Management Of Hepatic Trauma Research Articles

An Evaluation of the Role of the Radiologist and Surgeon in the Management of Hepatic Trauma at Qazi Hussain Ahmad Hospital, Nowshera, kpk

Aim: This study aims to compare the surgical results and CT scan findings in patients with hepatic trauma to evaluate the sensitivity and usefulness of sonographic data. Study Design: A Single-center study. Study duration : From Jan 2020 to Feb 2021, the Radiology and Surgery Divisions at Qazi Hussain Ahmad Hospital in Nowshera. Methods: There will be a retrospective chart review of all patients suspected of having sustained hepatic injuries admitted to the surgical department From Jan 2020 to Feb 2021 and subsequently present to the department of Radiology. There were two groups of patients: Group I, who had surgical intervention, and Group II, who were hospitalized and treated non-operatively. Prospective cohort research in which the sonographer and clinicians who analyzed emergency sonograms compiled data from all patients. Patients injured in their livers within this time frame were tracked down. Results: Overall, 291 patients (72% of the sample) were included in the study, with 83 patients (29% of the sample) requiring surgical intervention and 208 patients (71% of the model) being handled conservatively. All Group-06 patients had CT scans. Of the 83 patients who had surgery, 11 were classified as having a Grade-1 complication, 12 as having a Grade-11 difficulty, 44 as having a Grade-Ill complication, 18 as having a Grade-IV complication, and three as having a Grade-V complication. In a study with 208 patients who did not have surgery, 15 (73%) had a Grade-I fall, and 56(28%) experienced a Grade-11 fall. Sonographic data and surgical results in individuals who have had surgery, and how they compare and contrast. Cconclusion: Ultrasonography is the most sensitive method for determining the severity of liver damage caused by forceful abdominal trauma. Since it may be done at the bedside and repeated as needed, it serves as a primary diagnostic strategy in these patients and helps when paracentesis is necessary. Keywords: Abdominal injury, Shortened Surgical Terminology for Liver Trauma (AST), liver trauma grades, CT scan, bleed, liver injury,

Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications

Traumatic abdominal injuries are life-threatening emergencies frequently seen in the Emergency Department (ED). The most common is liver trauma, which accounts for approximately 5% of all ED admissions for trauma. The management of blunt liver trauma has evolved significantly over the past few decades and, according to the injury’s severity, it may require massive resuscitation, radiological procedures, endoscopy, or surgery. Patients admitted to the ED with blunt abdominal trauma require a multidisciplinary evaluation, including emergency physicians, surgeons, radiologists, and anesthetists, who must promptly identify the extent of the injury to prevent serious complications. In case of a patient’s death, the execution of a forensic examination carried out with a multidisciplinary approach (radiological, macroscopic, and histological) is essential to understand the cause of death and to correlate the extent of the injuries to the possibility of survival to be able to manage any medico-legal disputes. This manuscript aims to collect the most up-to-date evidence regarding the management of hepatic trauma in the emergency room and to explore radiological findings and medico-legal implications.

The role of liver resection in the management of severe blunt liver trauma.

The management of hepatic trauma has a historical progress from mandatory operation with selective non-operative treatment, to non-operative treatment with selective operation. Liver resection (LR) seems to have a minimal role in the management of liver injury. However, surgical treatment becomes the only life-saving treatment in cases with severe liver trauma. It is a retrospective presentation of five cases with severe blunt liver injury whose were admitted at our center during the 8-year period. The median age of patients was 30.8 (23-43). The most frequent mechanism of injury was pedestrian struck (60%). Two of five cases were transferred to our hospital from rural state hospitals after initial attempt to achieving hemostasis. The majority of liver injury was grade V (80%). The right lobe of the liver was injured in different extensions. Major vascular injury was associated to liver injury in four of five cases. The right hepatectomy (n=1), resectional debridement of segments 5, 6, and 7 (n=1), posterior sectorectomy (n=2), and segment 7 resection (n=1) were performed for hemostasis. Vascular injuries in the junction of inferior vena cava and right hepatic vein (n=1), the anterior surface of the right hepatic vein (n=1), the junction of segment 7 hepatic vein and right hepatic vein (n=1), the main portal vein (n=1), and the right renal vein (n=1) were repaired. Median operation time was 162 min (120-180 min). Operative mortality was 20%. Reoperation was needed in three of four survived cases. In-hospital complications were observed in two of four survived cases. Median stay in intensive care unit and hospital was 12.4 days (1-48 days) and 28.2 days (1-65 days), respectively. When a severe liver injury is unresponsive to packing, the surgeon must always keep in mind that extensive maneuvers for vascular control and LR are required for bleeding control.

Changes in the management of liver trauma leading to reduced mortality: 15-year experience in a major trauma centre.

