Surgical management of AAST grades III-V hepatic trauma by Damage control surgery with perihepatic packing and Definitive hepatic repair-single centre experience

Rare Complication of Cardiopulmonary Resuscitation-Liver Injury

Background and Objectives: Liver injury is a rare complication of cardiopulmonary resuscitation. Correct and early diagnosis and treatment are essential. The clinical signs of injury may be masked by the cardiac arrest. We present a single-centre retrospective observational study of traumatic liver injury after cardiopulmonary resuscitation. Materials and Methods: A retrospective analysis of the patients treated for liver injury after cardiopulmonary resuscitation was conducted. Demographic data, the cause of resuscitation, the duration of restoration of spontaneous circulation (ROSC), and the surgical approach were analysed. Results: We have treated nine patients with severe liver injury after cardiopulmonary resuscitation. The diagnosis was made on the basis of cardiopulmonary instability, a fall in the erythrocyte count in eight cases, and was confirmed by CT or ultrasound examination. The last one was diagnosed accidentally on MR. Surgery, in cases of unstable patients, was followed immediately after a diagnosis. We combined liver sutures and intra-abdominal packing with a planned second-look surgery. Five of the nine patients survived. Conclusions: Liver injury after cardiopulmonary resuscitation is rare and is associated with high mortality. The recurrence of cardiopulmonary instability and/or a low or falling red blood cell count are the main signs of this injury. Bedside ultrasound and CT scans are the most important methods to confirm the diagnosis. The rule of surgical repair is the same as in all liver injuries, regardless of aetiology. The key factors for survival include early diagnosis, together with the length of restoration of spontaneous circulation (ROSC).

Dual phenotypic characteristics of P-selectin in a mouse model of hemorrhagic shock and hepatectomy

BACKGROUND

Membrane-bound P-selectin induces endothelial adhesion of leucocytes and amplifies organ inflammations during major trauma, while soluble P-selectin (sP-sel) mediates survival rescue properties. This study characterized the differential effects of P-selectin in a "2-hit" model of hemorrhagic shock (HS) and partial hepatectomy (PH).

MATERIALS AND METHODS

HS was induced by withdrawing blood (0.3 mL) directly from the mouse femoral arteries. 70% or 50% of liver volumes were resected after inducing HS. Time of survival in P-selectin deficient (Selp -/-) mice treated with and without intraperitoneal injections of recombinant P-sel IgG-Fc fusion proteins (rP-sel-Fc, 1.5 mg/kg) were recorded for up to 72h after injury. In addition, liver regeneration at 72h after HS and 50% PH was assessed in wild-type and Selp -/- mice.

RESULTS

Compared to wild-types, Selp -/- mice had significantly higher mortality rates post HS and 70% PH, as none of these animals survived up to 48h postoperatively. The survival curve was restored in Selp -/- mice pre-treated with rP-sel-Fc. In the HS followed by 50% PH experimental arm, liver remnant growth ratios were significantly higher in Selp -/- mice (15.7 ± 3.1 vs 11.7 ± 4.9, P = 0.040). The elevated serum concentrations of alanine aminotransferase post-PH were significantly reduced in Selp -/- mice. Hepatocyte proliferation indices (CYP7a1 and PCNA) expression were enhanced and myeloperoxidase activity in the regenerated remnant liver was reduced in the Selp -/- mice.

CONCLUSION

In critical conditions induced by HS and PH, P-selectin mediates two distinct phenotypic characteristics. Soluble-form circulating P-selectin improves survival in the acute stage of HS and extensive loss of liver parenchyma; membrane-bound P-selectin induces regional pro-inflammatory reactions in the remnant liver after the acute stage of two insults, thereby inhibiting hepatic regeneration. The results of this pre-clinical study may provide molecular mechanistic insight and clinical therapeutic applications of P-selectin in the acute and regenerative phases of traumatic hepatic injury.

