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Obaid O, Torres-Ruiz T, Rady E, Rodriguez-Silva F, Barber MW, Cotterman RN. Contemporary epidemiologic overview of adult liver trauma management across the United States: Analysis of the American College of Surgeons Trauma Quality Improvement Program database. Surgery 2025; 183:109390. [PMID: 40328161 DOI: 10.1016/j.surg.2025.109390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2025] [Revised: 02/25/2025] [Accepted: 03/31/2025] [Indexed: 05/08/2025]
Abstract
INTRODUCTION Multiple definitive and temporizing management techniques have been devised for liver trauma, and we have shifted toward nonoperative management as endovascular capabilities have evolved. Despite management guidelines, no large-scale data on implementation exist. This study characterizes current nationwide liver trauma management. METHODS This was an analysis of 2017-2020 American College of Surgeons Trauma Quality Improvement Program. Adult patients with liver trauma were included, with the exclusion of those with severe extra-abdominal injuries (Abbreviated Injury Scale >3). Nonoperative management was defined as no exploratory laparotomy (ex-lap) within 6 hours. Primary outcomes were management strategies employed and failure of nonoperative management (ex-lap after 6 hours), stratified by injury mechanism, American Association for the Surgery of Trauma liver injury grade, and American College of Surgeons trauma center verification level. Secondary outcomes were mortality, survivor-only length of stay, and in-hospital complications. Interfacility transfer patients were subanalyzed. RESULTS A total of 96,652 patients with liver trauma were identified, of which 60,199 were included [24% penetrating; 74% blunt]. In total, 60% grade I/II injuries, 21% grade III, 14% grade IV, 5% grade V, and 0.2% grade VI. Mean age 39 ± 17 years, 65% male, 58% White, ISS was 17[12-24], liver-AIS 2[2-4], and lowest systolic blood pressure within 1-hour was 84 ± 31 mm Hg. Mortality was 5%, hospital length of stay was 6 [2-13] days, and intensive care unit length of stay 3 [2-6] days. Both blunt and penetrating liver injuries of all severities were more likely to undergo operative management at higher American College of Surgeons trauma center verification levels. Of 13,672 patients who were transferred, 92% underwent nonoperative management, 1.3% angioembolization, and only 3.4% failed nonoperative management. CONCLUSION Liver trauma remains a major public health burden with mortality approaching 66% among severely injured patients, and current management shows significant nationwide variability. Blunt liver trauma is primarily being managed nonoperatively, and angioembolization is assuming a growing role. Very few patients who were transferred to greater levels of care required operative intervention, having implications for resource allocation.
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Affiliation(s)
- Omar Obaid
- Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Tania Torres-Ruiz
- Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Emily Rady
- Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | | | - Meghan Wandtke Barber
- Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Robert N Cotterman
- Department of Surgery, Toledo Hospital, ProMedica Health System, Toledo, OH; Trauma Division, ACS Level I Trauma Center, Toledo Hospital, ProMedica Health System, Toledo, OH.
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Field X, Crichton J, Kong V, Ko J, Laing G, Bruce J, Clarke D. AAST grade of liver injury is not the single most important consideration in decision making for liver trauma. Injury 2024; 55:111526. [PMID: 38644076 DOI: 10.1016/j.injury.2024.111526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 02/28/2024] [Accepted: 04/02/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND The liver is one of the most injured organs in both blunt and penetrating trauma. The aim of this study was to identify whether the AAST liver injury grade is predictive of need for intervention, risk of complications and mortality in our patient population, and whether this differs between blunt and penetrating-trauma mechanisms. METHODS Retrospective review of all liver injuries from a single high-volume metropolitan trauma centre in South Africa from December 2012 to January 2022. Inclusion criteria were all adults who had sustained traumatic liver injury. Patients were excluded if they were under 15 years of age or had died prior to operation or assessment. Statistical analysis was undertaken using both univariate and multivariate models. RESULTS 709 patients were included, of which 351 sustained penetrating and 358 blunt trauma. Only 24.3 % of blunt compared to 76.4 % of penetrating trauma patients underwent laparotomy (p< 0.001). In blunt trauma, increasing AAST grade correlated directly with rates of laparotomy with an odds ratio of 1.7 (p < 0.001). In penetrating trauma, there was no statistical significance between increasing AAST grade and the rate of laparotomy. The rate of bile leak was 4.5 % (32/709) and of rebleed was 0.7 % (5/709). Five patients underwent ERCP and endoscopic sphincterotomy for bile leak, and three required angio-embolization for rebleeding. Increasing AAST grades were significantly associated with the odds of bile leak in both blunt and penetrating trauma. There was a statistically significant increase in the odds of a rebleed with increasing AAST grade in penetrating trauma. Five patients rebled, of which three died. Seven patients developed hepatic necrosis. Seventy-six patients died (10 %). There were 34/358 (9 %) deaths in the blunt cohort and 42 /351 (11 %) deaths in the penetrating trauma cohort. CONCLUSION AAST grade in isolation is not a good predictor of the need for operation in hepatic trauma. Increasing AAST grade was not found to correlate with increased risk of mortality for both blunt and penetrating hepatic trauma. In both blunt and penetrating trauma, increasing AAST grade is significantly associated with increased bile leak. The need for ERCP and endoscopic sphincterotomy to manage bile leak in our setting is low. Similarly, the rate of rebleeding and of angioembolization was low.
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Affiliation(s)
- Xavier Field
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand
| | - James Crichton
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand; Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Victor Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Department of Surgery, University of KwaZulu Natal, Durban, South Africa.
| | - Jonathan Ko
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Grant Laing
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - John Bruce
- Department of Surgery, University of KwaZulu Natal, Durban, South Africa
| | - Damian Clarke
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Department of Surgery, University of KwaZulu Natal, Durban, South Africa
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Alanezi T, Altoijry A, Alanazi A, Aljofan Z, Altuwaijri T, Iqbal K, AlSheikh S, Molla N, Altuwaijri M, Aloraini A, Altuwaijri F, Aldossary MY. Management and Outcomes of Traumatic Liver Injury: A Retrospective Analysis from a Tertiary Care Center Experience. Healthcare (Basel) 2024; 12:131. [PMID: 38255020 PMCID: PMC10815392 DOI: 10.3390/healthcare12020131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND although liver injuries are one of the most critical complications of abdominal trauma, choosing when to operate on these injuries is challenging for surgeons worldwide. METHODS We conducted a retrospective analysis of liver injury cases at our institution from 2016 to 2022 to describe the operative and nonoperative management (NOM) outcomes in patients with traumatic liver injuries. Baseline patient characteristics, liver injury details, treatments, and outcomes were analyzed. RESULTS Data from 45 patients (male, 77.8%) were analyzed. The mean age was 29.3 years. Blunt trauma was the most common injury mechanism (86.7%), whereas penetrating injuries were 8.9% of cases. Conservative management was associated with 18.9% of complications. The overall complication rate was 26.7%; delirium and sepsis were the most common (13.3%), followed by acute renal failure (4.4%), pneumonia, biliary leaks, and meningitis/seizures. CONCLUSIONS Notwithstanding its limitations, this retrospective analysis demonstrated that NOM can serve as a safe and effective strategy for hemodynamically stable patients with liver trauma, irrespective of the patient's injury grade. Nevertheless, careful patient selection and monitoring are crucial. Further investigations are necessary to thoroughly evaluate the management of traumatic liver injuries, particularly in the context of multiorgan injuries.
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Affiliation(s)
- Tariq Alanezi
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia (Z.A.)
| | - Abdulmajeed Altoijry
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (T.A.); (K.I.); (S.A.); (M.Y.A.)
| | - Aued Alanazi
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia (Z.A.)
| | - Ziyad Aljofan
- College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia (Z.A.)
| | - Talal Altuwaijri
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (T.A.); (K.I.); (S.A.); (M.Y.A.)
| | - Kaisor Iqbal
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (T.A.); (K.I.); (S.A.); (M.Y.A.)
| | - Sultan AlSheikh
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (T.A.); (K.I.); (S.A.); (M.Y.A.)
| | - Nouran Molla
- Department of Radiology and Medical Imaging, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia;
| | - Mansour Altuwaijri
- Division of Gastroenterology, Department of Medicine, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia;
| | - Abdullah Aloraini
- Division of General Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia;
| | - Fawaz Altuwaijri
- Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia;
| | - Mohammed Yousef Aldossary
- Division of Vascular Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh 11322, Saudi Arabia; (T.A.); (K.I.); (S.A.); (M.Y.A.)
- Division of Vascular Surgery, Department of Surgery, Dammam Medical Complex, Dammam 32245, Saudi Arabia
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L'Huillier R, Cayot B, Turc J, Milot L. Portal vein embolization following arterial portography for the management of an active portal bleeding after blunt liver trauma in a cirrhotic patient. CVIR Endovasc 2024; 7:5. [PMID: 38175362 PMCID: PMC10766936 DOI: 10.1186/s42155-023-00423-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The management of blunt liver trauma in cirrhotic patients is challenging, because while bleeding is most often of arterial origin, the increased pressure in the portal system associated with cirrhosis can increase the risk of portal bleeding, which is sometimes difficult to confirm on contrast-enhanced abdominal computed tomography. CASE PRESENTATION We managed a 54-year-old cirrhotic patient who presented with blunt liver trauma. Computed Tomography showed active intraperitoneal bleeding presumed to be of hepatic origin. Given the patient's hemodynamic stability, the decision was made to manage the patient non-surgically. The patient underwent hepatic arteriography to rule out an arterial origin to the bleeding. A superior mesenteric arterial portography confirmed the portal venous origin of the bleeding. To stop the bleeding, a distal portal vein embolization using coils and glue was performed by approaching a large paraumbilical vein. CONCLUSIONS Our case study shows the value of arterial portography in the management of these patients, when they are clinically stable enough to benefit from non-surgical management; This allows arterial bleeding to be excluded on hepatic arteriography, portal bleeding to be confirmed on portography following arteriography in the superior mesenteric artery, and guidance of portal vein embolization.
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Affiliation(s)
- Romain L'Huillier
- Department of Diagnostic and Interventional Radiology, Hôpital Edouard Herriot, Hospices Civils de Lyon, University of Lyon, Pavillon B, 5 Place D'Arsonval, Lyon, 69003, France.
- LabTAU - INSERM U1032, Lyon, 69003, France.
- The French Comprehensive Liver Center, Hospices Civils de Lyon, University of Lyon, Lyon, 69004, France.
| | - Bénédicte Cayot
- Department of Diagnostic and Interventional Radiology, Hôpital Edouard Herriot, Hospices Civils de Lyon, University of Lyon, Pavillon B, 5 Place D'Arsonval, Lyon, 69003, France
| | - Jean Turc
- Department of Anesthesiology and Intensive Care Unit, Hôpital Edouard Herriot, Hospices Civils de Lyon, University of Lyon, Lyon, 69003, France
| | - Laurent Milot
- Department of Diagnostic and Interventional Radiology, Hôpital Edouard Herriot, Hospices Civils de Lyon, University of Lyon, Pavillon B, 5 Place D'Arsonval, Lyon, 69003, France
- LabTAU - INSERM U1032, Lyon, 69003, France
- The French Comprehensive Liver Center, Hospices Civils de Lyon, University of Lyon, Lyon, 69004, France
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Hosseinpour H, Nelson A, Bhogadi SK, Spencer AL, Alizai Q, Colosimo C, Anand T, Ditillo M, Magnotti LJ, Joseph B. Delayed versus early hepatic resection among patients with severe traumatic liver injuries undergoing damage control laparotomy. Am J Surg 2023; 226:823-828. [PMID: 37543482 DOI: 10.1016/j.amjsurg.2023.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/22/2023] [Accepted: 06/24/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION We aimed to assess the effect of time to hepatic resection on the outcomes of patients with high-grade liver injuries who underwent damage control laparotomy (DCL). METHODS This is a 4-year (2017-2020) analysis of the ACS-TQIP. Adult trauma patients with severe liver injuries (AAST-OIS grade ≥ III) who underwent DCL and hepatic resection were included. We excluded patients with early mortality (<24 h). Patients were stratified into those who received hepatic resection within the initial operation (Early) and take-back operation (Delayed). RESULTS Of 914 patients identified, 29% had a delayed hepatic resection. On multivariable regression analyses, although delayed resection was not associated with mortality (aOR:1.060,95%CI[0.57-1.97],p = 0.854), it was associated with higher complications (aOR:1.842,95%CI[1.38-2.46],p < 0.001), and longer hospital (β: +0.129, 95%CI[0.04-0.22],p = 0.005) and ICU (β:+0.198,95%CI[0.14-0.25],p < 0.001) LOS, compared to the early resection. CONCLUSION Delayed hepatic resection was associated with higher adjusted odds of major complications and longer hospital and ICU LOS, however, no difference in mortality, compared to early resection.
