Management of blunt hepatic trauma

Abstract

For the last 20 years, nonoperative management (NOM) of blunt hepatic trauma (BHT) has been the initial policy whenever this is possible (80% of cases), i.e., in all cases where the hemodynamic status does not demand emergency laparotomy. NOM relies upon the coexistence of three highly effective treatment modalities: radiology with contrast-enhanced computerized tomography (CT) and hepatic arterial embolization, intensive care surveillance, and finally delayed surgery (DS). DS is not a failure of NOM management but rather an integral part of the surgical strategy. When imposed by hemodynamic instability, the immediate surgical option has seen its effectiveness transformed by development of the concept of abbreviated (damage control) laparotomy and wide application of the method of perihepatic packing (PHP). The effectiveness of these two conservative and cautious strategies for initial management is evidenced by current experience, but the management of secondary events that may arise with the most severe grades of injury must be both rapid and effective.

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

“…NOM could be the choice depends on the severity of liver blunt trauma and associated injuries. 5,7 Kozar et al, in his study revealed that global complication rate of NOM is 14 % but for grade V injuries the rate was higher around 52%. 31 Grade of liver injury can reflect the degree of hepatic parenchymal damage.…”

“…Non-operative management of liver injuries has gained wide support and adopted for approximately 80% of blunt liver injuries. 7 This nonoperative approach was at first apply to pediatric patients and has been rapidly extended to adults. 2 It is contraindicated for hemodynamic instability and peritonitis.…”

Contemporary Management of Hepatic Trauma: What IRs Need to Know

“…Understanding the numerous classification schemes in liver injury is of paramount importance in understanding the treatment options for these patients. There are four major classification systems which stratify various traumatic injuries by severity: the Abbreviated Injury Score (AIS), 10 the American Association for Surgery of Trauma (AAST) grading system, the Injury Severity Score, 11,12 and World Society of Emergency Surgery (WSES) grading system. 9 The AIS is an anatomically based global severity system that classifies injury severity by body region.…”

“…NOM is achievable in an estimated 80% of all hepatic trauma cases. 11 To qualify for NOM, patients must be hemodynamically stable, have an adequate response to initial resuscitation attempts, and have no peritoneal signs. These patients should be imaged with multiphase CT immediately and treated according to imaging findings.…”

“…Management of pediatric hepatic trauma, like splenic trauma, has shifted over the last few decades from primarily surgical to successful NOM in greater than 90% of cases. 11 NOM is more successful in pediatric patients than in adults, likely due to differences in physiology and ability to compensate for blood loss as well as differences in mechanism of injury. 4 To date, there is no consensus on the role of angioembolization in pediatric trauma patients with hepatic injury.…”