Is it more dangerous to perform inadequate packing?

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.

Reinterventions after damage control surgery

Damage control has well-defined steps. However, there are still controversies regarding whom, when, and how re-interventions should be performed. This article summarizes the Trauma and Emergency Surgery Group (CTE) Cali-Colombia recommendations about the specific situations concerning second interventions of patients undergoing damage control surgery. We suggest packing as the preferred bleeding control strategy, followed by unpacking within the next 48-72 hours. In addition, a deferred anastomosis is recommended for correction of intestinal lesions, and patients treated with vascular shunts should be re-intervened within 24 hours for definitive management. Furthermore, abdominal or thoracic wall closure should be attempted within eight days. These strategies aim to decrease complications, morbidity, and mortality.

Packing procedure effective for liver transplantation in hemophilic patients with HIV/HCV coinfection

We herein report an effective procedure for liver transplantation (LT) for severe cirrhotic patients with hemophilia. Three hemophilic patients suffering from liver cirrhosis due to human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfection underwent deceased donor LT in our institute. Basic clotting parameters were measured and evaluated during LT to determine the optimal packing procedure. All patients were treated with a gauze packing procedure to ensure stable hemostasis in relation to hemophilia during the peri-transplant period. The graft function of all patients recovered well upon gauze removal (depacking) procedure and the patients were finally discharged to home. The administration of clotting factor was discontinued on day 3 after deceased donor LT. No infectious complications occurred in any of the 3 patients. This technique could be an option for achieving successful LT in these patients. Cooperation between transplant surgeons and anesthesiologists can make this challenging operation possible.

New hemostatic device for grade IV-V liver injury in porcine model: a proof of concept

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.

Liver trauma: What current management?

BACKGROUND

The liver is the most commonly damaged organ in abdominal trauma. The management of liver trauma has experienced many changes over the last two decades. Currently there is a trend toward a non-operative treatment warranted by the successful pediatric experience and better results recorded in many trauma centers worldwide. This study aimed to evaluate outcomes of operative and non-operative management of liver trauma in our institution over the last five years.

METHODS

The patients with a diagnosis of blunt or penetrating liver injuries, admitted and managed in our hospital from January 2012 to December 2016 were retrospectively studied. The patients were divided into 2 groups, operated and non-operated groups, according to the initial management considered appropriate at the time of patient admission. Clinical features and outcomes were analyzed.

RESULTS

The study involved 83 patients, with a mean age of 33 years and a marked male predominance (85.5%). The most common type of lesions was blunt trauma and the main cause was road traffic accidents. Sixty-eight liver injuries (81.9%) were of low severity (grades I, II, III), while 15 (18.1%) were of high severity (grade IV or greater). Fifty-six patients (67.5%) had multiple injuries. Surgical treatment was performed in 26 (31.3%) patients. Non-operative management was undertaken in 57 cases (68.7%). The morbidity and mortality rates were clearly lower in non-operative patients compared to those in the operated group.

CONCLUSIONS

Careful non-operative management is an adequate therapeutic strategy for the patients suffering from liver trauma with stable hemodynamics. Patients with complex hepatic trauma and especially those with other organ injuries continue to have significantly higher mortality.

Surgical Management of Solid Organ Injuries

Surgery used to be the treatment of choice in patients with solid organ injuries. This has changed over the past 2 decades secondary to advances in noninvasive diagnostic techniques, increased availability of less invasive procedures, and a better understanding of the natural history of solid organ injuries. Now, nonoperative management (NOM) has become the initial management strategy used for most solid organ injuries. Even though NOM has become the standard of care in patients with solid organ injuries in most trauma centers, surgeons should not hesitate to operate on a patient to control life-threatening hemorrhage.

Surgical management and outcome of blunt major liver injuries: experience of damage control laparotomy with perihepatic packing in one trauma centre

INTRODUCTION

This retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries.

MATERIALS AND METHODS

From January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann-Whitney U test for continuous variables, either Pearson's chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p<0.05.

RESULTS

Of the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n=21), hepatorrhaphy (n=19), selective hepatic artery ligation (n=11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p=0.019), prolonged initial prothrombin time (PT) (p=0.004), active partial thromboplastin time (APTT) (p<0.0001) and decreased platelet count (p=0.005).

CONCLUSIONS

The mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries.

[Surgical treatment of blunt liver trauma, indications for surgery and results]

INTRODUCTION

The liver is the most frequently injured organ in blunt abdominal trauma. Patients that are hemodynamically unstable must undergo inmmediate surgical treatment. There are 2 surgical approaches for these patients; Anatomical Liver resection or non-anatomic liver resection. Around 80-90% of patients are candidates for non-operative management. -Several risk factors have been studied to select the patients most suited for a non operative management.

MATERIALS AND METHODS

We performed a retrospective study based on a prospective database. We searched for risk factors related to immediate surgical management and failed non-operative management. We also described the surgical procedures that were undertaken in this cohort of patients and their outcomes and complications.

