Damage Control in Penetrating Liver Trauma: Fear of the Unknown

The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.

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Damage control surgery for splenic trauma: "preserve an organ - preserve a life"

Colombia Medica ◽

10.25100/cm.v52i2.4794 ◽

2021 ◽

Vol 52 (2) ◽

pp. e4084794

Author(s):

Carlos Serna ◽

José Julian Serna ◽

Yaset Caicedo ◽

Natalia Padilla ◽

Linda M Gallego ◽

...

Keyword(s):

Damage Control ◽

Abdominal Cavity ◽

Damage Control Surgery ◽

Operative Management ◽

Splenic Trauma ◽

Severely Injured ◽

Severely Injured Patients ◽

Arterial Bleeding ◽

Non Operative Management ◽

Injured Patients

The spleen is one of the most commonly injured solid organs of the abdominal cavity and an early diagnosis can reduce the associated mortality. Over the past couple of decades, management of splenic injuries has evolved to a prefered non-operative approach even in severely injured cases. However, the optimal surgical management of splenic trauma in severely injured patients remains controversial. This article aims to present an algorithm for the management of splenic trauma in severely injured patients, that includes basic principles of damage control surgery and is based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. The choice between a conservative or a surgical approach depends on the hemodynamic status of the patient. In hemodynamically stable patients, a computed tomography angiogram should be performed to determine if non-operative management is feasible and if angioembolization is required. While hemodynamically unstable patients should be transferred immediately to the operating room for damage control surgery, which includes splenic packing and placement of a negative pressure dressing, followed by angiography with embolization of any ongoing arterial bleeding. It is our recommendation that both damage control principles and emerging endovascular technologies should be applied to achieve splenic salvage when possible. However, if surgical bleeding persists a splenectomy may be required as a definitive lifesaving maneuver.

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Damage control in the emergency department, a bridge to life

Colombia Medica ◽

10.25100/cm.v52i2.4801 ◽

2021 ◽

Vol 52 (2) ◽

pp. e4004801

Author(s):

Laureano Quintero ◽

Juan Jose Melendez-Lugo ◽

Helmer Emilio Palacios-Rodríguez ◽

Natalia Padilla ◽

Luis Fernando Pino ◽

...

Keyword(s):

Emergency Department ◽

Trauma Patient ◽

Damage Control ◽

Damage Control Surgery ◽

Hemodynamic Instability ◽

Massive Hemorrhage ◽

Severely Injured ◽

Airway Injury ◽

Hemostatic Resuscitation ◽

Altered State Of Consciousness

Patients with hemodynamic instability have a sustained systolic blood pressure less or equal to 90 mmHg, a heart rate greater or equal to 120 beats per minute and an acute compromise of the ventilation/oxygenation ratio and/or an altered state of consciousness upon admission. These patients have higher mortality rates due to massive hemorrhage, airway injury and/or impaired ventilation. Damage control resuscitation is a systematic approach that aims to limit physiologic deterioration through a group of strategies that address the physiologic debt of trauma. This article aims to describe the experience earned by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia in the management of the severely injured trauma patient in the emergency department following the basic principles of damage control surgery. Since bleeding is the main cause of death, the management of the severely injured trauma patient in the emergency department requires a multidisciplinary team, which should perform damage control maneuvers aimed at rapidly control bleeding, hemostatic resuscitation and/or prompt transfer to the operating room, if required.

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Damage control in penetrating carotid artery trauma: changing a 100-year paradigm

Colombia Medica ◽

10.25100/cm.v52i2.4807 ◽

2021 ◽

Vol 52 (2) ◽

pp. e4054807

Author(s):

José Julian Serna ◽

Carlos Alberto Ordoñez ◽

Michael W Parra ◽

Yaset Caicedo ◽

Alberto Rosero ◽

...

Keyword(s):

Carotid Artery ◽

Damage Control ◽

Hypovolemic Shock ◽

Damage Control Surgery ◽

Operative Management ◽

Altered Mental Status ◽

Massive Bleeding ◽

Carotid Artery Injuries ◽

Therapeutic Decision Making ◽

Non Operative Management

Carotid artery trauma carries a high risk of neurological sequelae and death. Surgical management of these injuries has been controversial because it entails deciding between repair or ligation of the vessel, for which there is still no true consensus either way. This article proposes a new management strategy for carotid artery injuries based on the principles of damage control surgery which include endovascular and/or traditional open repair techniques. The decision to operate immediately or to perform further imaging studies will depend on the patient's hemodynamic status. An urgent surgical intervention is indicated if the patient presents with massive bleeding, an expanding neck hematoma or refractory hypovolemic shock. An altered mental status upon arrival is a potentially poor prognosis marker and should be taken into account in the therapeutic decision-making. We describe a step-by-step algorithmic approach to these injuries, including open and endovascular techniques. In addition, conservative non-operative management has also been included as a potentially viable strategy in selected patients, which avoids unnecessary surgery in many cases.

