Pneumatic Packing Method for High-grade Liver Injuries

Abstract Background: Liver injury occurs in approximately 5% of all trauma admissions. The large size of the liver and its location makes it more susceptible to injuries. Nowadays, the majority of isolated liver injuries are successfully managed with non-operative methods, however, operative management is still the mainstay of treatment for hemodynamically unstable patients. There are many traditional ways of controlling hemorrhage from the liver and here we report a case in which a GIA 75 stapler was successfully used to manage Grade IV liver injury in a hemodynamically unstable patient.Case presentation: 45 years old policeman presented in the emergency, within 20 minutes after sustaining a gunshot injury to his abdomen. At presentation, he was hemodynamically unstable with a heart rate of 100 beats/min and blood pressures of 70/35 mm Hg. On examination, he had a single entry wound in the epigastrium with no exit wound and had generalized peritonitis. He was paraplegic and had a sensory level. He was rushed to the operating room (OR) for exploratory laparotomy which revealed a shattered left lobe of the liver. Gastrointestinal anastomosis 75 stapler device was used for non-anatomical left segmentectomy (segments I and II). Active bleeding from tributaries of left hepatic vein and small branches opening into retrohepatic inferior vena cava (IVC) was identified and the vessels were suture ligated. Perihepatic packing was done and the patient shifted to the surgical intensive care unit(SICU). His improved hemodynamically and was re-explored within 24 hours. No active bleeding was seen after the packs were removed and the abdomen was closed. The next day he was moved out of SICU and the rehabilitation program was initiated for his spine injury. He was discharged on the 10th day of admission.Discussion: Grade IV liver injuries are often very complex and challenging to manage in a hemodynamically unstable patient. The role of GIA staplers for hepatic resection is quite common and safe in elective settings but their similar use in the context of trauma is less described. The concept of damage control surgery rests on quick control of life-threatening bleeding and a GIA stapler can be effectively used for rapid non-anatomical resection of the liver in trauma. This can prevent the depletion of physiological reserves and the life-threatening death triad. Conclusion: GIA stapler device is an effective, safe, and rapidly deployable tool for managing high grade live injury in a hemodynamically unstable patient. It controls bleeding without any concomitant chances of bile leak and also resection of the shattered liver gives good access for inspecting the rest of the bleeding sites.

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Blunt Liver Injury in Children and Adults: Is There Really a Difference?

The American Surgeon ◽

10.1177/000313480807400904 ◽

2008 ◽

Vol 74 (9) ◽

pp. 798-801 ◽

Cited By ~ 1

Author(s):

W. Patrick Klapheke ◽

Glen A. Franklin ◽

David S. Foley ◽

Steven R. Casos ◽

Brian G. Harbrecht ◽

...

Keyword(s):

Liver Injury ◽

Trauma Center ◽

Nonoperative Management ◽

Adult Population ◽

Adult Patients ◽

High Grade ◽

Blunt Liver Injury ◽

Liver Injuries ◽

Related Mortality ◽

Overall Mortality

Hepatic injuries are increasingly managed nonoperatively with the availability of adjunctive procedures such as angiography, ERCP, and percutaneous drainage. Although extensively discussed in the adult population, little has been reported on outcomes and management of pediatric liver injury. Retrospective review of all patients with blunt liver injuries admitted to an adult Level I trauma center and pediatric trauma center within the same community was performed from 2004 to 2006. The necessity for operation, adjuncts to nonoperative management, and outcome were collected and compared for the pediatric (PED) (<18 years of age) versus the adult (≥18 years of age) injured patients. There were 389 liver injuries identified (PED = 90, adult = 299); 25 per cent of adult injuries were greater than or equal to grade III, while 23 per cent of PED injuries were high-grade injuries. Each group of patients had similar rates of primary operative intervention: adult patients (18%) versus PED patients (16%). Adjunctive therapies were rarely used in the PED patients with only one patient requiring a percutaneous drain and one patient undergoing ERCP twice. Conversely, the adult patient group required eight percutaneous drains, 15 angiograms, 6 ERCPs and 14 laparoscopic abdominal washout procedures. ICU and hospital LOS were 25 per cent and 33 per cent lower in the adult population for high-grade injuries. The overall mortality rates were similar at 7 per cent (PED) and 9 per cent (adult). Liver-related mortality was 50 per cent (3/6 deaths) in the PED group with no liver-related deaths in the adult group (27 deaths). Adult patients with blunt liver injury were no more likely to sustain high grade liver injuries than PED patients. Furthermore, adult and PED patients underwent similar rates of operative intervention and primary liver procedures. Adult patients used adjunctive measures as part of their nonoperative management more frequently, but both subsets had similar length of hospital stays and low overall mortality. A higher rate of liver-related mortality was seen in the PED population. Overall, PED patients seemed to sustain fewer liver related complications necessitating invasive procedures despite similar injury patterns.

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