Severe Liver Trauma Research Articles

A starry night: a case report of severe liver injury due to a close-range shotgun blast in Argentina.

This report presents the case of a 20-year-old man who sustained a severe liver injury from a closerange shotgun blast. A prompt medical intervention, including damage control exploratory laparotomy and surgical debridement, was undertaken due to the extent of liver damage. Despite challenges such as a nondirected biliary fistula and extensive liver parenchymal injury, comprehensive surgical management led to successful treatment. Postoperative complications, including biloma and fungal infection, were managed appropriately, highlighting the importance of vigilant follow-up care. The case underscores the complexity of managing severe liver trauma and emphasizes the evolving role of trauma damage control strategies and minimally invasive procedures in achieving favorable outcomes.

Use of angioembolization, treatment modalities and mortality in association with blunt liver trauma in Germany — a data analysis of the TraumaRegister DGU®

PurposeAngioembolization (ANGIO) is highly valued in national and international guideline recommendations as a treatment adjunct with blunt liver trauma (BLT). The literature on BLT shows that treatment, regardless of the severity of liver injury, can be accomplished with a high success rate using nonoperative management (NOM). An indication for surgical therapy (SURG) is only seen in hemodynamically instable patients. For Germany, it is unclear how frequently NOM ±\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\pm$$\\end{document} ANGIO is actually used, and what mortality is associated with BLT.MethodsA retrospective systematic data analysis of patients with BLT from the TraumaRegister DGU® was performed. All patients with liver injury AIS ≥ 2 between 2015 and 2020 were included. The focus was to evaluate the use ANGIO as well as treatment selection (NOM vs. SURG) and mortality in relation to liver injury severity. Furthermore, independent risk factors influencing mortality were identified, using multivariate logistic regression.ResultsA total of 2353 patients with BLT were included in the analysis. ANGIO was used in 18 cases (0.8%). NOM was performed in 70.9% of all cases, but mainly in less severe liver trauma (AIS ≤ 2, abbreviated injury scale). Liver injuries AIS ≥ 3 were predominantly treated surgically (64.6%). Overall mortality associated with BLT was 16%. Severity of liver injury ≥ AIS 3, age > 60 years, hemodynamic instability (INSTBL), and mass transfusion (≥ 10 packed red blood cells/pRBC) were identified as independent risk factors contributing to mortality in BLT.ConclusionANGIO is rarely used in BLT, contrary to national and international guideline recommendations. In Germany, liver injuries AIS ≥ 3 are still predominantly treated surgically. BLT is associated with considerable mortality, depending on the presence of specific contributing risk factors.

Improvements over time for patients following liver trauma: A 17-year observational study.

Centralisation of trauma care has been shown to be associated with improved patient outcomes. The establishment of Major Trauma Centres (MTC) and networks in England in 2012 allowed for centralisation of trauma services and specialties including hepatobiliary surgery. We aimed to investigate the outcomes for patients with hepatic injury over the last 17 years at a large MTC in England in relation to the MTC status of the centre. All patients who sustained liver trauma between 2005 and 2022 were identified using the Trauma Audit and Research Network database for a single MTC in the East Midlands. Mortality and complications were compared between patients before and after establishment of MTC status. Multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for complications according to MTC status, accounting for the potentially confounding variables of age, sex, severity of injuries and comorbidities for all patients, and the subgroup with severe liver trauma (AAST Grade IV and V). There were 600 patients; the median age was 33 (IQR 22-52) years and 406/600 (68%) were male. There were no significant differences in 90-day mortality or length of stay between the pre- and post-MTC patients. Multivariable logistic regression models showed both lower overall complications [OR 0.24 (95% CI 0.14, 0.39); p < 0.001] and lower liver-specific complications [OR 0.21 (95% CI 0.11, 0.39); p < 0.001] in the post-MTC period. This was also the case in the severe liver injury subgroup (p = 0.008 and p = 0.002 respectively). Outcomes for liver trauma were superior in the post-MTC period even when adjusted for patient and injury characteristics. This was the case even though patients in this period were older with more comorbidities. These data support the centralisation of trauma services for those with liver injuries.

