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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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Trintinalha PDEO, Cirino ERI, Marcante RFR, Jabur GR, Buso PL. Surgical treatment in hepatic trauma: factors associated with hospitalization time. Rev Col Bras Cir 2021; 48:e20202784. [PMID: 33787764 PMCID: PMC10683465 DOI: 10.1590/0100-6991e-20202874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/14/2020] [Indexed: 11/22/2022] Open
Abstract
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.
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3
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Ordoñez CA, Parra MW, Millán M, Caicedo Y, Guzmán-Rodríguez M, Padilla N, Salamea-Molina JC, García A, González-Hadad A, Pino LF, Herrera MA, Rodríguez-Holguín F, Serna JJ, Salcedo A, Aristizábal G, Orlas C, Ferrada R, Scalea T, Ivatury R. Damage Control in Penetrating Liver Trauma: Fear of the Unknown. COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e4134365. [PMID: 33795903 PMCID: PMC7968427 DOI: 10.25100/cm.v51i4.4422.4365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Juan Carlos Salamea-Molina
- Hospital Vicente Corral Moscoso, Division of Trauma and Acute Care Surgery, Cuenca, Ecuador.,Universidad del Azuay, Escuela de Medicina, Cuenca, Ecuador
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Gonzalo Aristizábal
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Claudia Orlas
- Brigham & Women's Hospital, Department of Surgery, Center for Surgery and Public Health, Boston, USA.,Harvard Medical School & Harvard T.H., Chan School of Public Health, Boston, USA
| | - Ricardo Ferrada
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Thomas Scalea
- University of Maryland, School of Medicine, Department of Surgery, Baltimore, MD USA
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
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Schembari E, Sofia M, Latteri S, Pesce A, Palumbo V, Mannino M, Russello D, La Greca G. Blunt liver trauma: effectiveness and evolution of non-operative management (NOM) in 145 consecutive cases. Updates Surg 2020; 72:1065-1071. [PMID: 32851597 DOI: 10.1007/s13304-020-00861-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors' approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10 years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10 years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10 years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.
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Affiliation(s)
- Elena Schembari
- General Surgery, Barts Health NHS Trust, Whipps Cross Hospital, London, UK.
| | - Maria Sofia
- General Surgery, Cannizzaro Hospital, Catania, Italy
| | - Saverio Latteri
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Antonio Pesce
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Valentina Palumbo
- General Surgery, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Maurizio Mannino
- General Surgery, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Domenico Russello
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gaetano La Greca
- Department of Surgical Sciences and Advanced Technologies "G. F. Ingrassia", Cannizzaro Hospital, University of Catania, Catania, Italy
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Management of liver trauma in urban university hospitals in India: an observational multicentre cohort study. World J Emerg Surg 2020; 15:58. [PMID: 33059728 PMCID: PMC7560107 DOI: 10.1186/s13017-020-00338-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low- and middle-income countries (LMICs) contribute to 90% of injuries occurring in the world. The liver is one of the commonest organs injured in abdominal trauma. This study aims to highlight the demographic and management profile of liver injury patients, presenting to four urban Indian university hospitals in India. METHODS This is a retrospective registry-based study. Data of patients with liver injury either isolated or concomitant with other injuries was used using the ICD-10 code S36.1 for liver injury. The severity of injury was graded based on the World Society of Emergency Surgery (WSES) grading for liver injuries. RESULTS A total of 368 liver injury patients were analysed. Eighty-nine percent were males, with road traffic injuries being the commonest mechanism. As per WSES liver injury grade, there were 127 (34.5%) grade I, 96 (26.1%) grade II, 70 (19.0%) grade III and 66 (17.9%) grade IV injuries. The overall mortality was 16.6%. Two hundred sixty-two patients (71.2%) were managed non-operatively (NOM), and 106 (38.8%) were operated. 90.1% of those managed non-operatively survived. CONCLUSION In this multicentre cohort of liver injury patients from urban university hospitals in India, the commonest profile of patient was a young male, with a blunt injury to the abdomen due to a road traffic accident. Success rate of non-operative management of liver injury is comparable to other countries.
