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Yonemitsu T, Shibata N, Shima N, Fuchigami J, Miyake Y, Ikoma A, Minamiguchi H, Sonomura T, Kato S. Permissive untreated pseudoaneurysm concept in damage control interventional radiology for traumatic pancreaticoduodenal artery injury. Acute Med Surg 2023; 10:e823. [PMID: 36844679 PMCID: PMC9949516 DOI: 10.1002/ams2.823] [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: 07/22/2022] [Accepted: 01/25/2023] [Indexed: 02/25/2023] Open
Abstract
Background Angioembolization for traumatic pancreaticoduodenal artery injury with unstable circulation, which characteristically requires a prolonged procedure time, does not yet have a standardized strategy for damage control interventional radiology. Case Presentation We encountered two cases of rare traumatic pancreaticoduodenal artery injury wherein the patients were saved by a multidisciplinary team with a shared goal of clinical success, rather than the procedural success of angioembolization. Both patients treated with angioembolization had residual pseudoaneurysm or faint extravasation in the pancreaticoduodenal artery arcade. We prioritized critical care with preemptive plasma transfusion and aggressive blood pressure control, and planned repeat angiography. The patients showed no clinical signs of rebleeding or pseudoaneurysm based on computed tomography during follow-up. Conclusion Our findings suggest that the permissive untreated pseudoaneurysm concept can be useful in developing damage control interventional radiology strategies for trauma cases with challenging time limitations, such as traumatic pancreaticoduodenal artery injury with circulatory collapse.
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Affiliation(s)
- Takafumi Yonemitsu
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayama CityJapan
| | - Naoaki Shibata
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayama CityJapan
| | - Nozomu Shima
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayama CityJapan
| | - Junya Fuchigami
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayama CityJapan
| | - Yuichi Miyake
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayama CityJapan
| | - Akira Ikoma
- Department of RadiologyWakayama Medical UniversityWakayama CityJapan
| | | | - Tetsuo Sonomura
- Department of RadiologyWakayama Medical UniversityWakayama CityJapan
| | - Seiya Kato
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayama CityJapan
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2
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Brigode W, Adra A, Capron G, Basu A, Messer T, Starr F, Bokhari F. The American Association for the Surgery of Trauma (AAST) Liver Injury Grade Does Not Equally Predict Interventions in Blunt and Penetrating Trauma. World J Surg 2022; 46:2123-2131. [PMID: 35595869 DOI: 10.1007/s00268-022-06595-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The AAST liver injury grade has a validated association with mortality and need for operation. AAST liver injury grade is the same regardless of the mechanism of trauma. METHODS A 5-year retrospective review of all liver injuries at an urban, level-one trauma center was performed. RESULTS Totally, 315 patients were included (29% blunt, 71% penetrating). In blunt trauma, AAST grade was associated with need for laparotomy (0%, 7%, 5%, 33%, 29%, Grade 1-5, p = 0.01), angiography (0%, 7%, 25%, 40%, 57%, p < 0.001), embolization (0%, 7%, 15%, 33%, 43%, p = 0.01), and percutaneous drainage procedures (13% use in Grade 4, otherwise 0%, p = 0.04), but not ERCP (0% for all grades). In penetrating trauma, AAST grade was associated with need for angiography (7%, 4%, 15%, 24%, 30%, p < 0.01) and percutaneous drainage (7%, 2%, 14%, 18%, 26%, p = 0.03) and had a marginal association with embolization (0%, 4%, 11%, 13%, 22%, p = 0.06). Laparotomy, ERCP, sphincterotomy, and stenting rates increased with AAST grade, but this was not statistically significant. CONCLUSION AAST grade is associated with the need for surgical hemostasis, angioembolization, and percutaneous drainage in both penetrating and blunt trauma. Operative, endoscopic, and percutaneous procedures are utilized more in penetrating trauma. Angioembolization was used more in blunt trauma. Mechanism should be considered when using AAST grade to guide management of liver injuries.
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Affiliation(s)
- William Brigode
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, 1969 West Ogden Avenue, Chicago, IL, 60612, USA.