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Affiliation(s)
- Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Adam Nelson
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Qaidar Alizai
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Tanya Anand
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
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Schütz ŠO, Rousek M, Pudil J, Záruba P, Malík J, Pohnán R. Delayed Post-Traumatic Hemobilia in a Patient With Blunt Abdominal Trauma: A Case Report and Review of the Literature. Mil Med 2023; 188:3692-3695. [PMID: 35894601 DOI: 10.1093/milmed/usac230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/22/2022] [Accepted: 07/20/2022] [Indexed: 11/12/2022] Open
Abstract
Hemobilia is a rare condition defined as bleeding in the biliary tract. The clinical presentation is variable. The typical manifestation consists of jaundice, upper gastrointestinal bleeding, and right upper quadrant abdominal pain. This set of symptoms is known as "Quincke's triad." It is present in only 22%-35% of cases. Post-traumatic hemobilia is an extraordinarily rare condition occurring in only 6% of the patients with hemobilia. In general, it occurs in less than 0.2% of patients with liver trauma. A delay in the development of bleeding after liver trauma is frequent. Early diagnosis is essential because massive bleeding into the biliary tract is a potentially life-threatening condition. We present a case of a patient with massive hemobilia developed 12 days after blunt abdominal trauma. Computed tomography angiography showed two pseudoaneurysms in hepatic segments V and VIII with contrast medium extravasation. We successfully performed digital subtraction angiography with selective transcatheter arterial embolization of the leaking segment VIII pseudoaneurysm. Embolization of the pseudoaneurysm in segment V was technically impracticable. Our article provides a review of the published literature focussing on the prevalence, diagnostics, and treatment of post-traumatic hemobilia.
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Affiliation(s)
- Štěpán-Ota Schütz
- Department of Surgery, Second Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, 16902, Czech Republic
| | - Michael Rousek
- Department of Surgery, Second Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, 16902, Czech Republic
| | - Jiří Pudil
- Department of Surgery, Second Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, 16902, Czech Republic
| | - Pavel Záruba
- Department of Surgery, Second Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, 16902, Czech Republic
| | - Jozef Malík
- Department of Radiology, Military University Hospital Prague, Prague, 16902, Czech Republic
| | - Radek Pohnán
- Department of Surgery, Second Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, 16902, Czech Republic
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Ranjan SK, Singh RK, Kumar S, Kumari P. Assessment of Frequency, Patterns, and Causes of Blunt Abdominal Trauma in a North Indian Cohort: An Autopsy-Based Study. Cureus 2023; 15:e44856. [PMID: 37809150 PMCID: PMC10560073 DOI: 10.7759/cureus.44856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction The abdomen is one of the most frequently damaged areas in trauma patients and is commonly encountered in road traffic accidents (RTAs). The present study evaluates the frequency, etiology, causation, and form of injury in blunt abdominal trauma (BAT) cases who had autopsies. Method An autopsy-based observational prospective study was conducted at the Department of Forensic Medicine and Toxicology, Nalanda Medical College and Hospital Patna, India, during the period from October 2018 to September 2020, which included a total of 940 autopsy cases showing blunt abdominal injuries. A predesigned proforma for the postmortem evaluation of BAT victims was used to collect the required information on the cases. Descriptive statistics were performed, and the data were presented as frequency (%) and mean±SD. Chi-square tests were performed to compare categorical variables between groups. Results BAT accounted for 120 (12.76%) cases of all autopsies performed. The majority of victims were male (92.48%). Victims aged 21-30 years (31, 25.83%) were the ones most usually engaged in BAT cases. Among the mechanisms accountable for BAT, RTAs were the most common (99, 82.50%), followed by assault (16, 13.30%). In most of the cases, the liver was injured (107, 89.16%), followed by the spleen (60, 50.00%) and kidney (24, 20.00%). The majority of blunt abdominal injury-related deaths were accidental (100, 83.33%), followed by homicidal (15, 12.5%) and suicidal cases (5, 4.17%). Hemorrhage and neurogenic shock were the most prevalent causes of mortality, particularly if the individual died within a few hours. Conclusion RTAs are the most frequent cause of BAT in autopsy cases, and the liver is the most affected organ. The majority of deaths occur within the first 24 hours of injury. Since blunt abdominal injuries have the propensity to increase morbidity and mortality, appropriate emphasis on their precise diagnosis and satisfactory therapy is mandated.
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Affiliation(s)
- Saroj Kumar Ranjan
- Forensic Medicine and Toxicology, Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, IND
| | - Ritesh Kumar Singh
- Forensic Medicine and Toxicology, Nalanda Medical College and Hospital (NMCH), Patna, IND
| | - Sanjeev Kumar
- Forensic Medicine and Toxicology, Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, IND
| | - Pinki Kumari
- Forensic Medicine and Toxicology, Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, IND
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Ooya Y, Takahira S. Hepatic subcapsular hematoma without elevated hepatic enzyme levels: A case report. Trauma Case Rep 2023; 46:100867. [PMID: 37396118 PMCID: PMC10310931 DOI: 10.1016/j.tcr.2023.100867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 07/04/2023] Open
Abstract
In cases of abdominal trauma, elevated liver enzyme levels can indicate hepatic injury. To date, there are no documented reports of hepatic trauma without liver enzyme abnormalities. Herein, we present a case of hepatic subcapsular hematoma following a motor vehicle accident without abnormal findings in blood and biochemical tests over the course of time. The patient was a woman in her 20s who had collided with a passenger car while driving a light motor vehicle. She walked by herself to see a nearby after-hour doctor as an outpatient. Radiography was performed, and the patient was discharged on the same day. She was reexamined the next day and referred to our medical center due to possible hepatic injury. Her respiratory and circulatory dynamics were stable; however, she experienced mild tenderness in her right upper abdomen upon arrival. Echo-free space was observed in Morrison's and Douglas' pouches on abdominal ultrasound, and abdominal computed tomography showed a hepatic subcapsular hematoma (grade II according to the American Association for the Surgery of Trauma liver injury scale). However, blood and biochemical tests did not reveal any abnormalities. The hematoma reduced with conservative treatment after admission, and the patient was discharged on the 18th hospital day. This case indicates that hepatic injury cannot be ruled out based on serodiagnosis alone; thus, diagnostic imaging is required in cases of blunt abdominal trauma.
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Affiliation(s)
- Yoshitaka Ooya
- Corresponding author at: Department of Trauma and Emergency Acute Medicine, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka-City, Saitama-Pref 350-1298, Japan.
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Mitricof B, Kraft A, Anton F, Barcu A, Barzan D, Haiducu C, Brasoveanu V, Popescu I, Moldovan CA, Botea F. Severe liver trauma with complex portal and common bile duct avulsion: A case report and review of the literature. World J Clin Cases 2023; 11:3837-3846. [PMID: 37383130 PMCID: PMC10294146 DOI: 10.12998/wjcc.v11.i16.3837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/02/2023] [Accepted: 04/12/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Given its size and location, the liver is the third most injured organ by abdominal trauma. Thanks to recent advances, it is unanimously accepted that the non-operative management is the current mainstay of treatment for hemodynamically stable patients. However, those patients with hemodynamic instability that generally present with severe liver trauma associated with major vascular lesions will require surgical management. Moreover, an associated injury of the main bile ducts makes surgery compulsory even in the case of hemodynamic stability, thereby imposing therapeutic challenges in the tertiary referral hepato-bilio-pancreatic centers’ setting.
CASE SUMMARY We present the case of a 38-year-old male patient with The American Association for the Surgery of Trauma grade V liver injury and an associated right branch of portal vein and common bile duct avulsion, due to a crush polytrauma. The patient was referred to the nearest emergency hospital and because of the hemorrhagic shock, damage control surgery was performed by means of ligation of the right portal vein branch and right hepatic artery, and hemostatic packing. Afterwards, the patient was referred immediately to our tertiary hepato-bilio-pancreatic center. We performed depacking, a right hepatectomy and Roux-en-Y hepaticojejunostomy. On the 9th postoperative day, the patient developed a high output anastomotic bile leak that required a redo of the cholangiojejunostomy. The postoperative period was marked by a surgical incision site of incomplete evisceration that was managed non-operatively by negative wound pressure. The follow-up was optimal, with no complications at 55 mo.
CONCLUSION In conclusion, the current case clearly supports that a favorable outcome in severe liver trauma with associated vascular and biliary injuries is achieved thru proper therapeutic management, conducted in a tertiary referral hepato-bilio-pancreatic center, where a stepwise and complex surgical approach is mandatory.
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Affiliation(s)
- Bianca Mitricof
- Medicine Doctoral School, Titu Maiorescu University of Bucharest, Bucharest 040441, Romania
| | - Alin Kraft
- Department of General Surgery, Regina Maria Military Emergency Hospital, Brasov 500007, Romania
| | - Florentina Anton
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest 050474, Romania
| | - Alexandru Barcu
- Medicine Doctoral School, Titu Maiorescu University of Bucharest, Bucharest 040441, Romania
| | - Darina Barzan
- Dan Setlacec Center for General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Carmen Haiducu
- Dan Setlacec Center for General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Vladislav Brasoveanu
- Dan Setlacec Center for General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
- Department of Medical-Surgical and Prophylactic Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
| | - Irinel Popescu
- Dan Setlacec Center for General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
- Department of Medical-Surgical and Prophylactic Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
| | - Cosmin Alec Moldovan
- Department of Medical-Surgical and Prophylactic Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
- Department of General Surgery, Witting Clinical Hospital, Bucharest 010243, Romania
| | - Florin Botea
- Dan Setlacec Center for General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
- Department of Medical-Surgical and Prophylactic Disciplines, Faculty of Medicine, Titu Maiorescu University of Bucharest, Bucharest 031593, Romania
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Sehgal M, Singh TR, Yadav D, Dhua A, Bajpai M. Traumatic Isolated Right Lobe Devascularization of the Liver: An Unusual Case. Cureus 2023; 15:e40621. [PMID: 37476146 PMCID: PMC10354828 DOI: 10.7759/cureus.40621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/22/2023] Open
Abstract
Isolated liver lobe devascularization is a very rare case, with conflicting literature regarding management. We describe a very unusual case of traumatic isolated right lobe devascularization of the liver with its attendant management challenges. An eight-year-old boy with a history of road traffic accidents presented with abdominal pain. Although the child was hemodynamically stable on presentation, extended focused assessment with sonography in trauma was positive. Contrast-enhanced computed tomography (CECT) scan of the torso revealed a nonenhancing right lobe of the liver involving segments 5-8 and the gross hemoperitoneum. Nonoperative management was tried. There were persistent high-grade fever spikes, for which prophylactic antibiotics were started, but the fever workup was negative. Abdominal drains were inserted to drain fluid and relieve distress. Output was noted to be bilious on day 21 of injury. Diagnostic laparoscopy on day 22 revealed hypertrophied left lobe of the liver with an absent (autolyzed) right lobe. The subsequent ward course was uneventful, and the child was discharged in stable condition. Thus, the indication of surgery in such cases is clinical deterioration, not radiological findings. Management should be in a dedicated trauma center with immediate operating room availability.