Is the Pringle manoeuvre becoming a lost art? Contemporary use for both severe liver trauma with ongoing hemorrhage and elective partial hepatectomy

SummaryThe Pringle manoeuvre (vascular inflow occlusion) has been a mainstay technique in trauma surgery and hepato-pancreato-biliary surgery since it was first described in the early 1900s. We sought to determine how frequently the manoeuvre is used today for both elective and emergent cases in these disciplines. To reflect on its evolution, we evaluated the Pringle manoeuvre over a recent 10-year period (2010–2020). We found it is used less frequently owing to more frequent nonoperative management and more advanced elective hepatic resection techniques. Continuing educational collaboration is critical to ensure continued insight into the impact of hepatic vascular inflow occlusion among trainees who observe this procedure less frequently.

Camera, action, liver injury: a preventable case of extreme sports body camera causing severe blunt abdominal liver trauma

Camera, action, liver injury: a preventable case of extreme sports body camera causing severe blunt abdominal liver trauma

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.

Haemorrhagic death from severe liver trauma has decreased in the era of haemostatic resuscitation.

Severe liver trauma can cause major haemorrhage and death. Haemostatic resuscitation principles are associated with improved survival in trauma patients with major haemorrhage. We hypothesised death from liver haemorrhage decreased in parallel with the introduction of haemostatic resuscitation. To establish the incidence of haemorrhagic death in patients with severe liver trauma and review how outcomes in two time periods associate with changes in resuscitation practice. A retrospective review of all adult patients admitted to Auckland City Hospital with liver trauma was undertaken for a 14-year period. Resuscitation fluid for patients with grade V liver trauma or death from liver haemorrhage was compared between the first and second half of the study (2006-2013 vs. 2013-2020). Four hundred and fifty patients were admitted with liver trauma during the 14-year period. Mortality from haemorrhage in patients with severe liver trauma (grade IV and V) decreased between the first and second half of the study (p=0.009). Pre-hospital and emergency department crystalloid fluid use decreased (p=0.002). Fresh frozen plasma in ED (p=0.076) and total cryoprecipitate use (p=0.072) increased. Tranexamic acid use increased (p=0.002). Use of colloid fluid was abandoned (p=0.013). There was no significant difference in pre-hospital time or time from hospital arrival until haemorrhage control laparotomy. Death from liver haemorrhage decreased in association with the introduction of haemostatic resuscitation while the incidence, severity and surgical management of liver trauma was comparable.

Nonoperative Management of Blunt Hepatic Trauma: Comparison of Level I and II Trauma Centers.

Most blunt liver injuries are treated with nonoperative management (NOM), and angiointervention (AI) has become a common adjunct. This study evaluated the use of AI, blood product utilization, pharmacological venous thromboembolic prophylaxis (VTEp), and outcomes in severe blunt liver trauma managed nonoperatively at level I versus II trauma centers. American College of Surgeons Trauma Quality Improvement Program (TQIP) study (2013-2016), including adult patients with severe blunt liver injuries (AIS score>/= 3) treated with NOM, was conducted. Epidemiological and clinical characteristics, severity of liver injury (AIS), use of AI, blood product utilization, and VTEp were collected. Outcomes included survival, complications, failure of NOM, blood product utilization, and length of stay (LOS). Study included 2825 patients: 2230(78.9%) in level I and 595(21.1%) in level II centers. There was no difference in demographics, clinical presentation, or injury severity between centers. Angiointervention was used in 6.4% in level I and 7.2% in level II centers (P=.452). Level II centers were less likely to use LMWH for VTEp (.003). There was no difference in mortality or failure of NOM. In level II centers, there was a significantly higher 24-hour blood product utilization (PRBC P = .015 and platelets P = .002), longer ventilator days (P = .012), and longer ICU (P< .001) and hospital LOS (P = .024). The incidence of ventilator-associated pneumonia was significantly higher in level II centers (P = .003). Utilization of AI and NOM success rates is similar in level I and II centers. However, the early blood utilization, ventilator days, and VAP complications are significantly higher in level II centers.

