Complex Liver Injuries Research Articles

Damage Control in Penetrating Liver Trauma: Fear of the Unknown

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.

Complex liver injury induced by combined Aloe Vera and vitamin A oral supplements, as assessed by histology and the updated RUCAM

A case of combined acute and chronic liver injury related to consumption of multi-ingredient nutritional oral supplements containing Aloe Vera gel and vitamin A among other vitamins, minerals and dietary elements such as fish and calamari oil in a 59-year-old female with unexplained hypertransaminasemia is reported. A unique complex liver injury was diagnosed on liver biopsy combining histological features of protracted acute hepatitis, mild manifestation of hypervitaminosis A and lipogranulomatous reaction attributed to Aloe Vera, vitamin A and lipids, respectively. Normalization of liver tests was achieved after discontinuation of all nutritional supplements. Updated Roussel Uclaf Causality Assessment Method (RUCAM) score (+8, probable) further supported herb-induced liver injury. The present case highlights the increasing incidence of complex histological liver injury linked to the constantly growing consumption of multi-ingredient dietary supplements and alternative medications.

Damage Control in Penetrating Liver Trauma: Fear of the Unknown.

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.

Evolution of non-operative management of liver trauma.

The management of complex liver injury has changed during the last 30 years. Operative management has evolved into a non-operative management (NOM) approach, with surgery reserved for those who present in extremis or become hemodynamically unstable despite resuscitation. This NOM approach has been associated with improved survival rates in severe liver injury and has been the mainstay of treatment for the last 20 years. Patients that fail NOM and require emergency surgery are associated with increased morbidity and mortality. Better patient selection may have an impact not only on the rate of failure of NOM, but the mortality rate associated with it. The aim of this article is to review the evidence that helped shape the evolution of liver injury management during the last 30 years.

Hepatic Pseudoaneurysm Incidence After Liver Trauma

BackgroundPosttraumatic hepatic artery pseudoaneurysm is a potentially devastating complication after complex liver injury. Increasing computed tomography (CT) use may lead to more frequent identification of posttraumatic hepatic complications. This study was designed to determine the rate of hepatic pseudoaneurysm after traumatic liver injury. MethodsWe conducted a retrospective review of patients at an urban level 1 trauma center over 5 y (2012-2016). Injury characteristics, patient management, and complications were extracted from trauma registry data and chart review. ResultsSix hundred thirty-four hepatic injuries (11 no grade/no CT, 159 grade I, 154 grade II, 165 grade III, 93 grade IV, and 52 grade V) were identified from our trauma registry. No patient with a grade I or II injury had a subsequent bleeding complication. Eighteen patients had a documented hepatic pseudoaneurysm: grade III n = 3 (1.8%), grade IV n = 6 (6.5%), grade V n = 9 (17.3%). The median time to pseudoaneurysm identification was 6.5 d. Seven pseudoaneurysms were found on asymptomatic surveillance CT-angiography on average 5 d after injury. Eleven patients were symptomatic at the time of CT-angiography performed at a median of 9 d after admission. Of the 11 symptomatic patients, four were in hemorrhagic shock, and two died from hepatic-related complications. ConclusionsThe incidence of hepatic artery pseudoaneurysm increases with higher grade liver injury. Aggressive surveillance for hepatic pseudoaneurysm with interval CT-angiography 5-7 d postinjury may be warranted, especially for grade IV and V injuries.

Hepatic Pseudoaneurysm Incidence after Liver Trauma

Abstract Background Posttraumatic hepatic artery pseudoaneurysm is a potentially devastating complication after complex liver injury. Increasing computed tomography (CT) use may lead to more frequent identification of posttraumatic hepatic complications. This study was designed to determine the rate of hepatic pseudoaneurysm after traumatic liver injury. Methods We conducted a retrospective review of patients at an urban level 1 trauma center over 5 y (2012-2016). Injury characteristics, patient management, and complications were extracted from trauma registry data and chart review. Results Six hundred thirty-four hepatic injuries (11 no grade/no CT, 159 grade I, 154 grade II, 165 grade III, 93 grade IV, and 52 grade V) were identified from our trauma registry. No patient with a grade I or II injury had a subsequent bleeding complication. Eighteen patients had a documented hepatic pseudoaneurysm: grade III n = 3 (1.8%), grade IV n = 6 (6.5%), grade V n = 9 (17.3%). The median time to pseudoaneurysm identification was 6.5 d. Seven pseudoaneurysms were found on asymptomatic surveillance CT-angiography on average 5 d after injury. Eleven patients were symptomatic at the time of CT-angiography performed at a median of 9 d after admission. Of the 11 symptomatic patients, four were in hemorrhagic shock, and two died from hepatic-related complications. Conclusions The incidence of hepatic artery pseudoaneurysm increases with higher grade liver injury. Aggressive surveillance for hepatic pseudoaneurysm with interval CT-angiography 5-7 d postinjury may be warranted, especially for grade IV and V injuries.

