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. 1992 May;215(5):492–502. doi: 10.1097/00000658-199205000-00012

Significant trends in the treatment of hepatic trauma. Experience with 411 injuries.

H L Pachter 1, F C Spencer 1, S R Hofstetter 1, H G Liang 1, G F Coppa 1
PMCID: PMC1242483  PMID: 1616386

Abstract

Several significant advances in the treatment of hepatic injuries have evolved over the past decade. These trends have been incorporated into the overall treatment strategy of hepatic injuries and are reflected in experiences with 411 consecutive patients. Two hundred fifty-eight patients (63%) with minor injuries (grades I to II) were treated by simple suture or hemostatic agents with a mortality rate of 6%. One hundred twenty-eight patients (31%) sustained complex hepatic injuries (grades III to V). One hundred seven patients (83.5%) with grades III or IV injury underwent portal triad occlusion and finger fracture of hepatic parenchyma alone. Seventy-three surviving patients (73%) required portal triad occlusion, with ischemia times varying from 10 to 75 minutes (mean, 30 minutes). The mortality rate in this group was 6.5% (seven patients) and was accompanied by a morbidity rate of 15%. Fourteen patients (11%) with grade V injury (retrohepatic cava or hepatic veins) were managed by prolonged protal triad occlusion (mean cross-clamp time, 46 minutes) and extensive finger fracture to the site of injury. In four of these patients an atrial caval shunt was additionally used. Two of these patients survived, whereas six of the 10 patients managed without a shunt survived, for an overall mortality rate of 43%. Over the past 4 years, six patients (4.7%) with ongoing coagulopathies were managed by packing and planned re-exploration, with four patients (67%) surviving and one (25%) developing an intra-abdominal abscess. One additional patient (0.8%) was managed by resectional debridement alone and survived. During the past 5 years, 25 hemodynamically stable and alert adult patients (6%) sustaining blunt trauma were evaluated by computed tomography scan and found to have grade I to III injuries. All were managed nonoperatively with uniform success. The combination of portal triad occlusion (up to 75 minutes), finger fracture technique, and the use of a viable omental pack is a safe, reliable, and effective method of managing complex hepatic injuries (grade III to IV). Juxtahepatic venous injuries continue to carry a prohibitive mortality rate, but nonshunting approaches seem to result in the lowest cumulative mortality rate. Packing and planned reexploration has a definitive life-saving role when used adjunctively in the presence of a coagulopathy. Nonoperative management of select hemodynamically stable adult patients, identified by serial computed tomography scans after sustaining blunt trauma is highly successful (95-97%).

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Andersson R., Bengmark S. Conservative treatment of liver trauma. World J Surg. 1990 Jul-Aug;14(4):483–486. doi: 10.1007/BF01658672. [DOI] [PubMed] [Google Scholar]
  2. BERNHARD W. F., McMURREY J. D., CURTIS G. W. Feasibility of partial hepatic resection under hypothermia. N Engl J Med. 1955 Aug 4;253(5):159–164. doi: 10.1056/NEJM195508042530501. [DOI] [PubMed] [Google Scholar]
  3. Balasegaram M., Joishy S. K. Hepatic resection: the logical approach to surgical management of major trauma to the liver. Am J Surg. 1981 Nov;142(5):580–583. doi: 10.1016/0002-9610(81)90430-x. [DOI] [PubMed] [Google Scholar]
  4. Baracco-Gandolfo V., Vidarte O., Baracco-Miller V., del Castillo M. Prolonged closed liver packing in severe hepatic trauma: experience with 36 patients. J Trauma. 1986 Aug;26(8):754–756. doi: 10.1097/00005373-198608000-00012. [DOI] [PubMed] [Google Scholar]
