Article

Severe hepatic trauma: a multi-center experience with 1,335 liver injuries.

Department of Surgery, Gundersen/Lutheran Medical Center, La Crosse, WI.
The Journal of trauma (Impact Factor: 2.96). 11/1988; 28(10):1433-8.
Source: PubMed

ABSTRACT The experience of six regional trauma centers with severe hepatic trauma was reviewed to identify trends in management, mortality, and postoperative complications. During the 5-year period ending June 1987, 210 complex liver injuries were identified at laparotomy. There were 92 Class III, 59 Class IV, and 59 Class V injuries. Mechanism of injury was blunt in 101 (48%) patients and penetrating in 109 (52%). Shock was observed in 38%, 46%, and 85% of Class III, IV, and V patients, respectively. Emergency department thoracotomy was performed in 31 patients. There was only one (3%) survivor. Resuscitative operating room thoracotomy was performed in 34 patients with three (9%) survivors. Class III injuries were most frequently treated with hepatotomy and individual vessel ligation (41%) and deep liver suturing (25%). Class IV injuries were most often managed by resectional debridement (36%). Class V injuries required caval shunt placement in 38 (64%) patients. There were only four (10%) survivors after caval shunt placement. There were 20 (59%) survivors of 34 patients treated with packing placed as an adjunct after hepatic injury repair. There was no significant increase in the incidence of abscess formation after perihepatic packing. Routine peritoneal drainage was used in 94% of patients. Overall mortality rates for Class III, IV, and V injuries were 25%, 46%, and 80%, respectively (p less than 0.01). Death rates due to the liver injury in Class III, IV, and V patients were 7%, 30%, and 66%, respectively (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

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    • "Even patients with severe liver injuries (grades 4 and 5) do not require an exploratory laparotomy, as long as they are hemodinamically stable. With advances in the use of massive blood transfusion protocols [1], along with the ability of intervention radiologists to perform selective embolization of arterial bleeds of the liver [2], the need for major operative intervention in liver trauma has diminished significantly [3] [4] [5] [6]. As trauma surgeons , most of us now rely on perihepatic packing, abbreviated surgery or damage control, and intervention radiology for the management of these important injuries. "
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    ABSTRACT: Background Severe liver trauma (grade 4 and 5) carries mortality greater than 40%. It represents a major surgical challenge in patients with hemodynamic instability who require an immediate exploratory laparotomy. Perihepatic packing and damage control can sometimes work, but for severe liver injuries, adjunct maneuvers might be needed (such as early embolization or hepatic artery ligation). During a patient’s first operation for severe liver trauma, anatomic resection is rarely tolerated. Materials and methods We managed a 31 year-old male with a blunt grade 5 right-lobe liver injury in severe hypovolemic shock. Results As part of the initial damage control operation, concurrently with intermittent Pringle maneuver, he underwent intra- and perihepatic packing; selective isolation and ligation of the right portal vein, right hepatic artery, and right hepatic vein; and repair of the retrohepatic inferior vena cava. Then, 36 h later, the patient underwent a right hepatectomy. Conclusion For patients with severe liver injuries, selective vascular isolation and ligation may be considered as part of damage control (in addition to intermittent Pringle maneuver) and might enable anatomic resection at a later stage.
    12/2014; 60. DOI:10.1016/j.ijscr.2014.12.021
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    • "In a series of 31 patients treated using this technique Burch et al. describe an operative mortality of 81% with technical difficulties with shunt placement occurring in 7 patients [10]. Similarly in a series of 34 patients treated by Cogbill et al. with caval shunting an operative mortality of 90% was reported [11]. Total vascular exclusion of the liver i.e. application of a prolonged pringle manoeuvre combined with clamping of the infrahepatic and suprahepatic IVC has been proposed as an alternative strategy to the management of these injuries [12]. "
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    ABSTRACT: Injuries to the retrohepatic vena cava are extremely rare and are associated with an operative mortality of up to 50% even in high volume trauma centres. We present a patient with such an injury who underwent successful repair using cardiopulmonary bypass and deep hypothermic circulatory arrest. A 23 year old male was transferred to our unit following laparotomy with packing of the abdomen after uncontrolled haemorrhage from the retrohepatic vena cava was experienced. The patient was placed on full cardiopulmonary bypass and cooled to 20 °C before clamping of the supracoeliac aorta and inferior vena cava. This facilitated exposure of the retrohepatic cava and allowed successful primary repair of a 5 cm laceration. Other techniques to allow repair of these injuries, such as atriocaval shunts and total vascular exclusion of the liver, are associated with a high mortality. We believe the technique described in this case report is an alternative strategy that can be used successfully to manage life threatening from the retrohepatic vena cava.
    Injury Extra 07/2014; 45(7). DOI:10.1016/j.injury.2014.03.013
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    • "However, despite the trend of non-operative treatment and continued advances in the areas of trauma and critical care, uncontrolled bleeding from major liver injury is still the leading cause of death and continues to frustrate trauma surgeons [21]. Cogbill et al. [12] in a retrospective 5-year, 6-trauma centres study consisting of 210 major liver injuries (blunt: 101, penetrating: 109) were identified at laparotomy that used the AAST-OIS for liver injury, reported 92 grade III, 59 grade IV, and 59 grade V injuries with a 25%, 46% and 80% mortality rate respectively. Of the "
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    ABSTRACT: This retrospective study aimed to assess the clinical experience and outcome of damage control laparotomy with perihepatic packing in the management of blunt major liver injuries. From January 1998 to December 2006, 58 patients of blunt major liver injury, American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) equal or greater than III, were operated with perihepatic packing at our institute. Demographic data, intra-operative findings, operative procedures, adjunctive managements and outcome were reviewed. To determine whether there was statistical difference between the survivor and non-survivor groups, data were compared by using Mann-Whitney U test for continuous variables, either Pearson's chi-square test or with Yates continuity correction for contingency tables, and results were considered statistically significant if p<0.05. Of the 58 patients, 20 (35%) were classified as AAST-OIS grade III, 24 (41%) as grade IV, and 14 (24%) as grade V. At laparotomy, depending on the severity of injuries, all 58 patients underwent various liver-related procedures and perihepatic packing. The more frequent liver-related procedures included debridement hepatectomy (n=21), hepatorrhaphy (n=19), selective hepatic artery ligation (n=11) and 7 patients required post-laparotomy hepatic transarterial embolization. Of the 58 patients, 28 survived and 30 died with a 52% mortality rate. Of the 30 deaths, uncontrolled liver bleeding in 24-h caused 25 deaths and delayed sepsis caused residual 5 deaths. The mortality rate versus OIS was grade III: 30% (6/20), grade IV: 54% (13/24), and grade V: 79% (11/14), respectively. On univariate analysis, the significant predictors of mortality were OIS grade (p=0.019), prolonged initial prothrombin time (PT) (p=0.004), active partial thromboplastin time (APTT) (p<0.0001) and decreased platelet count (p=0.005). The mortality rate of surgical blunt major liver injuries remains high even with perihepatic packing. Since prolonged initial PT, APTT and decreased platelet count were associated with high risk of mortality, we advocate combination of damage control resuscitation with damage control laparotomy in these major liver injuries.
    Injury 09/2013; 45(1). DOI:10.1016/j.injury.2013.08.022 · 2.46 Impact Factor
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