Major Liver Injuries Research Articles

Nonoperative management in blunt liver trauma: a 10-year center experience

Background Conservative management nowadays takes the upper hand for liver trauma management in hemodynamically stable patients. Aim To evaluate the outcomes of an operative and conservative management of patients with blunt liver injury over a 10-year period. Patients and methods A retrospective study was conducted in the period from June 2010 to June 2020. It included 327 patients admitted with blunt liver trauma in the surgical trauma unit, Zagazig University hospital. The patients were classified according to the way of management: group I, conservative management, and group II, operative management. Variables analyzed included demographic data, injury classification, associated lesions, surgical treatment, morbid-mortality, and hospital stay. Results Blunt liver trauma represented 33.89% of all blunt abdominal trauma cases in our emergency department. Our study included 327 patients. More than 50% of our patients were young males. Minor liver injuries (grades I–III) were detected in 256 (78.29%) patients, and major liver injuries (grade IV and V) were detected in 71 (21.71%) patients. Conservative management was done in 228 (69.72%) patients and operative management in 99 (30.27%). Mortality rate was 7.64% (25 patients). Conclusions Conservative management is a safe approach for stable hemodynamic patients and surgery the choice for hemodynamic unstable patients. Conservative management patients should be under close monitoring. Failure of conservative treatment did not show a higher incidence of morbidity or mortality.

Optimal treatments for hepato-pancreato-biliary trauma in severely injured patients: a narrative scoping review

Hepato-pancreato-biliary (HPB) injuries can be extremely challenging to manage. This scoping review (8438 citations) offers a number of recommendations. If diagnosis and therapy are rapid, patients with major hepatic injuries who present in physiologic extremis have high survival rates despite prolonged hospital stays. Nonoperative management of major liver injuries, as diagnosed using computed tomography, is typically successful. Adjuncts (e.g., angioembolization, laparoscopic washouts, biliary stents) are essential in managing high-grade injuries. Injury to the extrahepatic biliary tree is rare. Cholecystectomy is indicated for all gallbladder trauma. Full-thickness common bile duct injuries require a hepaticojejunostomy, although damage control remains closed suction drainage. Injuries to the pancreatic head often involve concurrent trauma to regional vasculature. Damage control necessitates drainage after stopping hemorrhage. Injury to the left pancreas commonly requires a distal pancreatectomy. Outcomes for high-grade pancreatic and liver injuries are improved by involving an HPB team. Complications are multidisciplinary and should be managed without delay.

Major liver trauma post-mechanical cardiopulmonary resuscitation-the first reported case of survival with normal cardiovascular and neurological outcome.

Cardiopulmonary resuscitation (CPR) is often conducted with mechanical devices, such as Lund University Cardiac Arrest System in the setting of cardiac arrest during coronary catheterization, to enable effective chest compressions for a prolonged period. Certain injuries from such devices are common such as skin lesions, sternal and rib fractures. Others are rarer, such as visceral injury to the heart, major vessels, lung, liver, spleen and stomach. Major liver injuries have been previously reported but were universally fatal. Here, we report the first case of a capsular liver tear post-mechanical CPR, requiring immediate laparotomy and primary repair, resulting in patient survival with a normal cardiovascular and neurological and outcome.

Hepatic transaminases as predictors of liver injury in abdominal trauma

Background: Our aim was to determine the usefulness of hepatic transaminases as hematological markers to predict the presence and severity of liver injury in adult patients with abdominal trauma.Methods: This is a retrospective study of patients admitted with abdominal trauma (blunt and penetrating) over a three-year period. Grading of liver injury was based on CT-scan or surgical findings. Patients in whom liver enzymes were estimated in the first 48 hours were included.Results: Out of the 66 patients in the study, 23 (63.89%) patients had minor liver injuries, while 13 (36.11%) had major liver injuries. Injury was blunt in 63 (95.45%) and penetrating in 3 (4.54%) patients. The mortality rate was 7.57% (n=5). The median SGOT and SGPT levels in the liver injury group were higher than those in the non-liver injury group SGOT (209LI vs. 43.5) U/L and SGPT (283.22 vs. 72.97) U/L, respectively, (p=0.001). Receiver operating characteristic (ROC) curve assessment, showed the optimum SGOT and SGPT thresholds to be >112.5 and >120.5U/L respectively, which were strongly associated with the presence of liver injuries. There was significant correlation between liver transaminases with grade of liver injury, SGOT (p=0.013) and SGPT (p=0.004).Conclusions: SGOT and SGPT values >112.5 and >120.5U/L respectively, are strongly suggestive of liver injury. Hepatic transaminases are useful screening hematological markers for liver injuries and should be included in the initial trauma blood test panel and may guide in the decision making especially in medical centers with limited facilities.