  5. Beal S. L. Fatal hepatic hemorrhage: an unresolved problem in the management of complex liver injuries. J Trauma. 1990 Feb;30(2):163–169. [PubMed] [Google Scholar]
  6. Bismuth H., Castaing D., Garden O. J. Major hepatic resection under total vascular exclusion. Ann Surg. 1989 Jul;210(1):13–19. doi: 10.1097/00000658-198907000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Buckman R. F., Jr, Piano G., Dunham C. M., Soutter I., Ramzy A., Militello P. R. Major bowel and diaphragmatic injuries associated with blunt spleen or liver rupture. J Trauma. 1988 Sep;28(9):1317–1321. doi: 10.1097/00005373-198809000-00004. [DOI] [PubMed] [Google Scholar]
  8. Buechter K. J., Sereda D., Gomez G., Zeppa R. Retrohepatic vein injuries: experience with 20 cases. J Trauma. 1989 Dec;29(12):1698–1704. [PubMed] [Google Scholar]
  9. Burch J. M., Feliciano D. V., Mattox K. L. The atriocaval shunt. Facts and fiction. Ann Surg. 1988 May;207(5):555–568. doi: 10.1097/00000658-198805000-00010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Calne R. Y., McMaster P., Pentlow B. D. The treatment of major liver trauma by primary packing with transfer of the patient for definitive treatment. Br J Surg. 1979 May;66(5):338–339. doi: 10.1002/bjs.1800660512. [DOI] [PubMed] [Google Scholar]
  11. Carmona R. H., Peck D. Z., Lim R. C., Jr The role of packing and planned reoperation in severe hepatic trauma. J Trauma. 1984 Sep;24(9):779–784. doi: 10.1097/00005373-198409000-00001. [DOI] [PubMed] [Google Scholar]
  12. Cogbill T. H., Moore E. E., Jurkovich G. J., Feliciano D. V., Morris J. A., Mucha P. Severe hepatic trauma: a multi-center experience with 1,335 liver injuries. J Trauma. 1988 Oct;28(10):1433–1438. [PubMed] [Google Scholar]
  13. Coln D., Crighton J., Schorn L. Successful management of hepatic vein injury from blunt trauma in children. Am J Surg. 1980 Dec;140(6):858–864. doi: 10.1016/0002-9610(80)90132-4. [DOI] [PubMed] [Google Scholar]
  14. Cox E. F., Flancbaum L., Dauterive A. H., Paulson R. L. Blunt trauma to the liver. Analysis of management and mortality in 323 consecutive patients. Ann Surg. 1988 Feb;207(2):126–134. doi: 10.1097/00000658-198802000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Croce M. A., Fabian T. C., Kudsk K. A., Baum S. L., Payne L. W., Mangiante E. C., Britt L. G. AAST organ injury scale: correlation of CT-graded liver injuries and operative findings. J Trauma. 1991 Jun;31(6):806–812. [PubMed] [Google Scholar]
  16. Cué J. I., Cryer H. G., Miller F. B., Richardson J. D., Polk H. C., Jr Packing and planned reexploration for hepatic and retroperitoneal hemorrhage: critical refinements of a useful technique. J Trauma. 1990 Aug;30(8):1007–1013. doi: 10.1097/00005373-199008000-00010. [DOI] [PubMed] [Google Scholar]
  17. Cywes S., Rode H., Millar A. J. Blunt liver trauma in children: nonoperative management. J Pediatr Surg. 1985 Feb;20(1):14–18. doi: 10.1016/s0022-3468(85)80383-3. [DOI] [PubMed] [Google Scholar]
  18. DeMaria E. J., Reichman W., Kenney P. R., Armitage J. M., Gann D. S. Septic complications of corticosteroid administration after central nervous system trauma. Ann Surg. 1985 Aug;202(2):248–252. doi: 10.1097/00000658-198508000-00017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Delva E., Camus Y., Nordlinger B., Hannoun L., Parc R., Deriaz H., Lienhart A., Huguet C. Vascular occlusions for liver resections. Operative management and tolerance to hepatic ischemia: 142 cases. Ann Surg. 1989 Feb;209(2):211–218. doi: 10.1097/00000658-198902000-00012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Fabian T. C., Croce M. A., Stanford G. G., Payne L. W., Mangiante E. C., Voeller G. R., Kudsk K. A. Factors affecting morbidity following hepatic trauma. A prospective analysis of 482 injuries. Ann Surg. 1991 Jun;213(6):540–548. doi: 10.1097/00000658-199106000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Fabian T. C., Stone H. H. Arrest of severe liver hemorrhage by an omental pack. South Med J. 1980 Nov;73(11):1487–1490. doi: 10.1097/00007611-198011000-00021. [DOI] [PubMed] [Google Scholar]