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Povrede jetre - nasa iskustva u tretmanu

Acta chirurgica iugoslavica ◽

10.2298/aci1001101v ◽

2010 ◽

Vol 57 (1) ◽

pp. 101-106

Author(s):

G. Vukovic ◽

B. Stefanovic ◽

G. Kaljevic ◽

V. Vukojevic ◽

V. Resanovic ◽

...

Keyword(s):

Liver Injury ◽

Damage Control ◽

Damage Control Surgery ◽

Liver Trauma ◽

Young Population ◽

Liver Injuries ◽

Critical Patients ◽

Care Problems ◽

Isolated Liver ◽

Standard Strategy

Background: Trauma is one of today's most serious and expensive health care problems, and it is the most common cause of mortality in young population. Non-operative treatment is standard strategy for management of blunt liver injuries in hemodynamically stable patients in last decade. Methods: Retrospective study included patients with liver trauma, admitted in the period december 1995-december 2005, in total 476. Results: 392 of 476 patients presenting with liver trauma had blunt and only 84 had penetrating injury. Isolated liver injury was identified in 27,5% and 72,5% had associated injuries. Average ISS value was 24.06 (SD=14.26). During the operation liver injury in patients was classified according to Moor. In 2% critical patients, due to hemodynamic unstability we performed 'damage control surgery'. Out of 476 patients 87,% were successfully managet, 6,1% died as 'mors in tabula' or during first 24 hours and 6,9% died during hospitalization. Conclusion: Higher proportion of nonoopertively treated is among patients with ISS less than and those with injuries grade I end II.

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Predictors of failure in non-operative management of blunt liver trauma

International Surgery Journal ◽

10.18203/2349-2902.isj20173870 ◽

2017 ◽

Vol 4 (9) ◽

pp. 2913 ◽

Cited By ~ 1

Author(s):

Andika A. Winata ◽

Reno Rudiman

Keyword(s):

Demographic Data ◽

Fluid Collection ◽

Transaminase Level ◽

Operative Management ◽

Nonoperative Treatment ◽

Liver Trauma ◽

Group I ◽

Liver Injuries ◽

Non Operative Management ◽

Blunt Liver Trauma

Background: Liver is the most injured organ in abdominal trauma. Nonoperative treatment (NOM) is increasingly being adopted as the initial management strategy. The aim of this study was to evaluate the results of operative and conservative management of patients with blunt liver injury treated in a single institution.Methods: A retrospective study, analyzing patients admitted from 2011-2015 with the diagnosis of liver trauma, was performed. The patients were classified according to the intention to treatment: Group I, NOM; Group II, operative management and Group III, fail in NOM management. We analyzed demographic data, injury classification, associated injuries, transfusions, shock, liver function test, lactate level, and mortality rates.Results: Over the five years period, 68 patients were recorded, 45 were successful (S-NOM) and 18 were failed (F-NOM). No differences in age, sex or initial hemodynamics were found between S-NOM and F-NOM. The F-NOM patients were more seriously injured, more acidotic, required transfusion, had more fluid collection at FAST, had worse transaminase level and higher mortality rate. Grade of liver injuries was the independent risk factor of failure in nonoperating management of blunt liver trauma with the cut-off point is 3.66.Conclusions: Non-operative management of blunt liver injuries is successful in some cases. Patients with more severe injury tend to have an operation. High-grade blunt liver injuries always present with a worse condition and require an operation.

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Demographic Profile of Liver Injury Managed at a Tertiary Care Hospital in Central Nepal -A Retrospective Study

Journal of College of Medical Sciences-Nepal ◽

10.3126/jcmsn.v14i1.18884 ◽

2018 ◽

Vol 14 (1) ◽

pp. 32-38

Author(s):

Narayan Prasad Belbase ◽

Aditya Kumar Jalan ◽

Hari Upadhyay ◽

Rohit Mishra ◽

Mukesh Karki ◽

...