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Affiliation(s)
- Mehak Sehgal
- Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Teg R Singh
- Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Devendra Yadav
- Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Anjan Dhua
- Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
| | - Minu Bajpai
- Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, IND
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Tang WR, Wu CH, Yang TH, Yen YT, Hung KS, Wang CJ, Shan YS. Impact of trauma teams on high grade liver injury care: a two-decade propensity score approach study in Taiwan. Sci Rep 2023; 13:5429. [PMID: 37012308 PMCID: PMC10070483 DOI: 10.1038/s41598-023-32760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 04/01/2023] [Indexed: 04/05/2023] Open
Abstract
High-grade liver laceration is a common injury with bleeding as the main cause of death. Timely resuscitation and hemostasis are keys to the successful management. The impact of in-hospital trauma system on the quality of resuscitation and management in patients with traumatic high-grade liver laceration, however, was rarely reported. We retrospectively reviewed the impact of team-based approach on the quality and outcomes of high-grade traumatic liver laceration in our hospital. Patients with traumatic liver laceration between 2002 and 2020 were enrolled in this retrospective study. Inverse probability of treatment weighting (IPTW)-adjusted analysis using the propensity score were performed. Outcomes before the trauma team establishment (PTTE) and after the trauma team establishment (TTE) were compared. A total of 270 patients with liver trauma were included. After IPTW adjustment, interval between emergency department arrival and managements was shortened in the TTE group with a median of 11 min (p < 0.001) and 28 min (p < 0.001) in blood test reports and duration to CT scan, respectively. Duration to hemostatic treatments in the TTE group was also shorter by a median of 94 min in patients receiving embolization (p = 0.012) and 50 min in those undergoing surgery (p = 0.021). The TTE group had longer ICU-free days to day 28 (0.0 vs. 19.0 days, p = 0.010). In our study, trauma team approach had a survival benefit for traumatic high-grade liver injury patients with 65% reduction of risk of death within 72 h (Odds ratio (OR) = 0.35, 95% CI = 0.14-0.86) and 55% reduction of risk of in-hospital mortality (OR = 0.45, 95% CI = 0.23-0.87). A team-based approach might contribute to the survival benefit in patients with traumatic high-grade liver laceration by facilitating patient transfer from outside the hospital, through the diagnostic examination, and to the definitive hemostatic procedures.
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Affiliation(s)
- Wen-Ruei Tang
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Hsien Wu
- Division of General Surgery, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Tsung-Han Yang
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Yi-Ting Yen
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Kuo-Shu Hung
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Chih-Jung Wang
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704.
| | - Yan-Shen Shan
- Division of General Surgery, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Gallaher J, Burton V, Schneider AB, Reid T, Raff L, Smith CB, Charles A. The Effect of Angioembolization Versus Open Exploration for Moderate to Severe Blunt Liver Injuries on Mortality. World J Surg 2023; 47:1271-1281. [PMID: 36705742 DOI: 10.1007/s00268-023-06926-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Blunt liver injury is common and is associated with a high morbidity and mortality. More severe injuries often require either angioembolization or open operative repair, depending on patient factors and facility capacity. We sought to describe patient outcomes based on intervention type. METHODS We analyzed the National Trauma Data Bank (2017-2019) using ICD-10 codes to identify adult patients with blunt liver injury and their interventions. AIS (Abbreviated Injury Scale) scores were used to group patients based on liver injury severity (AIS 2-6). Logistic regression modeling was used to estimate the adjusted odds ratio of death based on intervention type, excluding patients with severe injury. RESULTS Of 2,848,592 trauma patients, 50,250 patients had a blunt liver injury. Among patients with AIS 3/4/5 injury, 1,140 had angioembolization, 1,529 had an open repair, and 188 had both angioembolization and open repair. In comparison with no intervention and adjusted for age, sex, shock index, ISS, and transfusion total (first four hours), angioembolization was associated with a significant decrease in the odds of mortality for patients with an AIS 4 (OR 0.68, 95% CI 0.47, 0.99) and AIS 5 injury (OR 0.39, 95% CI 0.24, 0.64). In patients with an AIS 5 injury, open repair had an increased odds of mortality at OR 1.99 (95% CI 1.47, 2.69). CONCLUSION In an analysis of a national trauma database, patients with a moderate to severe injury (AIS 4 or 5), angioembolization was associated with a significant reduction in the adjusted odds of mortality compared to open repair and should be considered when clinically appropriate.
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Affiliation(s)
- Jared Gallaher
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA.
| | - Victoria Burton
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Andrew B Schneider
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Trista Reid
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Lauren Raff
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Charlotte B Smith
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
| | - Anthony Charles
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, 4006 Burnett Womack Building, Chapel Hill, NC, 27599-7228, USA
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Kagoura M, Monden K, Sadamori H, Hioki M, Ohno S, Takakura N. Outcomes and management of delayed complication after severe blunt liver injury. BMC Surg 2022; 22:241. [PMID: 35733106 PMCID: PMC9219165 DOI: 10.1186/s12893-022-01691-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/17/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The treatment of delayed complications after liver trauma such as bile leakage (BL) and hepatic artery pseudoaneurysms (HAPs) is difficult. The purpose of this study is to investigate the outcomes and management of post-traumatic BL and HAPs. METHODS We retrospectively evaluated patients diagnosed with blunt liver injury, graded by the American Association for the Surgery of Trauma Liver Injury Scale, who were admitted to our hospital between April 2010 and December 2019. Patient characteristics and treatments were analyzed. RESULTS A total of 176 patients with blunt liver injury were evaluated. Patients were diagnosed with grade I-II liver injury (n = 127) and with grade III-V injury (n = 49). BL was not observed in patients with grade I-II injury. Eight patients with grade III-V injury developed BL: surgical intervention was not needed for six patients with peripheral bile duct injury, but hepaticojejunostomy was needed for two patients with central bile duct injury. Out of 10 patients with HAPs, only three with grade I-II injury and one with grade III-V were treated conservatively; the rest six with grade III-V injury required transcatheter arterial embolization (TAE). All pseudoaneurysms disappeared. CONCLUSIONS Severe blunt liver injury causing peripheral bile duct injury can be treated conservatively. In contrast, the central bile duct injury requires surgical treatment. HAPs with grade I-II injury might disappear spontaneously. HAPs with grade III-V injury should be considered TAE.
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Affiliation(s)
- Masaaki Kagoura
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, Hiroshima, 721-8511, Japan
| | - Kazuteru Monden
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, Hiroshima, 721-8511, Japan.
| | - Hiroshi Sadamori
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, Hiroshima, 721-8511, Japan
| | - Masayoshi Hioki
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, Hiroshima, 721-8511, Japan
| | - Satoshi Ohno
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, Hiroshima, 721-8511, Japan
| | - Norihisa Takakura
- Department of Surgery, Fukuyama City Hospital, 5-23-1 Zao, Fukuyama, Hiroshima, 721-8511, Japan
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Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications. Diagnostics (Basel) 2022; 12:diagnostics12061456. [PMID: 35741266 PMCID: PMC9221646 DOI: 10.3390/diagnostics12061456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/09/2022] [Accepted: 06/11/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Biondo-Simões MDLP, Zwierzikowski JA, Antoria JCD, Ioshii SO, Robes RR. Biological compatibility of oxidized cellulose vs. porcine gelatin to control bleeding in liver lesions in rats. Acta Cir Bras 2022; 36:e361101. [PMID: 35019008 PMCID: PMC8734958 DOI: 10.1590/acb361101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/09/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To compare biological compatibility, hemostasis, and adhesion formation between oxidized regenerated cellulose and lyophilized hydrolyzed porcine collagen in liver trauma. METHODS Forty male Wistar rats constituted two groups: group A (oxidized cellulose) and group B (lyophilized hydrolyzed collagen). Standardized liver trauma was made, and the hemostatic agent was applied. Animals in subgroups A7 and B7 were submitted to euthanasia and relaparotomy after seven days, and in subgroups A14 and B14 after 14 days. Macroscopic and microscopic results were evaluated. RESULTS There was no fluid in the cavity in any of the animals, and adhesions were present in all of them. In the analysis after seven days, the adhesions were grades 3 or 4 and consisted of omentum, small intestine, and abdominal wall (p<0.05). In both groups, the mesh was surrounded by a capsule, which was not observed after 14 days. In the evaluation after 14 days, adhesions were grades 2 or 3 (p>0.05). The microscopic examination showed subacute and chronic reactions, in both groups and in both timepoints, with similar frequency. The intensity of fibrosis always presented positive scores. Microabscesses and xanthomatous macrophages were observed in both groups. CONCLUSIONS There was no superiority of one agent over the other.
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16
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Lee GR, Gallo D, Alves de Souza RW, Tiwari-Heckler S, Csizmadia E, Harbison JD, Shankar S, Banner-Goodspeed V, Yaffe MB, Longhi MS, Hauser CJ, Otterbein LE. Trauma-induced heme release increases susceptibility to bacterial infection. JCI Insight 2021; 6:e150813. [PMID: 34520397 PMCID: PMC8564912 DOI: 10.1172/jci.insight.150813] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/09/2021] [Indexed: 12/01/2022] Open
Abstract
Infection is a common complication of major trauma that causes significantly increased morbidity and mortality. The mechanisms, however, linking tissue injury to increased susceptibility to infection remain poorly understood. To study this relationship, we present a potentially novel murine model in which a major liver crush injury is followed by bacterial inoculation into the lung. We find that such tissue trauma both impaired bacterial clearance and was associated with significant elevations in plasma heme levels. While neutrophil (PMN) recruitment to the lung in response to Staphylococcus aureus was unchanged after trauma, PMN cleared bacteria poorly. Moreover, PMN show > 50% less expression of TLR2, which is responsible, in part, for bacterial recognition. Administration of heme effectively substituted for trauma. Finally, day 1 trauma patients (n = 9) showed similar elevations in free heme compared with that seen after murine liver injury, and circulating PMN showed similar TLR2 reduction compared with volunteers (n = 6). These findings correlate to high infection rates.
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Affiliation(s)
| | | | | | | | | | | | | | - Valerie Banner-Goodspeed
- Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael B Yaffe
- Department of Surgery and.,Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Maria Serena Longhi
- Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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17
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Re-visiting Drain Use in Operative Liver Trauma: A Retrospective Analysis. J Surg Res 2021; 270:76-84. [PMID: 34644621 DOI: 10.1016/j.jss.2021.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 07/18/2021] [Accepted: 08/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite the liver being one of the most frequently injured abdominal organs in trauma patients, clinical management strategies differ between trauma surgeons. Few studies have critically evaluated current practice patterns in the operative management of liver trauma. Historical studies recommended against the use of drains but there has not been a modern investigation of this issue. The objective of this study was to analyze outcomes associated with intra-operative drain use for liver trauma. METHODS A retrospective chart review of all adult trauma patients presenting to a Level I trauma center from 2012 to 2018 was performed. Patients who underwent operative management of liver trauma were divided into groups based on whether an intra-abdominal drain was utilized and differences in outcomes between the groups were analyzed. The primary endpoint evaluated was post-operative intra-abdominal abscesses. Univariate and multivariate analyses were performed. RESULTS 184 patients with operative management of liver trauma were included in the study. Closed suction drains were utilized in 26.1% of post-operative patients. Rate of intra-abdominal abscesses was significantly higher in the drain group (35.4% versus 8.8%, P < 0.001). Drains were more commonly used in patients receiving more units of PRBCs (median, 9 units [IQR 4-20] versus median 5.5 units, [IQR 2-14], P = 0.03). Drain use was found to be an independent risk factor for post-operative intra-abdominal abscess on multivariate analysis (OR 4.9, 95% CI 1.7-14, P = 0.003). CONCLUSIONS The results of this study support previous conclusions that drain placement for operative liver trauma is associated with increased risks of infectious complications. Drains were used in patients with more severe liver injury, intra-operative bile leaks, penetrating trauma, and increased blood transfusion requirements. Future studies should focus on the development of specific guidelines for the use of drains in liver trauma.