| | - Amal Adra
- Rush Medical College, 600 S Paulina St, Chicago, IL, 60612, USA
| | - Gweniviere Capron
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, 1969 West Ogden Avenue, Chicago, IL, 60612, USA
| | - Anupam Basu
- Department of Diagnostic Radiology, Rush University Medical Center, 1620 West Harrison St, Chicago, IL, 60612, USA
| | - Thomas Messer
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, 1969 West Ogden Avenue, Chicago, IL, 60612, USA
| | - Frederic Starr
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, 1969 West Ogden Avenue, Chicago, IL, 60612, USA
| | - Faran Bokhari
- Department of Trauma and Burn, John H. Stroger, Jr. Hospital of Cook County, 1969 West Ogden Avenue, Chicago, IL, 60612, USA
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3
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Biondo-Simões MDLP, Zwierzikowski JA, Antoria JCD, Ioshii SO, Robes RR. Biological compatibility of oxidized cellulose vs. porcine gelatin to control bleeding in liver lesions in rats. Acta Cir Bras 2022; 36:e361101. [PMID: 35019008 PMCID: PMC8734958 DOI: 10.1590/acb361101] [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: 07/06/2021] [Accepted: 10/09/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To compare biological compatibility, hemostasis, and adhesion formation between oxidized regenerated cellulose and lyophilized hydrolyzed porcine collagen in liver trauma. METHODS Forty male Wistar rats constituted two groups: group A (oxidized cellulose) and group B (lyophilized hydrolyzed collagen). Standardized liver trauma was made, and the hemostatic agent was applied. Animals in subgroups A7 and B7 were submitted to euthanasia and relaparotomy after seven days, and in subgroups A14 and B14 after 14 days. Macroscopic and microscopic results were evaluated. RESULTS There was no fluid in the cavity in any of the animals, and adhesions were present in all of them. In the analysis after seven days, the adhesions were grades 3 or 4 and consisted of omentum, small intestine, and abdominal wall (p<0.05). In both groups, the mesh was surrounded by a capsule, which was not observed after 14 days. In the evaluation after 14 days, adhesions were grades 2 or 3 (p>0.05). The microscopic examination showed subacute and chronic reactions, in both groups and in both timepoints, with similar frequency. The intensity of fibrosis always presented positive scores. Microabscesses and xanthomatous macrophages were observed in both groups. CONCLUSIONS There was no superiority of one agent over the other.
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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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5
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Mansor S, Aldiasy A, Algialany A, Buzaja A. The Operative Management for Gunshot Liver Injuries: an Experience of Seventy-One Patients in 5 Years. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02727-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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6
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Hu W, Xu Z, Shen X, Gu Y, Dai Z, Chen J, Zhu Z, Zhou Y, Zhao W, Chen C. Accident-related hepatic trauma in a medical clinical center in eastern China: a cross-sectional study. BMC Surg 2021; 21:16. [PMID: 33407367 PMCID: PMC7789588 DOI: 10.1186/s12893-020-01043-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/28/2020] [Indexed: 11/11/2022] Open
Abstract
Background The treatment of hepatic injury can be complex. Medical clinical centers are often the first line hospitals for the diagnosis and treatment of hepatic trauma in China. The aim of the study is to summarize the experience in the diagnosis and treatment of hepatic trauma in one medical clinical center in China. Methods This retrospective study included patients with hepatic trauma admitted between January 2002 and December 2019 at the Xishan People’s Hospital of Wuxi. The outcomes were cure rate and death within 14 days post-discharge. Results Among the 318 patients with hepatic trauma, 146 patients underwent surgical treatment, and 172 received conservative treatment; three patients were transferred to other hospitals for further treatment; 283 patients were cured, and 35 died. Severe hepatic trauma occurred in 74 patients, with a mortality rate of 31.1% and accounting for 65.7% of total mortality. American Association for the Surgery of Trauma (AAST) grading ≥ III (OR = 3.51, 95%CI: 1.32–9.37, P = 0.012) and multiple organ injury (OR = 7.51, 95%CI: 2.51–22.46, P < 0.001) were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death (OR = 0.08, 95%CI: 0.01–0.45, P = 0.004). Among patients with ASST ≥ III and who underwent surgery, age (OR = 5.29, 95%CI: 1.37–20.33, P = 0.015) and peri-hepatic packing (PHP) (OR = 5.54, 95%CI: 1.43–21.487, P = 0.013) were independently associated with death. Conclusions AAST grading ≥ III and multiple organ injury were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death. Among patients with ASST ≥ III and who underwent surgery, age and PHP were independently associated with death.
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Affiliation(s)
- Weidong Hu
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Zipeng Xu
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Xu Shen
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Yanyan Gu
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Zhengxing Dai
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Jie Chen
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Zhenghai Zhu
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Ying Zhou
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Wanwen Zhao
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China
| | - Chaobo Chen
- Department of General Surgery, Wuxi Xishan People's Hospital, Wuxi, No. 1128, Da-Cheng Road, Wuxi, 214105, Jiangsu, China. .,Department of Immunology, Ophthalmology and ORL, Complutense University School of Medicine, 28040, Madrid, Spain.
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7
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Early re-laparotomy for patients with high-grade liver injury after damage-control surgery and perihepatic packing. Surg Today 2020; 51:891-896. [PMID: 33170365 PMCID: PMC7652704 DOI: 10.1007/s00595-020-02178-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/18/2020] [Indexed: 02/05/2023]
Abstract
Purpose The likelihood of re-bleeding after damage-control surgery (DCS) and perihepatic packing for high-grade liver injuries is a major concern. Thus, although early re-laparotomy tends to be recommended, we conducted this study to evaluate the feasibility of performing definite laparotomy within ≤ 48 h in this clinical population. Methods The subjects of this retrospective study were 65 patients (n = 24, ≤ 48-h group; n = 41, > 48-h group) who underwent DCS and perihepatic packing. The primary outcome was the rate of repacking for bleeding during re-laparotomy and the secondary outcomes were mortality and length of stay in the intensive care unit (ICU). Results The ≤ 48-h group had a higher rate of angioembolization and transfusion of red blood cells (RBCs), fresh frozen plasma, and platelets, but the rates of repacking and mortality were not significantly different between the groups. However, the incidence of pneumonia and ventilation support requirement were significantly lower in the ≤ 48-h group than in the > 48-h group. Conclusion The re-laparotomy performed within ≤ 48 h after DCS and perihepatic packing is feasible for patients with high grade liver injury, using angioembolization and aggressive transfusion, as required. Early re-laparotomy reduces the need for prolonged ventilator support and the incidence of ventilator-associated pneumonia.
