from hepatic hematoma, associated splenic rupture and small bowel injury which mandate surgical intervention. Fifty-nine patients (23%) underwent emergent surgery in terms of packing, resection debridement, left lobe hepatectomy and splenectomy. Hepatic complications included biloma, pseudoaneurysm and massive liver necrosis. Subanalysis of data using the World Society of Emergency Surgery (WSES) classification revealed 19 patients were categorized as a WSES grade IV who needed surgical intervention without having an initial computerized tomography scanning. The overall mortality was 7.8% which was comparable among the conservative and operative group.

Conclusions

In our center, low grade liver injury in young males prevails. NOM is successful even for high graded injuries. All conservatively treated patients with high-grade liver injuries should be closely monitored for signs of failure of the non-operative management. Introducing the new WSES classification makes clear how is important the hemodynamic status of the patients despite the lesion. However, further larger prospective and multicenter studies are needed to support our findings.

Selective Angiographic Embolization of Blunt Hepatic Trauma Reduces Failure Rate of Nonoperative Therapy and Incidence of Post-Traumatic Complications

Background

Conflict still remains as to the benefit of angioembolization (AE) for non-operative therapy (NOT) of blunt hepatic trauma (BHT). The aim of this study was to determine whether AE could result in lower failure rates in hemodynamically stable BHT patients with high failure risk factors for NOT, and to systematically evaluate the effectiveness of AE for NOT of BHT.

Material/Methods

Medical records of all BHT patients from January 1, 1998 to December 31, 2015 at a large trauma center were collected and analyzed. Failure of NOT (FNOT) occurred if hepatic surgery was performed after attempted NOT. Logistic regression analysis was used to identify factors associated with FNOT. Hepatobiliary complications related to hepatic trauma during follow-up were reviewed.

Results

No significant difference in FNOT for the no angiographic embolization (NO-AE) group versus angiographic embolization (AE) group was found in hepatic trauma of grades I, II, and V. However, decrease in FNOT was significant with AE performed for hepatic trauma of grades III to IV. Risk factors for FNOT included grade III to IV injuries and contrast blush on CT. Follow-up data of six months also showed that the incidence of hepatobiliary complications in the NO-AE group was higher than the AE group.

Conclusions

Hemodynamically stable BHT patients with grade III to IV injuries, contrast blush on initial CT, and/or decreasing hemoglobin levels can be candidates for selective AE during NOT course.

Abdominal Trauma Revisited

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

General surgeon management of complex hepatopancreatobiliary trauma at a level I trauma center

BACKGROUND

The impact of general surgeons (GS) taking trauma call on patient outcomes has been debated. Complex hepatopancreatobiliary (HPB) injuries present a particular challenge and often require specialized care. We predicted no difference in the initial management or outcomes of complex HPB trauma between GS and trauma/critical care (TCC) specialists.

MATERIALS AND METHODS

A retrospective review of patients who underwent operative intervention for complex HPB trauma from 2008 to 2015 at an ACS-verified level I trauma center was performed. Chart review was used to obtain variables pertaining to demographics, clinical presentation, operative management, and outcomes. Patients were grouped according to whether their index operation was performed by a GS or TCC provider and compared.

RESULTS

180 patients met inclusion criteria. The GS (n = 43) and TCC (n = 137) cohorts had comparable patient demographics and clinical presentations. Most injuries were hepatic (73.3% GS versus 72.6% TCC) and TCC treated more pancreas injuries (15.3% versus GS 13.3%; P = 0.914). No significant differences were found in HPB-directed interventions at the initial operation (41.9% GS versus 56.2% TCC; P = 0.100), damage control laparotomy with temporary abdominal closure (69.8% versus 69.3%; P = 0.861), LOS, septic complications or 30-day mortality (13.9% versus 10.2%; P = 0.497). TCC were more likely to place an intraabdominal drain than GS (52.6% versus 34.9%; P = 0.043).

CONCLUSIONS

We found no significant differences between GS and TCC specialists in initial operative management or clinical outcomes of complex HPB trauma. The frequent and proper use of damage control laparotomy likely contribute to these findings.