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Singh A, Prasad G, Mishra P, Vishkarma K, Shamim R. Lessons learned from blunt trauma abdomen: Surgical experience in level I trauma centre. Turk J Surg 2021; 37:277-285. [DOI: 10.47717/turkjsurg.2021.4886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 07/16/2021] [Indexed: 11/23/2022]
Abstract
Objective: The number of accident cases is increasing day by day, so as the challenges. With an emphasis on trauma care, the government started a 120 bedded level I trauma centre in northern India catering to a population of 2.8 million in June 2018. Through this article, we aimed to share our experience of blunt abdominal trauma management from a new level I trauma centre.
Material and Methods: In this retrospective observational study, historical analysis of all available records from July 2018 to March 2020 was done. Inclusion criteria included blunt trauma abdomen with or without associated injuries. Data regarding age, sex, mechanism of injury, time taken to reach the hospital, the pattern of solid organs and hollow viscus injuries, associated extra abdominal injuries, mode of treatment, complications, length of ICU and hospital stay, and mortality were reviewed.
Results: Overall, 154 cases sustained abdominal injuries during the study period. Seventy-five percent were male. The most common cause of blunt trauma abdomen was road traffic crashes. Operative management was required in 57 (37.01%) cases while 97(62.98%) were managed non-operatively (NOM). Mean ICU stay was 05.73 days, while the average hospital stay was 12 days (range 10-60 days). Procedures performed included splenectomy, liver repair, primary closure of bowel injury, and stoma formation. Complications occured in 16.88% cases and the overall mortality rate was 11.68%.
Conclusion: The study revealed that among 154 cases of fatal blunt abdominal trauma, road traffic crash was the most common cause of blunt abdominal trauma, predominantly affecting males. The visceral and peritoneal injury frequently perceived was liver in 40 cases (25.9%), spleen 66 (43%), intestine 21(13.6%) and kidney 13 cases (09%). Abdominal injury was associated with other injuries like head, chest and extremity injuries in 52.5% cases. Duration of injury, presence of associated injury and preoperative ventilation requirement were independent predictors of mortality apart from contributary factors such as clinical presentation, organ involved and presence of complications.
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Yu SH, Park SH, Kim JW, Kim JH, Hwang JH, Park S, Lee KH. Imaging Features and Interventional Treatment for Liver Injuries and Their Complications. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:851-861. [PMID: 36238055 PMCID: PMC9514414 DOI: 10.3348/jksr.2020.0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 06/16/2023]
Abstract
Liver injury is a common consequence of blunt abdominopelvic trauma. Contrast-enhanced CT allows for the rapid detection and evaluation of liver injury. The treatment strategy for blunt liver injury has shifted from surgical to nonoperative management, which has been widely complemented by interventional management to treat both liver injury and its complications. In this article, we review the major imaging features of liver injury and the role of interventional management for the treatment of liver injury.
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The effect of silymarin on liver enzymes and antioxidant status in trauma patients in the intensive care unit: a randomized double blinded placebo-controlled clinical trial. Clin Exp Hepatol 2021; 7:149-155. [PMID: 34295981 PMCID: PMC8284169 DOI: 10.5114/ceh.2021.107067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/24/2021] [Indexed: 01/09/2023] Open
Abstract
Aim of the study This study was conducted to investigate the positive effect of silymarin on liver enzymes and antioxidant status in trauma patients with elevated liver enzymes due to trauma-induced liver injury, admitted to the intensive care unit. Material and methods This one-year, randomized, double-blinded, placebo-controlled clinical trial was conducted on 90 trauma patients. The participants were assigned to either receiving Livergol tablets containing 140 mg of silymarin or 140 mg of placebo three times daily for 14 days. Liver enzymes, including aspartate transaminase (AST), alanine transaminase (ALT) and alkaline phosphatase (ALP), were measured at baseline and days 3, 7, 9 and 14 after intervention. Also, antioxidant markers were measured at baseline and day 14 after treatment. Results Receiving silymarin supplement significantly lowered the liver enzymes, compared to placebo (p < 0.05). The mean serum level of malondialdehyde (MDA) was significantly decreased and the mean serum levels of total antioxidant capacity (TAC) and thiol groups were significantly increased in the silymarin group from baseline to day 14. In the placebo group, mean serum levels of MDA and thiol groups were significantly increased, while serum level of TAC was not significantly changed at day 14, compared to baseline. Also, the mean serum level of MDA was significantly lower, while the serum levels of thiol groups and TAC were significantly higher in the silymarin group. Conclusions Silymarin supplementation significantly improved some antioxidant markers (TAC and thiol) and decreased liver enzymes in patients with trauma-induced liver injury.
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21
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Dreizin D, Chen T, Liang Y, Zhou Y, Paes F, Wang Y, Yuille AL, Roth P, Champ K, Li G, McLenithan A, Morrison JJ. Added value of deep learning-based liver parenchymal CT volumetry for predicting major arterial injury after blunt hepatic trauma: a decision tree analysis. Abdom Radiol (NY) 2021; 46:2556-2566. [PMID: 33469691 PMCID: PMC8205942 DOI: 10.1007/s00261-020-02892-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/30/2020] [Accepted: 12/04/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE In patients presenting with blunt hepatic injury (BHI), the utility of CT for triage to hepatic angiography remains uncertain since simple binary assessment of contrast extravasation (CE) as being present or absent has only modest accuracy for major arterial injury on digital subtraction angiography (DSA). American Association for the Surgery of Trauma (AAST) liver injury grading is coarse and subjective, with limited diagnostic utility in this setting. Volumetric measurements of hepatic injury burden could improve prediction. We hypothesized that in a cohort of patients that underwent catheter-directed hepatic angiography following admission trauma CT, a deep learning quantitative visualization method that calculates % liver parenchymal disruption (the LPD index, or LPDI) would add value to CE assessment for prediction of major hepatic arterial injury (MHAI). METHODS This retrospective study included adult patients with BHI between 1/1/2008 and 5/1/2017 from two institutions that underwent admission trauma CT prior to hepatic angiography (n = 73). Presence (n = 41) or absence (n = 32) of MHAI (pseudoaneurysm, AVF, or active contrast extravasation on DSA) served as the outcome. Voxelwise measurements of liver laceration were derived using an existing multiscale deep learning algorithm trained on manually labeled data using cross-validation with a 75-25% split in four unseen folds. Liver volume was derived using a pre-trained whole liver segmentation algorithm. LPDI was automatically calculated for each patient by determining the percentage of liver involved by laceration. Classification and regression tree (CART) analyses were performed using a combination of automated LPDI measurements and either manually segmented CE volumes, or CE as a binary sign. Performance metrics for the decision rules were compared for significant differences with binary CE alone (the current standard of care for predicting MHAI), and the AAST grade. RESULTS 36% of patients (n = 26) had contrast extravasation on CT. Median [Q1-Q3] automated LPDI was 4.0% [1.0-12.1%]. 41/73 (56%) of patients had MHAI. A decision tree based on auto-LPDI and volumetric CE measurements (CEvol) had the highest accuracy (0.84, 95% CI 0.73-0.91) with significant improvement over binary CE assessment (0.68, 95% CI 0.57-0.79; p = 0.01). AAST grades at different cut-offs performed poorly for predicting MHAI, with accuracies ranging from 0.44-0.63. Decision tree analysis suggests an auto-LPDI cut-off of ≥ 12% for minimizing false negative CT exams when CE is absent or diminutive. CONCLUSION Current CT imaging paradigms are coarse, subjective, and limited for predicting which BHIs are most likely to benefit from AE. LPDI, automated using deep learning methods, may improve objective personalized triage of BHI patients to angiography at the point of care.
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Affiliation(s)
- David Dreizin
- Emergency and Trauma Imaging, Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD, 21201, USA.
| | - Tina Chen
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yuanyuan Liang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yuyin Zhou
- Department of Computer Science, Center for Cognition Vision and Learning, Johns Hopkins University, Baltimore, MD, USA
| | - Fabio Paes
- Emergency and Trauma Imaging, Department of Radiology, University of Miami - Miller School of Medicine, Jackson Memorial Hospital - Ryder Trauma Center, Miami, USA
| | - Yan Wang
- Department of Computer Science, Center for Cognition Vision and Learning, Johns Hopkins University, Baltimore, MD, USA
| | - Alan L Yuille
- Department of Computer Science, Center for Cognition Vision and Learning, Johns Hopkins University, Baltimore, MD, USA
| | - Patrick Roth
- Emergency and Trauma Imaging, Department of Radiology, University of Miami - Miller School of Medicine, Jackson Memorial Hospital - Ryder Trauma Center, Miami, USA
| | - Kathryn Champ
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Guang Li
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ashley McLenithan
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan J Morrison
- Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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de Freitas RK, Monsignore LM, Castro-Afonso LHD, Nakiri GS, Elias-Junior J, Muglia VF, Scarpelini S, Abud DG. Transarterial embolization with n-butyl cyanoacrylate for the treatment of active abdominopelvic bleeding in the polytraumatized patient. CVIR Endovasc 2021; 4:39. [PMID: 33956262 PMCID: PMC8102658 DOI: 10.1186/s42155-021-00222-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 03/22/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE An increasing number of polytraumatized patient presenting with active abdominal pelvic bleeding (APB) have been treated by endovascular selective embolization. However, reports on evaluate the efficacy, safety and complications caused by this technique have been limited. The aim of this study was to assess the safety and efficacy of embolization of APB using N-butyl cyanoacrylate glue (NBCA). MATERIALS AND METHODS Single center retrospective study, that included consecutive 47 patients presenting with traumatic APB treated by embolization with NBCA between January 2013 and June 2019. The efficacy endpoint was defined as the absence of contrast extravasation immediately after procedure and clinical stabilization in the following 24 h after procedure. Clinical stabilization was defined as no rebleeding after embolization or the need for a surgical approach until the patient is discharged. Safety endpoint were any technical or clinical complications related to the embolization procedure. RESULTS The mean age of patients was 38.6 years (3-81), with a predominance of males (87.2%). The major causal factor of APB being involvement in a car accident, accounting for 68% of cases. Of the 47 cases, 29.8% presented pelvic trauma and the remaining (70.2%) presented abdominal trauma. The efficacy rate was 100%, while no complications related to the procedure were observed. The mortality rate was 14.8% (7/47) due to neurologic decompensation and other clinical causes. CONCLUSION Endovascular embolization of traumatic abdominopelvic bleedings appear to be a highly safe and effective treatment, while avoiding emergent exploratory open surgeries.
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Affiliation(s)
- Rafael Kiyuze de Freitas
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, Avenida Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP 14048-090 Brazil
| | - Lucas Moretti Monsignore
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, Avenida Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP 14048-090 Brazil
| | - Luis Henrique de Castro-Afonso
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, Avenida Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP 14048-090 Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, Avenida Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP 14048-090 Brazil
| | - Jorge Elias-Junior
- Division of Abdominal Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Valdair Francisco Muglia
- Division of Abdominal Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Sandro Scarpelini
- Division of Emergency Surgery, Department of surgery and anatomy, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Radiology, Department of Radiology, Hematology and Oncology, Medical School of Ribeirão Preto, University of São Paulo, Avenida Bandeirantes, 3900, Monte Alegre, Ribeirão Preto, SP 14048-090 Brazil
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Nguyen I, Catanzano T. Hepatobiliary Injuries: A Pictoral Essay and Literature Review. Semin Ultrasound CT MR 2021; 42:332-346. [PMID: 34130847 DOI: 10.1053/j.sult.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Injuries to the liver and biliary tree carry significant morbidity and mortality if not diagnosed and managed rapidly. As clinical evaluation of suspected hepatobiliary injury is often limited in traumatic or post-surgical settings, imaging plays a critical role in the diagnosis of injury, assessment of treatment response and detection of delayed complications. In this paper, we review acute traumatic and iatrogenic hepatobiliary injuries and subsequent complications through different imaging modalities.
