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Grimsley EA, Lippincott M, Read MD, Lorch S, Farach SM, Kuo PC, Diaz JJ. Cirrhosis Increases the Rate of Failure of Nonoperative Management in Blunt Liver Injuries. Am Surg 2024:31348241241631. [PMID: 38531784 DOI: 10.1177/00031348241241631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
Pre-existing cirrhosis is associated with increased mortality in blunt liver injury. Despite widespread use of nonoperative management (NOM) for blunt liver injury, there is a relative paucity of data regarding how pre-existing cirrhosis impacts the success of NOM. Herein, we perform a retrospective cohort study using ACS TQIP 2017-2020 data to assess the relationship between cirrhosis and failure of NOM for adult patients with blunt liver injury. 37,176 patients were included (342 cirrhosis and 36,834 without cirrhosis). After propensity-score matching, patients with pre-existing cirrhosis had higher rates of failure of NOM (32.2 vs 14.1%, p < 0.01) and in-hospital mortality (36.3 vs 10.8%, p < 0.01) than patients without cirrhosis. Hesitancy to operate on patients with pre-existing cirrhosis and trauma, as well as significant underlying coagulopathy, may explain these findings.
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Affiliation(s)
- Emily A Grimsley
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Michelle Lippincott
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Meagan D Read
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Steven Lorch
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Sandra M Farach
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paul C Kuo
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Jose J Diaz
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA
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Heidorn EF, Xiao G, Sacks D, Moshkovsky F. Resection for Chronic Hepatic Abscess due to Infected Embolization Coils After Liver Injury. Am Surg 2022:31348221091942. [PMID: 35483376 DOI: 10.1177/00031348221091942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Liver injuries after blunt abdominal trauma are very common. Non-operative approaches to management are now the standard of care for many patients with up to and including grade V liver injuries. However, the long-term complications associated with coil embolization can be challenging to manage. We present the case of a 29-year-old male who presented with a chronic liver abscess which contained the coils following embolization of a grade IV liver injury and the subsequent transhepatic embolization of the pseudoaneurysm. In addition, the patient developed a fistula draining the abscess through the previously placed drain site that traversed the diaphragm. A multidisciplinary discussion was held between trauma surgery, hepatobiliary surgery, thoracic surgery, and interventional radiology to discuss the best treatment plan. The patient subsequently underwent liver resection, fistula tract resection, and diaphragm repair. This case presents a definitive management strategy for these complex patients.
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Affiliation(s)
- Elise F Heidorn
- Department of Surgery, Tower Health, 6823Reading Hospital, Reading, PA, USA
| | - Gary Xiao
- Department of Surgery, 419713Tower Health, Reading, PA, USA
| | - David Sacks
- Department of Interventional Radiology, Tower Health, 6823Reading Hospital, Reading, PA, USA
| | - Filip Moshkovsky
- Department of Trauma Surgery, Tower Health, 6823Reading Hospital, Reading, PA, USA
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Oo J, Smith M, Ban EJ, Clements W, Tagkalidis P, Fitzgerald M, Pilgrim CHC. Management of bile leak following blunt liver injury: a proposed guideline. ANZ J Surg 2021; 91:1164-1169. [PMID: 33459492 DOI: 10.1111/ans.16552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/19/2020] [Accepted: 12/19/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bile leak following blunt liver trauma is uncommon. Management is difficult due to complex vasculo-biliary and liver parenchymal injury and lack of consensus on optimal care compared with bile leak following elective hepatectomy especially in regards to endoscopic retrograde pancreaticocholangiography (ERCP) timing and patient selection. METHODS This is a retrospective cohort study from a level 1-trauma centre of patients with bile leak following blunt liver injury between July 2010 and December 2019 identified from the trauma registry. Clinical data retrieved include patient demographics, injury severity score, liver injury grading and its associated complications and treatment. This was supplemented by surgical audit database and patients' electronic medical record. RESULTS There were 31 bile leaks amongst 639 patients with blunt liver trauma (4.9%). Bile leak was associated with higher liver injury grade (odds ratio (OR) 36, P = 0.001), hepatic embolization (OR 16, P = 0.003) and need for trauma laparotomy (OR 14, P = 0.024). ERCP was performed in 58.1% (n = 18). This was complicated in 27.7% (n = 5) by mild pancreatitis (n = 1) and intra-abdominal sepsis (n = 4) requiring surgical drainage of abscess (n = 2) and liver resection (n = 1). Bile leak settled conservatively (including percutaneous drainage) without ERCP in the remaining patients (41.9%). Overall mortality was not increased in those with bile leak (P = 0.998). CONCLUSION Bile leaks resolved conservatively in 41.9% of patients. Complications following ERCP were seen in 27.7%, frequently requiring intervention. Failure of conservative management was more likely in patients with hepatic embolization, in whom early ERCP remains appropriate. ERCP should otherwise be reserved for those who fail conservative management to minimize infective complications.
