barnes liver injury

8/11/2019 BARNES Liver Injury

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ContemporaryManagement of LiverInjuries

Stephen L. Barnes MD FACSProfessor of Surgery & AnesthesiaChief, Division of Acute Care Surgery, Trauma & BurnProgram Director, Surgical Critical CareUniversity of Missouri School of Medicine


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Mechanism


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Are all liver injuries

created equal?


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AAST Classification

Liver InjuriesGrade Type Description

I Hematoma Subcapsular, non-expanding, 50% or bleeding, or ruptured; hematoma > 10cm or

growingLaceration >3cm

IV Hematoma Ruptured intraparenchymal hematoma

Laceration Destruction of 25-75% or 1-3 Couinaud segments in 1 lobe

V Laceration Destruction > 75% or 1-3 Couinauds segments in 1 lobe

Vascular Juxtahepatic venous injury (cava/major hepatic vein)

VI Vascular Hepatic avulsion


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Non-operative Management

(What? Is he crazy?)

Management of

Major Liver Injuries

Croce M, Fabian T, et al. Non-operative management of blunt hepatic trauma is the

treatment of choice for hemodynamically stable patients: Results of a prospective

trial. Ann Surg 1995;221:744-55.


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Longstanding Change in

Practice 85% of all blunt

hepatic trauma are

stable

Non operativemanagement

Improves outcomes

Fewer Infections

Fewer Transfusion

Decreased LOS


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Non-operative Management of

Major Liver Injuries

Is done routinely

Can be done successfully

With improved outcomes

Liberal use of angio-embolization,

especially if iv contrast blushes on CT

Watch these people closely !!!! If no acute surgery required, beware of

delayed complications


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Successful Non-operative Management

of Grade IV Blunt Liver Injury

Stable patient

No blood transfusions

CT scan two weeks

later showing healing

of lacerations


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Hepatic Angioembolization in

Non-operative Management

Vascular blush

Vascular blush = extravasation of iv contrast


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Hepatic Arteriography and

Embolization

Widely used/over-used

Effective in hemorrhage control

When?

as a component of non-operative

management, particularly if vascular

blush seen on CT

following urgent laparotomy and

packing


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Case #1

Too Much Punch at the Party


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IV contrast

extravasation

University student after 3 feet fall from

stepladder in dorm room


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Operative Management


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Acute surgery for Hemorrhage

Surgery for persistent hepatic bleeding during

non-operative management

Delayed surgery for sequelae of a

massive liver injury

Operative Management of

Massive Liver Injury


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Generous midline incision

Four quadrant packing

Extreme hypotension - clamp supraceliac aorta

Divide falciform ligament

Put in retractor system

Look quickly for splenic and mesenteric bleeding

If brisk bleeding from liver, apply Pringle

I ncision and

I nitial Exploration


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Pringles Maneuver =

Portal Triad Occlusion

Pringle JH. Notes of the Arrest of Hepatic Hemorrhage Due to Trauma. Ann Sur

1908; 48:541

A Key Maneuver

for the Massively

Bleeding Liver


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Pringles Maneuver =

Portal Triad Occlusion

Reduces blood loss while you operate

Diagnostic maneuver

Clamp and look behind the liver If there is brisk venous bleeding OR a

large retroperitoneal hematoma behind

the liver, you have a major problem on

your hands !!!!!

If you are leaving the clamp on a long time you

may be trying to do too much !!!


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Mobilize the liver up into the wound so you canexamine and work on it

BUT consider early whether the liver should be

definitively packed and left alone before you spend a

lot of time and effort

Exposure is Everything


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Damage Control Laparotomy

Surgery is resuscitative, not definitive

Expeditious control of hemorrhage,

primarily peri-hepatic packing

Key is knowing when to stop operating and

get out

Blood pressure, temperature, acidosis, andcoagulopathy are the key markers


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When is it time to pack?

Massive liver injury with limited

institutional resources

Massive liver injury with limited experience

Massive liver bleeding and patient in extremis

Active bleeding after control of identified

bleeding vessels and application of topical

hemostatic agents

Active retrohepatic hemorrhage


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When is it time to unpack?

Normal coagulation parametersNormothermic

Resolution of acidosis

Following hepaticangiography/embolization

24 - 48 hours after packing

Prepare for the worst, hope for the best

Control of bleeding points, debridement,

drainage


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Resectional Debridement


In the presence of active bleeding from a

massive liver injury try and avoid large

anatomical liver resections You may need to resect liver to get at a

source of active bleeding (eg. approach to

left hepatic vein thru liver) If a piece is dangling...remove it !


