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LIVER TRAUMA
Jonathan R. Hiatt, MD
LIVER TRAUMA
LIVER TRAUMA
LIVER TRAUMA
LIVER TRAUMA
1880 – 1900 1908 MORTALITY OF LIVER INJURY MODERN CONCEPTS
PACKS, RESECTION PRINGLE WW II – 27% KOREA – 14% VIETNAM – 8.5% URBAN TRAUMA CTRS.
LIVER TRAUMA
HISTORY
LIVER TRAUMA
EPIDEMIOLOGY CLASSIFICATION THERAPEUTIC STRATEGY NONOPERATIVE OPERATIVE MULTIDISCIPLINARY
PORTA HEPATIS INJURY
LIVER TRAUMA
LIVER TRAUMA
COMMON BLUNT
PENETRATING
INJURY PATTERNS
LIVER TRAUMA
HOUSTON 1500 31 54 15
DETROIT 1400 34 55 11
NEW ORLEANS 550 30 56 14
SAN FRANCISCO 1124 27 34 39
PATIENTS BY MECHANISM STAB WD GSW BLUNT HOSPITAL n
LIVER TRAUMA
HOUSTON 1 6 27 DETROIT 1 15 20 NEW ORLEANS 1 11 28 SAN FRANCISCO 1 6 16 SAN ANTONIO 2 12 12 DENVER 2 16 22
MORTALITY BY MECHANISM STAB WD GSW BLUNT
MOORE, CONTEMP SURG '79
HOSPITAL
LIVER TRAUMA
ASSOCIATED INJURIES COMMON
AFFECT MORTALITY
INJURY PATTERNS
LIVER TRAUMA
ASSOCIATED INJURIES (BLUNT)
MALHOTRA, ANN SURG 2000
LIVER TRAUMA
MORTALITY BY NO. OF INJURIES
0 (LIVER ONLY) 114 6 1 93 19 2 50 34 3 23 36 4 9 56 5 or > 9 67
MIKESKY, SGO 1956
n MORTALITY, % NO. OF ASSOC. INJURIES
LIVER TRAUMA
MORTALITY
RICHARDSON, ANN SURG 2000
TOTAL / LIVER RELATED
(n = 1842)
LIVER TRAUMA
MORTALITY: CAUSES TIME %
< 48 HR. > 48 HR.
BLEEDING ORGAN FAILURE
8.2 2.3
FELICIANO, ANN SURG 1989
LIVER TRAUMA
20-FOLD INCREASE WITH:
BASE DEFICIT < - 6
OPERATIVE BLOOD LOSS > 5 l
MORTALITY: RISK FACTORS
LIVER TRAUMA
MOORE, J TRAUMA 1979 & '94
CLASSIFICATION: AAST ORGAN INJURY SCALE
Freq, %
15
55
20 7 3
LIVER TRAUMA
MORTALITY BY INJURY CLASS
III 25 6.5
IV 46 30.5
V 80 66
COGBILL, J TRAUMA 1988
MORTALITY, %
HEPATIC MORTALITY, %
MOST NONBLEEDING
GRADED APPROACH TAILORED TO INJURY
MULTIPLE TECHNIQUES
LIVER TRAUMA
OPERATIVE PRINCIPLES
LIVER TRAUMA
LIVER TRAUMA
LIVER TRAUMA
ATTEMPT IN > 80% SUCCEED IN > 70% (90% OF ATT.) FAILURES: HIGHER INJURY GRADE HEMOPERITONEUM
OUTCOME IMPROVED LOS, INFECTION, TRANSFUSION
NONOPERATION: CURRENT STATUS
LIVER TRAUMA
NONOPERATIVE MGMT.
