East 2012 Guidelines
Level 1 1. Patients who are hemodynamically unstable or who have diffuse peritonitis after blunt abdominal trauma should be taken urgently for laparotomy. Level 2 1. A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis presenting with an isolated blunt hepatic injury. 2. In the hemodynamically stable blunt abdominal trauma patient without peritonitis, an abdominal CT scan with intravenous contrast should be performed to identify and assess the severity of injury to the liver. 3. Angiography with embolization may be considered as a first-line intervention for a patient who is a transient responder to resuscitation as an adjunct to potential operative intervention. 4. The severity of hepatic injury (as suggested by CT grade or degree of hemoperitoneum), neurologic status, age of more than 55 years, and/or the presence of associated injuries are not absolute contraindications to a trial of nonoperative management in a hemodynamically stable patient. 5. Angiography with embolization should be considered in a hemodynamically stable patient with evidence of active extravasation (a contrast blush) on abdominal CT scan. 6. Nonoperative management of hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Level 3 1. After hepatic injury, clinical factors such as a persistent systemic inflammatory response, increasing persistent abdominal pain, jaundice, or an otherwise unexplained drop in hemoglobin should prompt reevaluation by CT scan. 2. Interventional modalities including endoscopic retrograde cholangiopancreatography, angiography, laparoscopy, or percutaneous drainage may be required to manage complications (bile leak, biloma, bile peritonitis, hepatic abscess, bilious ascites, and hemobilia) that arise as a result of nonoperative management of blunt hepatic injury. 3. Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt hepatic injuries without increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined.
Biloma Bile peritonitis The Journal of Trauma: Injury, Infection, and Critical Care Volume 70(3), March 2011, pp 626-629 Conclusions: The length of observation should be based solely on clinical criteria. Patients with liver injuries may be safely discharged home in the presence of a normal abdominal examination and stable hemoglobin, regardless of the grade of injury. This guideline is safe and reduces LOS without increasing morbidity or mortality.
(The Journal of Trauma and Acute Care Surgery 2012;72(2):321–329)
- The Pringle Maneuver
- Rapid hepatotomy to injury site for ligation of bleeding vessels and lacerated bile ducts.
- Debridement of nonviable hepatic tissue.
- Placement of an omental pack into the injury site.
- Closed suction drainage for grades III-V injuries.
Portal Triad Occlusion Time
Under normothermic conditions, the safe cross-clamping time has been thought to be no more than 15 to 20 consecutive minutes. Topical hypothermia, on the other hand, has been shown to be highly beneficial in preventing ischemia/reperfusion injuries to the liver. Specifically, topical hypothermia has been shown to (i) decrease hepatic PMN infiltration and necrosis; (ii) decrease serum TNF-alpha levels; and (iii) attenuate pulmonary PMN infiltration and microvascular leakage.
The salient feature which makes the use of this treatment modality attractive lies in the ability of the omentum to (i) effectively exert a hemostatic tamponade effect; (ii) fill “dead space” with vascularized tissue; (iii) introduce peritoneal macrophages, the first line of defense in the peritoneal cavity, into a potential area of sepsis; and (iv) provide stromal call-derived factor 1-alpha, which may be vital to recruiting chemokine receptor cells vital to healing.
IMPROVISED BALLOON TAMPONADE
High-energy bilobar liver injuries present a unique challenge onto themselves. Hepatotomy via the finger fracture technique for selective ligation of lacerated blood vessels and bile ducts is not applicable to deep bilobar hepatic injuries because the zone of tracheotomy would be far too extensive while simultaneously running the risk of sacrificing multiple uninvolved vessels and bile ducts in both lobes of the liver or in multiple segments. As such, a different approach is required and the improvised balloon technique seems to offer a simple, safe, and effective solution to this problem.The balloon when blown up effectively tamponades lacerated vessels. When the balloon is deflated, usually at 24 hours to 36 hours, if no further bleeding ensues it can safely be removed. If, on the other hand, bleeding is evident when the balloon is deflated, reinflation and angioembolization can be lifesaving.
Juxtahepatic Venous Injury
A critical review of the management strategies when confronting a juxtahepatic venous injury by Buckman et al (J Trauma. 2008;65:1264–1270). has identified a serious flaw in the previous conception that wide hepatic mobilization is an essential maneuver. On the contrary, injudicious disruption of the natural containing structures such as the suspensory ligaments that surround the hepatic venous segments may lead to rapid exsanguinating hemorrhage which inevitably proves to be fatal. The better part of valor would be to dispense with the concept of “wide hepatic mobilization” and embark on other treatment strategies designed to arrest bleeding.
PREDICTORS OF FAILURE IN NONOPERATIVE MANAGEMENT
Several factors have been delineated as having a high correlation rate with failure of nonoperative management of blunt hepatic injuries:
- Rising intra-abdominal pressure: Chen et al.,57 in a study of 25 patients, showed a strong correlation between a rise in intra-abdominal pressure (>25 cm H2O) and failure of nonoperative management.
- Grade of injury: It stands to reason that as the grade of injury increases, the likelihood of eligibility for nonoperative management decreases. In a multicenter study encompassing 404 patients, Pachter et al.50 noted that only 14% of grades IV-V injuries qualified for nonoperative intervention. More importantly, 66% of the failures of nonoperative management were classified as being grade IV-V injury. Carrillo et al.,58 on the other hand, noted that 66% of grades IV-V injuries could be managed nonoperatively, but 50% of these required some type of interventional treatment, most notably angioembolization.
- Hemoperitoneum: Some maintain that the degree of hemoperitoneum is irrelevant as long as hemodynamic stability is maintained. While this may be true, I believe a reasonable and prudent approach would be to observe the patient if the hemoperitoneum is <500 mL or to resort to angiography if >500 mL is noted.
- Pooling of contrast material: Pooling of contrast material is not “one size fits all.” On imaging studies, there are three types of classifications of pooling of contrast material 59: a. Type I: Extravasation and pooling of contrast material into the peritoneal cavity. b. Type II: Simultaneous pooling of contrast material within the hepatic parenchyma. c. Type III: Pooling of contrast material within the hepatic parenchyma. Type I almost always requires operative intervention, whereas Types II and III are usually amenable to angioembolization.
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Angio after Hepatic Trauma?
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