Hepatic Trauma Interventions

The liver is the second most commonly involved solid organ (after spleen) to be injured in blunt abdominal trauma, but liver injury is the most common cause of death in such trauma. In patients with significant blunt abdominal injury, the liver is involved approximately 35 to 45% of the time. Its large size also makes it a vulnerable organ, commonly injured in penetrating trauma. Other than its position and size, the liver is surrounded by fragile parenchyma and its location under the diaphragm makes it vulnerable to shear forces during deceleration injuries. The liver is also a vascular organ made of large, thin-walled vessels with high blood flow. In severe hepatic trauma, hemorrhage is a common complication and uncontrolled bleeding is usually fatal. In fact, in patients with severe abdominal trauma, liver injury is the primary cause of death. This article reviews the clinical presentation of patients with liver injury, the grading system for such injuries that is most frequently used, and management of the patient with liver trauma.

SPHINCTEROTOMY ALONE VERSUS SPHINCTEROTOMY AND BILIARY STENT PLACEMENT IN THE TREATMENT OF BILE LEAKS: 10 YEAR EXPERIENCE AT A QUATERNARY HOSPITAL

ABSTRACT BACKGROUND: Hepatobiliary surgery and hepatic trauma are frequent causes of bile leaks and this feared complication can be safely managed by endoscopic retrograde cholangiopancreatography (ERCP). The approach consists of sphincterotomy alone, biliary stenting or a combination of the two but the optimal form remains unclear. OBJECTIVE: The aim of this study is to compare sphincterotomy alone versus sphincterotomy plus biliary stent placement in the treatment of post-surgical and traumatic bile leaks. METHODS: We retrospectively analyzed 31 patients with the final ERCP diagnosis of “bile leak”. Data collected included patient demographics, etiology of the leak and the procedure details. The treatment techniques were divided into two groups: sphincterotomy alone vs. sphincterotomy plus biliary stenting. We evaluated the volume of the abdominal surgical drain before and after each procedure and the number of days needed until cessation of drainage post ERCP. RESULTS: A total of 31 patients (18 men and 3 women; mean age, 51 years) with bile leaks were evaluated. Laparoscopic cholecystectomy was the etiology of the leak in 14 (45%) cases, followed by conventional cholecystectomy in 9 (29%) patients, hepatic trauma in 5 (16%) patients, and hepatectomy secondary to neoplasia in 3 (9.7%) patients. The most frequent location of the leaks was the cystic duct stump with 12 (38.6%) cases, followed by hepatic common duct in 10 (32%) cases, common bile duct in 7 (22%) cases and the liver bed in 2 (6.5%) cases. 71% of the patients were treated with sphincterotomy plus biliary stenting, and 29% with sphincterotomy alone. There was significant difference between the volume drained before and after both procedures (P<0.05). However, when comparing sphincterotomy alone and sphincterotomy plus biliary stenting, regarding the volume drained and the days needed to cessation of drainage, there was no statistical difference in both cases (P>0.005). CONCLUSION: ERCP remains the first line treatment for bile leaks with no difference between sphincterotomy alone vs sphincterotomy plus stent placement.

Studying the clinical profile of blunt hepatic trauma

Background: The liver is the largest intra-abdominal organ and is considered to be the second commonest organ to be injured in blunt abdominal trauma. Blunt hepatic injuries due to road traffic accidents are the sixth leading cause for death in India. Approximately 15-20% of abdominal injury presents as hepatic trauma and is liable for 50% of death resulting from abdominal trauma. The mortality rate is higher with blunt hepatic trauma than penetrating injuries. The advent of improved and expeditious imaging technologies amid advances in critical-care monitoring, prompted a significant shift towards conservative management of solid-organ abdominal injuries.Methods: The study was conducted over 96 patients in General Surgery Department, PGIMS, Rohtak with a history of blunt hepatic injury. The study duration was from 16th May 2018 till 1st June 2020. The aim of the study was to evaluate the pattern of blunt hepatic trauma and the patterns with which they presented in the emergency department.Results: In this study, 98.96% of the patients were managed conservatively whereas only 1.04% of patients needed surgical intervention. Conservative approach was possible because of strict patient monitoring, availability of experienced surgeons and radiologists, good intensive care unit care.Conclusions: The study concluded that conservative management of the patient is better than operative management and can be done in the patients who are hemodynamically stable. Most of the patients settle after 48 hours if managed conservatively.

Accident-related hepatic trauma in a medical clinical center in eastern China: a cross-sectional study

Background The treatment of hepatic injury can be complex. Medical clinical centers are often the first line hospitals for the diagnosis and treatment of hepatic trauma in China. The aim of the study is to summarize the experience in the diagnosis and treatment of hepatic trauma in one medical clinical center in China. Methods This retrospective study included patients with hepatic trauma admitted between January 2002 and December 2019 at the Xishan People’s Hospital of Wuxi. The outcomes were cure rate and death within 14 days post-discharge. Results Among the 318 patients with hepatic trauma, 146 patients underwent surgical treatment, and 172 received conservative treatment; three patients were transferred to other hospitals for further treatment; 283 patients were cured, and 35 died. Severe hepatic trauma occurred in 74 patients, with a mortality rate of 31.1% and accounting for 65.7% of total mortality. American Association for the Surgery of Trauma (AAST) grading ≥ III (OR = 3.51, 95%CI: 1.32–9.37, P = 0.012) and multiple organ injury (OR = 7.51, 95%CI: 2.51–22.46, P < 0.001) were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death (OR = 0.08, 95%CI: 0.01–0.45, P = 0.004). Among patients with ASST ≥ III and who underwent surgery, age (OR = 5.29, 95%CI: 1.37–20.33, P = 0.015) and peri-hepatic packing (PHP) (OR = 5.54, 95%CI: 1.43–21.487, P = 0.013) were independently associated with death. Conclusions AAST grading ≥ III and multiple organ injury were independently associated with death. Among patients with AAST grading ≥ III, surgery was an independent protective factor for death. Among patients with ASST ≥ III and who underwent surgery, age and PHP were independently associated with death.

The Role of Angioembolization in Hepatic Trauma

The liver is one of the most commonly injured solid organs in blunt abdominal trauma. Non-operative management is considered to be the gold standard for the care of most blunt liver injuries. Angioembolization has emerged as an important adjunct that is vital to the success of the non-operative management strategy for blunt hepatic injuries. This procedure, however, is fraught with some possible serious complications. The success, as well as rate of complications of this procedure, is determined by degree and type of injury, hepatic anatomy and physiology, and embolization strategy among other factors. In this review, we discuss these important considerations to help shed further light on the contribution and impact of angioembolization with regards to complex hepatic injuries.