RESULTS

During the study period 117 patients presented with blunt liver trauma. 19 patients (16.2%) required a laparotomy during the initial 24h after their admission. There were 11 deaths (58%) amongst these patients. Peri-hepatic packing and suturing were the most common procedures performed. A RTS Score<7.8 (RR: 7.3; IC 95%: 1.8-30.1), and ISS Score >20 (RR 2,5 IC 95%: 1.0-6.7), and associated intra-abdominal injuries (RR: 2.95; IC 95%: 1.25-6.92) were risk factors for immediate surgery. In 98 (83.7%) patients a non-operative management was performed. 7 patients had a failed non-operative management.

CONCLUSION

The need for immediate surgical management is related to the presence of associated intra-abdominal injuries, and the ISS and RTS scores. In this series the most frequently performed procedure for blunt liver trauma was peri-hepatic packing.

The 1-2-3 approach to abdominal packing

BACKGROUND

Abdominal packing (AP) in damage-control laparotomy (DCL) is a lifesaving technique that controls coagulopathic hemorrhage in severely injured trauma patients. However, the impact of the duration of AP on the incidence of re-bleeding and on intra-abdominal infections in penetrating abdominal trauma is not clear. The objective of the present study was to evaluate the complications related to the duration of AP and to determine the optimal time for AP removal.

METHODS

Prospectively collected/retrospectively analyzed data at an urban level I trauma center from January 2003 to December 2010 were used as the basis for this study. Inclusion criteria were adults (≥18 years old) with penetrating abdominal trauma, who had survived both the initial DCL procedure and their first re-laparotomy. All initial DCL patients included in the study underwent abdominal packing for coagulopathic hemorrhage control. The outcome measures of this study were re-bleeding after packing removal, intra-abdominal infection, and 30-day cumulative mortality. We considered time after packing as an independent variable. This was defined as the total amount of time (in days) that the packs were left in the patient's abdomen. Patients were grouped according to the duration in days of their AP in <1, 1-2, 2-3, and >3 days.

RESULTS

Of 503 patients with penetrating abdominal trauma, 121 underwent DCL and AP. The mean age was 30.1± 11.5 years, and the male to female ratio was 9:1. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) score was 17.6±7.2. The mean Injury Severity Score (ISS) score was 24.9±9.1. The right upper quadrant was packed in 39 (32.2%) patients, retroperitoneum in 70 (57.8%), pelvis in 13 (10.7%), and left upper quadrant in 9 (7.4%). Fifty-one patients (42.1%) had associated colon injuries and 58 (47.9%) had small bowel injuries. Twenty-six patients (21.5%) had AP<1 day, 42 patients (34.7%) had AP between 1 and 2 days, 35 patients (28.9%) had AP between 2 and 3 days, and 18 patients (14.8%) had AP>3 days. The re-bleeding rate in patients packed for 1-2 days compared to those packed for <1 day was a third lower, 14.3%, (95% confidence interval [95% CI]: 8.06, 20.5) versus 38.5% (95% CI: 25.4, 51.5). Conversely, an increasing trend toward intra-abdominal infection occurred as time after packing increased. The infection rate tripled from 16.7% (95% CI: 6.6, 26.7) to 44.4% (95% CI: 31.03, 57.7) when comparing 1-2 days versus >3 days. Overall mortality was 16.5%. Of these deaths, 8.26% were attributable to re-bleeding, and 13.2% to intra-abdominal infection. Deaths secondary to re-bleeding seemed to decrease with time of AP, whereas intra-abdominal infection deaths increased with time of AP (Chi square for trend p value=0.04).

CONCLUSIONS

The present study suggests that AP used in the setting of DCL for coagulopathic hemorrhage control should not be removed prior to the first postoperative day because of the increased risk of re-bleeding. The ideal length of AP is 2-3 days, and AP left in longer than 3 days is associated with a significantly increased risk of infectious complications.

Management of bleeding and coagulopathy following major trauma: an updated European guideline

INTRODUCTION

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

RESULTS

Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

CONCLUSIONS

A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.

Modified Perihepatic Packing; A Creative and Beneficial Method for Management of High Grade Liver Injury

OBJECTIVE

To evaluate the efficacy of modified perihepatic packing (MPHP) in reducing the rate of re-bleeding rate after packing removal.

METHODS

This was an experimental study being performed in Shiraz animal laboratory. High grade liver parenchymal injury was induced in 30 transgenic Australian rabbits which were then divided into two groups. Group A (control) included 14 and group B (experimental) comprised 16 rabbits. The animals in group A underwent standard perihepatic packing (SPHP) and those in group B were subjected to MPHP. Re-bleeding was assessed and compared between the two groups, after removal of perihepatic packings.

RESULTS

There was no significant difference between two study groups regarding baseline and perioperative characteristics. Rabbits in group A had significantly lower rate of postoperative re-bleeding compared to those in group A (57.1% vs. 12.5%; p=0.019). The mean bleeding volume was also significantly lower in group B compared to group A (76.88 ± 22.12 vs. 98.93 ± 33.8 mL; p<001). Although the survival rate was higher in group A compared to group B (93.8% vs. 78.6%) but the difference was not statistically significant (p=0.315).