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Affiliation(s)
- Ivy Nguyen
- Department of Radiology, University of Massachusetts Medical School - Baystate, Springfield, MA.
| | - Tara Catanzano
- Department of Radiology, University of Massachusetts Medical School - Baystate, Springfield, MA
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Hirooka R, Ito K, Takemura N, Mihara F, Kokudo N. Case report: direct suture repair of inferior vena cava to rescue a stab patient with hepatic and caval injury through left hepatectomy and total vascular exclusion. Surg Case Rep 2021; 7:55. [PMID: 33620557 PMCID: PMC7902743 DOI: 10.1186/s40792-021-01139-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The mortality of abdominal vena caval injuries is as high as 50-80%. Yet, there were few reports on how to repair injured inferior vena cava (IVC). This report presents a method of vena caval repair in a case of penetrating retrohepatic IVC injury, requiring hepatic resection and total vascular exclusion (TVE). CASE PRESENTATION The patient was a 20-year-old man with a stab wound in the epigastrium. An emergency laparotomy was performed in the emergency room, and a stab incision on the left liver was detected. As the Pringle's maneuver did not reduce bleeding, hepatic vein injury was suspected, and left hemihepatectomy was performed to confirm the bleeding point. After the hepatectomy, laceration was still evident deeper into the resection, and IVC injury was suspected. The bleeding was temporarily controlled by tentative hepatorrhaphy and gauze packing, and the initial damage control surgery was terminated. Definitive surgery was performed on the third postoperative day. The lacerated point was observed under TVE, and the laceration penetrated the retrohepatic IVC through its posterior wall. The slit of the posterior wall was sutured first, followed by suturing of the anterior wall of the IVC. Finally, the lacerated liver was closed with hepatorrhaphy. TVE was removed, and the massive bleeding was successfully controlled. CONCLUSION In severe liver injuries involving the retrohepatic IVC, hepatic resection and TVE may be useful for ensuring an optimized surgical field for repairing the injured IVC.
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Affiliation(s)
- Reina Hirooka
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
| | - Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
| | - Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine (NCGM), 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan
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25
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Jakob DA, Liasidis P, Schellenberg M, Matsushima K, Lam L, Demetriades D, Inaba K. Intra-Abdominal Hemorrhage Control: The Need for Routine Four-Quadrant Packing Explored. World J Surg 2021; 45:1014-1020. [PMID: 33454792 DOI: 10.1007/s00268-020-05906-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Routine four-quadrant packing (4QP) for hemorrhage control immediately upon opening is a standard practice for acute trauma laparotomy. The aim of this study was to evaluate the utility of 4QP for bleeding control in acutely injured patients undergoing trauma laparotomy. METHODS Retrospective single-center study (01/2015-07/2019), including adult patients who underwent trauma laparotomy within 4 h of admission. Only patients with active intra-abdominal hemorrhage, defined as bleeding within the peritoneal cavity or expanding retroperitoneal hematoma, were considered for analysis. Bleeding sources were categorized anatomically: liver/retrohepatic inferior vena cava (RIVC), spleen, retroperitoneal zones 1, 2 and 3, mesentery and others. Hemorrhage was further categorized as originating from a single bleeding site (SBS) or from multiple bleeding sites (MBS). The effectiveness of directed versus 4QP was evaluated for bleeding from the liver/RIVC, spleen and retroperitoneal zone 3, areas that are potentially compressible. Directed packing was defined as indicated if the bleeding was restricted to one of the anatomic sites suitable for packing, 4QP was defined as indicated if ≥ 2 of the anatomic sites suitable for packing were bleeding. RESULTS During the study time frame, 924 patients underwent trauma laparotomy, of which 148 (16%) had active intra-abdominal hemorrhage. Of these, 47% had a SBS and 53% had MBS. The liver/RIVC was the most common bleeding source in both patients with SBS (42%) and in patients with MBS (54%). According to our predefined indications, 22 of 148 patients (15%) would have benefitted from initial 4QP, 90 of 148 patients (61%) from directed packing and 36 of 148 patients (24%) packing would not have been of any value. CONCLUSION Routine four-quadrant packing is frequently practiced. However, this is only required in a small proportion of patients undergoing trauma laparotomy. Directed packing can be equally effective, saves time and decreases the risk of iatrogenic injury from unnecessary packing.
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Affiliation(s)
- Dominik A Jakob
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA, 90033, USA
| | - Panagiotis Liasidis
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA, 90033, USA
| | - Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA, 90033, USA
| | - Kazuhide Matsushima
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA, 90033, USA
| | - Lydia Lam
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA, 90033, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA, 90033, USA.
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Yoo J, Park SJ, Lee SH, Chung HH. Contrecoup Injury associated with Fatal Portal Vein Bleeding: A Case Report. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2021; 82:1594-1599. [PMID: 36238878 PMCID: PMC9431969 DOI: 10.3348/jksr.2020.0190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/21/2021] [Accepted: 05/11/2021] [Indexed: 12/04/2022]
Abstract
A 64-year-old male visited our emergency department due to severe right flank pain after falling from a 2-meter height. Contrast-enhanced CT revealed a right hemothorax with multiple fractures in the right ribs and iliac bone. A small hematoma in the right perihepatic space was noted, but there was no hepatic laceration on CT. Initial surgical management led to continuous uncontrolled bleeding around the porta hepatis, and subsequent arterial angiography could not demonstrate a bleeding focus. However, immediate follow-up CT showed contrast extravasation on the left side of abdomen, and a percutaneous transhepatic portal venogram revealed active bleeding from the left portal vein. Although the wound was embolized with a glue, the patient suffered from a cardiac arrest and finally expired. In conclusion, during evaluation of abdominal trauma patients, portal vein bleeding and contrecoup injuries should be considered when hepatic arteriography findings are nremarkable.
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Affiliation(s)
- Joonghyun Yoo
- Department of Radiology, Korea University Ansan Hospital, Ansan, Korea
| | - Sung-Joon Park
- Department of Radiology, Korea University Ansan Hospital, Ansan, Korea
| | - Seung Hwa Lee
- Department of Radiology, Korea University Ansan Hospital, Ansan, Korea
| | - Hwan Hoon Chung
- Department of Radiology, Korea University Ansan Hospital, Ansan, Korea
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Ibrahim AH, Osman AJ, Alarfaj MA, Alzamil AM, Abahussain MA, Alghamdi H. Case report: Evisceration of abdomen after blunt trauma. Int J Surg Case Rep 2020; 72:207-211. [PMID: 32544830 PMCID: PMC7298532 DOI: 10.1016/j.ijscr.2020.05.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/21/2020] [Accepted: 05/21/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Abdominal evisceration is uncommon after blunt abdominal trauma; therefore, it warrants urgent laparotomy. We report a young adult male who sustained multiple injuries due to a high impact mechanism resulting in blunt abdominal injury and underwent numerous laparotomies. CASE REPORT In a high-speed motorcycle accident, a twenty-six-year-old male sustained a direct, blunt injury to his abdomen, which resulted in a right hemothorax, perforation of the stomach, and small bowel. Multiple mesenteric vessels tear, a retroperitoneal hematoma, liver, and pancreatic injury. The abdominal wall split transversely, extruding intact bowel. After resuscitation, according to the ATLS protocol, the patient underwent eight laparotomies for damage control. After 45 days in the Surgical Intensive Care Unit, then 11 days in the surgical ward, he was discharged in a satisfactory condition. Eight months later, he was admitted electively for ileostomy reversal, which was uneventful. CONCLUSION Patients with high trauma mechanisms have high mortality and morbidity rate. Blunt injury with eviscerated abdominal contents requires prompt, expeditious, and timely intervention, particularly at the initial operative intervention with damage control procedures, both prompt management and structured approach, were tailored depending in the magnitude of the injury. A multidisciplinary approach is mandatory throughout the period of treatment until recovery and rehabilitation.
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Affiliation(s)
- Arwa H Ibrahim
- College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia.
| | - Adel J Osman
- King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Department of Surgery, Saudi Arabia
| | - Mosab A Alarfaj
- King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Department of Surgery, Saudi Arabia
| | - Areej M Alzamil
- College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia
| | - Munirah A Abahussain
- College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Saudi Arabia
| | - Hanan Alghamdi
- King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Department of Surgery, Saudi Arabia
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AbuAleid LH, Elshaar K, Alhazmi AA, Sherbini MA, Albohiri K. Intrahepatic pseudoaneurysm following penetrating abdominal injury: Surgical and endovascular management of 2 complicated cases. Int J Surg Case Rep 2020; 71:250-256. [PMID: 32492639 PMCID: PMC7264984 DOI: 10.1016/j.ijscr.2020.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Post-traumatic pseudoaneurysm of the hepatic artery is a rare complication of abdominal injury. Prompt intervention is essential to avoid a life-threatening hemorrhage. We report two complicated cases of intrahepatic pseudoaneurysm (IHPA). PRESENTATION OF CASES Case 1: A victim of a bomb blast with thoracoabdominal injury presented in hypovolemic shock. Emergency laparotomy revealed actively bleeding liver lacerations, which had been successfully controlled with perihepatic packing. After 72 h, computed tomography (CT) of the abdomen showed a 3 cm × 1.8 cm IHPA of the left hepatic artery, which was treated with endovascular microcoils embolization. Postoperatively, the patient developed bile leakage and biliopleural fistula, which were managed conservatively. Case 2: A patient suffered a shotgun injury to the abdomen. In laparotomy, a grade III liver laceration was noted. The bleeding was controlled with perihepatic packing. The packs were removed 48 h later. Ten days postoperatively, the patient developed severe abdominal pain with shock, CT of the abdomen showed; 24 cm × 13 cm × 8 cm subcapsular liver hematoma. Superselective hepatic angiography showed a 1-cm IHPA of the right hepatic artery. The entry and exit points of the aneurysm were successfully embolized with two microcoils. No complications related to angioembolizaion were encountered. DISCUSSION IHPA following bomb blast and shotgun injury is rarely reported. Timely diagnosis is crucial. CONCLUSION We advise to keep in mind the possibility of IHPA, when dealing with high-grade liver injury. CT is recommended before removal of perihepatic packs, as it may pick up a life-threatening pseudoaneurysm.
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Affiliation(s)
- Laila H AbuAleid
- Department of General Surgery, King Fahad Central Hospital, Jazan, Saudi Arabia.
| | - Khaled Elshaar
- Department of General Surgery, King Fahad Central Hospital, Jazan, Saudi Arabia
| | - Almoaiad A Alhazmi
- Department of Interventional Radiology, King Fahad Central Hospital, Jazan, Saudi Arabia
| | | | - Khalid Albohiri
- Department of Thoracic Surgery, King Fahad Central Hospital, Jazan, Saudi Arabia
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Hepatic autotransplant for hepatic vein avulsion after blunt abdominal trauma. J Trauma Acute Care Surg 2020; 89:e55-e58. [PMID: 32345904 DOI: 10.1097/ta.0000000000002750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gerrard AD, Lunevicius R, Heavey N. Traumatic bruising of the hepatoduodenal ligament can conceal a catastrophic injury to the hepatic artery. BMJ Case Rep 2019; 12:12/9/e230706. [PMID: 31537592 DOI: 10.1136/bcr-2019-230706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present the case of a 22-year-old man transferred to the regional major trauma centre following a fall of ~15 m. He remained consistently haemodynamically stable for over 10 hours of observation until he deteriorated suddenly with major haemorrhagic shock requiring immediate trauma laparotomy. At laparotomy, 2 L of blood was drained from the abdomen but no source of active bleeding identified. 30 minutes after closure of the abdomen, 500 mL of fresh blood was noted in the drain so he was returned to the theatre where the bleeding source was found to be-after manual compression of a mildly bruised hepatoduodenal ligament-the proper hepatic artery (PHA). This case describes an unusual finding at relaparotomy and shows that even when there is no active bleeding from abdominal organs or classified vessels, it is possible to have isolated injury to PHA.