Depacked patients who underwent a shortened perihepatic packing for severe blunt liver trauma have a high survival rate: 20 years of experience in a level I trauma center

IntroductionNon-operative management is currently the preferred approach in blunt liver trauma, including high grade liver lesions. However, hemodynamic instability imposes the need for an emergency laparotomy, with a perihepatic packing (PHP) to control liver bleeding in most cases. Our retrospective study aimed to assess the outcomes of liver trauma patients who underwent a shortened PHP. MethodsAll consecutive patients who underwent PHP for blunt liver trauma from 1998 to 2019 in our Level I trauma center were included in the study. Unstable patients with severe liver trauma were transferred to the operating room without any delay, and a collective decision was made to perform abbreviated laparotomy to pack the liver. Demographics, perioperative data, postoperative outcomes, and mortality were retrospectively collected, and survivors and deceased patients were compared with a paired t-test. ResultsFifty-nine patients of 206 patients admitted with severe liver injuries were treated with shortened PHP. Thirty-four (57.6%) patients died, including 26 (76.5%) within the first 24 h. Twelve (20.3%) patients had a selective hepatic embolization and eight (13.6%) had an extrahepatic embolization. Forty-eight patients had an extra abdominal associated injury. This was not a predictive factor of mortality. The removal of packing was performed in 24 patients within 72 h after laparotomy, with an 80% survival rate in these patients. ConclusionShortened PHP is an effective strategy for controlling liver bleeding in severe hepatic trauma. The mortality rate of these patients is high, but after the removal of packing, the survival is good.

Severe liver trauma among pediatric patients in the Japan Trauma Registry

BackgroundLimited information exists regarding the clinical characteristics, management practices, and outcomes of pediatric patients with liver injury in Japan. The aim of this study is to evaluate the characteristics, management,...

Definitive Surgery for Liver Trauma in a Tertiary HPB Center (with video).

Background: Surgery for severe liver trauma remains challenging even for HPB surgeons, mainly due the hemodynamical instability, involvement of major vascular and biliary elements, impaired background liver and frequent anatomical variants. In this setting, despite conservative policy, major liver resection is still required in selected cases. Also salvage liver transplantation may be needed. Our study aims to analyze the results after definitive surgery for hepatic injury (HI) in a tertiary HPB center. Methods: Sixty-six patients with HI were admitted and treated in our center between June 2000 and June 2021. The median age was 29 years (mean 35, range 10-76). The male/female ratio was 50/16. According to the American Association for the Surgery of Trauma (AAST) system, HIs were grade II in one patient (1.5%), grade III in 11 pts (16.7%), grade IV in 25 pts (37.9%), and grade V in 29 pts (43.9%); no patient had grade I or VI HI. Results: Fifty-two pts (78.8%) benefitted from surgery and 14 pts (21.2%) from non-operative treatment (NOT). Perihepatic packing was previously performed in 38 pts (73.1%). Surgery consisted in hepatic resections (HR) in 51 pts (77.3%) and liver transplantation in one patient (1.5%). The rate of major HR was 51.9% (27 HRs). The overall major morbidity and mortality rates were 33.3% (20 pts) and 13.6% (9 pts), respectively. For surgery, the major complication rate was 35.3% (18 pts), while for major and minor HR were 40.7% (11 pts) and 29.2% (7 pts), respectively; the mortality rate was 15.7% (8 pts). After NOT, the major morbidity and mortality rates were 14.3% (2 pts) and 7.1% (1 pt), respectively. Conclusions: Hepatic resections, especially major ones and/or involving vascular and biliary reconstructions, as well as non-operative treatment for severe hepatic injuries, are to be carried out in tertiary HPB centers, thus minimizing the morbidity and mortality rates, while having the liver transplantation as salvage option.