Hepatectomy During the Pandemic, a Curative Treatment in High-Grade and/or Hemodynamically Unstable Blunt Liver Trauma

The liver is among the most affected organs in the case of abdominal trauma. In the last decades there have been significant changes in therapeutic protocols, non-operative management is now the first intention in most cases due to good results offered previously. In high-grade or hemodynamically unstable injuries, hepatectomy is the best approach, even though this was viewed with skepticism in the past, technical advances in medicine have proven otherwise. This article presents a case report of a 29-year-old man with blunt abdominal trauma, who initially underwent conservative atypical right hepatectomy without a favourable outcome, later he was transferred to a liver transplant center where he underwent a controlled right hepatectomy, all this in a new epidemiological context, the COVID-19 Pandemic. We want to present the hypothesis that in making a therapeutic decision, the hemodynamic status of the patient must be considered equally along with the injury degree. This case represents an opportunity to review the role of liver resection in the management of complex liver injuries.

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

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

“Zooming” in strategies and outcomes for trauma cases with Injury Severity Score (ISS) ≥16: promise or passé?

OBJECTIVE:

Rescuing severe trauma cases is extremely demanding. The present study purposed to analyze the efficiency of trauma management at Emergency Centre, University Clinical Centre of Serbia, Belgrade, included outcome within 28 days.

METHODS:

This retrospective study involved 131 intensive care unit trauma cases with total Injury Severity Score ≥16, in terms of administrating the two strategies: (i) definitive surgical repair and (ii) damage control laparotomy.

RESULTS:

The damage control laparotomy cases revealed statistically higher Injury Severity Score and APACHE II scores, significant brain dysfunction, and hemorrhagic shock on arrival (p<0.001). In addition, the damage control laparotomy had a higher rate of respiratory complications, multiple organ deficiency syndrome, and surgical wound complications (p=0.017, <0.001, and 0.004, respectively), with more days on mechanical ventilation (p=0.003). Overall mortality was 29.8%. Although higher early mortality within ≤24 h in the damage control laparotomy (p=0.021) had been observed, no difference between groups (p=0.172) after the 4th day of hospitalization was detected.

CONCLUSIONS:

Trauma patients have a high mortality rate in the 1st hours after the incident. Compelling evidence linking host and pathogen factors, such as mitochondrial apoptosis pathways, appears to correlate with loss of organ dysfunction, both cytopathologically and histopathologically. Adequate selection of patients necessitating damage control laparotomy, allowed by the World Society of Emergency Surgery, abdominopelvic trauma classifications, and improvements in resuscitation, may improve the results of severe trauma treatment.

A deep learning framework for automated detection and quantitative assessment of liver trauma

Background

Both early detection and severity assessment of liver trauma are critical for optimal triage and management of trauma patients. Current trauma protocols utilize computed tomography (CT) assessment of injuries in a subjective and qualitative (v.s. quantitative) fashion, shortcomings which could both be addressed by automated computer-aided systems that are capable of generating real-time reproducible and quantitative information. This study outlines an end-to-end pipeline to calculate the percentage of the liver parenchyma disrupted by trauma, an important component of the American Association for the Surgery of Trauma (AAST) liver injury scale, the primary tool to assess liver trauma severity at CT.

Methods

This framework comprises deep convolutional neural networks that first generate initial masks of both liver parenchyma (including normal and affected liver) and regions affected by trauma using three dimensional contrast-enhanced CT scans. Next, during the post-processing step, human domain knowledge about the location and intensity distribution of liver trauma is integrated into the model to avoid false positive regions. After generating the liver parenchyma and trauma masks, the corresponding volumes are calculated. Liver parenchymal disruption is then computed as the volume of the liver parenchyma that is disrupted by trauma.

Results

The proposed model was trained and validated on an internal dataset from the University of Michigan Health System (UMHS) including 77 CT scans (34 with and 43 without liver parenchymal trauma). The Dice/recall/precision coefficients of the proposed segmentation models are 96.13/96.00/96.35% and 51.21/53.20/56.76%, respectively, in segmenting liver parenchyma and liver trauma regions. In volume-based severity analysis, the proposed model yields a linear regression relation of 0.95 in estimating the percentage of liver parenchyma disrupted by trauma. The model shows an accurate performance in avoiding false positives for patients without any liver parenchymal trauma. These results indicate that the model is generalizable on patients with pre-existing liver conditions, including fatty livers and congestive hepatopathy.