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8
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Brooks A, Reilly JJ, Hope C, Navarro A, Naess PA, Gaarder C. Evolution of non-operative management of liver trauma. Trauma Surg Acute Care Open 2020; 5:e000551. [PMID: 33178894 PMCID: PMC7640583 DOI: 10.1136/tsaco-2020-000551] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/19/2020] [Accepted: 08/31/2020] [Indexed: 11/03/2022] Open
Abstract
The management of complex liver injury has changed during the last 30 years. Operative management has evolved into a non-operative management (NOM) approach, with surgery reserved for those who present in extremis or become hemodynamically unstable despite resuscitation. This NOM approach has been associated with improved survival rates in severe liver injury and has been the mainstay of treatment for the last 20 years. Patients that fail NOM and require emergency surgery are associated with increased morbidity and mortality. Better patient selection may have an impact not only on the rate of failure of NOM, but the mortality rate associated with it. The aim of this article is to review the evidence that helped shape the evolution of liver injury management during the last 30 years.
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Affiliation(s)
- Adam Brooks
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - John-Joe Reilly
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Carla Hope
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Alex Navarro
- East Midlands Major Trauma Centre, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paal Aksel Naess
- Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ullevaal, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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9
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Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, Biffl W, Peitzman A, Horer T, Abu-Zidan FM, Sartelli M, Fraga GP, Cicuttin E, Ansaloni L, Parra MW, Millán M, DeAngelis N, Inaba K, Velmahos G, Maier R, Khokha V, Sakakushev B, Augustin G, di Saverio S, Pikoulis E, Chirica M, Reva V, Leppaniemi A, Manchev V, Chiarugi M, Damaskos D, Weber D, Parry N, Demetrashvili Z, Civil I, Napolitano L, Corbella D, Catena F. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020; 15:24. [PMID: 32228707 PMCID: PMC7106618 DOI: 10.1186/s13017-020-00302-7] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy.
| | - Raul Coimbra
- Riverside University Health System, CECORC Research Center, Loma Linda University, Loma Linda, USA
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | - Felipe Vega
- Department of Surgery, Hospital Angeles Lomas, Huixquilucan, Mexico
| | | | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital La Jolla, San Diego, CA, USA
| | - Andrew Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, FL, USA
| | - Mauricio Millán
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Nicola DeAngelis
- Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | - Kenji Inaba
- General and Trauma Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - George Velmahos
- General and Emergency Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Salomone di Saverio
- General and Trauma Surgery Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mircea Chirica
- Chirurgie Digestive, CHUGA-CHU Grenoble Alpes, Grenoble, France
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | | | - Ian Civil
- Trauma Surgery, Auckland University Hospital, Auckland, New Zealand
| | - Lena Napolitano
- Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
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10
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Segura-Sampedro JJ, Pineño-Flores C, Craus-Miguel A, Morales-Soriano R, González-Argente FX. New hemostatic device for grade IV-V liver injury in porcine model: a proof of concept. World J Emerg Surg 2019; 14:58. [PMID: 31889989 PMCID: PMC6916102 DOI: 10.1186/s13017-019-0277-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 11/18/2019] [Indexed: 12/21/2022] Open
Abstract
Background The liver is the most injured organ following abdominal trauma. Uncontrolled bleeding remains the main cause of early liver injury-related death, with a mortality rate of 50–54% in the first 24 h after admission and with 80% of operative deaths. Packing and reoperation account for the increased survival in severe liver trauma, and they are recommended for severe liver injuries (grades IV–V). Perihepatic packing can lead to several potential complications. An excessive packing can cause complications due to abdominal compartment syndrome, while a soft packing may be ineffective, and thus, bleeding can continue inadvertently with the consequent hypovolemic shock and potentially death. Methods We designed a new vacuum-based device to perform perihepatic packing without the negative side-effects of the classic technique. We conducted a prospective pilot feasibility study in a porcine model. We compared the traditional perihepatic packing (PHP) (n = 2) with the new VacBagPack device (VBP) (n = 2). Results Both pigs survived with the new device and showed an equivalent outcome to the one that survived in the traditional technique group. Blood tests were similar too. This suggests that VBP could be at least as effective as traditional PHP. Conclusions We establish a first step towards the development of a new packing device. A new study with a bigger sample size still in pigs will be conducted. Also, an industrial model of the device is currently in production.
