Management Of Blunt Hepatic Injury Research Articles

Grade IV blunt hepatic injury treated conservatively and successfully in a non-trauma centre: a case report

Management of blunt hepatic injury changed over the past three decades as a non-operative treatment is nowadays advocated by most in haemodynamically stable patients. We present the case of a young female patient with a high-grade blunt liver injury successfully treated in a non-trauma centre. She developed several complications secondary to the injury like a delayed bleeding, two different bilomas and a reactive pleural effusion requiring surgical expertise, interventional radiology, upper gastro-intestinal endoscopy and intensive care facilities. In the literature, the mortality and the morbidity rates for grade IV liver injuries respectively reach 16% and 39%. Because of potential delayed symptoms or signs and high complication rate, we think it should be appropriate to manage such a complex patient in a centre where at least above-mentioned specialities are available. Otherwise, a referral to a trauma centre should be a better option.

Post traumatic hepatic artery pseudoaneurysm: a tertiary care centre experience

In blunt trauma abdomen, liver is the most commonly injured organ after spleen. Management of blunt hepatic injury has shifted from operative to non-operative management NOM in hemodynamically stable patients. Main cause of failure of NOM is hemodynamic instability due to re-bleeding or secondary hemorrhage due to rupture of capsular hematoma. Post traumatic hepatic artery pseudoaneurysm HAP as a cause of failure of NOM is rare, reported in about 1.2%. HAP requires early intervention by angiographic embolisation or surgery to prevent catastrophic event. Here, we report our experience with four cases of HAP managed in our centre in past three years. Three patients were managed by selective angioembolisation and one patient was treated by surgery. All patients had uneventful recovery and are asymptomatic on follow-up. HAP is a rare life threatening complication which can present even after successful NOM as a delayed presentation. All symptomatic pseudoaneurysm has to be managed by angioembolisation or surgery depending on hemodynamic stability.

Non-operative management of blunt hepatic injury: Early return to function, chemical prophylaxis, and elucidation of Grade III injuries

Background: Selective non-operative management of blunt hepatic trauma has shown decreased mortality and iatrogenic injury. Evidence-based recommendations are difficult to obtain regarding management of Grade III hepatic injuries and safe timing to implement return to function measures (enteral intake, chemical deep vein thrombosis [DVT] prophylaxis, and ambulation). Materials and Methods: This is a prospective, observational study of 130 trauma patients with blunt hepatic injuries over 2 years. A guideline was utilized to emphasize early hepatobiliary iminodiacetic acid scan and return to function measures at 24 h after injury. Patients were treated non-operatively with endoscopic retrograde cholangiopancreatography, percutaneous drainage, or embolization per evidence-based guidelines. Results: Fifty-seven patients suffered Grade III–V blunt liver injury. The biliary leak rate was higher for Grade IV and V liver injuries than Grade III (48%, 43%, and 12%, respectively) compared to lower grade injuries (0%). There was no significant difference in complications from initiation of chemical DVT prophylaxis, ambulation, or early enteral intake as a function of grade of hepatic injury. The average time to progression of treatment was 24 h and independent of the grade of liver injury. High-grade liver injuries were associated with lower age, increased injury severity score, and increased Intensive Care Unit length of stay. Conclusions: Trauma providers should consider Grade III liver injuries as low-grade injuries and treat accordingly. However, Grade IV and V injuries fail non-operative management more often than other grade injuries. Early enteral nutrition, chemical DVT prophylaxis, and ambulation are safe regardless of the grade of hepatic injury. The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice-based learning and improvement, Systems-based practice.