Complex Liver Injury—a Quagmire to a Trauma Surgeon

Non-operative management has become a norm in patients with liver trauma and operative management is guided by hemodynamic status. Introduction of haemodynamic status. Introduction of contrast enhanced computed tomography (CECT) abdomen has made NOM possible by helping in exclusion of other injuries and identification of vascular injuries. Haemodynamic instability is now considered as an only absolute indication for operative intervention in liver injuries. However, liver trauma is associated with a large number of complications in the form of perihepatic abscess, hepatic necrosis, bile leak, etc. Patient’s undergoing operative intervention for liver trauma are more at risk for these complications. As such regular dynamic assessment is required for early identification and management of these complications. We present a case of a complex liver injury in a 27-year-old male who underwent operative intervention for liver trauma and had a varied number of liver trauma associated complications, with enterohepatic fistula as one of the rarest associated complications.

Clinical outcomes of primary arterial embolization in severe hepatic trauma: A systematic review.

This purpose of this systematic review was to determine the safety and efficacy of arterial embolization as the primary treatment for grade III-V liver trauma, excluding the postoperative use of arterial embolization. A total of 24 studies published between January 2000 and June 2018 qualified for inclusion in this study. Four of them were prospective studies and 20 were retrospective. A total of 3855 patients (mean age, 33.5 years; range: 22-52.5 years) were treated non-operatively and 659 patients (659/3855; 17.09%) with hepatic hemorrhage underwent primary arterial embolization from 2000 to 2017. Indication for arterial embolization was a contrast blush visible on computed tomography in hemodynamically stable patient in all studies. The arterial embolization success rate ranged from 80% to 97%. The most commonly reported complication was bile leak, with an incidence of 5.7%. Nineteen bilomas (2.8%) were reported in five studies with a range between 4% and 45%. Hepatic ischemia was reported in eight studies, with a mean incidence of 8.6%. Primary arterial embolization has a high success rate in patients with hepatic trauma. Complications, including biloma and hepatic ischemia, have acceptable rates in the context of a minimally-invasive procedure that allows stabilization of life-threatening, complex liver injuries.

Selective nonoperative management of liver gunshot injuries.

Nonoperative management (NOM) of gunshot liver injuries (GLI) is infrequently practiced. The aim of this study was to assess the safety of selective NOM of GLI. A prospective, protocol-driven study, which included patients with GLI admitted to a level 1 trauma center, was conducted over a 52-month period. Stable patients without peritonism or sustained hypotension with right-sided thoracoabdominal (RTA) and right upper quadrant (RUQ), penetrating wounds with or without localized RUQ tenderness, underwent contrasted abdominal CT scan to determine the trajectory and organ injury. Patients with established liver and/or kidney injuries, without the evidence of hollow viscus injury, were observed with serial clinical examinations. Outcome parameters included the need for delayed laparotomy, complications, the length of hospital stay and survival. During the study period, 54 (28.3%) patients of a cohort of 191 patients with GLI were selected for NOM of hemodynamic stability, the absence of peritonism and CT imaging. The average Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.841 and 25 (range 4-50), respectively. 21 (39%) patients had simple (Grades I and II) and 33 (61%) patients sustained complex (Grades III to V) liver injuries. Accompanying injuries included 12 (22.2%) kidney, 43 (79.6%) diaphragm, 20 (37.0%) pulmonary contusion, 38 (70.4%) hemothoraces, and 24 (44.4%) rib fractures. Three patients required delayed laparotomy resulting in an overall success of NOM of 94.4%. Complications included: liver abscess (1), biliary fistula (5), intrahepatic A-V fistula (1) and hospital-acquired pneumonia (3). The overall median hospital stay was 6 (IQR 4-11) days, with no deaths. The NOM of carefully selected patients with GLI is safe and associated with minimal morbidity.