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Resectional Debridement


MVC, failed

non-operative

management

Debridement of

devitalized liver,

hemostasis and drainage


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Retrohepatic IVC

and Hepatic Vein Injuries

Quick recognition

Dont pack and peek, pack and peek

Two main strategies: Pack and fight another day

Fix it now

Key Points:


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Retrohepatic IVC &

Hepatic vein injuries

Reports of unpacking these injuries with no

rebleeding

Angiography and embolization prior to pack

removal

Consider cavagram prior to pack removal

Endovascular venous stenting

Prepare for:

Atriocaval shunt/Venovenous bypass

Pack and fight another day:


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Retrohepatic IVC/hepatic vein injuries

Fix it now approach

Direct attack

Hepatic Vascular Isolation

Pringle, clamp IVC above and

below liver poorly tolerated

Atriocaval shunt

Venovenous bypass

The Approaches:


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Retrohepatic IVC/hepatic vein injuries

Direct attack approach

Advocated by some due to poor

results with vascular isolation

Need to know what you are

doing and be quick about it

Pringle, mobilize liver as required

One look behind liver to see if you can get itFinger fracture thru whatever liver is needed to

get directly at venous injury


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Case #2

Be Careful around Ambulance

Drivers

C


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Recent CaseDirect attack approach

Runner struck by ambulance during road

race

Talking, hypotensive, FAST +

Laparotomy

Bleeding from liver

Spleen/mesentery normal

Pringle applied, continued bleeding

Bleeding from right hepatic vein/IVC junction

C


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Recent CaseDirect attack approach

Venous repair performed

Expanding right renal hematoma, renal lac and

transection of renal artery

.nephrectomy Liver and right renal bed packed

Temporary abdominal wall closure

OR>>Hepatic angiography >>ICU

Bleeding, coagulopathy, acidosis and hypothermia

resolved

Return to OR, pack removal, closure


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Atriocaval Shunt

Generally done too late

Small experience

Results are generally poor

Trend is away from shunting

Not easy


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Pack liver

Median sternotomy

You need a shunt! Chest tube

Endotracheal tube

32Fr open heart bypass catheter

Control of intrapericardial IVC and

suprarenal infrahepatic IVC

How ?


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Atriocaval Shunt


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Venovenous Bypass

Makes you look like you know

what you are doing !!!Almost bloodless view of retrohepatic

IVC and hepatic veins

Maintains venous return to heart frombelow diaphragm

Can avoid sternotomy

What does it do for you?

V B


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Venovenous Bypass

Need to plan for itNeed help

Need time

Need catheters

Need pump (eg Biomedicus)

Need perfusionist

Need some luck

Do not need heparin


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Drains

Generally, drain grade IV/V

liver injuries

Place drains after packsremoved

Closed suction drains

You are draining for bile

If the drains dont drain bile

in 3-4 days, take them out

D l d C li i


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Delayed Complications

of Massive Liver Injury

Complications of open abdomen

fistula, hernia

Biliary fistula

Biliary peritonitis

Biloma

Hemobilia

Hepatic or peri-hepatic abscess

Hepatic failure


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Case#3

Beware when Shoveling Snow


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EMS Report

38 year old male

Struck by falling tree limb ~18 inchdiameter, from height of 30 feet after snow

storm while shoveling driveway.

Struck on right side and pinned

Brief loss of consciousness

Hemodynamically stable throughoutground transport


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Radiographic Evaluation

CT Abdomen /

Pelvis

Grade V* Liver

Laceration withextravasation of iv

contrast

Moderate

hemoperitoneum

Labs stable

Not acidotic

*AAST Organ Injury Scale J Trauma 1989


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Angiography

Extravasation, branchof right hepatic artery

Embolized with 3 mm

coils

Extravasation, branch

of left hepatic artery

Embolized with gelfoam

pellets No extravasation on

completion angiogram


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Hospital Course

Hospital day #3

Hct drop to 24% (36%)

PT/PTT normal

HR increased to 125 Complained of

increasing RUQ pain

2 U PRBC

Repeat CT Scan


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Hospital Course

CT scan revealed

intra-hepatic

extravasation of iv

contrast

Repeat angiogram

with successful

embolization ofpseudoaneurysm

Delayed Complications


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Delayed ComplicationsNon-operative Management

Hospital day 5

Surgical Floor

Hct stable

Increasing abdominaldistention and pain

Jaundice

Total bilirubin 4 mg/dl

HIDA Scan

Endoscopic Retrograde


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Endoscopic Retrograde

Cholangiography Hospital Day # 8

Biliary leak visualized

Unable to stent leak

10 french ampullarystent placed

Suspected biliary

peritonitis Laparoscopy following

stent placement

Laparoscopy & Drainage


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Laparoscopy & Drainage


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Hospital course

Discharged on POD

4

Hct stable ~ 30%

Afebrile, VSS JP drains in place

with minimal output

Tolerating regular

diet


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Case #4

Hunting with my Buddy

Complications of Massive


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Liver Injury

Transferred to Mizzou for clinical deterioration

Hunting Accident

GSW-RUQ/liver

Sick

Packed/unpacked/

drained &closed at

outside hospital

Lots of drain output



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Liver Injury

Draining infected

bilomaBile drainage of

1 liter/day


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Contemporary Management of


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Contemporary Management ofLiver Injuries Keys to Success

Hemodynamically unstable patients need tobe in the operating room

No patient should die as a result of nonoperative management

Beware of delayed complications of nonoperative management strategies

Role of angio\embolization Both Pre and/or Post Operative

Utilize minimally invasive technology whereappropriate in a multidisciplinary approach

Thank you


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Thank you

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