Management of severe blunt hepatic injury in the era of computed tomography and transarterial embolization: a systematic review and critical appraisal of the literature

BACKGROUND: During the last decade, the management of blunt hepatic injury has considerably changed. Three options are available as follows: nonoperative management (NOM), transarterial embolization (TAE), and surgery. We aimed to evaluate in a systematic review the current practice and outcomes in the management of Grade III to V blunt hepatic injury. METHOD: The MEDLINE database was searched using PubMed to identify English-language citations published after 2000 using the key words blunt, hepatic injury, severe, and grade III to V in different combinations. Liver injury was graded according to the American Association for the Surgery of Trauma classification on computed tomography (CT). Primary outcome analyzed was success rate in intention to treat. Critical appraisal of the literature was performed using the validated National Institute for Health and Care Excellence Quality Assessment for Case Series system. RESULTS: Twelve articles were selected for critical appraisal (n = 4,946 patients). The median quality score of articles was 4 of 8 (range, 2-6). Overall, the median Injury Severity Score (ISS) at admission was 26 (range, 0.6-75). A median of 66% (range, 0-100%) of patients was managed with NOM, with a success rate of 94% (range, 86-100%). TAE was used in only 3% of cases (range, 0-72%) owing to contrast extravasation on CT with a success rate of 93% (range, 81-100%); however, 9% to 30% of patients required a laparotomy. Thirty-one percent (range, 17-100%) of patients were managed with surgery owing to hemodynamic instability in most cases, with 12% to 28% requiring secondary TAE to control recurrent hepatic bleeding. Mortality was 5% (range, 0-8%) after NOM and 51% (range, 30-68%) after surgery. CONCLUSION: NOM of Grade III to V blunt hepatic injury is the first treatment option to manage hemodynamically stable patients. TAE and surgery are considered in a highly selective group of patients with contrast extravasation on CT or shock at admission, respectively. Additional standardization of the reports is necessary to allow accurate comparisons of the various management strategies. LEVEL OF EVIDENCE: Systematic review, level IV.

Management of severe blunt hepatic injury in the era of computed tomography and transarterial embolization: A systematic review and critical appraisal of the literature.

During the last decade, the management of blunt hepatic injury has considerably changed. Three options are available as follows: nonoperative management (NOM), transarterial embolization (TAE), and surgery. We aimed to evaluate in a systematic review the current practice and outcomes in the management of Grade III to V blunt hepatic injury. The MEDLINE database was searched using PubMed to identify English-language citations published after 2000 using the key words blunt, hepatic injury, severe, and grade III to V in different combinations. Liver injury was graded according to the American Association for the Surgery of Trauma classification on computed tomography (CT). Primary outcome analyzed was success rate in intention to treat. Critical appraisal of the literature was performed using the validated National Institute for Health and Care Excellence "Quality Assessment for Case Series" system. Twelve articles were selected for critical appraisal (n = 4,946 patients). The median quality score of articles was 4 of 8 (range, 2-6). Overall, the median Injury Severity Score (ISS) at admission was 26 (range, 0.6-75). A median of 66% (range, 0-100%) of patients was managed with NOM, with a success rate of 94% (range, 86-100%). TAE was used in only 3% of cases (range, 0-72%) owing to contrast extravasation on CT with a success rate of 93% (range, 81-100%); however, 9% to 30% of patients required a laparotomy. Thirty-one percent (range, 17-100%) of patients were managed with surgery owing to hemodynamic instability in most cases, with 12% to 28% requiring secondary TAE to control recurrent hepatic bleeding. Mortality was 5% (range, 0-8%) after NOM and 51% (range, 30-68%) after surgery. NOM of Grade III to V blunt hepatic injury is the first treatment option to manage hemodynamically stable patients. TAE and surgery are considered in a highly selective group of patients with contrast extravasation on CT or shock at admission, respectively. Additional standardization of the reports is necessary to allow accurate comparisons of the various management strategies. Systematic review, level IV.

Complications Associated with Non-Operative Management of Blunt Hepatic Injury: a Review

Non-operative management (NOM) is considered the gold standard treatment for blunt liver trauma in hemodynamically stable patients since it is both feasible and safe. The reported rate of NOM ranged from 82 to 100% according to different series. The feasibility of NOM is lower in patients with severe liver injury. Since NOM has reduced mortality rates, the focus now has shifted to lowering hepatic morbidity, which is reported to be significant, from 10 to 25%. There are four types of complications after NOM: abdominal compartment syndrome, bleeding, Infectious complications and biliary complications. When present, complications of complex blunt hepatic injuries are difficult to treat, the hospital stay is longer and the ICU mortality is higher. 85% of these complications can be safely managed non-operatively. A strict clinical follow-up and keeping in mind every possible complication let clinicians diagnose and treat quickly.