Traumatic Intraparenchymal Pseudoaneurysm on Initial Imaging Predicts Injury Progression in Patients with Nonoperative Major Blunt Liver Injury

Most patients who present with hemodynamic stability and no evidence of peritonitis after blunt liver injury are successfully managed nonoperatively. Little information is available regarding the utility of reimaging major blunt liver injuries for patients who are managed nonoperatively. A retrospective review of patients admitted to a level I trauma center with major blunt liver injuries (AAST grades 3–5) was conducted. Inclusion criteria were those admitted from July 2012 to June 2014 with blunt liver trauma who survived the first 24 hours and underwent repeat imaging. Data included demographics, procedures performed, and computerized tomography (CT) scan findings. Findings on the second CT scan were categorized as Unchanged, Worse, Improved, or Negative. A total of 128 patients had blunt major liver injuries; 66 patients underwent repeat imaging. The mean time to repeat CT was 1.95 days. On repeat CT, 47 were Unchanged, 3 Worse, 14 Improved, and 2 Negative. Three patients underwent angiography. One required embolization of a pseudoaneurysm. In 63 patients (95%), the second CT did not change the management plan. The presence of a pseudoaneurysm was significantly related to a worsening of the second CT (P = 0.0475). Patients with admission hematocrit (Hct) below 32% were more likely to have a worsened second CT (P = 0.0370). A pseudoaneurysm on admission CT and Hct <32% predict major liver injury progression suggesting that routine reimaging is warranted in this group.

Contemporary damage control surgery outcomes: 80 patients with severe abdominal injuries in the right upper quadrant analyzed

BackgroundDamage control laparotomy (DCL) is a well-established surgical strategy in the management of the severely injured abdominal trauma patients. The selection of patients by intra-abdominal organs involvement for DCL remains controversial. The aim of this study was to assess the injury to the abdominal organs that causing severe metabolic failure, needing DCL.MethodsSeverely injured abdominal trauma patients with a complex pattern of injuries were reviewed over a 52-month period. They were divided into DCL and definitive repair (DR) group according to the operative strategy. Factors identifying patients who underwent a DCL were analyzed and evaluated.ResultsTwenty-five patients underwent a DCL, and 55 patients had DR. Two patients died before or during surgery. The number and severity of overall injuries were equally distributed in the two groups of patients. Patients who underwent a DCL presented more frequently hemodynamically unstable (p = 0.02), required more units of blood (p < 0.0001) and intubation to secure the airway (p < 0.0001). The onset of metabolic failure was more profound in these group of patients than DR group. The mean Basedeficit was − 7.0 and − 3.8, respectively, (p = 0.003). Abdominal vascular (p = 0.001) and major liver injuries (p = 0.006) were more frequently diagnosed in the DCL group. The mortality, complications (p < 0.0001), hospital (p < 0.0001), and ICU stay (p < 0.009) were also higher in patients with DCL.ConclusionIn severely injured with an intricate pattern of injuries, 31% of the patients required a DCL with 92% survival rate. Severe metabolic failure following significant liver and abdominal vascular injuries dictates the need for a DCL and improves outcome in the current era.

Penetrating Liver Injuries

Injuries to the liver are common. In the past, virtually, all penetrating injuries to the liver were managed by laparotomy, direct surgical exploration of the injured liver and repair. However, stable patients with isolated liver injuries, particularly those with low grade injuries, are now able to be managed non-operatively. Operative management can be as simple as packing, suture repair, and/or application of topical hemostatics. More complicated repairs such as resectional debridement, finger fracture with direct ligation of bleeding vessels, and major non-anatomic liver resections are sometimes needed to obtain hemostasis in major liver injuries. Damage control surgical techniques seem ideally suited for major liver injuries. Hemostasis is obtained with packing and whatever other techniques are necessary. This is used as a bridge to angiographic embolization, which can be followed by unpacking and other operative therapy as needed when the patient is more stable. Minimally invasive techniques, such as laparoscopy, do not have a major role in the management of penetrating liver injuries, though that may be expanded as time goes on. Newer adjuncts for hemostasis, such as higher quality topical hemostatic bandages, as well as other innovative therapies, may soon become available. Hepatic failure is infrequent, even with major liver injury, but extracorporeal techniques can be used in the few cases where profound hepatic failure does occur.