Conclusion

The proposed algorithms are able to accurately segment the liver and the regions affected by trauma. This pipeline demonstrates an accurate performance in estimating the percentage of liver parenchyma that is affected by trauma. Such a system can aid critical care medical personnel by providing a reproducible quantitative assessment of liver trauma as an alternative to the sometimes subjective AAST grading system that is used currently.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12880-022-00759-9.

Improvement of mortality in severe liver injury after trauma center implementation: a propensity score matched study

PURPOSE

To evaluate changes in the management and outcome of severe liver injury after trauma center implementation.

METHODS

Trauma patients with severe liver injury (organ injury scale score ≥ 4) treated between January 2011 and December 2020 were retrospectively reviewed. A trauma center was built in 2016 at our institution, and patients were dichotomized into two groups: before trauma center (BTC) and after trauma center (ATC) group. Treatment methods and outcomes were compared between the groups with 1:1 propensity score matching.

RESULTS

We included 50 patients in the BTC group and 104 patients in the ATC group. Patients in the ATC group had frequent utilization of angiography (16% vs 47.1%, p < 0.001), faster transfusion [84 (37-152) min vs 17 (10-79) min, p < 0.001], and less fluid administration within 24 h [8.3 (5.7-13.7) L vs 5.7 (3.1-10.1) L, p = 0.002]. However, mortality rate was not significantly different between the groups (26.0% vs 20.2%, p = 0.416). 1:1 propensity score matching was performed using the variables of age, injury severity score, systolic blood pressure, Glasgow Coma Scale, and initial base excess level. After matching, the mortality rate (26.0% vs 10.0%, p = 0.037) and ventilator application (74.0% vs 54.0%, p = 0.037) significantly improved.

CONCLUSION

Severe liver injury management improved after trauma center implementation.

Hepatectomy as a Salvage procedure for blunt abdominal trauma:A case report

The liver is the organ most commonly injured in blunt abdominal trauma. Significant changes in the management of liver trauma have occurred over the last four decades with non-operative management being the first-line of treatment. Although hepatic resection for trauma is an accepted and established option for definitive treatment, it is rarely performed because of the associated morbidity and mortality, at least historically. Herein we describe a case of a 24-year old male who had blunt abdominal injury for which a right hepatectomy was eventually performed after an initial attempt at damage control surgery. We would like to highlight that early decision by a dedicated team of surgeons coupled with the necessary support from ancillary services as well as coordination between trauma surgeons led to a successful outcome in this case. This case presents an opportunity to revisit the role of hepatic resection in the management of complex liver injuries.

•

Liver is a frequently injured organ in blunt or penetrating injury.

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Non-operative management can be successful in majority of cases.

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Nonanatomic or anatomic hepatic resection can be a treatment option in select cases.

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Timely decision is paramount in the success of operative management for blunt trauma.

[Damage control strategy in surgical treatment of patients with severe gastroduodenal bleeding]

OBJECTIVE/

To objectify patient condition and improve treatment outcomes in patients with benign severe gastroduodenal bleeding.

MATERIAL AND METHODS

We analyzed the immediate results of staged surgical treatment of patients with benign severe gastroduodenal bleeding according to the accepted concept of «Damage Control Surgery». The Rockall risk scoring system and the Glasgow-Blatchford score (GBS) were used. We preferred two-stage intervention in patients with Rockall score ≥5 and Glasgow-Blatchford score ≥11.

RESULTS

Staged approach according to the concept of «Damage Control Surgery» in patients with benign severe gastroduodenal bleeding ensures positive results by minimizing surgical trauma and perioperative bleeding, early stabilization of hemostasis and subsequent successful restoration of digestive function.

CONCLUSION

The concept of «Damage Control Surgery» in patients with benign severe gastroduodenal bleeding can reduce mortality and incidence of postoperative complications.