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Affiliation(s)
- Adam Daniel Gerrard
- Department of General Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Raimundas Lunevicius
- Department of General Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, UK.,School of Medicine, University of Liverpool, Liverpool, UK
| | - Nicholas Heavey
- Aintree University Hospital NHS Foundation Trust, Liverpool, UK
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Saqib Y. A systematic review of the safety and efficacy of non-operative management in patients with high grade liver injury. Surgeon 2019; 18:165-177. [PMID: 31399317 DOI: 10.1016/j.surge.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 06/09/2019] [Accepted: 07/13/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The liver is the most frequently damaged organ in blunt abdominal trauma. It is widely accepted that hemodynamically stable patients with low-grade liver trauma should be treated with non-operative management, however there is controversy surrounding its safety and efficacy in high-grade trauma. The purpose of this review is to investigate the role of non-operative management in patients with high-grade liver trauma. METHODS PubMed and reference lists of PubMed articles were searched to find studies that examined the efficacy of non-operative management in high-grade liver injury patients, and compare it to operative management. Non-operative management was considered successful if rescue surgery was avoided. Outcomes considered were success, mortality, and complication rates. RESULTS The electronic search revealed 2662 records, 8 of which met the inclusion criteria. All 8 studies contained results suggesting that non-operative management was safe and effective in hemodynamically stable patients with high-grade liver trauma. By combining the outcomes of the different studies, non-operative management had a high success rate of 92.4% (194/210) in high-grade liver trauma patients, which was near the overall 95.0% non-operative management success rate. Non-operative management also had mortality and complication rates of 4.6% (9/194) and 9.7% (7/72) in high-grade injury patients, respectively, compared to operative management's 17.6% (26/148) and 45.5% (5/11). CONCLUSION Non-operative management of liver trauma is safe and effective in hemodynamically stable patients with high-grade liver injury. It is associated with significantly lower mortality compared with operative management. More studies are required to evaluate complications of non-operative management in high-grade liver injury.
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Affiliation(s)
- Yosuf Saqib
- Saba University School of Medicine, The Bottom, Caribbean Netherlands, the Netherlands.
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32
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Azzam AZ, Gazal AH, Kassem MI, Souror MA. The role of non-operative management (NOM) in blunt hepatic trauma. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Ayman Zaki Azzam
- General Surgery Department, Faculty of Medicine , Alexandria, Egypt
| | | | | | - Magdy A. Souror
- General Surgery Department, Faculty of Medicine , Alexandria, Egypt
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Paydar S, Mahmoudi Nezhad GS, Karami MY, Abdolrahimzadeh H, Samadi M, Makarem A, Noorafshan A. Stereological Comparison of Imbibed Fibrinogen Gauze versus Simple Gauze in External Packing of Grade IV Liver Injury in Rats. Bull Emerg Trauma 2019; 7:41-48. [PMID: 30719465 PMCID: PMC6360012 DOI: 10.29252/beat-070106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Objective To evaluate the effect of imbibed fibrinogen gauze on survival, bleeding and healing in liver trauma. Methods This animal experimental study was conducted on 20 adult male Sprague-Dawley rats; with a mean weight of 300±50 gram; divided into two groups. Grade IV injury was induced to the subjects' liver. Then, the bleeding site was packed with simple gauze in the control group, and imbibed fibrinogen gauze in the experimental group. All animals were re-evaluated for liver hemostasis 48 hours after the initial injury. Bleeding in the intra peritoneal cavity was measured using Tuberculosis Syringe in the first and second operations. Subjects were followed-up for 14 days. Eventually, the rats were sacrificed and their livers were sent to a lab for stereological assessment. Statistical comparisons were performed via Mann-Whitney U-test using SPSS. P-Values less than 0.05 were considered to be statistically significant. Results Half of the rats in the control group died, while all the rats in the imbibed fibrinogen gauze group survived after two weeks (p= 0.032). Bleeding in the imbibed fibrinogen gauze was significantly less than control group, 48 hours' post-surgery (p<0.001). According to the stereological results, granulation tissue in the imbibed fibrinogen gauze group were more than the control group (P= 0.032). Also, fibrosis in the imbibed fibrinogen gauze group were more than the control group (P= 0.014). Conclusion Our study indicated that imbibed fibrinogen gauze can potentially control liver bleeding and improve survival through increasing granulation tissue and fibrosis in injured liver.
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Affiliation(s)
- Shahram Paydar
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mohammad Yasin Karami
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Abdolrahimzadeh
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mojtaba Samadi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Makarem
- Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Noorafshan
- Department of Anatomy, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Frink M, Lechler P, Debus F, Ruchholtz S. Multiple Trauma and Emergency Room Management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:497-503. [PMID: 28818179 DOI: 10.3238/arztebl.2017.0497] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 10/16/2016] [Accepted: 04/24/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The care of severely injured patients remains a challenge. Their initial treatment in the emergency room is the essential link between first aid in the field and definitive in-hospital treatment. METHODS We present important elements of the initial in-hospital care of severely injured patients on the basis of pertinent publications retrieved by a selective search in PubMed and the current German S3 guideline on the care of severely and multiply traumatized patients, which was last updated in 2016. RESULTS The goal of initial emergency room care is the rapid recognition and prompt treatment of acutely life-threatening injuries in the order of their priority. The initial assessment includes physical examination and ultrasonography according to the FAST concept (Focused Assessment with Sonography in Trauma) for the recognition of intraperitoneal hemorrhage. Patients with penetrating chest injuries, massive hematothorax, and/or severe injuries of the heart and lungs undergo emergency thoracotomy; those with signs of hollow viscus perforation undergo emergency laparotomy. If the patient is hemo - dynamically stable, the most important diagnostic procedure that must be performed is computerized tomography with contrast medium. Therapeutic decision-making takes the patient's physiological parameters into account, along with the overall severity of trauma and the complexity of the individual injuries. Depending on the severity of trauma, the immediate goal can be either the prompt restoration of organ structure and function or so-called damage control surgery. The latter focuses, in the acute phase, on hemostasis and on the avoidance of secondary damage such as intra-abdominal contamination or compartment syndrome. It also involves the temporary treatment of fractures with external fixation and the planning of definitive care once the patient's organ functions have been securely stabilized. CONCLUSION The care of the severely injured patient should be performed in structured fashion according to the A-B-C-D-E scheme, which involves the securing of the airway, breathing, and circulation, the recognition of neurologic deficits, and whole-body examination by the interdisciplinary team.
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Affiliation(s)
- Michael Frink
- Center for Orthopedics and Trauma Surgery, Gießen and Marburg University Hospital, Marburg Campus, Marburg
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35
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Eschbach D, Horst K, Sassen M, Andruszkow J, Mohr J, Debus F, Vogt N, Steinfeldt T, Hildebrand F, Schöller K, Uhl E, Wulf H, Ruchholtz S, Pape H, Frink M. Hypothermia does not influence liver damage and function in a porcine polytrauma model. Technol Health Care 2018; 26:209-221. [PMID: 28968251 DOI: 10.3233/thc-171043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous studies revealed evidence that induced hypothermia attenuates ischemic organ injuries after severe trauma. In the present study, the effect of hypothermia on liver damage was investigated in a porcine long term model of multi-system injury, consisting of blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shockMETHODS: In 30 pigs, a standardized polytrauma including blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shock of 45% of total blood volume was induced. Following trauma, hypothermia of 33∘C was induced for 12 h and intensive care treatment was evaluated for 48 h. As outcome parameters, we assessed liver function and serum transaminase levels as well as a histopathological analysis of tissue samples. A further 10 animals served as controls. RESULTS Serum transaminase levels were increased at the end of the observation period following hypothermia without reaching statistical significance compared to normothermic groups. Liver function was preserved (p⩽ 0.05) after the rewarming period in hypothermic animals but showed no difference at the end of the observation period. In H&E staining, cell death was slightly increased hypothermic animals and caspase-3 staining displayed tendency towards more apoptosis in hypothermic group as well. CONCLUSIONS Induction of hypothermia could not significantly improve hepatic damage during the first 48 h following major trauma. Further studies focusing on multi-organ failure including a longer observation period are required to illuminate the impact of hypothermia on hepatic function in multiple trauma patients.
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Affiliation(s)
- D Eschbach
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - K Horst
- Trauma Department, University of Aachen, Aachen, Germany
| | - M Sassen
- Department of Anesthesiology and Critical Care, University Hospital Giessen and Marburg, Marburg, Germany
| | - J Andruszkow
- Institute of Pathology, University of Aachen, Aachen, Germany
| | - J Mohr
- Department of Trauma Surgery, University of Magdeburg, Magdeburg, Germany
| | - F Debus
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - N Vogt
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - T Steinfeldt
- Department of Anesthesiology and Critical Care, Diakonie-Klinikum Schwäbisch Hall, Germany
| | - F Hildebrand
- Trauma Department, University of Aachen, Aachen, Germany
| | - K Schöller
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - E Uhl
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - H Wulf
- Department of Anesthesiology and Critical Care, University Hospital Giessen and Marburg, Marburg, Germany
| | - S Ruchholtz
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - H Pape
- Department of Trauma, University of Zurich, Zurich, Switzerland
| | - M Frink
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
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Oliva-Vilarnau N, Hankeova S, Vorrink SU, Mkrtchian S, Andersson ER, Lauschke VM. Calcium Signaling in Liver Injury and Regeneration. Front Med (Lausanne) 2018; 5:192. [PMID: 30023358 PMCID: PMC6039545 DOI: 10.3389/fmed.2018.00192] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/11/2018] [Indexed: 12/12/2022] Open
Abstract
The liver fulfills central roles in metabolic control and detoxification and, as such, is continuously exposed to a plethora of insults. Importantly, the liver has a unique ability to regenerate and can completely recoup from most acute, non-iterative insults. However, multiple conditions, including viral hepatitis, non-alcoholic fatty liver disease (NAFLD), long-term alcohol abuse and chronic use of certain medications, can cause persistent injury in which the regenerative capacity eventually becomes dysfunctional, resulting in hepatic scaring and cirrhosis. Calcium is a versatile secondary messenger that regulates multiple hepatic functions, including lipid and carbohydrate metabolism, as well as bile secretion and choleresis. Accordingly, dysregulation of calcium signaling is a hallmark of both acute and chronic liver diseases. In addition, recent research implicates calcium transients as essential components of liver regeneration. In this review, we provide a comprehensive overview of the role of calcium signaling in liver health and disease and discuss the importance of calcium in the orchestration of the ensuing regenerative response. Furthermore, we highlight similarities and differences in spatiotemporal calcium regulation between liver insults of different etiologies. Finally, we discuss intracellular calcium control as an emerging therapeutic target for liver injury and summarize recent clinical findings of calcium modulation for the treatment of ischemic-reperfusion injury, cholestasis and NAFLD.
