Major Liver Trauma Research Articles

Multicenter Study of Perioperative Hepatic Angioembolization as an Adjunct for Management of Major Operative Hepatic Trauma.

The management of major liver trauma continues to evolve in trauma centers across the United States with increasing use of minimally invasive techniques. Data on the outcomes of these procedures remains minimal. The objective of this study was to evaluate patient complications after perioperative hepatic angioembolization as an adjunct to management of major operative liver trauma. A retrospective multi-institutional study was performed at 13 Level 1 and Level 2 trauma centers from 2012-2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Patients were divided into two groups, ANIGOEMBO and NO ANGIOEMBO. Univariate and multivariate analyses were performed. A total of 442 patients were included with angioembolization performed in 20.4% (n=90/442) of patients. The ANIGOEMBO group was associated with higher rates of biloma formation (p=0.0007), IAA (p=0.04), pneumonia (p=0.006), DVT (p=0.0004), ARF (p=0.004), and ARDS(p=0.0003) and had longer ICU and hospital LOS (p<0.0001). On multivariate analysis, the ANGIOEMBO had a significantly higher amount IAA formation (OR 2.13 95% CI 1.19 -3.99, p=0.02). This is one of the first multicenter studies comparing angioembolization in specifically operative high-grade liver injuries and found that patients with liver injury that undergo angioembolization in addition to surgery have higher rates of both intra and extra-abdominal complications. This provides important information that can guide clinical management.

Comparison of modified rapid deployment hemostat dressing with standard haemostat as part of standardized perihepatic packing for major liver trauma in a level 1 trauma center

Introduction Uncontrolled hemorrhage is a major cause of mortality in surgery and trauma. Damage control surgery (DCS) is essential in the management of these cases. The use of topical hemostatic agents has increased over the last two decades with the evolution of DCS and trauma-induced coagulopathy. The aim of this study was to compare the performance of standard perihepatic packing with the addition of either a MRDH (modified rapid deployment hemostat) or a non-MRDH hemostatic dressing. Methods This was a retrospective, comparative analysis of prospectively collected data held in the registry of a level I trauma center in Bologna, Italy, between 2005 and 2019. 33 patients with grade IV/V liver injuries who underwent a standardized perihepatic packing with hemostatic dressings were enrolled in the study. The study group included 21 patients treated with standard packing plus MRDH. The control group included 12 patients treated with standard packing plus a combination of fibrillar absorbable hemostat and human fibrin sealant. Results The two groups were homogeneous in terms of age and American Association for the Surgery of Trauma (AAST) grade although the MRDH one seemed to have more severe injury: hemodynamic instability was present in 95% of MRDH patients vs. 83% in the control group. Also, Injury Severity Score (ISS) and New Injury Severity Score (NISS) were 41 vs 35.5 and 47 vs 39.1, respectively. The incidence of re-bleeding requiring repacking at the second-look laparotomy was 4.7% in MRDH patients vs. 16.7% in non-MRDH patients ( p = .5, OR = 4). The overall complication rate was of 23% after the introduction of MRDH vs. 81% in the control group. Conclusion Despite the potential effectiveness of MRDH, this study does not seem to confirm a significant superiority of this hemostat over the standard.

Differences of liver CT perfusion of blunt trauma treated with therapeutic embolization and observation management

Massive hepatic necrosis after therapeutic embolization has been reported. We employed a 320-detector CT scanner to compare liver perfusion differences between blunt liver trauma patients treated with embolization and observation. This prospective study with informed consent was approved by institution review board. From January 2013 to December 2016, we enrolled 16 major liver trauma patients (6 women, 10 men; mean age 34.9 ± 12.8 years) who fulfilled inclusion criteria. Liver CT perfusion parameters were calculated by a two-input maximum slope model. Of 16 patients, 9 received embolization and 7 received observation. Among 9 patients of embolization group, their arterial perfusion (78.1 ± 69.3 versus 163.1 ± 134.3 mL/min/100 mL, p = 0.011) and portal venous perfusion (74.4 ± 53.0 versus 160.9 ± 140.8 mL/min/100 mL, p = 0.008) were significantly lower at traumatic parenchyma than at non-traumatic parenchyma. Among 7 patients of observation group, only portal venous perfusion was significantly lower at traumatic parenchyma than non-traumatic parenchyma (132.1 ± 127.1 vs. 231.1 ± 174.4 mL/min/100 mL, p = 0.018). The perfusion index between groups did not differ. None had massive hepatic necrosis. They were not different in age, injury severity score and injury grades. Therefore, reduction of both arterial and portal venous perfusion can occur when therapeutic embolization was performed in preexisting major liver trauma, but hepatic perfusion index may not be compromised.