Depacked patients who underwent a shortened perihepatic packing for severe blunt liver trauma have a high survival rate: 20 years of experience in a level I trauma center

INTRODUCTION

Non-operative management is currently the preferred approach in blunt liver trauma, including high grade liver lesions. However, hemodynamic instability imposes the need for an emergency laparotomy, with a perihepatic packing (PHP) to control liver bleeding in most cases. Our retrospective study aimed to assess the outcomes of liver trauma patients who underwent a shortened PHP.

METHODS

All consecutive patients who underwent PHP for blunt liver trauma from 1998 to 2019 in our Level I trauma center were included in the study. Unstable patients with severe liver trauma were transferred to the operating room without any delay, and a collective decision was made to perform abbreviated laparotomy to pack the liver. Demographics, perioperative data, postoperative outcomes, and mortality were retrospectively collected, and survivors and deceased patients were compared with a paired t-test.

RESULTS

Fifty-nine patients of 206 patients admitted with severe liver injuries were treated with shortened PHP. Thirty-four (57.6%) patients died, including 26 (76.5%) within the first 24 h. Twelve (20.3%) patients had a selective hepatic embolization and eight (13.6%) had an extrahepatic embolization. Forty-eight patients had an extra abdominal associated injury. This was not a predictive factor of mortality. The removal of packing was performed in 24 patients within 72 h after laparotomy, with an 80% survival rate in these patients.

CONCLUSION

Shortened PHP is an effective strategy for controlling liver bleeding in severe hepatic trauma. The mortality rate of these patients is high, but after the removal of packing, the survival is good.

Application of Damage Control Tactics and Transpapillary Biliary Decompression for Organ-Preserving Surgical Management of Liver Injury in Combat Patient

The combat penetrating gunshot injury is frequently associated with damage to the liver. Bile leak and external biliary fistula (EBF) are common complications. Biliary decompression is commonly applied for the management of EBF. Also, little is known about the features of combat trauma and its management in ongoing hybrid warfare in East Ukraine. A 23-year-old male was diagnosed with thoracoabdominal penetrating gunshot wound (GSW) by a high-energy multiple metal projectile. Damage control tactics were applied at all four levels of military medical care. Biliary decompression was achieved by endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and the placement of biliary stents. Occlusion of the stent was treated by stent replacement, and scheduled ERCP was performed. Partial EBF was diagnosed from the main wound defect of the liver and closed without surgical interventions on the 34th day after the injury. A combination of operative and nonoperative techniques for the management of the combat GSW to the liver is effective along with the application of damage control tactics. A scheduled ERCP application is an effective approach for the management of EBF, and liver resection could be avoided. A successful biliary decompression was achieved by the transpapillary intervention with the installation of stents. Stent occlusion could be diagnosed in the early post-traumatic period, which is effectively managed by scheduled ERCP as well as stent replacement with a large diameter as close as possible to the place of bile leak.

Surgical treatment in hepatic trauma: factors associated with hospitalization time

OBJECTIVE

the aim of this study was to identify associated factors with the increased length of hospital stay for patients undergoing surgical treatment for liver trauma, and predictors of mortality as well as the epidemiology of this trauma.

METHODS

retrospective study of 191 patients admitted to the Cajuru University Hospital, a reference in the treatment of multiple trauma patients, between 2010 and 2017, with epidemiological, clinicopathological and therapeutic variables analyzed using the STATA version 15.0 program.

RESULTS

most of the included patients were men with a mean age of 29 years. Firearm injury represents the most common trauma mechanism. The right hepatic lobe was injured in 51.2% of the cases, and hepatorraphy was the most commonly used surgical correction. The length of hospital stay was an average of 11 (0-78) days and the length of stay in the intensive care unit was 5 (0-52) days. Predictors for longer hospital stay were the mechanisms of trauma, hemodynamic instability at admission, number of associated injuries, degree of liver damage and affected lobe, used surgical technique, presence of complications, need for reoperation and other surgical procedures. Mortality rate was 22.7%.

CONCLUSIONS

the study corroborated the epidemiology reported by the literature. Greater severity of liver trauma and associated injuries characterize patients undergoing surgical treatment, who have increased hospital stay due to the penetrating trauma, hemodynamic instability, hepatic packaging, complications and reoperations.

