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

Abstract

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.

Surgical management of AAST grades III-V hepatic trauma by Damage control surgery with perihepatic packing and Definitive hepatic repair–single centre experience

“…Postoperative prolonged hemorrhage can be associated with coagulopathy [ 5 , 10 , 27 , 29 ]. While blood transfusion is necessary because of massive bleeding in trauma, it carries many complications [ 29 , 30 ].…”

“…Our study shows that non-survivors had higher AAST grade of injury, higher AST and ALT level, significant hypotension, higher ISS score and lower GCS on arrival; and significalntly more RBC units transfusions within the first 24 h. Early liver injury-related death is typically secondary to uncontrolled bleeding (20–60 %), which is worsened with attendant coagulopathy, whereas late mortality is usually secondary to multiorgan failure (MOF), Acute Respiratory Distress Syndrom (ARDS) in 27(32.1 %), and Multiple Organ Dysfunction Syndrome (MODS) [ 6 , 29 – 31 ]. Previous studies have shown that increased risk of ARDS and MODS has been associated with massive transfusion, which can itself contribute to coagulopathy [ 30 ]. In blunt liver trauma mortality also appears to be higher in older patients, those with higher grade injuries, and those with hemodynamic instability on presentation [ 29 – 31 ].…”

Management of severe blunt hepatic injury in the era of computed tomography and transarterial embolization

“…The primary search identified 29 articles published between January 2000 and June 2014 that were screened (Figure 1) (10,11). A further 17 articles were excluded: 9 that amalgamated penetrating and blunt hepatic injury (4,(12)(13)(14)(15)(16)(17)(18)(19), 6 where the demographics characteristics and outcome of grade III to V blunt hepatic injury was not comprehensively depicted (20)(21)(22)(23)(24), and 2 included exclusively patients with juxtahepatic venous injury (25,26).…”

Selective vascular isolation of the liver as part of initial damage control for grade 5 liver injuries: Shouldn’t we use it more frequently?

“…The advent of the acute care surgery fellowship might help. Trauma surgeons also need to consider collaborating more closely with colleagues who have real experience in liver surgery, including those in transplantation [26] . Involving the transplant team at an early stage in a patient’s course is important for another reason, namely, to help avoid long-term complications posttransplant.…”