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.

Control of Hemorrhage in Liver Trauma

Background: Control of hemorrhage in major liver trauma constitutes an ongoing surgical challenge even in nowadays, as surgeons often face difficult situations in its management. The goal of this study was to analyze our experience in the control of hemorrhage in major liver trauma. Materials and methods: Our study was performed prospectively covering a period of time from January 2009 till December 2012. 173 patients with liver trauma were included in our study. Results: Temporary haemostasis maneuvers in the setting of urgent laparotomy consisted of: bimanual compression 13 patients (15.3%), Pringle maneuver 23 patients (27%), perihepatic packing 10 patients (11,8%), Foley catheter balloon tamponade 2 patients (2.4%), intrahepatic tamponade in penetrating trauma 4 patients (4.7%). Definitive haemostasis methods used in urgent laparotomy were: electro-coagulation of the liver injury 12 patients (14.1%), haemostasis and biliostasis followed by hepatic closure 41 patients (48.2%), haemostasis and biliostasis without hepatic closure 6 patients (7.1%), tamponade with a pedicled vascularized omental flap (pedicled omentum hepatorrhaphy) 7 patients (8.2%), anatomic liver resection 1 patient (1.2%), nonanatomic/atypical liver resection 7 patients (8.2%), right hepatic artery ligation 1 patient (1.2%). Surgical techniques in preplanned laparotomies consisted of: left hepatectomy 1 patient (16.6%), right hepatectomy 1 patient (16,6%), nonanatomic/atypical liver resections 4 patients (66.7%). The success of treatment was significantly related to the grade of liver injury (z= 5.2912, p=&lt;0.00001), other concomitant abdominal organ injuries (z=4.0743, p=0.00005), amount of blood transfusion received (p=0.03207), and age (p=0.04944). Overall mortality rate was 13%. Conclusion: Perihepatic packing and performing the surgical intervention in two sessions has significantly improved survival rates in major liver trauma from our experience.

Biliovascuar complications: a price to pay for non-operative management of major liver trauma.

With non-operative management of major liver trauma, there has been an increased incidence of biliovascular complications which are reported variably. Fifty-six patients with age of 29.79±11.40 years and M:F 8.3:1, with grade III or more liver trauma were evaluated after stabilization for the development of liver related complications. Patients with active contrast extravasation at admission were managed with immediate angioembolization. Patients with prolonged hospital stay underwent repeat CT prior to discharge. Radiological, endoscopic and surgical interventions were carried out as appropriate. Ninety-eight percent had blunt abdominal injury. Mean injury severity score was 25.68±10.389. Four (7%) required damage control laparotomy. CECT showed grade III injuries in 52%, grade IV in 30.4%, and grade V in 18%. 11% had laceration extending to porta. Seventeen patients had 21 liver-related complications: 4 biliary, 12 vascular and 1 combined biliary and vascular. Liver related complications were- 3.5% in grade III, 52% in grade IV and 70% in grade V. One patient with active arterio-portal fistula required urgent angioembolization while other arterial pseudoaneurysms were detected 7.23±5.14 days after trauma. Angioembolization was successful in 83% patients. On univariate and multivariate analysis, PRBC requirement and injury grade were the predictors of bilivascular complications. Laceration extending to porta was a predictor for biliary complications and not vascular. Repeat CT picked up 13 complications in 10 patients. Biliovascular complications are managed by multidisciplinary approach. Lacerations extending to porta and grade IV/V injuries have a higher chance of developing biliovascular complications and should be observed closely.

Biliovascular complications of major liver trauma

Biliovascular complications of major liver trauma

Biloma following hepatic artery embolisation (HAE) for major liver trauma at the alfred - is early endoscopic or surgical intervention required?