Predictive factors for early failure of transarterial embolization in blunt hepatic injury patients

To evaluate the early success of transarterial embolization (TAE) in patients with traumatic liver haemorrhage and to determine independent factors for its failure. From January 2009 to December 2012, TAE was performed in 48 patients for traumatic liver haemorrhage. Their medical charts were reviewed for demographic information, pre-TAE vital signs and laboratory data, injury grade, type of contrast medium extravasation (CME) at CT, angiography findings, and early failure. "Early failure" was defined as the need for repeated TAE or a laparotomy for hepatic haemorrhage within 4 days after TAE. Variables were compared between the early success and early failure groups. Variables with univariate significance were also analysed using multivariate logistic regression for predictors of early failure. Among 48 liver TAE cases, nine (18.8%) were early failures due to liver haemorrhage. Early failure was associated with injury grade (p = 0.039), major liver injury (grades 4 and 5; p = 0.007), multiple CMEs at angiography (p = 0.031), incomplete TAE (p = 0.002), and elevated heart rate (p = 0.026). Incomplete embolization (OR = 8; p = 0.042), and heart rate >110 beats/min (bpm; OR = 8; p = 0.05) were independent factors for early failure of TAE in the group with major liver injuries. Major hepatic injury is an important factor in early failure. Patients with a heart rate >110 bpm and incomplete embolization in the major injury group have an increased rate of early failure. The success rate of proximal TAE was comparable to that of the more time-consuming, superselective, distal TAE.

Management of biliary complications in 412 patients with liver injuries.

Bile leaks occur in 4% to 23% of patients after major liver injuries. The role of conservative management versus internal biliary drainage has not been clearly defined. The safety and efficacy of nonoperative management of bile leaks were studied. Four hundred twelve patients with liver injuries were assessed in a prospective study between 2008 and 2013. All patients with clinically significant injuries to the intrahepatic biliary tract were evaluated. Bile leaks were classified as minor or major (>400 mL/d or persistent drainage >14 days). Minor leaks were managed conservatively, and major leaks underwent endoscopic retrograde cholangiogram and endoscopic biliary stenting. Fifty-one patients (12%) developed a bile leak after liver trauma. Eleven patients (22%) with an extrahepatic duct injury underwent open surgery. Forty patients (78%) had an intrahepatic bile leak. Twenty-six patients (65%) with minor bile leaks were treated conservatively, and 14 patients (35%) with major leaks underwent endoscopic retrograde cholangiogram and internal drainage. All bile leaks resolved. There was no significant difference in the two groups with respect to septic complications (p = 0.125), intensive care unit stay (p = 0.534), hospital stay (p = 0.164), or mortality (p = 1.000). Sixty-five percent of the intrahepatic bile leaks following trauma are minor and easily managed conservatively. Endoscopic retrograde cholangiogram and internal drainage should be reserved for major leaks. Therapeutic study, level IV.

The impact of a massive transfusion protocol (1:1:1) on major hepatic injuries: Does it increase abdominal wall closure rates?

Massive transfusion protocols (MTPs) using high plasma and platelet ratios for exsanguinating trauma patients are increasingly popular. Major liver injuries often require massive resuscitations and immediate hemorrhage control. Current published literature describes outcomes among patients with mixed patterns of injury. We sought to identify the effects of an MTP on patients with major liver trauma. Patients with grade 3, 4 or 5 liver injuries who required a massive blood component transfusion were analyzed. We compared patients with high plasma:red blood cell:platelet ratio (1:1:1) transfusions (2007-2009) with patients injured before the creation of an institutional MTP (2005-2007). Among 60 patients with major hepatic injuries, 35 (58%) underwent resuscitation after the implementation of an MTP. Patient and injury characteristics were similar between cohorts. Implementation of the MTP significantly improved plasma: red blood cell:platelet ratios and decreased crystalloid fluid resuscitation (p = 0.026). Rapid improvement in early acidosis and coagulopathy was superior with an MTP (p = 0.009). More patients in the MTP group also underwent primary abdominal fascial closure during their hospital stay (p = 0.021). This was most evident with grade 4 injuries (89% vs. 14%). The mean time to fascial closure was 4.2 days. The overall survival rate for all major liver injuries was not affected by an MTP (p = 0.61). The implementation of a formal MTP using high plasma and platelet ratios resulted in a substantial increase in abdominal wall approximation. This occurred concurrently to a decrease in the delivered volume of crystalloid fluid.