Trauma hepático: uma experiência de 21 anos

To evaluate the epidemiological aspects, behavior, morbidity and treatment outcomes for liver trauma. We conducted a retrospective study of patients over 13 years of age admitted to a university hospital from 1990 to 2010, submitted to surgery or nonoperative management (NOM). 748 patients were admitted with liver trauma. The most common mechanism of injury was penetrating trauma (461 cases, 61.6%), blunt trauma occurring in 287 patients (38.4%). According to the degree of liver injury (AAST-OIS) in blunt trauma we predominantly observed Grades I and II and in penetrating trauma, Grade III. NOM was performed in 25.7% of patients with blunt injury. As for surgical procedures, suturing was performed more frequently (41.2%). The liver-related morbidity was 16.7%. The survival rate for patients with liver trauma was 73.5% for blunt and 84.2% for penetrating trauma. Mortality in complex trauma was 45.9%. trauma remains more common in younger populations and in males. There was a reduction of penetrating liver trauma. NOM proved safe and effective, and often has been used to treat patients with penetrating liver trauma. Morbidity was high and mortality was higher in victims of blunt trauma and complex liver injuries.

Management of persistent bile leak after complex liverinjury with a rendezvous procedure:Report of a case

Management of persistent bile leak after complex liverinjury with a rendezvous procedure:Report of a case

Non-operative management of blunt liver trauma in a level II trauma hospital in Saudi Arabia

Background:To evaluate our experience with non-operative management of blunt liver trauma at a level II trauma hospital in the Kingdom of Saudi Arabia.Materials and Methods:We prospectively evaluated 56 patients treated for blunt liver trauma at our hospital over a 4-year period (April 2008 to April 2012). Patients who were hemodynamically stable [non-operative group I (NOP)] were treated conservatively in the intensive or intermediate care unit (ICU or IMCU). Patients who were hemodynamically unstable or needed laparotomy for other injuries were treated by urgent laparotomy [operative group II (OP)]. All NOP group patients had computed tomography (CT) of the abdomen with oral and intravenous contrast. Injuries grades were classified according to the American Association for the Surgery of Trauma (AAST). Follow-up CT of the abdomen was performed after 2 weeks in some cases.Results:A total of 56 patients were treated over a 4-year period. Twenty patients (35.7%) were treated by immediate surgery. NOP group of 36 patients (64.3%) were managed in the ICU by close monitoring. Surgically treated group had more patients with complex liver injury (90% versus 58.3%), required more units of blood (6.05 versus 1.5), but had a longer hospital stay (16.6 days versus 15.1 days). None of the patients from the non-operated group developed complications nor did they need operation. The only mortality (in two patients) was in the operated group.Conclusion:The NOP treatment is a safe and effective method in the management of hemodynamically stable patients with blunt liver trauma. The NOP treatment should be the treatment of choice in such patients whenever CT and ICU facilities are available.

Advanced operative techniques in the management of complex liver injury

Advanced operative techniques in the management of complex liver injury

Nonoperative management for patients with grade IV blunt hepatic trauma

IntroductionThe treatment of complex liver injuries remains a challenge. Nonoperative treatment for such injuries is increasingly being adopted as the initial management strategy. We reviewed our experience, at a University teaching hospital, in the nonoperative management of grade IV liver injuries with the intent to evaluate failure rates; need for angioembolization and blood transfusions; and in-hospital mortality and complications.MethodsThis is a retrospective analysis conducted at a single large trauma centre in Brazil. All consecutive, hemodynamically stable, blunt trauma patients with grade IV hepatic injury, between 1996 and 2011, were analyzed. Demographics and baseline characteristics were recorded. Failure of nonoperative management was defined by the need for surgical intervention. Need for angioembolization and transfusions, in-hospital death, and complications were also assessedResultsEighteen patients with grade IV hepatic injury treated nonoperatively during the study period were included. The nonoperative treatment failed in only one patient (5.5%) who had refractory abdominal pain. However, no missed injuries and/or worsening of bleeding were observed during the operation. None of the patients died nor need angioembolization. No complications directly related to the liver were observed. Unrelated complications to the liver occurred in three patients (16.7%); one patient developed a tracheal stenosis (secondary to tracheal intubation); one had pleural effusion; and one developed an abscess in the pleural cavity. The hospital length of stay was on average 11.56 days.ConclusionsIn our experience, nonoperative management of grade IV liver injury for stable blunt trauma patients is associated with high success rates without significant complications.