J TRAUMA ’12
LIVER TRAUMA
NONOPERATIVE MGMT. (Blunt injury)
J TRAUMA ’12
Level 1 1. Urgent laparotomy: Hemodynamically unstable Diffuse peritonitis
LIVER TRAUMA
NONOPERATIVE MGMT. (Blunt injury)
J TRAUMA ’12
Level 2 Stable w/o peritonitis: 1. No routine laparotomy 2. Abdominal CT w/ IV contrast 3. Transient responder: Consider angio/embolization as adjunct to operation 4. Grade, hemoperitoneum, neuro status, age>55y, associated injuries are not absolute contraindications 5. Angio/embolization with active contrast blush on CT 6. Environment: Monitoring, serial exams, available OR
LIVER TRAUMA
NONOPERATIVE MGMT. (Blunt injury)
J TRAUMA ’12
Level 2 Stable w/o peritonitis:
1. No routine laparotomy 2. Abdominal CT w/ IV contrast Angiography/embolization:
3. Consider as adjunct to op. for transient responder
5. With active contrast blush on CT
4. Grade, hemoperitoneum, neuro status, age>55y, associated injuries are not absolute contraindications 6. Environment: Monitoring, serial exams, available OR
LIVER TRAUMA
NONOPERATIVE MGMT. (Blunt injury)
J TRAUMA ’12
Level 3
1. Repeat CT: persistent SIR, pain, jaundice, Hgb drop
2. Interventional modalities incl.ERCP, angio, laparoscopy, IR drainage for complications (bile leak, biloma, bile peritonitis, liver abscess, bilious ascites, hemobilia)
3. Pharmacologic VTE prophylaxis can be used w/o increasing failure rate, but timing of safe initiation not determined
LIVER TRAUMA
NONOPERATIVE MGMT. (Blunt injury)
J TRAUMA ’12
Cannot make recommendations 1. Frequency of Hgb measurements 2. Frequency of abdominal exams 3. Intensity and duration of monitoring 4. Time to resuming oral intake
5. Duration/intensity of activity restriction (hospital and DC)
6. Optimal length of ICU and hospital stay 7. Timing of initiation of DVT prophylaxis
LIVER TRAUMA
MECHANISM BLUNT Tangential penetrating
STABLE, EVALUABLE MINIMAL TRANSFUSION ICU MONITORING RESPONSIBLE SURGEON
NONOPERATION: PRINCIPLES
LIVER TRAUMA
669 pts; nonop 65% BP < 90 10% 23 deaths (5%) 2 hepatic deaths (MSOF) 87 hepatic complics. in 61 pts. (13%)
Kozar, Arch Surg 2006
Nonoperation: Morbidity Risk Factors
LIVER TRAUMA
Kozar, Arch Surg 2006
Nonoperation: Morbidity Risk Factors
Post-injury day
LIVER TRAUMA
Nonoperation: Morbidity in Children 185 nonop; successful in 90% 10 died (5.4%): CNS 7, MOSF 3, hepatic 0 Complications 7(3.8%)
Giss, J Trauma 2006
LIVER TRAUMA
MORBIDITY / MORTALITY related to:
PARENCHYMAL DAMAGE INITIAL INJURY OPERATIVE INTERVENTIONS
HEPATIC VEINS
CLASSIFICATION: LIMITATIONS
LIVER TRAUMA
WIDE PREP LONG MIDLINE INCISION CONTROL HEMORRHAGE MOBILIZE LIVER DIVIDE HEPATIC LIGAMENTS FIXED RETRACTOR
OPERATIVE APPROACH
LIVER TRAUMA
INITIAL HEMORRHAGE CONTROL
LIVER TRAUMA
SCORE, ACS Surg
LIVER TRAUMA
PRINGLE OCCLUSION STOPS FORWARD FLOW HEPATIC ARTERIAL PORTAL VENOUS
? EXCLUDES HEPATIC VENOUS BLEEDING ? DURATION
LIVER TRAUMA
Portal Occlusion - Elective (Portal triad clamping)
(ischemic preconditioning)
Richardson, HPB 2012
LIVER TRAUMA
EXTENDED INCISION
LIVER TRAUMA
WIDE PREP LONG MIDLINE INCISION CONTROL HEMORRHAGE MOBILIZE LIVER DIVIDE HEPATIC LIGAMENTS FIXED RETRACTOR
OPERATIVE APPROACH
LIVER TRAUMA
FALCIFORM LIGAMENT
LIVER TRAUMA
LIVER TRAUMA
> 70% OF PATIENTS LACERATIONS, CAPSULAR TEARS TECHNIQUES ELECTROCAUTERY, ARGON BEAM HEMOSTATIC AGENTS + CLOSED SUCTION DRAINAGE
SIMPLE INJURIES (GRADES I-II, OIS)
LIVER TRAUMA
TOPICAL HEMOSTATIC AGENTS
LIVER TRAUMA
DIRECT APPROACH
HEPATOTOMY / HEPATORRHAPHY
RESECTIONAL DEBRIDEMENT
RESECTION
DAMAGE CONTROL TECHNIQUES
COMPLEX INJURIES (GRADES III-VI, OIS)
LIVER TRAUMA
HEPATORRHAPHY
LIVER TRAUMA
LIVER TRAUMA
RESECTIONAL DEBRIDEMENT
Omental pedicle
LIVER TRAUMA
EMERGENT
PARENCHYMAL DIVISION
ELECTIVE
LIVER TRAUMA
SUBCAPSULAR HEMATOMA
LIVER TRAUMA
SCORE, ACS Surg
LIVER TRAUMA
STORM – LONGMIRE CLAMP
PARTIAL HEPATECTOMY
LIVER TRAUMA
SELECTIVE HEPATIC ARTERY LIGATION
LIVER TRAUMA
ABSORBABLE MESH HEPATORRHAPHY
LIVER TRAUMA
HIGH MORTALITY INTRA- OR EXTRAHEPATIC THERAPEUTIC OPTIONS DIRECT REPAIR VASCULAR ISOLATION ATRIOCAVAL SHUNT DAMAGE CONTROL
HEPATIC VENOUS INJURIES
LIVER TRAUMA
LIVER TRAUMA
SCORE, ACS Surg
LIVER TRAUMA
YELLIN, ARCH SURG 1971
LIVER TRAUMA
SCORE, ACS Surg
LIVER TRAUMA
RETROHEPATIC INFERIOR VENA CAVA
LIVER TRAUMA
VENOUS INJURIES: MORTALITY
RICHARDSON, ANN SURG 2000
(n = 1842)
LIVER TRAUMA
VENOUS INJURIES: THERAPY
RICHARDSON, ANN SURG 2000
(n = 1842)
LIVER TRAUMA
MORTALITY RELATED TO: INTERVENTIONS TIME BLOOD LOSS (6u = failed intervention)
DAMAGE CONTROL: RATIONALE
LIVER TRAUMA
Inability to achieve hemostasis (coagulopathy) Inaccessible major venous injury Time-consuming procedure in patient with suboptimal response to resuscitation Mgmt. of extra-abd. life-threatening injury Reassessment of intra-abdominal contents Inability to close fascia (visceral edema)
DAMAGE CONTROL: INDICATIONS
SHAPIRO, J TRAUMA 2000
LIVER TRAUMA
DECIDE EARLY VICIOUS CYCLE HYPOTHERMIA ACIDOSIS COAGULOPATHY
REOP: when cycle reversed RISK: INFECTION
PERIHEPATIC PACKING
LIVER PACKS
LIVER TRAUMA
LIVER TRAUMA
SCORE, ACS Surg
LIVER TRAUMA
LIVER INJURY
HEMOPERITONEUM
OTHER ORGAN INJURIES
GUIDES NONOP MGMT.