Worldwide, the evolution of management of liver injury has resulted in improved outcomes. The aim of this study was to examine the trend in the management and outcomes of patients with liver injury. Primary outcomes were defined as mortality and hospital length of stay. The secondary aim was to identify independent predictors of mortality. This study utilized hospital trauma registry data of all trauma patients with liver injuries admitted from 1999 to 2013. Patients in this 15-year period were divided into three periods of 5 years each and compared in terms of demographics, management and outcomes. A total of 725 patients with hepatic trauma were included. Patient demographics were similar, except for an increase in patient transfers from rural locations. Non-operative management increased significantly. There was a significant increase in the use of damage control surgery with perihepatic packing in high-grade liver injuries managed operatively. Hepatic angioembolization commenced midway through the study period. The overall mortality decreased by approximately threefold (P < 0.001) and mortality within 24 h of arrival to hospital by approximately fivefold (P < 0.001). Controlling for independent predictive factors of mortality, the mortality within 24 h reduced from 18.8% in period 1 to 3.6% in period 3 (P = 0.001). At this institution, an integrated trauma service has led to an evolution in the management of hepatic trauma, favouring non-operative management, damage control surgery and the use of hepatic angioembolization. We experienced a significantly improved mortality within 24 h of arrival to hospital in patients with liver trauma.

Major hepatectomy for complex liver trauma.

The liver is the most frequently injured intraperitoneal organ, despite its relatively protected location. The liver consisting of a relatively fragile parenchyma contained within the Glisson capsule, which is thin and does not provide it with great protection. The management of hepatic trauma has undergone a paradigm shift over the past several decades with significant improvement in outcomes. Shifting from mandatory operation to selective nonoperative treatment, and, presently, to nonoperative treatment with selective operation. Operative management emphasizes packing, damage control, and utilization of interventional radiology, such as angiography and embolization. Because of the high morbidity and mortality, liver resection seems to have a minimal role in the management of hepatic injury in many reports, but in a specialized referral center, like our institute, surgical treatment becomes, in many cases, the only life-saving treatment. Innovations in liver transplant surgery, living liver donation, and the growth of specialized liver surgery teams have changed the way that surgeons and hepatic resection are done.

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.

Balanced management of hepatic trauma is associated with low liver-related mortality

Hepatic trauma is a rare surgical emergency with significant morbidity and mortality. Therapeutic strategies have been controversially discussed during the last decades. The medical records of 47 consecutive patients with hepatic trauma treated at the University Hospital of Leipzig between 2004 and 2008 were retrospectively reviewed for the severity of liver injury, management, morbidity, and mortality and compared to a preceding cohort. Logistic regression analysis was performed to identify risk factors influencing mortality. Compared to 63 patients treated between 1993 and 2003, moderate liver injuries (grades I-III) occurred more frequently (p = 0.0006), and the proportion of patients that were managed operatively decreased from 68.9% to 37.5%. Twenty patients (42.6%) were treated conservatively (all grades I to III) and 27 surgically (47.4%). In detail, five patients were treated by hepatic packing alone, 13 by suture or coagulation, five by atypical resection, and four by hemihepatectomy. The overall mortality was 8.5% with a liver-related mortality rate of 2.1%. According to severity grades I-III, IV, and V, mortality rates were 0%, 18.2%, and 50.0%, respectively. Univariate analysis identified Injury Severity Score (ISS) >30, Moore grades IV and V, hemoglobin at admission <6.0 mmol/L, and need for transfusion of >12 erythrocyte concentrates to be significant risk factors for early posttraumatic death, while multivariate analysis only ISS >30 revealed to be of prognostic significance for early postoperative survival. Compared to a previous cohort in the same hospital, more patients were treated conservatively. Management of liver injuries presented with a low liver-related mortality rate. Grades I-III injuries can safely be treated by conservative means with excellent results. However, complex hepatic injuries may often require surgical treatment ranging from packing to complex hemihepatectomy. Hence, for selection of appropriate therapeutic options, patients with hepatic injuries should be treated in a specialized institution.

Certain issues in management of hepatic trauma

临床上急诊处理肝外伤,首先必须关注的问题是腹腔内出血以及可能导致的出血性休克,循环复苏是抢救的要点.肝外伤常伴有大血管、胆管或其他脏器的损伤,病情危急,急诊处理的方式意义重大.由于肝外伤多为非上班时间或夜间急诊入院,经验丰富的高年资医师多不在现场,值班医师对肝外伤的严重程度和患者的状况的评估以及选择治疗方式至关重要。

Current management of hepatic, biliary and pancreatic trauma

The management of hepatic trauma should be, if possible, non-operative and is initially determined by hemodynamic stability, absence of coagulopathy and limited need for blood transfusions. In hemodynamically unstable patients specific attempts to control intraparenchymal hemorrhage and resection are contraindicated. Perihepatic packing is the therapy of choice. If the hemorrhage cannot be controlled, parenchymal resection or hepatectomy with subsequent transplantation must be performed. Biliary leakage is the cause of chronic complications. The current management of intraparenchymal lesions consists of longterm drainage or stenting as combined radiological and endoscopical techniques. Pancreatic ruptures without ductal injury are treated non-operatively or by external drainage. Ductal lesions with persistent fistulas are handled depending on localization either by distal resection, pancreaticojejunostomy of the injured segment, or partial pancreaticoduodenectomy if massive disruption of the pancreatic head, duodenum or bile duct are present.