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Affiliation(s)
- Juan José Segura-Sampedro
- 1General & Digestive Surgery Department, University Hospital Son Espases, Palma de Mallorca, Spain.,Health Research Institute of Balearic Islands, Palma de Mallorca, Spain.,3School of Medicine, University of Balearic Islands, Palma de Mallorca, Spain
| | - Cristina Pineño-Flores
- 1General & Digestive Surgery Department, University Hospital Son Espases, Palma de Mallorca, Spain.,Health Research Institute of Balearic Islands, Palma de Mallorca, Spain
| | - Andrea Craus-Miguel
- 1General & Digestive Surgery Department, University Hospital Son Espases, Palma de Mallorca, Spain.,Health Research Institute of Balearic Islands, Palma de Mallorca, Spain
| | - Rafael Morales-Soriano
- 1General & Digestive Surgery Department, University Hospital Son Espases, Palma de Mallorca, Spain.,Health Research Institute of Balearic Islands, Palma de Mallorca, Spain
| | - Francesc Xavier González-Argente
- 1General & Digestive Surgery Department, University Hospital Son Espases, Palma de Mallorca, Spain.,Health Research Institute of Balearic Islands, Palma de Mallorca, Spain.,3School of Medicine, University of Balearic Islands, Palma de Mallorca, Spain
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11
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Abstract
Of all the intra-abdominal solid organs, the liver is the most vulnerable to blunt abdominal trauma. The majority of liver ruptures present in combination with other abdominal or extra-abdominal injuries. Over the last three decades, the management of blunt liver trauma has evolved from obligatory operative to non-operative management in over 90% of cases. Penetrating liver injuries more often require operative intervention and are managed according to adult protocols. The greatest clinical challenge remains the timely identification of the severely damaged liver with immediate and aggressive resuscitation and expedition to laparotomy. The operative management can be taxing and should ideally be performed in a dedicated paediatric surgical centre with experience in dealing with such trauma. Complications can occur early or late and include haemobilia, intrahepatic duct rupture with persistent biliary fistula, bilaemia, intrahepatic haematoma, post-traumatic cysts, vascular outflow obstruction, and gallstones. The prognosis is generally excellent.
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Affiliation(s)
- A B van As
- Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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12
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Coccolini F, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Ceresoli M, Montori G, Sartelli M, Weber D, Fraga G, Naidoo N, Moore FA, Zanini N, Ansaloni L. WSES classification and guidelines for liver trauma. World J Emerg Surg 2016; 11:50. [PMID: 27766112 PMCID: PMC5057434 DOI: 10.1186/s13017-016-0105-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/13/2016] [Indexed: 11/10/2022] Open
Abstract
The severity of liver injuries has been universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale. In determining the optimal treatment strategy, however, the haemodynamic status and associated injuries should be considered. Thus the management of liver trauma is ultimately based on the anatomy of the injury and the physiology of the patient. This paper presents the World Society of Emergency Surgery (WSES) classification of liver trauma and the management Guidelines.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore Hospital, Parma, Italy
| | | | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Walter Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Marco Ceresoli
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Gustavo Fraga
- Faculdade de Ciências Médicas (FCM)-Unicamp, Campinas, SP Brazil
| | - Noel Naidoo
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | | | - Nicola Zanini
- General Surgery Department, Infermi Hospital, Rimini, Italy
| | - Luca Ansaloni
- General Emergency and Trauma Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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Williamson JML, Rees JRE, Streets CG, Strickland AD, Finch-Jones MD. Management of liver trauma. Br J Hosp Med (Lond) 2016; 74:432-8. [PMID: 23958980 DOI: 10.12968/hmed.2013.74.8.432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J M L Williamson
- General Surgical Speciality Training Registrar in the Department of Hepato-pancreato-biliary Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol
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Peri-hepatic gauze packing for the control of haemorrhage during liver transplantation: A retrospective study. Dig Liver Dis 2016; 48:414-22. [PMID: 26725163 DOI: 10.1016/j.dld.2015.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 11/11/2015] [Accepted: 11/20/2015] [Indexed: 12/11/2022]
Abstract
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.