Management of Liver Trauma

In the last 30 years, the management of liver injury has evolved significantly. The advancement of imaging studies has played an important role in the conservative approach for management. A shift from operative to nonoperative management for most hemodynamically stable patients with hepatic injury has been prompted by speed and sensitivity of diagnostic imaging and by advances in critical care monitoring. In this review article, the up-to-date recommendation on the management approach of liver trauma will be discussed.

The efficacy of a novel saline/bipolar radiofrequency energy instrument for arresting ongoing solid and non-solid organ hemorrhage in a swine model

INTRODUCTION

Ongoing hemorrhage is often life threatening and can be challenging to stop in critically injured patients. Traditional techniques for addressing this issue include high voltage cautery (Bovie), topical hemostatic application, and the delivery of ignited argon gas. The goal of this study was to evaluate the efficacy of a novel energy device for arresting ongoing bleeding from both solid and non-solid organs within a swine model.

METHODS

A novel instrument utilizing bipolar radiofrequency (RF) energy which acts to ignite/boil dripping saline from a small hand piece was employed to arrest ongoing hemorrhage from an escalating series of injuries in large male swine. Liver, spleen, kidney, lung, heart, inferior vena cava and abdominal wall targets were evaluated and digitally recorded. Methodology was descriptive.

RESULTS

Four large male swine received escalating injuries to their liver, spleen, kidney, lung, heart, inferior vena cava and abdominal wall. Injury patterns included a variety of surface decapsulation, superficial lacerations, deep lacerations, "through and through" missiles and complete transections. Application of the bipolar/RF instrument to sites of ongoing hemorrhage was successful in 97% of all scenarios. Depth of tissue penetration via microscopic evaluation ranged from 1.1mm to 3.0mm depending on the target organ composition. No air leaks were observed following application to the bleeding lung. Surgeon reported 'ease of use' score was high (4.8/5).

CONCLUSION

This energy technology is successful in arresting ongoing hemorrhage from varying intensities of traumatic injuries to the liver, spleen, kidney, abdominal wall, lung and heart in the swine model. Additional testing is required before advocating its use on any thoracic organs.

WSES classification and guidelines for liver trauma

The severity of liver injuries has been universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale. In determining the optimal treatment strategy, however, the haemodynamic status and associated injuries should be considered. Thus the management of liver trauma is ultimately based on the anatomy of the injury and the physiology of the patient. This paper presents the World Society of Emergency Surgery (WSES) classification of liver trauma and the management Guidelines.

Use of a novel saline/bipolar radiofrequency energy instrument as an adjunct for arresting ongoing solid organ surface and laceration bleeding in critically injured patients

INTRODUCTION

Solid organ (liver, spleen and kidney) haemorrhage is often life threatening and can be difficult to stop in critically ill patients. Traditional techniques for arresting this ongoing bleeding include coagulation by high voltage cautery (Bovie), topical haemostatic application, and the delivery of ignited argon gas. The goal of this study was to evaluate the efficacy of a new energy device for arresting persistent solid organ haemorrhage.

PATIENTS AND METHODS

A novel instrument utilizing bipolar radiofrequency (RF) energy which acts to ignite/boil dripping saline from a simple hand piece was employed to arrest ongoing bleeding from solid organ injuries at 2 high volume, level 1 trauma centres. This instrument is extrapolated from experience within elective hepatic resections. Standard statistics were employed (p<0.05=significant).

RESULTS

From January 2013 to January 2015, 36 severely injured patients (mean injury severity score=31; blunt mechanisms=32/36 (89%)) underwent use of this new saline/RF energy instrument to arrest ongoing haemorrhage from the liver (29), spleen (5) and kidney (2). Of these patients, 25 received instrument use during an initial laparotomy, while 11 patients underwent use following removal of sponges during a return laparotomy after an initial damage control procedure. Success in arresting ongoing haemorrhage was 97% (35/36) in these highly selected cases. The surgeons reported an 'ease of use' score of 4.9 out of 5. No postoperative complications (including delayed haemorrhage) were noted as a direct result of the energy instrument.