Non-surgical management of blunt liver trauma contributed to reduced mortality from liver trauma. Hepatic artery embolisation (HAE) has become a key part of the treatment algorithm for treatment of hepatic trauma with arterial extravasation. However, significant complications can follow HAE. We aimed to identify the incidence of endoscopic or surgical intervention after HAE. We performed a 10 year retrospective review of a prospectively maintained database of patients undergoing HAE for severe liver trauma (AIS >3). Demographics, site of liver injury, vessel embolised and complications were recorded and analysed. There were 358 cases of severe liver trauma (AIS >3) in the study period. Thirty one (8.6%) patients underwent HAE (10 grade III, 19 grade IV and 2 grade V). There were no deaths in the patients undergoing HAE. The most common mechanism was blunt trauma (n=27/31; 87%) and segments V-VIII were more commonly injured (n=25/31; 81%). Fifty percent (11/22) of patients who underwent HAE with grade IV-V liver injuries developed a biloma that required either percutaneous or endoscopic drainage Overall, of 31 patients undergoing HAE, 5 underwent early hepatectomy for major hepatic necrosis following HAE and 8 underwent early ERCP and stenting to treat biloma formation. 5 patients also required percutaneous drainage. Severe liver trauma requiring HAE is associated with intrahepatic biliary complications. Further intervention is required in a significant proportion of these patients and represents a significant health care burden arising from HAE that should be anticipated and treated early.

Role of elevated liver transaminase enzymes in diagnosis of liver injury in cases after abdominal trauma

Background: Major liver trauma in polytraumatic patients accounts for significant morbidity and mortality. Delayed diagnosis of patients with severe liver injuries is associated with an adverse outcome. Diagnostic modalities include serial abdominal examination, focused abdominal sonography for trauma, computed tomography scanning, diagnostic peritoneal lavage. The objective of this study was to detect relationship between raise of serum levels of hepatic transaminase enzymes and liver injury, and if the degree of the rise may also correlate with the severity of hepatic injury after abdominal trauma. Methods: cross sectional, prospective study observational study of all patients admitted emergency department in Suez Canal university hospital. Patients with abdominal trauma were subdivided (according to either surgical record after abdominal exploration or CT scans reports released by radiology department) in two groups, group with liver injury (31) cases and those without liver injuries (31) cases. Results: As regard to alanine aminotransferases (ALT) our study showed that serum ALT was raised in 28 cases from 31 cases of liver injury and only 4 patients with raised serum ALT did not have liver trauma (sensitivity: 90.3%, specificity: 87% , CI: 88.7%). Regarding aspartate aminotransferases (AST) our study showed serum AST was raised in about 21 cases from 31 cases of liver injury and only 7 patients with raised serum AST did not have liver trauma (sensitivity: 93.5%, specificity: 77.4% , CI: 87.1%). Conclusions: An abnormal ALT and AST can predict the presence of hepatic injuries in abdominal trauma patients, while the level of the abnormality can determine the severity of the insult to the liver. Also we can conclude that ALT is more specific for liver injury more than AST, Although AST show high sensitivity for liver injury than ALT.

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.

Nonoperative Management of Major Liver Trauma—When Failure May Be a Success

Nonoperative Management of Major Liver Trauma—When Failure May Be a Success

Vascular Injuries Associated with Major Liver Trauma: A Management Challenge

Major vessel injuries (like inferior vena cava and hepatic veins) can be associated with severe liver injuries and are potentially devastating and associated with high mortality. Generally, major vascular injuries with hepatic trauma are caused by stabs and penetrating wounds, but we encountered two cases last year where severe liver injuries after blunt trauma were associated with injuries of the inferior vena cava in one and of inferior vena cava with hepatic veins in the other case. Emergency repair of inferior vena cava was done in the first case and initial packing followed by planned re-exploration after 24 hours was done in the second case after taking proper proximal and distal control. The first patient died on the seventh postoperative day due to multiorgan failure while the second patient recovered well without any residual complication. The cases are being reported to emphasize the fact that injuries of the retrohepatic vena cava and the hepatic veins still remain a challenge for the skills of even an experienced surgeon.

Arterial Embolization for Hemorrhage Caused by Hepatic Arterial Injury

Fewer than 10% of patients with major liver trauma have life-threatening bleeding. Laparoscopic operations, endoscopic procedures, and percutaneous interventions such as drainages, vascular or tumor sclerosis, biopsies, and transjugular intrahepatic portocaval shunt (TIPS) have increased the number of iatrogenic vascular and bile duct injuries. Due to its therapeutic success, arterial embolization (AE) has become the standard treatment for late complications of hepatic injury. In some cases, this procedure may be used as the first approach on accidental or iatrogenic arterial trauma and in several hepatic arterial diseases. The result of this method depends on physician experience, size of the wound, and stability of the patient. Persistent hemorrhage and rebleeding may be treated with a new AE or an operation. Precise indication and a correctly performed AE are key factors for a successful treatment. Rebleeding episodes are a rare occurrence, which may be treated with AE as well.