CT SCAN
LIVER TRAUMA
MULTIDISCIPLINARY TECHNIQUES INVASIVE RADIOLOGY ANGIOGRAPHY / EMBOLIZATION
CT GUIDED DRAINAGE
ERCP LAPAROSCOPY
LIVER TRAUMA
PRIMARY THERAPY
ADJUNCTIVE TO OP / NONOP
FOR COMPLICATIONS OF OP / NONOP
MULTIDISCIPLINARY TECHNIQUES
LIVER TRAUMA
VASCULAR BLEEDING INTRA-ABDOMINAL INTRAHEPATIC
ANEURYSMS, FISTULAE BILIARY LEAKS, STRICTURES
INFECTION / ABSCESS
ABDOMINAL COMPLICATIONS
LIVER TRAUMA
INITIAL CT: CONTRAST BLUSH
LATE BLEEDING / HEMOBILIA
AFTER DAMAGE CONTROL
ANGIOEMBOLIZATION
Pseudoaneurysm
LIVER TRAUMA
ANGIOEMBOLIZATION Post - occlusion
LIVER TRAUMA
VENOUS STENTING
DENTON, J TRAUMA 1997
Disruption of R hepatic vein at IVC
Wallstent >
LIVER TRAUMA
TRIAD GI bleeding, RUQ pain, jaundice
ETIOLOGY Liver injury (incl. iatrogenic) Abscess, aneurysm, tumor (rare)
DX / RX: angiography / embolization
HEMOBILIA
LIVER TRAUMA
ERCP DIAGNOSIS OF HEMOBILIA
LIVER TRAUMA
PORTAL TRIAD INJURIES
JURKOVICH, J TRAUMA 2003
PORTAL VEIN 42 57% HEPATIC ARTERY 16 56% BILE DUCT 26 19% TOTAL 84 45% MULTIPLE 15 80%
n MORTALITY
LIVER TRAUMA
PORTAL TRIAD INJURIES
JURKOVICH, J TRAUMA 2003
LIVER TRAUMA
EXTRAHEPATIC BILIARY TRACT
LIVER TRAUMA
Carrel patch w/ cystic duct
EXTRAHEPATIC BILE DUCT
LIVER TRAUMA
VENOVENOUS BYPASS
BIFFL, J TRAUMA 1998
LIVER TRAUMA
LIVER TRAUMA
n 8 2 1 Veins injured 5 0 1 Indic.: Bleeding 4 0 0 Late necrosis 4 2 1 Temporary PC shunt 6 0 0 Retransplantation 2 1 0 Survived 2 1 1
TRANSPLANTATION RINGE ESQUIVEL ANGSTADT
BR J SURG ’95
J TRAUMA ’87
J TRAUMA ’89
LIVER TRAUMA
DECISION TIMING ORGAN AVAILABILITY ANHEPATIC MANAGEMENT ETHICAL ISSUES
TRANSPLANTATION: CHALLENGES
LIVER TRAUMA
SCORE, ACS Surg
ALGORITHM FOR BLEEDING MGMT.
LIVER TRAUMA
TRAUMA CENTERS NONOPERATIVE MGMT. ADJUNCTIVE THERAPIES LIVER TRANSPLANTATION
MAJOR ADVANCES
LIVER TRAUMA
COMMON INJURIES MOST MGMT. NOW NONOPERATIVE COMPLEX INJURIES: TECHNICAL CHALLENGES REMAIN FORMIDABLE MULTIDISCIPLINARY THERAPIES
SUMMARY
Ali M. Cheaito, MD Bach. Sci., University of Michigan MD, Boston University General Surgery: Henry Ford Hospital Multiorgan Transplantation: UCLA Assistant Professor of Surgery, Division of General Surgery