Surgical Management of Complex Liver Trauma: A Single Liver Transplant Center Experience

Complex liver trauma often presents major diagnostic and management problems. Current operative management is mainly centered on packing, damage control, and early utilization of interventional radiology for angiography and embolization. In this retrospective observational study of patients admitted to the Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy, from 1999 to 2010, we included patients that underwent hepatic resection for complex liver injuries (grade I to V according to the American Association for the Surgery of Trauma-Organ Injury Scale). Age, gender, mechanism of trauma, type of resection, surgical complications, length of hospital stay, and mortality were the variables analyzed. A total of 53 adult patients were admitted with liver injury and 29 underwent surgical treatment; the median age was 26.7 years. Mechanism was blunt in 52 patients. The overall morbidity was 30 per cent, morbidity related to liver resection was 15.3 per cent. Mortality was 2 per cent in the series of patients undergoing liver resection for complex hepatic injury, whereas in the nonoperative group, morbidity was 17 per cent and mortality 2 per cent. Liver resection should be considered a serious surgical option, as initial or delayed management, in patients with complex liver injury and can be accomplished with low mortality and liver-related morbidity when performed in specialized liver surgery/transplant centers.

Complications of high grade liver injuries: management and outcomewith focus on bile leaks

BackgroundAlthough liver injury scale does not predict need for surgical intervention, a high-grade complex liver injury should alert the physician to expect an increased risk of hepatic complications following trauma. The aim of the current study was to define hepatic related morbidity in patients sustaining high-grade hepatic injuries that could be safely managed non-operatively.Patients and methodsThis is a retrospective study of patients with liver injury admitted to Hadassah-Hebrew University Medical Centre over a 10-year period. Grade 3-5 injuries were considered to be high grade. Collected data included the number and types of liver-related complications. Interventions which were required for these complications in patients who survived longer than 24 hours were analysed.ResultsOf 398 patients with liver trauma, 64 (16%) were found to have high-grade liver injuries. Mechanism of injury was blunt trauma in 43 cases, and penetrating in 21. Forty patients (62%) required operative treatment. Among survivors 22 patients (47.8%) developed liver-related complications which required additional interventional treatment. Bilomas and bile leaks were diagnosed in 16 cases post-injury. The diagnosis of bile leaks was suspected with abdominal CT scan, which revealed intraabdominal collections (n = 6), and ascites (n = 2). Three patients had continuous biliary leak from intraabdominal drains left after laparotomy. Nine patients required ERCP with biliary stent placement, and 2 required percutaneous transhepatic biliary drainage. ERCP failed in one case. Four angioembolizations (AE) were performed in 3 patients for rebleeding. Surgical treatment was found to be associated with higher complication rate. AE at admission was associated with a significantly higher rate of biliary complications. There were 24 deaths (37%), the majority from uncontrolled haemorrhage (18 patients). There were only 2 hepatic-related mortalities due to liver failure.ConclusionsA high complication rate following high-grade liver injuries should be anticipated. In patients with clinical evidence of biliary complications, CT scan is a useful diagnostic and therapeutic tool. AE, ERCP and temporary internal stenting, together with percutaneous drainage of intra-abdominal or intrahepatic bile collections, represents a safe and effective strategy for the management of complications following both blunt and penetrating hepatic trauma.