Packing for Control of Hemorrhage in Major Liver Trauma

Packing for complex liver injuries has been associated with an increased risk of abdominal sepsis and bile leaks. The aim of the present study was to determine the optimum timing of pack removal and to assess whether the total duration of packing increases the incidence of these complications. The study was based on a retrospective review of all patients requiring liver packing over an 8-year period in a level 1 trauma center. Ninety-three (17%) of 534 liver injuries identified at laparotomy required perihepatic packing. Penetrating and blunt trauma occurred in 72 (77%) and 21 (23%), respectively. The mean total duration of packing was 2.4 days (range: 0.5-6.0 days). There was no association between the total duration of packing and the development of liver-related complications (P = 0.284) or septic complications (P = 0.155). Early removal of packs at 24 h was associated with a higher rate of re-bleeding than removal of packs at 48 h (P = 0.006). The total duration of liver packing does not result in an increase in septic complications or bile leaks. The first re-look laparotomy should only be performed after 48 h. An early re-look at 24 h is associated with re-bleeding and does not lead to early removal of liver packs.

Traumatic pediatric bile duct injury: nonoperative intervention as an alternative to surgical intervention

Background Nonoperative management of blunt pediatric liver injuries has become the standard of care in the absence of hemodynamic instability. However, associated bile duct injuries remain as difficult challenges. Few case reports have demonstrated the benefits of conservative approaches, but others have found better outcomes with surgical intervention. In this study, we report on our experience with interventional endoscopic and radiologic management of 5 pediatric patients with bile duct injuries who underwent unsuccessful surgical interventions. Methods We conducted a retrospective review of medical records of all pediatric patients who were admitted with major blunt liver trauma and bile duct injuries over a period of 5 years. Results There were 5 patients (4 boys and 1 girl) whose ages range from 3 to 11 years in this study. All patients had major liver laceration and bilomas. Two had intrahepatic and 3 had extra hepatic bile duct injuries (2 right hepatic ducts and 1 junction of cystic duct with common bile duct). All of them underwent previous laparotomies, once in 2 patients, twice in 2 patients, and thrice in 1 patient. All 5 patients were eventually treated successfully with interventional endoscopic and radiologic techniques. Three underwent endoscopic retrograde cholangiopancreatography stenting with percutaneous drainage. Two patients were managed with percutaneous drainage alone. The follow-up is up to 2.5 years with normal liver function test and bile duct ultrasound. Conclusion With the current advancement in endoscopic retrograde cholangiopancreatography and intervention radiology techniques, we believe that interventional endoscopic and radiologic management of bile duct injuries caused by blunt trauma in children is successful and efficacious even after multiple laparotomies.

The treatment of major liver trauma by primary packing with transfer of the patient for definitive treatment

Four patients are reported in whom massive haemorrhage from severe hepatic trauma was managed initially by conservative surgery and packing. The patients were then transferred by ambulance to Addenbrooke's Hospital where further treatment involved elective surgery and removal of packs. All 4 patients were discharged from hospital and have made full recoveries. It is felt that the management of liver trauma should be to do the minimum that is necessary to staunch bleeding, by suture, arterial ligation, lobectomy, resectional debridement or simply by packing. This allows the patient's haemodynamic state to be restored to normal before further surgery is attempted.

Benefits of early diagnosis and preemptive treatment of biliary tract complications after major blunt liver trauma in children