Early surgical management of severe liver trauma with vascular complication can lead to early discharge

Intrahepatic arterio-portal fistulas are rare complications of blunt hepatic trauma. We describe a case of a 35-year-old male sustaining blunt abdominal trauma resulting in a grade IV liver injury complicated by arterio-portal fistula, portal venous pseudoaneurysm and concomitant bile duct injury. Although arterial embolisation is the mainstay of treatment for arterio-portal fistula, we describe a rationale for early involvement of a hepatobiliary surgeon for multidisciplinary management. Hepatic resection for acute hepatic trauma can, in selected cases, promptly manage all elements of portal triad injury, and in this particular case facilitated early uncomplicated discharge.

Surgical treatment for severe liver injuries: a single-center experience.

The liver is one of the most frequently injured organs in abdominal trauma. The advancements in diagnosis and interventional therapy shifted the management of liver trauma towards a non-operative management (NOM). Nevertheless, in severe liver injuries (LI), surgical treatment often involving liver resection (LR) and rarely liver transplantation (LT) remains the main option. The present paper analyses a single center experience in a referral HPB center on a series of patients with high-grade liver trauma. Forty-five patients with severe LI, that benefitted from NOM (6 pts), LRs (38 pts), and LT (1 pt) performed in our center between June 2000 and June 2019, were included in a combined prospective and retrospective study. The median age of the patients was 29 years (median 33, range 10-76), and the male/female ratio of 33/12. Almost all cases had blunt trauma, except 2 with stab wound (4.4%). LIs classified according to the American Association for the Surgery of Trauma (AAST) system were 13.3% (grade III), 44.2% (grade IV), and 42.2% (grade V); none were grade I, II or VI. The rate of major LR was 56.4% (22 LRs). The median operative time was 200 minutes (mean 236; range 150-420). The median blood loss was 750 ml (mean 940; range 500-6500). Overall and major complication rates were 100% (45 pts) and 33.3% (15 pts), respectively. Overall mortality rate was 15.6% (7 pts). Severe liver trauma, often involving complex liver resections, should be managed in a referral HPB center, thus obtaining the best results in terms of morbidity and mortality.

New hemostatic device for grade IV\u2013V liver injury in porcine model: a proof of concept

BackgroundThe liver is the most injured organ following abdominal trauma. Uncontrolled bleeding remains the main cause of early liver injury-related death, with a mortality rate of 50–54% in the first 24 h after admission and with 80% of operative deaths. Packing and reoperation account for the increased survival in severe liver trauma, and they are recommended for severe liver injuries (grades IV–V).Perihepatic packing can lead to several potential complications. An excessive packing can cause complications due to abdominal compartment syndrome, while a soft packing may be ineffective, and thus, bleeding can continue inadvertently with the consequent hypovolemic shock and potentially death.MethodsWe designed a new vacuum-based device to perform perihepatic packing without the negative side-effects of the classic technique. We conducted a prospective pilot feasibility study in a porcine model. We compared the traditional perihepatic packing (PHP) (n = 2) with the new VacBagPack device (VBP) (n = 2).ResultsBoth pigs survived with the new device and showed an equivalent outcome to the one that survived in the traditional technique group. Blood tests were similar too. This suggests that VBP could be at least as effective as traditional PHP.ConclusionsWe establish a first step towards the development of a new packing device. A new study with a bigger sample size still in pigs will be conducted. Also, an industrial model of the device is currently in production.

Damage control surgery Concept

Damage control surgery concept (DCS) consists of performing a staged surgery and allowing resuscitation in severe trauma patients who require surgical management. Initially, the DCS has been described in severe liver trauma associated with coagulopathy. Over time, Due to the observed advantages, the DSC approach has become standard practice for abdominal trauma with the extent to extra-abdominal trauma and acute abdominal emergencies.

Utility of the Glissonean Pedicle Ligation Method as the New Optional Surgical Technique for Severe Liver Trauma

Utility of the Glissonean Pedicle Ligation Method as the New Optional Surgical Technique for Severe 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.