Keyword(s):

Retrospective Study ◽

Liver Injury ◽

Tertiary Care ◽

Operative Management ◽

Hemodynamic Instability ◽

Solid Organ ◽

Care Hospital ◽

Demographic Profile ◽

Liver Injuries ◽

The Mean

Background & Objectives:The liver is one of the commonly injured solid organ following abdominal trauma. The aim of this study was to determine the outcome of liver injuries managed operatively or non-operatively and predict factors affecting morbidity and mortality.Materials & Methods:This was a retrospective study of 40 liver injuries managed in the department of Surgical Gastroenterology at College of Medical Sciences over a period of 2 years. The liver injury was classified in accordance with the American Association for the Surgery of Trauma liver injury scoring scale. Patients were divided into two groups those managed operatively or non-operatively and were compared in terms of demographic profile and outcome.Results:Forty patients were analyzed. The mean age of the patients was 29.95years. Male predominance was seen with 72.5% of the cases. Road traffic accidents were the commonest mode of injury seen in 72.5% cases. The mean Revised Trauma Score (RTS) and Injury severity score (ISS) were 7.11and 22.58. The mean systolic BP, hospital stay and ICU stay were 93.80 mm of mercury, 11.55 days and 3.55 days respectively. Twenty six patients (65%) were initially managed non-operatively and 14 patients were managed operatively. Five patients had to be converted to operative management for hemodynamic instability. Mortality was 7.6% in patient undergoing non-operative management and 21.43% in patients managed operatively. Low systolic BP at presentation, low RTS score, high ISS score, high AST, ALT and prothrombin time were significantly associated with operative management and mortality.Conclusion:Patients with hemodynamic instability, low RTS score, high ISS score, high liver enzymes have high likelihood of operative management.

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Risk factors for mortality in blunt abdominal trauma with surgical approach

Revista do Colégio Brasileiro de Cirurgiões ◽

10.1590/0100-69912015004011 ◽

2015 ◽

Vol 42 (4) ◽

pp. 259-264 ◽

Cited By ~ 1

Author(s):

SILVANIA KLUG PIMENTEL ◽

GUILHERME VINICIUS SAWCZYN ◽

MELISSA MELLO MAZEPA ◽

FELIPE GUILHERME GONÇALVES DA ROSA ◽

ADONIS NARS ◽

...

Keyword(s):

Risk Factors ◽

Damage Control ◽

Damage Control Surgery ◽

Hemodynamic Instability ◽

The Other ◽

Organ Injury ◽

Solid Organ ◽

Solid Organ Injury ◽

Serious Injury ◽

Serious Injuries

ABSTRACTObjective:identify risk factors for mortality in patients who underwent laparotomy after blunt abdominal trauma.Methods:retrospective study, case-control, which were reviewed medical records of blunt trauma victims patients undergoing laparotomy, from March 2013 to January 2015, and compared the result of the deaths group with the group healed.Results:of 86 patients, 63% were healed, 36% died, and one patient was excluded from the study. Both groups had similar epidemiology and trauma mechanism, predominantly young adults males, automobilistic accident. Most cases that evolved to death had hemodynamic instability as laparotomy indication - 61% against 38% in the other group (p=0.02). The presence of solid organ injury was larger in the group of deaths - 80% versus 48% (p=0.001) and 61% of them had other associated abdominal injury compared to 25% in the other group (p=0.01). Of the patients who died 96% had other serious injuries associated (p=0.0003). Patients requiring damage control surgery had a higher mortality rate (p=0.0099). Only one of 18 patients with isolated hollow organ lesion evolved to death (p=0.0001). The mean injury score of TRISS of cured (91.70%) was significantly higher than that of deaths (46.3%) (p=0.002).Conclusion:the risk factors for mortality were hemodynamic instability as an indication for laparotomy, presence of solid organ injury, multiple intra-abdominal injuries, need for damage control surgery, serious injury association and low index of trauma score.

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Surgical Management of Complex Liver Trauma: A Single Liver Transplant Center Experience

The American Surgeon ◽

10.1177/000313481207800113 ◽

2012 ◽

Vol 78 (1) ◽

pp. 20-25 ◽

Cited By ~ 9

Author(s):

Sergio Li Petri ◽

Salvatore Gruttadauria ◽

Duilio Pagano ◽

Gabriel J. Echeverri ◽

Fabrizio Di Francesco ◽

...