  22. Farnell M. B., Spencer M. P., Thompson E., Williams H. J., Jr, Mucha P., Jr, Ilstrup D. M. Nonoperative management of blunt hepatic trauma in adults. Surgery. 1988 Oct;104(4):748–756. [PubMed] [Google Scholar]
  23. Federico J. A., Horner W. R., Clark D. E., Isler R. J. Blunt hepatic trauma. Nonoperative management in adults. Arch Surg. 1990 Jul;125(7):905–909. doi: 10.1001/archsurg.1990.01410190103016. [DOI] [PubMed] [Google Scholar]
  24. Feliciano D. V., Mattox K. L., Burch J. M., Bitondo C. G., Jordan G. L., Jr Packing for control of hepatic hemorrhage. J Trauma. 1986 Aug;26(8):738–743. doi: 10.1097/00005373-198608000-00010. [DOI] [PubMed] [Google Scholar]
  25. Feliciano D. V., Mattox K. L., Jordan G. L., Jr, Burch J. M., Bitondo C. G., Cruse P. A. Management of 1000 consecutive cases of hepatic trauma (1979-1984). Ann Surg. 1986 Oct;204(4):438–445. doi: 10.1097/00000658-198610000-00012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Feliciano D. V., Mattox K. L., Jordan G. L., Jr Intra-abdominal packing for control of hepatic hemorrhage: a reappraisal. J Trauma. 1981 Apr;21(4):285–290. doi: 10.1097/00005373-198104000-00005. [DOI] [PubMed] [Google Scholar]
  27. Feliciano D. V., Pachter H. L. Hepatic trauma revisited. Curr Probl Surg. 1989 Jul;26(7):453–524. doi: 10.1016/0011-3840(89)90014-2. [DOI] [PubMed] [Google Scholar]
  28. Figueroa I., Santiago-Delpín E. A. Steroid protection of the liver during experimental eschemia. Surg Gynecol Obstet. 1975 Mar;140(3):368–370. [PubMed] [Google Scholar]
  29. Fischer R. P., Miller-Crotchett P., Reed R. L., 2nd Gastrointestinal disruption: the hazard of nonoperative management in adults with blunt abdominal injury. J Trauma. 1988 Oct;28(10):1445–1449. [PubMed] [Google Scholar]
  30. Foley W. D., Cates J. D., Kellman G. M., Langdon T., Aprahamian C., Lawson T. L., Middleton W. D. Treatment of blunt hepatic injuries: role of CT. Radiology. 1987 Sep;164(3):635–638. doi: 10.1148/radiology.164.3.3615861. [DOI] [PubMed] [Google Scholar]
  31. Fortner J. G., Shiu M. H., Kinne D. W., Kim D. K., Castro E. B., Watson R. C., Howland W. S., Beattie E. J., Jr Major hepatic resection using vascular isolation and hypothermic perfusion. Ann Surg. 1974 Oct;180(4):644–652. doi: 10.1097/00000658-197410000-00030. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Hiatt J. R., Harrier H. D., Koenig B. V., Ransom K. J. Nonoperative management of major blunt liver injury with hemoperitoneum. Arch Surg. 1990 Jan;125(1):101–103. doi: 10.1001/archsurg.1990.01410130107016. [DOI] [PubMed] [Google Scholar]
  33. Huguet C., Nordlinger B., Bloch P., Conard J. Tolerance of the human liver to prolonged normothermic ischemia. A biological study of 20 patients submitted to extensive hepatectomy. Arch Surg. 1978 Dec;113(12):1448–1451. doi: 10.1001/archsurg.1978.01370240070012. [DOI] [PubMed] [Google Scholar]
  34. Ivatury R. R., Nallathambi M., Gunduz Y., Constable R., Rohman M., Stahl W. M. Liver packing for uncontrolled hemorrhage: a reappraisal. J Trauma. 1986 Aug;26(8):744–753. doi: 10.1097/00005373-198608000-00011. [DOI] [PubMed] [Google Scholar]
  35. Knudson M. M., Lim R. C., Jr, Oakes D. D., Jeffrey R. B., Jr Nonoperative management of blunt liver injuries in adults: the need for continued surveillance. J Trauma. 1990 Dec;30(12):1494–1500. doi: 10.1097/00005373-199012000-00009. [DOI] [PubMed] [Google Scholar]
  36. Kudsk K. A., Sheldon G. F., Lim R. C., Jr Atrial-caval shunting (ACS) after trauma. J Trauma. 1982 Feb;22(2):81–85. doi: 10.1097/00005373-198202000-00001. [DOI] [PubMed] [Google Scholar]
