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European Journal of Trauma and Emergency Surgery
Published in: European Journal of Trauma and Emergency Surgery 3/2015

01-06-2015 | Review Article

Management of blunt liver injury: what is new?

Authors: J. Ward, L. Alarcon, A. B. Peitzman

Published in: European Journal of Trauma and Emergency Surgery | Issue 3/2015

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Abstract

Nonoperative management has become the surgical treatment of choice in the hemodynamically stable patient with blunt hepatic trauma. The increased use and success of nonoperative management have been facilitated by the development of increasingly higher resolution computed tomography imaging, improved management of physiology and resuscitation (damage control), and routine availability of interventional procedures such as angiography and embolization, image-guided percutaneous drainage, and endoscopy. On the other hand, recognition of the patient who should proceed to immediate laparotomy is of utmost importance. A systematic and logical approach to the control of hemorrhage is required in the operating room. Thorough knowledge of the anatomy and surgical techniques, such as perihepatic packing, effective Pringle maneuver, hepatic mobilization, infrahepatic and suprahepatic control of the IVC, and stapled hepatectomy, is essential.

Literature
  1. Matthes G, Stengel D, Seifert J, Rademacher G, Mutze S, Ekkernkamp A. Blunt liver injuries in polytrauma: results from a cohort study with the regular use of whole-body helical computed tomography. World J Surg. 2003;27(10):1124–30. doi:10.​1007/​s00268-003-6981-0.PubMedView Article
  2. Lee SK, Carrillo EH. Advances and changes in the management of liver injuries. Am Surg. 2007;73(3):201–6.PubMed
  3. Malhotra AK, Fabian TC, Croce MA, Gavin TJ, Kudsk KA, Minard G, et al. Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990s. Ann Surg. 2000;231(6):804–13.PubMed CentralPubMedView Article
  4. Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg. 2003;138(8):844–51. doi:10.​1001/​archsurg.​138.​8.​844.PubMedView Article
  5. Kozar RA, Moore FA, Cothren CC, Moore EE, Sena M, Bulger EM, et al. Risk factors for hepatic morbidity following nonoperative management: multicenter study. Arch Surg. 2006;141(5):451–8. doi:10.​1001/​archsurg.​141.​5.​451 (discussion 8–9).PubMedView Article
  6. Peitzman AB, Marsh JW. Advanced operative techniques in the management of complex liver injury. J Trauma Acute Care Surg. 2012;73(3):765–70. doi:10.​1097/​TA.​0b013e318265cef5​.PubMedView Article
  7. Polanco P, Leon S, Pineda J, Puyana JC, Ochoa JB, Alarcon L, et al. Hepatic resection in the management of complex injury to the liver. J Trauma. 2008;65(6):1264–9. doi:10.​1097/​TA.​0b013e3181904749​ (discussion 9–70).PubMedView Article
  8. Becker CD, Mentha G, Terrier F. Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Part 1: liver and spleen. Eur Radiol. 1998;8(4):553–62.PubMedView Article
  9. Ochsner MG. Factors of failure for nonoperative management of blunt liver and splenic injuries. World J Surg. 2001;25(11):1393–6.PubMed
  10. Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF Jr, Kato K, et al. Focused assessment with sonography for trauma (FAST): results from an international consensus conference. J Trauma. 1999;46(3):466–72.PubMedView Article
  11. Sirlin CB, Brown MA, Andrade-Barreto OA, Deutsch R, Fortlage DA, Hoyt DB, et al. Blunt abdominal trauma: clinical value of negative screening US scans. Radiology. 2004;230(3):661–8. doi:10.​1148/​radiol.​2303021707.PubMedView Article
  12. Wallis A, Kelly MD, Jones L. Angiography and embolisation for solid abdominal organ injury in adults—a current perspective. World J Emerg Surg. 2010;5:18. doi:10.​1186/​1749-7922-5-18.PubMed CentralPubMedView Article
  13. Kozar RA, Moore FA, Moore EE, West M, Cocanour CS, Davis J, et al. Western Trauma Association critical decisions in trauma: nonoperative management of adult blunt hepatic trauma. J Trauma. 2009;67(6):1144–8. doi:10.​1097/​TA.​0b013e3181ba361f​ (discussion 8–9).PubMedView Article
