Blunt Liver Trauma Research Articles

Isolated blunt liver trauma: Is nonoperative treatment justified?

During the past 8 years 13 children with isolated blunt liver trauma were managed nonoperatively. All patients selected for this management were hemodynamically stable after initial resuscitation and were without signs of other associated intraabdominal injuries on ultrasonogram and/or computed tomography. Patients were observed in an intensive care unit for at least 48 hours with repeated clinical assessments, laboratory studies, and bed rest. One patient with type 3 injury was operated on 8 days after injury because of sudden intraperitoneal bleeding on ambulation. Five patients required blood transfusions of not more than 300 mL per patient. Laboratory values returned to normal from 7 to 21 days after injury. Resolution of hepatic injury on ultrasonogram took from 1 to 3 months. Complete bed rest was prescribed for at least 10 days depending on the type of injury, with restricted activities up to 3 months postinjury. No complications were seen in this series.

INDICATION OF OPERATIVE TREATMENT FOR BLUNT LIVER INJURY

We reviewed the indication for surgery in patients with blunt liver trauma. Patients were divided into two groups: Group A, in which emergent surgery was performed and Group B, in which initial therapy was conservative. In Group A, the blood pressure upon arrival at our hospital was 90±29 mmHg (mean±S. D.), versus 117±21 mmHg in Group B. The blood pressure after rapid fluid infusion was 98±22 mmHg in Group A and 117±15 mmHg in Group B. Peritoneal signs were elicited in 61% of patients in Group A and 15% of those in Group B. This difference was significant. Free fluid within the peritoneal cavity was observed ultrasonography in all patients in Group A in whom the examination was performed, but in only 15% of patients in Group B. Ultrasonographic signs of intrahepatic hematoma and hepatic rupture were found in 25% and 19% in Group A and 32% and 5% of patients in Group B, respectively. As to multiple trauma, there was no significant difference in the incidence of associated rib fracture, pulmonary contusion, or hemo/pneumothorax between both groups. A predominant concomitant injury to the spleen or pancreas was observed in group A compared to the other. Patients with blunt trauma may have concomitant intra-abdominal injury even when the degree of liver injury is not severe. Patients with hypotension unresponsive to fluid challenge, peritoneal signs, and a large, or expanding, intra-abdominal fluid collection may require laparotomy to control bleeding.

Death following non-operative management of blunt liver trauma

Death following non-operative management of blunt liver trauma

Blunt liver trauma in children

From 1978 to 1988 228 children under 13 years of age with liver injury following blunt abdominal trauma were studied prospectively. Motor vehicle related accidents were responsible for 85 per cent of the injuries. Isotope liver scan established the diagnosis and identified the pattern of injury. Multiple injuries were seen in 157 patients — predominantly head injuries. The liver was the only intra-abdominal organ injured in 119 patients. There were 69 associated splenic, 33 renal, 21 pancreatic and 3 bowel injuries. There were two deaths (0.88 per cent). Management was non-operative in 215 patients, with resolution of the liver injury in 214. Blood was transfused in 92 patients (40 per cent) (mean volume 20 ml/kg). There were 10 complications; two liver abscesses responded to antibiotics. Follow-up showed complete resolution of the liver injuries. Eight underwent laparotomy because of instability, deterioration or other extrahepatic visceral injuries. All required blood transfusion (mean volume 30 ml/kg). There were eight complications following surgery.

Pediatric blunt liver injury: Establishment of criteria for appropriate management

There is no consensus regarding the most appropriate management of pediatric blunt liver injury. This study addresses this issue by reviewing our experience with blunt liver trauma in relationship to the grade of injury. Forty-one pediatric patients with blunt abdominal trauma and documented liver injury were managed from 1979 to 1989. Fifteen (37%) underwent celiotomy. Three children had extensive parenchymal injuries (grade IV or V) requiring resection and three others died intraoperatively, secondary to exsanguinating hemorrhage of associated injuries (grade V) to the hepatic veins and inferior vena cava. The need for celiotomy was obvious in these patients. In 9 of the 15 children who underwent exploration (60%), bleeding from the liver injury (grade II or III) had ceased by the time of celiotomy. These children did not appear to benefit from the operation. Twenty-six of the 41 patients (63%) were selected for nonoperative management because they were hemodynamically stable after initial resuscitation and did not show signs of associated intraabdominal injuries requiring surgical intervention. These children underwent evaluation by abdominal computed axial tomography scan (grade I, II, III, and IV injuries). Blood transfusions were given to keep the hematocrit above 30%. Seventeen of the 26 children managed nonoperatively (65%) did not require blood replacement. The mean (±SEM) transfusion volume for the remaining nine children was 14.8 ± 2.5 mL/kg. Blunt liver injury represents a spectrum from a minimal parenchymal hematoma to massive liver disruption. We conclude that celiotomy is necessary for hepatic injury when it is associated with continued massive bleeding. Hemodynamically stable injured children with transfusion requirements less than 40 mL/kg can be managed nonoperatively in an appropriate setting.