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Affiliation(s)
- June Oo
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Marty Smith
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Hepatopancreaticobiliary Surgery, Western Hospital, Melbourne, Victoria, Australia
| | - Ee Jun Ban
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Trauma, Alfred Hospital, Melbourne, Victoria, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Victoria, Australia.,Department of Surgery, Monash University Central Clinical School, Melbourne, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Peter Tagkalidis
- Department of Gastroenterology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Department of Trauma, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Charles H C Pilgrim
- Department of Hepatopancreaticobiliary Surgery, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Hepatopancreaticobiliary Surgery, Frankston Hospital, Melbourne, Victoria, Australia
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Parrado R, Notrica DM, Garcia NM, Alder AC, Eubanks JW, Maxson RT, Letton RW, Ponsky TA, St Peter SD, Leys C, Bhatia A, Tuggle DW, Lawson KA, Ostlie DJ. Use of Laparoscopy in Pediatric Blunt and Spleen Injury: An Unexpectedly Common Procedure After Cessation of Bleeding. J Laparoendosc Adv Surg Tech A 2019; 29:1281-1284. [PMID: 31397620 DOI: 10.1089/lap.2019.0160] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Recently, several series have reported the use of laparoscopy in pediatric trauma, most commonly for bowel and pancreatic injury within the first 12 or 24 hours. During a multicenter trial at 10 Level 1 pediatric trauma centers, selective use of laparoscopy in children with blunt liver or spleen injury (BLSI) was noted. A secondary analysis was performed to describe the frequency and application of these procedures to pediatric BLSI. Patients and Methods: Prospective data were collected on all children age ≤18 years with BLSI presenting to 1 of 10 pediatric trauma centers. An unplanned secondary analysis of children who underwent laparoscopy was done. Results: Of 1008 children with BLSI, 59 initially underwent a laparotomy, but 11 underwent a laparoscopic procedure during their index admission; 1 of these was 22 hours postlaparotomy and 2 others were laparoscopy-assisted and converted to laparotomy. Median age of patients undergoing a laparoscopic procedure was 11.5 years (interquartile range [IQR]: 5.8-16.4). Laparoscopy was performed at 7 of the 10 centers. Median time to surgery was 42 hours (IQR: 8-96). Most patients had a liver (n = 6) injury; 4 had spleen and 1 had both. One of the laparoscopies was for pancreatic surgery, and 2 were for bowel injury (but converted to open). Conclusions: Laparoscopy was utilized in 16% of children requiring abdominal surgery after BLSI, with a median time of 42 hours postinjury. Uses included diagnostic laparoscopy, drain placement, laparoscopic pancreatectomy, and washout of hematoma.
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Affiliation(s)
- Raphael Parrado
- Level I Pediatric Trauma Center, Phoenix Children's Hospital, Phoenix, Arizona
| | - David M Notrica
- Level I Pediatric Trauma Center, Phoenix Children's Hospital, Phoenix, Arizona
| | - Nilda M Garcia
- Pediatric Trauma Center, Dell Children's Medical Center, Austin, Texas
| | - Adam C Alder
- Pediatric Surgery Department, Children's Medical Center, Dallas, Texas
| | - James W Eubanks
- Department of Pediatric Surgery, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - R Todd Maxson
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Robert W Letton
- Department of Surgery, The Children's Hospital at OU Medical Center, Oklahoma City, Oklahoma
| | - Todd A Ponsky
- Department of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio
| | - Shawn D St Peter
- Pediatric Surgery, Mercy Children's Hospital, Kansas City, Missouri
| | - Charles Leys
- Pediatric Surgery, American Family Children's Hospital, Madison, Wisconsin
| | - Amina Bhatia
- Department of Pediatric Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - David W Tuggle
- Pediatric Trauma Center, Dell Children's Medical Center, Austin, Texas
| | - Karla A Lawson
- Pediatric Trauma Center, Dell Children's Medical Center, Austin, Texas
| | - Daniel J Ostlie
- Level I Pediatric Trauma Center, Phoenix Children's Hospital, Phoenix, Arizona
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