Background/Purpose: Nonoperative management of blunt liver trauma may delay diagnosis of related biliary complications leading to delayed surgical intervention and related morbidity. The aim of this study was to see whether technetium (tc) 99 trimethylbromo-im-indolacetic acid (TBIDA) nuclear scan would allow noninvasive early diagnosis of bile leak and pre-emptive management. Methods: Retrospective analysis of the patient records and radiologic investigations of 7 patients admitted between April 1998 and December 2000 with “major” blunt liver trauma (parenchymal fracture of less than 4 cm on computed tomography [CT] scan or involving porta hepatis) and various types of biliary complications. Patients with or without early TBIDA diagnosis were compared. Results: There were 7 patients. The first 2 patients were treated conventionally without TBIDA, and late diagnosis was associated with further related problems (sepsis, life-threatening hemorrhage in both cases) and prolonged hospital stay. The subsequent 5 consecutive patients benefited from early diagnosis (TBIDA scan, 2 to 4 days after trauma), and preemptive management was done (tailored to each case). There was no further or related morbidity. All 7 patients currently are alive and well. Conclusions: A TBIDA nuclear medicine scan was efficient in providing an early diagnosis of biliary leakage, thus, allowing adequate preemptive management. In turn, this may have helped avoid related added morbidity compared with cases of late diagnosis. Early TBIDA scan should be performed routinely when the initial CT scan confirms liver trauma graded as “major.” J Pediatr Surg 37:1287-1292. Copyright 2002, Elsevier Science (USA). All rights reserved.

Liver repair and hemorrhage control by using laser soldering of liquid albumin in a porcine model.

We evaluated laser soldering by using liquid albumin for welding liver injuries. Major liver trauma has a high mortality because of immediate exsanguination and a delayed morbidity from septicemia, peritonitis, biliary fistulae, and delayed secondary hemorrhage. Eight laceration (6 x 2 cm) and eight nonanatomic resection injuries (raw surface, 6 x 2 cm) were repaired. An 805-nm laser was used to weld 50% liquid albumin-indocyanine green solder to the liver surface, reinforcing it with a free autologous omental scaffold. The animals were heparinized and hepatic inflow occlusion was used for vascular control. All 16 soldering repairs were evaluated at 3 hours. All 16 laser mediated liver repairs had minimal blood loss as compared with the suture controls. No dehiscence, hemorrhage, or bile leakage was seen in any of the laser repairs after 3 hours. Laser fusion repair of the liver is a reliable technique to gain hemostasis on the raw surface as well as weld lacerations.

Is a conservative approach justified in penetrating liver injury?

Objective. To establish the mortality and morbidity associated with major penetrating liver injuries and to describe the nature and treatment of complications related to these injuries. We postulated that there had been a trend toward less radical initial surgery, as well as an increased utilization of modern imaging techniques in both diagnosing and treating postoperative complications following penetrating liver trauma. Design. A retrospective survey of medical records and radiology files. Setting. A university trauma center in an urban setting. Patients. Of the 188 patients admitted to our trauma center with penetrating liver trauma between April 1988 and December 1991, 36 had major liver trauma (grades 3 through 5) and are described in this report. Main Outcome 4easures. The mortality rate, type of operative treatment, and the nature and treatment of complications for each grade of major liver injury. Results. The mortality rate from major liver injuries was 17%. Surgical techniques employed primarily consisted of the use of hemostatic agents and cautery, simple suturing, direct vessel ligation, and packing. Fifty-two percent of the survivors had major complications related to the liver injury itself, but only two required operative therapy. The remaining patients were successfully treated with interventional radiologic techniques. Conclusions. The morbidity and mortality following major penetrating liver injuries remain significant. The majority of hepatobiliary complications can be successfully managed without further surgery but require the combined efforts of the surgeon and interventional radiologist.

Morbidity and Mortality Following Major Penetrating Liver Injuries

To establish the mortality and morbidity associated with major penetrating liver injuries and to describe the nature and treatment of complications related to these injuries. We postulated that there had been a trend toward less radical initial surgery, as well as an increased utilization of modern imaging techniques in both diagnosing and treating postoperative complications following penetrating liver trauma. A retrospective survey of medical records and radiology files. A university trauma center in an urban setting. Of the 188 patients admitted to our trauma center with penetrating liver trauma between April 1988 and December 1991, 36 had major liver trauma (grades 3 through 5) and are described in this report. The mortality rate, type of operative treatment, and the nature and treatment of complications for each grade of major liver injury. The mortality rate from major liver injuries was 17%. Surgical techniques employed primarily consisted of the use of hemostatic agents and cautery, simple suturing, direct vessel ligation, and packing. Fifty-two percent of the survivors had major complications related to the liver injury itself, but only two required operative therapy. The remaining patients were successfully treated with interventional radiologic techniques. The morbidity and mortality following major penetrating liver injuries remain significant. The majority of hepatobiliary complications can be successfully managed without further surgery but require the combined efforts of the surgeon and interventional radiologist.