CONCLUSIONS

This simple saline/RF energy instrument has the potential to arrest ongoing solid organ surface/capsular bleeding, as well as moderate haemorrhage associated with deep lacerations.

Outcomes and complications of angioembolization for hepatic trauma: A systematic review of the literature

BACKGROUND

The liver is one of the most frequently injured abdominal organs. Hepatic hemorrhage is a complex and challenging complication following hepatic trauma. Significant shifts in the treatment of hepatic hemorrhage, including the increasing use of angioembolization, are believed to have improved patient outcomes. We aimed to describe the efficacy of angioembolization in the setting of acute hepatic arterial hemorrhage as well as the complications associated with this treatment modality.

METHODS

A systematic review of published literature (MEDLINE, SCOPUS, and Cochrane Library) describing hepatic angioembolization in the setting of trauma was performed. Articles that fulfilled the predetermined inclusion and exclusion criteria were included. We analyzed the efficacy rate of angioembolization in the setting of traumatic hepatic hemorrhage as well as the complications associated with hepatic angioembolization.

RESULTS

Four hundred fifty-nine articles were identified in the literature search. Of these, 10 retrospective studies and 1 prospective study met inclusion and exclusion criteria. Efficacy rate of angioembolization was 93%. The most frequently reported complications following hepatic angioembolization included hepatic necrosis (15%), abscess formation (7.5%), and bile leaks.

CONCLUSION

Although the outcomes of hepatic angioembolization were generally favorable with a high success rate, the treatment modality is not without associated morbidity. The most frequently associated major complication was hepatic necrosis. Rates of complications were affected by study heterogeneity and should be better defined in future studies.

LEVEL OF EVIDENCE

Systematic review, level III.

The role of computed tomographic scan in ongoing triage of operative hepatic trauma: A Western Trauma Association multicenter retrospective study

BACKGROUND

A subset of patients explored for abdominal injury have persistent hepatic bleeding on postoperative computed tomography (CT) and/or angiography, either not identified or not manageable at initial laparotomy. To identify patients at risk for ongoing hemorrhage and guide triage to angiography, we investigated the relationship of early postoperative CT scan with outcomes in operative hepatic trauma.

METHODS

This is a retrospective review of 528 patients with hepatic injury taken to laparotomy without imaging within 6 hours of arrival to six trauma centers from 2007 to 2013, coordinated through the Western Trauma Association multicenter trials group.

RESULTS

A total of 528 patients were identified, with a mean age of 31 years, 82% male, and 37% blunt injury; mean (SD) Injury Severity Score (ISS) was 27 (16) and base deficit was -9 (6); in-hospital mortality was 26%. Seventy-three patients died during initial exploration. Of 455 early survivors, 123 (27%) had a postoperative contrast CT scan within 24 hours of laparotomy. CT patients had more common blunt injury, higher ISS, and lower base deficit than those who did not undergo CT. CT identified hepatic contrast extravasation or pseudoaneurysm in 10 patients (8%). Hepatic bleeding on CT was 83% sensitive and 75% specific (likelihood ratio, 3.3) for later positive angiography; negative CT finding was 96% sensitive and 83% specific (likelihood ratio, 5.7) for later negative or not performed angiography. Despite occurring in a more severely injured cohort, performance of early postoperative CT was associated with reduced mortality (odds ratio, 0.16) in multivariate analysis. Blunt mechanism was also a multivariate predictor of mortality (odds ratio, 3.0).

CONCLUSION

Early postoperative CT scan after laparotomy for hepatic trauma identifies clinically relevant ongoing bleeding and is sufficiently sensitive and specific to guide triage to angiography. Contrast CT should be considered in the management algorithm for hepatic trauma, particularly in the setting of blunt injury. Further study should identify optimal patient selection criteria and CT scan timing in this population.

LEVEL OF EVIDENCE

Care management/therapeutic study, level IV; epidemiologic/prognostic study, level III.