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Affiliation(s)
- Nuria Oliva-Vilarnau
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Simona Hankeova
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden.,Faculty of Science, Institute of Experimental Biology, Masaryk University, Brno, Czechia
| | - Sabine U Vorrink
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Souren Mkrtchian
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Emma R Andersson
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden.,Department of Cell and Molecular Biology, Karolinska Institutet, Stockholm, Sweden
| | - Volker M Lauschke
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Renson A, Musser B, Schubert FD, Bjurlin MA. Seatbelt use is associated with lower risk of high-grade hepatic injury in motor vehicle crashes in a national sample. J Epidemiol Community Health 2018; 72:746-751. [PMID: 29636398 DOI: 10.1136/jech-2018-210437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Seatbelt use, alone and in conjunction with an airbag, is associated with lower risk of mortality, blunt abdominal trauma and kidney injury in motor vehicle crashes (MVCs). However, the effect of these protective devices on risk of severe liver injury is not well characterised. METHODS This retrospective cohort study included patient admissions with liver injuries from MVCs from the National Trauma Data Bank (NTDB), collected from 2010 to 2015 in the USA. We examined associations between injury severity and seatbelt use and airbag presence individually and in the presence of additive interaction. Secondary outcomes were mortality, complications and discharge disposition. RESULTS We analysed 55 543 records from the National Trauma Data Bank. In adjusted analysis, seatbelt use alone was protective against severe (AAST VI or above) hepatic injury (risk ratio (RR) 0.79, 95% CI 0.75 to 0.84), while airbag presence alone was not (RR 1.05, 95% CI 0.8 to 1.12). The joint association of seatbelt use and airbag presence with injury severity was greater than seatbelts alone (RR 0.74, 95% CI 0.70 to 0.79), with 13% of the joint lower risk attributable to interaction (95% CI 3% to 24%). The adjusted mortality risk of those without protective devices (10.3%, n=2297) was nearly double that of patients who used a seatbelt in conjunction with a present airbag (5.3%, n=699, p<0.001). CONCLUSIONS Seatbelts are associated with lower liver injury severity and are more protective with airbags present, while airbags without seatbelt use were not protective against severe injury among patients with liver injury.
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Affiliation(s)
- Audrey Renson
- Department of Clinical Research, New York University (NYU) Langone - Brooklyn, Brooklyn, New York, USA.,Department of Epidemiology and Biostatistics, City University of New York School of Public Health, New York City, New York, USA
| | - Brynne Musser
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Finn D Schubert
- Department of Clinical Research, New York University (NYU) Langone - Brooklyn, Brooklyn, New York, USA
| | - Marc A Bjurlin
- Department of Urology, NYU School of Medicine, New York City, New York, USA
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Real-time elastography evaluation of differential penetrating liver trauma in a rabbit model. Am J Emerg Med 2018; 36:1627-1630. [PMID: 29502976 DOI: 10.1016/j.ajem.2018.01.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/18/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Real-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 METHODS Eighty 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. RESULTS There 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). CONCLUSIONS RTE may be able to distinguish mild or severe penetrating liver trauma at 60min or more after injury.
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von Herrmann PF, Nickels DJ, Mansouri M, Singh A. Imaging of Blunt and Penetrating Abdominal Trauma. Emerg Radiol 2018. [DOI: 10.1007/978-3-319-65397-6_9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Chong CN, Cheung YS, Lee KF, Rainer TH, Lai BSP. Traumatic Liver Injury in Hong Kong: The Management Strategy and Outcome. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790901600403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction Management of liver injury is challenging and evolving. The aim of this article is to review the outcome of traumatic liver injury in Chinese people in Hong Kong. Materials & methods Records of 40 patients with hepatic injury who received treatment at the Prince of Wales Hospital between December 2000 and May 2005 were reviewed. Demographic data, severity of liver injury, Injury Severity Score (ISS), haemodynamic status and Glasgow Coma Scale (GCS) score on admission, investigations made, concomitant injuries, management scheme, and outcome of patients were analysed. Results There were 23 male and 17 female patients with a mean age of 31.3 (SD=15.4) years. Road traffic accident was the most common injury mechanism (65%). Half of the patients were treated by non-operative management (NOM). None of them required surgery during subsequent management. Patients in the operative management (OM) group had a significantly higher ISS (p=0.026), but there was no significant difference in the mortality rate between the OM and NOM groups. Patients with stable haemodynamic status and who were treated non-operatively had a significantly shorter hospital stay (p=0.006). High grade liver injury (OR=8.0, 95% CI=1.2 to 53.8, p=0.03) and ISS greater than 25 (OR=21.6, 95% CI=2.0 to 225.3, p=0.01) were independent risk factors for mortality on multivariate analysis. Conclusions Non-operative management of liver injury can be safely accomplished in haemodynamically stable patients, with the possible benefit of a shorter hospital stay.
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Affiliation(s)
| | | | | | - TH Rainer
- Prince of Wales Hospital, Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong
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Stavrou GA, Lipp MJ, Oldhafer KJ. [Approach to liver, spleen and pancreatic injuries including damage control surgery of terrorist attacks]. Chirurg 2017; 88:841-847. [PMID: 28871350 DOI: 10.1007/s00104-017-0503-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Terrorist attacks have outreached to Europe with more and more attacks on civilians. Derived from war surgery experience and from lessons learned from major incidents, it seems mandatory for every surgeon to improve understanding of the special circumstances of trauma following a terrorist attack and its' management. METHOD A short literature review is followed by outlining the damage control surgery (DCS) principle for each organ system with practical comments from the perspective of a specialized hepatobiliary (HPB) surgery unit. CONCLUSION Every surgeon has to become familiar with the new entities of blast injuries and terrorist attack trauma. This concerns not only the medical treatment but also tailoring surgical treatment with a view to a lack of critical resources under these circumstances. For liver and pancreatic trauma, simple treatment strategies are a key to success.
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Affiliation(s)
- G A Stavrou
- Allgemein- und Viszeralchirurgie, Chirurgische Onkologie, Asklepios Klinik Barmbek, Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Rübenkamp 220, 29221, Hamburg, Deutschland.
| | - M J Lipp
- Allgemein- und Viszeralchirurgie, Chirurgische Onkologie, Asklepios Klinik Barmbek, Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Rübenkamp 220, 29221, Hamburg, Deutschland
| | - K J Oldhafer
- Allgemein- und Viszeralchirurgie, Chirurgische Onkologie, Asklepios Klinik Barmbek, Medizinische Fakultät, Semmelweis Universität, Campus Hamburg, Rübenkamp 220, 29221, Hamburg, Deutschland
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Sun Y, Zhang G, Yu J, Dong L, Liu W, Liang P. Evaluation of percutaneous microwave coagulation therapy for hepatic artery injury. Heliyon 2016; 1:e00030. [PMID: 27441219 PMCID: PMC4939808 DOI: 10.1016/j.heliyon.2015.e00030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/17/2015] [Accepted: 09/18/2015] [Indexed: 11/16/2022] Open
Abstract
Objectives To evaluate the in vivo efficacy of 915 MHz percutaneous coagulation in the treatment of hepatic artery injury. Methods After inducing hepatic artery injury, 8 dogs in each group underwent 915 MHz microwave percutaneous coagulation therapy and 8 dogs were injected with batroxobin and α-cyanoacrylate. Results The hemostatic effects of 915 MHz microwave were better than drug injection, and the amount of bleeding was significantly lower (p < 0.05). Pathological examination showed that vessel wall necrosis were greater. Conclusion Contrast ultrasound guided 915 MHz microwave percutaneous coagulation treatment has potent hemostatic effects in the repair of in vivo hepatic artery injury.
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Affiliation(s)
- Yuanyuan Sun
- Department of Ultrasound, The General Hospital of Jinan Military Region, Jinan 250031, China
| | - Guoming Zhang
- Department of Cardiology, The General Hospital of Jinan Military Region, Jinan 250031, China
| | - Jie Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
| | - Lei Dong
- Department of Ultrasound, The General Hospital of Jinan Military Region, Jinan 250031, China
| | - Wei Liu
- The Nanjing Kangyou Institute of Microwave Energy, Nanjing 210000, China
| | - Ping Liang
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing 100853, China
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Chamseddine G, Khalifeh M, Khoury G, Hoballah J, El Nounou G, Nassar H, Faraj W. Mesh-wrapping for the treatment of fractured liver-A case report. Int J Surg Case Rep 2016; 25:37-9. [PMID: 27318015 PMCID: PMC4915953 DOI: 10.1016/j.ijscr.2016.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/12/2016] [Accepted: 05/12/2016] [Indexed: 11/24/2022] Open
Abstract
Liver injuries can be managed conservatively but operative management is needed once patients are hemodynamically unstable. Peri-hepatic packing is considered a life-saving procedure in complex liver injuries; however, it is not very efficient in case of significant liver injury. Intra-operative liver bed bleeding was initially controlled by high beam cauterization, surgicel and some Argon beam. The liver was later wrapped with a polyester mesh with collagen barrier; the mesh was wrapped completely over the right lobe of the liver and was sutured to itself and to the diaphragm surface as well as to the falciform ligament. Using an absorbable mesh on a traumatized and fragmented liver appears to be a safe and effective approach to high grade liver injury. Introduction Major liver trauma is a potentially fatal injury. Management of liver injuries has considerably changed over the past decades with a trend towards a multidisciplinary approach. Most liver injuries can be managed conservatively; however, some cases need operative management. Presentation of case We present a case of a 73 year old female who underwent laparoscopic cholecystectomy that was complicated by a life-threatening liver fracture and was successfully managed by staged laparotomies and liver mesh-wrapping. Discussion Mesh wrapping is an effective approach for achieving hemostasis by a temponading effect. An alternative to liver packing would be the resection of the affected segmented, however this should be assessed based on the extent of the injury as well as on the hemodynamic stability of the patient who, in majority, are hemodynamically compromised. The advantage however of liver wrapping is that there is no need for reoperation to remove the mesh, the hazard of re-bleeding is diminished because the mesh is left in place, and the incidence of septic complications is low. In this case, the mesh was sutured to the diaphragmatic crus as well as to the falciform ligament to secure the mesh on two anchoring points. Conclusion Using an absorbable mesh on a traumatized and fragmented liver appears to be a safe and effective approach to high grade liver injury. The judicious use of cauterization, beaming or suturing to the liver bed to control oozing or bleeding should be advocated in order to avoid this highly morbid complication.
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Affiliation(s)
- Ghassan Chamseddine
- Department of General Surgery, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Mohamed Khalifeh
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Ghattas Khoury
- Department of General Surgery, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Jamal Hoballah
- Department of General Surgery, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Ghina El Nounou
- Department of General Surgery, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Hussein Nassar
- Faculty of Medicine, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon
| | - Walid Faraj
- Liver Transplantation and Hepatopancreaticobiliary Surgery, Department of General Surgery, American University of Beirut Medical Center, P.O. Box 11-0236, Beirut, Lebanon.
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Abstract
CLINICAL/METHODOLOGICAL ISSUE The acute radiological diagnostics of polytrauma patients has become an essential part of the interdisciplinary treatment in the emergency room. The incidence of polytrauma patients with an injury severity score (ISS) >16 is approximately 450 cases/million inhabitants/year in Europe. Injuries of the parenchymal organs are of utmost importance for the prognosis and treatment of these patients. The injury patterns are complex and a great deal of experience is necessary to be able to obtain the correct diagnosis within minutes. This review article deals with the radiological diagnostics and grading of the severity of injuries to the spleen, liver, pancreas and kidneys. STANDARD RADIOLOGICAL METHODS The use of ultrasound for the evaluation of polytraumatized patients will be discussed. The most important trauma-associated findings for the above mentioned organs using multidetector computed tomography (MDCT) will be described and illustrated by dedicated case findings. METHODOLOGICAL INNOVATIONS Ultrasound contrast agents can supply valuable, additional diagnostic information in the evaluation of polytraumatized patients. Computed tomography has become established as the most relevant imaging modality in severe trauma. Innovative organ-adapted and contrast application protocols improve the diagnostic performance of MDCT. PRACTICAL RECOMMENDATIONS The use of focused assessment sonography for trauma (FAST) scanning as a screening tool is in agreement with the other clinical disciplines of the trauma team. The use of MDCT is trauma-dependent and the classification of the severity of the different parenchymal organ injuries is ultimately decisive for further treatment and prognosis of trauma victims.