Surgical management and outcome of blunt major liver injuries: Experience of damage control laparotomy with perihepatic packing in one trauma centre

IntroductionThis retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries. Materials and methodsFrom January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann–Whitney U test for continuous variables, either Pearson's chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p<0.05. ResultsOf the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n=21), hepatorrhaphy (n=19), selective hepatic artery ligation (n=11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p=0.019), prolonged initial prothrombin time (PT) (p=0.004), active partial thromboplastin time (APTT) (p<0.0001) and decreased platelet count (p=0.005). ConclusionsThe mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries.

MDCT diagnosis of post-traumatic hepatic arterio-portal fistulas

The purpose of this study is to evaluate the performance of multidetector computed tomography (MDCT) in diagnosing arterioportal fistulas (APF) in high-grade liver injury. A retrospective analysis of catheter-based hepatic angiograms performed for major penetrating and blunt liver injuries identified 11 patients with APFs. Using the trauma registry, two additional demographically matched groups with and without liver injury were formed. A randomized qualitative consensus review of 33 MDCTs was performed by three trauma radiologists for the following MDCT findings of APF: transient hepatic parenchymal attenuation differences (THPAD), early increased attenuation of a peripheral or central portal vein compared with the main portal vein, and the "double-barrel" or "rail tract" signs. THPAD was the most sensitive finding and also had a high specificity for diagnosing APF. Both the early increased attenuation of a peripheral or central portal vein compared with the main portal vein and the double-barrel or rail tract signs had a100% specificity and a sensitivity of 64% and 36%, respectively. Measurement of differences in attenuation values between the APF and the contralateral central portal vein was most sensitive and specific in diagnosing APF. Traumatic APF of the liver can be optimally diagnosed with arterial phase imaging of solid organ using MDCT.

Emergency strategies and trends in the management of liver trauma

The liver is the most frequently injured organ during abdominal trauma. The management of hepatic trauma has undergone a paradigm shift over the past several decades, with mandatory operation giving way to nonoperative treatment. Better understanding of the mechanisms and grade of liver injury aids in the initial assessment and establishment of a management strategy. Hemodynamically unstable patients should undergo focused abdominal sonography for trauma, whereas stable patients may undergo computed tomography, the standard examination protocol. The grade of liver injury alone does not accurately predict the need for operation, and nonoperative management is rapidly becoming popular for high-grade injuries. Hemodynamic instability with positive focused abdominal sonography for trauma and peritonitis is an indicator of the need for emergent operative intervention. The damage control concept is appropriate for the treatment of major liver injuries and is associated with significant survival advantages compared with traditional prolonged surgical techniques. Although surgical intervention for hepatic trauma is not as common now as it was in the past, current trauma surgeons should be familiar with the emergency surgical skills necessary to manage complex hepatic injuries, such as packing, Pringle maneuver, selective vessel ligation, resectional debridement, and parenchymal sutures. The present review presents emergency strategies and trends in the management of liver trauma.

Gerota's Fascia Flap: A Technique for Autogenous Packing in Major Liver Injuries

Hepatic trauma occurs in ∼ 5% of patients admitted to emergency rooms and nonoperative management has become the standard of care in hemodynamically stable patients with blunt trauma, for most of the injured solid organs. However, the staged surgery represents the first line of treatment in hemodynamically instable patients. The abdominal packing is considered the first step of this surgical policy. The authors describe a new surgical technique consisting of Gerota's fascia dissection that provide an autogenous pedunculated flap to obtain a definitive hemostasis of the injured liver with a permanent packing system.