Peri-hepatic gauze packing for the control of haemorrhage during liver transplantation: A retrospective study

BACKGROUND

Albeit accepted in the trauma setting, use of peri-hepatic gauze packing has been rarely reported during liver transplantation.

AIMS

To assess the results of packing in liver transplantation.

METHODS

We reviewed clinical characteristics, intraoperative events and postoperative outcome of consecutive adult liver transplantation recipients between 2003 and 2013. Patients treated with packing were compared to no-packing patients and to matched controls selected using a propensity score.

RESULTS

Of 1396 recipients, 107 were treated with packing for peri-hepatic bleeding (76.6%), allograft damage (12.1%) or partial outflow obstruction (11.2%). Urgent reoperation for ongoing haemorrhage was required in 6 (5.6%). Correction of haemodynamic and coagulation parameters was constantly achieved. Overall, patient (90% vs. 98%, p<0.001) and graft (83.2% vs. 94.7%, p<0.001) 3-month survival was significantly reduced in packing patients. However, after matching, no significant difference was observed in patient (89.3% vs. 95.2%, p=0.12) and graft (83.5% vs. 92.2%, p=0.06) 3-month survival. Patient survival was associated with recipient age (HR 2.59; p=0.04) and donor age × recipient MELD (HR 2.04; p=0.02), but not with packing (HR 1.81; p=0.29).

CONCLUSIONS

In our experience, packing was a valuable adjunct to conventional means of haemostasis during liver transplantation and, after accounting for confounding covariates, was not associated with inferior outcomes.

Evaluation of the Safe Ischemic Time of Clamping During Intermittent Pringles Maneuver in Rabbits

BACKGROUND

The liver is the most commonly injured organ in blunt abdominal trauma. Although major hepatic bleeding may be partially controlled with portal triade clamping (the Pringle's maneuver), continuous prolonged clamping results in liver ischemia.

OBJECTIVES

The purpose of this study was to determine the safe time of Pringle maneuver based on pathologic changes of liver in rabbit models.

MATERIALS AND METHODS

In an experimental study, 20 New-Zealand white rabbits were selected. In laparotomy, a blunt dissector was passed through the foramen of Winslow and the hepato-duodenal ligament encircled with an umbilical tape. En masse Pringle maneuver was performed using atraumatic flexible clamps. Rabbits were divided into four groups based on Pringle maneuver time (30 minutes, 45 minutes, 60 minutes, and 75 minutes). A hepatic biopsy was performed at the beginning of operation. The degree of tissue injury was evaluated using blood markers.

RESULTS

There were five rabbits in each group. At the end of 60 minutes ischemia, only minor alterations were observed in pathological specimens. At the end of 75 minutes, hepatocyte damage and necrosis were observed. The serum levels of alanine aminotransferase (Group A: P = 0.02; Group B: P = 0.01; Group C: P = 0.0002; Group D: P = 0.01) and Aspartate aminotransferase (Group A: P = 0.03; Group B: P = 0.002; Group C: P = 0.0004; Group D: P = 0.0003) were significantly increased post-operatively. The maximum level was in the first day after operation.

CONCLUSIONS

Continuous portal triade clamping (the Pringle maneuver) during liver ischemia (30 and 45 minutes) in rabbits resulted in no ischemic change. Increasing time of clamping to 30 minutes was safe in intermittent Pringle maneuver.

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

BACKGROUND

During the last decade, the management of blunt hepatic injury has considerably changed. Three options are available as follows: nonoperative management (NOM), transarterial embolization (TAE), and surgery. We aimed to evaluate in a systematic review the current practice and outcomes in the management of Grade III to V blunt hepatic injury.

METHOD

The MEDLINE database was searched using PubMed to identify English-language citations published after 2000 using the key words blunt, hepatic injury, severe, and grade III to V in different combinations. Liver injury was graded according to the American Association for the Surgery of Trauma classification on computed tomography (CT). Primary outcome analyzed was success rate in intention to treat. Critical appraisal of the literature was performed using the validated National Institute for Health and Care Excellence "Quality Assessment for Case Series" system.