  14. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38(3):323–4.PubMedView Article
  15. Poletti PA, Mirvis SE, Shanmuganathan K, Killeen KL, Coldwell D. CT criteria for management of blunt liver trauma: correlation with angiographic and surgical findings. Radiology. 2000;216(2):418–27. doi:10.​1148/​radiology.​216.​2.​r00au44418.PubMedView Article
  16. Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, et al. CT in blunt liver trauma. Radiographics. 2005;25(1):87–104. doi:10.​1148/​rg.​251045079.PubMedView Article
  17. Taourel P, Vernhet H, Suau A, Granier C, Lopez FM, Aufort S. Vascular emergencies in liver trauma. Eur J Radiol. 2007;64(1):73–82. doi:10.​1016/​j.​ejrad.​2007.​07.​013.PubMedView Article
  18. Nance ML, Peden GW, Shapiro MB, Kauder DR, Rotondo MF, Schwab CW. Solid viscus injury predicts major hollow viscus injury in blunt abdominal trauma. J Trauma. 1997;43(4):618–22 (discussion 22–23).PubMedView Article
  19. Bilgic I, Gelecek S, Akgun AE, Ozmen MM. Predictive value of liver transaminases levels in abdominal trauma. Am J Emerg Med. 2014;32(7):705–8. doi:10.​1016/​j.​ajem.​2014.​03.​052.PubMedView Article
  20. Tan KK, Bang SL, Vijayan A, Chiu MT. Hepatic enzymes have a role in the diagnosis of hepatic injury after blunt abdominal trauma. Injury. 2009;40(9):978–83. doi:10.​1016/​j.​injury.​2009.​02.​023.PubMedView Article
  21. Tian Z, Liu H, Su X, Fang Z, Dong Z, Yu C, et al. Role of elevated liver transaminase levels in the diagnosis of liver injury after blunt abdominal trauma. Exp Ther Med. 2012;4(2):255–60. doi:10.​3892/​etm.​2012.​575.PubMed CentralPubMed
  22. Christmas AB, Wilson AK, Manning B, Franklin GA, Miller FB, Richardson JD, et al. Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy. Surgery. 2005;138(4):606–10. doi:10.​1016/​j.​surg.​2005.​07.​018 (discussion 10–11).PubMedView Article
  23. Feliciano DV. Continuing evolution in the approach to severe liver trauma. Ann Surg. 1992;216(5):521–3.PubMed CentralPubMedView Article
  24. Pachter HL, Knudson MM, Esrig B, Ross S, Hoyt D, Cogbill T, et al. Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma. 1996;40(1):31–8.PubMedView Article
  25. Badger SA, Barclay R, Campbell P, Mole DJ, Diamond T. Management of liver trauma. World J Surg. 2009;33(12):2522–37. doi:10.​1007/​s00268-009-0215-z.PubMedView Article
  26. David Richardson J, Franklin GA, Lukan JK, Carrillo EH, Spain DA, Miller FB, et al. Evolution in the management of hepatic trauma: a 25-year perspective. Ann Surg. 2000;232(3):324–30.PubMed CentralPubMedView Article
  27. Pachter HL. Prometheus bound: evolution in the management of hepatic trauma–from myth to reality. J Trauma Acute Care Surg. 2012;72(2):321–9. doi:10.​1097/​TA.​0b013e31824b15a7​.PubMed
  28. Parks NA, Davis JW, Forman D, Lemaster D. Observation for nonoperative management of blunt liver injuries: how long is long enough? J Trauma. 2011;70(3):626–9. doi:10.​1097/​TA.​0b013e31820d1c69​.PubMedView Article
  29. Piper GL, Peitzman AB. Current management of hepatic trauma. Surg Clin North Am. 2010;90(4):775–85. doi:10.​1016/​j.​suc.​2010.​04.​009.PubMedView Article
  30. Raza M, Abbas Y, Devi V, Prasad KV, Rizk KN, Nair PP. Non operative management of abdominal trauma—a 10 years review. World J Emerg Surg. 2013;8:14. doi:10.​1186/​1749-7922-8-14.PubMed CentralPubMedView Article
  31. Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S288–93. doi:10.​1097/​TA.​0b013e318270160d​.PubMedView Article
  32. Leppaniemi AK, Mentula PJ, Streng MH, Koivikko MP, Handolin LE. Severe hepatic trauma: nonoperative management, definitive repair, or damage control surgery? World J Surg. 2011;35(12):2643–9. doi:10.​1007/​s00268-011-1309-y.PubMedView Article
  33. van der Wilden GM, Velmahos GC, Emhoff T, Brancato S, Adams C, Georgakis G, et al. Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the research consortium of new England centers for trauma. Arch Surg. 2012;147(5):423–8. doi:10.​1001/​archsurg.​2012.​147.PubMed