Hepatic enzymes have a role in the diagnosis of hepatic injury after blunt abdominal trauma

Introduction Delayed diagnosis of patients with severe liver injuries is associated with an adverse outcome. As computed tomographic (CT) scan is not always available in the management of blunt abdominal trauma worldwide, the present study was undertaken to determine the accuracy of selected haematological markers in predicting the presence of hepatic injury and its severity after blunt abdominal trauma. Methods A retrospective review of all patients with blunt abdominal trauma presented to our institution over a 3-year period was performed. Patients were excluded if they suffered penetrating injuries, died in the emergency department or if the required blood tests were not performed within 24 h of the accident. The grading of the hepatic injury was verified using CT scans or surgical findings. Results Ninety-nine patients with blunt abdominal trauma had the required blood tests performed and were included in the study. The median injury severity score was 24 (range 4–75). Fifty-five patients had hepatic injuries, of which 47.3% were minor (Grades I and II) while 52.7% had major hepatic injuries (Grades III–V). There were no patients with Grade VI injuries. A raised ALT was strongly associated with presence of hepatic injuries (OR, 109.8; 95% CI, 25.81–466.9). This relation was also seen in patients with raised AST > 2 times (OR, 21.33; 95% CI, 7.27–62.65). This difference was not seen in both bilirubin and ALP. ALT > 2 times normal was associated with major hepatic injuries (OR, 7.15; 95% CI, 1.38–37.14; p = 0.012) while patients with simultaneous raised AST > 2 times and ALT > 2 times had a stronger association for major hepatic injuries (OR, 8.44; 95% CI, 1.64–43.47). Conclusion Abnormal transaminases levels are associated with hepatic injuries after blunt abdominal trauma. Patients with ALT and AST > 2 times normal should be assumed to possess major hepatic trauma and managed accordingly. Patients with normal ALT, AST and LDH are unlikely to have major liver injuries.

Is the Grading of Liver Injuries a Useful Clinical Tool in the Initial Management of Blunt Trauma Patients?

Computed tomography (CT) has become the preferred method for evaluation of the abdomen for victims of blunt trauma. Grading of liver injuries, primarily by CT, has been advocated as a measure of severity and, by implication, the likelihood for intervention or complications. We have sought to determine if grading of liver injuries, as a clinical tool, affects immediate or extended management of patients. We have retrospectively reviewed all patients sustaining blunt liver injuries as diagnosed by CT over a five-year period at a Level I trauma center to determine if grading of injury influenced management. The AAST organ scaling system was utilized (major grade 4-5, minor grade 1-3), as well as the ISS, AIS, mortality, morbidity, and treatment. There were 133 patients available for review. The patients were grouped into major (n = 20) and minor (n = 113) liver injuries and operative (n = 12) and nonoperative (n = 121) management. Major liver injuries had a higher ISS (39 + 13 vs. 27 + 15, p = 0.001) and were more likely to require operative intervention (5/20 vs. 7/113, p = 0.02). Mortality in this group was not different (major vs. minor), and there were no differences in the incidence of complications. Twelve patients (9%) required operation, all for hemodynamic instability, all within 24 h, and 11/12 within 6 h. At operation 8/12 patients had other sources of bleeding beside the liver injury, and 7/12 had minor hepatic injuries. The operative patients had higher ISS and AIS scores (head/neck, chest, abdomen, extremities) than those managed nonoperatively. More patients died in the operative group (6/12 vs. 8/121, p = 0.0003). There were more pulmonary (6/12 vs. 16/121, p = 0.005), cardiovascular (6/12 vs. 19/121, p = 0.01), and infectious (5/12 vs. 20/121, p = 0.049) complications in the operative group. There were 14 deaths overall; 13/14 were due to traumatic brain injury, and 8/14 required urgent operation for hemorrhage. In conclusion, grading of liver injuries does not seem to influence immediate management. Physiologic behavior dictated management and need for operative intervention, as well as prognosis. However, both major hepatic injuries and need for early operation reflected overall severity and the possibility of associated injuries.

Emergency Department Thoracotomy: Still Useful After Abdominal Exsanguination?