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Simon G, Heckmann V, Tóth D, Pauka D, Petrus K, Molnár TF. The effect of hepatic steatosis and fibrosis on liver weight and dimensions. Leg Med (Tokyo) 2020; 47:101781. [PMID: 32889367 DOI: 10.1016/j.legalmed.2020.101781] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/23/2020] [Indexed: 12/23/2022]
Abstract
The liver is the most commonly injured abdominal organ, accounting for around half of abdominal organ injuries. The emergence of liver injury is determined by the injury mechanism, force, and tissue vulnerability. The vulnerability of the liver depends on the strength of the capsule and parenchyma, as well as the weight and dimensions of the liver. The common hepatic diseases, like steatosis, fibrosis, and cirrhosis, can change the organ weight and dimensions, but their exact correlation is not well known. This study was designed to evaluate the correlation between liver diseases, weight, and dimensions. The liver weight, horizontal, vertical, and antero-posterior length were measured obtained by 213 forensic autopsies. The recorded data were compared with body height, age, and liver histology. Body height positively correlated with liver weight (R2 = 0.252), but the correlation was much stronger in the case of livers without structural disease (R2 = 0.450). The liver size seems to significantly decrease with age (R2 = 0.081), but the effect is mostly due to structural alterations that are proven by histology. The comparison of the liver weight in various histological groups clearly indicated that steatosis increases the liver size, but fibrosis does not (if no steatosis is present at the same time). In general, liver dimensions increase proportionally to the liver weight. However, hepatic steatosis causes disproportional enlargement: it does not have a significant effect on the horizontal dimension and has only a minor effect on the vertical dimension. Steatosis affects disproportionally the dimensions with a strange tendency to expand liver anteroposteriorly.
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Affiliation(s)
- Gábor Simon
- Department of Forensic Medicine, Medical School, University of Pécs, Pécs, Hungary.
| | - Veronika Heckmann
- Department of Forensic Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dénes Tóth
- Department of Forensic Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dénes Pauka
- Department of Forensic Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Karola Petrus
- Department of Forensic Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Tamás F Molnár
- Department of Operational Medicine, Medical Humanities Unit, Medical School, University of Pécs, Pécs, Hungary; Department Surgery, St Sebastian Thoracic Surgery Unit, Petz A University Teaching Hospital, Győr, Hungary
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Tarchouli M, Elabsi M, Njoumi N, Essarghini M, Echarrab M, Chkoff MR. Liver trauma: What current management? Hepatobiliary Pancreat Dis Int 2018; 17:39-44. [PMID: 29428102 DOI: 10.1016/j.hbpd.2018.01.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 11/02/2017] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Mohamed Tarchouli
- Department of Digestive Surgery, Mohammed V Military Hospital, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fes, Morocco.