Letter to the Editor Coronary artery dissection, traumatic liver and spleen injury after cardiopulmonary resuscitation – a and review of the literature

Letter to the Editor Coronary artery dissection, traumatic liver and spleen injury after cardiopulmonary resuscitation – a and review of the literature

Nonoperative management of blunt hepatic injury

During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (http://www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient's clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.

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

This is a recommended algorithm of the Western Trauma Association for the operative management of blunt hepatic injuries. Because there are few published prospective randomized trials, the recommendations are based on available published prospective, observational, and retrospective data and expert

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

Management of Blunt Hepatic Injury and Splenic Injury

Management of Blunt Hepatic Injury and Splenic Injury

Complex Hepatic Injuries: an Audit from a Tertiary Center.

Nonoperative management is being increasingly employed in the management of blunt hepatic injuries. We analyzed patients with complex hepatic injuries over a period of 10 years (1996-2006). Two hundred and ten patients with blunt hepatic injury were admitted and 103 patients had complex liver injuries. The predominant mode of injury was road traffic accidents in 91.2%. The grade distribution of liver injuries was grade III (72.8%), grade IV (23.3%) and grade V (4.9%). Twenty-four patients (23.3%) underwent surgery for persistent hemodynamic instability, persistent fall in hemoglobin level, bile leaks and intra-abdominal collection with sepsis. Associated intra-abdominal injuries were present in 19.4%, and 58.4% had associated extra-abdominal injuries. The operative procedures included hepatectomy (1), suture hepatorraphy (12), T-tube drainage for bile duct injuries (5), perihepatic sponge and gel foam packing (9), liver abscess drainage (3), and resection and debridement of liver tissue in six patients. The mortality and morbidity in this series was 10.7 and 56.4%, respectively. Multiorgan failure was present in 5, single organ failure in 37, sepsis in 24, biliary complications in 16 and intra-abdominal collection in 17 patients. Endoscopic management for bile leaks was performed in five patients, image-guided pig-tail drainage for abscesses in 11 patients, while angioembolization was done in two patients for right hepatic artery bleed. The mortality was not significantly different in surgical and nonoperative groups but operated patients had significantly higher morbidity. Complex liver injuries can be managed successfully with conservative treatment in majority, with low mortality and acceptable morbidity. Surgery is reserved for selected indications.

Complications of Nonoperative Management of High-Grade Blunt Hepatic Injuries

Nonoperative management of blunt hepatic injuries is highly successful. Complications associated with high-grade injuries, however, have not been well characterized. The purpose of the present study was therefore to define hepatic-related complications and associated treatment modalities in patients undergoing nonoperative management of high-grade blunt hepatic injuries. Three hundred thirty-seven patients from two regional Level I trauma centers with grade 3 to 5 blunt hepatic injuries during a 40-month period were reviewed. Complications and treatment of hepatic-related complications in patients not requiring laparotomy in the first 24 hours were identified. Of 337 patients with a grade 3 to 5 injury, 230 (68%) were managed nonoperatively. There were 37 hepatic-related complications in 25 patients (11%); 63% (5 of 8) of patients with grade 5 injuries developed complications, 21% (19 of 92) of patients with grade 4 injuries, but only 1% (1 of 130) of patients with grade 3 injuries. Complications included bleeding in 13 patients managed by angioembolization (n = 12) and laparotomy (n = 1), liver abscesses in 2 patients managed with computed tomography-guided drainage (n = 2) and subsequent laparotomy (n = 1). In one patient with bleeding, hepatic necrosis followed surgical ligation of the right hepatic artery and required delayed hepatic lobectomy. Sixteen biliary complications were managed with endoscopic retrograde cholangiopancreatography and stenting (n = 7), drainage (n = 5), and laparoscopy (n = 4). Three patients had suspected abdominal sepsis and underwent a negative laparotomy, whereas an additional three patients underwent laparotomy for abdominal compartment syndrome. Nonoperative management of high-grade liver injuries can be safely accomplished. Mortality is low; however, complications in grade 4 and 5 injuries should be anticipated and may require a combination of operative and nonoperative management strategies.