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Management of severe blunt hepatic injury in the era of computed tomography and transarterial embolization: A systematic review and critical appraisal of the literature. J Trauma Acute Care Surg 2015; 79:468-74. [PMID: 26307882 DOI: 10.1097/ta.0000000000000724] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Coccolini F, Montori G, Catena F, Di Saverio S, Biffl W, Moore EE, Peitzman AB, Rizoli S, Tugnoli G, Sartelli M, Manfredi R, Ansaloni L. Liver trauma: WSES position paper. World J Emerg Surg 2015; 10:39. [PMID: 26309445 PMCID: PMC4548919 DOI: 10.1186/s13017-015-0030-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/24/2015] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | | | | | | | - Andrew B Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, Pensylvania USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Gregorio Tugnoli
- General, Emergency and Trauma Surgery, Maggiore Hospital, Bologna, Italy
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Roberto Manfredi
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
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Doklestić K, Stefanović B, Gregorić P, Ivančević N, Lončar Z, Jovanović B, Bumbaširević V, Jeremić V, Vujadinović ST, Stefanović B, Milić N, Karamarković A. Surgical management of AAST grades III-V hepatic trauma by Damage control surgery with perihepatic packing and Definitive hepatic repair-single centre experience. World J Emerg Surg 2015; 10:34. [PMID: 26236391 PMCID: PMC4522150 DOI: 10.1186/s13017-015-0031-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 07/27/2015] [Indexed: 12/19/2022] Open
Abstract
Background Severe liver injury in trauma patients still accounts for significant morbidity and mortality. Operative techniques in liver trauma are some of the most challenging. They include the broad and complex area, from damage control to liver resection. Material and method This is a retrospective study of 121 trauma patients with hepatic trauma American Association for Surgery of Trauma (AAST) grade III–V who have undergone surgery. Indications for surgery include refractory hypotension not responding to resuscitation due to uncontrolled hemorrhage from liver trauma; massive hemoperitonem on Focused assessment by ultrasound for trauma (FAST) and/or Diagnostic peritoneal lavage (DPL) as well as Multislice Computed Tomography (MSCT) findings of the severe liver injury and major vascular injuries with active bleeding. Results Non-survivors have significantly higher AAST grade of liver injury and higher Injury Severity Score (ISS) (p = 0.000; p = 0.0001). Non-survivors have significant hypotension on arrival and lower Glasgow Coma Scale (GCS) on admission (p = 0.000; p = 0.0001). Definitive hepatic repair was performed in 62(51.2 %) patient. Damage Control, liver packing and planned re-laparotomy after 48 h were used in 59(48.8 %). There was no statistically significant difference in terms of the surgical approach. There was significant difference in the amount of red blood cells (RBC) transfusion in the first 24 h between survivors and non-survivors (p = 0.001). Overall mortality rate was 33.1 %. Regarding complications non-survivors had significantly prolonged bleeding and higher rate of Acute respiratory distress syndrome (ARDS) (p = 0.0001; p = 0.0001), while survivors had significantly higher rate of pleural effusion (p = 0.0001). Conclusion All efforts in the treatment of severe liver injuries should be directed to the rapid and effective control of bleeding, because uncontrollable hemorrhage is the cause of early death and it requires massive blood transfusion, all of which contributes to the late fatal complication.
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Affiliation(s)
- Krstina Doklestić
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia
| | - Branislav Stefanović
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia
| | - Pavle Gregorić
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia
| | - Nenad Ivančević
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia
| | - Zlatibor Lončar
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia
| | - Bojan Jovanović
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Department for Anesthesiology, University of Belgrade, Serbia, Belgrade, Serbia
| | - Vesna Bumbaširević
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Department for Anesthesiology, University of Belgrade, Serbia, Belgrade, Serbia
| | - Vasilije Jeremić
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia
| | - Sanja Tomanović Vujadinović
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Physical and Rehabilitation Medicine, Clinical Center of Serbia, Belgrade, Serbia
| | - Branislava Stefanović
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Department for Anesthesiology, University of Belgrade, Serbia, Belgrade, Serbia
| | - Nataša Milić
- Faculty of Medicine and Institute for Medical Statistics and Informatics, University of Belgrade, Belgrade, Serbia
| | - Aleksandar Karamarković
- Faculty of Medicine, University of Belgrade and Clinical Center of Serbia, Clinic for Emergency Surgery, University of Belgrade, Serbia, Pasteur Str.2, Belgrade, 11000 Serbia
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Latifi R, Khalaf H. Selective vascular isolation of the liver as part of initial damage control for grade 5 liver injuries: Shouldn't we use it more frequently? Int J Surg Case Rep 2014; 6C:292-5. [PMID: 25569195 PMCID: PMC4334949 DOI: 10.1016/j.ijscr.2014.12.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 12/11/2014] [Accepted: 12/13/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Severe liver trauma (grade 4 and 5) carries mortality greater than 40%. It represents a major surgical challenge in patients with hemodynamic instability who require an immediate exploratory laparotomy. Perihepatic packing and damage control can sometimes work, but for severe liver injuries, adjunct maneuvers might be needed (such as early embolization or hepatic artery ligation). During a patient's first operation for severe liver trauma, anatomic resection is rarely tolerated. MATERIALS AND METHODS We managed a 31 year-old male with a blunt grade 5 right-lobe liver injury in severe hypovolemic shock. RESULTS As part of the initial damage control operation, concurrently with intermittent Pringle maneuver, he underwent intra- and perihepatic packing; selective isolation and ligation of the right portal vein, right hepatic artery, and right hepatic vein; and repair of the retrohepatic inferior vena cava. Then, 36h later, the patient underwent a right hepatectomy. CONCLUSION For patients with severe liver injuries, selective vascular isolation and ligation may be considered as part of damage control (in addition to intermittent Pringle maneuver) and might enable anatomic resection at a later stage.