Real-time elastography evaluation of differential penetrating liver trauma in a rabbit model

BackgroundReal-time ultrasound elastography (RTE) is used to examine liver fibrosis and benign and malignant lesions, but its use for the diagnosis of liver trauma has not been examined. The purpose of this study was to examine the use of RTE for the evaluation of differential penetrating liver trauma in a rabbit model. Material and methodsEighty New Zealand rabbits were divided into 2 groups. In one group, a single incision (type “-” lesion) was made, and in the other group a hash mark incision (type “#” lesion) was made (about 0.5cm in depth; 1.0–2.0cm in length). RTE was performed at 10, 30, and 60min after injury. ResultsThere were no differences in mean RTE scores between the 2 types of lesions at 10 and 30min. However, the mean values for the 2 types of lesions increased from 10min to 60min (type ‘-’ lesion: 0.88±0.32 to 2.06±0.88; type ‘#’ lesion: 0.89±0.34 to 2.63±1.16). At 60min, the mean elasticity score in the type ‘#’ lesion group was significantly higher than in the type ‘-’ lesion group (P<.001). Strain ratios were not different between the groups at each time point, but in each group the values decreased from the 10min time point to the 60min time point (P-value for the trends, <.001). ConclusionsRTE may be able to distinguish mild or severe penetrating liver trauma at 60min or more after injury.

Molecular Adsorbent Recirculating System Effectively Replaces Hepatic Function in Severe Acute Liver Failure.

Patients with severe acute liver failure (ALF) have extreme physiologic dysfunction and often die if transplantation is not immediately available. Patients may be supported with MARS (Baxter International Inc., Deerfield, IL) until transplantation or spontaneous recovery occurs. We present the largest series in the United States of MARS therapy as temporary hepatic replacement for ALF. MARS was used to support patients with severe liver trauma (SLT), in ALF patients as a bridge to transplantation (BTT), and as definitive therapy for toxic ingestion or idiopathic liver failure (DT) in a level 1 trauma center and large transplant center. Patient demographics, etiology of ALF, and laboratory values were recorded. Endpoints were patient survival ± liver transplant and/or recovery of liver function. Twenty-seven patients with severe ALF received MARS therapy. Five patients with SLT had a 60% survival with recovery of liver and renal function. Thirteen patients received MARS as a BTT, of which 9 were transplanted with a 1-year survival of 78% (program overall survival 85% at 1 year). All 4 who were not transplanted expired. Nine patients with ALF from toxic ingestion received MARS as DT with liver recovery and survival in 67%. MARS therapy resulted in significant improvement in liver function, coagulation, incidence of encephalopathy, and creatinine. MARS therapy successfully replaced hepatic function in ALF allowing time for spontaneous recovery or transplantation. Spontaneous recovery was remarkably common if support can be sustained.

Clinical analysis of gauze packing oppression in 18 cases of patients with severe liver injury of

Objective To investigate the effects of application of gauze packing oppression in severe liver trauma therapy. Methods Clinical data of gauze packing oppression treated 18 patients with severe liver laceration were retrospectively analysized, with gauze packing oppression, postoperative hemostatic, antibiotic therapy and nutritional support, a t 5-7 d began plucking gauze, 12-14 d after pulling, no bleeding wounds gradually healed. Results 17 cases were cured, 1 died, the cure rate of 95%, the cause of death as multiple injuries caused by the merger of multiple organ failure; postoperative pull gauze(or bandage) again bleeding in 6 cases, 2 cases of secondary hemorrhage, the drug was difficult to control again laparotomy to stop bleeding; after 4 cases of subphrenic effusion, infection, complicated with biliary fistula in 5 cases, liver abscess in 2 cases, 3 cases of abdominal infection, wound infection in 3 cases. Conclusion For patients with severe liver rupture gauze packing to stop bleeding is still simple and effective ways to deal under an emergency situation for the hospital, both a method of treatment, but also packing oppression to stop bleeding temporarily for processing and then sent to a higher level hospital completely win time, can effectively reduce the mortality and reduce complications. Key words: Rupture of liver; Surgical sponges; Endotamponade; Surgical procedures, operative