RESULTS

Twelve articles were selected for critical appraisal (n = 4,946 patients). The median quality score of articles was 4 of 8 (range, 2-6). Overall, the median Injury Severity Score (ISS) at admission was 26 (range, 0.6-75). A median of 66% (range, 0-100%) of patients was managed with NOM, with a success rate of 94% (range, 86-100%). TAE was used in only 3% of cases (range, 0-72%) owing to contrast extravasation on CT with a success rate of 93% (range, 81-100%); however, 9% to 30% of patients required a laparotomy. Thirty-one percent (range, 17-100%) of patients were managed with surgery owing to hemodynamic instability in most cases, with 12% to 28% requiring secondary TAE to control recurrent hepatic bleeding. Mortality was 5% (range, 0-8%) after NOM and 51% (range, 30-68%) after surgery.

CONCLUSION

NOM of Grade III to V blunt hepatic injury is the first treatment option to manage hemodynamically stable patients. TAE and surgery are considered in a highly selective group of patients with contrast extravasation on CT or shock at admission, respectively. Additional standardization of the reports is necessary to allow accurate comparisons of the various management strategies.

LEVEL OF EVIDENCE

Systematic review, level IV.

Management of children with solid organ injuries after blunt torso trauma

BACKGROUND

Management of children with intra-abdominal solid organ injuries has evolved markedly. We describe the current management of children with intra-abdominal solid organ injuries after blunt trauma in a large multicenter network.

METHODS

We performed a planned secondary analysis of a prospective, multicenter observational study of children (<18 years) with blunt torso trauma. We included children with spleen, liver, or kidney injuries identified by computed tomography, laparotomy/laparoscopy, or autopsy. Outcomes included disposition and interventions (blood transfusion for intra-abdominal hemorrhage, angiography, laparotomy/laparoscopy). We performed subanalyses of children with isolated injuries.

RESULTS

A total of 12,044 children were enrolled; 605 (5.0%) had intra-abdominal solid organ injuries. The mean (SD) age was 10.7 (5.1) years, and injured organs included spleen 299 (49.4%), liver 282 (46.6%), and kidney 147 (24.3%). Intraperitoneal fluid was identified on computed tomography in 461 (76%; 95% confidence interval [CI], 73-80%), and isolated solid organ injuries were present in 418 (69%; 95% CI, 65-73%). Treatment included therapeutic laparotomy in 17 (4.1%), angiographic embolization in 6 (1.4%), and blood transfusion in 46 (11%) patients. Laparotomy rates for isolated injury were 11 (5.4%) of 205 (95% CI, 2.7-9.4%) at non-freestanding children's hospitals and 6 (2.8%) of 213 (95% CI, 1.0-6.0%) at freestanding children's hospitals (difference, 2.6%; 95% CI, -7.1% to 12.2%). Dispositions of the 212 children with isolated Grade I or II organ injuries were home in 6 (3%), emergency department observation in 9 (4%), ward in 114 (54%), intensive care unit in 73 (34%), operating suite in 7 (3%), and transferred in 3 (1%) patients. Intensive care unit admission for isolated Grade I or II injuries varied by center from 9% to 73%.

CONCLUSION

Most children with solid organ injuries are managed with observation. Blood transfusion, while uncommon, is the most frequent therapeutic intervention; angiographic embolization and laparotomy are uncommon. Emergency department disposition of children with isolated Grade I to II solid organ injuries is highly variable and often differs from published guidelines.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Major hepatectomy for complex liver trauma

The liver is the most frequently injured intraperitoneal organ, despite its relatively protected location. The liver consisting of a relatively fragile parenchyma contained within the Glisson capsule, which is thin and does not provide it with great protection. The management of hepatic trauma has undergone a paradigm shift over the past several decades with significant improvement in outcomes. Shifting from mandatory operation to selective nonoperative treatment, and, presently, to nonoperative treatment with selective operation. Operative management emphasizes packing, damage control, and utilization of interventional radiology, such as angiography and embolization. Because of the high morbidity and mortality, liver resection seems to have a minimal role in the management of hepatic injury in many reports, but in a specialized referral center, like our institute, surgical treatment becomes, in many cases, the only life-saving treatment. Innovations in liver transplant surgery, living liver donation, and the growth of specialized liver surgery teams have changed the way that surgeons and hepatic resection are done.