  37. Lucas C. E., Ledgerwood A. M. Prospective evaluation of hemostatic techniques for liver injuries. J Trauma. 1976 Jun;16(6):442–451. doi: 10.1097/00005373-197606000-00003. [DOI] [PubMed] [Google Scholar]
  38. MADDING G. F., PENISTON W. H. Liver hemostasis. Surg Gynecol Obstet. 1957 May;104(5):417–424. [PubMed] [Google Scholar]
  39. Meyer A. A., Crass R. A., Lim R. C., Jr, Jeffrey R. B., Federle M. P., Trunkey D. D. Selective nonoperative management of blunt liver injury using computed tomography. Arch Surg. 1985 May;120(5):550–554. doi: 10.1001/archsurg.1985.01390290032005. [DOI] [PubMed] [Google Scholar]
  40. Mirvis S. E., Whitley N. O., Vainwright J. R., Gens D. R. Blunt hepatic trauma in adults: CT-based classification and correlation with prognosis and treatment. Radiology. 1989 Apr;171(1):27–32. doi: 10.1148/radiology.171.1.2928537. [DOI] [PubMed] [Google Scholar]
  41. Moore E. E., Shackford S. R., Pachter H. L., McAninch J. W., Browner B. D., Champion H. R., Flint L. M., Gennarelli T. A., Malangoni M. A., Ramenofsky M. L. Organ injury scaling: spleen, liver, and kidney. J Trauma. 1989 Dec;29(12):1664–1666. [PubMed] [Google Scholar]
  42. Pachter H. L., Spencer F. C., Hofstetter S. R., Liang H. C., Coppa G. F. The management of juxtahepatic venous injuries without an atriocaval shunt: preliminary clinical observations. Surgery. 1986 May;99(5):569–575. [PubMed] [Google Scholar]
  43. Pachter H. L., Spencer F. C. Recent concepts in the treatment of hepatic trauma: facts and fallacies. Ann Surg. 1979 Oct;190(4):423–429. doi: 10.1097/00000658-197910000-00001. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Pringle J. H. V. Notes on the Arrest of Hepatic Hemorrhage Due to Trauma. Ann Surg. 1908 Oct;48(4):541–549. doi: 10.1097/00000658-190810000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Rovito P. F. Atrial caval shunting in blunt hepatic vascular injury. Ann Surg. 1987 Mar;205(3):318–321. doi: 10.1097/00000658-198703000-00017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Santiago Delpín E. A., Figueroa I., López R., Vázquez J. Protective effect of steroids on liver ischemia. Am Surg. 1975 Nov;41(11):683–685. [PubMed] [Google Scholar]
  47. Stain S. C., Yellin A. E., Donovan A. J. Hepatic trauma. Arch Surg. 1988 Oct;123(10):1251–1255. doi: 10.1001/archsurg.1988.01400340077013. [DOI] [PubMed] [Google Scholar]
  48. Stone H. H., Lamb J. M. Use of pedicled omentum as an autogenous pack for control of hemorrhage in major injuries of the liver. Surg Gynecol Obstet. 1975 Jul;141(1):92–94. [PubMed] [Google Scholar]
  49. Svoboda J. A., Peter E. T., Dang C. V., Parks S. N., Ellyson J. H. Severe liver trauma in the face of coagulopathy. A case for temporary packing and early reexploration. Am J Surg. 1982 Dec;144(6):717–721. doi: 10.1016/0002-9610(82)90557-8. [DOI] [PubMed] [Google Scholar]
  50. Vock P., Kehrer B., Tschaeppeler H. Blunt liver trauma in children: the role of computed tomography in diagnosis and treatment. J Pediatr Surg. 1986 May;21(5):413–418. doi: 10.1016/s0022-3468(86)80511-5. [DOI] [PubMed] [Google Scholar]
  51. Walt A. J. Founder's lecture: The mythology of hepatic trauma--or Babel revisited. Am J Surg. 1978 Jan;135(1):12–18. doi: 10.1016/0002-9610(78)90003-x. [DOI] [PubMed] [Google Scholar]
  52. Walt A. J. The surgical management of hepatic trauma and its complications. Ann R Coll Surg Engl. 1969 Dec;45(6):319–339. [PMC free article] [PubMed] [Google Scholar]
  53. Wing V. W., Federle M. P., Morris J. A., Jr, Jeffrey R. B., Bluth R. The clinical impact of CT for blunt abdominal trauma. AJR Am J Roentgenol. 1985 Dec;145(6):1191–1194. doi: 10.2214/ajr.145.6.1191. [DOI] [PubMed] [Google Scholar]

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