  34. Velmahos GC, Toutouzas K, Radin R, Chan L, Rhee P, Tillou A, et al. High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg. 2003;138(5):475–80. doi:10.​1001/​archsurg.​138.​5.​475 (discussion 80–81).PubMedView Article
  35. Tinkoff G, Esposito TJ, Reed J, Kilgo P, Fildes J, Pasquale M, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207(5):646–55. doi:10.​1016/​j.​jamcollsurg.​2008.​06.​342.PubMedView Article
  36. Polanco PM, Brown JB, Puyana JC, Billiar TR, Peitzman AB, Sperry JL. The swinging pendulum: a national perspective of nonoperative management in severe blunt liver injury. J Trauma Acute Care Surg. 2013;75(4):590–5. doi:10.​1097/​TA.​0b013e3182a53a3e​.PubMedView Article
  37. Carrillo EH, Spain DA, Wohltmann CD, Schmieg RE, Boaz PW, Miller FB, et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma. 1999;46(4):619–22 (discussion 22–24).PubMedView Article
  38. Goldman R, Zilkoski M, Mullins R, Mayberry J, Deveney C, Trunkey D. Delayed celiotomy for the treatment of bile leak, compartment syndrome, and other hazards of nonoperative management of blunt liver injury. Am J Surg. 2003;185(5):492–7.PubMedView Article
  39. Fang JF, Chen RJ, Wong YC, Lin BC, Hsu YB, Kao JL, et al. Pooling of contrast material on computed tomography mandates aggressive management of blunt hepatic injury. Am J Surg. 1998;176(4):315–9.PubMedView Article
  40. Fang JF, Wong YC, Lin BC, Hsu YP, Chen MF. The CT risk factors for the need of operative treatment in initially hemodynamically stable patients after blunt hepatic trauma. J Trauma. 2006;61(3):547–53. doi:10.​1097/​01.​ta.​0000196571.​12389.​ee (discussion 53–54).PubMedView Article
  41. Croce MA, Fabian TC, Menke PG, Waddle-Smith L, Minard G, Kudsk KA, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Results of a prospective trial. Ann Surg. 1995;221(6):744–53 (discussion 53–55).PubMed CentralPubMedView Article
  42. Ciraulo DL, Luk S, Palter M, Cowell V, Welch J, Cortes V, et al. Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries. J Trauma. 1998;45(2):353–8 (discussion 8–9).PubMedView Article
  43. Huang YC, Wu SC, Fu CY, Chen YF, Chen RJ, Hsieh CH, et al. Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury. Am J Surg. 2012;203(4):448–53. doi:10.​1016/​j.​amjsurg.​2011.​01.​031.PubMedView Article
  44. Letoublon C, Morra I, Chen Y, Monnin V, Voirin D, Arvieux C. Hepatic arterial embolization in the management of blunt hepatic trauma: indications and complications. J Trauma. 2011;70(5):1032–6. doi:10.​1097/​TA.​0b013e31820e7ca1​ (discussion 6–7).PubMedView Article
  45. Misselbeck TS, Teicher EJ, Cipolle MD, Pasquale MD, Shah KT, Dangleben DA, et al. Hepatic angioembolization in trauma patients: indications and complications. J Trauma. 2009;67(4):769–73. doi:10.​1097/​TA.​0b013e3181b5ce7f​.PubMedView Article
  46. Mohr AM, Lavery RF, Barone A, Bahramipour P, Magnotti LJ, Osband AJ, et al. Angiographic embolization for liver injuries: low mortality, high morbidity. J Trauma. 2003;55(6):1077–81. doi:10.​1097/​01.​TA.​0000100219.​02085.​AB (discussion 81–82).PubMedView Article
  47. Abdelrahman H, Ajaj A, Atique S, El-Menyar A, Al-Thani H. Conservative management of major liver necrosis after angioembolization in a patient with blunt trauma. Case Rep Surg. 2013;2013:954050. doi:10.​1155/​2013/​954050.PubMed CentralPubMed
  48. Dabbs DN, Stein DM, Philosophe B, Scalea TM. Treatment of major hepatic necrosis: lobectomy versus serial debridement. J Trauma. 2010;69(3):562–7. doi:10.​1097/​TA.​0b013e3181ebf591​.PubMedView Article
  49. Kanakis MA, Thomas T, Martinakis VG, Brountzos E, Varsamidakis N. Successful management of severe blunt hepatic trauma by angiographic embolization. Updates Surg. 2012;64(4):303–6. doi:10.​1007/​s13304-011-0122-3.PubMedView Article
  50. Wahl WL, Brandt MM, Hemmila MR, Arbabi S. Diagnosis and management of bile leaks after blunt liver injury. Surgery. 2005;138(4):742–7. doi:10.​1016/​j.​surg.​2005.​07.​021 (discussion 7–8).PubMedView Article
  51. Yuan KC, Wong YC, Fu CY, Chang CJ, Kang SC, Hsu YP. Screening and management of major bile leak after blunt liver trauma: a retrospective single center study. Scand J Trauma Resusc Emerg Med. 2014;22(1):26. doi:10.​1186/​1757-7241-22-26.PubMed CentralPubMedView Article