Blunt injury of liver: mechanical response of porcine liver in experimental impact test

OBJECTIVE

The liver is frequently injured in blunt abdominal trauma caused by road traffic accidents. The testing of safety performance of vehicles, e.g. belt usage, head support, seat shape, or air bag shape, material, pressure and reaction, could lead to reduction of the injury seriousness. Current trends in safety testing include development of accurate computational human body models (HBMs) based on the anatomical, morphological, and mechanical behavior of tissues under high strain.

APPROACH

The aim of this study was to describe the internal pressure changes within porcine liver, the severity of liver injury and the relation between the porcine liver microstructure and rupture propagation in an experimental impact test. Porcine liver specimens (n = 24) were uniformly compressed using a drop tower technique and four impact heights (200, 300, 400 and 500 mm; corresponding velocities: 1.72, 2.17, 2.54 and 2.88 m s^-1). The changes in intravascular pressure were measured via catheters placed in portal vein and caudate vena cava. The induced injuries were analyzed on the macroscopic level according to AAST grade and AIS severity. Rupture propagation with respect to liver microstructure was analyzed using stereological methods.

MAIN RESULTS

Macroscopic ruptures affected mostly the interface between connective tissue surrounding big vessels and liver parenchyma. Histological analysis revealed that the ruptures avoided reticular fibers and interlobular septa made of connective tissue on the microscopic level.

SIGNIFICANCE

The present findings can be used for evaluation of HBMs of liver behavior in impact situations.

Early re-laparotomy for patients with high-grade liver injury after damage-control surgery and perihepatic packing

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.

Liver trauma: hepatic vascular injury on computed tomography as a predictor of patient outcome

OBJECTIVES

To evaluate hepatic vascular injury (HVI) on CT in blunt and penetrating trauma and assess its relationship to patient management and outcome.

METHOD AND MATERIALS

This retrospective study was IRB approved and HIPAA compliant. Informed consent was waived. Included were patients ≥ 16 years old who sustained blunt or penetrating trauma with liver laceration seen on a CT performed at our institution within 24 h of presentation over the course of 10 years and 6 months (August 2007-February 2018). During this interval, 171 patients met inclusion criteria (123 males, 48 females; mean age 34; age range 17-80 years old). Presence of HVI was evaluated and liver injury was graded in a blinded fashion by two radiologists using the 1994 and 2018 American Association for the Surgery of Trauma (AAST) liver injury scales. Hospital length of stay and treatment (angioembolization or operative) were recorded from the electronic medical record. Multivariate linear regressions were used to determine our variables' impact on the length of stay, and logistic regressions were used for categorical outcomes.

RESULTS

Of the included liver trauma patients, 25% had HVI. Patients with HVI had a 3.2-day longer length of hospital stay on average and had a 40.3-fold greater odds of getting angioembolization compared to those without. Patients with high-grade liver injury (AAST grades IV-V, 2018 criteria) had a 3.2-fold greater odds of failing non-operative management and a 14.3-fold greater odds of angioembolization compared to those without.

CONCLUSION

HVI in liver trauma is common and is predictive of patient outcome and management.

KEY POINTS

• Hepatic vascular injury occurs commonly (25%) with liver trauma. • Hepatic vascular injury is associated with increased length of hospital stay and angioembolization. • High-grade liver injury is associated with failure of non-operative management and with angioembolization.

Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays?

Purpose of Review

The purpose of this review is to briefly outline the current state of hemorrhage control and resuscitation in trauma patients with a specific focus on the role viscoelastic assays have in this complex management, to include indications for use across all phases of care in the injured patient.

Recent Findings

Viscoelastic assay use to guide blood-product resuscitation in bleeding trauma patients can reduce mortality by up to 50%. Viscoelastic assays also reduce total blood products transfused, reduce ICU length of stay, and reduce costs. There are a large number of observational and retrospective studies evaluating viscoelastic assay use in the initial trauma resuscitation, but only one randomized control trial. There is a paucity of data evaluating use of viscoelastic assays in the operating room, post-operatively, and during ICU management in trauma patients, rendering their use in these settings extrapolative/speculative based on theory and data from other surgical disciplines and settings.

