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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