| | - Mohamed Elabsi
- Department of Visceral Surgical Emergency, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Noureddine Njoumi
- Department of Digestive Surgery, Mohammed V Military Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Mohamed Essarghini
- Department of Digestive Surgery, Mohammed V Military Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Mahjoub Echarrab
- Department of Visceral Surgical Emergency, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Mohamed Rachid Chkoff
- Department of Visceral Surgical Emergency, Ibn Sina Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
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Kalil M, Amaral IMA. Epidemiological evaluation of hepatic trauma victims undergoing surgery. Rev Col Bras Cir 2017; 43:22-7. [PMID: 27096853 DOI: 10.1590/0100-69912016001006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 11/30/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to evaluate the epidemiological variables and diagnostic and therapeutic modalities related to hepatic trauma patients undergoing laparotomy in a public referral hospital in the metropolitan region of Vitória-ES. METHODS we conducted a retrospective study, reviewing charts of trauma patients with liver injuries, whether isolated or in association with other organs, who underwent exploratory laparotomy, from January 2011 to December 2013. RESULTS We studied 392 patients, 107 of these with liver injury. The male: female ratio was 6.6 : 1 and the mean age was 30.12 years. Penetrating liver trauma occurred in 78.5% of patients, mostly with firearms. Associated injuries occurred in 86% of cases and intra-abdominal injuries were more common in penetrating trauma (p <0.01). The most commonly used operative technique was hepatorrhaphy and damage control surgery was applied in 6.5% of patients. The average amounts of blood products used were 6.07 units of packed red blood cells and 3.01 units of fresh frozen plasma. The incidence of postoperative complications was 29.9%, the most frequent being infectious, including pneumonia, peritonitis and intra-abdominal abscess. The survival rate of patients suffering from blunt trauma was 60%, and penetrating trauma, 87.5% (p <0.05). CONCLUSION despite technological advances in diagnosis and treatment, mortality rates in liver trauma remain high, especially in patients suffering from blunt trauma in relation to penetrating one.
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Affiliation(s)
- Mitre Kalil
- Departamento de Clínica Cirúrgica, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória, Brasil
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El-Menyar A, Abdelrahman H, Al-Hassani A, Peralta R, AbdelAziz H, Latifi R, Al-Thani H. Single Versus Multiple Solid Organ Injuries Following Blunt Abdominal Trauma. World J Surg 2017; 41:2689-2696. [DOI: 10.1007/s00268-017-4087-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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10
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Noyola-Villalobos HF, Loera-Torres MA, Jiménez-Chavarría E, Núñez-Cantú O, García-Núñez LM, Arcaute-Velázquez FF. [Non-surgical management after blunt traumatic liver injuries: A review article]. CIR CIR 2016; 84:263-6. [PMID: 27036671 DOI: 10.1016/j.circir.2016.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 12/26/2015] [Indexed: 11/28/2022]
Abstract
Hepatic trauma is a common cause for admissions in the Emergency Room. Currently, non-surgical management is the standard treatment in haemodynamically stable patients with a success rate of around 85 to 98%. This haemodynamic stability is the most important factor in selecting the appropriate patient. Adjuncts in non-surgical management are angioembolisation, image-guided drainage and endoscopic retrograde cholangiopancreatography. Failure in non-surgical management is relatively rare but potentially fatal, and needs to be recognised and aggressively treated as early as possible. The main cause of failure in non-surgical management is persistent haemorrhage. The aim of this paper is to describe current evidence and guidelines that support non-surgical management of liver injuries in blunt trauma.
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Affiliation(s)
| | - Marco Antonio Loera-Torres
- Departamento de Cirugía Hepato-Bilio-Pancreática y Trasplante, Hospital Central Militar, Secretaría de la Defensa Nacional México, Ciudad de México, México
| | - Enrique Jiménez-Chavarría
- Departamento de Cirugía Hepato-Bilio-Pancreática y Trasplante, Hospital Central Militar, Secretaría de la Defensa Nacional México, Ciudad de México, México
| | - Olliver Núñez-Cantú
- Sub-sección de Cirugía del Trauma, Hospital Central Militar, Secretaría de la Defensa Nacional México, Ciudad de México, México
| | - Luis Manuel García-Núñez
- Departamento de Urgencias, Hospital Central Militar, Secretaría de la Defensa Nacional México, Ciudad de México, México
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12
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Affiliation(s)
- A N Smolyar
- N.V. Sklifosovsky Research Institute of Emergency Care, Department of Health, Moscow
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13
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Pereira BM. Management of liver injuries: can we really predict the need of operation and damage control surgery? Injury 2014; 45:2112-3. [PMID: 24842768 DOI: 10.1016/j.injury.2014.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 04/06/2014] [Indexed: 02/02/2023]
Affiliation(s)
- B M Pereira
- University of Campinas, Department of Surgery, Division of Trauma, Campinas, Brazil.
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