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Affiliation(s)
- Rifat Latifi
- Department of Surgery, University of Arizona, Tucson, AZ, USA; Trauma Section, Hamad Medical Corporation, Doha, Qatar.
| | - Hatem Khalaf
- Hamad Medical Corporation, Transplant Section, Doha, Qatar
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Patrono D, Brunati A, Romagnoli R, Salizzoni M. Liver transplantation after severe hepatic trauma: a sustainable practice. A single-center experience and review of the literature. Clin Transplant 2014; 27:E528-37. [PMID: 23923975 DOI: 10.1111/ctr.12192] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2013] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Damiano Patrono
- General Surgery 8 and Liver Transplantation Center, San Giovanni Battista - Molinette University Hospital, A. O. Città della Salute e della Scienza, Turin, Italy
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A comprehensive five-step surgical management approach to penetrating liver injuries that require complex repair. J Trauma Acute Care Surg 2013; 75:207-11. [DOI: 10.1097/ta.0b013e31829de5d1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Slotta JE, Justinger C, Kollmar O, Kollmar C, Schäfer T, Schilling MK. Liver injury following blunt abdominal trauma: a new mechanism-driven classification. Surg Today 2013; 44:241-6. [PMID: 23459788 PMCID: PMC3898124 DOI: 10.1007/s00595-013-0515-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 11/15/2012] [Indexed: 11/28/2022]
Abstract
Purposes The current classifications for blunt liver trauma focus only on the extent of liver injury. However, these scores are independent from the localization of liver injury and mechanism of trauma. Methods The type of liver injury after blunt abdominal trauma was newly classified as type A when it was along the falciform ligament with involvement of segments IVa/b, III, or II, and type B when there was involvement of segments V–VIII. With the use of a prospectively established database, the clinical, perioperative, and outcome data were analyzed regarding the trauma mechanism, as well as the radiological and intraoperative findings. Results In 64 patients, the type of liver injury following blunt abdominal trauma was clearly linked with the mechanism of trauma: type A injuries (n = 28) were associated with a frontal trauma, whereas type B injuries (n = 36) were found after complex trauma mechanisms. The demographic data, mortality, ICU stay, and hospital stay showed no significant differences between the two groups. Interestingly, all patients with type A ruptures required immediate surgical intervention, whereas six patients (16.7 %) with type B ruptures could be managed conservatively. Conclusions This new classification for blunt traumatic hepatic injury is based on the localization of parenchymal disruption and correlates with the mechanism of trauma. The type of liver injury correlated with the necessity for surgical therapy.
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Affiliation(s)
- J E Slotta
- Department of General Surgery, Visceral, Vascular and Paediatric Surgery, University of Saarland, Homburg/Saar, 66421, Saarland, Germany,
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Defining the percentage of intra-abdominal hemorrhage in abdominal computerized tomography using stereology in patients with blunt liver injury and determining its relationship with outcomes. J Trauma Acute Care Surg 2013; 74:224-9. [DOI: 10.1097/ta.0b013e318270df0e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Abstract
The liver is one of the commonest intra-abdominal organs injured worldwide in blunt and penetrating trauma and its management has evolved significantly in the last 30 years. Mandatory laparotomy has been replaced by an acceptance that for most blunt hepatic trauma, a selective non-operative approach is safe and effective with a failure rate ie the need to proceed to delayed laparotomy of approximately 10%. There is a markedly lower rate of complications in those that are managed non-operatively. Adjuncts to this conservative regimen such as angioembolisation and delayed laparoscopy to treat biliary peritonitis increase the chances of avoiding laparotomy. This belief in non-operative management has also been transferred to some degree to penetrating liver trauma, where there is a gradual accumulation of evidence to support this non-operative approach in a carefully selected group of patients. This article examines the evidence supporting the selective non-operative management of both blunt and penetrating liver trauma and describes the outcomes and complications.
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Affiliation(s)
- C Swift
- Department of General Surgery, Rotherham NHS Foundation Trust, Rotherham South Yorkshire S60 2UD
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Zago TM, Tavares Pereira BM, Araujo Calderan TR, Godinho M, Nascimento B, Fraga GP. Nonoperative management for patients with grade IV blunt hepatic trauma. World J Emerg Surg 2012; 7 Suppl 1:S8. [PMID: 23531162 PMCID: PMC3425664 DOI: 10.1186/1749-7922-7-s1-s8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction The treatment of complex liver injuries remains a challenge. Nonoperative treatment for such injuries is increasingly being adopted as the initial management strategy. We reviewed our experience, at a University teaching hospital, in the nonoperative management of grade IV liver injuries with the intent to evaluate failure rates; need for angioembolization and blood transfusions; and in-hospital mortality and complications. Methods This is a retrospective analysis conducted at a single large trauma centre in Brazil. All consecutive, hemodynamically stable, blunt trauma patients with grade IV hepatic injury, between 1996 and 2011, were analyzed. Demographics and baseline characteristics were recorded. Failure of nonoperative management was defined by the need for surgical intervention. Need for angioembolization and transfusions, in-hospital death, and complications were also assessed Results Eighteen patients with grade IV hepatic injury treated nonoperatively during the study period were included. The nonoperative treatment failed in only one patient (5.5%) who had refractory abdominal pain. However, no missed injuries and/or worsening of bleeding were observed during the operation. None of the patients died nor need angioembolization. No complications directly related to the liver were observed. Unrelated complications to the liver occurred in three patients (16.7%); one patient developed a tracheal stenosis (secondary to tracheal intubation); one had pleural effusion; and one developed an abscess in the pleural cavity. The hospital length of stay was on average 11.56 days. Conclusions In our experience, nonoperative management of grade IV liver injury for stable blunt trauma patients is associated with high success rates without significant complications.