Blunt Liver Trauma at SunnybrookMedical Centre: A 13 Year Experience

Between June 1, 1976 and June 30, 1989 The Regional Trauma Unit at Sunnybrook Medical Centre in Toronto, Ontario, Canada received 3730 patients. Of these 335 (9%) sustained a liver injury, 95% being due to blunt trauma. Open peritoneal lavage was performed on 80% of liver trauma patients (267/335), 99% being true positive. A laparotomy was performed on 97% of patients (324/335). Major surgical treatment was required in 132 patients (41%) and minor treatment in 192 patients (59%). The remaining 11 patients were treated conservatively (n = 3) or died during resuscitation (n = 8). Morbidity directly related to the liver injury was seen in 29 of 249 surviving patients (11%) although overall morbidity was 27% (67/249). Reoperation was required in 6% (14/249) with abscess or hematoma accounting for 11 of 14 operations. The overall mortality rate was 26% (86/335). Eighty two percent of patients (n = 276) had a grade I, II or III liver trauma according to Moore’s classification with a mortality of 12% (n = 32). The remaining 18% of patients (n = 59) had a grade IV or V liver trauma with a mortality of 44% (n = 26). Of the 86 deaths, head injury accounted for 48 (56% of deaths); liver hemorrhage for 17 (20%), liver sepsis for (1%) and other causes for 20 deaths (23%). Thus death due to the liver injury itself (hemorrhage and sepsis) occurred in 18 out of 335 patients (5% overall). Head injury accounted for the death of 48 out of 335 patients (14% overall). Over the past 13 years a trend has occurred at our institution whereby we are seeing less liver trauma in our population of multiply injured patients from 12% (1976–1983) down to 7% (1985–1989); with a gradual decline in overall mortality from 32% (1976–1983) to 19% (1985–1989), whereas the precentage of deaths due to head injuries and liver injury have increased.

The role of hepatic resection in the management of blunt liver trauma

Forty-two (14%) of 306 patients with liver injuries presenting to Westmead Hospital over a 10-year period required hepatic resection as their definitive treatment. Two types of resection were performed: Resectional debridement utilized the plane of injury as the line of resection while anatomical resection utilized anatomical planes. Resectional debridement was used in 35 patients. In 29, the major technical problem was bleeding and 21 of these patients had associated hepatic vein injuries. In 5, the major problem was devitalized parenchyma, and, in 1, it was an intrahepatic bile duct injury. Anatomical resection was performed in 7 patients: 3 with bleeding, 2 with devitalized parenchyma, and 2 with intrahepatic bile duct injuries. Overall, 15 patients died (36%). The most common cause of death was bleeding in 9 of the 15 patients. Survivors spent a median of 32 days in hospital (range: 11-162 days) and sustained a median of 2 complications (range: 0-6). The most common complications were respiratory infection and/or failure, coagulopathy, and sepsis. Resection successfully addressed bleeding, devitalized parenchyma, and intrahepatic bile duct injuries with an acceptable mortality in critically ill patients who would otherwise have died.