Liver trauma: WSES position paper

The liver is the most injured organ in abdominal trauma. Road traffic crashes and antisocial, violent behavior account for the majority of liver injuries. The present position paper represents the position of the World Society of Emergency Surgery (WSES) about the management of liver injuries.

Liver Trauma in the Kitchen: Preparing Whipped Cream with a Siphon Is Not without Risk

We report the case of a 36-year-old woman suffering from liver injury caused by the malfunction of a whipped cream siphon. When this patient handled the whipped cream siphon, the screwed metallic upper part of the siphon was suddenly dissociated from its base and came violently striking her right hypochondrium. At first, the severity of injury was underestimated. Subsequently, due to the persistence of pain experienced by the patient, an abdominal CT scan was performed. It highlighted a severe liver injury with rupture of a branch of the hepatic artery. The evolution was favorable after completion of an embolization and a secondary capsular rupture.

Use of a novel energy technology for arresting ongoing liver surface and laceration hemorrhage

Persistent hemorrhage from liver capsular injuries has remained a technical challenge without an optimal solution. This report discusses an easy to use device that is commonly used within elective hepatic surgery and can be successful in arresting ongoing surface and laceration bleeding in patients with solid organ injuries.

Hemostatic effects of microbubble-enhanced low-intensity ultrasound in a liver avulsion injury model

OBJECTIVES

Microbubble-enhanced therapeutic ultrasound (MEUS) can block the blood flow in the organs. The aim of this study was to evaluate the hemostatic effect of microbubble-enhanced pulsed, low-intensity ultrasound in a New Zealand White rabbit model of avulsion trauma of the liver. The therapeutic ultrasound (TUS) transducer was operated with the frequency of 1.2 MHz and an acoustic pressure of 3.4 MPa. Microbubble-(MB) enhanced ultrasound (MEUS) (n = 6) was delivered to the distal part of the liver where the avulsion was created. Livers were treated by TUS only (n = 4) or MB only (n = 4) which served as controls. Bleeding rates were measured and contrast enhanced ultrasound (CEUS) was performed to assess the hemostatic effect, and liver hemoperfusion before and after treatment. Generally, bleeding rates decreased more than 10-fold after the treatment with MEUS compared with those of the control group (P<0.05). CEUS showed significant declines in perfusion. The peak intensity value and the area under the curve also decreased after insonation compared with those of the control group (P<0.05). Histological examination showed cloudy and swollen hepatocytes, dilated hepatic sinusoids, perisinusoidal spaces with erythrocyte accumulation in small blood vessels, obvious hemorrhage around portal areas and scattered necrosis in liver tissues within the insonation area of MEUS Group. In addition, necrosis was found in liver tissue 48 h after insonation. We conclude that MEUS might provide an effective hemostatic therapy for serious organ trauma such as liver avulsion injury.

Liver transplantation after severe hepatic trauma: a sustainable practice. A single-center experience and review of the literature

Severe hepatic trauma is a rare indication for liver transplantation (LT). We report our single-center experience of LT for hepatic trauma. Four new cases are discussed in light of a literature review in order to depict the pathways leading from hepatic trauma to LT and to assess the outcomes of this practice. LT is generally indicated in case of uncontrollable hemorrhage, acute liver failure, or post-traumatic late sequelae. Hepatic vessels thrombosis, sepsis, major hepatic resections, and a late referral are factors associated with the progression toward irreversible liver failure. Considering all reported cases, early patient and graft survival reached 68% and 62%, respectively, but in the last decade both have improved to 84%. LT after severe hepatic trauma is a sustainable practice considering the current good outcomes and the ineluctable death of these patients without LT.