Summary

Both hypocoagulable and hypercoagulable states exist in trauma patients, and better indicate what therapy may be most appropriate. Further study is needed, particularly in the operating room and post-operative/ICU settings in trauma patients.

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.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Nonoperative management of blunt liver injury in hemodynamically stable versus unstable patients: a retrospective study

PURPOSE

The success rate of nonoperative management (NOM) of traumatic liver injury is approximately 90%. Although NOM has become the standard treatment when patients' vital signs are stable, open surgical hemostasis is often selected when these signs are unstable. At our hospital, we extensively use NOM along with transcatheter arterial embolization (TAE) to treat patients with severe abdominal trauma, as per our original protocol. We also apply NOM for severe liver injury with unstable hemodynamics. This retrospective study aimed to investigate the efficacy of NOM for blunt liver injury in hemodynamically stable and unstable patients.

METHODS

We retrospectively examined 23 patients with severe liver injuries who underwent NOM after visiting our emergency outpatient department between 2007 and 2017. Patients were assigned to either the stable group with stable hemodynamics or the unstable group with unstable hemodynamics.

RESULTS

The stable group comprised 13 patients, and the unstable group comprised 10 patients. All patients underwent TAE. While all patients in the stable group were discharged alive, one patient in the unstable group died during the hospital stay. The response rate to NOM was 90%, and no patient switched from NOM to open surgery. A higher rate of complications with a significantly longer average stay in the intensive care unit was observed in the unstable group.

CONCLUSIONS

Even in the unstable group, NOM with TAE performed under careful general management facilitated avoidance of open surgery and provided high survival rates.

[Approach to liver, spleen and pancreatic injuries including damage control surgery of terrorist attacks]

BACKGROUND

Terrorist attacks have outreached to Europe with more and more attacks on civilians. Derived from war surgery experience and from lessons learned from major incidents, it seems mandatory for every surgeon to improve understanding of the special circumstances of trauma following a terrorist attack and its' management.

METHOD

A short literature review is followed by outlining the damage control surgery (DCS) principle for each organ system with practical comments from the perspective of a specialized hepatobiliary (HPB) surgery unit.

CONCLUSION

Every surgeon has to become familiar with the new entities of blast injuries and terrorist attack trauma. This concerns not only the medical treatment but also tailoring surgical treatment with a view to a lack of critical resources under these circumstances. For liver and pancreatic trauma, simple treatment strategies are a key to success.

“Beyond saving lives”: Current perspectives of interventional radiology in trauma

Interventional radiology (IR) has become an integral part in the management of traumatic injuries. There is an ever-increasing role of IR in traumatic injuries of solid abdominal organs, pelvic and peripheral arteries to control active bleeding by therapeutic embolization or vascular reconstruction using stent grafts. Traditionally, these endovascular treatments have been offered to hemodynamically stable patients. However, in recent times endovascular approach has become preferable to surgery even in hemodynamically unstable patients with injury of surgically difficult-to-access sites. With shifting trends towards non operative management coupled with availability of the current state-of-the-art equipments, hardware and technical expertise, IR has gained an impeccable role in trauma management. However, due to lack of awareness and widespread acceptance, IR continues to remain an ocean of unexplored potentialities.

Treatment strategy for hepatic trauma

Liver is one of the organs with the highest injury rate, and in recent decades, the guidelines for the treatment of liver trauma have changed considerably. Now, there is a growing consensus that the most important step is diagnosis and depending upon the degree of severity, non-operative therapy is the main treatment method for hepatic trauma if conditions permit. For serious hepatic trauma patients such as those with hemodynamic instability, they should be operated upon as soon as possible. Regardless of the surgical options, doctors should control damage to patients and try to prevent complications. New therapies such as hepatic artery embolization and liver transplantation have been more and more used for the treatment of serious hepatic damage in clinics.

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

BACKGROUND

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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