Early Physiologic Predictors of Injury Severity and Death in Blunt Multiple Trauma

The importance of admission physiological and biochemical variables was modeled on data from 185 patients with blunt liver trauma with regard to their significance in prediction of mortality. The variables used were admission Glasgow Coma Score, base excess (or deficit), arterial lactate, Injury Severity Score, and initial 24-hour volume of blood required for replacement. Each variable was modeled as a predictor of survival alone and in combination, using a linear logistic model. In any two-variable combination, Glasgow Coma Score had a high likelihood ratio for prediction representing the influence of brain injury. But as a single variable reflecting the probability of death, both base excess (LD50 = -11.8 mmol/L) and initial 24-hour volume of blood (LD50 = 5.4 L) were highly significant. A combined logistic model of admission Glasgow Coma Score and base excess had the greatest likelihood of accurate prediction of outcome: P death = e lambda/l + e lambda; where lambda = -0.21(Glasgow Coma Score) -0.147(base excess) + 0.285. Testing of this predictive model on data from 323 additional patients with multiple trauma who had pelvic fracture as their index injury also showed it to be a highly significant early predictor of outcome.

Severe Juxtahepatic Venous Injury: Survival after Prolonged Hepatic Vascular Isolation Without Shunting

Survival following major juxtahepatic venous injury is rare in blunt liver trauma despite the use of intracaval shunting. Prolonged liver arterial inflow control, total hepatic venous isolation and lobectomy without shunting was used in a patient to repair a combined vena caval and hepatic venous injury after blunt liver injury. An extended period of normothermic hepatic ischemia was tolerated. Early recognition of retrohepatic venous injury and temporary liver packing to control bleeding and correct hypovolemia are essential before caval occlusion. Hepatic vascular isolation without shunting is an effective simple alternative technique allowing major venous repair in complex liver trauma.

Nonoperative Management of Blunt Pediatric Liver Injury–Late Complications

Selective nonoperative management of blunt liver injuries has become a standard of care, especially in pediatric trauma centers. Recent studies report few complications with this form of therapy. Complications that occur arise over a wide time period, frequently weeks after injury. We report a patient with blunt liver trauma managed nonoperatively, who developed hemobilia 56 days after injury.

Blunt trauma to the liver. Analysis of management and mortality in 323 consecutive patients.

This study represents a 6 year 4 month experience with blunt trauma to the liver of patients from the Maryland Institute for Emergency Medical Services Systems, a major regional trauma center. The significance of this study is that it describes a large, relatively homogeneous population and analyzes what the state of the art for liver trauma has been in a center dedicated solely to trauma that has a full-time staff of trained traumatologists. Three hundred twenty-three consecutive patients with blunt liver trauma are presented, representing 3.5% of 9271 patients admitted to the institute over the period of this study. Ninety per cent had associated traumatic injuries requiring operative intervention. A mortality rate of 31% (101 patients) was noted; 41.5% of the deaths, due primarily to liver injury, occurred intraoperatively during the initial operation following admission. The use of simple suture techniques and resectional debridement to control hemorrhage are advocated. Anatomic lobectomy, intracaval shunting, and hepatic artery ligation were uniformly unsuccessful. The use of drains was associated with a significantly increased incidence of infectious complications (p less than 0.00002).

Blunt liver trauma at Sunnybrook Medical Centre.

Between 1 June 1976 and 30 June 1985 Sunnybrook Medical Centre Regional Trauma Unit admitted 2,016 patients of whom 220 (11%) sustained liver injury. Of these 220 patients, 211 (96%) sustained blunt liver trauma; 175 of 176 patients who underwent open peritoneal lavage had a true positive lavage. Resuscitation was successful in 212 patients, of whom 209 underwent laparotomy and three were treated nonoperatively: 129 of 209 patients (62%) required only minor surgical treatment; the remaining 80 patients (38%) required major surgical procedures. The overall mortality was 29% (64/220). Eight patients died during resuscitation, one of them of liver hemorrhage. Of the 56 patients who died after admission, the cause of death was head injury in 31, liver hemorrhage in 11 (five intraoperatively) and 14 died of other causes. Overall, liver hemorrhage was the cause of death in 12 of 64 deaths (19%). In other words, 12 of the total of 220 patients (6%) died from liver-related mortality.

Blunt liver trauma in children: The role of computed tomography in diagnosis and treatment

In a retrospective evaluation of 12 children with blunt liver trauma studied by computed tomography (CT), all patients studied preoperatively had subcapsular hematomas (6/6). Eleven of twelve patients had parenchymal lesions that were located predominantly in the superior subsegments of the right lobe: 9/12 posteriorly (segment no. 7) and 7/12 anteriorly (segment no. 8) where transections were most frequent. Lacerations were accompanied by intraparenchymal hematomas. Intravenous bolus contrast enhancement visualizes segmental anatomy and is absolutely necessary in order to map lacerations, recognize nonviable tissue, and relate them to major vessels. Except in critically unstable patients, noninvasive imaging of hepatic and other combined abdominal lesions can avoid diagnostic laparotomy or justify planning of a tailored, maybe less radical surgical procedure. Complications, such as abscess formation, can be demonstrated and drained percutaneously. Despite cost, CT is currently the single best imaging method in acute liver trauma.