Routine Follow-Up Imaging Is Unnecessary in the Management of Blunt Hepatic Injury

Nonoperative management of hemodynamically stable patients with blunt hepatic injuries has become the standard of care over the past decade. However, controversy regarding the role of in-hospital follow-up computed tomographic (CT) scans as a part of this nonoperative management scheme is ongoing. Although many institutions, including our own, have advocated routine in-hospital follow-up scans, others have suggested a more selective policy. Over time, we have perceived a low yield from follow-up studies. The hypothesis for this study is that routine follow-up imaging of asymptomatic patients is unnecessary. All patients selected for nonoperative management of blunt hepatic injury were evaluated for utility of follow-up CT scans over a 4-year period. There were 530 stable patients with hepatic injury on admission CT scans in which follow-up scans were obtained within a week of admission. All injuries were classified according to the revised American Association for the Surgery of Trauma Organ Injury Scale: 102 (19.2%) grade I, 181 (34.1%) grade II, 158 (29.8%) grade III, 74 (13.9%) grade IV, and 15 (2.8%) grade V. Follow-up scans showed that most injuries were either unchanged (51%) or improved (34.7%). Only three patients underwent intervention based on their follow-up scans: two patients had arteriography (one with therapeutic embolization) and one had percutaneous drainage. Each of those patients had clinical signs or symptoms that were indicative of ongoing hepatic abnormality. These data demonstrate that, regardless of injury grade, routine in-hospital follow-up scans are not indicated as part of the nonoperative management of blunt liver injuries. Follow-up scans are indicated for patients who develop signs or symptoms suggestive of hepatic abnormality.

Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy

The justification and preference for operative versus nonoperative management of hepatic injuries caused by blunt trauma remains ambiguous. This review assesses the outcome of operative and nonoperative management of liver injury after blunt trauma. We retrospectively reviewed the demographics, severity of injury, severity of liver injury, associated concomitant injuries, management scheme, and outcome of patients with documented hepatic injury from 1993 to 2003. The overall mortality rate was 9.4%, with 3.7% caused by the liver injury itself. Fifty-nine percent (330 of 561) of liver injuries were of low severity (grades I and II), with an overall mortality rate of 6.6% caused by concomitant injuries and liver-related mortality of 0%. Forty-one percent (231 of 561) of liver injuries were high-severity injuries (grades III, IV, and V). Mortality for nonoperative management of high-severity liver injuries was 2.2%. If operative intervention was required because of hemodynamic instability or concomitant injuries then the mortality rate was significantly higher at 30%. Forty-two of the 378 (11%) liver injuries treated nonoperatively required an adjunctive procedure for successful management. Selective management of liver injuries presented a low liver-related mortality rate. Low-grade injuries can be managed nonoperatively with excellent results. High-grade injuries can be managed nonoperatively, if operative intervention is not required for hemodynamic instability or associated injuries, with a low mortality. In these patients, adjunctive procedures will be required selectively for successful nonoperative management of high-grade liver injuries. High-grade injuries requiring operative management because of hemodynamic instability or concomitant injuries continue to have significantly higher mortality.

Management of blunt hepatic injury in children: usefulness of emergency transcatheter arterial embolization: Y Ohtsuka, K Iwasaki, S Okazumi, et al. Pediatr Surg Int 19:29–34, (April), 2003

Management of blunt hepatic injury in children: usefulness of emergency transcatheter arterial embolization: Y Ohtsuka, K Iwasaki, S Okazumi, et al. Pediatr Surg Int 19:29–34, (April), 2003

Non-operative management of blunt hepatic injury in multiply injured adult patients