Critical decisions in the management of hepatic trauma

It is a great honor to present the 10th Annual Edgar J. Poth Lecture to the Southwestern Surgical Congress. Befitting this 10th anniversary, I would like to briefly outline Dr. Poth’s distinguished career. Born in Seguin, Texas on February 1, 1899, Dr. Poth earned his undergraduate degree at the University of Texas in Austin and his doctorate in physical chemistry at the University of California. He completed medical school at Johns Hopkins University and returned west for surgical training at Stanford University. Dr. Poth joined the University of Texas in Galveston in 1942. Over the ensuing two decades, as director of surgical research, he made important contributions to various aspects of peptic ulcer disease, intestinal obstruction, and bowel antisepsis. Indeed, his pioneering work with sulfonamides and later, neomycin is the basis for the operative colon preparation in use today. In 1964, Dr. Poth was awarded the Ashbel Smith Professorship in Surgery and has remained in that capacity since. His contributions to the Southwestern Surgical Congress are no less noteworthy. Serving in numerous capacities, perhaps his most gratifying accomplishments have been chairing the committee that established the Sponsored Residents’ Program and serving as our Society’s president in 1963. To Dr. Edgar J. Poth, I dedicate this lecture entitled, “Critical Decisions in the Management of Hepatic Trauma.” The liver is the most commonly injured organ following abdominal trauma. Although the basic principles in management (control of hemorrhage,, removal of devitalized tissue, and perihepatic drainage) have been well established [l-5], the optimal techniques to achieve them remain controversial. I will review the decision points in management of acute hepatic trauma and characterize the prevailing trends in operative treatment today.

Interventional radiology in the management of hepatic trauma.

Interventional radiology (catheter placement under radiologic guidance) is a safe and effective technique in the management of hemorrhage and infection after hepatic trauma. Twenty procedures in 17 patients were reviewed. All patients with hemorrhage, vascular lesions, and intra-abdominal fluid collections were successfully treated without mortality or substantial morbidity. These techniques are recommended in complicated liver trauma.

Hepatic resection: The logical approach to surgical management of major trauma to the liver

Recent reports on the management of hepatic trauma have discouraged hepatic resection and supported hepatic artery ligation, “resectional debridement” and even packing. These nonresectional procedures are based on misguided principles and should never replace resection. Traditional methods of conducting hepatic resection in an emergency as used in the West probably cause delay in achieving immediate hemostasis, thus contributing to mortality. Compared with Western reports, our mortality for major hepatic resections is considerably low. This is probably due to faster resection and achievement of hemostasis by our clamping techniques. We conclude that it is quite logical to perform resection as the first line of treatment in major hepatic trauma.

Selectivity in the management of hepatic trauma

The Journal of Trauma: Injury, Infection, and Critical Care: December 1977 - Volume 17 - Issue 12 - p 982

Selectivity in the Management of Hepatic Trauma

Retrospective review of 178 consecutive patients who sustained hepatic injuries confirms that selective application of hepatic artery ligation is an efficient means of definitive hemostasis. Only two of 20 immediate deaths resulted from hepatic parenchymal hemorrhage. Over-all mortality (20%) was not significantly increased where hepatic artery ligation was used. Sepsis was the most frequent complication after severe hepatic trauma.

Diagnosis and management of hepatic trauma.

Resection of shattered liver tissue might seem to be a radical treatment, but a look at the mortality figures tells the story. The mortality for large bursting injuries of the liver was as high as 90 percent until recently and is about 25 percent with resectional therapy. Removal of the shattered tissue by “finger fracture” is preferable to the older method of dissection with a scalpel handle.

Experiences in the management of hepatic trauma.

Because of its large size and particular location, the liver is probably the most commonly injured of all the intra-abdominal organs. This appears to be true for both penetrating and nonpenetrating trauma. In addition, during the past decade there has been an increase in those forms of trauma that are likely to result in more massive liver injury, as well as a greater involvement of associated organs. 1,2 Specifically, the ice pick and knife have been replaced by the pistol and shotgun as weapons of violence, while in the same period injuries consequent to automobile accidents have become more common and have resulted from greater degrees of acute deceleration. Material During the 22-year period from Jan 1, 1947, through Dec 1, 1968, 546 patients were admitted to Grady Memorial Hospital with some form of hepatic trauma (Table 1). Penetrating injuries accounted for 465 of these liver wounds, of which 271