Keyword(s):

Liver Resection ◽

Liver Injury ◽

Damage Control ◽

Length Of Hospital Stay ◽

Operative Management ◽

Liver Trauma ◽

Organ Injury ◽

Transplant Center ◽

Liver Injuries ◽

Mechanism Of Trauma

Complex liver trauma often presents major diagnostic and management problems. Current operative management is mainly centered on packing, damage control, and early utilization of interventional radiology for angiography and embolization. In this retrospective observational study of patients admitted to the Mediterranean Institute for Transplantation and Advanced Specialized Therapies, Palermo, Italy, from 1999 to 2010, we included patients that underwent hepatic resection for complex liver injuries (grade I to Vaccording to the American Association for the Surgery of Trauma-Organ Injury Scale). Age, gender, mechanism of trauma, type of resection, surgical complications, length of hospital stay, and mortality were the variables analyzed. A total of 53 adult patients were admitted with liver injury and 29 underwent surgical treatment; the median age was 26.7 years. Mechanism was blunt in 52 patients. The overall morbidity was 30 per cent, morbidity related to liver resection was 15.3 per cent. Mortality was 2 per cent in the series of patients undergoing liver resection for complex hepatic injury, whereas in the nonoperative group, morbidity was 17 per cent and mortality 2 per cent. Liver resection should be considered a serious surgical option, as initial or delayed management, in patients with complex liver injury and can be accomplished with low mortality and liver-related morbidity when performed in specialized liver surgery/transplant centers.

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Study of blunt trauma abdomen involving liver injuries based on grade of injury, management: a single centre study

International Surgery Journal ◽

10.18203/2349-2902.isj20190470 ◽

2019 ◽

Vol 6 (3) ◽

pp. 793 ◽

Cited By ~ 1

Author(s):

Vinod Kumar Jyothiprakasan ◽

Chinthakindhi Madhusudhan ◽

Challa Sravya Reddy

Keyword(s):

Operative Management ◽

Liver Trauma ◽

Single Centre ◽

Initial Management ◽

Mortality And Morbidity ◽

Injury Management ◽

Operative Repair ◽

Liver Injuries ◽

Single Centre Study ◽

Non Operative Management

Background: Modern treatment of liver trauma is increasingly non-operative. Advantages of non-operative management include avoidance of non-therapeutic celiotomies and the associated cost and morbidity, fewer intra-abdominal complications compared to operative repair and reduced transfusion risks. It is associated with a low overall morbidity and mortality and does not result in increase in length of the hospital stay. The objectives was to study efficacy of non-operative management of blunt liver injury.Methods: Seventy patients were studied, out of which 59 were initially given a trial of non-operative management and 11 patients were immediately shifted to the operating room. Of the 59 patients initially considered for non-operative management, 5 of them became unstable hemodynamically and were operated. Any complications arising in patients in non-operative group were managed with the help of interventional radiological procedures.Results: Total 54 patients were managed successfully without operative intervention which included patients with higher grade of injuries. 11 patients were shifted to surgery on arrival as they did not respond to resuscitation measures. Mortality and morbidity were found to be higher in patients undergoing surgery. Also, number of transfusions required, ICU stay and total number of days in hospital were higher in operated group. High ISS, low BP at admission, higher grade of injury in this study were seen in patients who failed non-operative management.Conclusions: Non-operative management is the initial management of choice in hemodynamically stable patients, irrespective of the grade of injury and is associated with less mortality and morbidity.

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Colon Trauma: Evidence-Based Practices

Clinics in Colon and Rectal Surgery ◽

10.1055/s-0037-1602175 ◽

2017 ◽

Vol 31 (01) ◽

pp. 011-016 ◽

Cited By ~ 3

Author(s):

Ryo Yamamoto ◽

Mark Muir ◽

Alicia Logue

Keyword(s):

Damage Control ◽

Primary Anastomosis ◽

Scientific Evidence ◽

Damage Control Surgery ◽

Operative Management ◽

Fascial Closure ◽

Hollow Viscus ◽

Management Algorithm ◽

Increased Risk ◽

Colon Injuries

AbstractColon injury is not uncommon and occurs in about a half of patients with penetrating hollow viscus injuries. Despite major advances in the operative management of penetrating colon wounds, there remains discussion regarding the appropriate treatment of destructive colon injuries, with a significant amount of scientific evidence supporting segmental resection with primary anastomosis in most patients without comorbidities or large transfusion requirement. Although literature is sparse concerning the management of blunt colon injuries, some studies have shown operative decision based on an algorithm originally defined for penetrating wounds should be considered in blunt colon injuries. The optimal management of colonic injuries in patients requiring damage control surgery (DCS) also remains controversial. Studies have recently reported that there is no increased risk compared with patients treated without DCS if fascial closure is completed on the first reoperation, or that a management algorithm for penetrating colon wounds is probably efficacious for colon injuries in the setting of DCS as well.

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