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Affiliation(s)
- Thiago Messias Zago
- Rua Alexander Fleming, 181 Zip code: 13,083-970, Cidade Universitaria "Prof, Zeferino Vaz, Campinas - SP, Brazil.
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Pereira BMT. Non-operative management of hepatic trauma and the interventional radiology: an update review. Indian J Surg 2012; 75:339-45. [PMID: 24426473 DOI: 10.1007/s12262-012-0712-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 07/18/2012] [Indexed: 12/22/2022] Open
Abstract
The growing trend to manage hepatic injuries nonoperatively has been increasing demand for advanced endovascular interventions. This brings up the necessity for general and trauma surgeons to update their knowledge in such matter. Effective treatment mandates a multispecialty team effort that is usually led by the trauma surgeon and includes vascular surgery, orthopedics, and, increasingly, interventional radiology. The focus on hemorrhage control and the angiographer's unique access to vascular structures gives interventional radiology (IR) an important and increasingly recognized role in the treatment of patients with hemodynamic instability. Our aim is to review the basic concepts of IR primarily in hepatic trauma and secondarily in some other special situations. A liver vascular anatomy review is also needed for better understanding the roles of IR. As a final point we propose a guideline for the operative/nonoperative management of traumatic hepatic injuries. The benefit of multidisciplinary approach (TAE) appears to be a powerful weapon in the medical arsenal against the high mortality of injured trauma liver patients.
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Affiliation(s)
- Bruno Monteiro Tavares Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences (FCM), University of Campinas (UNICAMP), Campinas, SP Brazil ; Faculty of the Division of Trauma Surgery, School of Medicine-University of Campinas-UNICAMP, Campinas, Brazil ; UNICAMP, 181 Rua Alexander Fleming, 13.083-970 Campinas, SP Brazil
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Use of Sengstaken-Blakemore Intrahepatic Balloon: An Alternative for Liver-Penetrating Injuries. World J Surg 2012; 36:2119-24. [DOI: 10.1007/s00268-012-1625-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Leppäniemi AK, Mentula PJ, Streng MH, Koivikko MP, Handolin LE. Severe hepatic trauma: nonoperative management, definitive repair, or damage control surgery? World J Surg 2012; 35:2643-9. [PMID: 21989646 DOI: 10.1007/s00268-011-1309-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Management of severe liver injuries has evolved to include the options for nonoperative management and damage control surgery. The present study analyzes the criteria for choosing between nonoperative management and early surgery, and definitive repair versus damage control strategy during early surgery. METHODS In a retrospective analysis of 144 patients with severe (AAST grade III-V) liver injuries (94% blunt trauma), early laparotomy was performed in 50 patients. Initial management was nonoperative in 94 blunt trauma patients with 8 failures. Uni- and multivariate analyses were used to calculate predictor odds ratios (OR) with 95% confidence intervals (CI). RESULTS Factors associated with early laparotomy in blunt trauma included shock on admission, associated grade IV-V splenic injury, grade IV-V head injury, and grade V liver injury. Only shock was an independent predictor (OR, 26.1; 95% CI, 8.9-77.1; P < 0.001). The presence of a grade IV-V splenic injury predicted damage control strategy (OR infinite; P = 0.021). Failed nonoperative management was associated with grade IV-V splenic injury (OR, 14.00; 95% CI, 1.67-117.55), and shock (OR, 6.82; 95% CI, 1.49-31.29). The hospital mortality rate was 15%; 8 of 21 deaths were liver-related. Shock (OR, 9.3; 95% CI, 2.4-35.8; P = 0.001) and severe head injury (OR, 9.25; 95% CI, 3.0-28.9; P = 0.000) were independent predictors for mortality. CONCLUSIONS In patients with severe liver injury, associated severe splenic injury favors early laparotomy and damage control strategy. Patients who arrive in shock or have an associated severe splenic injury should not be managed nonoperatively. In addition to severe head injury, uncontrollable bleeding from the liver injury is still a major cause of early death.
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Affiliation(s)
- Ari K Leppäniemi
- Department of Abdominal Surgery, Helsinki University Hospital, Meilahti, Haartmaninkatu 4, PO Box 340, 00029, HUS, Finland.