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Affiliation(s)
- C R Krestan
- Abteilung für Allgemeine Radiologie und Kinderradiologie, Klinik für Radiologie und Nuklearmedizin, Medizinische Universität Wien AKH, Währinger Gürtel 18-20, 1090, Wien, Österreich,
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Arumugam S, Al-Hassani A, El-Menyar A, Abdelrahman H, Parchani A, Peralta R, Zarour A, Al-Thani H. Frequency, causes and pattern of abdominal trauma: A 4-year descriptive analysis. J Emerg Trauma Shock 2015; 8:193-8. [PMID: 26604524 PMCID: PMC4626935 DOI: 10.4103/0974-2700.166590] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/30/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The incidence of abdominal trauma is still underreported from the Arab Middle-East. We aimed to evaluate the incidence, causes, clinical presentation, and outcome of the abdominal trauma patients in a newly established trauma center. MATERIALS AND METHODS A retrospective analysis was conducted at the only level I trauma center in Qatar for the patients admitted with abdominal trauma (2008-2011). Patients demographics, mechanism of injury, pattern of organ injuries, associated extra-abdominal injuries, Injury Severity Score (ISS), Abbreviated Injury Scale, complications, length of Intensive Care Unit, and hospital stay, and mortality were reviewed. RESULTS A total of 6888 trauma patients were admitted to the hospital, of which 1036 (15%) had abdominal trauma. The mean age was 30.6 ± 13 years and the majority was males (93%). Road traffic accidents (61%) were the most frequent mechanism of injury followed by fall from height (25%) and fall of heavy object (7%). The mean ISS was 17.9 ± 10. Liver (36%), spleen (32%) and kidney (18%) were most common injured organs. The common associated extra-abdominal injuries included chest (35%), musculoskeletal (32%), and head injury (24%). Wound infection (3.8%), pneumonia (3%), and urinary tract infection (1.4%) were the frequently observed complications. The overall mortality was 8.3% and late mortality was observed in 2.3% cases mainly due to severe head injury and sepsis. The predictors of mortality were head injury, ISS, need for blood transfusion, and serum lactate. CONCLUSION Abdominal trauma is a frequent diagnosis in multiple trauma and the presence of extra-abdominal injuries and sepsis has a significant impact on the outcome.
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Affiliation(s)
- Suresh Arumugam
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Trauma Surgery Section, Clinical Research, HMC, Doha, Qatar
- Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ashok Parchani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Ahmad Zarour
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar
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Cirocchi R, Trastulli S, Pressi E, Farinella E, Avenia S, Morales Uribe CH, Botero AM, Barrera LM, Cochrane Injuries Group. Non-operative management versus operative management in high-grade blunt hepatic injury. Cochrane Database Syst Rev 2015; 2015:CD010989. [PMID: 26301722 PMCID: PMC9250243 DOI: 10.1002/14651858.cd010989.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Surgery used to be the treatment of choice in cases of blunt hepatic injury, but this approach gradually changed over the last two decades as increasing non-operative management (NOM) of splenic injury led to its use for hepatic injury. The improvement in critical care monitoring and computed tomographic scanning, as well as the more frequent use of interventional radiology techniques, has helped to bring about this change to non-operative management. Liver trauma ranges from a small capsular tear, without parenchymal laceration, to massive parenchymal injury with major hepatic vein/retrohepatic vena cava lesions. In 1994, the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma (AAST) revised the Hepatic Injury Scale to have a range from grade I to VI. Minor injuries (grade I or II) are the most frequent liver injuries (80% to 90% of all cases); severe injuries are grade III-V lesions; grade VI lesions are frequently incompatible with survival. In the medical literature, the majority of patients who have undergone NOM have low-grade liver injuries. The safety of NOM in high-grade liver lesions, AAST grade IV and V, remains a subject of debate as a high incidence of liver and collateral extra-abdominal complications are still described. OBJECTIVES To assess the effects of non-operative management compared to operative management in high-grade (grade III-V) blunt hepatic injury. SEARCH METHODS The search for studies was run on 14 April 2014. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), PubMed, ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), clinical trials registries, conference proceedings, and we screened reference lists. SELECTION CRITERIA All randomised trials that compare non-operative management versus operative management in high-grade blunt hepatic injury. DATA COLLECTION AND ANALYSIS Two authors independently applied the selection criteria to relevant study reports. We used standard methodological procedures as defined by the Cochrane Collaboration. MAIN RESULTS We were unable to find any randomised controlled trials of non-operative management versus operative management in high-grade blunt hepatic injury. AUTHORS' CONCLUSIONS In order to further explore the preliminary findings provided by animal models and observational clinical studies that suggests there may be a beneficial effect of non-operative management versus operative management in high-grade blunt hepatic injury, large, high quality randomised trials are needed.
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Affiliation(s)
- Roberto Cirocchi
- University of PerugiaDepartment of General SurgeryTerniItaly05100
| | | | - Eleonora Pressi
- Liver Unit and Department of Digestive Surgery, Hospital of TerniTerniItaly
| | - Eriberto Farinella
- Chelsea and Westminster Hospital NHS Foundation TrustGeneral and Colorectal Surgery369 Fulham RoadLondonUKSW10 9NH
| | - Stefano Avenia
- University of PerugiaDepartment of General SurgeryTerniItaly05100
| | | | - Ana Maria Botero
- Universidad de AntioquiaDepartment of General SurgeryCarrera 38 No 6 B Sur 25 Apto 1102MedellínAntioquiaColombia574
| | - Luis M Barrera
- Universidad de AntioquiaDepartment of General SurgeryCarrera 38 No 6 B Sur 25 Apto 1102MedellínAntioquiaColombia574
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Hemostasis Plug for an Electromagnetic Thermotherapy and Its Application for Liver Laceration. Ann Biomed Eng 2015; 44:1310-20. [PMID: 26139296 DOI: 10.1007/s10439-015-1365-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 06/11/2015] [Indexed: 10/23/2022]
Abstract
Accident-induced liver trauma is a significant human health concern, as this organ is readily injured during periods at which the abdominal region is compromised. In this work, electromagnetic thermotherapy was successfully developed and employed in vitro and in vivo to treat livers that had been lacerated. Briefly, a new hemostasis plug was integrated with an electromagnetic thermotherapy system (ETS) to perform surgery on lacerated livers. The high-frequency, alternating electromagnetic field (EMF) was generated by the ETS and was shown to induce a pre-set temperature increase within the hemostasis plug embedded in the target tissue. In order to prevent overheating and maintain a constant hemostasis temperature, a temperature feedback control system was utilized. The effect of the intensity of the EMF on the heating capacity of the ETS-hemostasis system was first explored. Furthermore, the relationship between the coagulation zone and operating temperature were investigated in vitro. By utilizing the temperature feedback control system, the hemostasis plug could be heated to a specific temperature for efficient hemostasis. With this approach, the optimal treatment temperature and time were investigated for liver laceration. Lacerated livers from New Zealand white rabbits were successfully treated with the hemostasis plug and ETS within a short period of time. When compared with the traditional perihepatic packing approach, the volume of blood loss from liver laceration surgeries treated by ETS has been dramatically reduced by 83%, suggesting a high therapeutic potential for this system.
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Swaid F, Peleg K, Alfici R, Olsha O, Jeroukhimov I, Givon A, Kessel B. The severity of liver injury following blunt trauma does not correlate with the number of fractured ribs: an analysis of a national trauma registry database. Surg Today 2015; 45:846-850. [PMID: 24996646 DOI: 10.1007/s00595-014-0975-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Rib fractures are a marker of severe injury, predicting a higher incidence of associated injuries. The purpose of this study was to assess whether an increasing number of rib fractures predicts the severity of liver injury in blunt trauma patients. METHODS We performed a retrospective cohort study involving blunt trauma patients with concomitant liver injuries and rib fractures who were registered in a national trauma registry. RESULTS Of 57,130 patients with blunt torso injuries, 14,651 patients sustained rib fractures, and 2,899 patients suffered liver injuries. Concomitant liver injury occurred in 1,087 of the patients with rib fractures (7.4%), while 1,812 patients sustained liver injury without rib fractures (4.3%). The presence of six or more rib fractures predicted a higher incidence of liver injury. Among the patients with liver injury, those with concomitant rib fractures had a higher Injury Severity Score (ISS), but similar mortality rates. Among the patients with concomitant rib fractures and liver injury, there was no relationship between the number of fractured ribs and the severity of the liver injury. CONCLUSIONS Although the presence of rib fractures was associated with an increased probability of liver injury in patients with blunt torso trauma, there is no relationship between the number of fractured ribs and the severity of liver injury.
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Affiliation(s)
- Forat Swaid
- General Surgery Department, Bnai-Zion Medical Center, Rappoport Medical School, Technion, Haifa Golomb 47, Haifa, 31048, Israel,
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Ward J, Alarcon L, Peitzman AB. Management of blunt liver injury: what is new? Eur J Trauma Emerg Surg 2015; 41:229-37. [PMID: 26038039 DOI: 10.1007/s00068-015-0521-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/11/2015] [Indexed: 12/26/2022]
Abstract
Nonoperative management has become the surgical treatment of choice in the hemodynamically stable patient with blunt hepatic trauma. The increased use and success of nonoperative management have been facilitated by the development of increasingly higher resolution computed tomography imaging, improved management of physiology and resuscitation (damage control), and routine availability of interventional procedures such as angiography and embolization, image-guided percutaneous drainage, and endoscopy. On the other hand, recognition of the patient who should proceed to immediate laparotomy is of utmost importance. A systematic and logical approach to the control of hemorrhage is required in the operating room. Thorough knowledge of the anatomy and surgical techniques, such as perihepatic packing, effective Pringle maneuver, hepatic mobilization, infrahepatic and suprahepatic control of the IVC, and stapled hepatectomy, is essential.
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Affiliation(s)
- J Ward
- Department of Surgery, University of Pittsburgh, F-1281, UPMC-Presbyterian, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
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Is it possible to use transaminases for deciding on surgical or non-operative treatment for blunt liver trauma? Wien Klin Wochenschr 2015; 127:954-8. [PMID: 25720571 DOI: 10.1007/s00508-015-0708-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 01/19/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND We aimed to research the relation of transaminase levels in blunt liver trauma (BLT) with the intensity of the trauma and the use of transaminase levels for deciding on surgical or non-operative treatment. METHODS In all, 44 patients with BLT diagnosed by computerized tomography (CT) were involved in this retrospective study. By testing the correlation of the transaminase levels and the grade of liver injury with receiver operator characteristics (ROC), area under the curve (AUC) was calculated; besides, the sensitivity, specificity, and cut-off values of transaminases were calculated separately for the grades. Moreover, same method was repeated for the surgically and non-operatively treated patients. Cut-off value was assessed for surgical and non-operative treatments. The efficiency of transaminases in deciding non-operative treatment was compared with that of other methods using ROC test applied on focused abdominal sonography in trauma (FAST), hemodynamic instability, blood replacement rate, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). RESULTS It was observed that the AUC, sensitivity, and specificity increased correspondingly with the grade rise of transaminase levels in BLT. In the selection of non-operative treatment/surgery, following values have been confirmed: AUC for AST: 0.851 (sensitivity: 86%, specificity: 73%, cut-off value: 498 U/L), AUC for ALT: 0.880 (sensitivity: 86%, specificity: 81%, cut-off value: 498 U/L), AUC for replacement: 0.948 (sensitivity: 86%, specificity: 94%), AUC for hemodynamic instability: 0.902 (sensitivity: 86%, specificity: 94%), and AUC for FAST: 0.642 (sensitivity: 57%, specificity: 75%). CONCLUSIONS It was found that in BLT, transaminases can predict the injury rating with higher accuracy as the grade rises, and they outrival FAST in terms of determining the need for laparotomy.
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