Non-operative management of blunt liver trauma has now evolved into a common practice especially since abdominal CT has enabled a more precise evaluation of these patients. Sixty-three patients, haemodynamically stable, were eligible for the study and enrolled into the protocol of non-operative management of blunt hepatic injury. Fifty-two (82.5%) patients were successfully managed non-operatively (non-operative group). The remaining 11 (17.5%) patients failed the non-operative management and underwent exploratory laparotomy (laparotomy group). Patients managed non-operatively tended to be younger than patients managed operatively (p < 0.05). The mean values of ISS were 16.2 +/- 6.1, 26.1 +/- 8.5, p < 0.001, in the non-operative and laparotomy groups, respectively. Stay in the ICU was significantly decreased in the non-operative patients (p < 0.001). Patients who had a laparotomy significantly increased requirement for blood transfusion (p < 0.001). Six (9.5%) patients managed non-operatively developed complications; perihepatic collections were observed in two patients, an urinoma in one patient and chest infection in three patients. Perihepatic collections and urinoma were successfully drained percutaneously by CT guidance and no further treatment was required. The mortality rate of the entire series of patients was 4.8% (three patients); one death could be related to hepatic injury itself and the other two deaths were attributed to non-hepatic causes. No deaths occurred in the non-operative group. Non-operative management should be the initial approach to all patients with blunt liver injuries if haemodynamic stability can be ensured. When continued bleeding can be safely ruled out, a period of close monitoring in the ICU is warranted.

Delayed hemorrhage after nonoperative management of blunt hepatic trauma in children: A rare but significant event

Purpose: Nonoperative management of blunt hepatic injury (BHI) has become widely accepted in hemodynamically stable children without ongoing transfusion requirements. However, late hemorrhage, especially after discharge from the hospital can be devastating. The authors report the occurrence of serious late hemorrhage and the sentinel signs and symptoms in children at risk for this complication. Methods: Nonoperative management of hemodynamically stable children included computed tomography (CT) evaluation on admission and hospitalization with bed rest for 7 days, regardless of injury grade. Activity was restricted for 3 months after discharge. Hepatic injuries were classified according to grade, amount of hemoperitoneum, and periportal hypoattenuation. Results: Over 5 years, nonoperative management was successful in 74 of 75 children. One child returned to the hospital 3 days after discharge with recurrent hemorrhage necessitating surgical control. Review of the CT findings demonstrated that he was the only child with severe liver injury in all four classifications. A second child, initially treated at an outside hospital, presented 10 days after injury with ongoing bleeding and died despite surgical intervention. Only the two children with delayed bleeding had persistent right abdominal and shoulder discomfort in the week after BHI. Conclusions: Our findings support nonoperative management of BHI. However, late hemorrhage heralded by persistence of right abdominal and shoulder pain may occur in children with severe hepatic trauma and high injury severity scores in multiple classifications.

Pooling of contrast material on computed tomography mandates aggressive management of blunt hepatic injury

Background: Nonoperative management of blunt hepatic injury is currently a widely accepted treatment modality. Computed tomography (CT) is an important imaging study both for diagnosis and follow-up of these patients. There is, however, no reliable predictor of failure of nonoperative treatment other than the ultimate development of hemodynamic instability. Previous reports mostly were based on the data obtained from low-speed dynamic incremental scanners. The purpose of this study is to evaluate the value of a high-speed helical scanner in predicting the outcome of patients managed nonoperatively. Methods: During a 30-month period, 194 patients with blunt hepatic injury were treated, 150 of them were hemodynamically stable after initial resuscitation and underwent abdominal CT examination. All CT scans were performed with the High Speed Advantage Scanner. The CT scans and medical records were reviewed. Results: Nonoperative management was successfully applied to all patients with grade I and II, 93% of grade III, 87% of grade IV, and 67% of grade V liver injuries. Twelve patients required liver-related celiotomy. Pooling of contrast material was detected on the CT scans of 8 patients. Six (75%) of these patients developed hemodynamic instability and required liver-related celiotomy later. Pooling of contrast material can be detected in 50% of the patients receiving liver-related celiotomy. Conclusion: The presence of pooling of contrast material within the hepatic parenchyma indicates free extravasation of blood as a result of active bleeding. In patients with blunt hepatic injury, if this sign is detected, nonoperative treatment should be terminated and angiography or celiotomy undertaken promptly. With the increasing use of high-speed spiral CT scanner and improvement in scanning technique, pooling of contrast material may become a sensitive sign for active bleeding and may be used as a guide for the selection of treatment modality.