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Leppäniemi AK. Dealing with liver trauma. TRAUMA-ENGLAND 2011. [DOI: 10.1177/1460408610390975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Bleeding from a traumatic liver injury often ceases spontaneously, which is the basis for non-operative management, currently used in about 80% of patients with blunt hepatic trauma. The selection of patients for non-operative management is based on the assessment of haemodynamic stability and the presence of associated organ injuries requiring surgical repair. In patients requiring surgery, definitive repair is preferred in stable patients with normal tissue perfusion and temperature, and ranges from the use of local haemostats and sutures to non-anatomic hepatic resection and direct repair of juxtahepatic venous injuries. In the most seriously injured patients with major bleeding causing severe physiological derangement, a damage control strategy including perihepatic packing is the treatment method of choice. Adjunctive procedures including hepatic angiography and embolisation are often needed in high-grade liver injuries whether undergoing surgical or non-operative management. The multidisciplinary approach also includes procedures performed for biliary complications, such as percutaneous or endoscopic drainage of bile leaks.
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Affiliation(s)
- AK Leppäniemi
- Department of Surgery, Meilahti Hospital, University of Helsinki, Finland,
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29
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Abstract
BACKGROUND Major hepatic necrosis (MHN) is a common complication after angioembolization (AE) for severe liver injuries. We compared the outcomes of two treatment modalities. METHODS Patients with MHN were retrospectively reviewed from January 2002 to October 2007. Demographics, Injury Severity Scale score, length of stay, admission Glasgow Coma Scale Score, mortality, transfusion requirements, intra-abdominal complications, admission physiologic variables, and the number and type of abdominal procedures (operative or nonoperative) were collected. These patients were then divided into two groups-those treated with hepatic lobectomy (HL) and those treated with multiple procedures including serial operative debridements and/or percutaneous drainage (IR/OR). RESULTS Thirty patients (41%) with MHN were identified from 71 patients who had AE. Sixteen patients with MHN underwent HL and 14 patients underwent multiple IR/OR procedures. The two groups were similar at baseline, except that the HL group had a higher Injury Severity Scale score. Outcomes between the two groups were similar. There was a significantly higher complication rate and increased number of procedures in the IR/OR group. There were no deaths in patients who had early HL (<5 days). There was one death in the later lobectomy group. CONCLUSION MHN is a common complication after AE. This complication can be safely managed with a series of operative debridements in conjunction with interventional procedures or with HL. Lobectomy is associated with a lower complication rate and a fewer number of procedures. Early lobectomy may be better than a delayed procedure.
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30
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Major hepatic necrosis: a common complication after angioembolization for treatment of high-grade liver injuries. ACTA ACUST UNITED AC 2009; 66:621-7; discussion 627-9. [PMID: 19276729 DOI: 10.1097/ta.0b013e31819919f2] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of high-grade liver injuries often involves a combination of operative and nonoperative strategies. Angioembolization (AE) is frequently used in the management of these injuries. Morbidity in patients with high-grade hepatic injuries remains high despite improvements in mortality with a multimodality approach. Major hepatic necrosis (MHN) is a morbid, but underappreciated complication of AE in this patient population. This study will examine the risk factors and outcomes of patients with high-grade liver injures managed with AE who developed the complication of MHN. METHODS Patients admitted to the R Adams Cowley Shock Trauma Center between January 2002 and December 2007 with high-grade blunt or penetrating liver injuries (grades III-VI) were identified from the trauma registry and the medical records were retrospectively reviewed. Demographic and injury specific data, complications, and admission physiologic variables were collected. Patients who had therapeutic AE, either preoperatively or postoperatively, and went on to develop liver-related complications including MHN were reviewed. RESULTS There were 538 patients with high-grade liver injuries admitted during a 5-year period. One hundred and sixteen patients (22%) underwent angiography, and 71 (13%) had a therapeutic AE. Sixteen patients (22.5%) had grade III injuries, 44 (62%) had grade IV injuries, and 11 (15.5%) had grade V injuries. Overall mortality in this group was 14% with eight patients (11.3%) dying as a result of their liver injury. Complication rates were 18.8%, 65.9%, and 100% in the patients with grades III, IV, and V injuries, respectively, for an overall complication rate of 60.6%. Thirty patients (42.2%) went on to develop MHN. Patients who developed MHN were compared with those who did not. Baseline characteristics, Injury Severity Score, and hemodynamic parameters at admission were no different between the two groups. Patients with MHN had higher grade injuries, required significantly more blood product transfusions, and had a significantly longer length of stay (all p < 0.001). Patients who developed MHN were more likely to have undergone operative intervention (96.7% vs. 41.5%, p < 0.001), with 87% having a damage control laparotomy. Other liver-related complications occurred more frequently in the patients that developed MHN (60.0% vs. 34.1%, p = 0.03). However, mortality was not different in the two groups. CONCLUSION High-grade liver injuries pose significant challenges to those who care for trauma patients. Many patients can be successfully managed nonoperatively, but there are still patients that require laparotomy. AE is the logical augmentation of damage control techniques for controlling hemorrhage. However, given the nature and severity of these injuries, these therapies are not without complications. MHN was found to be a common complication in our study. It tended to occur in high-grade injures, was associated with higher complication rates, longer hospital length of stay, and higher transfusion requirements. Management of MHN can be challenging. Factors that still need to be elucidated are the role of perihepatic packing and timing of second look operation.
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