  52. Bala M, Gazalla SA, Faroja M, Bloom AI, Zamir G, Rivkind AI, et al. Complications of high grade liver injuries: management and outcomewith focus on bile leaks. Scand J Trauma Resusc Emerg Med. 2012;20:20. doi:10.​1186/​1757-7241-20-20.PubMed CentralPubMedView Article
  53. Singh V, Narasimhan KL, Verma GR, Singh G. Endoscopic management of traumatic hepatobiliary injuries. J Gastroenterol Hepatol. 2007;22(8):1205–9. doi:10.​1111/​j.​1440-1746.​2006.​04780.​x.PubMedView Article
  54. Carrillo EH, Reed DN Jr, Gordon L, Spain DA, Richardson JD. Delayed laparoscopy facilitates the management of biliary peritonitis in patients with complex liver injuries. Surg Endosc. 2001;15(3):319–22. doi:10.​1007/​s004640000300.PubMedView Article
  55. Letoublon C, Chen Y, Arvieux C, Voirin D, Morra I, Broux C, et al. Delayed celiotomy or laparoscopy as part of the nonoperative management of blunt hepatic trauma. World J Surg. 2008;32(6):1189–93. doi:10.​1007/​s00268-007-9439-y.PubMedView Article
  56. Pilgrim CH, Usatoff V. Role of laparoscopy in blunt liver trauma. ANZ J Surg. 2006;76(5):403–6. doi:10.​1111/​j.​1445-2197.​2006.​03731.​x.PubMedView Article
  57. Pearl LB, Trunkey DD. Compartment syndrome of the liver. J Trauma. 1999;47(4):796–8.PubMedView Article
  58. Devakumar Murugesan S, Sathyanesan J, Lakshmanan A, Ramaswami S, Perumal S, Ulagendra Perumal S, et al. Massive hemobilia: a diagnostic and therapeutic challenge. World J Surg. 2014;. doi:10.​1007/​s00268-013-2435-5.
  59. Green MH, Duell RM, Johnson CD, Jamieson NV. Haemobilia. Br J Surg. 2001;88(6):773–86. doi:10.​1046/​j.​1365-2168.​2001.​01756.​x.PubMedView Article
  60. Srivastava DN, Sharma S, Pal S, Thulkar S, Seith A, Bandhu S, et al. Transcatheter arterial embolization in the management of hemobilia. Abdom Imaging. 2006;31(4):439–48. doi:10.​1007/​s00261-005-0392-7.PubMedView Article
  61. Buckman RF Jr, Miraliakbari R, Badellino MM. Juxtahepatic venous injuries: a critical review of reported management strategies. J Trauma. 2000;48(5):978–84.PubMedView Article
  62. Li Petri S, Gruttadauria S, Pagano D, Echeverri GJ, Di Francesco F, Cintorino D, et al. Surgical management of complex liver trauma: a single liver transplant center experience. Am Surg. 2012;78(1):20–5.PubMed
  63. Baumgartner F, Scudamore C, Nair C, Karusseit O, Hemming A. Venovenous bypass for major hepatic and caval trauma. J Trauma. 1995;39(4):671–3.PubMedView Article
  64. Gillmore D, McSwain NE Jr, Browder IW. Hepatic trauma: to drain or not to drain? J Trauma. 1987;27(8):898–902.PubMedView Article
  65. Mohseni S, Talving P, Kobayashi L, Kim D, Inaba K, Lam L, et al. Closed-suction drain placement at laparotomy in isolated solid organ injury is not associated with decreased risk of deep surgical site infection. Am Surg. 2012;78(10):1187–91.PubMed
  66. Mullins RJ, Stone HH, Dunlop WE, Strom PR. Hepatic trauma: evaluation of routine drainage. South Med J. 1985;78(3):259–61.PubMedView Article
  67. Noyes LD, Doyle DJ, McSwain NE Jr. Septic complications associated with the use of peritoneal drains in liver trauma. J Trauma. 1988;28(3):337–46.PubMedView Article
  68. Dabbs DN, Stein DM, Scalea TM. Major hepatic necrosis: a common complication after angioembolization for treatment of high-grade liver injuries. J Trauma. 2009;66(3):621–7. doi:10.​1097/​TA.​0b013e31819919f2​ (discussion 7–9).PubMedView Article
  69. Anand RJ, Ferrada PA, Darwin PE, Bochicchio GV, Scalea TM. Endoscopic retrograde cholangiopancreatography is an effective treatment for bile leak after severe liver trauma. J Trauma. 2011;71(2):480–5. doi:10.​1097/​TA.​0b013e3181efc270​.PubMedView Article
Metadata
Title
Management of blunt liver injury: what is new?
Authors
J. Ward
L. Alarcon
A. B. Peitzman
Publication date
01-06-2015
Publisher
Springer Berlin Heidelberg
Published in
European Journal of Trauma and Emergency Surgery / Issue 3/2015
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI
https://doi.org/10.1007/s00068-015-0521-0

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