Blunt liver trauma in children: Nonoperative management

Since 1978, we have treated 19 of 23 (83%) children with blunt liver trauma nonoperatively. Management consisted of observation in an intensive care unit, repeated physical examination, frequent reevaluation of laboratory values, special investigations, and bed rest. The 19 patients all remained stable, required no surgical intervention, and showed resolution of the hepatic injuries with no early or delayed complications. Ultrasonography, although not as reliable a method as computed tomography or liver isotope scans for identification of hepatic trauma at first presentation, provided a very useful method for documenting subsequent progress and eventual healing of the lesions. The presence of an isolated hepatic injury is insufficient indication for surgery. If there is significant extrahepatic injury requiring surgery, or if the patient with hepatic trauma is deteriorating, operative intervention is mandatory.

Problems in the management of liver trauma (author's transl)

In the last ten years 43 patients with blunt liver trauma and 11 with penetrating liver wounds have been treated. The mortality rate after blunt liver trauma was close to 63%; all penetrating wounds were survived. The prognosis after trauma depended significantly on the number of additional wounds, the extent of blood loss, and the age of the patients. Management of liver trauma was performed in most of the cases (n = 41) by suture and drainage. Packing of the wounds and resection were performed in four cases each. In nine cases, the bleeding did not stop sufficiently after suture, debridement, or packing of the wounds. It is concluded that in those cases hepatic resection or hepatic artery ligation - depending on the extent of trauma - should be done in future.

Management of 1,590 consecutive cases of liver trauma.

Between 1939 and 1974, more than 1,500 patients have been treated for penetrating or blunt liver trauma at our institution. Gunshot wounds and major blunt trauma have increased, stab wounds decreased, as percent of total. In most cases techniques other than partial hepatic resection were used, although this was performed in 49 instances. Choledochostomy was infrequently employed. Intracaval shunts were useful in 15 selected patients with massive hepatic, concomitant suprarenal vena caval, or hepatic vein injuries. The overall mortality of this group was 13.1%. The improvement in mortality from liver injuries is attributable to (1) early exploration for suspected intra-abdominal traumatic injury, (2) a conservative approach to the liver injury, and (3) the limitation of lobar resection, vascular cannulae, and afferent vascular compression to highly selected cases.

Lobar dearterialization in liver trauma.

Two cases of blunt liver trauma managed by hepatic artery ligation are reported. Lobar dearterialization is a simple and effective method of achieving haemostasis in exsanguinating wounds of the liver. The postoperative management and scope of this procedure are discussed.

CONTROL OF HAEMORRHAGE FROM HEPATIC VEIN AND VENA CAVA AFTER BLUNT TRAUMA

A case of uncontrollable haemorrhage after blunt liver trauma is described in which a technique was used to expose rapidly and ligate the right hepatic vein, and suture the vena cava at the expense of the right lobe of the liver. It is believed that this method may be appropriate and life saving when techniques of vascular isolation of the liver appear too cumbersome in the emergency situation.

Management of blunt trauma to the liver and hepatic veins.

CURRENTLY accepted management of liver trauma outlined by Madding et al¹has reduced overall mortality from 60% prior to World War II^2,3to between 9% and 27%.^4-6To further reduce mortality the treatment of blunt liver injuries must be improved.⁷The mortality from penetrating wounds has been relatively low, ranging from 0.8% to 14.3%,^6,8but blunt trauma has been reported to be fatal in 25% to 55% of recent series.^8,9 Review of the experience at San Francisco General Hospital showed that hepatic vein injuries were a significant factor in the high mortality from blunt liver trauma. A new approach to management of hepatic vein injuries has been devised. <h3>Material</h3> From 1960 to 1966, 61 patients with liver injury were admitted to San Francisco General Hospital. Thirty-two patients had stab wounds, nine had gunshot wounds, and 20 had blunt trauma. The 47 males and 14