Trauma Hepático: Principais Características E Importância do Tratamento Conservador

RESUMO Introdução As lesões de fígado estão presentes em 8% dos traumas contusos. Pacientes com lesões hepáticas complexas são tratados cada vez mais conservadoramente. Mais de dois terços das lesões de alto grau requerem laparotomia, com ressecção hepática em até 5% e mortalidade de até 9%. O objetivo é caracterizar as condutas no trauma hepático em serviço de trauma, enfatizando a decisão por tratamento conservador ou não, resultados e quadro associado. Desenho do estudo Estudo retrospectivo com revisão de 50 prontuários de pacientes com trauma hepático no período de abril/2011 a abril/2012. Resultados Nesse grupo, 80% dos pacientes foram submetidos a tratamento não-operatório, e não foram observadas falhas nesse tratamento em até 72 horas. O tempo de internamento médio foi de 11,88 dias no tratamento não-operatório, e de 13,8 dias nos laparotomizados. Os mecanismos de trauma mais freqüentes foram acidentes de moto e queda de outro nível (ambos com 20%). O grau de lesão II foi o mais prevalente (40%). Nas laparotomias exploradoras, as lesões eram graus II ou III. Os pacientes do tratamento cirúrgico receberam transfusão de, em média, 2,6 mais hemocomponentes que o grupo não cirúrgico. 8% foram a óbito por causas associadas. Nos laparotomizados, optou-se por não tratar a lesão hepática em 20% (grau II). Conclusão Seguiu-se a tendência atual de tratamento majoritariamente conservador do trauma hepático, obtendo-se dados condizentes com a literatura indicativa que apenas 13% dos casos é operatório. Constatou-se uma taxa de 100% de sucesso no tratamento conservador, pois os óbitos ocorridos se deram devido à severidade das lesões extra-abdominais. A literatura mostra taxas de sucesso entre 85 e 95%. Notouse número significativo de lesões graus II e III tratadas com laparotomia, não sendo um padrão comum na literatura. Não foram relatadas complicações próprias do trauma hepático. O tratamento conservador diminuiu morbidade, tempo de internamento e necessidade de hemoderivados.

Management of adult blunt hepatic trauma

To review the nonoperative and operative management of blunt hepatic injury in the adult trauma population. Although liver injury scale does not predict need for surgical intervention, a high-grade complex liver injury should alert the physician to a patient at increased risk of hepatic complications following nonoperative management. Blunt hepatic injury remains a frequent intraabdominal injury in the adult trauma population. The management of blunt hepatic injury has undergone a major paradigm shift from mandatory operative exploration to nonoperative management. Hemodynamic instability with a positive focused abdominal sonography for trauma and peritonitis are indications for emergent operative intervention. Although surgical intervention for blunt hepatic trauma is not as common as in years past, it is imperative that the current trauma surgeon be familiar with the surgical skill set to manage complex hepatic injuries. This study represents a review of both nonoperative and operative management of blunt hepatic injury.

Western Trauma Association Critical Decisions in Trauma: Nonoperative Management of Adult Blunt Hepatic Trauma

Western Trauma Association Critical Decisions in Trauma: Nonoperative Management of Adult Blunt Hepatic Trauma

Selective Nonoperative Management of Liver Gunshot Injuries

Nonoperative management (NOM) of liver gunshot injuries is yet to gain general acceptance. The aim of this study was to assess the feasibility and safety of selective NOM of liver gunshot injuries. A prospective, protocol-driven study, which included all liver gunshot injuries admitted to a level I trauma center, was conducted over a 4-year period. Patients with right-sided thoracoabdominal, and right upper quadrant gunshot wounds with or without localized right upper quadrant tenderness underwent contrasted abdominal computed tomography scan evaluation to detect the presence of a liver injury. Patients with confirmed liver injuries were observed with serial clinical examinations. Outcome parameters included need for delayed laparotomy, complications, length of hospital stay, and survival. During the study period, 63 patients with liver gunshot injuries were selected for NOM. The mean injury severity score was 19.6 (range, 4-34). Simple liver injuries (grades I and II) occurred in 26 (41.3%) patients and complex liver injuries (grades III, IV, and V) occurred in 37 (58.7%) patients. Associated injuries included 14 (22.2%) kidney, 44 (69.8%) diaphragm, 43 (68.3%) lung contusion, 42 (66.7%) hemothorax and/or pneuomothorax, and 21 (33.3%) rib fractures. Five patients required delayed laparotomy resulting in successful NOM rate of 92%. Complications included liver abscess (3), biliary fistula (3), retained hemothorax (4), and nosocomial pneumonia (5). The mean hospital stay was 6.1 (range, 3-23 days). There was no mortality. The NOM of appropriately selected patients with liver gunshot injuries is feasible, safe, and effective, regardless of the liver injury severity.