Although literature regarding emergency department thoracotomy (EDT) outcome after abdominal exsanguination is limited, numerous reports have documented poor EDT survival in patients with anatomic injuries other than cardiac wounds. As a result, many trauma surgeons consider prelaparotomy EDT futile for patients dying from intra-abdominal hemorrhage. Our primary study objective was to prove that prelaparotomy EDT is beneficial to patients with exsanguinating abdominal hemorrhage. A retrospective review of 237 consecutive EDTs for penetrating injury (2000-2006) revealed 50 patients who underwent EDT for abdominal exsanguination. Age, gender, injury mechanism and location, field and emergency department (ED) signs of life, prehospital time, initial ED cardiac rhythm, vital signs, Glasgow Coma Score, blood transfusion requirements, predicted mortality, primary abdominal injuries, and the need for temporary abdominal closure were analyzed. The primary study endpoint was neurologically intact hospital survival. The 50 patients who underwent prelaparotomy EDT for abdominal exsanguination were largely young (mean, 27.3 +/- 8.2 years) males (94%) suffering firearm injuries (98%). Patients presented with field (84%) and ED signs of life (78%) after a mean prehospital time of 21.2 +/- 9.8 minutes. Initial ED cardiac rhythms were variable and Glasgow Coma Score was depressed (mean, 4.2 +/- 3.2). Eight (16%) patients survived hospitalization, neurologically intact. Of these eight, all were in hemorrhagic shock because of major abdominal vascular (75%) or severe liver injuries (25%) and all required massive blood transfusion (mean, 28.6 +/- 17.3 units) and extended intensive care unit length of stay (mean, 36.3 +/- 25.7 days). Despite critical injuries, 16% survived hospitalization, neurologically intact, after EDT for abdominal exsanguination. Our results suggest that prelaparotomy EDT provides survival benefit to penetrating trauma victims dying from intra-abdominal hemorrhage.

Surgical management of diaphragmatic injuries

Traumatic diaphragmatic lesions have variable presentations and need a high index of suspicion to be diagnosed in the acute phase. Delayed diagnosis is frequently associated with considerable comorbidity. The present retrospective study aims to evaluate the radiological findings and discuss the surgical approach for the repair of the injured diaphragm. This study includes fifteen cases with diaphragmatic injuries, which were surgically managed between 1994 and 2005. Injuries resulted from violent blunt trauma in twelve patients and three patients had penetrating injuries. Patients presented with hypotension, respiratory insufficiency, acute abdomen and hemothorax. Preoperative diagnosis was established in 12/15 (80%) patients depending on the clinical and the chest skiagram findings. Intra-operative diagnosis was made in the rest. Injuries were more common on the left side (11/15, 73.33%). All these patients underwent repair of the defect by direct closure in double layer using monofilament polypropylene suture. In addition, laparotomy was performed in four patients who had liver and spleen injury. Concomitant procedures included lobectomy, segmentectomy, repair of lung laceration, spleenectomy, spleenorraphy, repair of gastric perforation, intestinal perforation and mesenteric tear. One patient died (1/15, 6.66%) of associated injuries. Two patients with major liver injuries had prolonged drainage and repeated subdiaphragmatic collections. Associated lesions particularly influence the outcome after traumatic lesions of the diaphragm. Surgical exploration is mandatory whenever diaphragmatic injuries are suspected. Right-sided injuries are best exposed and managed through the right thoracotomy. Direct suture is effective in preventing future specific complications.

Hepatic injury

Hepatic trauma occurs in approximately 5% of all admissions in emergency rooms. The anatomic location and the size of the liver make the organ even more susceptible to trauma and frequently in penetrating injuries. The American Association for the Surgery of Trauma established a detailed classification system that provides for uniform comparisons of hepatic injury. Diagnosis of hepatic injury can be sometimes easy; however the use diagnostic modalities as diagnostic peritoneal lavage, ultrasound and computed tomography allow faster and more accurate diagnosis. Nonoperative management of the hemodynamically stable patient with blunt injury has become the standard of care in most trauma centers. Few penetrating abdominal lesions allow conservative management; exceptions can be some penetrating wounds to right upper abdominal quadrant. Operative treatment of minor liver injuries requires no fixation or can only be managed with eletrocautery or little sutures. Major liver injuries continue, despite technical advances, a challenge to surgeons. Many procedures can be done as direct repair, debridement associated to resections, or even in more severe lesions, packing. This constitutes a damage control which can allow time to recovery of patient and decreasing mortality shortly after trauma.

The Abdominal Compartment Syndrome Complicating Nonoperative Management of Major Blunt Liver Injuries: Recognition and Treatment Using Multimodality Therapy

Yang, Edmund Y. MD, PhD; Marder, Shelley R. MD; Hastings, Geoff MD; Knudson, M. Margaret MD Author Information