CONCLUSION

MPHP is a simple and safe procedure for surgical management of high grade liver parenchymal injury concomitant with severe loss of glisson's capsule. This procedure significantly decreases re-bleeding after packing removal in comparison with SPHP.

Experience with managing liver trauma in southeastern Nigeria

BACKGROUND

All over the world, liver trauma occurs as a result of blunt or penetrating abdominal injury.

AIM AND OBJECTIVE

To review the management, morbidity and mortality of liver trauma in our resource-deprived centre, and to see how we can improve these outcomes, our poor facilities notwithstanding.

TYPE OF STUDY

This is a descriptive epidemiology.

PLACE OF STUDY

Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria.

PATIENTS AND METHODS

Patients who were treated for liver trauma in our centre between 2004 and 2010 were reviewed for aetiology of injury, management, morbidity and mortality.

RESULTS

Of the 162 patients who were treated for liver trauma during the period, only 156 patients were recruited into the study. One hundred and nineteen (119) were males and 37 were females. Majority were blunt injuries while others were penetrating injuries. The blunt injuries were usually solitary, affecting only the liver whereas the penetrating injuries occasionally involved both the liver and some other organ(s). The commonest cause of blunt injuries was road traffic accident followed by fall from height. The commonest cause of penetrating injury was gunshot wound, followed by stab wound.

CONCLUSION

Morbidity and mortality following liver trauma can be reduced by applying prompt and appropriate management modalities within the ambit of available resources. However, outcome will improve if adequate facilities are available.

Management of blunt hepatic trauma

Management of blunt liver trauma has progressed over the last 20 years with the adoption of conservative non-operative management (CM) as the gold standard in 80-90% of patients. Clinical and hemodynamic changes, and CT imaging guide the conservative attitude or pose an indication for urgent surgical intervention in unstable patients. The adoption of CM for blunt liver trauma has resulted in an increased incidence of late complications. These consist principally of persistent hemorrhage, fistulas and bile leaks, the abdominal compartment syndrome, and hepatic necrosis or abscess. These late complications can be managed secondarily by planned interventions via laparotomy or laparoscopy, interventional radiology and/or endoscopic techniques in a non-emergency setting as indicated by circumstances and with the benefit of multidisciplinary consultation. These secondary interventions should not be considered a failure of conservative treatment, but rather as an anticipated eventuality in the management of these patients.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Current management of hepatic trauma

With the shift toward nonoperative management, most hepatic injuries are managed nonoperatively. On the other hand, up to two-thirds of high-grade hepatic injuries require laparotomy; these cases are technically difficult and challenging. Damage-control approaches, understanding of liver anatomy, and advances in technology have dramatically changed the approach to hepatic trauma, with improved outcomes. Anatomic or nonanatomic liver resection is required in 2% to 5% of liver injuries. Mortality with liver injury following resection is 9% with current advances.

Management of bleeding following major trauma: an updated European guideline

INTRODUCTION

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

RESULTS

Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

CONCLUSIONS

This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

[Damage control concept in liver trauma. Package strategies and secondary measures]

Liver injuries may occur alone as well as within the broader context of polytrauma. Immediate surgical intervention is indicated in hemodynamically instable patients with detection of free intra-abdominal fluid as demonstrated by imaging studies. For these patients, a damage control concept has been devised in order to decrease early mortality after trauma. With this strategy complex reconstructive interventions are avoided during the initial phase. Stabilization of the patient by treatment of the lethal triad consisting of hypothermia, coagulopathy and metabolic acidosis is at the core of this therapeutic concept. Should there be a need for reconstructions or other major surgical interventions these will be performed with delay after stabilization of the patient. Packing for the temporary treatment of liver injuries is part of the damage control concept.

Management of resistant cardiac depression after hepatic trauma controlled with a packing procedure

In addition to hemorrhage, which is one of the most well-known factors, there are many other causative factors for serious hypotension after hepatic trauma. In this report, we present patients with persistent cardiac depression after perihepatic packing due to high grade liver injury and report on treatment modalities, including the early second-look procedure. Three patients with isolated hepatic trauma were included. Two of the patients who underwent perihepatic packing were transferred from outside hospitals, and one patient required repacking due to severe hemorrhage. All patients had grade IV injuries due to blunt (n=2) or penetrating injury (n=1). In the intensive care unit, central venous pressure (8, 12, 13 mmHg) and hematocrit (26, 27, 29%) were in the normal range, but blood pressure (40/60, 50/70, 45/75mmHg) was abnormal despite the use of inotropic support. The three patients underwent an unpacking procedure 8, 10, and 14 hours later, respectively. Inotropic support was not required after postoperative hours 3, 5, and 6, respectively. The management of post reperfusion syndrome due to hepatic trauma can be achieved, but close collaboration between the surgeon and anesthesiologist is absolutely necessary. In the case of resistance cardiac depression in patients with packing, second-look procedures should be performed as early as possible.